Medical Semiology Lectures PDF 2022/23

Melanie Kolassovits Medical Semiology 2022/23 Medical Semiology lectures – Semester 5 Contents Medical Semiology lectures – Semester 5................................................................................. 1 General info.............................................................................................................................. 11 1. Definitions............................................................................................................................ 12 2. History taking....................................................................................................................... 13 2.1. Pain................................................................................................................................ 14 3. Physical examination............................................................................................................ 16 3.1. mental state.................................................................................................................. 17 3.1.1. perception + sensory disorders.............................................................................. 17 3.1.1.1. positive sensory symptoms............................................................................. 18 3.1.1.2. negative sensory symptoms............................................................................ 18 3.1.1.3. illusions............................................................................................................ 19 3.1.1.4. hallucinations.................................................................................................. 19 3.1.2. psychosis................................................................................................................ 19 3.1.3. memory disorders.................................................................................................. 22 3.1.3.1. amnesia........................................................................................................... 22 3.1.4. thought disorders................................................................................................... 22 3.1.4.1. Formal though disorders................................................................................. 22 3.1.4.2. content though disorders................................................................................ 23 3.1.4.3. delirium........................................................................................................... 24 3.1.5. emotional disorders............................................................................................... 24 3.1.6. activity/motor disorders........................................................................................ 25 3.1.7. consciousness disorders......................................................................................... 25 3.1.7.1. syncope........................................................................................................... 26 3.1.7.1.1. vascular syncope...................................................................................... 26 3.1.7.1.2. cardiac syncope........................................................................................ 27 3.1.7.1.3. neurological syncope............................................................................... 27 3.1.7.1.4. metabolic syncope................................................................................... 27 3.1.7.2. coma................................................................................................................ 28 3.1.7.2.1. etiology..................................................................................................... 28 3.1.7.2.2. Glasgow coma scale................................................................................. 28 3.1.8. anxiety.................................................................................................................... 29 1 Melanie Kolassovits Medical Semiology 2022/23 3.1.9. depression + suicide............................................................................................... 29 3.2. Constitutional type (somatic development) + stature development........................... 31 3.2.1. somatic development............................................................................................. 31 3.2.2. causes of short stature (dwarfism)........................................................................ 32 3.2.2.1. nanism “dwarfism”.......................................................................................... 32 3.2.2.2. achondroplasia................................................................................................ 33 3.2.2.3. short stature in endocrine disorders............................................................... 33 3.2.2.4. rickets.............................................................................................................. 34 3.2.3. excessive growth – gigantism................................................................................. 34 3.3. static + dynamic changes............................................................................................... 35 3.3.1. muscle volume....................................................................................................... 36 3.3.1.1. atrophy............................................................................................................ 36 3.3.2. abnormal postures due to neurologic pathology.................................................. 37 3.3.2.1. Signs of meningeal irritation........................................................................... 37 3.3.2.1.1. Nuchal rigidity.......................................................................................... 37 3.3.2.1.2. opisthotonos............................................................................................ 37 3.3.2.1.3. Kernig’s Test............................................................................................. 37 3.3.2.1.4. Brudzinski’s Test....................................................................................... 37 3.3.2.2. other abnormal postures................................................................................ 37 3.3.2.2.1. pyramidal posture (Wernicke Mann posture)......................................... 38 3.3.2.2.2. wrist drop, foot drop................................................................................ 38 3.3.2.2.3. claw hand................................................................................................. 38 3.3.2.2.4. pes cavus.................................................................................................. 38 3.3.3. involuntary movements......................................................................................... 38 3.3.3.1. tremor............................................................................................................. 39 3.3.3.1.1. flapping tremor (asterixis)........................................................................ 40 3.3.3.2. chorea.............................................................................................................. 41 3.3.3.3. athetosis.......................................................................................................... 41 3.3.3.4. fasciculations................................................................................................... 41 3.3.3.5. myoclonic jerks................................................................................................ 41 3.3.3.6. seizure............................................................................................................. 41 3.3.3.7. tics................................................................................................................... 42 3.3.4. muscle tone............................................................................................................ 42 3.3.4.1. progressive muscular atrophy......................................................................... 44 2 Melanie Kolassovits Medical Semiology 2022/23 3.3.5. reflexes................................................................................................................... 44 3.3.5.1. Spinal reflexes: muscle stretch response........................................................ 45 3.3.5.2. cutaneous + mucosea reflexes........................................................................ 46 3.3.6. muscle power......................................................................................................... 47 3.3.7. paresis tests............................................................................................................ 48 3.3.8. coordination........................................................................................................... 48 3.3.9. stance + balance..................................................................................................... 49 3.4. Facies............................................................................................................................. 51 3.4.1. Alterations of the facial skeleton........................................................................... 51 3.4.1.1. Acromegaly...................................................................................................... 51 3.4.1.2. Adenoid face = “long face syndrome”............................................................ 52 3.4.1.3. Congenital syphilis........................................................................................... 52 3.4.1.4. Mongoloid facies “chipmunk facies”............................................................... 52 3.4.1.5. Down syndrome.............................................................................................. 52 3.4.2. Changes in the soft parts of the face..................................................................... 53 3.4.2.1. Myxedema....................................................................................................... 53 3.4.2.2. Cushing syndrome / cushing disease.............................................................. 53 3.4.2.3. Scleroderma.................................................................................................... 