Polymyositis and dermatomyositis physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for [[muscle weakness]], [[hyporeflexia]], [[skin]] lesions, [[Respiratory system|respiratory]] symptoms. The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis. [[Muscle atrophy]] in severe, long standing disease might occur. | |||
==Physical Examination== | ==Physical Examination== | ||
*Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for | *Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for [[muscle weakness]], [[hyporeflexia]], [[skin]] lesions, [[Respiratory system|respiratory]] symptoms.<ref name="KhanChristopher-Stine2011">{{cite journal|last1=Khan|first1=Sabiha|last2=Christopher-Stine|first2=Lisa|title=Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features|journal=Rheumatic Disease Clinics of North America|volume=37|issue=2|year=2011|pages=143–158|issn=0889857X|doi=10.1016/j.rdc.2011.01.001}}</ref><ref name="DoblougGaren2015">{{cite journal|last1=Dobloug|first1=Cecilie|last2=Garen|first2=Torhild|last3=Bitter|first3=Helle|last4=Stjärne|first4=Johan|last5=Stenseth|first5=Guri|last6=Grøvle|first6=Lars|last7=Sem|first7=Marthe|last8=Gran|first8=Jan Tore|last9=Molberg|first9=Øyvind|title=Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort|journal=Annals of the Rheumatic Diseases|volume=74|issue=8|year=2015|pages=1551–1556|issn=0003-4967|doi=10.1136/annrheumdis-2013-205127}}</ref><ref name="ChinoyFertig2007">{{cite journal|last1=Chinoy|first1=H.|last2=Fertig|first2=N.|last3=Oddis|first3=C. V|last4=Ollier|first4=W. E R|last5=Cooper|first5=R. G|title=The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis|journal=Annals of the Rheumatic Diseases|volume=66|issue=10|year=2007|pages=1345–1349|issn=0003-4967|doi=10.1136/ard.2006.068502}}</ref><ref name="DalakasHohlfeld2003">{{cite journal|last1=Dalakas|first1=Marinos C|last2=Hohlfeld|first2=Reinhard|title=Polymyositis and dermatomyositis|journal=The Lancet|volume=362|issue=9388|year=2003|pages=971–982|issn=01406736|doi=10.1016/S0140-6736(03)14368-1}}</ref><ref name="DouglasTazelaar2001">{{cite journal|last1=Douglas|first1=William W.|last2=Tazelaar|first2=Henry D.|last3=Hartman|first3=Thomas E.|last4=Hartman|first4=Robert P.|last5=Decker|first5=Paul A.|last6=Schroeder|first6=Darrell R.|last7=Ryu|first7=Jay H.|title=Polymyositis–Dermatomyositis-associated Interstitial Lung Disease|journal=American Journal of Respiratory and Critical Care Medicine|volume=164|issue=7|year=2001|pages=1182–1185|issn=1073-449X|doi=10.1164/ajrccm.164.7.2103110}}</ref> | ||
*The presence of | *The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis. | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
| Line 15: | Line 16: | ||
===Vital Signs=== | ===Vital Signs=== | ||
*Low-grade fever | *Low-grade [[fever]] | ||
===Skin=== | ===Skin=== | ||
*Skin | *[[Skin]] manifestations of dermatomyositis are as follow:<ref name="KhanChristopher-Stine2011">{{cite journal|last1=Khan|first1=Sabiha|last2=Christopher-Stine|first2=Lisa|title=Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features|journal=Rheumatic Disease Clinics of North America|volume=37|issue=2|year=2011|pages=143–158|issn=0889857X|doi=10.1016/j.rdc.2011.01.001}}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
!Lesion | !Lesion | ||
!Location | !Location | ||
!Percentage | !Percentage | ||
!Pathognomonic | !Pathognomonic | ||
|- | |- | ||
!Gottron papules | |||
|Dorsal aspect of interphalangeal or metacarpophalangeal | |Dorsal aspect of [[interphalangeal]] or [[Metacarpophalangeal joint|metacarpophalangeal joints]] | ||
|80% | |80% | ||
|Pathognomonic | |Pathognomonic | ||
|- | |- | ||
!Heliotrope rash | |||
|Eyelids and periorbital tissue | |[[Eyelid|Eyelids]] and periorbital tissue | ||
| | | | ||
|Pathognomonic | |||
|- | |- | ||
!Gottron sign | |||
| | |Dorsal aspect of the [[interphalangeal]] or [[Metacarpophalangeal joint|metacarpophalangeal]] joints, [[Olecranon|olecranon process]], [[patella]], and medial malleoli | ||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
|Macular violaceous | ![[Macule|Macular]] violaceous [[erythema]] | ||
|Symmetric distribution in classic areas | |Symmetric distribution in classic areas | ||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
!Shawl sign | |||
|Nape of the neck, shoulders, and upper | |Nape of the [[neck]], [[Shoulder|shoulders]], and upper [[Human back|back]] | ||
| | |||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
!“V sign” | |||
|V-shaped region of the neck and upper | |V-shaped region of the [[neck]] and upper [[chest]] | ||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
!Linear extensor [[erythema]] | |||
|Extensor aspects of the legs, thighs, arms, fingers, hands, and feet | |Extensor aspects of the [[Leg|legs]], [[Thigh|thighs]], [[Arm|arms]], [[Finger|fingers]], [[Hand|hands]], and [[Foot (length)|feet]] | ||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
!Mechanic’s hands | |||
|Palms and | |[[Hand|Palms]] and [[Finger|fingers]] | ||
| | |||
| | | | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
|Nail abnormalities | ![[Nail (anatomy)|Nail]] abnormalities such as | ||
| | * Nailfold [[Telangiectasia|telangiectasias]] | ||
* Cuticular overgrowth | |||
* Prominent periungual [[erythema]] | |||
|[[Nail (anatomy)|Nail]] of [[Hand|hands]] and [[Foot (length)|feet]] | |||
|30-60% | |30-60% | ||
|Characteristic | |Characteristic | ||
|- | |- | ||
![[Calcinosis cutis|Cutaneous calcinosis]] | |||
|Sites of compression, such as [[Elbow|elbows]] and [[buttocks]] | |||
|30-70% in [[Juvenile dermatomyositis|JDM]] | |||
|Cutaneous | |||
|Sites of compression, such as elbows and buttocks | |||
|30-70% in JDM | |||
10% in DM | 10% in DM | ||
| | | | ||
|- | |- | ||
| | !Flagellate [[erythema]] | ||
|[[Trunk]], [[Human back|back]], and proximal [[Limb (anatomy)|extremities]] | |||
| | |||
| | | | ||
|Rare | |Rare | ||
|- | |- | ||
| | ![[Poikiloderma of civatte|Poikiloderma]] | ||
|Sun exposed areas | |||
| | |||
| | | | ||
|Rare | |||
|- | |- | ||
![[Pityriasis rubra pilaris]]–like lesions | |||
| | |dorsal aspect of the [[Hand|hands]] and [[Foot (length)|feet]], frequently over the bony prominences | ||
| | |||
| | |||
| | | | ||
|Rare | |||
|- | |- | ||
!Nonscarring [[alopecia]] | |||
| | |[[Head]] | ||
| | | | ||
|Rare | |Rare | ||
|- | |- | ||
![[Erythroderma]] | |||
| | | | ||
| | | | ||
|Rare | |||
|- | |||
!Vesiculobullous lesions | |||
| | | | ||
| | | | ||
| | |Rare | ||
|- | |- | ||
!Cutaneous [[vasculitis]] such as | |||
* Palpable [[purpura]] | |||
* [[Urticaria]]-like lesions | |||
* [[Livedoid vasculitis|Livedo reticularis]] | |||
* Digital [[Ulcer|ulcerations]] | |||
| | | | ||
| | | | ||
| | |Rare | ||
|- | |- | ||
![[Hypersensitivity vasculitis|Leukocytoclastic vasculitis]] | |||
|Underlying [[Cancer|malignancy]] | |||
| | | | ||
| | |Rare | ||
|- | |- | ||
![[Raynaud's phenomenon|Raynaud phenomenon]] | |||
| | | | ||
| | |25% | ||
| | | | ||
|} | |} | ||
===HEENT=== | ===HEENT=== | ||
* Periorbital | * [[Periorbital edema]] | ||
===Neck=== | ===Neck=== | ||
* Neck examination of patients with polymyositis and dermatomyositis is usually normal. | * Neck examination of patients with polymyositis and dermatomyositis is usually normal. | ||
===Lungs=== | ===Lungs=== | ||
* Asymmetric chest expansion | * Asymmetric [[Respiratory examination|chest expansion]] | ||
*Lungs are | *Lungs are hyporesonant | ||
*Fine [[crackles]] upon auscultation of the lung bilaterally | *Fine [[crackles]] upon auscultation of the lung bilaterally | ||
*[[Wheezing]] may be present | *[[Wheezing]] may be present | ||
| Line 179: | Line 152: | ||
* Genitourinary examination of patients with polymyositis and dermatomyositis is usually normal. | * Genitourinary examination of patients with polymyositis and dermatomyositis is usually normal. | ||
===Neuromuscular=== | ===Neuromuscular=== | ||
*Patient is usually oriented to persons, place, and time | *Patient is usually oriented to persons, place, and time. | ||
* Symmetric proximal [[muscle weakness]] mostly in: | * Symmetric proximal [[muscle weakness]] mostly in: | ||
**Deltoids | **[[Deltoid|Deltoids]] | ||
**Hips | **[[Hip (anatomy)|Hips]] | ||
**Neck flexors | **[[Neck]] flexors | ||
* Mild distal muscle weakness | * Mild distal [[muscle weakness]] | ||
* Hyporeflexia / areflexia | * [[Hyporeflexia]] / [[Hyporeflexia|areflexia]] | ||
* Muscle rigidity | * [[Hypertonia|Muscle rigidity]] | ||
===Extremities=== | ===Extremities=== | ||
*Muscle atrophy in severe, long standing disease | *[[Muscle atrophy]] in severe, long standing disease | ||
*Fasciculations in the upper/lower extremity | *[[Fasciculation|Fasciculations]] in the upper/lower extremity | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Latest revision as of 13:20, 4 June 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for muscle weakness, hyporeflexia, skin lesions, respiratory symptoms. The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis. Muscle atrophy in severe, long standing disease might occur.
Physical Examination
- Physical examination of patients with polymyositis and dermatomyositis is usually remarkable for muscle weakness, hyporeflexia, skin lesions, respiratory symptoms.[1][2][3][4][5]
- The presence of Gottron's papules and the heliotrope eruption on physical examination is pathognomonic of dermatomyositis.
Appearance of the Patient
- Patients with polymyositis and dermatomyositis usually appear normal. They might be weak in severe cases.
Vital Signs
- Low-grade fever
Skin
| Lesion | Location | Percentage | Pathognomonic |
|---|---|---|---|
| Gottron papules | Dorsal aspect of interphalangeal or metacarpophalangeal joints | 80% | Pathognomonic |
| Heliotrope rash | Eyelids and periorbital tissue | Pathognomonic | |
| Gottron sign | Dorsal aspect of the interphalangeal or metacarpophalangeal joints, olecranon process, patella, and medial malleoli | Characteristic | |
| Macular violaceous erythema | Symmetric distribution in classic areas | Characteristic | |
| Shawl sign | Nape of the neck, shoulders, and upper back | Characteristic | |
| “V sign” | V-shaped region of the neck and upper chest | Characteristic | |
| Linear extensor erythema | Extensor aspects of the legs, thighs, arms, fingers, hands, and feet | Characteristic | |
| Mechanic’s hands | Palms and fingers | Characteristic | |
Nail abnormalities such as
|
Nail of hands and feet | 30-60% | Characteristic |
| Cutaneous calcinosis | Sites of compression, such as elbows and buttocks | 30-70% in JDM
10% in DM |
|
| Flagellate erythema | Trunk, back, and proximal extremities | Rare | |
| Poikiloderma | Sun exposed areas | Rare | |
| Pityriasis rubra pilaris–like lesions | dorsal aspect of the hands and feet, frequently over the bony prominences | Rare | |
| Nonscarring alopecia | Head | Rare | |
| Erythroderma | Rare | ||
| Vesiculobullous lesions | Rare | ||
Cutaneous vasculitis such as
|
Rare | ||
| Leukocytoclastic vasculitis | Underlying malignancy | Rare | |
| Raynaud phenomenon | 25% |
HEENT
Neck
- Neck examination of patients with polymyositis and dermatomyositis is usually normal.
Lungs
- Asymmetric chest expansion
- Lungs are hyporesonant
- Fine crackles upon auscultation of the lung bilaterally
- Wheezing may be present
Heart
- Cardiovascular examination of patients with polymyositis and dermatomyositis is usually normal.
Abdomen
- Abdominal examination of patients with polymyositis and dermatomyositis is usually normal.
Back
- Back examination of patients with polymyositis and dermatomyositis is usually normal.
Genitourinary
- Genitourinary examination of patients with polymyositis and dermatomyositis is usually normal.
Neuromuscular
- Patient is usually oriented to persons, place, and time.
- Symmetric proximal muscle weakness mostly in:
- Mild distal muscle weakness
Extremities
- Muscle atrophy in severe, long standing disease
- Fasciculations in the upper/lower extremity
References
- ↑ 1.0 1.1 Khan, Sabiha; Christopher-Stine, Lisa (2011). "Polymyositis, Dermatomyositis, and Autoimmune Necrotizing Myopathy: Clinical Features". Rheumatic Disease Clinics of North America. 37 (2): 143–158. doi:10.1016/j.rdc.2011.01.001. ISSN 0889-857X.
- ↑ Dobloug, Cecilie; Garen, Torhild; Bitter, Helle; Stjärne, Johan; Stenseth, Guri; Grøvle, Lars; Sem, Marthe; Gran, Jan Tore; Molberg, Øyvind (2015). "Prevalence and clinical characteristics of adult polymyositis and dermatomyositis; data from a large and unselected Norwegian cohort". Annals of the Rheumatic Diseases. 74 (8): 1551–1556. doi:10.1136/annrheumdis-2013-205127. ISSN 0003-4967.
- ↑ Chinoy, H.; Fertig, N.; Oddis, C. V; Ollier, W. E R; Cooper, R. G (2007). "The diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis". Annals of the Rheumatic Diseases. 66 (10): 1345–1349. doi:10.1136/ard.2006.068502. ISSN 0003-4967.
- ↑ Dalakas, Marinos C; Hohlfeld, Reinhard (2003). "Polymyositis and dermatomyositis". The Lancet. 362 (9388): 971–982. doi:10.1016/S0140-6736(03)14368-1. ISSN 0140-6736.
- ↑ Douglas, William W.; Tazelaar, Henry D.; Hartman, Thomas E.; Hartman, Robert P.; Decker, Paul A.; Schroeder, Darrell R.; Ryu, Jay H. (2001). "Polymyositis–Dermatomyositis-associated Interstitial Lung Disease". American Journal of Respiratory and Critical Care Medicine. 164 (7): 1182–1185. doi:10.1164/ajrccm.164.7.2103110. ISSN 1073-449X.