Rheumatic fever physical examination


 * Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.

Overview

 * Fever
 * Cardiac murmurs may be noted on cardiac auscultation if heart valves are involved. Regurgitant murmurs are common.
 * Sydenham's chorea
 * Migratory polyarthritis may be noted in 70-75% of patients. Often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) are involved progressing below-upwards.
 * Subcutaneous nodules over extensor surface of limbs, bony prominences such as elbows, knees, ankles and knuckles
 * Erythema marginatum, also known as erythema annulare are pink-red rash frequently located on trunk, limbs and seldom on face.

General appearance
High index of suspicion is required in diagnosing rheumatic fever. Patients presents frequently with joint involvement and fatigue.

Vital signs

 * Fever
 * Normotension or Hypotension (if heart or pericardium is involved)
 * Tachycardia
 * Tachypnea (if heart valves, pericardium or myocardium are involved leading to cardiac dysfunction)

Cardiac examination
Cardiac involvement is the second most common complication of rheumatic fever.


 * Tachycardia
 * Jugular venous distension, S3 or occasionally a summation gallop may be noted if the patient has congestive heart failure secondary to valvular or myocardial involvement.
 * Precordial heave may be noted in chronic rheumatic disease with mitral valve involvement.
 * Cardiac murmurs may be noted if heart valves are involved. Regurgitant murmurs are common in acute rheumatic fever, while chronic rheumatic fever is associated with murmurs of valve stenosis.
 * Mitral insufficiency (holosystolic murmur) is the most common valvular abnormality reported in rheumatic fever and may be accompanied by aortic insufficiency (early diastolic murmur).
 * Aortic stenosis (systolic ejection murmur) or mitral stenosis (mid diastolic murmur) may be noted in chronic rheumatic fever secondary to scarring and calcification of damaged valves.
 * Pericardial friction rub and low intensity heart sounds may be evident if pericardium is involved causing pericarditis and effusion respectively.

Respiratory examination

 * Epistaxis may be present in rheumatic fever if associated with severe carditis.
 * The lung fields may be dull on percussion in presence of infection or pleural effusion
 * Basilar crackles may be heard on auscultation, which may be suggestive of pulmonary edema
 * Decreased breath sounds may be noted in presence of an accompanying pleural effusion

Neurological examination

 * Sydenham's chorea also known as St. Vitus' dance is a characteristic series of rapid movements of the face and arms without purpose and emotional disturbances . This can occur very late in the disease for at least three months from onset of infection. Usually only one side of the body is involved and ceases during sleep.


 * Hand writing samples may be used in assessing the progress or resolution of the condition.
 * Spooning sign which is the ﬂexion of the wrists and extension of the ﬁngers when the hands are extended
 * Pronator sign which is turning outwards of the arms and palms when held above the head
 * Inability to maintain protrusion of the tongue.
 * Milk maids' sign may be noted, which is an intermittent increase and decrease of hand grip pressure as demonstrated in the video below.



Abdominal examination
Ascites may be observed if heart failure and fluid overload is present.

Extremities

 * Arthritis may be noted in 70-75% of patients. Often large joints of lower limbs (knee and ankle joints) and upper limbs (elbow and wrist joints) are involved progressing below-upwards. However, other small joints can also be affected . Arthritis in rheumatic fever is know to be migratory in nature and affecting multiple joints, persisting at each site for approximately one week.
 * Affected joints may be swollen, erythematous, warm and tender, limiting the normal range of movement.
 * Subcutaneous nodules may be noted in approximately 10% of rheumatic fever patients. They are usually symmetric and appear on extensor surface of limbs, over bony prominences such as elbows, knees, ankles and knuckles . These nodules are firm and non-tender without involvement of the overlying skin. These nodules are usually associated with severe carditis.
 * Pedal edema may be observed if congestive heart failure and fluid overload are present.

Skin
Erythema marginatum, also known as erythema annulare are pink-red rash frequently located on trunk, limbs and seldom on face. They appear as non-pruretic macules or papules extending centrifugally outwards with central clearing and raised outer margins. The rash may resolve and reappear within few hours and can be accentuated by heat in the form of hot shower.