54 3.4.2.4. Hippocratic / cachetic facies........................................................................... 54 3.4.2.5. Sjögren syndrome........................................................................................... 54 3.4.2.6. Mikulicz syndrome.......................................................................................... 54 3.4.2.7. Leonine facies – lepromatous leprosy............................................................ 55 3.4.2.8. Relapsing polychondritis................................................................................. 55 3.4.3. Colour changes....................................................................................................... 55 3.4.3.1. Mitral stenosis facies....................................................................................... 55 3.4.3.2. Rubeosis diabetica........................................................................................... 55 3.4.3.3. Rosacea............................................................................................................ 55 3.4.3.4. Lupus erythematosus...................................................................................... 56 3.4.3.5. Dermatomyositis............................................................................................. 56 3.4.4. Eye changes............................................................................................................ 56 3.4.4.1. Hyperthyroidism.............................................................................................. 56 3.4.4.2. Xanthelasma/xanthoma.................................................................................. 56 3.4.4.3. Marfan syndrome............................................................................................ 56 3.4.4.4. Eyeballs............................................................................................................ 57 3 Melanie Kolassovits Medical Semiology 2022/23 3.4.5. Changes in facial expressions................................................................................. 57 3.4.5.1. Trismus............................................................................................................ 57 3.4.5.2. Depression....................................................................................................... 57 3.4.5.3. Myasthenia gravis........................................................................................... 57 3.4.5.4. Parkinson’s disease......................................................................................... 57 3.4.6. Ear changes............................................................................................................ 57 3.5. skin (structural)............................................................................................................. 58 3.5.1. primary skin lesions................................................................................................ 58 3.5.1.1. macule............................................................................................................. 58 3.5.1.1.1. measles..................................................................................................... 59 3.5.1.1.2. Rubella...................................................................................................... 60 3.5.1.1.3. typhoid fever............................................................................................ 60 3.5.1.2. papule.............................................................................................................. 60 3.5.1.2.1. scarlet fever.............................................................................................. 60 3.5.1.3. plaque.............................................................................................................. 61 3.5.1.3.1. wheal = hive = urticaria............................................................................ 61 3.5.1.3.2. erysipelas.................................................................................................. 61 3.5.1.3.3. dermatomyositis...................................................................................... 61 3.5.1.4. nodule.............................................................................................................. 62 3.5.1.4.1. erythema nodosum.................................................................................. 62 3.5.1.4.2. tophi......................................................................................................... 62 3.5.1.4.3. xanthoma + xanthelasma......................................................................... 62 3.5.1.4.4. acne.......................................................................................................... 62 3.5.1.5. vesicle.............................................................................................................. 62 3.5.1.5.1. chickenpox................................................................................................ 63 3.5.1.5.2. smallpox................................................................................................... 63 3.5.1.5.3. herpes....................................................................................................... 63 3.5.1.5.4. shingles..................................................................................................... 63 3.5.2. secondary skin lesions............................................................................................ 64 3.5.2.1. scales + flakes.................................................................................................. 64 3.5.2.2. crust................................................................................................................. 64 3.5.2.3. lichenification.................................................................................................. 64 3.5.2.4. scar.................................................................................................................. 65 3.5.2.5. fissure.............................................................................................................. 65 4 Melanie Kolassovits Medical Semiology 2022/23 3.5.2.6. erosion............................................................................................................. 65 3.5.2.7. ulcer................................................................................................................. 65 3.5.2.7.1. bedsores = decubitus ulcer...................................................................... 65 3.5.2.8. gangrene.......................................................................................................... 65 3.5.2.9. atrophy................................................................................................................ 66 3.5.2.9.1. stretchmarks............................................................................................. 66 3.5.3. vascular skin lesions............................................................................................... 66 3.5.3.1. haemorrhagic lesions...................................................................................... 66 3.5.3.1.1. Henoch schonlein purpura....................................................................... 66 3.5.3.1.2. petechiae.................................................................................................. 66 3.5.3.1.3. ecchymoses.............................................................................................. 66 3.5.3.2. dilatations of small blood vessels (teleangectasies)....................................... 67 3.5.3.2.1. arachnoid telangiectasia (spider angioma).................................................. 67 3.5. Skin + mucosa changes – physical examination............................................................ 68 3.5.1. Skin colour.............................................................................................................. 68 3.5.1.1. Pallor................................................................................................................ 68 3.5.1.1.1. generalized pallor – anemia..................................................................... 69 3.5.1.1.2. localized pallor......................................................................................... 69 3.5.1.2. redness............................................................................................................ 70 3.5.1.2.1. dermatographia / skin writing / stress hives........................................... 71 3.5.1.2.2. carcinoid syndrome.................................................................................. 71 3.5.1.2.3. persistent redness.................................................................................... 71 3.5.1.3. cyanosis........................................................................................................... 71 3.5.1.3.1. Central cyanosis....................................................................................... 72 3.5.1.3.2. peripheral cyanosis.................................................................................. 72 3.5.1.3.3. pseudocyanosis........................................................................................ 73 3.5.1.4. pigmentation disorders................................................................................... 73 3.5.1.4.1. hypopigmentation.................................................................................... 73 3.5.1.4.2. hyperpigmentation disorders.................................................................. 74 3.5.1.5. jaundice........................................................................................................... 74 3.5.2. moisture................................................................................................................. 76 3.5.3. elasticity + mobility................................................................................................ 76 3.6. Integumentary system – hair + nails............................................................................. 77 3.6.1. hair.......................................................................................................................... 77 5 Melanie Kolassovits Medical Semiology 2022/23 3.6.1.1. conditions associated with abnormal hair quantity / distribution................. 