Smallpox physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Physical Examination
Appearance of the Patient
Depending on the stage of the disease, the smallpox patient might have different appearances. These may range from
- Asymptomatic, if the patient had contact with someone with smallpox, got the infection and is currently in the incubation period
- Extremely ill, if it is someone who is in the prodromal period, who appears extremely ill, vomiting and fatigued
Vitals
Temperature
- A fever is often present
- Hypothermia may be present
Pulse
Rate
- Tachycardia may be present
- Bradycardia may be present
Rhythm
- The pulse is regular
- The pules is irregularly irregular
Strength
- The pulse may be weak
- The pulse may be bounding
- The pulse may be alternating in strength (pulsus alternans)
- A paradoxical pulse may be present
Symmetry
- The pulses may be asymmetric
Blood Pressure
- Hypotension may be present
- Hypertension may be present
- A wide pulse pressure may be present
- A narrow pulse pressure may be present
Respiratory Rate
- Tachypnea may be present
- Bradypnea may be present
- Kussmaul respirations may be present
Skin
- Cyanosis may be present
- Jaundice may be present
- A rash may be present
- Pallor may be present
- Lesions may be present
Head
- Abnormalities of the head/hair may include ___
- There may be evidence of trauma
Eyes
- Icteric sclera may be present
- Nystagmus may be present.
- Extra-ocular movements may be abnormal
- Pupils may not react to light
- Ophthalmoscopic exam may be abnormal with findings of ___
Ears
- Hearing acuity may be reduced
- Weber test may be positive
- Rinne test may be positive
- There may be exudate from the ear canal
- There may be tenderness on movement of the pinnae
Nose
- Nares may be inflamed
- There may be epistaxis
- There may be purulent exudate from the nares
- There may be tenderness to percussion of the sinuses
- The nares may be congested
Throat
- The throat may be erythematous
- There may be exudate in the throat
- There may be petechiae seen in the throat
- There may be tonsillar inflammation
Neck
- Jugular venous pressure may be elevated
- Carotid bruits may be present
- Lymph nodes may be present
- Thyromegaly may be present
- Hepatojugular reflux may be present
Lungs
- Pulmonary edema and rales may be present
- Wheezing may be present
- Consolidation may be present with reduced breath sounds auscultated
- Rales may be present
- Egophony may be present
- Chest movement may be assymetric
Heart
- A heave may be present
- A thrill may be present
- A friction rub may be pressent
Auscultation
- S1
- S2
- S3
- S4
- Gallops
- A systolic murmur best heard at the base may be present
- A systolic murmur best heard at the apex may be present
- A diastolic murmur may be present
Abdomen
- Abdominal distention may be present
- Abdominal tenderness may be present
- Rebound tenderness may be present
- An acute abdomen may be present
- An abdominal mass may be present
- Guarding may be present
- Hepatomegaly may be present
- Splenomegaly may be present
- Genitourinary exam if relevant
Extremities
Neurologic
- Mental status may be altered
- Glasgow coma scale is ___
- Clonus may be present
- Hyperactive reflexes may be present
- There are deficits in cranial nerves ___
This is a chart that describes a patient with a a generalized vesicular or pustular rash. It is also based upon the risk of smallpox to the patient.
Presentation
The first general symptom of smallpox will be small red spots on places such as the face, mouth, etc. These spots will eventually turn into vesicles and then pustules. A rash will then begin forming on the skin around the face which will eventually move down the body to the feet. After having the rash for approximately 3 days, raised pustules will begin to form. These pustules will be filled with an opaque fluid with a depression in the middle. This is one of the signature characteristics of smallpox.
For diagnosing smallpox, there are some major and minor criteria needed during the physical examination.
Major
- On any singular part of the body, there needs to be lesions in the same stage of development
- Characteristic pustules:
- Well circumscribed and round
- Confluent or they will have a depression in the middle
- Fever occurring approximately 1-4 days before rash begins.
- The fever is usually > than 102 degrees Fahrenheit.
- With fever, have at least one of the following symptoms.
Minor
- Patient appears toxic or near death
- Initial lesions will be on the face, forearms, and oral palate
- There will be lesions on the palms and soles
- Most of the lesions will be on the distal extremities and face (greatest concentration)
- Evolution of rash from macules to papules to pustules to scabs is a slow process
Images
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Man with smallpox -
Smallpox lesions on skin of trunk. Picture taken in Bangladesh, 1973. -
These smallpox pustules are round, smooth, deep, and all at the same stage. -
Smallpox eruptions on arm and palm. -
This photograph depicted a male smallpox patient whose skin displayed the characteristics of late-stage maculopapular scarring on his face, arms and chest.
