The Physical Examination

Proven Lupus Treatment By Dr Gary Levin

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Scalene Lymph Node
Fig. 4.3 Palpation of the right scalene lymph node. The patient should tilt the head forwards and to the right to relax the sternomastoid during the examination.

Abnormal findings. The speed with which a paiieni can dress or undress is often a useful index of respiratory disability. Evidence of recent w:eight loss may suggest malignancy or a chronic infective condition such as tuberculosis. Abnormality of the voice will occur in patients with a laryngeal nerve palsy (p. 211) and where there is chronic lung sepsis, e.g. bronchiectasis, there may be fetor of the breath.

Cyanosis. Central cyanosis of respiratory origin is most frequently seen in chronic obstructive pulmonary disease. In such cases peripheral vasodilatation due to carbon dioxide retention (type II respiratory failure) leads to warm blue hands, but the colour of the tongue is a more reliable indicator of central cyanosis. Central cyanosis may occur in many other diseases, including pneumonia, bronchial asthma, pulmonary infarction, allergic alveolitis and any disease causing pulmonary fibrosis but only when these conditions are severe or extensive. Peripheral cyanosis affecting the face and neck, and sometimes the upper limbs, is one of the features of superior venal caval obstruction (see below). Severe chronic hypoxia of either pulmonary or cardiac origin is often associated with polycythaemia and extreme degrees of cyanosis, partly central and partly peripheral. The cardiac causes of cyanosis are described on page 81.

Oedema, The presence of peripheral oedema in patients with chronic obstructive airways disease suggests right ventricular failure as a consequence of pulmonary hypertension. Oedema of a different distribution is seen in superior vena caval obstruction. This is most commonly a complication of bronchial carcinoma. When the superior vena cava is obstructed, the jugular veins become grossly distended but no venous pulsation is visible in the neck. After a few days, dilated superficial veins and venules appear on the anterior and lateral aspects of the chest wall from the clavicles to below the costal margins (Fig. 4.4). These veins convey blood from the territories of the subclavian and axillary veins to the drainage area of the inferior vena cava, The face and neck become swollen and puffy - although the tissues seldom pit on pressure - and conjunctival oedema (chcmosis) is often present. There may be pitting oedema of the hands and forearms. The dilated veins on the dorsum of the hand remain full when lifted well above the level of the suprasternal notch.

The hands. Clubbing of the fingers occurs in a variety of respiratory, cardiovascular and alimentary diseases (see Disorders hex, p. 127). The swelling of the terminal phalanges in clubbing, which usually, but less obviously, affects the toes also, is due to interstitial oedema and dilatation of the arterioles and capillaries. The early features of clubbing comprise loss of the normal angle between the nail and nail bed and fluctuation of the nail bed.

The test is positive when the sensation of movement of the nail is greater than the very slight degree of fluctuation which can be dctceted in normal lingers. When fluctuation is marked, palpation of the nail itself may give the impression that it is floating free on its bed.

With more advanced degrees of clubbing, various visible changes develop progressively (Fig. 2.27A):

1. Swelling of the subcutaneous tissues over the base of the nail causes the overlying skin to become tense, shiny and red, with obliteration of the skin creases.

DISORDERS - Some causes of finger clubbing

Respiratory

• Bronchial carcinoma

• Intrathoracic suppuration

- Bronchiectasis

- Empyema

- Lung abscess

• Fibrosing alveolitis

Cardiovascular

• Cyanotic congenital heart disease

• Bacterial endocarditis

Alimentary

• Hepatic cirrhosis

• Ulcerative colitis

Coeliac disease

Congenital m Familial clubbing

Bronchiectasis And Lung Abscess
Fig. 4.5 Inspecting the nail bed angle. Note the difference between [a] normal and ib clubbing, with loss of nail bed angle and Increased curvature of the nail.

2. Later, as the swelling involves the nail bed. the curvature of the nail, especially in its long axis, increases (Fig. 4.5).

3. Finally, swelling of the pulp of the finger in all its dimensions occurs in fully developed clubbing. In a few cases there may also be hypertrophic pulmonary osteoarthropathy causing pain and swelling of the hands, wrists, knees, feet and ankles, with radiographic evidence of subperiosteal new bone formation.

Increased curvature of the fingernails mav occur in normal subjects and, as an isolated phenomenon without other evidence of clubbing, is of no significance.

The neck. When a node is found it should be assessed as indicated on page 58. Nodes which are > 0.5 cm in diameter.

Lymphoma Neck

Fig. 4,6 Metastatic nodes of bronchial carcinoma over the left chest.

(The red linear marks have been applied as radiotherapy markers.)

Fig. 4,6 Metastatic nodes of bronchial carcinoma over the left chest.

(The red linear marks have been applied as radiotherapy markers.)

lirm in consistency and round in shape are usually pathological, a common cause being metastases from a bronchial carcinoma. Large, fixed masses are present in some cases. Hard, craggy nodes may, however, be caused by healed and calcified tuberculosis; sn such cases calcification is visible on radiographic examination. Other pathological processes include lymphoma or sarcoidosis.

Other features. Some of the cutaneous and subcutaneous lesions associated with respiratory disease are listed in Table 4.14. Metastatic subcutaneous tumour nodules from bronchial carcinoma are shown in Figure 4.6. Examination of the eyes may reveal conditions implicating respiratory disease (see Table 4.15) such as Horner's syndrome (Fig. 6.9, p. 198). Where there is CO, retention, ophthalmoscopy may show either venous dilatation or, in extreme cases, papilledema (see p. 255), In patients with severe type II respiratory failure, a flapping tremor of the hand is often present. When the arm is held outstretched with the wrists cocked upwards, a downward intermittent flap of the hands is noted.

TABLE 4.14 Skin lesions which may yield information of diagnostic

importance

Erythema nodosum

May be the initial clinical manifestation of

(Flg. 2.17A)

tuberculosis and sarcoidosis

Metastatic tumour nodules

May be derived from a primary bronchial

(Fig. 4.6)

carcinoma

Cutaneous sarcoids and

May occur in association with intrathoracic

lupus pernio (Fig. 4.7)

sarcoidosis

Lupus erythematosus

May be associated with pulmonary or pleural

(Fig 4.8)

manifestations

Herpetic vesicles

May identify the cause of unilateral chest pain

(Fig. 2.19A)

TABLE 4.15 Examples of eye conditions in respiratory disorders

Condition Disease

Carcinoma of the bronchus

Primary tuberculosis

Tuberculosis Sarcoidosis

Miliary tuberculosis

Hypercapnia

Superior vena caval obstruction

Miliary Tuberculosis Skin

Fig. 4.8 The characteristic rash of systemic lupus erythematosus,

TABLE 4.15 Examples of eye conditions in respiratory disorders

Condition Disease

Homer's syndrome Phlyctenular keratoconjunctivitis Iridocyclitis

Choroidal tubercles

Chemosis, conjunctival and relinal vein dilatation (may develop papilledema)

Carcinoma of the bronchus

Primary tuberculosis

Tuberculosis Sarcoidosis

Miliary tuberculosis

Hypercapnia

Superior vena caval obstruction

Fig. 4.7 Sarcoidosis associated with bilateral parotid swelling. The skin of the nose and right cheek is also involved ('lupus pernio')

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