77 3.6.1.1.1. hypotrichosis............................................................................................ 77 3.6.1.1.2. alopecia.................................................................................................... 77 3.6.1.1.3. hypertrichosis + hirsutism........................................................................ 78 3.6.1.2. conditions associated with abnormalities in hair texture / colour................. 78 3.6.2. nails........................................................................................................................ 79 3.6.2.1. nail clubbing (Hippocratic fingers).................................................................. 79 3.6.2.2. Terry’s nails..................................................................................................... 80 3.6.2.3. Koilonychia (spoon nails)................................................................................. 80 3.6.2.4. Beau’s lines...................................................................................................... 80 3.6.2.5. Melanoma (longitudinal melanotic bands)..................................................... 80 3.6.2.6. onycholysis...................................................................................................... 80 3.6.2.7. yellow nails...................................................................................................... 80 3.6.2.8. Hypertrophic osteoarthropathy (Marie-Bamberger disease)......................... 81 3.7. subcutaneous cellular tissue – nutrition status – subcutaneous edema – collateral circulation – lymph nodes.................................................................................................... 81 3.7.1. Oedema.................................................................................................................. 81 3.7.1.1. cardiac edema................................................................................................. 82 3.7.1.2. renal edema.................................................................................................... 82 3.7.1.3. lymphedema / lymphatic edema.................................................................... 83 3.7.1.3.1. elephantiasis / lymphatic filariasis........................................................... 83 3.7.1.4. localized edema............................................................................................... 84 3.7.2. collateral circulation............................................................................................... 85 3.7.2.1. arterial collateral circulation........................................................................... 85 3.7.2.2. venous collateral circulation........................................................................... 85 3.7.2.2.1. collateral pathways in portal hypertension............................................. 85 3.7.3. nutrition status....................................................................................................... 86 3.7.3.1. somatotypes.................................................................................................... 86 3.7.3.1.1. ectomorphic body type............................................................................ 86 3.7.3.1.2. mesomorphic body type.......................................................................... 86 3.7.3.1.3. endomorphic body type........................................................................... 87 3.7.3.2. measurements of nutrition status.................................................................. 87 3.7.3.2.1. body mass index....................................................................................... 87 3.7.3.2.2. waist circumference................................................................................. 87 6 Melanie Kolassovits Medical Semiology 2022/23 3.7.3.2.3. sagittal abdominal diameter.................................................................... 88 3.7.3.3. measuring body fatness.................................................................................. 88 3.7.3.4. Variations of weight........................................................................................ 88 3.7.3.4.1. obesity...................................................................................................... 89 3.7.3.4.2. metabolic syndrome................................................................................ 90 3.7.3.4.3. cushing’s disease...................................................................................... 91 3.7.3.4.4. anorexia.................................................................................................... 91 3.7.3.4.5. bulimia...................................................................................................... 91 3.7.3.4.6. emaciation................................................................................................ 92 3.7.3.4.7. cachexia.................................................................................................... 93 3.7.3.4.8. marasmus................................................................................................. 93 3.7.3.4.9. kwashiorkor (edematous malnutrition)................................................... 93 3.7.4. lymphatic system.................................................................................................... 94 3.7.4.1. lymph nodes.................................................................................................... 94 3.8. muscular (musculoskeletal) system.............................................................................. 98 3.8.1. bone pathology...................................................................................................... 98 3.8.1.1. bone deformities............................................................................................. 98 3.8.1.2. endocrine disorders (acromegaly).................................................................. 98 3.8.1.3. metabolic disorders......................................................................................... 98 3.8.1.4. osteoporosis.................................................................................................... 99 3.8.2. joint pathology....................................................................................................... 99 3.8.2.1. skin changes.................................................................................................. 100 3.8.2.1.1. colour modifications.............................................................................. 100 3.8.2.1.2. other skin changes................................................................................. 100 3.8.2.2. nail changes................................................................................................... 101 3.8.2.3. mucous membrane lesions........................................................................... 101 3.8.2.4. subcutaneous changes.................................................................................. 101 3.8.2.5. swelling.......................................................................................................... 102 3.8.2.6. pain................................................................................................................ 102 3.8.2.6. Muscular changes.......................................................................................... 105 3.8.2.7. deformity....................................................................................................... 105 3.8.2.8. mobility.......................................................................................................... 106 3.8.3. eye changes.......................................................................................................... 108 3.8.4. pain provocation tests.......................................................................................... 108 7 Melanie Kolassovits Medical Semiology 2022/23 3.8.4.1. lasegue test................................................................................................... 108 3.8.4.2. Gaenslen’s test.............................................................................................. 108 3.8.4.3. Patrick’s test.................................................................................................. 109 3.8.4.4. Tinel sign........................................................................................................ 109 3.8.5. diseases................................................................................................................ 109 3.8.5.1. Carpal tunnel syndrome................................................................................ 109 3.8.5.2. Osteoarthritis................................................................................................ 110 3.8.5.3. Ankylosing spondylitis................................................................................... 110 3.8.5.4. rheumatoid Arthritis...................................................................................... 111 3.8.5.5. Sjogren’s syndrome....................................................................................... 111 3.8.6. posture + gait....................................................................................................... 112 3.8.6.1. physical examination..................................................................................... 112 3.8.6.1.1. inspection............................................................................................... 112 3.8.6.1.2. palpation................................................................................................ 112 3.8.6.1.3. percussion.............................................................................................. 113 3.8.6.1.4. auscultation............................................................................................ 115 3.8.6.2. material......................................................................................................... 115 3.8.6.2.1. stethoscope............................................................................................ 