Scleroderma: Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

  • General physical examination – including blood pressure, pulse, body weight, height [determination of BMI]; further:
    • Inspection (viewing).
      • Skin
        • Skin foci with “lilac-ring” (bluish-red border)?
        • Vascular regions (Raynaud’s syndrome, especially on the hands), telangiectasias (vascular veins)?
      • Mucous membranes [whitish horny foci of oral mucosa (infestation of the genital mucosa is also possible)?]
      • Sclerae (white part of the eye)
      • Face, general [mask face (rigid facial expression)?, microstomia (the mouth can no longer be opened wide)?, problems with eyelid closure (due to reduction of the palpebral fissures)?, tight facial skin?, “tobacco pouch mouth” (folds arranged in a radial pattern around the mouth)?]
      • Hands [“Madonna fingers” (the fingers are severely narrowed)?, edematous (storage of fluid in the tissues) finger swelling?, “rat bite necrosis” (acral (belonging to the extremities ends) ulcerations (ulcers))?, deformations of the hands: so-called “claw hand” (fixation of the fingers in a flexed position)?, shortening and tapering of the finger end links?]
      • Nails [dermatomyositis (muscle inflammation with skin involvement)?, nail plate deformities?, growth disorders?]
  • Auscultation (listening) of the heart (due topossible involvement).
  • Examination of the lungs (due topossible involvement):
    • Auscultation (listening) of the lungs.
    • Bronchophony (checking the transmission of high-frequency sounds; the patient is asked to pronounce the word “66” several times in a pointed voice while the physician listens to the lungs)[increased sound conduction due to pulmonary infiltration/compaction of the lung tissue (e.g. e.g. in pneumonia) the consequence is, the number “66” is better understood on the diseased side than on the healthy side; in case of decreased sound conduction (attenuated or absent: e.g. in pleural effusion, pneumothorax, emphysema). The result is, the number “66” is barely audible to absent over the diseased part of the lung, because the high-frequency sounds are strongly attenuated]
    • Percussion (knocking sound) of the lungs [e.g., in emphysema; box tone in pneumothorax]
    • Vocal fremitus (checking the transmission of low frequencies; the patient is asked to pronounce the word “99” several times in a low voice while the physician places his hands on the patient’s chest or back)[increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e. e.g. in pneumonia) the consequence is, the number “99” is better understood on the diseased side than on the healthy side; in case of reduced sound conduction (attenuated: e.g. atelectasis, pleural rind; strongly attenuated or absent: in case of pleural effusion, pneumothorax, pulmonary emphysema). The result is, the number “99” is barely audible to absent over the diseased part of the lung, because the low-frequency sounds are strongly attenuated]
  • Palpation (palpation) of the abdomen (pressure pain?, knocking pain?, coughing pain?, defensive tension?, hernial gates?, kidney bearing knocking pain?) [ [due topossible involvement of the gastrointestinal tract (gastrointestinal tract)]
  • Health check

Square brackets [ ] indicate possible pathological (pathological) physical findings.

Scleroderma and malnutrition

Approximately 30% of scleroderma patients are at increased risk for malnutrition. Malnutrition per se is associated with increased morbidity (incidence of disease) and ultimately mortality (morbidity) and consequently worsens survival. Therefore, screening for malnutrition should be routinely performed in every scleroderma patient. In the studies, only the MUST questionnaire (Malnutrition Universal Screening Tool) has been used in patients with systemic scleroderma so far. This test applies the following parameters to assess malnutrition:

  • BMI
  • Unintentional weight loss
  • Acute disease
Parameter 0 points 1 point 2 points
BMI (kg/m²) ≥ 20,0 20,0-18,5 ≤ 18,5
Weight loss (%) ≤ 5 5-10 ≥ 10
Acute illness None Food abstinence expected to last more than five days

Evaluation

Total Risk Measure Implementation
0 points Low Repeat test
  • Clinic: weekly
  • Home: monthly
  • Outpatient: annually
1 point Medium Observe
  • Clinic: nutritional protocol over three days
  • Home: nutrition protocol over three days
  • Outpatient: Repeat test in a few months; if necessary SGA* , dietary counseling.
2 points High Treat Clinic/home/outpatient: SGA, begin nutrition therapy

Furthermore, there are several schemes that define malnutrition differently:

BMI (kg/m²) Triceps skin fold (mm) man/woman Mid-arm muscle circumference(cm) man/woman Classification of malnutrition
19-25 12,5/ 16,5 29,3/ 28,5 Normal weight
< 18,5 10,0/ 13,2 23,4/ 22,8 Grade 1 of malnutrition
< 17,0 7,5/ 9,9 20,5/ 19,9 Grade 2 of malnutrition
< 16,0 5,0/ 6,6 17,6/ 17,1 Grade 3 of malnutrition

Subjective Global Assessment of Nutritional Status (SGA)

The following parameters are considered in this test to assess malnutrition:

  • Weight loss in the last six months
  • Food intake
  • Gastrointestinal symptoms such as diarrhea (diarrhea) or nausea/vomiting.
  • General physical status
  • Stress
  • Clinical signs such as loss of subcutaneous fat (subcutaneous adipose tissue) or appearance of edema (water retention)

As a result, there is a subjective assessment of nutritional status:

  • A= well nourished
  • B= moderately malnourished or suspected malnutrition.
  • C= severely malnourished

Nutritional Risk Index

This index refers to malnutrition when:

  • BMI < 20.5 kg/m²
  • Weight loss > 5% in three months
  • Current decreased food intake
  • Severity of the disease

This test is mainly used in hospitals. * SGA (= Subjective Global Assessment of Nutritional Status).