Monkeypox physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Bassel Almarie, M.D.
Overview
Physical Examination
Vital Signs
- Low-grade fever (temperature, 100.8°F, 38.2°C)[1]
- Fever before rash is a key characteristics to identifying monkeypox[2]
Skin
Skin lesions develop after the prodrome (early set of symptoms). The United States Centers for Disease Control and Prevention described with following characteristics of lesions to identify monkeypox[2]:
- Relatively the same size and same stage of development on a single site of the body
- Well-circumscribed, deep seated, and often develop umbilication (resembles a dot on the top of the lesion)
- Disseminated rash is centrifugal (more lesions on extremities, face)
- Includes palms and soles
- often painful until the healing phase when they become itchy (crusts)
The skin lesions start off as macular (1-2 days), then evolve to papular (1-2 days), vesicular (1-2 days), pustular (5-7 days), and finally scabs (7-14 days).
Note: To describe a rash, always report additional details that include the color (e.g. erythematous), shape (e.g. flat / bullous), dermarcation (e.g. well-circumscribed / diffuse), location (e.g. truncal / on the face / on the extremities), enclosing fluid (e.g. vesicular / filled with pus, clear), and if possible smell (e.g. foul-smelling / odorless)
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Description (Adapted from Dermatology Atlas)
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Description (Adapted from Dermatology Atlas)
HEENT
- Abnormalities of the head/hair may include ___
- Evidence of trauma
- Icteric sclera
- Nystagmus
- Extra-ocular movements may be abnormal
- Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
- Ophthalmoscopic exam may be abnormal with findings of ___
- Hearing acuity may be reduced
- Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
- Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
- Exudate from the ear canal
- Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
- Inflamed nares / congested nares
- Purulent exudate from the nares
- Facial tenderness
- Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
Neck
- Jugular venous distension
- Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
- Lymphadenopathy (describe location, size, tenderness, mobility, and symmetry)
- Thyromegaly / thyroid nodules
- Hepatojugular reflux
Lungs
- Asymmetric chest expansion / Decreased chest expansion
- Lungs are hypo/hyperresonant
- Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
- Rhonchi
- Vesicular breath sounds / Distant breath sounds
- Expiratory/inspiratory wheezing with normal / delayed expiratory phase
- Wheezing may be present
- Egophony present/absent
- Bronchophony present/absent
- Normal/reduced tactile fremitus
Heart
- Chest tenderness upon palpation
- PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
- Heave / thrill
- Friction rub
- S1
- S2
- S3
- S4
- Gallops
- A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
Abdomen
- Abdominal distention
- Abdominal tenderness in the right/left upper/lower abdominal quadrant
- Rebound tenderness (positive Blumberg sign)
- A palpable abdominal mass in the right/left upper/lower abdominal quadrant
- Guarding may be present
- Hepatomegaly / splenomegaly / hepatosplenomegaly
- Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
Back
- Point tenderness over __ vertebrae (e.g. L3-L4)
- Sacral edema
- Costovertebral angle tenderness bilaterally/unilaterally (may also be referred to as Murphy's punch sign, which is different from Murphy's sign that suggests cholecystitis. To avoid confusion, write "costovertebral angle tenderness")
- Buffalo hump
Genitourinary
- A pelvic/adnexal mass may be palpated
- Inflamed mucosa
- Clear/(color), foul-smelling/odorless penile/vaginal discharge
Write additional pathognomonic findings, such as discharge that resembles cottage cheese for C. albicans vulvovaginitis / fish-odor for T. vaginalis ifnection
Extremities
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
Neuromuscular
- Patient is usually oriented to persons, place, and time
- Altered mental status
- Glasgow coma scale is ___ / 15
- Clonus may be present
- Hyperreflexia / hyporeflexia / areflexia
- Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
- Muscle rigidity
- Proximal/distal muscle weakness unilaterally/bilaterally
- ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Positive straight leg raise test
- Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
- Positive/negative Trendelenburg sign
- Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
- Normal finger-to-nose test / Dysmetria
- Absent/present dysdiadochokinesia (palm tapping test)
References
- ↑ Fleischauer AT, Kile JC, Davidson M, Fischer M, Karem KL, Teclaw R; et al. (2005). "Evaluation of human-to-human transmission of monkeypox from infected patients to health care workers". Clin Infect Dis. 40 (5): 689–94. doi:10.1086/427805. PMID 15714414.
- ↑ 2.0 2.1 "Clinical Recognition | Monkeypox | Poxvirus | CDC". Retrieved 2022-06-15.