115 3.8.6.2.2. sphygmomanometer.............................................................................. 116 3.8.6.2.3. reflex hammer........................................................................................ 116 3.8.6.2.4. other instruments.................................................................................. 116 3.8.6.3. posture.......................................................................................................... 117 3.8.6.3.1. forced antalgic positions........................................................................ 117 3.8.6.3.2. forced antidyspneic postures................................................................. 117 3.8.6.3.3. abnormal postures due to osteomuscular changes............................... 117 3.8.6.4. gait................................................................................................................. 119 3.8.6.4.1. hemiparetic (spastic) gait....................................................................... 121 3.8.6.4.2. scissors gait............................................................................................ 121 3.8.6.4.3. parkinsonian gait.................................................................................... 121 3.8.6.4.4. cerebellar ataxic gait.............................................................................. 121 3.8.6.4.5. steppage gait.......................................................................................... 122 3.8.6.4.6. myopathic gait (Trendelenburg)............................................................ 122 3.10. body temperature..................................................................................................... 123 3.10.1. fever................................................................................................................... 123 8 Melanie Kolassovits Medical Semiology 2022/23 3.10.2. hyperthermia...................................................................................................... 125 3.10.3. hypothermia....................................................................................................... 126 4. Respiratory system............................................................................................................. 127 4.1. history taking............................................................................................................... 127 4.2. main respiratory symptoms........................................................................................ 129 4.2.1. dyspnea................................................................................................................ 129 4.2.1.1. Pickwick syndrome........................................................................................ 132 4.2.1.2. central sleep apnea syndrome...................................................................... 133 4.2.2. thoracic pain......................................................................................................... 133 4.2.2.1. retrosternal pain........................................................................................... 133 4.2.2.2. parietal thoracic pain.................................................................................... 134 4.2.2.3. pleuro-pulmonary chest pain........................................................................ 134 4.2.3. cough.................................................................................................................... 134 4.2.4. expectoration....................................................................................................... 135 4.2.5. hemoptysis........................................................................................................... 137 4.3. physical examination................................................................................................... 137 4.3.1. vocal/pectoral fremitus........................................................................................ 138 4.3.2. percussion............................................................................................................ 138 4.3.3. auscultation.......................................................................................................... 138 4.3.3.1. normal respiratory sounds:........................................................................... 138 4.3.3.2. abnormal respiratory sounds:....................................................................... 138 4.3.3.2.1. pathological bronchial breathing........................................................... 139 4.4. investigations.............................................................................................................. 139 4.4.1. thoracentesis........................................................................................................ 139 4.4.2. spirometry............................................................................................................ 143 4.4.3. pulse oximetry...................................................................................................... 145 4.4.4. sputum examination............................................................................................ 146 4.4.5. radiological exams................................................................................................ 148 4.4.5.1. X-ray.............................................................................................................. 148 4.4.5.1.1. consolidation syndromes....................................................................... 150 4.4.5.1.2. interstitial syndromes............................................................................ 151 4.4.5.1.3. cavitary syndrome.................................................................................. 152 4.4.5.1.4. pleural syndromes.................................................................................. 153 4.4.5.2. computerised tomography (CT) scan............................................................ 154 9 Melanie Kolassovits Medical Semiology 2022/23 4.4.5.3. Angio-CT........................................................................................................ 155 4.4.5.4. Scintigraphy................................................................................................... 155 4.5. tracheal syndrome...................................................................................................... 156 4.5.1 croup...................................................................................................................... 158 4.6. bronchitis syndrome.................................................................................................... 159 4.6.1. acute bronchitis.................................................................................................... 159 4.6.2. chronic bronchitis................................................................................................. 160 4.6.3. chronic obstructive pulmonary disease (COPD).................................................. 161 4.6.4. asthma.................................................................................................................. 163 4.6.4.1. status asthmaticus........................................................................................ 165 4.6.5. bronchiectasis...................................................................................................... 165 4.7. consolidation syndrome.............................................................................................. 167 4.7.1. pneumonia........................................................................................................... 167 4.7.1.1. typical community-acquired pneumonia...................................................... 168 4.7.1.2. bronchopneumonia....................................................................................... 169 4.7.1.3. atypical pneumonia....................................................................................... 170 4.7.2. lung abscess.......................................................................................................... 172 4.7.3. pulmonary infarction (PI)..................................................................................... 174 4.7.4. lung tumors.......................................................................................................... 175 4.8. pulmonary hyperinflation syndrome.......................................................................... 178 4.8.1. pulmonary emphysema....................................................................................... 178 4.9. obstructive lung disease.............................................................................................. 183 4.9.1. chronic obstructive pulmonary disease (COPD).................................................. 183 4.9.1.1. cor pulmonale............................................................................................... 187 4.10. cavitary syndrome..................................................................................................... 187 10 Melanie Kolassovits Medical Semiology 2022/23 General info paypal.me/melaniekolassovits 11 Melanie Kolassovits Medical Semiology 2022/23 1. Definitions * paraclinical explorations: e.g. blood tests, ECG, X ray, ultrasound, MRI, CT, endoscopy Final diagnosis = positive Diagnosis Syndrome: - A group of symptoms + signs which consistently occur together, synthesizing the features of several diseases, without identifiable cause Disease: - Medical condition that is associated with specific signs + symptoms - Health condition that has a clearly defined reason behind it - Particular abnormal medical condition that negatively affects the structure / function of all/part of an organism - It is not immediately due to any external injury - = established condition that has clearly defined reason behind it, distinct + measurable Disorder: - indicates that a specific disease is possible, but there is not enough clinical evidence for a diagnosis Syndrome ≠ disease ≠ disorder ≠ condition Exeptions: syndrome = disease when a proper name is used (e.g. Down syndrome, Turner syndrome, …) 12 Melanie Kolassovits Medical Semiology 2022/23 Syndrome examples: - Pulmonary consolidation syndrome o Pneumonia o Pulmonary infarction o Lung cancer - Acute renal failure o Acute tubular necrosis o Severe burns o Cocaine intoxication o Severe dehydration - Acute respiratory failure o Pneumonia o Opioid overdose o Stroke o Lung injury o Spinal cord injury 2. History taking - Identifying data o Name, age, gender, place of birth, marital status, occupation o Source of history: patient, family member, friend, officer, medical record o Date + time are always important - Source of reliability of history o Reliability of information my be questioned in elderly patients with cognitive impairment - Chief complaint o Main cause for which the patient comes seeking for healthcare o Concise + clear enumeration of symptoms + classification of them (digestive, cardiovascular, respiratory, …) o Accusations are ranked in order of gravity + relevance) - History of present illness o Time + kind of onset (sudden, progressive) o Potential causes o Periodic, acute, progressive symptom progression? o Previous treatment o Info about primary functions – appetite, changes in urination + urinary volume, progression of weight curve, digestive transit, sleep disturbances - Medications, allergies, tobacco, alcohol, drugs o Medication: name, dose, route, frequency of use, non-prescription drugs, home remedies, … o Allergies: to medication, food, dust …, first diagnosis of allergy, triggers, symptoms o Alcohol: type, quantity, abuse 13 Melanie Kolassovits Medical Semiology 2022/23 - Past history o Childhood illness ▪ Typical infectious diseases (rubella, mumps, measles, …) ▪ Chronic childhood illnesses (e.g. asthma, diabetes, …) o Adult illness ▪ Medical ▪ Surgical ▪ Obstetric/gynaecologic ▪ Psychiatric ▪ Health maintenance (immunizations, screenings, tests) - Family history o Data about immediate relatives - Personal + social history o Personality, interests, support, coping mechanisms, strengths o Employment, education, living arrangements, long-term stressors, religion, financial situation o Diet, exercise - Review of system 2.1. Pain Semiological description: - Location - Radiation - Character (pressure, knife, torsion) - Severity - Duration - Special times of occurrence - Aggravating factors - Relieving factors - Associated manifestations SOCRATES (Site, Onset, Character, Radiation, Associated manif., Timing, Exacerb./reliev factors, Severity) Onset Palliation/provocation Quality Region/Radiation Symptoms associated Severity Timing 14 Melanie Kolassovits Medical Semiology 2022/23 Obstetric/gynaecologic history: - Menarche - Duration + sequence of menstrual cycles - Characteristics of menstrual flow - Premenstrual syndrome - Pregnancy + childbirth - Menopause 15 Melanie Kolassovits Medical Semiology 2022/23 3. Physical examination 1. Mental state 2. Constitutional type + stature development 3. Static + dynamic changes (attitude, dynamic disorders, reflexes, involuntary movements, balance, walking disorders) 4. Face + cephalic extremity (facies, segmental changes of cephalic extremity) 5. Skin + mucous membranes 6. Integumentary system – hair + nails 7. Subcutaneous cellular tissue – nutrition status, subcutaneous oedema, collateral circulation, lymph nodes 8. Muscular system 9. Osteoarticular system 10. Body temperature 16 Melanie Kolassovits Medical Semiology 2022/23 3.1. mental state Manifestations related to mental condition assessed during anamnesis + objective clinical examination: - Aspect + behaviour o General aspect (personal hygiene, clothing) o Emotional status (worried, indifferent, docile, irritated) o Body language (posture, visual contact, facial expression) - Cognitive abilities o State of consciousness (oriented in time and space) o Memory (short and long term) o Attention (spontaneous and deliberate) o Imagination o Thinking (ability for analysis, synthesis, comparison) - Emotional balance o Behavior and emotions (signs of depression or anxiety) o Sensitivity and perception (illusions, hallucinations) - Speech + language o Voice features (dysphonia, intensity) o Articulation of words (pronunciation, fluency, rhythm, ease of speech) o Comprehension (understanding content) o Coherence o Aphasia General info: - Clothes may provide important information regarding the mental health status o Untidiness in states of confusion related to dementia, schizophrenia or oligophrenia o Dirty clothes – mud, blood, traces of feces or urine – reveal a post-convulsion state – epilepsy or alcohol intoxication o flashing colour clothes, rich ornaments suggest manic episodes o dull clothes and colours indicate a depressive disorder - Swiftly moving eyes, fixation glances are specific of manic states - Faded, still and absent gaze is encountered in depression - confused patient will have a perplexed look - fixed gaze, full of hate and rage is frequent in personality disturbances 3.1.1. perception + sensory disorders - sensations = mental processes that reflect features of surrounding objects + phenomena, inner bodily states triggered by stimuli on sensory organs - perception = sum of sensations received through analyser organs 17 Melanie Kolassovits Medical Semiology 2022/23 3.1.1.1. positive sensory symptoms Hyperesthesia: - increased sensitivity to a stimulus - troublesome intensified perception o at level of a sensory organ (photophobia) o at a general level (cutaneous) - in cases of fatigues, stress, neurasthenia, fever, meningitis, intoxication with psychoactive substances, hyperthyroidism, or at the onset of psychosis paresthesia: - spontaneous abnormal sensations which are not unduly painful dysesthesia - painful paresthesia allodynia - painful sensation resulting from nonpainful stimulus (e.g. stroking, high sounds) hyperalgesia - increased sensitivity to a painful stimulus 3.1.1.2. negative sensory symptoms hypoesthesia - reduced sensitivity to any stimulus - patient perceives environment with difficulty + unclear - in cases of stress, depression, oligophrenia, dementia, catatonic schizophrenia, severe toxic infections hypoalgesia - reduced sensitivity to painful stimulus analgesia - absent sensitivity to painful stimulus anaesthesia - absent sensitivity to any stimulus - abolishment of sensory acuity - in certain neurological conditions involving injuries of afferent pathways, areas of cortical projection, hysteria, oligophrenia, dementia, psychopathies 18 Melanie Kolassovits Medical Semiology 2022/23 agnosia - inability to acknowledge + identify an object according to its features - of an object: paragnosia - colours: colour agnosia - words: alexia - numbers - graphical symbols - calculus: acalculia 3.1.1.3. illusions - erroneous perceptions of existing objects - may occur in o particular environmental circumstances (darkness, fog, twilight) o physiological conditions (fatigue, fear) - in certain pathological conditions the patient does not acknowledge the error of perception and takes it for reality (psychoses, alcohol, cocaine, LSD, TLC poisoning, fever, infectious confusions) 3.1.1.4. hallucinations - false, imaginary perceptions, in the absence of an object as stimulus - hallucinatory perception is real and truthful for the patient (auditive, visual, tactile, olfactive, kinesthesic hallucinations) - in severe toxic and infectious states, schizophrenia, acute psychotic disorders, weaning with delirium etc 3.1.2. psychosis - critical mental illness - occurs due to loss of contact with reality + deep disturbance of relationships with other people, causing social unacceptance - types of psychotic disorders: schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, brief psychotic disorder, substance induced psychotic disorder, bipolar disorder, postpartum psychosis, severe depression, psychosis suicide genetic + environmental vulnerability factors that can add up to psychosis: 19 Melanie Kolassovits Medical Semiology 2022/23 Other questions: - Is psychosis a symptom, sign or syndrome? - Is psychosis synonym with schizophrenia? - Is psychosis different from schizophrenia ? - Psychosis is present in schizophrenia ? - What is the difference between a positive and a negative symptom? What symptoms define a psychotic episode? 3 main symptoms: - Hallucinations - Delusions - Confused + disturbed thoughts Definition of psychosis: - An episode when a patient lose contact with reality - might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions) - Psychosis is characterized as disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what isn’t. Psychosis vs. schizophrenia: - Psychosis o Episode where one is detached from reality o A symptom of sleep deprivation, substance use, mental illness o Signs: ▪ Hallucinations ▪ Delusions ▪ Agitation ▪ Disorganized thought + behaviour - Schizophrenia o Mental illness that impacts thought processes, emotions, behaviour o To be diagnosed, one must experience at least 2 of the following symptoms for 6 months, including one of the first 3 ▪ Delusions ▪ Hallucinations ▪ Disorganized speech ▪ Catatonic behaviour ▪ Negative symptoms (lessened emotional expression) 20 Melanie Kolassovits Medical Semiology 2022/23 Positive + negative symptoms of schizophrenia: Positive: - Presence of problematic behaviours - Hallucinations (esp. auditory) - Delusions (esp. persecutory) - Disorganized thought + nonsensical speech - Bizarre behaviours Negative: - Absence of healthy behaviours - Flat affect (no emotion showing in the face) - Reduced social interaction - Anhedonia (no feeling of enjoyment) - Avolition (less motivation, initiative, focus on tasks) - Alogia (speaking less) - Catatonia (moving less) 21 Melanie Kolassovits Medical Semiology 2022/23 3.1.3. memory disorders - causes: aging, brain injury, infections, trauma, mental disorders, medication, substance abuse, genetic disorders, memory disorders, poor nutrition - hypermnesia o recollections are quick, involuntary, rich, stormy o in case of fever, intox, PTSD, OCD, paranoia - hypomnesia o decrease in memory function o in overstress, convalescence, oligophrenia, dementia, depressive states 3.1.3.1. amnesia - definition: total loss of memory capacity - anterograde o impossibility to place new events o events prior to falling sick are remembered without difficulty o associated with: Korsakoff syndrome, after cranio-cerebral trauma, alcoholism, drug addiction, Alzheimer’s dementia - retrograde o progressive extension of the memory disturbance into the past o before the onset of the current disease and even back to childhood o occurs in cranio-cerebral trauma of alcoholic patients, at the onset and during dementia 3.1.4. thought disorders Classified as formal and content disorders 3.1.4.1. Formal though disorders - alterations of the thoughts speed, rhythm and fluency - tachypsychia o acceleration of thinking rhythm, namely a quick succession of ideas o may be found in a manic episode o Extreme tachypsychia is called flight of ideas ▪ characterized by an excessive inflow of ideas ▪ a shifting attention and logorrhea ▪ make it impossible to have a logical expression of facts or events ▪ in manic states, fever, caffeine or alcohol poisoning, fatigue, stress, psychodysleptics - bradypsychia or slow thought o decrease of thinking rhythm o may be associated with bradylalia o found in neurasthenia, depressive states, hypothyroidism, mental retardation, demented cognitive impairment, Parkinson’s disease - mental barrier o sudden arrest while delivering a speech 22 Melanie Kolassovits Medical Semiology 2022/23 o occurs in schizophrenia. 3.1.4.2. content though disorders - disturbances of the thought content - prevalent ideas o represent a set of ideas that organize the entire behaviour o patient does not acknowledge it as a disease, seeks arguments that support his ideas and is totally obstinate to other arguments o occurs in alcoholism, schizoid conditions, affective disorders, epilepsy - obsession o recurrent or persisting idea or image that takes over and compells the whole thinking, the patient making efforts to get rid of it. o may appear with fatigue, after psychological trauma, obsessive-compulsive disorders, depression, schizophrenia - phobia o obsessive fear of a certain situation which is not normally a source of anxiety o patient is aware of the irrational nature of his fear and acts to avoid the situation o most common phobias are claustrophobia (fear of enclosed spaces), agoraphobia (fear of open spaces), zoophobia (fear of animals), nosophobia (fear of disease), cancerophobia symptoms of OCD: - repeated thought about contamination + dirt - fear of losing control - fear of losing possessions or items - persistent worries about uncertainty - scary feelings about aggression, sexual activity, religious subjects - desperately avoiding trigger situations - persistent thoughts about hurting yourself or someone else - frightening images of yourself performing violent acts - repeatedly checking things like locking doors, turning of stove - arranging things in a specific way - excessive attention on superstitious thoughts or luck - repetitive + unpleasant sexual thoughts or images 23 Melanie Kolassovits Medical Semiology 2022/23 3.1.4.3. delirium - idea with a false content that entails the patient’s firm belief in its truth - patient cannot be convinced by logical arguments or proofs - predisposing causes: personality changes (schizoid, schizotypic, paranoid), delirious disorders, infectious diseases, brain tumors etc. - Classified as: o Systematic ▪ paranoid (based on the patient’s conviction regarding malevolent intentions, persecution, influence, chasing by the others) ▪ expansive (based on overrating one’s own abilities, such as grandomania, megalomania, filiation etc.) ▪ micromania (based on the underestimation of one’s own person and abilities, associated with ideas of humility, decay, self-guilt) o non-systematic ▪ manifests through chaotic, disheveled, and contradicting ideas. 3.1.5. emotional disorders - emotions represent personal subjective side of our mental state - hypothymia o represents the lessening of emotional response, of variable degrees o is found in severe mental retardation, dementia, confusional states, posttraumatic stress disorders, overstress, end-of-life state, convalescence - athymia or apathy o complete abolishment of emotions o occurs in depression, schizophrenia, mental confusion, mental retardation, dementia - hyperthymia o represents an exaggeration of emotions o Positive hyperthymia is represented by euphoria o Negative hyperthymia is a sad mood, manifested by fever, manic-depression psychosis, light inebriation - Anxiety o fear without reason, accompanied by uncertainity, unrealistic, tiring expectations and neurovegetative symptoms (tachycardia, dyspnea, sweating, xerostomia) o occurs in overstress, anxious neurosis, addictions o Anxiety associated with organic diseases is called angor, such as in angor pectoris, which may go as far as a feeling of imminent death 24 Melanie Kolassovits Medical Semiology 2022/23 3.1.6. activity/motor disorders - set of psychomotor feats known as actions, operations, and movements - hyperkinesia o excessive psychomotor activity beyond the normal range o Face becomes hypermobile and expressive, gestures are ample, continuous, and rapid o occurs in manic states - psychomotor unrest o extreme form of hyperkinesia o may occur in: ▪ manic episodes (patient’s acts and gestures are unrestrained, exaggerated) ▪ psychotic depression (associated with anxiety, laments, motor disarray, auto- or hetero-aggressive tendencies) ▪ schizophrenia (agitation is unpredictable, incomprehensible, patient utters inarticulate cries, laughs, followed by a state of immobility) ▪ dementia (at night) ▪ personality disorders ▪ hysteria ▪ mental development retardation or brain organic injuries (vascular, tumoral, traumatic) 3.1.7. consciousness disorders - state of consciousness is the extent of a person’s presence in his environment (integration in space and time) and the degree of response to various external stimuli - Disorders of consciousness are the following, in order of severity: sleepiness, obnubilation, stupor and loss of consciousness - sleepiness or torpor: o like the sleep induction phase, the patient is drowsy, speaks with a slur and even voice, answers poorly. It occurs in overstress, fever, depression - obnubilation: o bradypsychia, bradykinesia, effort for time-space orientation, answers are inadequate, movements are out of order o Found in states of fever, intoxication, infection, acute alcohol intoxication, carbon monoxide and drug poisoning, epilepsy, metabolic or hypertensive encephalopathies etc. - stupor: o severe state of consciousness alteration, characterized by time-space disorientation, fixed gaze and amnesia o Reflex activity is normal o occurs in neurosis, psychoses (schizophrenic, or epileptic confusion stupor), severe toxic states, brain tumours. 25 Melanie Kolassovits Medical Semiology 2022/23 total loss of consciousness: short = syncope, long term = coma - syncope o sudden, transient, short-term (3-5 minutes) loss of consciousness and muscle tone, with quick and complete recovery o cause is diffuse cerebral hypoxia triggered by the low blood flow to the central nervous system o During syncope, the patient collapses to the ground and presents retrograde amnesia o Sometimes a syncope is preceded by fainting (pre-syncope) - Lypothymia o mild, incomplete loss of consciousness lasting a few minutes and ending progressively o patient does not drop suddenly, is not injured, but presents extreme asthenia, visual disturbance, tinnitus, hearing loss, dizziness, pallor, sweating, nausea etc. 3.1.7.1. syncope - vascular - cardiac - neuropsychiatric - metabolic 3.1.7.1.1. vascular syncope - caused by vagal hyperactivity which leads to the decrease of heart rate (bradycardia) - According to the circumstances of onset they are classified into: - Essential vasovagal syncope o the most common o May be encountered in young people, who are emotionally and mentally unstable o triggered by pain, emotions, prolonged standing, high temperature, stuffy rooms etc. o After the syncope the patient may be tired for a time, present nausea, diarrhea etc. o sympathetic hypotonia takes place, parietal left ventricle pressure decreases, followed by a sudden reversal of adaptation reflex, with decrease of the sympathetic tonus and increase of the vagal one - vascular syncope o caused by vagal hyperactivity leads to the sudden drop of heart rate (bradycardia) and blood pressure - reflex visceral vagal syncope o triggered by certain conditions (cough, defecation, urination, colic etc.), invasive medical interventions (punctures, infiltrations, surgery, endoscopy etc.) o or manoeuvers that excite the vagal system (Valsalva, carotid sinus massage, pressure on eyeballs) 26 Melanie Kolassovits Medical Semiology 2022/23 - orthostatic syncope o occurs at the sudden upstanding from a reclining position o They are more frequent in elderly persons, in the morning or after meals o due to hypovolemia or the alteration of the barro-reflex arch at the sudden change of position. 3.1.7.1.2. cardiac syncope - triggered by the sudden drop of cardiac output, which leads to brain hypoxia anoxia - may be caused by obstruction (aortic stenosis, obstructive cardio-myopathy) - or rhythm disturbances (Adams-Stokes syncope at the onset of grade III atrioventricular block) 3.1.7.1.3. neurological syncope - includes the loss of consciousness in transient cerebral ischemia and vertebrobasilar insufficiency - differential diagnosis of syncope is with other medical conditions causing a temporary loss of consciousness, but which have a pathophysiological mechanism other than the decrease of blood flow to the brain - these are: o epilepsy ▪ occurs in the absence of precipitating causes, preceded by a short aura (sensory, mental or motor) ▪ evolves with tonic-clonal convulsions, tongue biting, loss of sphincter control ▪ Pulse and blood pressure are within normal ranges or with minor alterations ▪ Recovery is slow, followed by post-critical sleep, headaches or altered behavior ▪ Compared to the syncope, the electroencephalogram is abnormal o hysteria, or conversion disorder ▪ loss of consciousness that occurs in public, theatrically, preceded by crying and agitation ▪ fall is never traumatic, while patchy amnesia is relative 3.1.7.1.4. metabolic syncope - hypoglycemia - hypocapnia - carbon monoxide poisoning 27 Melanie Kolassovits Medical Semiology 2022/23 3.1.7.2. coma Coma vs. precoma: - coma o state of long-term loss of consciousness, from which the patient cannot be woken o patient in coma is motionless, unconscious, with relaxed muscles, unresponsive to verbal, tactile or pain stimuli, abolished reflexes (tendon, cornea, swallowing), with preserved vital functions (breathing, pulse), and generally normal metabolic functions - precoma o precedes coma o when the patient is still able to respond “primitively”, by moans and erratic movements, to powerful speech or pain o in vigil coma the reflex activity is preserved, the patient responds to strong painful stimuli by moans or defence reactions o In deep coma the reflex activity is abolished, the general state alters progressively, along with the vital functions o We speak of inanimate coma when the patient’s life is maintained only by assisted breathing and circulation. 3.1.7.2.1. etiology - Brain injuries (trauma, hemorrhage, ischemia, embolism, tumours) - Exogenous poisoning (drugs, alcohol) - Metabolic disturbances (uremia, hypercapnia, hypoglycemia, myxedema, hepatic encephalopathy) - Severe infections (sepsis, typhoid fever) Each type has specific diagnostic clinical signs 3.1.7.2.2. Glasgow coma scale - For assessing level of consciousness + comas - Based on verbal, motor, eye-opening responses to specific stimuli - Max: 15 points, min: 3 points, < 7 = severe prognosis - Patients with 3-8: in coma 28 Melanie Kolassovits Medical Semiology 2022/23 3.1.8. anxiety Symptom, syndrome or disorder? Types: - Generalized anxiety disorder o Excessive worry + tension without reason - Panic disorder o Sudden, intense fear bringing a panic attack - Specific phobia o Intense fear of a specific object/situation - Separation anxiety disorder o Occurs when a person you’re close to leaves your sight - Agoraphobia o Fear of being in place hard to escape - Social anxiety disorder o Overwhelming fear worry and self-consciousness 3.1.9. depression + suicide Are somatic symptoms present in major depressive disorder? - Patients with major depressive disorder present with a combination of psychological, psychiatric and somatic symptoms - In primary care, somatic symptoms often dominate the clinical picture. - Effects on body: o Insomnia o Headaches o Fatigue o Chronic pain o Diarrhea, constipation o Inflammation o Increased risk of heart disease o Weight loss or gain o nausea o Loss of libido o Dyspareunia Is there an association between major depressive disorder and suicide? - Although the majority of people who have depression do not die by suicide, having major depression does increase suicide risk compared to people without depression - The risk of death by suicide may, in part, be related to the severity of the depression. 29 Melanie Kolassovits Medical Semiology 2022/23 Major risk factors for suicide: - Prior suicide attempts - Misuse and abuse of alcohol or other drugs - Mental disorders, particularly depression and other mood disorders - Access to lethal means - Knowing someone who died by suicide, particularly a family member - Social isolation - Chronic disease and disability Mental health risk factors vs. protective factors 30 Melanie Kolassovits Medical Semiology 2022/23 3.2. Constitutional type (somatic development) + stature development - Constitution = psychosomatic + metabolic traits - Habitus = anthropometric traits - Hippocrate’s classification: 3.2.1. somatic development - Determined by numerous factors: hereditary, endocrine, emotional, environmental, geoclimatic conditions, diet and intercurrent diseases - evidence supports “pre-natal and post-natal growth can have a profound impact on adult phenotypes” - Many controversies? links between somatic growth, aging, and longevity - Measured with the altimeter or the centimetre in orthostatism - After birth, there are several stages of height and weight growth: o rapid growth phase from 0 to 4 years o period of slow and steady growth o puberty period with a height and weight growth peak at the end of puberty o welding of the diaphyses and epiphyses marks the end of statural development anamnesis: - Modalities of weight loss – gradual / rapid/ development - estimates food intake, lifestyle habits - Appetite - the presence of anorexia or inappetence may be responsible for weight loss, but appetite may be normal/increased: o hyperthyroidism o drugs: thyroid extracts, amphetamines o chronic diarrhea o insulin-dependent diabetes mellitus - height + weight growth is assessed on growth curves/charts - Tanner’s TH formula: o Target height = (mother’s height + father’s height)/2 +- 6,5 cm o Corrected target height = (father height + mother height +- 13cm)/2 ▪ + 13 for boys ▪ - 13 for girls 31 Melanie Kolassovits Medical Semiology 2022/23 Stature hypotrophy = dwarfism / short stature (< 1,5 m) Stature hypertrophy = excess growth / gigantism (> 2 m) 3.2.2. causes of short stature (dwarfism) - Short family height – antenatal growth retardation is most common (growth curves are regular, the delay is present at birth and remains stable later) - Chromosomal abnormalities and malformation syndromes - osteochondrodysplasias, Turner syndrome (45X), trisomy 21 - Nutritional and chronic diseases that cause nutritional deficiencies: intestinal malabsorption (celiac disease, cystic fibrosis of the pancreas), IRC - Chronic hypoxia: cyanotic heart disease, respiratory failure - Endocrine causes (STH deficiency, hypothyroidism) 3.2.2.1. nanism “dwarfism” - generally defined as an adult height of 4 feet 10 inches (147 centimeters) or less - proportionate short stature (PSS) – a general lack of growth in the body, arms and legs “Harmonic” - disproportionate short stature (DSS) – where the arms and legs are particularly short “Disharmonic” - defined as height-vertex below two standard deviations (-2SD) or in the third percentile for a given age and sex - aversion to the term dwarf and identify themselves as "Little people“ harmonic nanism “dwarfism”: - Causes: metabolic and hormonal disorders (Growth hormone deficiency) - subjects that do not exceed 120-150 cm - without sexualization at puberty - ~ 20% - AD monogenic disorder caused by a gain-of-function point mutation in the transmembrane region of FGFR3 (fibroblast growth factor receptor 3 gene) - ~ 80% spontaneous genetic mutation - signs: o Height below the third percentile on standard pediatric growth charts o Growth rate slower than expected for age o Delayed or no sexual development during the teen years 32 Melanie Kolassovits Medical Semiology 2022/23 Other causes for dwarfism: - undernutrition - juvenile idiopathic arthritis - inflammatory bowel disease (IBD) - celiac disease - chronic kidney disease (CKD) - pulmonary/cardiac/immunologic/me tabolic diseases - cancers - glucocorticoid therapy - Malnutrition → ↓growth velocity → short stature - gestational period → underweight or small for gestational age (SGA) childhood leading to stunted growth - chromosomal disorders: turner syndrome (45X) - acquired hypothyroidism 3.2.2.2. achondroplasia - accounting for ~ 70% of cases of D nanism - Characteristics: short stature caused by rhizomelic shortening of the limbs, macrocephaly – “Basset” - large head with a prominent forehead - flattened bridge of the nose - protruding jaw - crowded and misaligned teeth - forward curvature of the lower spine - bowed legs, flat, short, broad feet - Double-jointedness 3.2.2.3. short stature in endocrine disorders - Congenital hypothyroidism, congenital myxedema o disharmonious dwarfism o overweight o coarse features o hoarse voice o macroglossia o dry skin o severe intellectual retardation - Acquired hypothyroidism - a slowing of stature associated with weight gain 33 Melanie Kolassovits Medical Semiology 2022/23 3.2.2.4. rickets - stunted growth and short stature - Typically: o bowing of the legs by widening of wrist bones o by protuberant ends of ribs at the sternum (rachitic rosary) - Other skeletal deformities: o an oddly shaped skull o protruding breastbone o a curved spine o pelvic deformities - teeth deformities, such as: o delayed tooth formation o enamel defects o abscesses o defects in the tooth structure o an increased number of cavities 3.2.3. excessive growth – gigantism - A large size is rarer a reason for consultation - Reasons: o Family – harmonious development o Chromosomal abnormalities (Klinefelter syndrome, Marfan syndrome) o Endocrine causes (pituitary gigantism - hypersecretion of growth hormone before ossification of the growth cartilages) 34 Melanie Kolassovits Medical Semiology 2022/23 3.3. static + dynamic changes Contents of neurologic examination: - Muscle volume - Abnormal postures due to neurologic pathology - Involuntary movements - Muscle tones - Reflexes - Muscle power - Paresis tests - Coordination - Stance + balance * inspection * inspection + palpation + percussion Physical examination: - Inspection - Palpation - Percussion - Auscultation 35 Melanie Kolassovits Medical Semiology 2022/23 Neurological examination: - Evaluation of a persons nervous system - Can be done in healthcare providers office - Does not include imagistic methods or lab tests - Diagnosis instruments: o Neurologic hammer o Lantern o Spatula o Needle o Diapason o Chopsticks or cotton wool o Eye chart o Otoscope Purpose of neurological exam: - Formulating a clinical diagnosis = syndrome - Checking hypothesis formulated during anamnesis (finding clinical signs that confirm the symptoms) - Determining the central / peripheral location of the lesions (neuroanatomical diagnosis) 3.3.1. muscle volume - Muscle volume changes can be assessed mainly by static + dynamic inspection. To which is added palpation + measurement of limb circumference - We evaluate: size, shape, symmetry 3.3.1.1. atrophy - Muscle hypotrophy (muscular atrophy, amyotrophy) = a decrease in muscle volume - Generalized muscle hypotrophy occurs in patients immobilized for a long time in bed (stroke, advanced stages of dementia, Parkinson’s stage 4, H+Y) - Causes: o Lack of physical activity, aging o Alcohol-associated myopathy o Injuries (including burns, fractures) o Malnutrition o Spinal cord injuries o Stroke o Long-term corticosteroid therapy o Amyotrophic lateral sclerosis (ALS) o Dermatomyositis, polymyositis o Guillain-Barre syndrome, MS o Muscular dystrophy o Neuropathy (nerve damage) o Osteoarthritis o polio 36 Melanie Kolassovits Medical Semiology 2022/23 3.3.2. abnormal postures due to neurologic pathology 3.3.2.1. Signs of meningeal irritation 1 opisthotonos - nuchal rigidity (neck stiffness) - opisthotonos - photophobia - Kernig’s sign - Brudzinski’s sign Symptoms of meningitis: - Headache, altered mental state - Phonophobia - Photophobia - Neck stiffness - High fever - Petechiae (if meningococcal infections) 3.3.2.1.1. Nuchal rigidity - Patient being in supine position, with lower limbs in extension; flexion movements of head + chest will be made - When meningeal irritation is present: neck muscle resistance + pain 3.3.2.1.2. opisthotonos - Abnormal posture where back becomes extremely arched bc of muscle spasms - Usually a sign of serious brain conditions (e.g. meningitis, tetanus, Arnold-Chiari syndrome, severe brain trauma) 3.3.2.1.3. Kernig’s Test - Performed with patient supine or in a chair - Hip + knee are flexed to 90° + attempt is made to extend knee - = positive if manoeuvre causes pain in neck or back - Resistance to extension of the leg while hip is flexed 3.3.2.1.4. Brudzinski’s Test - Flexion of the neck causes flexion of the hips + knees 3.3.2.2. other abnormal postures 37 Melanie Kolassovits Medical Semiology 2022/23 3.3.2.2.1. pyramidal posture (Wernicke Mann posture) - Upper limb on affected side is flexed + adducted - Lower limb is usually extended + rotated internally - Feature of pyramidal weakness due to cortico-spinal lesion 3.3.2.2.2. wrist drop, foot drop Wrist drop: - When lifting the arm, the hand hangs flexed on forearm, fingers are semi-flexed - Due to radial nerve or C7 root lesion Foot drop: - Patient has limited dorsiflexion of foot -> difficult to lift front part of foot - Patient might drag foot on the ground or lift the knee compensatory - Secondary to common peroneal nerve / L5 root lesion 3.3.2.2.3. claw hand - Produced by extension of first phalanx + semiflexion of other phalanges of fingers 4-5 - Due to ulnar nerve or C8-T1 root injury 3.3.2.2.4. pes cavus - High plantar arch - Secondary to calf + foot muscle waste + tendons retraction - Seen in peripheral neuropathy 3.3.3. involuntary movements - Abnormal movements due to muscle contractions that occur independently of the patients will - Semiological analysis is done according to: o Topography o Rhythm o Amplitude o Exaggerating + diminishing factors (posture, activity, fatigue, emotions) o Associated signs 38 Melanie Kolassovits Medical Semiology 2022/23 When assessing the involuntary movements we look for: - Location (which anatomical part is affected) - When they appear (at rest or during voluntary actions; relation to posture/activity) - Rate, rhythm, speed, amplitude - If they are spontaneous or provoked - Duration - If accompanied by fatigue, emotion, other related signs 3.3.3.1. tremor - Involuntary movements in the form of rhythmic oscillations - Lead to displacements of body segments on one side, and the other of the equilibrium position - Exaggerated emotions, overwork, excessive coffee consumption, hyperthyroidism, alcoholism – fine rapid tremors, especially in upper limbs - Severe hypoglycemia, prolonged exposure to cold or chills – intense tremors, spread throughout body - Parkinsonian tremor (sign of the “slip” – movements of pencil against index imitating the action of counting coins), tremor affecting head - Cerebellar tremor: broad, irregular, involves all limbs, intentional (appears during initial contraction to maintain a position) Tremor: rhythmic, symmetrical/asymmetrical movements of limbs/head – types - Resting (static) tremor o occur when limbs are at rest o more pronounced in case of emotions or cognitive stress o decreases with voluntary movements - tremor in Parkinson’s disease o slow, rhythmic, asymmetric, “pill-rolling” (like holding pill between thumb + forefinger + rolling it around), “supination + pronation” o amplified by emotions, lessen while sleeping/during active movement - postural tremor o appears when maintaining a posture, disappears at rest, high amplitude, influenced by emotions o occurs in alcohol/drug use, essential tremor, physiological tremor 39 Melanie Kolassovits Medical Semiology 2022/23 - action tremor (intention) o observed during an action o amplitude increases as limb segment approaches target o characteristic of cerebellar disorders 3.3.3.1.1. flapping tremor (asterixis) - flapping tremor (asterixis) o brisk, muscle contractions, cause wider movements, “flapping” appearance of hands o in hepatic, uremic, hypercapnic encelopathy o = liver flap = asterixis o Alcohol tremor o Often witnessed when hands + wrists are extended outward, another person pushes back on their hands o Usually present in early stages of hepatic encelopathy is sometimes likened to a bird flapping its wings Mechanism of hepatic flapping tremor - Patient should be able to perceive the command to outstretch the hands + maintain it - Sensory cortex relays command to motor cortex - Motor cortex commands effector organs to obey the command to outstretch hands - Cerebellum is directed to maintain the outstretched hands - As relay system between cerebellum + cerebrum is under the toxic effect of neurotoxins, cerebellum fails to maintain coordination, there is a fall. The repetition of this process results in the flapping tremors - Very common in parkinsons 40 Melanie Kolassovits Medical Semiology 2022/23 3.3.3.2. chorea - Sudden, jerky, irregular movements - Occur on muscle hypotonia, at rest or interrupt movement - Accentuated by emotions, speech or voluntary motor activity - Disappear in sleep - Seen in Sydenham chorea (with rheumatic fever), Huntington disease, hyperglycemia, hyperthyroidism 3.3.3.3. athetosis - Slow, irregular oscillations between hyperextension + flexion positions, more twisting with greater amplitude than chorea - Mainly occurs on face + extremities - In exam: what is the difference between chorea + athetosis? - It disappears during sleep, is aggravated by fatigue, emotions, cutaneous stimuli - Occurs in premature infants with cerebral palsy or Huntingtons 3.3.3.4. fasciculations - Fast, isolated muscle twitches that occur at rest - Caused by spontaneous contractions of individual motor unit - Aris spontaneously or precipitated by precussion of muscles - Most easily seen at surface of large muscles - Part of lower motor neuron syndrome or myopathies - Irregular ripples/twitches under skin overlying muscles at rest - Usually in wasted muscles - Non-pathological fasciculation: possible after vigorous exercise 3.3.3.5. myoclonic jerks - Sudden, shock-like contractions of 1 or more muscles - May be localized or diffuse, involving a whole limb - May occur singly or repetitively - In association with epilepsy, diffuse brain damage, dementias - Healthy individuals: when falling asleep or surprised by a sudden noise 3.3.3.6. seizure The 7 main symptoms: - Staring - Jerking movements of arms + legs = myoclonic jerks - Stiffening of the body - Loss of consciousness - Breathing problems / stopping breathing - Loss of bowel or urinary bladder control !!! falling suddenly for no apparent reason, especially when associated with loss of consciousness 41 Melanie Kolassovits Medical Semiology 2022/23 Remember: - Disturbance to extrapyramidal pathways may lead to: dystonias, chorea, athetosis - Dystonia = slow development of abnormal posture which is maintained (often in limb or neck) - Chorea + athetosis = writhing movements o Chorea is irregular, jerky, brief o Athetosis is slower, more sustained, affects distal part of limbs o Choreoathetoid movements is in between the 2 - Hemiballismus: proximal involvement, forceful, high amplitude, flail-like 3.3.3.7. tics - Sudden, stereotyped, repetitive movements that affect synergistic muscles - Preceded by urge to perform the movements - Can be temporarily suppressed voluntarily - Disappear during sleep - E.g. blinking, grimacing, head movements - Often appear in healthy individuals or in Gilles de la Tourette disease - tourette syndrome = neurological condition that causes involuntary motor + vocal tics 3.3.4. muscle tone - The amount of tension (or resistance to movement) in muscles - Examination of muscle tone is done by palpation + assessment of the resistance that the examiner feels during passive movements of a segment - Increased muscle tone (hypertonia) can be determined by lesions of pyramidal + extrapyramidal system - Pyramidal hypertonia (spasticity): progressive resistance to passive mobilization up to a limit beyond which stops suddenly (penknife phenomenon) - Extrapyramidal hypertension: in extrapyramidal lesions, resistance that persists throughout the passive movement (in parkinsons: rigidity in a lead pipe) o Clinical characteristics: result of lesions that equally affect agonist + antagonist muscles - Hypotonie = decrease in muscle tone 42 Melanie Kolassovits Medical Semiology 2022/23 o Localized hypotonia = associated with muscle atrophy, hyporeflexia, occurs in peripheral motor neuron lesions - Paratonia = difficulty of obtaining muscle relaxation during passive movements o Frequently in patients with dementia Muscle tone - Permanent state of alternating contraction of approx. 25-30% of muscle fibres of a muscle - Allows initiating a rapid movement or maintaining a particular posture - Examined with: o Inspection: size + contour of muscles, do they look flat/concave? Unilateral/bilateral changes? Proximal/distal? o Palpation: assessment of muscle consistency o Passive mobilization of large joints: assessment of resting muscle tension by feeling resistance of muscle to passive stretching + by quantifying movement amplitude - Passive movements of joints should be through as full a range as possible, both slowly + quickly - Reduced tone indicates lower motor neuron lesion - Increased tone: upper motor neuron lesion - In upper limb: hold patients hand as if shaking hands, use other hand to support patients elbow. Rotate forearm, flex + extend wrist, elbow, shoulder, varying speed + direction of movement - With lower limb: roll/rotate the leg from side to side, lift leg, allow to fall - When increased muscle tone, reduced joint movements amplitude: hypertonia o Spasticity ▪ in central corticospinal tract diseases (upper motor neuron syndrome) ▪ predominates distally ▪ Affected muscles (flexor muscles of upper limbs, extensors of lower limbs) are firm, do not flap at palpation, form contractures o Rigidity ▪ In extrapyramidal dysfunction ▪ predominates proximally ▪ Increased resistance throughout range of movement, in both directions ▪ Affects agonist + antagonist muscle group equally ▪ Mainly effects flexor muscles of l

Medical Semiology Lectures PDF 2022/23

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue