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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 1 - T h e D i a g n o s t i c F r a me w o r k > C h a p t e r 1 - D i a g n o s i s

Chapter 1 Diagnosis
Varieties of Medical Exam inations
T h e r e a r e a t l e a s t s e v e n v a r i e t i e s o f me d i c a l e xa mi n a t i o n s t h a t d i f f e r f r o m o n e another in their purposes, their stereotyped procedures, and their diagnostic tests.

T h e f i r s t s i x e xa mi n a t i o n s i n v o l v e s p e c i a l , s t e r e o t y p e d r o u t i n e s f o r p e r s o n s h a v i n g s y mp t o ms a n d w h o a r e p r e s u me d t o b e w e l l . R e c o mme n d a t i o n s b a s e d o n y i e l d a n d cost are periodically revised by various professional groups. T he absence of s y mp t o ms ma k e s t h e p e r f o r ma n c e a n d i n t e r p r e t a t i o n o f t h e s e e xa mi n a t i o n s d i f f e r e n t f r o m t h a t o f a d i a g n o s t i c e xa mi n a t i o n . 1. Ex ami nat i on of Young Sc hool c hi l T hen: xa mi n a t i o n u s u a l l y e mp h a s i ze s dr e e t e s t s o f v i s i o n a n d h e a r i n g , p h y s i c a l a n d s o c i a l d e v e l o p me n t , c o o r d i n a t i o n , a n d language skills. 2. Ex ami nat i on of At hl etT h : e xa mi n e r s t r e s s e s t e s t s o f c a r d i o p u l mo n a r y es e f u n c t i o n , mu s c l e p e r f o r ma n c e , f l e xi b i l i t y, a n d i n j u r y p r e v e n t i o n . 3. Ex ami nat i on f or M i l i t ar y Ser T ih i e: r e s e mb l e s t h e e xa mi n a t i o n f o r a t h l e t e s v cs but adds testing of the special senses and psyche.

4. Ex ami nat i on f or Li f e I ns ur ance r o u t i n e i s g e n e r a l l y e s t a b l i s h e d b y t h e T h e: i n s u r a n c e c o mp a n y ; i t u s u a l l y c o n s i s t s o f a h i s t o r y f o r m, a n a b b r e v i a t e d p h y s i c a e xa mi n a t i o n , a n d a f e w l a b o r a t o r y t e s t s t o e xc l u d e t h e p r e s e n c e o f c h r o n i c d i s e a s e s t h a t a f f e c t l o n g e v i t y, s u b s t a n c e a b u s e , a n d H IV i n f e c t i o n .

5. Per i odi c Heal t h Ex ami natF on:i n f a n t s , f o l l o w t h e r e c o mme n d a t i o n s o f t h e i or Ame r i c a n Ac a d e my o f P e d i a t r i c s f o r w e l l - c h i l d e xa mi n a t i o n s a n d i mmu n i za t i o n s . T h e c l i n i c i a n e s p e c i a l l y s e a r c h e s f o r b i r t h d e f e c t s a n d me a s u r e s g r o w t h a n d s o c i a l d e v e l o p me n t . An n u a l e xa mi n a t i o n s o f s e xu a l l y a c t i v e a d u l t s w i t h n e w s e xu a l p a r t n e r s s h o u l d b e p e r f o r me d w i t h P a p t e s t i n g o f w o me n a n d s c r e e n i n g f o r s e xu a l l y t r a n s mi t t e d d i s e a s e s i n w o me n , a n d p o s s i b l y me n . In p e r s o n s o l d e r t h a n a g e 4 5 y e a r s , a n n u a l e xa mi n a t i o n s s e e k t o d e t e c t t h e e a r l y o n s e t o f c a r d i o v a s c u l a r d i s e a s e , d i a b e t e s me l l i t u s , h y p e r c h o l e s t e r o l e mi a , h y p e r t e n s i o n , a n d c a n c e r. In a d d i t i o n , t h e c l i n i c i a n p r o v i d e s c o u n s e l i n g a b o u t a g e - r e l a t e d l i f e c h a n g e s , d i e t a n d e xe r c i s e , P. 4 a n d a p p r o p r i a t e i mmu n i za t i o n s . T h e v i s i t s ma y f o s t e r o p t i ma l p a t i e n t p h y s i c i a n r e l a t i o n s h i p s . S e e t h e c u r r e n t r e c o mme n d a t i o n s o f t h e U S P u b l i c H e a l t h S e r v i c e Ta s k F o r c e [ n P K J . H i s t o r i c a l c h a n g e s i n t h e o b j e c t i v e s o f t h e p e r i o d i c h e a l t h Ha
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e xa mi n a t i o n . Ann I nt er n M ed9 9 7 ; 1 2 7 : 9 1 0 9 1 7 1 ]. 6. I ndus t r i al Ex ami nat i onse c i a l i ze d p r o c e d u r e s d e t e c t t h e h a za r d s o f p a r t i c u l a r Sp : i n d u s t r i e s : t e s t i n g f o r l e a d a n d c a r b o n mo n o xi d e i n t h e b l o o d , s e e k i n g s i g n s o f p n e u mo c o n i o s i s o r t u b e r c u l o s i s i n r a d i o g r a p h s o f t h e c h e s t , me a s u r i n g t h e r a d i a t i o n e xp o s u r e o f t h o s e w h o w o r k w i t h x- r a y s o r r a d i o i s o t o p e s . 7. Pr eoper at i v e Sc r eeniS e e P a r t III,h a p t e r 1 6 ng: C .

8. Di agnos t i c Ex ami nat iT h i s p r o c e d u r e i s n o t r e s t r i c t e d i n i t s a p p r o a c h , b u t i s on: mo r e s e a r c h i n g . It s t a r t s w i t h t h e p a t i e n t ' s c h i e f c o mp l a i n t a n d , u s i n g s y mp t o ms a n d s i g n s a s c l u e s , s e e k s t o f i n d a n e xp l a n a t i o n f o r t h e d i s c o mf o r t o r dysfunction, a diagnosis. T he urgency of the situation dictates the form the e xa mi n a t i o n w i l l t a k e . F o r e xa mp l e , i n a p a t i e n t w i t h c h r o n i c c o mp l a i n t s a n d a n e xa m t h a t r e v e a l s n o u r g e n t p r o b l e ms , t h e d i a g n o s t i c e v a l u a t i o n mi g h t s p a n s e v e r a l c l i n i c v i s i t s o v e r a mo n t h o r t w o . In c o n t r a s t , t h e t r a u ma p a t i e n t r e q u i r e a n e xp e d i t e d p r i ma r y s u r v e y o f t h e a i r w a y, b r e a t h i n g , c i r c u l a t i o n , a n d n e u r o l o g i c f u n c t i o n s t o d e t e r mi n e t h e n e e d f o r r e s u s c i t a t i o n . T h i s i s f o l l o w e d b y a s e c o n d a r y s u r v e y : t h e h i s t o r y, a p h y s i c a l e xa mi n a t i o n , a n d s e l e c t i o n o f l a b o r a t o r y a n d r a d i o l o g i c s t u d i e s t o p e r mi t f o r mu l a t i o n o f a d e f i n i t i v e c a r e p l a n . A c o n c e p t u a l a p p r o a c h t o t h e d i a g n o s t i c e xa m i s t h e f o c u s o f t h i s c h a p t e r.

T he Diagnostic Exam ination

Ap p r o p r i a t e me d i c a l c a r e d e p e n d s u p o n t h e p h y s i c i a n ' s r e c o g n i zi n g t h e a b n o r ma l i t i e o f t h e p a t i e n t ' s p h y s i o l o g i c f u n c t i o n s , s t r u c t u r e , a n d me n t a t i o n . E a c h r e c o g n i za b l e disease possesses clinical and/or laboratory features that serve as clues to d i f f e r e n t i a t e i t f r o m s i mi l a r c o n d i t i o n s . D u r i n g t h e d i a g n o s t i c e xa mi n a t i o n , t h e c l i n i c i a n i s p e r f o r mi n g t w o p a r a l l e l t a s k s : ( a ) a s e a r c h f o r s y mp t o ms a n d s i g n s t o d e v e l o p a l i s t o f p r o b l e ms , a n d f r o m t h i s , ( b ) t h e g e n e r a t i o n a n d s e l e c t i o n o f p h y s i o l o g i c a n d d i a g n o s t i c h y p o t h e s e s a i me d a t e s t a b l i s h i n g o n e o r mo r e d i a g n o s e s

Why is Diagnosis Important?

T h e p u r p o s e o f p e r f o r mi n g a h i s t o r y a n d p h y s i c a l e xa mi n a t i o n i s t o a s s i s t i n ma k i n g t h e d i a g n o s i s . Ac c u r a t e d i a g n o s i s a l l o w s t h e c l i n i c i a n t o p e r f o r m t h e t h r e e t a s k s t h a a r e c e n t r a l t o t h e h e a l i n g p r o f e s s i o n s : e xp l a n a t i o n , p r o g n o s t i c a t i o n , a n d t h e r a p y. T h e s e t h r e e t a s k s h a v e b e e n c o n s i s t e n t l y p e r f o r me d b y p h y s i c i a n s t h r o u g h o u t t i me and across cultures, regardless of the belief system or theory underpinning the p r a c t i c e : ma g i c , f a i t h , r a t i o n a l i s m, o r s c i e n c e . T h e y p r o v i d e a n s w e r s t o t h e p a t i e n t ' t h r e e f u n d a me n t a l q u e s t i o n s : ( a ) W h a t i s h a p p e n i n g t o me a n d P. 5 w h y ? ( b ) W h a t d o e s t h i s me a n f o r my f u t u r e ? ( c ) W h a t c a n b e d o n e a b o u t i t a n d h o w w i l l t h a t c h a n g e my f u t u r e ? e[n J J . R e me mb e r i n g t h e r e a l q u eAnn n s . er n Coh s t i o I nt M ed 1 9 9 8 ; 1 2 8 : 5 6 3 5 6 6r a v i t z R L , C a l l a h a n E J . P a t i e n t s ' p e r c e p t i o n s o f o mi t t e d ;K e xa mi n a t i o n s a n d t e s t s : A q u a l i t a t i v e aJ a l y s i s nt er n M ed 0 0 ; 1 5 : 3 8 ]4 5 n Gen I . 20 .

F a i l u r e t o p u r s u e a d i a g n o s i s ma y p e r mi t y o u r p a t i e n t ' s d i s e a s e t o p r o g r e s s f r o m a s t a g e t h a t r e s p o n d s t o t r e a t me n t t o o n e t h a t d o e s n o t . P a r a d o xi c a l l y, f o r ma n y a c u t e c o mp l a i n t s , i n o t h e r w i s e h e a l t h y p e o p l e w i t h n o a l a r m s y mp t o ms o r s i g n s , a n a c c u r a t e a n d g o o d p r o g n o s i s c a n b e a s c e r t a i n e d w i t h o u t k n o w i n g t h e e xa c t c a u s e o
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t h e c o mp l a i n t , f o r i n s t a n c e , a n u p p e r r e s p i r a t o r y i n f e c t i o n o r b a c k p a i n . In t h i s s i t u a t i o n , t h e e xp e r i e n c e d c l i n i c i a n c a n r e a s s u r e t h e p a t i e n t t h a t f u r t h e r t e s t i n g t o e s t a b l i s h t h e e xa c t c a u s e i s u n n e c e s s a r y a n d w i l l n o t c h a n g e t h e p r o g n o s i s o r t r e a t me n t . It t a k e s e xp e r i e n c e , k n o w l e d g e o f t h e me d i c a l l i t e r a t u r e , g o o d j u d g me n t , a n d a n u n d e r s t a n d i n g o f t h e f u n d a me n t a l s o f c l i n i c a l e p i d e mi o l o g y a n d d e c i s i o n ma k i n g t o d e t e r mi n e w h e n p u r s u i t o f a s p e c i f i c d i a g n o s i s i s w a r r a n t e d . F o r a n e xc e l l e n t r e v i e w o f t h e p r i n c i p l e s o f e p i d e mi o l o g y i n a h i g h l y r e a d a b l e f o r ma t , s e e F l e t c h e r e t aF.l e t c h e r R H , F l e t c h e r S W, Wa g n e r iE Hc al Epi demi ol ogy, t he l [ Cl ni . Es s ent i al s3. r d e d . B a l t i mo r e : W i l l i a ms & W i l k i n s , 1 9 9 6 ].

Diseases and Syndromes: An Entry to the M edical Literature

For thousands of years physicians have recorded recurring patterns of disordered b o d i l y s t r u c t u r e , f u n c t i o n , a n d me n t a t i o n t h a t s u g g e s t a c o mmo n c a u s e . E a c h p a t t e r r e c e i v e s a s p e c i f i c n a me . W h e n a c o mmo n e t i o l o g y a n d p a t h o p h y s i o l o g y a r e c o n f i r me d , w e d e s i g n a t e t h e c o n ddi is eas .e O t h e r c l u s t e r s o f a t t r i b u t e s , k n o w n it on a b y a c o mb i n a t i o n o f f e a t u r e s n o t c l e a r l y r e l a t e d t o a s i n g l e c a u s e , a r e c a l l e d s y ndr omesD i s e a s e s a n d s y n d r o me s a r e i n t e l l e c t u a l c o n s t r u c t s a l l o w i n g t h e . p h y s i c i a n s t o s t u d y g r o u p s o f p a t i e n t s w i t h r e l a t i v e l y h o mo g e n e o u s p h y s i o l o g i c d i s o r d e r s ; t h e y d o n o t e xi s t i n d e p e n d e n t l y o f t h e p a t i e n t s w h o ma n i f e s t t h e m. T h e d i a g n o s i s o f a d i s e a s e o r s y n d r o me p r o v i d e s a n e n t r y t o t h e me d i c a l l i t e r a t u r e t o o b t a i n i n f o r ma t i o n a b o u t e t i o l o g y, d i a g n o s t i c f i n d i n g s , t r e a t me n t , a n d p r o g n o s i s .

An a c c u r a t e d i a g n o s i s i s i n d i s p e n s a b l e t o o f f e r i n g y o u r p a t i e n t s e v i d e n c e - b a s e d t h e r a p y, t h a t i s , t h e r a p y v a l i d a t e d i n c l i n i c a l t r i a l s b a s e d u p o n a c c u r a t e d i a g n o s i s o participating subjects.

Finding Clues to the Diagnosis

T h e d i a g n o s t i c e xa mi n a t i o n h a s f o u r c o mp o n e n t s : ( a ) h i s t o r y t a k i n g , w h e r e c l u e s a r s y mpt oms a b n o r ma l i t i e s p e r c e i v e d b y t h e p a t i e n t ' s o w n s e n s e s ) ; ( b ) p h y s i c a l ( e xa mi n a t i o n , w h e r e t h e p h ys i ignsa r e c l u e s ( a b n o r ma l i t i e s p e r c e i v e d b y t h e s cal e xa mi n e r ' s s e n s e s ) ; ( c ) l a b o r a t o r y e xa mi n a t i o n , w h e r e t h e c l u e s a r e f i n d i n g s f r o m c y t o l o g i c , c h e mi c a l a n d i mmu n o l o g i c t e s t s o f t i s s u e s , b o d y f l u i d s , a n d e xc r e t a ; a n d ( d ) s p e c i a l a n a t o mi c a n d p h y s i o l o g i c e xa mi n a t i o n s , w h e r e t h e c l u e s a p p e a r o n x- r a y f i l ms , c o mp u t e d t o mo g r a p h y ( C T ) o r ma g n e t i c r e s o n a n c e i ma g i n g P. 6 ( M R I) s c a n s , u l t r a s o n o g r a ms , i n t r a v a s c u l a r p r e s s u r e r e c o r d i n g s a n d e l e c t r i c a l me a s u r e me n t s s u c h a s e l e c t r o c a r d i o g r a ms ( E C G s ) , c a r d i a c e l e c t r o p h y s i o l o g i c s t u d i e s , e l e c t r o my o g r a ms ( E M G s ) , n e r v e c o n d u c t i o n v e l o c i t y s t u d i e s ( N C V) , e l e c t r o e n c e p h a l o g r a ms ( E E G s ) , o r p o l y s o mn o g r a p h y. O u r f o c u s i s o n t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n a n d t h e p r o c e s s o f h y p o t h e s i s g eo l e r a t i B n , [ W o l l a n B n and oJ P C , S i l v e r s t e i n M D . R e v i e w o f s y s t e ms , p h y s i c a l e xa mi n a t i o n , a n d r o u t i n e t e s t s f o r c a s e - f i n d i n g i n a mb u l a t o r y p a tAm tJ .M ed Sc1 9 9 5 ; 3 0 9 : 1 9 4 2 0 0 l a n d B J , ien s i ; Bo W o l l a n P C , S i l v e r s t e i n M D . Yi e l d o f l a b o r a t o r y t e s t s f o r c a s e - f i n d i n g i n t h e a mb u l a t o r y g e n e r a l me d i c a l e xa mi n a t i o nM ed1 9 9 6 ; 1 0 1 : 1 4 2 1 5 2 u r r e n t Am J . ]. C e v i d e n c e s u g g e s t s t h a t mo s t d i a g n o s e s r e s u l t f r o m f i n d i n g s i n t h e h i s t o r y, a n d t o a l e s s e r e xt e n t , t h e p h y s i c a l e xa mi n a t i o n a n d l a b o r a t o re t ee s oin g [C , Py tr t n M
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H o l b r o o k J H , Vo n H a l e s D , e t a l . C o n t r i b u t i o n s o f t h e h i s t o r y, p h y s i c a l e xa mi n a t i o n , a n d l a b o r a t o r y i n v e s t i g a t i o n i n ma k i n g me d i c a l dWes toJ e s . 1 9 9 2 ; 1 5 6 : 1 6 3 i a g n s M ed 1 6 5 R e i l l y B M . P h y s i c a l e xa mi n a t i o n i n t h e c a r e o f me d i c a l i n p a t i e n t s : a n ; o b s e r v a t i o n a l s t uLanc et2 0 0 3 , 3 6 2 : 11 0 0 11. 0 5 d y. ]

T he clinician uses a recursive process to work his way toward the final diagnosis. F i r s t , f r o m t h e h i s t o r y a n d p h y s i c a l e xa mi n aftfiern , ai al di agnos i s di o ent is c o n s t r u c t e d o f t h e mo s t p r o b a b l e p a t h o p h y s i o l o g i c a b n o r ma l i t i e s a n d / o r s p e c i f i c disease states. Second, choosing tests with appropriate likelihood ratios, these hypotheses are tested. T he results of the testing changes the probability of each h y p o t h e s i s ; s o me a r e n o w mo r e p r o b a b l e , w h i l e o t h e r s a r e l e s s p r o b a b l e . T h e c l i n i c i a n r e t u r n s t o t h e p a t i e n t , r e v i e w s t h e h i s t o r y, a n d r e p e a t s s p e c i f i c p a r t s o f t h e xa mi n a t i o n t o r e a c h a n e w, r e f i n e d d i f f e r e n t i a l d i a g n o s i s t o b e t e s t e d mo r e s p e c i f i c a l l y. T h i s p r o c e s s r e p e a th ,t i me r et ur ni ng t o t he pat i rent e p a t i e n t ' s eac s fo th ongoing history and to search for new or changing physical findings, until one or mo r e s p e c i f i c d i a g n o s e s a r e e s t a b l i s h e d t h a t f u l l y e xp l a i n t h e p a t i e n t ' s i l l n e s s .

T h e d i a g n o s t i c e xa m b e g i n s w i t h t h e f i r s t p a t i e n t c o n t a c t . T h e p a t i e n t ' s a g e i s a s u r r o g a t e f o r d i s e a s e s mo r e o r l e s s c o mmo n i n t h a t a g e g r o u p . T h e d u r a t i o n o f i l l n e s s i s i mp o r t a n t ; f o r e xa mp l e , a d i s e a s e l a s t i n g mo r e t h a n 3 y e a r s i s u n l i k e l y t o a g g r e s s i v e c a n c e r. E t h n i c i t y i s i mp o r t a n t f o r d i a g n o s i n g s o me d i s e a s e s ; f o r e xa mp l e s i c k l e c e l l a n e mi a r a r e l y o c c u r s i n n o r t h e r n E u r o p e a n w h i t e s . S e x- l i n k e d d i s e a s e s s u c h a s h e mo p h i l i a a r e r a r e l y e n c o u n t e r e d i n f e ma l e s . M a l e s d o n ' t g e t p r e g n a n t . Al t h o u g h o b v i o u s , i t i s i mp o r t a n t t o ma k e e a c h o f t h e s e c a t e g o r i c a l p r o b a b i l i t y d e c i s i o n s e xp l i c i t . S o me t i me s i t i s a d i s e a s e t h a t w a s e xc l u d e d b y u s i n g o n e o f t h e s c r i t e r i a ( u s u a l l y w i t h o u t c o n s c i o u s l y r e c o g n i zi n g i t ) t h a t t u r n s o u t t o b e t h e d i a g n o s s u c h a s a p p e n d i c i t i s i n t h e 8 0 - y e a r - o l d w i t h a b d o mi n a l p a i n .

W h i l e s e a r c h i n g , e a c h e me r g i n g c l u e i s e xa mi n e d c l o s e l y b e f o r e i t i s a c c e p t e d . If i t a s y mp t o m, a s s e s s t h e r e l i a b i l i t y o f t h e o b s e r v e r : Ar e t h e o b s e r v e r ' s p e r c e p t i o n s a c c u r a t e a n d c o n s i s t e n t o r a r e t h e y c o l o r e d b y e mo t i o n o r s e c o n d a r y c o n s i d e r a t i o n s Is t h e o b s e r v e r ' s me mo r y a d e q u a t e ? W h a t i mp o r t a n c e d o e s t h e p a t i e n t a t t a c h t o t h e s y mp t o m? D o e s t h e p a t i e n t r e g a r d i t f e a r f u l l y o r w i t h r e l a t i v e u n c o n c e r n ? O b t a i n h i s t o r y f r o m c o l l a t e r a l o b s e r v e r s , f a mi l y, a n d f r i e n d s w h e n e v e r p o s s i b l e . D o t h e y corroborate the patient's history?

P. 7 If t h e c l u e i ss agn i s i t w i t h i n t h e r a n g e o f n o r ma l , h a s i t c h a n g e d f r o m p r e v i o u s i , e xa ms o r i s i t c l e a r l y a b n o r ma l ? Is i t c o n s t a n t l y p r e s e n t o r d o e s i t v a r y w i t h p o s i t i o n o r mo t i o n ? W i t h l a b o r a t o r y f i n d i n g s , o n e mu s t c o n s t a n t l y s u s p e c t t h e mi xi n g o f s p e c i me n s a n d l a b o r a t o r y e r r o r. D o t h e r e p o r t s a c c o r d w i t h w h a t y o u e xp e c t e d ? Wa s t h e r e o p p o r t u n i t y f o r t h e a d u l t e r a t i o n o f s p e c i me n s ? W h a t i s t h e l a b o r a t o r y ' s r e p u t a t i o n f o r a c c u r a c y ? If t h e c l u e w a s f o u n d i n t h e x- r a y f i l ms , w a s i t p r e s e n t i n p r e v i o u s f i l ms ? Wa s t h e r e p r o p e r i d e n t i f i c a t i o n o f t h e p a t i e n t i n o b t a i n i n g t h e i ma g e s ? W e r e t h e i ma g e s i n t e r p r e t e d b y c o mp e t e n t p e r s o n s ?

Select Hypotheses: The Differential Diagnosis


Physiologic and Diagnostic Hypotheses
C l u e s a r e s o u g h t b y t a k i n g a h i s t o r y, p e r f o r mi n g a p h y s i c a l e xa mi n a t i o n , a n d
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o b t a i n i n g l a b o r a t o r y t e s t s a n d i ma g i n g . T h e s p e c i f i c f i n d i n g s s u g g e s t a l i s t o f p r o b l e ms f r o m w h i c h i s g e n ephye d ol ogi c hy pot heso e xp l a i n t h e me c h a n i s m rat si t es o f d i s e a s e a n d agnos t i c hy pot hesd i s,e a s e s t h a t a r e k n o w n t o c a u s e t h e s p e c i f i c di es s y mp t o ms , s i g n s , a n d p a t h o p h y s i o l o g y. A l i s t o f a l l p o s s i b l e d i a g n o s e s i s r a r e l y o f mu c h b e n e f i t , a n d d o e s n o t p r o v i d e a g u i d e f o r e f f i c i e n t e v a l u a t i o n . R a t h e r, f r o m t h i l i s t w e u s e t h e s p e c i f i c f i n d i n g s f r o m t h e h i s t o r yof n d e xa m i ent a t hi s pat t o di f f er ent i atte e r e l a t i v e p r o b a b i l i t i e s o f t h e p o t e n t i a l c o n d i t i o n s t o c r e a t e a s h o r t l i s t h o f t h e mo s t l i k e l y c o n d i t i o n s , f tf h eent i al di agnos i u r. t h e r h i s t o r y a n d e xa m a n d di er Fs specific laboratory tests are used to support or refute each condition in the d i f f e r e n t i a l d i a g n o s i s t o f i n a l l y a r r i v e a t a d i a g n o s i s . P r o b l e m- b a s e d l e a r n i n g p r e p a r e s t h e s t u d e n t t o e mb r a c e t h i s d i a g n o s t i c p r o c e s s .

Because the clues that allow us to differentiate between disease of high and low p r o b a b i l i tfy t hi s pat i ent e u n i q u e t o t h i s p a t i e n t , a d i f f e r e n t i a l d i a g n o s i s i s o n l y or ar p o s s i b l e f o r a n i n d i v i d u a l p a t i e n t , n o t a p r o b l e m. F o r a n i s o l a t e d s y mp t o m o r s i g n w c a n g e n e r a t e a l i s t o f p o t e n t i a l d i a g n o s e s , b u t h a v e n o me a n s t o d i f f e r e n t i a t e t h e i r p r o b a b i l i t i e s . In t h i s b o o k , u n d e r ma n y s y mp t o ms a n d s i g n s , w e h a v e p l a c e d a l i s t o s u c hC l i n i c a l O c c u r r e n c e s i s u p t o t h e c l i n i c i a n , p e r h a p s u s i n g t h i s l i s t a s a . It o r g a n i za t i o n a l t o o l , t o g e n e r a t e a me a n i n g f u l d i f f e r e n t i a l d i a g n o s i s f o r h e r p a t i e n t . When specific clues will help in generating the differential diagnosis, we have liste t h e m a f t e r t h eD X: s y mb o l i n t h e t e xt . D

T he differential diagnoses are a list of the diseases that are considered as h y p o t h e s e s f o r f u r t h e r e v a l u a t i o n . E a c h d i s e a s e o r c o n d i t i o n i s mo r e o r l e s s p r o b a b b a s e d u p o n h o w w e l l i t e xp l a i n s t h e f u l l r a n g e o f t h e p a t i e n t ' s p r o b l e ms . S t u d i e s show that the average clinician carries coincidentally 4 or 5 diseases on the clinician's differential list; but often a total of 13 to 15 diseases will have appeared o n t h e d i f f e r e n t i a l l i s t a t s o me t i me d u r i n g t h e e xa mi n a t i o n .

Hypothesis Generation

T he process by which skilled clinicians arrive at hypotheses has attracted attention f r o m p h y s i c i a n s , ma t h e ma t i c i a n s , a n d p s y c h o l o g i s t s . M u c h o f P. 8 t h i s l i t e r a t u r e i s f o u n d i n w r i t i n g s o n me d i c a l d e c i s i o n ma k i n g , me d i c a l l o g i c , o r c l i n i c a l p r o b l e m s o l v i n g . Al t h o u g h s e v e r a l me t h o d s o f p r o b l e m s o l v i n g h a v e b e e n c o n s i d e r e d , b r a n c h i n g a n d ma t c h i n g a r e mo s t c o mmo n l y u s e d w h e n p a t t e r n recognition has not occurred.

P atte r n R e c ognition.
T h e w h o l e o f t h e p a t i e n t ' s i l l n e s s i s g r e a t e r t h a n t h e s u m o f i t s p a r t s a n d a s i mp l e ma t h e ma t i c a l s u mmi n g o f t h e s e n s i t i v i t y a n d s p e c i f i c i t y o f e a c h f i n d i n g i s p r o b a b l y f a r l e s s a c c u r a t e t h a n t h e p a t t e r n f o r me d i n t h e mi n d o f t h e s k i l l e d e xa mi n e r b y t h e t o t a l i t y o f t h e o b s e r v a t i o n s . F o r e xa mp l e , i t i s u n l i k e l y t h a t w e c o u l d a c c u r a t e l y i d e n t i f y a p e r s o n b y l o o k i n g s i n g l y a t e a c h e a r, e a c h e y e , t h e h a i r, t h e f o r e h e a d , t h c h e e k s , t h e n o s e , t h e l i p s , o r t h e c h i n . E a c h e xa m w o u l d l a c k t h e s e n s i t i v i t y a n d specificity we desire for identification. But with just a glance at the pattern of the whole, we can identify with great accuracy literally hundreds of distinct faces. We e v e n r e c o g n i ze o u r f r i e n d s a f t e r i n j u r i e s o r w h e n mu c h o f t h e f a c e i s c o v e r e d ( i . e . ,
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ma n y o f t h e p a r t s a r e d i f f e r e n t o r d i s t o r t e d ) b e c a u s e o f t h e p e r s i s t i n g u n i t y o f t h e w h o l e . W e u s e t h i s p o w e r f u l c o g n i t i v e a b i l i t y i n e v e r y d a y l i f e a n d i n me d i c a l p r a c t i c It i s n o t a n e xe r c i s e i n r e d u c t i o n i s m: t h e w h o l e i s g r e a t e r t h a n t h e s u m o f t h e p a r t s . T h i s a b i l i t y t o r e c o g n i ze p a t t e r n s i s o n e o f t h e mo s t p o w e r f u l p r o p e r t i e s o f t h e h u ma b r a i n , w h i c h n o c o mp u t e r o r a l g o r i t h m c a n ma t c h .

M o s t c l i n i c i a n s b e l i e v e t h a t c o mp o s i t e p i c t u r e s o f d i s e a s e , a l t h o u g h c o mp r i s i n g ma n s i g n s , s t r i k e t h e m a t a g l a n c e . T h e G e r ma n s r e c o g n i ze t h i s c o n c e p t w h e n t h e y r e f e r t o Au g e n b l i c k d i a g n o s e s ( l i t e r a l l y, a b l i n k o f t h e e y e ) . P a t t e r n r e c o g n i t i o n i s t h e current English term describing this concept.

B r anc hing H ypothe s e s .

C l i n i c i a n s f o l l o w a s e a r c h f o r c l u e s t h a t l e a d s f r o m o n e h y p o t h e s i s t o a n o t h e r. A c l u c a l l s t o mi n d a d i s e a s e w i t h s i mi l a r a t t r i b u t e s a n d t h e o t h e r a t t r i b u t e s o f t h e d i s e a s a r e c o n s i d e r e d . T h e h y p o t h e s e s a r e e n t e r e d o n t h e e xa mi n e r ' s i ma g i n a r y s l a t e , r e v i s e d , a n d r e v i e w e d , a n d e a c h n e w c l u e ma y h i n t a t o t h e r d i s e a s e s f o r consideration.

M atc hing H ypothe s e s .

T h e p a t i e n t ' s s y mp t o ms a n d s i g n s a r e ma t c h e d w i t h t h o s e o f t h e h y p o t h e s i ze d d i s e a s e s . T h e b e s t ma t c h i s s e l e c t e d a s t h e d i a g n o s i s o f t h e p a t i e n t . F o r e xa mp l e , s u p p o s e t h e e xa mi n a t i o n o f t h e p a t i e n t ( p t ) y i e l d s a t t r i b u t e s , o r c l u e s , a , d , e , k , a n n ; w e ma y d e s i g n a t e t h e p a t i e n t a s ( p t ) a d e k n . F r o m me mo r y, o r r e f e r e n c e s i n t h i s b o o k u n d e r t h e h e a d C l i n i c a l O c c u r r e n c e , t h e e xa mi n e r e n t e r s o n t h e i ma g i n a r y s l a t e a l i s t o f d i s e a s e s h a v i n g t h e s a me a t t r i b u t e a . T h e d i s e a s e s o n t h e l i s t c a n b e d e s i g n a t e d a s V, W, X, Y, a n d Z . In ma t c h i n g , t h e e xa mi n e r f i n d s t h a t t h e d i s e a s e s h a v e t h e f o l l o w i n g a t t r i b u t e s i n c o mmo n w i t h t h e p a t i e n t : ( V) a b c d e h a s a d e i n c o mmo n ; ( W ) a c e f g h a s a e i n c o mmo n ; ( X) a d f i j h a s a d i n c o mmo n ; ( Y ) a f h k l h a s a k i n c o mmo n ; a n d ( Z ) a e k g n h a s a e k n i n c o mmo n . W i t h o u t a n y o t h e r c o n s i d e r a t i o n s , this last would be eligible as the diagnosis.

D e c is ions B as e d on P r obability.

As f a r a s w e k n o w, t h e ma t h e ma t i c s a p p l i e d t o d e c i s i o n ma k i n g i n me d i c i n e h a s b e e f o c u s e d o n d e t e r mi n i n g P. 9 t h e mo s t p r o b a b l e d i a g n o s i s . If t h e e xa mi n e r f o l l o w e d t h i s p r i n c i p l e r i g i d l y, a r a r e disease would never be diagnosed.

N e v e r t h e l e s s , u s i n g s t a t i s t i c a l me t h o d s t o e v a l u a t e t h e s e n s i t i v i t y a n d s p e c i f i c i t y o f clinical findings and tests and the positive and negative likelihood ratios for variou test results helps us to understand the usefulness of each individual part of the d i a g n o s t i c e xa mi n a t i o n . A v e r y u s e f u l b o o k t h a t s u mma r i ze s mo s t o f w h a t i s c u r r e n t l k n o w n a b o u t t h e s e n s i t i v i t y, s p e c i f i c i t y, a n d p o s i t i v e a n d n e g a t i v e l i k e l i h o o d r a t i o s s p e c i f i c p h y s i c a l f i n d i n g s i idenc e- Bas ed Phy s i c al Di agnosG e e S . Ev s [M c i s Ev i denc e- Bas ed Phy s i c al Di agnosii ls .d e l p h i a : W B S a u n d e r s ,] .2 0 0 1 Ph a

Soft Focus and Hard Focus


Pattern recognition results from a soft focus, taking in the observations without
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u n d u e e mp h a s i s o n a n y o n e ; t h e o b s e r v e r l e t s t h e p a t t e r n e me r g e a s t h e i r s y s t e ma t o b s e r v a t i o n s a r e f i l t e r e d t h r o u g h t h e l e n s o f t h e i r k n o w l e d g e a n d e xp e r i e n c e . P e r f o r ma n c e o f t h e s c r e e n i n g p h y s i c a l e xa m i n a s t r u c t u r e d a n d r e l a t i v e l y s t e r e o t y p s e q u e n c e a l l o w s t h e e xa mi n e r t o o b s e r v e e a c h p a t i e n t i n a s i mi l a r ma n n e r s o t h a t t h r e p e t i t i v e p a t t e r n s b e t w e e n p a t i e n t s b e c o me mo r e e v i d e n t . W h e n t h e e xa mi n a t i o n p r o c e s s b e c o me s a r o u t i n e , l i t t l e o r n o t h o u g h t i s r e q u i r e d t o p e r f o r m o r s e q u e n c e t h e p h y s i c a l a c t s o f t h e e xa m, s o t h e mi n d i s f r e e t o o b s e r v e .

When the focus of attention is sharp, as is often the case with beginners, one thing ma y b e s e e n , w h i l e mu c h i s mi s s e d . T h i s i s d e mo n s t r a t e d b y a c l a s s i c e xa mp l e f r o m p s y c h o l o g y. In t h e d a y s w h e n p o c k e t w a t c h e s w e r e c o mmo n a n d o f t e n h a d t h e 6 o n the dial replaced by a second hand, a lecturing professor pointed out to his student t h a t t h e y h a d l o o k e d a t t h e i r w a t c h e s t h o u s a n d s o f t i me s , b u t ma n y p r o b a b l y c o u l d not recall if they had a 6 on their dials. Many in the audience took surreptitious g l a n c e s a t t h e i r t i me p i e c e s . Af t e r t h e w a t c h e s h a d b e e n p o c k e t e d , t h e p r o f e s s o r a s k e d i f t h e y k n e w w h a t t i me i t w a s ; ma n y h a d n o t n o t e d t h e t i me . T h e y h a d s e e n w h a t t h e y w e r e l o o k i n g f o r, b u t n o t a l l t h a t w a s t o b e s e e n . T h e t i me f o r s h a r p f o c u s is when testing your hypotheses by searching for specific signs.

O n e o f t h e mo s t i mp o r t a n t o b s e r v a t i o n s ma d e b y t h e e xp e r i e n c e d c l i n i c i a n u s i n g p a t t e r n r e c o g n i t i o n w i t h a s o f t f o c u s i s t h e o v e r a l l a s s e s s me n t o f s e v e r i t y o f i l l n e s s H o w s i c k i s t h e p a t i e n t ? Al t h o u g h o n e c o u l d l i s t ma n y a t t r i b u t e s o f s e v e r e i l l n e s s , f o e xa mp l e , a b n o r ma l v i t a l s i g n s , p a l l o r, d i a p h o r e s i s , a n xi o u s o r f r i g h t e n e d e xp r e s s i o n t h e g l o b a l a s s e s s me n t o f s e v e r i t y ma d e b y t h e e xp e r i e n c e d c l i n i c i a n a l s o i n c l u d e s ma n y i n t a n g i b l e s , o f t e n b a s e d u p o n p r i o r k n o w l e d g e a n d e xp e r i e n c e w i t h t h e p a t i e n S e v e r i t y o f i l l n e s s s c o r e s , s u c h a s APAC H E ( Ac u t e P h y s i o l o g y a n d C h r o n i c H e a l t h E v a l u a t i o n ) II s c o r e s , a r e a t t e mp t s t o s y s t e ma t i ze t h i s g l o b a l a s s e s s me n t . Yo u r e xp e r i e n c e - b a s e d e mo t i o n a l c u e s a r e a n i mp o r t a n t p a r t o f t h i s a s s e s s me n t .

Use of Computers
T h e r e a r e s e v e r a l a r e a s i n w h i c h c o mp u t e r s h a v e p r o v e n v a l u a b l e i n t h e d i a g n o s t i c e xa mi n a t i o n . O n e o f t h e s e i s i n t h e r a p i d c o mmu n i c a t i o n o f l a b o r a t o r y r e s u l t s a n d r a d i o l o g i c i ma g e s a n d i n t e r p r e t a t i o n s t o c l i n i c i a n s . P. 1 0 An o t h e r i s i n t h e c o mp r e h e n s i v e s e a r c h o f t h e me d i c a l l i t e r a t u r e t o e v a l u a t e c l u e s a n d h y p o t h e s e s g e n e r a t e d d u r i n g a n e xa mi n a t i o n . C o mp u t e r l i t e r a t u r e s e a r c h e s should be available on the clinical floors of every hospital and in the offices and h o me s o f p h y s i c i a n s .

A c o mp u t e r o u t p u t l i s t i n g t h e r a n k o r d e r o f d i s e a s e p r o b a b i l i t y b a s e d u p o n a s i mp l e l i s t o f s y mp t o ms a n d s i g n s ma y r e a s s u r e p h y s i c i a n s w h o f e a r t h e y w i l l f o r g e t a d i s e a s e f o r i n c l u s i o n i n t h e d i f f e r e n t i a l d i a g n o s i s . S u c h a l i s t mi g h t b e v a l u a b l e i n s o l v i n g c o mp l e x p r o b l e ms o f d i f f e r e n t i a l d i a g n o s i s , o r i d e n t i f y i n g r a r e d i s e a s e s , b u t i t s u t i l i t y f o r a n e xp e r i e n c e d c l i n i c i a n i s p r o b a b l y t o o l o w t o e n c o u r a g e i t s u s e f o r mo s t p r o b l e ms . M o r e o v e r, y o u s t i l l mu s t h a v e t h e e xp e r i e n c e a n d j u d g me n t t o e v a l u a t e t h e l i s t a n d d e t e r mi n e w h i c h i t e ms t o p u r s u e a n d h o w. If y o u h a v e t h o s e s k i l l s , y o u p r o b a b l y d o n o t n e e d t h e c o mp u t e r - g e n e r a t e d l i s t .

U n d o u b t e d l y, t e c h n o l o g i c p r o g r e s s w i l l p r o v i d e p h y s i c i a n s w i t h n e w o p p o r t u n i t i e s f o c o mp u t e r a s s i s t a n c e i n t h e d i a g n o s t i c e xa mi n a t i o n . S a t i s f a c t o r y a n s w e r s t o a f e w
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b a s i c q u e s t i o n s s h o u l d p r e c e d e t h e a d o p t i o n o f a c o mp u t e r - a s s i s t e d d i a g n o s t i c s y s t e m: W h o d e v e l o p e d t h e p r o g r a m a n d w i t h w h i c h d a t a ? H o w f r e q u e n t l y w i l l t h e p r o g r a m b e u p d a t e d a n d b y w h oim? r[ R A, G a r d n e r R M . S u mma r y M lle r e c o mme n d a t i o n s f o r r e s p o n s i b l e mo n i t o r i n g a n d r e g u l a t i o n o f c l i n i c a l s o f t w a r e s y s t e ms Ann I nt er n M ed9 9 7 ; 1 2 7 : 8 4 2 8 4 5 i l l i t s a v e t i me ? Is i t p o r t a b l e ? H o w . 1 ]. W w i l l a c c e s s t o c o n f i d e n t i a l i n f o r ma t i o n b e c o n t r o l l e d ? H o w e xp e n s i v e i s i t ?

Tests of the Diagnosis


In c h o o s i n g a d i a g n o s i s f r o m s e v e r a l h y p o t h e s e s , t h e ma t c h i n g o f t h e p a t i e n t ' s a t t r i b u t e s w i t h t h o s e o f t h e h y p o t h e t i c a l d i s e a s e ma y n o t b e e n t i r e l y c o n c l u s i v e . S e v e r a l a d d i t i o n a l c r i t e r i a ma y b e u s e d t o h e l p e l u c i d a t e t h e mo s t l i k e l y d i a g n o s i s .

Parsimony

T h e d i a g n o s i s h a s a h i g h e r p r o b a b i l i t y o f b e i n g c o r r e c t i f o n e d i s e a s e c a n e xp l a i n t h e e n t i r e c l u s t e r o f c l u e s , r a t h e r t h a n a t t e mp t i n g t o a c c o u n t f o r t h e f i n d i n g s b y a c o i n c i d e n c e o f s e v e r a l d i s e a s e s . T h i s i s k n o w n a s O c c a m' s r a zo r : t h e s i mp l e s t s o l u t i o n i s l i k e l y t o b e c o r r e c t . W h e n o n e d i a g n o s i s d o e s n o t e xp l a i n a l l t h e f i n d i n g s those that are able to account for the greatest proportion of the patient's signs and s y mp t o ms a r e mo s t l i k e l y t o b e c o r r e c t . O l d e r p e r s o n s mo r e o f t e n h a v e t w o o r mo r e coincident disorders.

Chronology
It i s p o s s i b l e t o h a v e a p e r f e c t ma t c h o f a t t r i b u t e s b e t w e e n p a t i e n t a n d d i s e a s e , b u i f t h e e p i d e mi o l o g y, o n s e t , a n d c o u r s e a r e n o t a p p r o p r i a t e t o t h e d i s e a s e , t h e hypothesis is probably wrong.

Sev erity of Illness

N o t i n f r e q u e n t l y, a n i n e xp e r i e n c e d c l i n i c i a n w i l l d i a g n o s e t h e p a t i e n t ' s c o n d i t i o n a s , f o r i n s t a n c e , a n u p p e r r e s p i r a t o r y i n f e c t i o n , w h e r e a s a mo r e e xp e r i e n c e d c l i n i c i a n w i l l l o o k a t t h e p a t i e n t a n d s u g g e s t t h e d i a g n o s i s o f p n e u mo n i a , e xp l a i n i n g t h a t t h e patient looks too sick for the first P. 11 condition. T he severity of illness is valid and diagnostically useful, but it is difficul e xp l a i n o r d e s c r i b e .

Prognosis

If t w o h y p o t h e s e s s e e m e q u a l l y p r o b a b l e a n d n e i t h e r c a n b e p r o v e d i mme d i a t e l y, t h e p a t i e n t s h o u l d b e i n f o r me d o f t h e d i a g n o s t i c a n d p r o g n o s t i c p o s s i b i l i t i e s a n d e n c o u r a g e d t o d i s c u s s t h i s w i t h h i s f a mi l y. In t h e s e s i t u a t i o n s , w e h a v e f o u n d i t b e s to help the patient prepare for the worst and hope for the best. Regular follow-up a frequent reevaluation are required. Often, referral to a specialist will help both the p a t i e n t a n d t h e p h y s i c i a n d e a l w i t h t h e u n c e r t a i n t y.

Therapeutic Trials

If t h e r e i s u n c e r t a i n t y b e t w e e n a n u n t r e a t a b l e mo r b i d d i s e a s e a n d o n e w i t h p o t e n t i a l l y s u c c e s s f u l t h e r a p y, t r y a t h e r a p e u t i c t r i a l . Al t h o u g h e xp e r i e n c e s h o w s t h s u c h t r i a l s a r e o f t e n i n c o n c l u s i v e o r d i f f i c u l t t o i n t e r p r e t , t h e y ma y s a v e a l i f e ; f o r
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e xa mp l e , w h e n a p p e n d i c i t i s c a n n o t b e e xc l u d e d , p e r f o r m a n a p p e n d e c t o my a c c e p t i n t h a t s o me n o r ma l a p p e n d i c e s w i l l b e r e mo v e d .

Selection of Diagnostic Tests

E xp e r i e n c e d c l i n i c i a n s s e l e c t d i a g n o s t i c t e s t s i n d i c a t e d b y c l u e s f r o m t h e h i s t o r y a n t h e p h y s i c a l e xa mi n a t i o n . T h e y h a v e r e p e a t e d l y l e a r n e d t h a t r o u t i n e t e s t i n g o r u n c r i t i c a l t e s t i n g f o r r e mo t e d i a g n o s t i c p o s s i b i l i t i e s f r e q u e n t l y y i e l d r e s u l t s t h a t r e q u i r e e xp l a n a t i o n b y mo r e t e s t i n g , a l l w i t h o u t a n s w e r i n g t h e p r i ma r y d i a g n o s t i c q u e s t i o n . T h i s c a s c a d e e f f e c t h e i g h t e n s t h e p a t i e n t ' s a n xi e t y, i s h a za r d o u s a n d e xp e n s i v e , a n d d e l a y s t r e a t me n C hS e ee r 1 7o r a d i s c u s s i o n o f t h e a p p r o p r i a t e t. apt f selection of diagnostic tests.

Rare Diseases

S o me p h y s i c i a n s , e s p e c i a l l y t h e i n e xp e r t , h a v e a t e n d e n c y t o d i a g n o s e r a r e d i s e a s e w i t h u n c o mmo n f r e q u e n c y. It i s w e l l t o r e c a l l t h a t r a r e d i s e a s e s o c c u r r a r e l y. T h e o l s a y i n g i s , w h e n y o u h e a r h o o f b e a t s t h i n k o f h o r s e s , n o t ze b r a s . J u s t r e me mb e r, t h i s w o r k s i n Ame r i c a , n o t Af r i c a , s o y o u n e e d t o k n o w t h e e p i d e mi o l o g y a n d d e mo g r a p h i c s o f y o u r p a t i e n t a n d p a t i e n t p o p u l a t i o n b e f o r e y o u r e a l l y k n o w w h a t i s c o mmo n a n d w h a t i s r a r e .

Certainty and Diagnosis

W h e n a d i a g n o s i s i s e s t a b l i s h e d f o r t h e p a t i e n t , h o w c e r t a i n s h o u l d t h e e xa mi n e r b e t h a t i t i s c o r r e c t ? U n f o r t u n a t e l y, t h e r e i s n o a c c e p t e d s c a l e o f d e g r e e s o f c e r t a i n t y w h e r e b y t h e e xa mi n e r c a n e xp r e s s t h e e xt e n t t o w h i c h t h e d i a g n o s i s h a s b e e n e s t a b l i s h e d . O n t h e o n e h a n d , t h e d i a g n o s i s i s d e f i n e d b y t h e i ma g e , t h e l a b o r a t o r y test, the culture, or the biopsy result. For instance, a fracture of the tibia is d i a g n o s e d w h e n t h e f r a c t u r e c a n b e s e e n o n t h e x- r a y f i l m w i t h a b s o l u t e a s s u r a n c e . Many P. 1 2 t y p e s o f n e o p l a s i a a n d i n f l a mma t o r y d i s e a s e s a r e d i a g n o s e d b y b i o p s y. C u l t u r e , s e r o l o g y o r p o l y me r a s e c h a i n r e a c t i o n ( P C R ) i d e n t i f i c a t i o n o f s p e c i f i c o r g a n i s ms establishes the diagnosis of specific infectious diseases. Laboratory tests are s p e c i f i c f o r e n d o c r i n e a n d me t a b o l i c d i s e a s e s . O n t h e o t h e r h a n d , w e s p e a k o f a d i a g n o s i s o f r h e u ma t o i d a r t h r i t i s , w h e r e o f t e n t h e r e i s mu c h l e s s c e r t a i n t y, a n d n o definitive diagnostic tests. T he diagnosis is supported by the clinical picture, and b s u c h n o n s p e c i f i c t e s t s a s x- r a y e xa mi n a t i o n s a n d t e s t s f o r r h e u ma t o i d f a c t o r.

In e a c h c l i n i c a l s i t u a t i o n , t h e c l i n i c i a n mu s t c o n s c i o u s l y e s t a b l i s h a s t o p p i n g r u l e . T h a t i s , t h e c l i n i c i a n mu s t d e c i d e h o w mu c h c e r t a i n t y i s r e q u i r e d , a n d s t o p f u r t h e r investigation when that point is reached. T his decision is based upon the severity o t h e i l l n e s s , a n e s t i ma t e o f t h e p r o g n o s i s ( b a s e d u p o n t h e s e v e r i t y o f i l l n e s s a n d t h e p a t i e n t ' s c o mo r b i d i t i e s ) , a n d w h e t h e r a s p e c i f i c d i a g n o s i s i s n e e d e d t o g u i d e a d e c i s i o n b e t w e e n mu t u a l l y e xc l u s i v e i n t e r v e n t i o n s w h i c h w o u l d h a r m t h e p a t i e n t i f a p p l i e d t o t h e w r o n g d i s e a s e ; f o r e xa mp l e , a n t i b i o t i c s o r c o r t i c o s t e r o i d s .

Deferred Diagnoses
When a satisfactory diagnosis cannot be identified, the physician can proceed with
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t h e f o l l o w i n g f i v e s u p p l e me n t a r y s t e p s .

Repeat the History and the Physical Examination

T h i s t e s t s t h e p a t i e n t ' s me mo r y ; i t ma y p r o v e t o h a v e b e e n f a u l t y, o r r e c a l l ma y h a v b e e n s t i mu l a t e d b y t h e f i r s t i n q u i r y. Ta l k t o mo r e r e l a t i v e s a n d a t t e n d a n t s t o c o n f i r m or deny the original story and to add details. Carefully repeat the physical e xa mi n a t i o n t o c o n f i r m y o u r p r e v i o u s e v a l u a t i o n a n d t o s e a r c h f o r s i g n s t h a t w e r e o v e r l o o k e d t h e f i r s t t i me .

Repeat Laboratory Tests


S p e c i me n s ma y h a v e b e e n mi xe d o n t h e i n i t i a l o c c a s i o n , o r a n e r r o r i n t h e f i r s t t e s t ma y b e u n c o v e r e d .

Make a Prov isional Diagnosis

Al t h o u g h a me t i c u l o u s p h y s i c i a n ma y q u a l i f y t h e d i a g n o s i s b y t h e w o r d p r o b a b l e o r q u e s t i o n ma r k , t h e s e mo d i f i e r s o f t e n g e t d r o p p e d w h e n t h e r e c o r d h a s p a s s e d t h r o u g h s e v e r a l t r a n s c r i p t i o n s . U n f o r t u n a t e l y, t h e s e i mp o r t a n t a d j e c t i v e s a n d a d v e r b ma y b e i mp a t i e n t l y d i s c a r d e d b y l a w y e r s , i n s u r a n c e a d j u s t o r s , a n d me d i c a l c h a r t c o d e r s . O t h e r s t a t e me n t s o f u n c e r t a i n t y a r e p r e l i mi n a r y d i a g n o s i s , d i a g n o s t i c i mp r e s s i o n , t e n t a t i v e d i a g n o s i s , w o r k i n g d i a g n o s i s , p r o v i s i o n a l d i a g n o s i s , a n d probable diagnosis.

Defer Diagnosis
C a r e f u l l y e xp l a i n t h e s i t u a t i o n t o s e c u r e t h e p a t i e n t ' s c o n f i d e n c e s o t h a t a r e t u r n e xa mi n a t i o n ma y b e ma d e w h e n n e w s y mp t o ms o r s i g n s h a v e a p p e a r e d o r t i me h a s g i v e n mo r e p e r s p e c t i v e t o t h e c a s e . R e t a i n t h e P. 1 3 p r o b l e m l i s t , b u t ma r k t h e r e c o r d D i a g n o s i s D e f e r r e d ; d o n o t l e t t h e me d i c a l r e c o r r u l e s o r t h e i n s u r a n c e c o mp a n y f o r c e a p r e ma t u r e d i a g n o s i s .

Seek Wise Consultation

Often presenting the case to colleagues as an unknown and asking for their input, o s e e k i n g c o n s u l t a t i o n w i t h a n e xc e l l e n t g e n e r a l i s t o r a p p r o p r i a t e s u b s p e c i a l i s t w i l l a s s i s t i n ma k i n g t h e d i a g n o s i s , a n d , e v e n i f n o t , ma y r e a s s u r e t h e p a t i e n t a n d p h y s i c i a n . It i s b e t t e r t o o f f e r t h i s o p t i o n t o t h e p a t i e n t t h a n t o w a i t f o r t h e p a t i e n t t i n s i s t o u t o f f r u s t r a t i o n . H o w e v e r, a v o i d e xc e s s i v e c o n s u l t a t i o n o r v i s i t s t o mu l t i p l e p h y s i c i a n s . L i k e e xc e s s i v e l a b o r a t o r y t e s t i n g , t h i s i s mo r e l i k e l y t o a d d c o n f u s i o n t h a n c l a r i t y.

A Summary of the Diagnostic Process


Step 1: Take a History
E l i c i t s y mp t o ms a n d t h e p a t t e r n o f t h e i l l n e s s t o b e g i n a p r o b l e m l i s t .

Step 2: Dev elop Hypotheses


G e n e r a t e a me n t a l l i s t o f p a t h o p h y s i o l o g i c p r o c e s s e s a n d d i s e a s e s t h a t mi g h t p r o d u c e t h e s y mp t o ms .
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Step 3: Perform a Physical Examination


L o o k f o r s i g n s o f t h e p h y s i o l o g i c p r o c e s s e s a n d d i s e a s e s s u g g e s t e d b y t h e h i s t o r y, and identify new findings for the problem list.

Step 4: Generate a Differential Diagnoses


L i s t t h e mo s t p r o b a b l e h y p o t h e s e s i n t h e o r d e r o f t h e i r p r o b a b i l i t y.

Step 5: Test the Hypotheses


S e l e c t l a b o r a t o r y t e s t s , i ma g i n g s t u d i e s , a n d o t h e r p r o c e d u r e s w i t h a p p r o p r i a t e likelihood ratios to evaluate your hypotheses.

Step 6: Modify your Differential Diagnosis


U s e t h e r e s u l t s o f a l l o f t h e t e s t s t o e v a l u a t e y o u r h y p o t h e s e s , p e r h a p s e l i mi n a t i n g s o me a n d a d d i n g o t h e r s a n d a d j u s t i n g t h e p r o b a b i l i t i e s .

Step 7: Repeat Steps 1 to 6

Reiterate your process until you have reached a diagnosis or decided that a definite d i a g n o s i s i s n e i t h e r l i k e l y o r n e c e s s a r y.

Step 8: Make the Diagnosis or Diagnoses


W h e n t h e t e s t s o f y o u r h y p o t h e s e s a r e o f s u f f i c i e n t c e r t a i n t y t h a t t h e y me e t y o u r stopping rule, you have reached a diagnosis.

Step 9: If Uncertain, Consider a Prov isional Diagnosis or Watchful Waiting


D e c i d e w h e t h e r mo r e i n v e s t i g a t i o n ( r e t u r n t o s t e p 1 ) , c o n s u l t a t i o n , t r e a t me n t , o r watchful observation is the best course based upon the severity P. 1 4 o f i l l n e s s , t h e p r o g n o s i s , a n d c o mo r b i d i t i e s . If t h e d i a g n o s i s r e ma i n s o b s c u r e , r e t a i a p r o b l e m l i s t o f t h e u n e xp l a i n e d s y mp t o ms a n d s i g n s , a s w e l l a s l a b o r a t o r y a n d i ma g i n g f i n d i n g s , a s s e s s t h e u r g e n c y f o r f u r t h e r e v a l u a t i o n a n d s c h e d u l e r e g u l a r follow-up visits.

Caveat

T h e c o mp l e x p r o c e s s w e h a v e d i s c u s s e d i s p r i ma r i l y s u i t e d t o t h e p r o b l e ms o f c h r o n i c a n d r e l a t i v e l y o b s c u r e d i s e a s e s c o mmo n l y e n c o u n t e r e d i n t h e f i e l d s o f i n t e r n a l me d i c i n e a n d p e d i a t r i c s . A ma j o r i t y o f p a t i e n t s s e e n b y mo s t p h y s i c i a n s d o n o t r e q u i r e s u c h a c o mp r e h e n s i v e p r o c e s s . Al t h o u g h t h e p r i n c i p l e s o f d i a g n o s i s h o l d f o r a l l p a t i e n t s , v a r i a t i o n s f r o m t h e d e s c r i b e d p r o c e s s ma y b e a p p r o p r i a t e f o r a g i v e p a t i e n t ' s c o n d i t i o n a n d t h e me d i c a l o r s u r g i c a l s p e c i a l t y i n v o l v e d . M a n y c o n d i t i o n s r e q u i r i n g mi n o r s u r g e r y n e e d f e w o r n o s y mp t o ms t o ma k e a d i a g n o s i s ; t h e s i t u a t i o n i s o b v i o u s b y n o t i n g t h e a n a t o mi c d e r a n g e me n t o r b y t a k i n g x- r a y f i l ms . T h e d e r ma t o l o g i s t c a n ma k e ma n y d i a g n o s e s w i t h o u t h e a r i n g a b o u t a n y s y mp t o ms . O n the other hand, the psychiatrist leans heavily on the history given by friends, r e l a t i v e s , a n d a t t e n d a n t s , a n d o n d i a l o g u e w i t h t h e p a t i e n t . It f o l l o w s t h a t t h e s c o p e
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a n d l e n g t h o f t h e h i s t o r y v a r y g r e a t l y a mo n g me d i c a l s p e c i a l t i e s .

An Example of the Diagnostic Process

T h e o b j e c t i v e o f t h e d i a g n o s t i c e xa mi n a t i o n i s t o d i s c o v e r t h e p h y s i o l o g i c c a u s e o f t h e p a t i e n t ' s c o mp l a i n t , i d e n t i f y t h e s p e c i f i c d i s e a s e , a n d d e t e r mi n e t h e s e v e r i t y a n p r o g n o s i s o f t h e d i s e a s e . Yo u n e e d t h e s e d a t a t o c o u n s e l y o u r p a t i e n t r e g a r d i n g t h e i n d i c a t i o n s f o r t r e a t me n t .

A 2 1 - y e a r - o l d w o ma n c o n s u l t s y o u a b o u t a p a i n l e s s l u mp i n h e r n e c k ( s y mp t o m) . Yo u c o n s i d e r h e r a g e a n d s e l e c t h y p o t h e s e s t h a t i n c l u d e l y mp h o ma , i n f e c t i o n , a n d c o l l a g e n v a s c u l a r d i s e a s e , w h i c h l e a d t o q u e s t i o n s a b o u t f e v e r, i t c h i n g , w e i g h t l o s s e xp o s u r e t o p e t s , t u b e r c u l o s i s , a r t h r a l g i a s , a n d R a y n a u d p h e n o me n o n . Yo u r e xa mi n a t i o n r e v e a l s a s i n g l e , f i r m, 3 - c m n o n t e n d e r l y mp h n o d e i n t h e r i g h t c e r v i c a l chain (sign), but the spleen is not palpable and there are no other signs of disease T h e p a t i e n t ' s b l o o d c o u n t s a r e n o r ma l ( l a b ) , a n d a b i o p s y o f t h e e n l a r g e d n o d e ( s u p p l e me n t a l t e s t ) d i s c l o s e s H o d g k i n d i s e a s e . B o n e ma r r o w b i o p s y a n d i ma g i n g s t u d i e s o f t h e c h e s t a n d a b d o me n f a i l t o r e v e a l mo r e d i s e a s e ( p r o g n o s i s a n d s t a g i n tests). Yo u ma k e a d i a g n o s i s o f s t a g e I H o d g k i n d i s e a s e a n d d i s c u s s t h e d i a g n o s i s w i t h y o u r p a t i e n t , i n f o r mi n g h e r o f t h e p r o g n o s i s w i t h o u t t r e a t me n t , a n d t h e r i s k s a n d benefits of radiotherapy at this stage of the disease.

The Autopsy

T h e g o l d s t a n d a r d s i n c e t h e mi d - n i n e t e e n t h c e n t u r y f o r d i a g n o s t i c a c c u r a c y h a s b e e n t h e a u t o p s y, a n d i t r e ma i n s s o . U n f o r t u n a t e l y, a u t o p s y r a t e s h a v e d e c l i n e d i n r e c e n t d e c a d e s , a n d w i t h t h e m v a l u a b l e l e a r n i n g e xp e r i e n c e s f o r p h y s i c i a n s t o v a l i d a t e o r c o r r e c t t h e i r d i a g n o s t i c i mp r e s s i o n s . P. 1 5 In t h e c u r r e n t c l i ma t e ma n y p h y s i c i a n s h a v e n o t l e a r n e d t h e v a l u e o f a n a u t o p s y a n d ma n y f a mi l i e s h a v e n o t r e c e i v e d a f u l l e xp l a n a t i o n o f t h e d i s e a s e s o f t h e i r l o v e d o n e s . D e s p i t e t h e c u r r e n t a b u n d a n c e o f l a b o r a t o r y t e s t s a n d i ma g i n g t e c h n o l o g i e s , there is considerable evidence that clinical diagnoses in difficult cases are not u n c o mmo n l y w r o n g , t h a t s i g n i f i c a n t d i s e a s e i s mi s s e d , a n d t h a t t h e a d d i t i o n o f t e c h n o l o g y h a s n o t s u b s t a n t i a l l y a l t e r e d t h eK ie cfh c t s S c h a f i C . M i s d i a g n o s i s s r a W, [ a t a u n i v e r s i t y h o s p i t a l i n 4 me d i c a l edia s .ne ( Bal t i mor e)9 6 ; 7 5 : 2 9 ]4 0 M er ci 19 . P h y s i c i a n s s h o u l d w o r k c l o s e l y w i t h p a t i e n t s a n d t h e i r f a mi l i e s t o e n c o u r a g e a u t o p s i e s i n mo s t i n - h o s p i t a l d e a t h s . T h i s i s a c r i t i c a l p a r t o f o u r p r o f e s s i o n a l d e v e l o p me n t a n d t h e c o n t i n u o u s s t r u g g l e t o i mp r o v e o u r c lM ci Pa le s kSl Js [ in c h e i l . T h e a u t o p s y. An a n t i d o t e t o mi s d i a g nediic i.ne ( Bal t i mor e)9 6 ; 7 5 : 4 1 ]4 3T h e M os s 19 . i s s u e i s n o t o n e o f a s s i g n i n g b l a me o r r e s p o n s i b i l i t y, i t i s o n e o f i mp r o v i n g o u r diagnostic and therapeutic strategies. P. 1 6

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 1 - T h e D i a g n o s t i c F r a me w o r k > C h a p t e r 2 - H i s t o r y Ta k i n g a n d t h e M e d i c a l R e c o r d

Chapter 2 History Taking and the M edical Record


P. 1 7

. . . [ T] her e i s no mor e di f f i c ul t ar t t o ac qui r e t han t he ar t of obs er v at i on, and f or s ome men i t i s qui t e as di f f i c ul t t o r ec or d an obs er v at i on i n br i ef and pl ai n l anguage.
- -S i r W i l l i a m O s l e r

P r o p e r c a r e o f a p a t i e n t o v e r t i me r e q u i r e s t h a t a c o mp l e t e me d i c a l r e c o r d b e k e p t a t h e s i t e o f c a r e . T h e r e c o r d s h o u l d r e c o r d , p r e f e r a b l y o n s t a n d a r d i ze d f o r ms , b a s i c p a t i e n t d a t a , s u c h a s t h e i r d e mo g r a p h i c s , l i s t o f a c t i v e a n d p a s t me d i c a l p r o b l e ms , s u r g i c a l h i s t o r y, i n j u r y h i s t o r y, me d i c a t i o n h i s t o r y, a l l e r g i e s a n d d r u g i n t o l e r a n c e s , s e xu a l h i s t o r y, f a mi l y h i s t o r y, s o c i a l h i s t o r y, p e r s o n a l h a b i t s , p r o s t h e s e s u s e d , p r e v e n t i v e c a r e s e r v i c e s , a n d s p e c i f i c c o u n s e l i n g p r o v i d e d . U s i n g s t a n d a r d i ze d f o r m e n a b l e s t h e i n f o r ma t i o n t o b e r e c o r d e d i n a u n i f o r m w a y f o r e a c h p a t i e n t , a l l o w i n g r a p i d r e v i e w o f t h e p e r t i n e n t i n f o r ma t i o n a t e a c h v i s i t . W h e n r e c o r d i n g i n f o r ma t i o n o t h e s e f o r ms , i t i s i mp o r t a n t t o e n t e r i n f o r ma t i o n i n s u c h a w a y t h a t i t i s a l w a y s c u r r e n t ; f o r e xa mp l e , i n t h e f a mi l y h i s t o r y r e c o r d , t h e f i r s t n a me s o f c h i l d r e n a n d siblings with their year of birth (rather than age).

Outline of the Medical Record

T h e p a r t s o f t h e me d i c a l h i s t o r y f o l l o w a s t a n d a r d i ze d s e q u e n c e , d i f f e r i n g o n l y i n s ma l l d e t a i l s f r o m o n e i n s t i t u t i o n t o a n o t h e r. T h e f o l l o w i n g s e q u e n c e i s u s e d f o r a d u p a t i e n t s i n t h e D e p a r t me n t o f In t e r n a l M e d i c i n e a t t h e U n i v e r s i t y o f Io w a . A d i f f e r e n order is usually preferred by pediatricians, who set the birth history and the past history ahead of the present illness. I. Id e n t i f i c a t i o n II. In f o r ma n t III. C h i e f C o mp l a i n t s ( C C ) IV. H i s t o r y o f P r e s e n t Il l n e s s ( H P I) V. P a s t M e d i c a l a n d S u r g i c a l H i s t o r y ( P H ) A. G e n e r a l h e a l t h B. C h r o n i c a n d e p i s o d i c i l l n e s s e s
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P. 1 8 C. O p e r a t i o n s a n d i n j u r i e s D. P r e v i o u s h o s p i t a l i za t i o n s VI. F a mi l y H i s t o r y ( F H ) VII. S o c i a l H i s t o r y ( S H ) VIII R e v i e w o f S y s t e ms ( R O S ) . IX. M e d i c a t i o n s X. Al l e r g i e s a n d M e d i c a t i o n In t o l e r a n c e s XI. P r e v e n t i v e C a r e S e r v i c e s XII. P h y s i c a l E xa mi n a t i o n ( P E ) XIII L a b o r a t o r y a n d Ima g i n g S t u d i e s . XIV As s e s s me n t . XV. P l a n

Procedure for Taking the History Definition of the M edical History

T h e me d i c a l h i s t o r y i s a n a c c o u n t o f t h e e v e n t s i n t h e p a t i e n t ' s l i f e t h a t h a v e r e l e v a n c e t o t h e p a t i e n t ' s me n t a l a n d p h y s i c a l h e a l t h . M u c h mo r e t h a n t h e p a t i e n t ' s u n p r o mp t e d n a r r a t i v e , i t i s a s p e c i a l i ze d l i t e r a r y f o r m i n w h i c h t h e p h y s i c i a n w r i t e s a c c o u n t o f t h e p e r c e p t i o n s a n d e v e n t s s u p p l i e d b y t h e p a t i e n t o r o t h e r i n f o r ma n t s . T h e h i s t o r y ma y b e o f f e r e d s p o n t a n e o u s l y o r s e c u r e d b y s k i l l f u l p r o b i n g . O f t e n , a d d i t i o n a l h i s t o r y i s r e v e a l e d b y r e p e a t e d q u e s t i o n i n g o v e r t i me , a s t h e p a t i e n t i s e n c o u r a g e d t o r e f l e c t o n h e r e xp e r i e n c e . In t a k i n g t h e h i s t o r y, t h e c l i n i c i a n s h o u l d r e c o r d k e y s t a t e me n t s i n t h e p a t i e n t ' sThe rhis .t or y i s t he pat i ent ' s hi s t or y of wo d s t hei r i l l nes s , not t he phy s i c i an' s i nt er pr et at i on of t he pat i T h e' sc hinsi t or y. ent l i c i a n s h o u l d t a k e p a r t i c u l a r c a r e t o e s t a b l i s h t h e s e q u e n c eThe e v eni tc i .an' s t as k of cl i n s at t hi s t i me i s t o t r y t o under s t and t he pat i ent ' s ex per i enc e and i nt er pr et at i on of he i l l nes s .

Scope of the History

W h e n p a t i e n t s c o n s u l t t h e i r p h y s i c i a n s f o r d e r ma t i t i s , t h e n e c e s s a r y d i a g n o s t i c history is very brief, possibly only a few sentences. For a person brought into the hospital with a fractured tibia, a long diagnostic history is unnecessary and even i n h u ma n e . In c o n t r a s t , a c h r o n i c , o b s c u r e d i s e a s e ma y r e q u i r e a l o n g , c a r e f u l h i s t o r p e r h a p s r e p e a t e d a n d e xp a n d e d , w i t h s u p p l e me n t s f r o m t i me t o t i me a s t h e r e s u l t s o further studies open new diagnostic possibilities. Writings on history taking always d i s c u s s t h e e xt e n d e d h i s t o r y, w h i c h i s c o mp l i c a t e d a n d d e ma n d s ma xi ma l s k i l l . H o w e v e r, i t w o u l d b e f o l l y t o i n s i s t o n a n e xt e n d e d h i s t o r y f o r e v e r y p a t i e n t ; i n ma n c o n d i t i o n s , i t w o u l d b e u n n e c e s s a r y, a n d b y i n s i s t i n g o n i t t h e p h y s i c i a n w o u l d b e a b l e t o c a r e f o r o n l y a f e w p a t i e n t s i n a d a y. T h e e xp e r i e n c e d p h y s i c i a n a d j u s t s t o t h e p a t i e n t ' s p r o b l e ms . To t e s t i f t h e h i s t o r y i s s u f f i c i e n t f o r t h e i n d i v i d u a l c a s e , a s
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yourself if you can picture the patient's lifestyle and how the patient's illness affect it and is affected by it. P. 1 9

M ethods in History Taking

T h e b e s t h i s t o r y i s o b t a i n e d b y t h e c l i n i c i a n w h o i s e mp a t h e t i c w i t h t h e p a t i e n t , k n o w s t h e ma n i f e s t a t i o n s o f d i s e a s e , a n d u n d e r s t a n d s h o w p a t i e n t s d e s c r i b e t h e s y mp t o ms o f v a r i o u s d i s e a s e s . Yo u r s k i l l i n h i s t o r y t a k i n g w i l l c o n t i n u e t o i mp r o v e t mo r e y o u l e a r n o f p e o p l e , l i f e , a n d d i s e a s e . T h e f a c e - t o - f a c e i n t e r a c t i o n o f t a k i n g a g o o d h i s t o r y p e r mi t s y o u t o s e e t h e e mp h a s i s y o u r p a t i e n t p u t s o n h i s o r h e r s y mp t o ms , a l l o w s y o u t o l e a r n a b o u t y o u r p a t i e n t ' s p e r s o n a l i t y, a n d p r o v i d e s a n o p p o r t u n i t y t o d e v e l o p a s u p p o r t i v e p h y s i c i a n p a t i e n t r e l a t i o n s h i p . U s e o f me d i c a l i n t a k e q u e s t i o n n a i r e s t o a s s i s t i n o b t a i n i n g a c o mp l e t e me d i c a l , f a mi l y, a n d s o c i a l h i s t o r y w i t h i n t h e t i me c o n s t r a i n t s o f p r a c t i c e i s e n c o u r a g eP G[, C u r t i s J R , R a ms e y d P a a u w D S , e t a l . H i s t o r y - t a k i n g a n d p r e v e n t i v e me d i c i n e s k i l l s a mo n g p r i ma r y c a r e p h y s i c i a n s : An a s s e s s me n t u s i n g s t a n d a r d i ze d Am t iJe n t ed1 9 9 8 ; 1 0 4 : 1 5 2 pa M s. 158. ]

W e b e l i e v e t h a t e xt e n s i v e w r i t t e n i n s t r u c t i o n s a b o u t i n t e r r o g a t i o n o f t h e p a t i e n t a r e u n r e w a r d i n g ; y o u c a n o n l y b e c o me p r o f i c i e n t a t h i s t o r y t a k i n g b y a c t u a l l y interviewing patients. A few guidelines are useful: (a) listen actively; (b) don't interrupt the patient; (c) ask open-ended questions; and (d) be patient, give the p a t i e n t t i me t o t h i n k a n d s p e a k .

C l i n i c a l e xp e r i e n c e , a n d r e f l e c t i o n u p o n y o u r e xp e r i e n c e , i s n e c e s s a r y t o l i n k y o u r knowledge of diseases with the history being obtained from the patient without c o n s c i o u s t h o u g h t . W h e n a d i s e a s e o r s y n d r o me t h u s c o me s t o mi n d , i t s h o u l d r e c a l a c l u s t e r o f s y mp t o ms a n d s i g n s a n d c h r o n o l o g i c d a t a a b o u t w h i c h t o a s k t h e p a t i e n W h e n y o u h a v e a c q u i r e d t h i s k n o w l e d g e a n d e xp e r i e n c e , y o u c a n f a c e t h e p a t i e n t c o n f i d e n t l y a n d r e a d i l y i mp r o v i s e me t h o d s o f i n t e r r o g a t i o n . Ta k i n g a d i a g n o s t i c h i s t o r y h a s f o u r o b j e c t i v e s : ( a ) d i s c o v e r i n g s y mp t o ms , ( b ) obtaining accurate quantitative descriptions, (c) securing a precise chronology of e v e n t s , a n d ( d ) d e t e r mi n i n g h o w t h e i l l n e s s h a s c h a n g e d t h e p a t i e n t ' s l i f e .

Conducting the Interview


Arrangement

T h i s d e s c r i p t i o n d e a l s w i t h t h e t a k i n g o f a n e xt e n d e d h i s t o r y i n t h e p h y s i c i a n ' s c l i n i i n t h e f o l l o w i n g c i r c u ms t a n c e s : t h e p a t i e n t i s i n n o a c u t e d i s t r e s s ; t i me l i mi t a t i o n s a n o t u r g e n t ; a n d t h e d i s e a s e i s r e l a t i v e l y o b s c u r e . C i r c u ms t a n c e s o f t e n v a r y g r e a t l y from these stipulations.

Ad d r e s s p a t i e n t s f o r ma l l y, d o n o t u s e t h e i r f i r s t n a me u n l e s s t h e y r e q u e s t i t . T h e conversation should not be overhead by others, although the presence of the p a t i e n t ' s s p o u s e o r a r e l a t i v e i s o f t e n h e l p f u l i n c o n f i r mi n g t h e n a r r a t i v e a n d s u p p l e me n t i n g t h e p a t i e n t ' s o b s e r v a t i o n s . L i mi t t h e i n t e r v i e w t o t h e p a t i e n t a n d o n e o t h e r i n f o r ma n t ; mo r e i n f o r ma n t s w a s t e t i me i n t h e i r d i s a g r e e me n t s o n d e t a i l s t h a t o u t w e i g h t h e s l i g h t e xt r a y i e l d o f i n f o r ma t i o n .
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Physician's Manner

To o b t a i n t h e p a t i e n t ' s c o n f i d e n c e a n d r a p p o r t , p r e s e n t y o u r s e l f a s u n h u r r i e d , i n t e r e s t e d , a n d s y mp a t h e t i c . S i t a t e y e l e v e l w i t h o u t a d e s k b e t w e e n P. 2 0 y o u . In n o w a y s h o u l d y o u e xp r e s s a mo r a l j u d g me n t o n t h e p a t i e n t ' s a c t i o n s o r b e l i e f s . P e r mi t p a t i e n t s t o b e g i n t h e i r s t o r y i n t h e i r o w n w a y ; l i s t e n f o r s e v e r a l mi n u t e s b e f o r e g r a d u a l l y i n j e c t i n g q u e s t i o n s t o g u i d e t h e i n t e r v i e w. G e n t l y, b u t f i r m k e e p t h e d i s c u s s i o n c e n t e r e d o n t h e p a t i e n t ' s p r o b l e ms . B y a l l me a n s , a v o i d discussing your own health, even when a patient invites you to do so.

Note Taking

W r i t e s p a r i n g l y w h i l e t h e p a t i e n t t a l k s . Af t e r y o u h a v e r e c o r d e d s o me r o u t i n e d a t a , b a c k a n di s t ent o t h e n a r r a t i v e f o r a w h i l e , i n t e r j e c t i n g o n l y a f e w q u e s t i o n s . Av o i d l w r i t i n g t h e p a t i e n t ' s n a r r a t i v e v e r b a t i m; i t i s u s u a l l y t o o l e n g t h y a n d p o o r l y o r g a n i ze U s e o f s t a n d a r d i ze d f o r ms f o r r e c o r d i n g t h e p a s t me d i c a l h i s t o r y, f a mi l y h i s t o r y, a n d social history (which can be filled out by the patient before the interview) will great d e c r e a s e t h e n e e d f o r ma k i n g n o t e s . R e me mb e r t h a t t h e p a t i e n t i s t e l l i n g y o u a s t o r y o u s h o u l d t r y t o u n d e r s t a n d t h e i r s t o r y a n d r e me mb e r k e y w o r d s a n d p h r a s e s . T hese can be jotted down to assist recall.

Language
F r o m t h e b e g i n n i n g , g a u g e t h e p a t i e n t ' s me a n i n g o f t h e w o r d s t h e y u s e ; w o r d s ma y h a v e d i f f e r e n t me a n i n g s f o r d i f f e r e n t p e o p l e . P u t y o u r q u e s t i o n s i n s i mp l e , n o n t e c h n i c a l w o r d s . E v e n l a y w o r d s ma y b e mi s u n d e r s t o o d . T h e E n g l i s h v o c a b u l a r y i s v a s t a n d f o r mi d a b l e , e v e n t o t h e s c h o l a r. E xc l u d i n g y o u r s c i e n t i f i c a n d me d i c a l v o c a b u l a r y, y o u ma y b e a b l e t o u s e 1 0 0 , 0 0 0 w o r d s , w h i l e t h e a d u l t w i t h a v e r a g e e d u c a t i o n g e t s a l o n g w i t h 3 0 , 0 0 0 t o 6 0 , 0 0 0 . S o t h e p a t i e n t ma y n o t k n o w h a l f t h e w o r d s y o u u s e i n E n g l i s h . P a t i e n t s ma y l e a v e t h e i n t e r v i e w w i t h t h e f e a r t h a t t h e y h a v e p r e s e n t e d t h e i r s y mp t o ms p o o r l y b e c a u s e t h e y h a v e a n s w e r e d q u e s t i o n s t h e y did not understand.

Belief Systems

P h y s i c i a n s a r e t r a i n e d i n t h e s c i e n t i f i c me t h o d a n d i n s c i e n c e - b a s e d r u l e s o f e v i d e n c e . F o r ma n y p a t i e n t s , i f n o t mo s t , t h i s i s n o t t h e s t r u c t u r e o f t h e i r b e l i e f s y s t e m. O t h e r b e l i e f s y s t e ms i n c l u d e ma g i c , r e l i g i o n , a n d r a t i o n a l i s m. It i s e s s e n t i a to understand how the patient views cause and effect, to what sources they attribut disease and illness. T he clinician's task is to understand the patient; it is not, p r i ma r i l y, t h e p a t i e n t ' s t a s k t o u n d e r s t a n d t h e c l i n i c i a n . E d u c a t i o n o f p a t i e n t s b e c o me s a n i mp o r t a n t p a r t o f p r o v i d i n g p r o p e r c a r e f o r ma n y c h r o n i c d i s e a s e s .

Patient's Motiv ation


T h e u s e f u l n e s s o f t h e h i s t o r y f o r d i a g n o s i s d e p e n d s o n t h e a s s u mp t i o n , f r e q u e n t l y f o r g o t t e n , t h a t t h e p a t i e n t ' s s o l e mo t i v e i s t o a s s i s t t h e p h y s i c i a n i n d i a g n o s i s a n d t r e a t me n t , a n d , t h e r e f o r e , t h e d e s c r i p t i o n s o f t h e p a t i e n t ' s s y mp t o ms a r e t r u t h f u l . A f a r a s p o s s i b l e , t h i s a s s u mp t i o n mu s t b e c o n f i r me d b y e xc l u d i n g o t h e r mo t i v e s t h a t mi g h t p r o mp t mi s r e p r e s e n t a t i o n . S o me p a t i e n t s , e n t i r e l y t r u t h f u l , p r e s e n t s y mp t o ms t h a t a r e b a f f l i n g u n t i l t h e p h y s i c i a n l e a r n s o f t h e i r r e s e mb l a n c e t o t h o s e o f a f r i e n d
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t h a t a r e b a f f l i n g u n t i l t h e p h y s i c i a n l e a r n s o f t h e i r r e s e mb l a n c e t o t h o s e o f a f r i e n d r e l a t i v e w h o h a s d i e d o f c a n c e r, a n d t h e p a t i e n t f e a r s t h e s a me f a t e . T h e p h y s i c i a n mu s t a s c e r t a i n w h e t h e r t h e p a t i e n t i s c o n t e mp l a t i n g P. 2 1 a l a w s u i t f o r d a ma g e s , c l a i mi n g w o r k e r ' s c o mp e n s a t i o n , o r a p p l y i n g f o r v e t e r a n ' s b e n e f i t s . T h e n a r c o t i c a d d i c t ma y p r e s e n t s y mp t o ms c a l c u l a t e d t o o b t a i n d r u g s . L a c k i n g d i s c e r n i b l e mo t i v e s , a f e w p a t i e n t s f a b r i c a t e me d i c a l h i s t o r i e s t h a t ma y l e a t o e xt e n s i v e d i a g n o s t i c e xa mi n a t i o n s [R . M u n c h a u s e n ' s s y n d rLanc.et As h e r o me 1 9 5 1 ; 1 : 3 3 9 3]4 1 .

Procedure

Af t e r i n t r o d u c i n g y o u r s e l f a n d c o n f i r mi n g t h e i d e n t i f y i n g d a t a f o r t h e p a t i e n t , s t a r t t p a t i e n t ' s n a r r a t i v e b y s a y i n g , Te l l me a b o u t y o u r p r o b l e m, o r G i v e me y o u r s t o r y. D o n ' t a s k , W h a t i s t h e ma t t e r w i t h y o u ? o r W h a t i s t r o u b l i n g y o u ? b e c a u s e t h e p a t i e n t i s l i k e l y t o r e s p o n d , T h a t ' s w h a t I c a me h e r e t o f i n d o u t . L i s t e n t o t h e s t o r w i t h o u t i n t e r r u p t i o n f o r s e v e r a l mi n u t e s ; u s e o p e n - e n d e d q u e s t i o n s t o e n c o u r a g e t h p a t i e n t t o s p e a k . Af t e r t h e g e n e r a l o u t l i n e b e c o me s a p p a r e n t , y o u ma y n e e d t o a s k s p e c i f i c d i r e c t e d q u e s t i o n s t o e s t a b l i s h t h e n a t u r e o f t h e s y mp t o ms , t h e me d i c a t i o n , t h e c h r o n o l o g y, a n d t h e d i s a b i l i t y. Al s o a s k a b o u t s y mp t o ms n o t me n t i o n e d t h a t a r e p r o mp t e d b y y o u r s e a r c h f o r d i a g n o s t i c c l u e s . T h e n p a u s e a n d w r i t e d o w n n o t e s t o assist your recall, including key words and phrases.

N e xt , r e c o r d a n y r e ma i n i n g i n f o r ma t i o n t o c o mp l e t e t h e p a s t me d i c a l h i s t o r y ; s u r g i c a h i s t o r y ; i n j u r y h i s t o r y ; r e v i e w o f me d i c a t i o n s a n d a l l e r g i e s ; f a mi l y h i s t o r y ; s o c i a l h i s t o r y ; s e xu a l , o b s t e t r i c a l , a n d g y n e c o l o g i c h i s t o r y ; r e v i e w o f s y s t e ms a n d p r e v e n t i v e c a r e h i s t o r y, i n c l u d i n g p r o c e d u r e s ( e . g . , ma mmo g r a p h y, c o l o n o s c o p y ) ; t e s t s ( e . g . P a p s me a r s , p u r i f i e d p r o t e i n d e r i v a t i v e [ P P D ] ) ; a n d i mmu n i za t i o n s .

Com pletion of the Medical Record

It i s t h e c l i n i c i a n ' s r e s p o n s i b i l i t y t o s e e t h a t t h e me d i c a l r e c o r d i s c o mp l e t e a n d a c c u r a t e . Yo u r s i g n a t u r e a t t e s t s t o t h e a c c u r a c y o f t h e i n f o r ma t i o n a n d t h a t y o u h a v v e r i f i e d i t t o y o u r s a t i s f a c t i o n . ent er ed and s i gned, t he i nf or mat i on i n t he Onc e medi c al r ec or d c annot be al ttero u g h a d d e n d u ms a n d c o r r e c t i o n s added. h ed, can be

Identification

Data under this heading are frequently recorded by the physician's receptionist or the hospital registration clerk. During the history taking, the physician should check t h e a c c u r a c y o f a l l p r e v i o u s l y r e c o r d e d i t e ms .

Patient's Name

In s i s t o n r e c o r d i n g t h e c o mp l e t e n a me , i n c l u d i n g t h e f a mi l y n a me a n d a l l g i v e n n a me s . T h e f a mi l y n a me s h o u l d b e p l a c e d f i r s t , f o l l o w e d b y a c o mma a n d a l l g i v e n n a me s . B e c a r e f u l t o o b t a i n t h e c o r r e c t s p e l l i n g . An y me d i c a l r e c o r d s d e p a r t me n t o f c o n s i d e r a b l e s i ze c o n t a i n s t h e r e c o r d s o f s e v e r a l p a t i e n t s w i t h i d e n t i c a l o r c l o s e l y s i mi l a r n a me s . B e c a u s e f a t a l e r r o r s h a v e o c c u r r e d w h e n t w o p a t i e n t s w i t h t h e s a me n a me h a v e b e e n u n d e r t r e a t me n t i n t h e h o s p i t a l s i mu l t a n e o u s l y, e a c h p a t i e n t P. 2 2 i s g i v e n a u n i q u e h o s p i t a l n u mb e r, w h i c h s h o u l d b e u s e d f o r i d e n t i f i c a t i o n b e f o r e a
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t r e a t me n t i s i n s t i t u t e d .

F o r a ma r r i e d w o ma n w h o h a s t a k e n h e r h u s b a n d ' s n a me , u s e h e r o w n g i v e n n a me s a f t e r t h e f a mi l y n a me o f h e r h u s b a n d ; a f t e r t h e s e , p l a c e h e r h u s b a n d ' s g i v e n n a me s i n p a r e n t h e s e s , a s B r o w n , M a r y E l i za b e t h ( M r s . E d w a r d C h a r l e s ) . T h i s a r r a n g e me n t i s n e c e s s a r y b e c a u s e s h e ma y s i g n h e r n a me a s M r s . E d w a r d C . B r o w n i n correspondence about her case. She can be distinguished from other Mary Browns w i t h d i f f e r i n g mi d d l e n a me s . D e t e r mi n e w h e t h e r s h e w i s h e s t o b e a d d r e s s e d a s M s . or Mrs.

Sex
U s u a l l y, t h i s i s o b v i o u s . In c a s e s o f i n t e r s e x, t h e p r o b l e m o f s e x ma y b e d i f f i c u l t t o e s t a b l i s h a c c u r a t e l y, b u t i t i s s u f f i c i e n t t o g i v e t h e s e x t h e p a t i e n t h a s a s s u me d .

Residence
T h e a d d r e s s s h o u l d b e c o n f i r me d a n d r e c o r d e d a s c o mp l e t e l y a s p o s s i b l e t o f a c i l i t a t e e f f i c i e n t ma i l i n g o f c o r r e s p o n d e n c e . O c c a s i o n a l l y, t h e a d d r e s s i s u s e d t o d i s t i n g u i s h t h e i d e n t i t y o f t w o p a t i e n t s w i t h t h e s a me n a me .

Birth Date and Age

T h e p a t i e n t ' s s t a t e me n t o f t h e b i r t h d a t e s h o u l d b e r e c o r d e d , i n a d d i t i o n t o t h e s t a t a g e . T h e b i r t h d a t e i s r e q u i r e d f o r mo s t i n s u r a n c e c l a i ms . C o mp a r i s o n o f i t w i t h t h e s t a t e d a g e o n s u b s e q u e n t h o s p i t a l v i s i t s ma y d i s c l o s e d i s c r e p a n c i e s , r e f l e c t i n g o n t h e p a t i e n t ' s v e r a c i t y o r me mo r y. T h e b i r t h d a t e ma y h e l p d i s t i n g u i s h b e t w e e n p a t i e n t s w i t h t h e s a me n a me .

Source of Referral
If y o u r p a t i e n t w a s r e f e r r e d b y a n o t h e r p h y s i c i a n , c o n f i r m t h e n a me , a d d r e s s , t e l e p h o n e n u mb e r, a n d r e a s o n f o r r e f e r r a l .

The Informant
The Sources of the History

T h e h i s t o r y ma y b e o b t a i n e d f r o m t h e p a t i e n t o r o t h e r s . In e i t h e r c a s e , r e c o r d y o u r j u d g me n t o f t h e a c c u r a c y a n d c r e d i b i l i t y o f t h e i n f o r ma n t ' s a n s w e r s . E r r o r s a r e frequent when orientation is judged from a casual conversation. A person who c o n v e r s e s n o r ma l l y ma y, o n d i r e c t q u e s t i o n i n g , b e u n a b l e t o t e l l t h e d a y o f t h e w e e k t h e mo n t h , t h e y e a r, o r e v e n t h e n a me o f t h e c i t y w h e r e y o u a r e me e t i n g .

Interpreters

When the patient does not speak your language, be cautious about interpreters who a r e n o t me d i c a l l y t r a i n e d . A f r e q u e n t e xp e r i e n c e w i t h a l a y i n t e r p r e t e r r e s e mb l e s t h e f o l l o w i n g . Yo u a s k , D o e s t h e p a t i e n t h a v e a n y p a i n ? T h e i n t e r p r e t e r e n g a g e s t h e p a t i e n t i n a n i ma t e d c o n v e r s a t i o n i n l a n g u a g e i n c o mp r e h e n s i b l e t o y o u . Af t e r 3 o r 4 mi n u t e s , mu c h P. 2 3 l o n g e r t h a n a s i mp l e q u e s t i o n s h o u l d t a k e , y o u t h i n k s u r e l y t h e i n t e r p r e t e r w i l l p r o v i d e y o u w i t h a d e t a i l e d s t o r y. F i n a l l y, t h e i n t e r p r e t e r t u r n s b a c k t o y o u a n d s a y s
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p r o v i d e y o u w i t h a d e t a i l e d s t o r y. F i n a l l y, t h e i n t e r p r e t e r t u r n s b a c k t o y o u a n d s a y s N o , s h e d o e s n ' t h a v e a n y p a i n . If y o u c o u l d h a v e f o l l o w e d t h i s my s t e r i o u s e xc h a n g e , y o u w o u l d h a v e f o u n d t h a t t h e i n t e r p r e t e r h a d e mb r a c e d t h e o p p o r t u n i t y a p p l y h i s o r h e r c o n c e p t s o f me d i c i n e t o h i s t o r y t a k i n g a n d h a d s t a t e d a l l s o r t s o f q u e s t i o n s t h a t y o u d i d n o t p r o p o s e . Yo u c a n n o t e v a l u a t e t h e a n s w e r s u n l e s s y o u k n o w w h a t q u e s t i o n s w e r e a s k e d . Yo u r o n l y r e c o u r s e i s t o a s k s h o r t q u e s t i o n s a n d f i r ml y i n s i s t t h a t t h e r e s u l t i n g c o n v e r s a t i o n i s n o t l o n g e r t h a n y o u j u d g e n e c e s s a r y your question.

Chief Complaints

T h e h i s t o r y o f s y mp t o ms b e g i n s w i t h t h e c h i e f c o mp l a i n t s , a b b r e v i a t e d C C . T h e s e s h o u l d c o n s i s t o f a l i s t o f o n e o r mo r e s y mp t o ms t h a t c a u s e d t h e p a t i e n t t o s e e k a t t e n t i o n . T h e c o mp l a i n t s a r e u s u a l l y t a b u l a t e d , e a c h o n a s e p a r a t e l i n e , f o l l o w e d b t h e a p p r o xi ma t e d u r a t i o n i n t i me u n i t s ; t h e y a r e w r i t t e n a s w o r d s o r p h r a s e s , n o t a s c o mp l e t e s e n t e n c e s . C o mp l a i n t s a r e n o t d i a g n o s e s b y t h e p h y s i c i a n o r t h e p a t i e n t . i s c u s t o ma r y t o a d v i s e t h e p a t i e n t t o s t a t e t h e c h i e f c o mp l a i n t s i n t h e p a t i e n t ' s o w n w o r d s s o t h a t i n t e r p r e t a t i o n d o e s n o t a l t e r t h e m. T h e p a t i e n t ' s w o r d s ma y b e s o a mb i g u o u s a s t o b e u s e l e s s w i t h o u t f u r t h e r i n t e r r o g a t i o n . T h e c h i e f c o mp l a i n t s s h o u l d b e e xp r e s s e d a s t h e p r o b l e ms o f mo s t c o n c e r n t o t h e p a t i e n t .

T h e r e a r e t w o p u r p o s e s f o r i s o l a t i n g c e r t a i n s y mp t o ms a s c h i e f c o mp l a i n t s . F i r s t , t h e y o f t e n s e r v e a s i mp o r t a n t c l u e s w i t h w h i c h t o b e g i n ma k i n g a d i f f e r e n t i a l d i a g n o s i s ; t h e d e t a i l s o f t h e s e s y mp t o ms s h o u l d a l w a y s b e s o u g h t o u t . S e c o n d i s t o r e mi n d y o u t h a t t h e s e a r e t h e s y mp t o ms t h a t b r o u g h t t h e p a t i e n t t o s e e k t r e a t me n t ; t h e y r e q u i r e t h e r a p y o r a n e xp l a n a t i o n o f w h y t h e r a p y i s n o t g i v e n . T h e p a t i e n t ' s c h i e f c o mp l a i n t s h o u l d b e t h e f i r s t p r o b l e m o n y o u r p r o b l e m l i s t . T h i s w o u l d s e e m obvious, but occasionally the physician finds an interesting disease, entirely u n r e l a t e d t o t h e c h i e f c o mp l a i n t s ; t h e me d i c a l l y a t t r a c t i v e c o n d i t i o n r e c e i v e s a l l t h e a t t e n t i o n , a n d t h e c h i e f c o mp l a i n t s a r e i g n o r e d . In e l i c i t i n g t h e c h i e f c o mp l a i n t s , d o n o t p r e s s p a t i e n t s f o r t h e m t o o e a r l y i n t h e i n t e r v i e w. P a t i e n t s w i l l b e b e t t e r a b l e t o s e l e c t t h e m a f t e r t h e y h a v e t o l d s o me o f t h e i r s t o r y ; y o u ma y h a v e t o h e l p i d e n t i f y t h e m. O c c a s i o n a l l y, w h e n p a t i e n t s a r e a s k e d f o r t h e i r s y mp t o ms , t h e y p r o d u c e a p i e c e o f p a p e r c o n t a i n i n g a l i s t o f n o t e s . T h e F r e n c h l a b e l tlh i s a mal adi e de pet i t papi o r me r l y, t h i s p r a c t i c e w a s F er. considered a sign of neurosis. Many doctors now encourage their patients to keep t r a c k o f s y mp t o ms , s i g n s , t e mp e r a t u r e , b l o o d p r e s s u r e , w e i g h t , b l o o d s u g a r s , b l o o d c o u n t s , a n d t h e l i k e , s o a s t o o b t a i n a mo r e a c c u r a t e e v a l u a t i o n o f t h e i r p r o g r e s s .

History of Present Illness (HPI)


Symptoms

T h e w o r d s y mp t o m i s d e r i v e d f r o m a G r e e k w o r d me a n i n g s o me t h i n g t h a t h a s b e f a l l e n o n e . A s y mp t o m i s u s u a l l y c o n s i d e r e d t o b e a n a b n o r ma l P. 2 4 sensation that is perceived by the patient, in contrast to a physical sign that can be s e e n , f e l t , o r h e a r d b y t h e e xa mi n e r. T h e e l e me n t s o f t h e me d i c a l h i s t o r y c a n b e c l a s s i f i e d a s ( a ) s e n s a t i o n s t h a t c a n n e v e r b e o b s e r v e d b y t h e e xa mi n e r ; ( b ) a b n o r ma l i t i e s n o t e d b y t h e p a t i e n t a t s o me p a s t t i me s o t h e y c a n n o t b e c o n f i r me d b
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t h e p h y s i c a l e xa mi n a t i o n ; ( c ) e v e n t s i n t h e p a s t , n o t r e a d i l y v e r i f i a b l e , s u c h a s f o r m d i a g n o s e s o r t r e a t me n t s ; a n d ( d ) t h e p a t i e n t ' s u n d e r s t a n d i n g o f t h e i r f a mi l y h i s t o r y a n d d e s c r i p t i o n o f t h e i r s o c i a l s i t u a t i o n . D i a g n o s t i c e v a l u a t i o n o f a s y mp t o m i s s i mp w h e n t h e p a t i e n t s a y s , I' v e f o u n d a l u mp i n my n e c k ( s y mp t o m) , a n d t h e e xa mi n e r c a n p a l p a t e a ma s s ( p h y s i c a l s i g n ) . B u t w h e n t h e p a t i e n t c o mp l a i n s o f p a i n i n t h e c h e s t a n d n o p h y s i c a l s i g n s c a n b e d e t e c t e d , mu c h mo r e i n f o r ma t i o n a b o u t t h e n a t u r e o f t h e p a i n i s r e q u i r e d b e f o r e t h e s y mp t o m c a n s e r v e a s a d i a g n o s t i c c l u e . Yo u c a n o b t a i n mo r e d i a g n o s t i c i n f o r ma t i o n b y f u r t h e r q u e s t i o n i n g t h e p a t i e n t a b o u t t h e a t t r i b u t e s o f h i s s y mp t o ms . S p e c i f i c a l l y a s k va b o u t v e o r l l i a t i v e Pr o o c a t i Pa ma n e u v e r sQu a l i t y o f t h e s y mp t o m,Re g i o n i n v o l v e d , tSe v e r i t y a nT e mp o r a l , the he d p a t t e r n o f t h e s y mp t o m. U s e t h e iP QtRa l s a s a mn e mo n i c t o r e me mb e r t o a s k ni i ST t h e s e q u e s t i o n s . S e e t h e d i s c u s s i o n o fhp a itn r( ,4p a g e 9 5 ) a s a n e xa mp l e . C ap e

T h e h i s t o r y o f p r e s e n t i l l n e s s i s t h e h e a r t o f t h e d i a g n o s t i c h i s t o r y. It s h o u l d b e w r i t t e n a s a l u c i d , s u c c i n c t , c h r o n o l o g i c n a r r a t i v e w i t h c o mp l e t e s e n t e n c e s i n g o o d E n g l i s h . T h e p a t i e n t ' s s y mp t o ms s h o u l d b e a c c u r a t e l y r e c o r d e d i n t h e i r o w n w o r d s ; i n s i s t o n s y mp t o ms f r o m t h e p a t i e n t a n d d o n o t a c c e p t d i a g n o s e s o r me d i c a l j a r g o n . W h e n a s y mp t o m i s me n t i o n e d t h a t s u g g e s t s s e v e r a l c o n d i t i o n s , a c c o mp a n y i t w i t h s t a t e me n t s a b o u t t h e a b s e n c e o f c o n c o mi t a n t s y mp t o ms t h a t y o u h a v e a s c e r t a i n e d b y d i r e c t q u e s t i o n i n g ( p e r t i n e n t n e g a t i v e s ) . F o r e xa mp l e , w h e n t h e p a t i e n t h a s h a d a t t a c k s o f p a i n i n t h e r i g h t u p p e r a b d o mi n a l q u a d r a n t , y o u r d e s c r i p t i o n s h o u l d include the fact that jaundice was not present, the urine was not dark-colored, no p r u r i t u s w a s e xp e r i e n c e d , a n d t h e p a i n d i d n o t r a d i a t e t o t h e r i g h t s c a p u l a ( a l l s i g n a n d s y mp t o ms o f h e p a t o b i l i a r y d i s e a s e ) .

Id e a l l y, t h e H P I s h o u l d b e b r i e f , s o t h a t i t i s e a s i l y r e a d a n d d i g e s t e d . T h i s o b j e c t i v c a n o n l y b e a c h i e v e d i f t h e d i a g n o s i s i s r e l a t i v e l y s i mp l e a n d e a s i l y ma d e . W h e n t h c o n d i t i o n i s o b s c u r e , t h e a u t h o r i n c l u d e s mo r e d e t a i l s , b e i n g u n c e r t a i n w h a t i s p e r t i n e n t a n d w i l l u l t i ma t e l y b e u s e f u l . B e c a u s e o f t h i s u n c e r t a i n t y, t h e c l i n i c i a n mu a v o i d o v e r i n t e r p r e t a t i o n o f t h e p a t i e n t ' s h i s t o r y, r e p l a c e me n t o f t h e i r w o r d s w i t h i n t e r p r e t i v e me d i c a l t e r mi n o l o g y, a n d e l i mi n a t i o n o f s e e mi n g l y i r r e l e v a n t d e t a i l s .

Searching for Diagnostic Clues

T h e c h i e f p u r p o s e o f t h e h i s t o r y i s t o f u r n i s h c l u e s f o r d i a g n o s i s . As t h e n a r r a t i v e u n f o l d s , y o u s h o u l d b e s i mu l t a n e o u s l y p e r f o r mi n g t h r e e o p e r a t i o n s : ( a ) t h e a c c u mu l a t i o n o f f a c t s ( o b t a i n i n g t h e h i s t o r y ) , ( b ) e v a l u a t i o n o f t h e f a c t s ( t e s t i n g t h e c r e d i b i l i t y o f s y mp t o ms , s e e k i n g mo r e d e t a i l s o f t i me a n d q u a n t i t y ) , a n d ( c ) p r e p a r a t i o n o f h y p o t h e s e s . H a v i n g f o r me d a l i s t o f h y p o t h e s e s , q u e s t i o n t h e p a t i e n t a b o u t o t h e r s y mp t o ms s p e c i f i c f o r d i s e a s e s o n t h e l i s t , e i t h e r t o s u p p o r t o r t o d i s c a a h y p o t h e s i s . F o r e xa mp l e , w h e n t h e p a t i e n t c o mp l a i n s o f p a i n i n t h e c h e s t , P. 2 5 a s k i f i t i s r e l a t e d t o r e s p i r a t o r y mo v e me n t s . A p o s i t i v e a n s w e r p r o mp t s q u e s t i o n s a b o u t i n f l a me d mu s c l e s , f r a c t u r e d r i b s , a n d p l e u r i s y. W h e n t h e p a t i e n t d e n i e s e xa c e r b a t i o n o f p a i n b y t h o r a c i c mo v e me n t , a s k f o r a n a s s o c i a t i o n w i t h e xe r t i o n a n d d i s t r i b u t i o n o f p a i n r e s e mb l i n g t h a t o f a n g i n a p e c t o r i s . If t h e p a t i e n t a d mi t s t o s u c h distribution, then ask about onset of pain and its duration. T hus, each step in the narrative leads to another run through the sequence, resulting in frequent shifts in the list of hypotheses.
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Nature of the Symptoms


T h e p a t i e n t ' s d e s c r i p t i o n o f s y mp t o ms mu s t b e c l a r i f i e d a n d q u a n t i f i e d .

C lar ific ation.

Q u e s t i o n t h e p a t i e n t u n t i l s u f f i c i e n t d e t a i l s a r e o b t a i n e d t o c a t e g o r i ze t h e s y mp t o m. D o n o t a c c e p t v a g u e c o mp l a i n t s s u c h a s I d o n ' t f e e l w e l l . If t h e p a t i e n t c o mp l a i n s w e a k n e s s , a s c e r t a i n i f s h e i s w e a k i n o n e o r mo r e mu s c l e g r o u p s o r i f s h e e xp e r i e n c e s l a s s i t u d e , ma l a i s e , o r my a l g i a . W h e n a p a t i e n t s a y s s h e i s d i zzy, i n q u i r if she feels weak and unstable or if her surroundings seem to whirl about, as in v e r t i g o . D e t e r mi n e w h e t h e r d y s p n e a o c c u r s a t r e s t o r w i t h e xe r t i o n .

Quantific ation.

Q u a n t i f i c a t i o n i s i mp o r t a n t t o t h e e v a l u a t i o n o f s y mp t o ms . Av o i d r e c o r d i n g a s y mp t o w i t h o u t a s t a t e me n t o f q u a n t i t y. A w o ma n ma y t e l l y o u t h a t s h e h a s a t e r r i b l e p a i n , b u t h e r r e ma r k a t t a i n s a d i f f e r e n t s i g n i f i c a n c e w h e n s h e a d mi t s o n q u e s t i o n i n g t h a t t h e p a i n h a s n e v e r i n t e r f e r e d w i t h h e r w o r k , s l e e p , o r o t h e r a c t i v i t i e s . Al t h o u g h p a i n c a n n o t b e me a s u r e d , i t s s e v e r i t y c a n b e j u d g e d b y h o w i t a f f e c t s t h e p a t i e n t . E xe r t i o n a l d y s p n e a c a n b e a s s e s s e d b y t h e a mo u n t o f e xe r t i o n r e q u i r e d t o p r o d u c e i t ; f o r e xa mp l e , a s k , C a n y o u c l i mb a f l i g h t o f s t a i r s ? C a n y o u w a l k t w o b l o c k s w i t h o u t s t o p p i n g ? N e i t h e r y o u n o r y o u r r e a d e r c a n i n t e r p r e t w h a t a h e a v y s mo k e r me a n s . H e a v y i s a v a l u e j u d g me n t w h o s e me a n i n g v a r i e s f r o m o n e p e r s o n t o a n o t h e r ; b u t a r e c o r d o f s mo k i n g 2 0 c i g a r e t t e s a d a y i s a me a s u r e e v e r y o n e c a n u n d e r s t a n d . D o n ' t l a b e l a p a t i e n t a s a n a l c o h o l i c ; p u t d o w n t h e v o l u me o f a l c o h o l t h e p a t i e n t d r i n k s i n a s t a t e d t i me . T h e p a t i e n t w h o h a d h e mo p t y s i s s h o u l d b e i n s t r u c t e d t o e s t i ma t e t h e a mo u n t o f b l o o d l o s t i n h o u s e h o l d me a s u r e s , s u c h a s t e a s p o o n f u l s , c u p f u l s , o r q u a r t s . T h e a mo u n t o f s p u t u m r a i s e d s h o u l d b e r e c o r d e d ; t h e v o l u me s e r v e s a s a n i mp o r t a n t c o n s i d e r a t i o n i n d i f f e r e n t i a l d i a g n o s i s .

C hr onology.

T h e d u r a t i o n o f a s y mp t o m a n d i t s t i me o f a p p e a r a n c e i n t h e c o u r s e o f d i s e a s e a r e frequently significant for diagnosis. When the disease is chronic and the course c o mp l i c a t e d , t h e p a t i e n t ma y d i s c l a i m a b i l i t y t o p l a c e e v e n t s i n c h r o n o l o g i c s e q u e n c e . A w o r k c h a r t ma y b e s k e t c h e d t h a t w i l l a s s i s t t h e p a t i e n t i n c l a r i f y i n g t h e d e t a i l s . O n a p i e c e o f p a p e r, t h e p h y s i c i a n d r a w s a s e r i e s o f s t e p s , w i t h t h e i r h o r i zo n t a l d i me n s i o n s r e p r e s e n t i n g d u r a t i o n i n a p p r o xi ma t e t i me u n i t s , s u c h a s d a y s w e e k s , mo n t h s , o r y e a r s . Af t e r l a b e l i n g t h e t i me u n i t s , t h e p h y s i c i a n i n d i c a t e s o n t h chart the few dates supplied by the patient. Seeing the chart, the patient can f r e q u e n t l y r e c a l l f u r t h e r d e t a i l s a n d i n d i c a t e t h e o c c u r r e n c e o f s y mp t o ms o n t h e t i m s c a l e . T h e s e q u e n c e a n d d o s e s o f me d i c a t i o n c a n a l s o b e g r a p h e d . P. 2 6

C ur r e nt Ac tivity.

In c l u d e t h i s i n a s e p a r a t e p a r a g r a p h o f t h e P r e s e n t Il l n e s s . T h e p h y s i c i a n n e e d s t d e t e r mi n e h o w t h e d i s e a s e h a s d i mi n i s h e d t h e p a t i e n t ' s q u a l i t y o f l i f e a n d w h e t h e r t h e r a p y h a s i mp r o v e d i t . T h i s i n f o r ma t i o n i s a l s o n e e d e d t o s u b s t a n t i a t e t h e p a t i e n t claim for insurance. Obtain a detailed picture of the patient's average day to
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evaluate the patient's reaction to illness, the severity of the disease, and the r e s p o n s e t o t h e r a p y.

S um m ar iz ation.

Review your understanding of the history and ask the patient for corrections and c o n f i r ma t i o n . Te s t t h e c o mp l e t e n e s s o f y o u r h i s t o r y b y a s k i n g w h e t h e r y o u r s u mma r c o n v e y s a c l e a r p i c t u r e o f t h e p a t i e n t ' s e xp e r i e n c e o f t h e i r i l l n e s s , t h a t i s , h o w t h e i l l n e s s h a s a f f e c t e d t h e m a n d t h e i r f a mi l y, h o w i t h a s i n t e r f e r e d w i t h t h e i r w o r k , a n d h o w t h e s y mp t o ms h a v e p r o g r e s s e d .

Past M edical and Surgical History

O r d i n a r i l y, t h e i t e ms i n t h e p a s t h i s t o r y h a v e l e s s d i a g n o s t i c v a l u e . If t h e y p r o v i d e c l u e s f o r t h e d i a g n o s i s , t h e f a c t s ma y b e i n t e r p o l a t e d i n t h e p r e s e n t i l l n e s s , b u t t h e still should be recorded separately in this section. T he significance of past illnesse ma y b e a p p r e c i a t e d a f t e r f u t u r e d e v e l o p me n t s i n t h e p a t i e n t ' s c o n d i t i o n a n d a s n e w r e c o g n i ze d d i s e a s e a s s o c i a t i o n s a r e r e p o r t e d .

General Health

T h e p a t i e n t ' s l i f e t i me h e a l t h , b e f o r e t h e p r e s e n t i l l n e s s , i s s o me t i me s r e v e a l i n g . F a c t o r s t o c o n s i d e r i n c l u d e b o d y w e i g h t ( p r e s e n t , ma xi mu m, a n d mi n i mu m, w i t h d a t e o f e a c h ) , p r e v i o u s p h y s i c a l e xa mi n a t i o n s ( d a t e s a n d f i n d i n g s ) , a n d a n y p e r i o d s o f me d i c a l d i s a b i l i t y.

Chronic and Episodic Illnesses


C hr onic M e dic al I llne s s .

L i s t a l l i l l n e s s f o r w h i c h t h e p a t i e n t r e c e i v e s , o r h a s r e c e i v e d , c h r o n i c me d i c a l t r e a t me n t s . T h e s e i n c l u d e , b u t a r e n o t l i mi t e d t o , o b e s i t y, d i a b e t e s , h y p e r t e n s i o n , g o u t , r h e u ma t o i d a r t h r i t i s , c a n c e r, p s y c h i a t r i c i l l n e s s e s , s e i zu r e d i s o r d e r s , a n d s l e e disorders.

I nfe c tious D is e as e s .

In f e c t i o u s d i s e a s e s h a v e h a d a n i mp o r t a n t h i s t o r y i n me d i c i n e . K n o w l e d g e o f p a s t i n f e c t i o n s i s i mp o r t a n t t o u n d e r s t a n d c u r r e n t a n d f u t u r e i n f e c t i o n r i s k . L i s t d a t e s a n c o mp l i c a t i o n s o f me a s l e s , G e r ma n me a s l e s , mu mp s , w h o o p i n g c o u g h , c h i c k e n p o x, s ma l l p o x, d i p h t h e r i a , t y p h o i d f e v e r, ma l a r i a , h e p a t i t i s , s c a r l e t f e v e r, r h e u ma t i c f e v e c h o r e a , p n e u mo n i a , t u b e r c u l o s i s , s e xu a l l y t r a n s mi t t e d d i s e a s e s , a n d H IV. G i v e d a t e o f c h e mo t h e r a p y a n d a n t i b i o t i c t r e a t me n t . In c l u d e r e a c t i o n s t o a n t i b i o t i c s u n d e r t h e h e a d i n g , Al l e r g i e s a n d M e d i c a t i o n In t o l e r a n c e s .

Operations and Injuries


Give dates and nature of injuries, operations, operative diagnoses, and infection, h e mo r r h a g e o r o t h e r c o mp l i c a t i o n s . P. 2 7

Prev ious Hospitalizations


R e c o r d e a c h h o s p i t a l i za t i o n , i n c l u d i n g t h e d a t e s a n d n a me s o f h o s p i t a l s a n d t h e i r
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l o c a t i o n s . If t h e h o s p i t a l r e c o r d s a r e a v a i l a b l e , s u mma r i ze t h e d a t e s a n d d i a g n o s e s f o r e a c h a d mi s s i o n .

Family History (FH)

A f a mi l y h i s t o r y i s e s s e n t i a l f o r a l l p a t i e n t s r e c e i v i n g mo r e t h a n t h e mo s t c u r s o r y o f care. T his should include four generations, when available: grandparents, parents, aunts and uncles, siblings, and children. For parents and grandparents, record the birth year and current health or age at death and causes. For aunts, uncles, sibling a n d c h i l d r e n , r e c o r d t h e b i r t h y e a r, f i r s t n a me , a n d c u r r e n t h e a l t h o r c a u s e o f d e a t h a n d a g e a t d e a t h . M a k e n o t e o f a n y f a mi l y h i s t o r y o f h y p e r t e n s i o n , h e a r t d i s e a s e , d i a b e t e s , k i d n e y d i s e a s e , a u t o i mmu n e d i s e a s e s , g o u t , a t o p y, a s t h ma , o b e s i t y, endocrine disorders, osteoporosis, cancer (particularly breast, colon, ovarian and e n d o c r i n e c a n c e r s ) , h e mo p h i l i a o r o t h e r b l e e d i n g d i s e a s e s , v e n o u s t h r o mb o e mb o l i s m, s t r o k e , mi g r a i n e , n e u r o l o g i c o r mu s c u l a r d i s o r d e r s , me n t a l o r e mo t i o n a l d i s t u r b a n c e s , s u b s t a n c e a b u s e , a n d e p i l e p s y.

Social History (SH)


Place of Birth.
T h i s i n f o r ma t i o n ma y b e u s e f u l i n a s s e s s i n g s o c i a l o r n a t i o n a l i n c i d e n c e o f d i s e a s e T h e e xa mi n e r ma y g a i n s o me i n s i g h t i n t o t h e p r o b a b i l i t y o f t h e p a t i e n t ' s u n d e r s t a n d i n g t h e n u a n c e s o f t h e E n g l i s h l a n g u a g e i n g i v i n g a h i s t o r y.

Nationality and Ethnicity.

T h e c o r r e c t c l a s s i f i c a t i o n ma y r e q u i r e c o n s i d e r a b l e k n o w l e d g e o f g e o g r a p h y, h i s t o r y a n d a n t h r o p o l o g y. T h e p a t i e n t ma y n o t b e a b l e t o g i v e a p r e c i s e a n s w e r. It ma y b e helpful to learn the nationality and ethnicity of the parents. Ethnic and genetic b a c k g r o u n d s a r e o f s o me i mp o r t a n c e i n d i a g n o s i s , f o r e xa mp l e , o f d i s e a s e s s u c h a s h e mo g l o b i n o p a t h i e s a n d F a mi l i a l M e d i t e r r a n e a n F e v e r.

Marital Status.
U n d e r t h i s h e a d i n g , n o t e w h e t h e r t h e p a t i e n t i s s i n g l e , ma r r i e d , d i v o r c e d , o r w i d o w e d , a n d t h e d u r a t i o n o f e a c h ma r r i a g e a n d a n e xp l a n a t i o n o f i t s t e r mi n a t i o n .

Occupations.

Precise knowledge of the patient's work history sheds light on education, social s t a t u s , p h y s i c a l e xe r t i o n , p s y c h o l o g i c t r a u ma , e xp o s u r e t o n o xi o u s a g e n t s , a n d a v a r i e t y o f c o n d i t i o n s t h a t ma y c a u s e d i s e a s e . S o me d i s e a s e s p r o d u c e s y mp t o ms y e a r s a f t e r e xp o s u r e , s o t a b u l a t e p a s t o c c u p a t i o n s a s w e l l a s c u r r e n t w o r k . D o n o t a c c e p t t h e p a t i e n t ' s c a t e g o r i za t i o n o f a n o c c u p a t i o n w i t h o u t d e t a i l e d q u e s t i o n i n g a b o u t w h a t i s a c t u a l l y d o n e a t w o r k . T h e ma n u a l l a b o r e r ma y a c t u a l l y e n g a g e i n l i t t h e a v y p h y s i c a l w o r k o n t h e j o b b u t ma y b e e xp o s e d t o h e a v y - me t a l p o i s o n s o r s i l i c a d u s t . As k t h e p a t i e n t i f c o w o r k e r s r e c o g n i ze s o me d i s e a s e c o n n e c t e d w i t h t h e i r s u r r o u n d i n g s . S o me w o me n ma y P. 2 8 g i v e t h e i r o c c u p a t i o n a s h o u s e w i f e , n e g l e c t i n g t o me n t i o n a d d i t i o n a l p a r t - t i me o r f u l l - t i me e mp l o y me n t . W h e n a w o ma n s a y s s h e i s a h o u s e w i f e , a s c e r t a i n t h e n u mb e r
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o f r o o ms i n t h e h o u s e , h o w ma n y p e r s o n s s h e c a r e s f o r, i f s h e h a s a s s i s t a n c e w i t h h e r w o r k , a n d i f s h e t a k e s a n a p d u r i n g t h e d a y. If t h e w o ma n l i v e s o n a f a r m, h o w mu c h f i e l d w o r k d o e s s h e p e r f o r m? F o r b o t h s e xe s o n t h e f a r m, l e a r n w h a t c o n t a c t s w i t h p o i s o n o u s c h e mi c a l s t h e y h a v e a n d h o w mu c h e xp o s u r e ? W i t h f a c t o r y w o r k e r s a s c e r t a i n i f o t h e r w o r k e r s i n t h e s a me p l a n t o r d e p a r t me n t h a v e s y mp t o ms s i mi l a r t o t h o s e o f t h e p a t i e n t . D e t e r mi n e h o w mu c h a n xi e t y a n d t e n s i o n a c c o mp a n y t h e j o b , the attitudes of superiors, and the degree of fatigue from work.

Military History.

N o t e a d mi s s i o n s t o t h e a r me d s e r v i c e s , b r a n c h o f s e r v i c e , g e o g r a p h i c l o c a t i o n s o f service, discharge (honorable or dishonorable), and eligibility for veteran's benefits

Gender Preference.

L a b e l s s u c h a s h e t e r o s e xu a l , h o mo s e xu a l , a n d b i s e xu a l a r e o f t e n mo r e c o n f u s i n g t h a n h e l p f u l . As k e a c h p a t i e n t i f t h e y h a v e h a d s e x w i t h a n y o n e o f t h e s a me s e x. F o e xa mp l e , a s k me n , H a v e y o u e v e r h a d s e x w i t h me n ? If t h e p a t i e n t a n s w e r s y e s , y o u s h o u l d a s k f u r t h e r q u e s t i o n s a b o u t s e x w i t h w o me n a n d t h e p a t i e n t ' s p a s t a n d c u r r e n t p r a c t i c e s a n d p r e f e r e n c e . N o n j u d g me n t a l i n q u i r y a b o u t e xc h a n g e o f s e x f o r d r u g s , mo n e y, o r s e r v i c e s c a n d i s c l o s e h i g h - r i s k b e h a v i o r s .

Social and Economic Status.


R e c o r d t h e p a t i e n t ' s y e a r s o f f o r ma l e d u c a t i o n , v o c a t i o n a l t r a i n i n g , c u r r e n t h o u s i n g t y p e , l i v i n g a r r a n g e me n t s , a n d a n y s p e c i a l f i n a n c i a l p r o b l e ms .

Habits.
D e t e r mi n e t h e p a t i e n t ' s f o r me r a n d c u r r e n t u s e o f t o b a c c o , c o f f e e , a l c o h o l , s e d a t i v e s , i l l i c i t d r u g s ( e s p e c i a l l y a n y i n j e c t i o n d r u g u s e ) , p l a c e me n t o f t a t t o o s , a n body piercing.

Violence and Safety.

R e c o r d t h e p a t i e n t ' s u s e o f v e h i c l e r e s t r a i n t s , h e l me t s w i t h b i c y c l i n g o r mo t o r c y c l i n a n d t h e p r e s e n c e o f s mo k e a n d c a r b o n mo n o xi d e a l a r ms i n t h e h o me .

D o me s t i c , c h i l d , a n d e l d e r a b u s e a r e c o mmo n p r o b l e ms t h a t g o u n i d e n t i f i e d u n l e s s t h e y a r e a s k e d a b o u t e xp l i c i t l y, b u t d i s c r e e t l y. In c o mp l e t e p r i v a c y, i n q u i r e w h e t h e r t h e p a t i e n t h a s e v e r b e e n i n a r e l a t i o n s h i p i n w h i c h s h e f e l t u n s a f e . If t h e a n s w e r i s y e s , a s k i f h e r s i t u a t i o n i s s a f e a t t h e p r e s e n t t i me . If s h e a n s w e r s n o , a s k i f s h w i s h e s y o u t o h e l p h e r f i n d a s a f e e n v i r o n me n t . At n o t i me t r y t o e xp l i c i t l y i d e n t i f y t i n d i v i d u a l w h o m t h e p a t i e n t f i n d s t h r e a t e n i n g , u n l e s s t h i s i n f o r ma t i o n i s v o l u n t e e r e d b y t h e p a t i e n t e[l h a u s K M , K o zi o l - M c L a i n J , Ams b u r y H L , e t a l . Ac c u r a c y o f 3 b r i e f F s c r e e n i n g q u e s t i o n s f o r d e t e c t i n g p a r t n e r v i o l e n c e i n t h e e me r g e n c y d e p a r t me n t . J AM A 1 9 9 7 ; 2 7 7 : 1 3 5 7 1 3.6 1 ]

Prostheses and In-Home Assistance.


Record the patient's use of eyeglasses, dentures and dental appliances, hearing a i d e s , a mb u l a t i o n a s s i s t a n c e d e v i c e s ( c a n e , w a l k e r, s c o o t e r, w h e e l c h a i r ) , b r a c e s , prosthetic
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P. 2 9 f o o t w e a r, a n d a n y a i d e o r a s s i s t a n c e r e c e i v e d i n t h e h o me ( v i s i t i n g n u r s e , p h y s i c a l t h e r a p y, h o me ma k e r s e r v i c e s ) .

Review of Systems (ROS)

T h e f o l l o w i n g o u t l i n e c a n h e l p y o u ma k e a c a r e f u l r e v i e w o f t h e h i s t o r y b y i n q u i r i n g f o r s a l i e n t s y mp t o ms a s s o c i a t e d w i t h e a c h s y s t e m o r a n a t o mi c r e g i o n . S y mp t o ms r e l a t e d t o t h e p a t i e n t ' s c u r r e n t p r o b l e m, d i s c o v e r e d d u r i n g y o u r R O S i n q u i r y, s h o u l d b e r e c o r d e d u n d e r P r e s e n t Il l n e s s . B e c o me f a mi l i a r w i t h t h e s e s y mp t o ms a n d l e a r n t h e i r d i a g n o s t i c s i g n i f i c a n c e . In p r a c t i c e , t h e p a t i e n t ' s a n s w e r s a r e n o t w r i t t e n d o w n e xc e p t w h e n t h e y a r e p o s i t i v e , o r w h e n a n e g a t i v e r e s p o n s e i s p a r t i c u l a r l y p e r t i n e n t o t h e d i f f e r e n t i a l d i a g n o s i s . W e s u g g e s t t h a t y o u a s k t h e q u e s t i o n s w h i l e e xa mi n i n g t h e p a r t o f t h e b o d y t o w h i c h t h e q u e s t i o n s p e r t a i n . In t a k i n g t h e p r e s e n t i l l n e s s , w h e n o n e o f t h e s y mp t o ms e me r g e s , i n q u i r e a b o u t t h e a s s o c i a t e d s y mp t o ms i n t h i s o u t l i n e . U s e o f a s t a n d a r d i ze d p a t i e n t q u e s t i o n n a i r e w i l l g r e a t l y f a c i l i t a t e i d e n t i f i c a t i o n o f p o s i t i v e i t e ms o n a t h o r o u g h s y s t e m r e v i e w a n d s a v e t h e c l i n i c i a n v a l u a b l e t i me .

Integument
S k i n : C o l o r, p i g me n t a t i o n , t e mp e r a t u r e , mo i s t u r e , e r u p t i o n s , p r u r i t u s , s c a l i n g , b r u i s i n g , b l e e d i n g .i r : C o l o r, t e xt u r e , a b n o r ma l l o s s o r g r o w t h , d i sNra blu t:i o n . Ha t ii s Color changes, brittleness, ridging, pitting, curvature.

Lymph Nodes
E n l a r g e me n t , p a i n , s u p p u r a t i o n , d r a i n i n g s i n u s e s , l o c a t i o n .

Bones, Joints, and Muscles

F r a c t u r e s , d i s l o c a t i o n s , s p r a i n s , a r t h r i t i s , my o s i t i s , p a i n , s w e l l i n g , s t i f f n e s s , mi g r a t d i s t r i b u t i o n , d e g r e e o f d i s a b i l i t y, mu s c u l a r w e a k n e s s , w a s t i n g , o r a t r o p h y, n i g h t c r a mp s .

Hemopoietic System
An e mi a ( t y p e , t h e r a p y, a n d r e s p o n s e ) , l y mp h a d e n o p a t h y, b l e e d i n g o r c l o t t i n g ( s p o n t a n e o u s , t r a u ma t i c , f a mi l i a l ) .

Endocrine System
H i s t o r y o f g r o w t h , b o d y c o n f i g u r a t i o n , a n d w e i g h t ; s i ze o f h a n d s , f e e t , a n d h e a d , e s p e c i a l l y c h a n g e s d u r i n g a d u l t h o o d ; h a i r d i s t r i b u t i o n ; s k i n p i g me n t a t i o n ; g o i t e r, e xo p h t h a l mo s , d r y n e s s o f s k i n a n d h a i r, i n t o l e r a n c e t o h e a t o r c o l d , t r e mo r ; polyphagia, polydipsia, polyuria, glycosuria; secondary sex characteristics, i mp o t e n c e , s t e r i l i t y, t r e a t me n t .

Allergic and Immunologic History

D e r ma t i t i s , u r t i c a r i a , a n g i o e d e ma , e c ze ma , h a y f e v e r, v a s o mo t o r r h i n i t i s , a s t h ma , mi g r a i n e , v e r n a l c o n j u n c t i v i t i s a n d s e a s o n a l o c c u r r e n c e o f t h e s e ; k n o w n s e n s i t i v i t y t o p o l l e n s , f o o d s , d a n d e r s , x- r a y c o n t r a s t a g e n t s , b e e s t i n g s ; p r e v i o u s s k i n t e s t s a n their results; results of tuberculin tests


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P. 3 0 a n d o t h e r s ; d e s e n s i t i za t i o n , s e r u m i n j e c t i o n s , v a c c i n a t i o n s , a n d i mmu n i za t i o n s .

Head
H e a d a c h e s , mi g r a i n e , t r a u ma , v e r t i g o , s y n c o p e , c o n v u l s i v e s e i zu r e s .

Eyes
L o s s o f v i s i o n o r c o l o r b l i n d n e s s , d i p l o p i a , h e mi a n o p s i a , t r a u ma , i n f l a mma t i o n , g l a s s e s ( d a t e o f r e f r a c t i o n ) , d i s c h a r g e , e xc e s s i v e t e a r i n g .

Ears
D e a f n e s s , t i n n i t u s , v e r t i g o , d i s c h a r g e f r o m t h e e a r s , p a i n , ma s t o i d i t i s , o p e r a t i o n s .

Nose
C o r y za , r h i n i t i s , s i n u s i t i s , d i s c h a r g e , o b s t r u c t i o n , e p i s t a xi s .

Mouth
S o r e n e s s o f mo u t h o r t o n g u e , s y mp t o ms r e f e r a b l e t o t e e t h .

Throat
Hoarseness, sore throats, tonsillitis, voice changes.

Neck
S w e l l i n g , s u p p u r a t i v e l e s i o n s , e n l a r g e me n t o f l y mp h n o d e s , g o i t e r, s t i f f n e s s , a n d l i mi t a t i o n o f mo t i o n .

Breasts

D e v e l o p me n t , l a c t a t i o n , t r a u ma , l u mp s , p a i n s , d i s c h a r g e f r o m n i p p l e s , g y n e c o ma s t i a changes in nipples.

Respiratory System

P a i n , s h o r t n e s s o f b r e a t h , w h e e zi n g , d y s p n e a , n o c t u r n a l d y s p n e a , o r t h o p n e a , c o u g h s p u t u m, h e mo p t y s i s , n i g h t s w e a t s , f e v e r s , p l e u r i s y, b r o n c h i t i s , t u b e r c u l o s i s ( h i s t o r y o f c o n t a c t s ) , p n e u mo n i a , a s t h ma , o t h e r r e s p i r a t o r y i n f e c t i o n s .

Cardiov ascular System

P a l p i t a t i o n , t a c h y c a r d i a , i r r e g u l a r i t i e s o r r h y t h m, p a i n i n t h e c h e s t , e xe r t i o n a l d y s p n e a , p a r o xy s ma l n o c t u r n a l d y s p n e a , o r t h o p n e a , c o u g h , c y a n o s i s , a s c i t e s , e d e ma ; i n t e r mi t t e n t c l a u d i c a t i o n , c o l d e xt r e mi t i e s , t h r o mb o s e s , p o s t u r a l o r p e r ma n e c h a n g e s i n s k i n c o l o r ; h y p e r t e n s i o n , r h e u ma t i c f e v e r, c h o r e a , s y p h i l i s , d i p h t h e r i a ; drugs such as digitalis, quinidine, nitroglycerin, diuretics, anticoagulants, antiplate a g e n t s , a n d o t h e r me d i c a t i o n s .

Gastrointestinal System

Ap p e t i t e , c h a n g e s i n w e i g h t , d y s p h a g i a , n a u s e a , e r u c t a t i o n , f l a t u l e n c e , a b d o mi n a l p a i n o r c o l i c , v o mi t i n g , h e ma t e me s i s , j a u n d i c e ( p a i n , f e v e r, i n t e n s i t y, d u r a t i o n , c o l o
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o f u r i n e a n d s t o o l s ) , s t o o l s ( c o l o r, f r e q u e n c y, P. 3 1 i n c o n t i n e n c e , c o n s i s t e n c y, o d o r, g a s , c a t h a r t i c s ) , h e mo r r h o i d s , c h a n g e i n b o w e l habits.

Genitourinary System

C o l o r o f u r i n e , p o l y u r i a , o l i g u r i a , n o c t u r i a , d y s u r i a , h e ma t u r i a , p y u r i a , u r i n a r y r e t e n t i o n , u r i n a r y f r e q u e n c y, i n c o n t i n e n c e , p a i n o r c o l i c , p a s s a g e o f s t o n e s o r g r a v e G y n e c o l o g i c H i s t o r y :e o f o n s e t , f r e q u e n c y o f p e r i o d s , r e g u l a r i t y, d u r a t i o n , Ag a mo u n t o f f l o w, l e u k o r r h e a , d y s me n o r r h e a , d a t e o f l a s t n o r ma l a n d p r e c e d i n g p e r i o d s , d a t e a n d c h a r a c t e r o f me n o p a u s e , p o s t me n o p a u s a l b l e e d i n g ; p r e g n a n c i e s ( n u mb e r, a b o r t i o n s , mi s c a r r i a g e s , s t i l l b i r t h s , c h r o n o l o g i c s e q u e n c e ) , c o mp l i c a t i o n s p r e g n a n c y ; b i r t h c o n t r o l p r a c t i c e s ( o r a l c o n t r a c e p t i v e me d i c a t i o n s , b a r r i e r me t h o d s , e t c . ) .M a l e H i s t o r y : r e c t i l e d y s f u n c t i o n , p r e ma t u r e e j a c u l a t i o n , b l o o d i n t h e s e me n , E c o n t r a c e p t i v e me t h o d s a n d c o n d o m u se r.e a l D i s e a s e H i s t o re xu a l a c t i v i t y Ve n e S y: ( s e x o f p a r t n e r s a n d p r a c t i c e s ) , c h a n c r e , b u b o , u r e t h r a l d i s c h a r g e , t r e a t me n t o f venereal diseases.

Nerv ous System

C r a n i a l N e r ve s :i s t u r b a n c e s o f s me l l ( c r a n i a l n e r v e I) , v i s u a l d i s t u r b a n c e s ( C N II, D III, IV, VI) ; o r o f a c i a l p a r e s t h e s i a s a n d d i f f i c u l t y i n c h e w i n g ( C N V) ; f a c i a l w e a k n e s s a n d t a s t e d i s t u r b a n c e s ( C N VII) ; d i s t u r b a n c e s i n h e a r i n g a n d e q u i l i b r i u m ( C N VIII) ; d i f f i c u l t i e s i n s p e e c h , s w a l l o w i n g , a n d t a s t e ( C N IX, X, XII) ; l i mi t a t i o n i n mo t i o n o f n e c k ( C N XII) .o t o r S y s t e mP a r a l y s e s , a t r o p h y, i n v o l u n t a r y mo v e me n t s , M : c o n v u l s i o n s , g a i t , i n c o o r d i n a te o n .o r y S y s t e m :a i n , l i g h t n i n g p a i n , g i r d l e p a i n , S ins P p a r e s t h e s i a , h y p e s t h e s i a , a n e s t h e s i a , a lAo d y n i o m i c S y s t e m : n t r o l o f l uton a. Co u r i n a t i o n a n d d e f e c a t i o n , s w e a t i n g , e r y t h e ma , c y a n o s i s , p a l l o r, r e a c t i o n t o h e a t a n d cold.

Psychiatric History

Describe difficulties with interpersonal relationships (with parents, siblings, spouse c h i l d r e n , f r i e n d s a n d a s s o c i a t e s ) , s e xu a l a d j u s t me n t s , e mp l o y me n t s u c c e s s a n d d i f f i c u l t i e s , i mp u l s e c o n t r o l , s l e e p d i s o r d e r s , mo o d s w i n g s , d i f f i c u l t y w i t h concentration, thought or the presence of hallucinations.

M edications

In a s e p a r a t e s e c t i o n , l i s t a l l me d i c a t i o n s b e i n g t a k e n : t h e i r n a me s , d o s e s , e f f e c t s , r e a s o n f o r t a k i n g , a n d d u r a t i o n . As k t h e p a t i e n t t o b r i n g t h e p h a r ma c i s t ' s c o n t a i n e r s w i t h t h e s p e c i f i c d a t a o n t h e l a b e l s . If t h e l a b e l s a r e a b s e n t , i d e n t i f y t a b l e t s , p i l l s , c a p s u l e s , a n d s u p p o s i t o r i e s b y a s k i n g t h e p h a r ma c i s t w h o i s s u e d t h e d r u g . B e s u r e t o l i s t a l l n o n p r e s c r i p t i o n d r u g s , h e r b a l r e me d i e s , s u p p l e me n t s , a n d v i t a mi n s .

Allergies and M edication Intolerances

A n o t a t i o n o f p a s t me d i c a t i o n s a n d u n t o w a r d d r u g r e a c t i o n s s h o u l d b e a s e xp l i c i t a s p o s s i b l e . As k t h e p a t i e n t f o r t h e t y p e o f r e a c t i o n o r i n t o l e r a n c e P. 3 2 h e e xp e r i e n c e d w i t h e a c h me d i c a t i o n ; ma n y p a t i e n t s l i s t a l l e r g i e s t o me d i c a t i o n s t o
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w h i c h t h e y e xp e r i e n c e d c o mmo n s i d e e f f e c t s , n o t a l l e r g i c r e a c t i o n s , f o r e xa mp l e , s t o ma c h u p s e t w i t h c o d e i n e o r e r y t h r o my c i n . Id e n t i f y a l l k n o w n o r s u s p e c t e d c a u s e s o f a n a p h y l a xi s , i n c l u d i n g d r u g s , s t i n g s , a n d f o o d s ( e . g . , p e a n u t s ) . T h i s s u mma r y o f a l l e r g i e s a n d me d i c a t i o n i n t o l e r a n c e s mu s t b e c o n s u l t e d w h e n a n y d r u g s a r e prescribed in the future.

Preventive Care Services


Here you should record the patient's history of preventive care services. List the d a t e s a n d r e s u l t s o f s c r e e n i n g t e s t s ( e . g . , ma mmo g r a ms , P a p s me a r s , t u b e r c u l i n t e s t s ) , i n s u r a n c e e xa mi n a t i o n s , a n d i mmu n i za t i o n s u s i n g a g e - a n d s e x- s p e c i f i c national guidelines as your standard.

Advance Directives

Each adult should be asked if they have a living will and or durable power of a t t o r n e y f o r h e a l t h c a r e a n d , i f s o , w h o i s t h e i r s u r r o g a t e d e c i s i o n ma k e r. Al l p a t i e n s h o u l d b e g i v e n i n f o r ma t i o n a b o u t t h e s e a d v a n c e d i r e c t i v e s a n d b e g i v e n a n o p p o r t u n i t y t o r e c o r d t h e i r w i s h e s c o n c e r n i n g r e s u s c i t a t i o n , me c h a n i c a l v e n t i l a t i o n , a n d p r o l o n g e d l i f e s u p p o r t . Al t h o u g h t h e s e d i s c u s s i o n s a r e mo r e l i k e l y t o b e p a r t i c u l a r l y r e l e v a n t t o t h e f r a i l e l d e r l y, y o u s h o u l d i n i t i a t e t h i s d i s c u s s i o n w i t h a l l a d u l t s o v e r a g e 5 0 , y e a r s b e f o r e t h e a n t i c i p a t e d t i me o f n e e d .

Physical Examination
H e r e y o u s h o u l d r e c o r d t h e f i n d i n g f r o m y o u r p h y s i c a l e xa mi n a t i o n i n a s y s t e ma t i c f a s h i o n . T h e s e q u e n c e o f p r e s e n t a t i o n b e l o w i s s u g g e s t e d a s a c o mmo n a n d p r a c t i c a l me t h o d : Vi t a l s i g n s General appearance Head, eyes, ears, nose, and throat (HEENT ) Neck and spine Chest: breasts Chest: chest wall and lungs C h e s t : h e a r t , ma j o r a r t e r i e s , a n d n e c k v e i n s Ab d o me n G e n i t o u r i n a r y e xa m, i n c l u d i n g i n g u i n a l h e r n i a s R e c t a l e xa m E xt r e mi t i e s Ly mp h n o d e s N e u r o l o g i c e xa m, i n c l u d i n g t h e me n t a l s t a t u s e xa m Skin

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Laboratory
Record the results of the initial laboratory finding which you have used to assist in t h e d e v e l o p me n t o f y o u r d i f f e r e n t i a l d i a g n o s i s . P. 3 3

Assessment
Case Summary

Af t e r r e c o r d i n g t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n , a n a l y ze t h e c h r o n o l o g y, s y mp t o ms , s i g n s , a n d l a b o r a t o r y f i n d i n g s o f t h e i l l n e s s . It i s a d v i s a b l e t o w r i t e a b r i s u mma r y o f y o u r f i n d i n g s a s a n a b s t r a c t o f t h e s i g n i f i c a n t o b s e r v a t i o n s .

The Assessment or Problem List


W r i t e d o w n y o u r l i s t o f a l l t h e d i a g n o s t i c a n d ma n a g e me n t p r o b l e ms t h e p a t i e n t p r e s e n t s ( v a r i o u s l y l a b e l e d a s i n i t i a l a s s e s s me n t , i mp r e s s i o n , p r o b l e m l i s t , o r d i a g n o s i s ) . A d i a g n o s t i c p r o b l e m ma y b e a s y mp t o m, a s i g n , a l a b o r a t o r y f i n d i n g , o r c o mp l e x o f s e v e r a l i t e ms t h a t e xp e r i e n c e h a s t a u g h t a r e a s s o c i a t e d w i t h d i s e a s e . A p r e v i o u s l y d i a g n o s e d d i s e a s e , o r o n e u n d e r c o n s i d e r a t i o n f o r d i a g n o s i s , ma y b e l i s t e d a s a p r o b l e m. W h e n t h e d i a g n o s i s i s o b s c u r e , b e w a r e o f l u mp i n g p r o b l e ms t o g e t h e r p r e ma t u r e l y ; t h i s ma y s e r v e t o o b s c u r e r a t h e r t h a n t o c l a r i f y t h e d i a g n o s i s

G e n e r a t e di f f er ent i al di agnos i rs e a c h me d i c a l p r o b l e m. As d i s c u s s e d ti e r a fo Chap n 1, t h e d i f f e r e n t i a l d i a g n o s i s c a n b e p a t h o p h y s i o l o g i c , d i a g n o s t i c , o r b o t h . It i s a g o o p r a c t i c e t o k e e p t h e p a t i e n t ' s c h i e f c o mp l a i n t t h e f i r s t p r o b l e m o n y o u r p r o b l e m l i s t . B e y o n d t h a t , w e d o n o t f e e l t h a t a t t e mp t s t o n u mb e r t h e p r o b l e m l i s t i n a p r i o r i t i ze d o r n u me r i c a l l y c o n s i s t e n t f a s h i o n i s u s e f u l , b e c a u s e p r i o r i t i e s c h a n g e a s t h e e v a l u a t i o n a n d t r e a t me n t p r o c e e d a n d p r o b l e ms d i s a p p e a r o r c o n s o l i d a t e a s mo r e i n f o r ma t i o n i s a c q u i r e d .

A W o r k i n g P r o b l e m L i s to u l d b e ma i n t a i n e d a s a s e p a r a t e p a g e i n t h e h o s p i t a l o r sh c l i n i c c h a r t t o r e c o r d t h e n u mb e r e d p r o b l e ms w i t h n o t e s a n d d a t e s i n d i c a t i n g t h e s t a t u s o f e a c h . It i s i mp o r t a n t t o ma i n t a i n , u p d a t e , a n d r e v i s e t h i s p r o b l e m l i s t . B y constantly reviewing the problem list, you can see that every problem is considered O f t e n t h e k e y t o t h e d i a g n o s t i c p u zzl e i s f i n d i n g h o w t h e o d d p r o b l e m f i t s t h e p a t t e r D i a g n o s t i c p r o b l e m s o l v i n g i s mu c h l i k e p u t t i n g t o g e t h e r a j i g s a w p u zzl e w i t h o u t t h e p i c t u r e a n d w i t h o n l y a f e w p i e c e s p r o v i d e d a t a t i me . To g e t t h e p i e c e s t o g e t h e r c o r r e c t l y, y o u h a v e t o h a v e a l l t h e p i e c e s o n t h e t a b l e a t t h e s a me t i me a n d k e e p l o o k i n g a t t h e m a s n e w p i e c e s a p p e a r t o s e e t h e p a t t e r n e me r g e . T h e p r o b l e m l i s t i s y o u r t a b l e f u l l o f p i e c e s , y o u r h y p o t h e s e s a r e a t t e mp t s t o e xp l a i n t h e p a t t e r n . It i s o f t e n t h e o d d p i e c e t h a t d o e s n ' t s e e m t o f i t a n y w h e r e t h a t i s t h e k e y t o t h e p u zzl e .

The Plan

F o r e a c h p r o b l e m, a n d t h e p a t i e n t a s a w h o l e , y o u n e e d t o d e v e l o p a p l a n . T h e p l a n for each problem has three parts: (a) plans for testing your hypothesis or differentia diagnosis; (b) therapy to be considered or given; and (c) education for the patient a n d f a mi l y.

A pl an i s onl y as good as t he di agnos t i c hy pot hes es t hat gener at ed i t . Our e mp h a s i s i n t h i s t e xt i s t o h e l p y o u t h i n k a b o u t t h e i n f o r ma t i o n a c q u i r e d i n t h e


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p e r f o r ma n c e o f t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n s o t h a t y o u c a n g e n e r a t e s o u n d testable hypotheses. Once you have generated a P. 3 4 c o n c i s e a n d t h o u g h t f u l d i f f e r e n t i a l d i a g n o s i s , y o u c a n c o n s u l t t e xt b o o k s o f me d i c i n e f o r e xa mp l e , r i s on' s Pr i nc i pl es of I nt er nal M edir c iu n w a l d E , F a u c i AS , Har [B a ne K a s p e r D L , e t a l . ( e d s ) .r i s on' s Pr i nc i pl es of I nt er nal M edi5ct ih e d . N e w Har 1 ne. Yo r k : M c G r a w - H i l l , 2 0 0 1 d i r e c t l y s e a r c h t h e me d i c a l l i t e r a t u r e t o a s s i s t i n t h e ], or mo s t e c o n o mi c a l a n d e f f i c i e n t me t h o d s f o r t e s t i n g y o u r h y p o t h e s e s .

T he Oral Presentation

T h e o p t i ma l o r a l p r e s e n t a t i o n h o l d s y o u r l i s t e n e r ' s a t t e n t i o n f o r 5 t o 7 mi n u t e s w h i l e y o u i d e n t i f y y o u r p a t i e n t a n d b r i e f l y s u mma r i ze t h e c a s e . S t a r t w i t h a s t a t e me n t o f t h e p a t i e n t ' s p r o b l e ms o r d i a g n o s e s s o y o u r l i s t e n e r s c a n a n a l y ze y o u r s u b s e q u e n t narrative for the evidence used to support the diagnosis and therapeutic plan you p r o p o s e . T h e n s u mma r i ze t h e h i s t o r y a n d p r e s e n t a t i o n , r e v i e w t h e v i t a l s i g n s a n d pertinent physical findings and laboratory test results, state the diagnostic i mp r e s s i o n s o r p r o b l e ms , a n d t h e n r e c o mme n d a d i a g n o s t i c a n d t h e r a p e u t i c p l a n . E xc e l l e n t p r e s e n t a t i o n s r e q u i r e t h a t y o u e d i t a n d o r g a n i ze t h e i n f o r ma t i o n y o u h a v e c o l l e c t e d , t o t e l l t h e s t o r y o f t h e i l l n e s s a s i t a p p e a r s t o y o u . If y o u r e g u r g i t a t e a l l o t h e e xt e n s i v e i n f o r ma t i o n t h a t y o u p l a c e i n t h e me d i c a l r e c o r d , y o u w i l l q u i c k l y l o s e your audience. T h e o r a l p r e s e n t a t i o n o f t h e d i a g n o s t i c e xa mi n a t i o n i s n o t s i mp l y a n a c a d e mi c e xe r c i s e . B r i e f , a c c u r a t e p r e s e n t a t i o n s w i l l b e n e f i t y o u r p a t i e n t s b y c l e a r l y c o mmu n i c a t i n g t h e i r p r o b l e ms t o o t h e r s w h o w i l l p a r t i c i p a t e i n t h e i r c a r e : y o u r teachers, fellow house officers, sign-out partners in practice, and consultants [L e h ma n n L S , B r a n c a t i F L , C h e n M - C , e t a l . T h e e f f e c t o f b e d s i d e c a s e p r e s e n t a t i o n s o n p a t i e n t ' s p e r c e p t i o n s o f t h e i r me Ni c a l c aJ e . ed d Engl r M 1 9 9 7 ; 3 3 6 : 11 5 0 11 5 5 r g u s G R , C h a p ma n G B , L e v y B T, e t a l . C l i n i c a l d i a g n o s i s ; Be a n d t h e o r d e r o f i n f o r maM o n . Dec i s M ak i ng 9 8 ; 1 8 : 4 1 2 4] 1 7 t i ed 19 .

Other Clinical Notes Inpatient Progress Notes

P r o g r e s s n o t e s a r e ma d e d a i l y a n d w h e n e v e r n e c e s s a r y. E a c h n o t e s h o u l d b e d a t e d a n d t h e t i me o f d a y r e c o r d e d . E a c h n o t e h a s f o u r s u b - h e a d s . U s e t h e mn e mo n i c S O AP t o r e me mb e r t h e m: j e c t i v e d a t a ( s y mp t o ms a n d c h a n g e s i n s y mp t o ms , t h e i r Su b a p p e a r a n c e a n d d i s a p p e a r a n c e , a n d t h e i r r e s p o n s e t o t he c tai p y ) ; a t a Ob j e r v e d (changes in or new physical signs and laboratory findings and response to therapy) As s e s s me n t s ( u p d a t e s t o y o u r p r o b l e m l i s t a n d h y p o t hPlsa n s ; ( d in d n o s t i c e es) a ag tests, therapeutic interventions and instructions to the patient and nursing staff). When a problem is resolved by inclusion in another diagnosis, or by cure or disappearance, it should be so noted in the progress note and in the Working Problem List. T h e f u l l a n d l e g i b l e n a me o f t h e w r i t e r s h o u l d b e a p p e n d e d t o e a c h p r o g r e s s n o t e . T h e n a me s h o u l d b e f o l l o w e d b y a s l a s h ma r k a n d a n a b b r e v i a t i o n P. 3 5
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i n d i c a t i n g h o s p i t a l r a n k . H e r e a r e s o me e xa mp l e s : ( j u n i o r me d i c a l s t u d e n t ) , ( s e c o n d year resident), or RN (student nurse or graduate), Joan Doe/S (staff).

Off-Service Note
Write a note in the chart when you leave a service and turn over the care of the p a t i e n t t o y o u r s u c c e s s o r. C u s t o ma r i l y, a b r i e f r s u m o f t h e c a s e i s r e c o r d e d , s t a t i n g t h e d i a g n o s i s o r p r o b l e ms , t h e t r e a t me n t , a n d r e s p o n s e , s u g g e s t i o n s f o r c o n t i n u i n g t r e a t me n t a r e i n c l u d e d . D o n o t i n c l u d e s t a t e me n t s l i k e , G o o d l u c k !

Discharge Summary

When the patient leaves the hospital, the physician should enter a final note containing an abstract of the case, with the diagnosis or problem list and the t r e a t me n t g i v e n i n t h e h o s p i t a l a n d p r e s c r i b e d f o r h o me u s e . N o t e t h e p a t i e n t ' s c o n d i t i o n a n d f u n c t i o n a l s t a t u s a t d i s c h a r g e a n d a n y i n f o r ma t i o n o r i n s t r u c t i o n s g i v e t o t h e p a t i e n t a n d a t t e n d a n t s f o r h o me a n d f o l l o w - u p c a r e .

Clinic Notes

C l i n i c n o t e s f o l l o w t h e s a me S O AP f o r ma t d e s c r i b e d f o r p r o g r e s s n o t e s i n t h e h o s p i t a l . If t h e c h a r t c o n t a i n s s t a n d a r d i ze d f o r ms a s p a r t o f t h e me d i c a l r e c o r d t h e n o t e ma y r e f e r t h e r e a d e r t o t h o s e f o r ms f o r c u r r e n t i n f o r ma t i o n , s o t h a t i t n e e d n o t b e r e p e a t e d i n t h e w r i t t e n n o t e . Al l c l i n i c n o t e s s h o u l d s t a t e t h e e xp e c t e d r e s p o n s e interventions, when that response is anticipated and when the patient is to be seen in follow up.

T he Patient's Medical Record

T h e p a t i e n t ' s me d i c a l r e c o r d i s a d o c u me n t c o n t a i n i n g ( a ) t h e me d i c a l h i s t o r y ; ( b ) t h f i n d i n g s f r o m t h e p h y s i c a l e xa mi n a t i o n ; ( c ) t h e r e p o r t s o f l a b o r a t o r y t e s t s ; ( d ) t h e f i n d i n g s a n d c o n c l u s i o n s f r o m s p e c i a l e xa mi n a t i o n s ; ( e ) t h e f i n d i n g s a n d d i a g n o s e s of consultants; (f) the diagnoses of the responsible physician; (g) notes on t r e a t me n t , i n c l u d i n g me d i c a t i o n , s u r g i c a l o p e r a t i o n s , r a d i a t i o n , p h y s i c a l t h e r a p y ; a n (h) progress notes by physicians, nurses, and others.

Purposes
T h e p u r p o s e s o f t h e p a t i e n t ' s me d i c a l r e c o r d ma y b e c l a s s i f i e d a s f o l l o w s :

Medical Purposes
1. To a s s i s t t h e p h y s i c i a n i n ma k i n g d i a g n o s e s .

2. To a s s i s t p h y s i c i a n s , n u r s e s , a n d o t h e r s i n t h e c a r e a n d t r e a t me n t o f t h e p a t i e n 3. To s e r v e a s a r e c o r d f o r t e a c h i n g me d i c i n e a n d f o r c l i n i c a l r e s e a r c h . P. 3 6

Legal Purposes
1. To d o c u me n t i n s u r a n c e c l a i ms f o r t h e p a t i e n t .
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2. To s e r v e a s l e g a l p r o o f i n c a s e s o f ma l p r a c t i c e , c l a i ms f o r i n j u r y o r c o mp e n s a t i o n , c a s e s o f p o i s o n i n g , a n d c a s e s o f h o mi c i d e .

Reimbursement

T h e f e d e r a l g o v e r n me n t h a s d e v e l o p e d d o c u me n t a t i o n g u i d e l i n e s f o r e v a l u a t i o n a n d ma n a g e me n t ( E / M ) s e r v i c e s t h a t d e f i n e t h e s t a n d a r d s t h a t M e d i c a r e c a r r i e r s e mp l o y i n r e v i e w i n g d o c u me n t a t i o n p h y s i c i a n s mu s t u s e t o b i l l f o r h i s t o r y t a k i n g , p h y s i c a l e xa mi n a t i o n s , a n d me d i c a l d e c i s i o n ma k i n g . U s u a l l y, t h e p h y s i c i a n c o mp o s e s t h e p a t i e n t ' s r e c o r d w i t h a t t e n t i o n f o c u s e d o n t h e me d i c a l p u r p o s e s o f ma k i n g d i a g n o s e s , c a r i n g f o r t h e p a t i e n t , t e a c h i n g me d i c i n e , a n d f u r t h e r i n g r e s e a r ce i s[ e r S J . T h e c l i n i c a l r e c o r d i n me d i c i nnt. er n M ed Rh Ann I e 1 9 9 1 ; 11 4 : 9 0 2 9 0 7 , 9 8 0 .9 Af t e r t h e i l l n e s s , s o me t i me s y e a r s l a t e r, t h e me d i c a l ] 85 r e c o r d ma y b e c o n s u l t e d t o f u l f i l l t h e l e g a l p u r p o s e s i n s u p p o r t o f c l a i ms a n d t h e d e mo n s t r a t i o n o f f a c t s i n l i t i g a t i o n . In t h e s e c o n t i n g e n c i e s , t h e p h y s i c i a n ma y b e l a t e d l y d i s c o v e r o mi s s i o n s a n d i n a c c u r a c i e s . To p r e v e n t l a t e r e c r i mi n a t i o n s , a l w a y s c o mp l e t e l y d o c u me n t e a c h p a t i e n t e n c o u n t e r a t t h e t i me o f s e r v i c e . Ad d e n d u ms ma y b e a d d e d a t a l a t e r d a t e , b u t t h e o r i g i n a l n o t e mu s t n e v e r b e altered.

At t e mp t s a t g r a d i n g d i a g n o s e s a r e e n c o u n t e r e d i n s o me h o s p i t a l s a n d i n s o me i n s u r a n c e f o r ms t h a t c a l l f o r a p r i ma r y d i a g n o s i s a n d a s e c o n d a r y d i a g n o s i s . At f a c e v a l u e , t h i s r e q u e s t s e e ms r a t i o n a l , b u t a n a b s u r d i t y a p p e a r s w h e n t h e s a me r e c o r d s a r e g r a d e d b y d i f f e r e n t s p e c i a l i s t s . T h e p r i ma r y d i a g n o s i s i s o f t e n d i f f e r e n t f r o m t h e view of the internist, the surgeon, the orthopedist, or the otolaryngologist. Each s e l e c t s t h e d i s e a s e p e r t a i n i n g t o h i s o r h e r o w n s p e c i a l t y. T h e c o n f u s i o n i s d i mi n i s h e d w h e n t h e f o r m s t a t e s t h a t t h e p r i ma r y d i a g n o s i s i s t h e r e a s o n f o r t h e c l i n i c v i s i t o r h o s p i t a l i za t i o n .

T h e p r i ma r y p u r p o s e s o f e n a b l i n g a p h y s i c i a n t o d o c u me n t h i s o r h e r c a r e i n t h e me d i c a l r e c o r d a r e t o s e r v e t h e me mo r y o f t h e c a r e g i v e r a n d c o mmu n i c a t e t h e s e data to other physicians caring for the patient. Uses of the record for legal and billing purposes are secondary and should not distract or interfere with good patien c a r e . L a w y e r s a n d i n s u r e r s i n s i s t o n w r i t t e n d o c u me n t a t i o n a s e v i d e n c e o f p e r f o r ma n c e , b u t g u i d e l i n e s t h a t e n c o u r a g e t r e a t i n g c h a r t s i n s t e a d o f p a t i e n t s a r e b a d me d i c i n e r[e t t AS . N e w g u i d e l i n e s f o r c o d i n g p h y s i c i a n ' s s e r v i c e s A s t e p B b a c k w a r dN Engl J M ed 9 9 8 ; 3 3 9 : 1 7 0 5 1 7 0 8 s s i r e r J P, An g e l l M . E v a l u a t i o n . 1 ; Ka a n d ma n a g e me n t g u i d e l i n e s F a t a l l y fNaEngl. J M ed 9 9 8 ; 3 3 9 : 1 6 9 7 1 6.9 8 l wed 1 ]

Physician's Signature

E a c h s h e e t , b r i e f e n t r y, a n d d o c t o r ' s o r d e r c o mp o s e d b y t h e p h y s i c i a n f o r t h e me d i c a l r e c o r d s h o u l d b e a c c o mp a n i e d b y t h e p h y s i c i a n ' s s i g n a t u r e a n d t h e d a t e a n t i me o f s i g n i n g a s p r o o f o f a u t h o r s h i p . In t h e P. 3 7 h o s p i t a l r e c o r d , t h e p h y s i c i a n ' s i n i t i a l s a r e i n a d e q u a t e ; t h e c o mp l e t e w r i t t e n s i g n a t u r e s h o u l d b e l e g i b l e . Al l d a t e s s h o u l d i n c l u d e t h e mo n t h , d a y o f t h e mo n t h , a n d y e a r. In t e a c h i n g h o s p i t a l s , w h e r e ma n y p e r s o n s c o n t r i b u t e t o t h e r e c o r d , t h e e n t r i e s o f me d i c a l s t u d e n t s a n d n u r s e s s h o u l d b e d a t e d a n d a c c o mp a n i e d b y t h e i r


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s i g n a t u r e s , a f f i xe d w i t h s u i t a b l e a b b r e v i a t i o n s i n d i c a t i n g t h e i r s t a t u s i n t h e me d i c a l o r g a n i za t i o n .

Custody of the Record

T h e r e c o r d ma y r e s t i n t h e p h y s i c i a n ' s l o c k e d o f f i c e f i l e s , o r i t ma y b e i n t h e c u s t o d o f t h e h o s p i t a l w h e r e t h e p a t i e n t r e c e i v e d me d i c a l c a r e . T h e c o n t e n t s o f t h e me d i c a r e c o r d mu s t b e g u a r d e d a g a i n s t a c c e s s b y u n a u t h o r i ze d p e r s o n s . T h e r e c o r d e d f a c t a r e p r i v i l e g e d c o mmu n i c a t i o n s u n d e r t h e l a w ; t h e y c a n n o t b e r e v e a l e d t o a n o t h e r person without the written consent of the patient.

T h e me d i c a l r e c o r d s h o u l d b e c o mp o s e d w i t h t h e c o n s t a n t r e a l i za t i o n t h a t a t s o me f u t u r e t i me t h e p a t i e n t ma y r e a d i t o r t h a t i t ma y b e c o me a l e g a l d o c u me n t ; t h e d a t e a n d a u t h o r s h i p o f e a c h e n t r y ma y b e i mp o r t a n t . T h e r e c o r d s h o u l d n o t c o n t a i n f l i p p a n t o r d e r o g a t o r y r e ma r k s a b o u t t h e p a t i e n t o r c o l l e a g u e s .

Electronic Medical Records

O v e r t h e p a s t 3 0 y e a r s , e n t h u s i a s t s o f me d i c a l i n f o r ma t i c s h a v e c o n t i n u e d t o d e v e l o t h e e l e c t r o n i c me d i c a l r e c o r d . Ad v a n c e s i n t e c h n o l o g y p e r mi t a p h y s i c i a n t o d i c t a t e f i n d i n g s f r o m t h e d i a g n o s t i c e xa mi n a t i o n a n d t h e t r e a t me n t p l a n i n t o a n e l e c t r o n i c f o r ma t t h a t c a n b e r e a d i l y v i e w e d o n a c o mp u t e r s c r e e n . T h i s a l l o w s y o u t o r e c a l l y o u r d o c u me n t a t i o n a n d t h e p a t i e n t ' s s t u d y r e s u l t s a t a n a p p r o p r i a t e c o mp u t e r t e r mi n a l . It s h o u l d f a c i l i t a t e t h e t r a n s f e r o f t h e p a t i e n t ' s r e c o r d t o c o n s u l t a n t s , r e f e r r i n g p h y s i c i a n s , a n d i n s u r e r s . In d e e d , s p e c i a l i s t s i n t h e b u r g e o n i n g f i e l d o f t e l e me d i c i n e , w h o h a v e a u t h o r e d p r o g r a ms f o r t h e t r a n s f e r o f e l e c t r o c a r d i o g r a ms a n d r a d i o l o g i c i ma g e s , e n v i s i o n e n h a n c e d d e v e l o p me n t o f i n t e r a c t i v e v i s u a l c o n s u l t a t i o n a n d r o b o t i c s u r g e r y d i r e c t e d f r o m a r e mo t e s o u r c e .

P h y s i c i a n s c o n t e mp l a t i n g t h e u s e o f a f u l l y c o mp u t e r i ze d p a t i e n t c h a r t h a v e h a d c o n c e r n s r e g a r d i n g t h e e a s e o f p r e p a r i n g i t a n d t h e t i me r e q u i r e d t o d o s o , i t s accessibility to the physician, its cost and protection against system failure. M o r e o v e r, t h e y a r e a l s o c o n c e r n e d a b o u t t h e s e c u r i t y o f s e n s i t i v e p a t i e n t i n f o r ma t i o f r o m u n a u t h o r i ze d p e r s o n s ( e . g . , c r e d i t o r s , i n v e s t i g a t o r s , c o mp u t e r h a c k e r s ) . T h e s o l u t i o n o f t h e s e p r o b l e ms s h o u l d o v e r c o me t h e r e l u c t a n c e o f p h y s i c i a n s t o a d o p t t h e e l e c t r o n i c me d i c a l r e c o r d . P. 3 8

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 1 - T h e D i a g n o s t i c F r a me w o r k > C h a p t e r 3 - T h e S c r e e n i n g P h y s i c a l E xa mi n a t i o n : M e t h o d s a n d P r o c e d u r e

Chapter 3 The Screening Physical Examination: M ethods and Procedure


P. 3 9

In o u r e r a o f h i g h t e c h n o l o g y, t h e c o n t i n u e d n e e d f o r t h e p e r f o r ma n c e o f a p r o p e r p h y s i c a l e xa mi n a t i o n ma y s u r p r i s e t h e u n i n fa c k e t d D L . T h e s c i e n c e o f t h e S o r me t [ a r t o f t h e c l i n i c a l e xa mi n a tAM A 1 9 9 2 ; 2 6 7 : 2 6 5 0 2 ;6Ad o l p h R J . T h e v a l u e o f J ion. 52 b e d s i d e e xa mi n a t i o n i n a n e r a o f h i g h t e c Hearo g y. s St r ok e 9 4 ; 3 1 : 1 2 8 h n o l t Di 19 1 3 1 . T h e i mp o r t a n c e o f a s y s t e ma t i c h i s t o r y a n d p h y s i c a l e xa m i s b e s t u n d e r s t o o d ] b y c o n s i d e r i n g t h e f o l l o w i n g p o i n t s : ( a ) At t e n t i o n t o t h e s t o r y o f t h e p a t i e n t ' s i l l n e s s a n d t h o u g h t f u l p e r f o r ma n c e o f t h e p h y s i c a l e xa mi n a t i o n ( t h e l a y i n g o n o f h a n d s ) establishes a personal relationship of trust and respect between the patient and c l i n i c i a n n e c e s s a r y f o r g o o d me d i c a l c a r e . ( b ) P e r f o r mi n g l a b o r a t o r y t e s t s a n d i ma g i n g s t u d i e s w i t h o u t d i a g n o s t i c h y p o t h e s e s g e n e r a t e d f r o m t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n i s e xp e n s i v e a n d o f t e n p r o d u c e s f a l s e - p o s i t i v e r e s u l t s , d e l a y i n p r o p e r d i a g n o s i s . ( c ) C o n c l u s i o n s d r a w n f r o m t h e r e s u l t s o f b l o o d t e s t s , i ma g i n g p r o c e d u r e s , a n d e v e n b i o p s y ma t e r i a l , a r e b a s e d u p o n t h e p r e t e s t p r o b a b i l i t y o f t h e various diagnoses under consideration. T he pretest probability is derived from the h i s t o r y, p h y s i c a l e xa mi n a t i o n , a n d k n o w l e d g e o f d i s e a s e p r e v a l e n c e . ( d ) Ad d i t i o n a l l y l a r g e s t u d i e s h a v e s h o w n t h a t t h e h i s t o r y a n d p h y s i c a l e xa m a r e mo r e s e n s i t i v e a n d s p e c i f i c t h a n i ma g i n g t e s t s i n mo s t d i f f i c u l t d i a g n o s t i c isric u aW,o n s h a f i C . K th ti Sc [ M i s d i a g n o s i s a t a u n i v e r s i t y h o s p i t a l i n 4 me dM edi e r a s . ( Bal t i mor e) i c a l c i ne 1 9 9 6 ; 7 5 : 2 9 4.0 ] E a c h p h y s i c a l e xa mi n a t i o n i s a n o p p o r t u n i t y t o t r a i n t h e f o u r s e n s e s : s i g h t , t o u c h , h e a r i n g , a n d s me l l . W i t h r e f l e c t i v e p r a c t i c e a n d k n o w l e d g e o f a n a t o my, p h y s i o l o g y, a n d p a t h o l o g y, y o u w i l l p e r c e i v e a b n o r ma l i t i e s i n s t r u c t u r e a n d f u n c t i o n o v e r l o o k e d b y a n u n t r a i n e d e xa mi n e r. T h e p h y s i o l o g i c a n d d i s e a s e h y p o t h e s e s g e n e r a t e d d u r i n t h e h i s t o r y a n d p h y s i c a l e xa m a r e t e s t e d i n t h e v a r i o u s l a b o r a t o r i e s l e a d i n g t o p r e c i s e d i a g n o s i s w i t h a n e c o n o mi c a l u s e o f r e s o u r c e s .

We use each of our four senses to elicit signs of disease: inspection (sight and s me l l ) , p a l p a t i o n ( t o u c h ) , p e r c u s s i o n ( t o u c h a n d h e a r i n g ) , a n d a u s c u l t a t i o n ( h e a r i n g O n l y mi n i ma l ma n u a l d e xt e r i t y i s r e q u i r e d f o r p e r c u s s i o n a n d p a l p a t i o n . R e me mb e r t b e g e n t l e o n i n i t i a t i o n o f t h e e xa m; f o r c e f u l p a l p a t i o n a n d p e r c u s s i o n a r e r a r e l y n e c e s s a r y a n d w i l l c a u s e t h e p a t i e n t t o t e n s e t h e i r mu s c l e s a n d r e s i s t y o u r e xa mi n a t i o n . W i t h e xp e r i e n c e y o u w i l l b e a b l e t o a s s e s s t h e s e v e r i t y o f i l l n e s s a n d t h e u r g e n c y f
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t r e a t me n t . To b e c o me a s k i l l f u l d i a g n o s t i c i a n , y o u mu s t

P. 4 0 c o n s t a n t l y r e f l e c t o n t h e f i n d i n g s f r o m y o u r e xa mi n a t i o n , t h e c o r r e l a t i o n s b e t w e e n y o u r e xa m a n d t h e l a b o r a t o r y a n d i ma g i n g s t u d i e s , a n d t h e a c c u r a c y o f y o u r f i n d i n g a n d h y p o t h e s e s b a s e d u p o n t h e f i n a l c o n f i r me d d i a g n o s e s . In s h o r t , y o u mu s t p r a c t i c e a n d s t u d y. N o o n e s t a r t e d a s a n e xp e r t h i s t o r y t a k e r, p h y s i c a l e xa mi n e r, o r d i a g n o s t i c i a n . T h e e xp e r t s a r e t h o s e w h o h a v e l e a r n e d f r o m t h e i r e xp e r i e n c e a n d refined their senses and skills through repetition, reflection and correlation of their p h y s i c a l f i n d i n g s w i t h t h e r e s u l t s o f i ma g i n g a n d l a b o r a t o r y t e s t s .

Methods for Physical Exam ination Inspection

In s p e c t i o n i s t h e s e a r c h f o r p h y s i c a l s i g n s b y o b s e r v i n g t h e p a t i e n t w i t h y o u r e y e s a n d s e n s e o f s me l l . O f t h e e xa mi n a t i o n me t h o d s , i n s p e c t i o n i s t h e l e a s t me c h a n i c a l a n d t h e h a r d e s t t o l e a r n , b u t i t y i e l d s ma n y i mp o r t a n t p h y s i c a l s i g n s . B e c a u s e w e t e n d t o s e e t h i n g s t h a t h a v e me a n i n g f o r u s , i n s p e c t i o n d e p e n d s e n t i r e l y o n t h e k n o w l e d g e a n d e xp e c t a t i o n s o f t h e o b s e r v e r. T h i s i s e p i t o mi ze d i n ma xi ms s u c h a s W e s e e w h a t ' s b e h i n d t h e e y e s ( W i n t r o b e ) , T h e e xa mi n a t i o n d o e s n o t w a i t t h e r e mo v a l o f t h e s h i r t ( Wa r i n g ) , a n d Wa s M a n W e i s s , M a n s i e h t ( G o e t h e : W h a t o n e knows, one sees ). T he layperson looks at a person and concludes that there is s o me t h i n g p e c u l i a r a b o u t t h a t p e r s o n ; t h e p h y s i c i a n s e e s a c r o me g a l y. T h e e xp e r t o b s e r v e r c a n d i s s e c t t h e p e c u l i a r i t y a n d r e c o g n i ze t h e d i a g n o s t i c c o mp o n e n t s , s u c h a s t h e e n l a r g e d s u p r a o r b i t a l r i d g e s , t h e w i d e l y s p a c e d t e e t h , t h e ma c r o g l o s s i a t h e b u f f a l o h u mp , t h e h u g e h a n d s a n d f e e t . P r a c t i c e i s r e q u i r e d t o l e a r n i n s p e c t i o n : r e me mb e r t h a t s i g h t i s a f a c u l t y, w h e r e a s s e e i n g i s a n a r t .

S me l l s a r e i mp o s s i b l e t o d e s c r i b e , o n l y e xp e r i e n c e w i t h s i mi l a r s e n s a t i o n s w i l l g i v e y o u a c o n t e xt f o r i n t e r p r e t a t i o n . T h e b o d y o d o r s o f p o o r h y g i e n e , t h e f e t o r o f a d v a n c e d l i v e r d i s e a s e , t h e p u t r i d s me l l o f a n a e r o b i c i n f e c t i o n s , t h e s me l l o f a l c o h o o r a c e t o n e o n t h e b r e a t h , a n d ma n y o t h e r s a r e u s e f u l d i a g n o s t i c c l u e s a p p a r e n t t o t h e t r a i n e d o b s e r v e r.

General Visual Inspection

T h e i n i t i a l s t e p i n p h y s i c a l e xa mi n a t i o n i s i n s p e c t i o n o f t h e p e r s o n a s a w h o l e . It begins at your first encounter with the patient. Note how the patient is dressed and g r o o me d ; w h e t h e r e y e c o n t a c t i s e s t a b l i s h e d ; t h e t o n e a n d p a t t e r n o f s p e e c h ; h o w t h e p a t i e n t mo v e s a n d c h a n g e s p o s i t i o n ; f a c i a l e xp r e s s i o n ; s k i n t y p e ; o v e r a l l b o d y f o r m a n d p r o p o r t i o n s ; d e f o r mi t i e s o r a s y mme t r y o f f a c e , l i mb s , o r t r u n k ; n u t r i t i o n ; s p e c i f i c b e h a v i o r s ; s i g n s o f p a i n o r t r e mo r. Yo u s h o u l d a l s o b e a r i n mi n d t h a t t h e p a t i e n t w i l l b e i n s p e c t i n g y o u a t t h e s a me t i me .

Close Visual Inspection

C l o s e o r f o c u s e d i n s p e c t i o n c o n c e n t r a t e s o n a s i n g l e a n a t o mi c r e g i o n ; t h e c l o s e r y o l o o k , t h e mo r e y o u s e e . T h e a r t i s i n s e e i n g w h a t i s i mp o r t a n t a n d d i s t i n g u i s h i n g i t from what is not. P. 4 1


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Vi s u a l i n s p e c t i o n u s u a l l y r e f e r s t o o b s e r v a t i o n w i t h t h e u n a i d e d e y e s . O b v i o u s l y, t h d e r ma t o l o g i s t r e l i e s h e a v i l y o n t h e a p p e a r a n c e o f s k i n l e s i o n s t o ma k e a d i a g n o s i s . Ac t u a l l y, h o w e v e r, v i s u a l s i g n s a r e t h e p r i n c i p a l f i n d i n g s i n t h e u s e o f t h e o p h t h a l mo s c o p e , s l i t l a mp , o t o s c o p e , l a r y n g o s c o p e , b r o n c h o s c o p e , g a s t r o s c o p e , thoracoscope, laparoscope, cystoscope, anoscope, colonoscope, and s i g mo i d o s c o p e . T h e p a t h o l o g i s t u s e s t h e mi c r o s c o p e ; t h e r a d i o l o g i s t i n s p e c t s i ma g e g e n e r a t e d i n a n y n u mb e r o f w a y s . Al l a r e u s i n g v i s u a l i n s p e c t i o n t o e l i c i t i n f o r ma t i o

Proper visual inspection of the body surface requires a uniform white light source to a v o i d c o l o r d i s t o r t i o n . A h a n d - h e l d l e n s o r a n o t o s c o p e o r o p h t h a l mo s c o p e c a n b e u s e d f o r ma g n i f i c a t i o n . O b l i q u e l i g h t i n g i s o f t e n v e r y u s e f u l t o d e t e c t s u b t l e c h a n g e i n s u r f a c e c o n t o u r s a n d t o d e t e c t mo t i o n t h a t ma y b e i n v i s i b l e w i t h d i r e c t l i g h t i n g ; f e xa mp l e , l o o k i n g f o r a n a p i c a l i mp u l s e o n t h e c h e s t . As w i t h a l l p a r t s o f t h e p h y s i c a e xa mi n a t i o n i t i s i mp o r t a n t n o t j u s t t o s e e a n a b n o r ma l i t y, y o u mu s t l e a r n t o accurately describe what you see without using language that draws a conclusion o p r e s u me s a d i a g n o s i s .

Olfactory InspectionSmell
Al t h o u g h s o me p h y s i c i a n s s e e m t o r e g a r d t h e u s e o f t h e n o s e f o r d i a g n o s i s a s i n d e l i c a t e , o d o r s ma y p r o v i d e v a l u a b l e a n d i mme d i a t e c l u e s .

B r e ath.
O d o r s o n t h e b r e a t h f r o m a c e t o n e , a l c o h o l , a n d s o me p o i s o n s ma y l e a d q u i c k l y t o a diagnosis.

S putum .
F o u l - s me l l i n g s p u t u m s u g g e s t s b r o n c h i e c t a s i s o r l u n g a b s c e s s .

Vom itus .

T h e g a s t r i c c o n t e n t s ma y e mi t t h e o d o r s o f a l c o h o l , p h e n o l , o r o t h e r p o i s o n s , o r t h e s o u r s me l l o f f e r me n t i n g f o o d r e t a i n e d o v e r - l o n g . A f e c a l o d o r f r o m t h e v o mi t u s ma y indicate intestinal obstruction.

Fe c e s .
P a r t i c u l a r l y f o u l - s me l l i n g s t o o l s a r e c o mmo n i n p a n c r e a t i c i n s u f f i c i e n c y.

U r ine .
An a mmo n i a c a l o d o r i n t h e u r i n e ma y r e s u l t f r o m f e r me n t a t i o n w i t h i n t h e b l a d d e r.

P us .

A n a u s e a t i n g l y s w e e t o d o r, l i k e t h e s me l l o f r o t t i n g a p p l e s , i s e v i d e n c e t h a t p u s i s c o mi n g f r o m a r e g i o n o f g a s g a n g r e n e . A f e c a l o d o r i s i mp a r t e d b y a n a e r o b i c b a c t e r i a . S o me a n a e r o b i c b a c t e r i a i n a b s c e s s e s p r o d u c e a n o d o r l i k e t h a t o f o v e r r i p C a me mb e r t c h e e s e .

Palpation
T he usual definition of palpation is the act of feeling using the sense of touch; but
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t h i s i s t o o l i mi t e d . W h e n y o u l a y y o u r h a n d s o n t h e p a t i e n t , y o u p e r c e i v e p h y s i c a l s i g n s b y t a c t i l e s e n s e , t e mp e r a t u r e s e n s e , a n d t h e k i n e s t h e t i c s e n s e s o f p o s i t i o n a n v i b r a t i o n . As w i t h t h e o t h e r f o r ms o f o b s e r v a t i o n , a l l n o r ma l p e r s o n s p o s s e s s t h e s e senses, but training and practice will enable you to identify findings that escape the l a y p e r s o n . If y o u d o u b t t h e i n f l u e n c e o f p r a c t i c e o n p a l p a t i o n , o b s e r v e a b l i n d p e r s o P. 4 2 r e a d i n g a b o o k p r i n t e d i n b r a i l l e , t h e n c l o s e y o u r e y e s a n d a t t e mp t t o d i s t i n g u i s h b e t w e e n t w o b r a i l l e l e t t e r s b y t o u c h i n g t h e m.

Sensitiv e Parts of the Hand


Tac tile S e ns e .
T h e t i p s o f t h e f i n g e r s a r e mo s t s e n s i t i v e f o r f i n e t a c t i l e d i s c r i mi n a t i o n .

Te m pe r atur e S e ns e .
U s e t h e d o r s a o f t h e h a n d s o r f i n g e r s ; t h e s k i n i s mu c h t h i n n e r t h a n e l s e w h e r e o n the hand.

Vibr ator y S e ns e .

P a l p a t e w i t h t h e p a l ma r a s p e c t s o f t h e me t a c a r p o p h a l a n g e a l j o i n t s o r t h e u l n a r s i d e o f t h e h a n d ( f i f t h me t a c a r p a l a n d f i f t h p h a l a n g e s ) r a t h e r t h a n w i t h t h e f i n g e r t i p s t o perceive vibrations such as thrills. Prove the superiority for yourself by touching fir t h e f i n g e r t i p a n d t h e n t h e p a l ma r b a s e o f y o u r f i n g e r w i t h a v i b r a t i n g t u n i n g f o r k .

S e ns e of P os ition and C ons is te nc y.


Use the grasping fingers so you perceive with sensations from your joints and mu s c l e s .

Structures Examined by Palpation

P a l p a t i o n i s e mp l o y e d o n e v e r y p a r t o f t h e b o d y a c c e s s i b l e t o t h e e xa mi n i n g f i n g e r s a l l e xt e r n a l s t r u c t u r e s , a l l s t r u c t u r e s a c c e s s i b l e t h r o u g h t h e b o d y o r i f i c e s , t h e b o n e j o i n t s , mu s c l e s , t e n d o n s h e a t h s , l i g a me n t s , s u p e r f i c i a l a r t e r i e s , t h r o mb o s e d o r t h i c k e n e d v e i n s , s u p e r f i c i a l n e r v e s , s a l i v a r y d u c t s , s p e r ma t i c c o r d , s o l i d a b d o mi n a l v i s c e r a , s o l i d c o n t e n t s o f h o l l o w v i s c e r a , a n d a c c u mu l a t i o n s o f b o d y f l u i d s , p u s , o r blood.

Specific Qualities Elicited by Palpation


Te x tur e .
T h e s u r f a c e c h a r a c t e r i s t i c s o f t h e s k i n a n d h a i r a r e n o t e d . Is e a c h d r y, b r i t t l e , c o a r s e , t h i c k , t h i n , r o u g h e n e d o r s mo o t h ?

M ois tur e .
As s e s s t h e mo i s t u r e c o n t e n t o f t h e s k i n , h a i r, a n d mu c o u s me mb r a n e s . Ar e t h e y mo i s t a n d s u p p l e o r d r y a n d c r a c k e d ?

S k in Te m pe r atur e .
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P a l p a t e t h e h e a d , f a c e , t r u n k , a r ms , h a n d s , l e g s , a n d f e e t t o a s s e s s t h e l o c a l s k i n t e mp e r a t u r e a n d t h e d i s t r i b u t i o n o f h e a t .

C har ac te r is tic s of M as s e s .
W h e n a ma s s o r e n l a r g e d o r g a n i s d i s c o v e r e d , r e c o r d i t s s i ze , s h a p e , c o n s i s t e n c y, mo t i l i t y, s u r f a c e r e g u l a r i t y a n d t h e p r e s e n c e o r a b s e n c e o f e xp a n s i l e o r t r a n s mi t t e d pulsation.

P r e c or dial C ar diac Thr us t.


P a l p a t e t h e p r e c o r d i u m f o r s i g n s o f h e a r t a cCi h a p(t s e e8p a g e 3 6)1 t on er , .

C r e pitus .
D u r i n g e xa mi n a t i o n o f t h e b o n e s , j o i n t s , t e n d o n s h e a t h s , p l e u r a , a n d s u b c u t a n e o u s tissue note crepitation.

Te nde r ne s s .

E l i c i t a t i o n o f d i s c o mf o r t o r p a i n o n p a l p a t i o n o f a c c e s s i b l e t i s s u e s a n d o v e r ma j o r o r g a n s s h o u l d b e n o t e d . H o w mu c h p r e s s u r e i s r e q u i r e d t o i n d u c e t h e u n c o mf o r t a b l e sensation? P. 4 3

Thr ills .
P a l p a t e t h e p r e c o r d i u m f o r t h r i l l s . If b r u i t s a r e h e a r d i n t h e ma j o r a r t e r i e s , p a l p a t e them for thrills.

Voc al Fr e m itus .
P a l p a t i o n o f v o c a l v i b r a t i o n s t h r o u g h t h e c h e s t w a l l p r o v i d e s i mp o r t a n t i n f o r ma t i o n a b o u t t h e u n d e r l y i n g p l e u r a a n d l u n gh ( s e e r ,8p a g e 3 5)4 C apt .

Methods of Palpation
Light P alpation.

Al w a y s b e g i n p a l p a t i o n w i t h a l i g h t t o u c h . Yo u r s e n s e o f t o u c h i s mo s t a c u t e w h e n lightly applied and the patient will be put at ease. Gently sliding your fingertips ove t h e s k i n s u r f a c e w i l l o f t e n d e t e c t s u b t l e o r mo b i l e ma s s e s t h a t a r e u n d e t e c t e d b y f o r c e f u l p a l p a t i o n . Yo u w i l l a l s o l o c a t e a r e a s o f p a r t i c u l a r t e n d e r n e s s , w h i c h s h o u l d b e e xa mi n e d l a s t .

D e e p P alpation.
Firm pressure is applied to displace the superficial tissues allowing palpation for d e e p e r l e s i o n s . T h i s i s e s p e c i a l l y u s e f u l i n t h e a b d o me n , b u t i s a l s o u s e f u l i n t h e n e c k , b r e a s t s , a n d l a r g e mu s c l e ma s s e s . Av o i d f i r m p a l p a t i o n o v e r n e r v e s o r o t h e r tender structures whenever possible.

B im anual P alpation.

In t h i s t e c h n i q u e , t h e t i s s u e i s e xa mi n e d b e t w e e n t h e f i n g e r s o f t h e t w o h a n d s . It i s u s e f u l f o r s o f t t i s s u e s u c h a s t h e b r e a s t s , i n t r a o r a l , a b d o mi n a l a n d p e l v i c
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e xa mi n a t i o n s , a n d e xa mi n a t i o n o f t h e mu s c l e s a n d j o i n t s .

Percussion

Percussion is the act of striking the surface of the body to elicit a sound. When the body surface is struck, the underlying tissues vibrate to produce percussion notes h a v i n g mi xe d f r e q u e n c i e s t h a t v a r y w i t h t h e d e n s i t y o f t h e o r g a n a n d t h e c o mp o s i t i o overlying tissue.

Bimanual, Mediate, or Indirect Method of Percussion

S t r i k i n g t h e p e r c u s s i o n b l o w o n a n i n a n i ma t e o b j e c t o r y o u r f i n g e r i s i n d i r e c t o r me d i a t e p e r c u s s i o n . T h i s i s t h e f o r m o f p e r c u s s i o n mo s t c o mmo n l y u s e d . T h e p a l ma s u r f a c e o f t h e l e f t l o n g f i n g e r i s f i r ml y p r e s s e d o n t o t h e b o d y s u r f a c e , a s a pl ex i met er, n l y t h e d i s t a l p h a l a n x s h o u l d t o u c h t h e w a lex or,t hae t i p o f t h e o pl l . As right long finger strikes a sharp blow on the distal interphalangeal joint of the p l e xi me t e r f i n g e ri g(. 3 -)1 T h e e xa mi n e r h o l d s t h e p l e xo r f i n g e r p a r t l y f l e xe d a n d F . rigid and delivers the blow by bending only the wrist, so the weight of the hand lend mo me n t u m e n s u r i n g r e p e t i t i v e b l o w s o f e q u a l f o r c e . T h e w r i s t mu s t b e r e l a xe d a n d n e i t h e r t h e e l b o w n o r t h e s h o u l d e r s h o u l d b e mo v e d . Af t e r t h e s t r o k e , t h e p l e xo r s h o u l d r e b o u n d q u i c k l y f r o m t h e p l e xi me t e r t o a v o i d d a mp i n g t h e v i b r a t i o n s . U s u a l l y t w o o r t h r e e s t a c c a t o b l o w s a r e s t r u c k i n o n e p l a c e , a n d t h e n t h e p l e xi me t e r i s mo v e d e l s e w h e r e f o r a s e c o n d s e r i e s o f b l o w s t o c o mp a r e t h e s o u n d s . M o s t p h y s i c i a n s e mp l o y t h i s b i ma n u a l me t h o d f o r p e r c u s s i o n o f b o t h t h e t h o r a x a n d a b d o me n . P. 4 4

F i g . 3 - 1 M e t h o d o f i n d i r e c t ( b i m a n u a l ) p e r cThe ito nmi nal di gi t of t he u s s er . l ef t l ong f i nger i s f i r ml y appl i ed t o an i nt er s pac e, or ot her body s ur f ac e, as a pl ex i met er. The di s t al i nt er phal angeal j oi nt of t hat f i nger i s s t r uc k a s har p bl ow wi t h t he t i p of t he f l ex ed r i ght l ong f i nger. To f ur ni s h bl ows of equal i nt ens i t y, t he f i nger s of t he r i ght hand ar e hel d par t l y f l ex ed and t he wr i s t i s l oos e s o t hat t he s t r i k i ng hand pi v ot s ex c l us i v el y at t he r el ax ed wr i s t . To av oi d dampeni ng t he v i br at i ons af t er s t r i k i ng t he bl ow, wi t hdr aw t he pl ex or hand r api dl y f r om t he pl ex i met er.

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Direct Percussion
When you elicit sound by striking the body surface directly with your fingers, hand, o r r e f l e x h a mme r, t h e p r o c e d u r e i sdi r ece dor i mmedi at e per c us s i h i s call t T on. me t h o d i s n o t c o mmo n l y u s e d , b u t c a n b e v e r y r e w a r d i n g . S i n c e y o u r f i n g e r i s n o t r e c e i v i n g t h e b l o w, b e c a r e f u l t o n o t s t r i k e t h e p a t i e n t t o o f i r ml y.

Sonorous Percussion

Sonorous percussion is used to detect alterations in the density of an organ. For e xa mp l e , s t r i k i n g a n a i r - f i l l e d l u n g p r o d u c e s o n e s o u n d ; a l u n g f i l l e d w i t h f l u i d p r o d u c e s q u i t e a n o t h e r. T h e c h a n g e i n s o u n d s i s d e t e r mi n e d b y t h e c h a n g e i n t i s s u d e n s i t i e s . T h e d i f f e r e n t s o u n d s a r e g i v e n s p e c i a l n a me s . P e r c u s s i n g t h e g a s t r i c a i r b u b b l e y i e l d s a s o u n d c aylmpany ; h e w o r d i s d e r i v e d f r o m t h e G r e e k f o r d r u m, t l ed t a n d t h e s o u n d v a g u e l y r e s e mb l e s a d r u mb e a t . T h e p e r c u s s i o n n o t e f r o m t h e a i r - f i l l e l u n g i s o f q u i t e d i f f e r e n t p i t c h a n d t i mb r e ,ese r me d e. s e n t i n t h e n o r ma l r t onanc Ab b o d y,hy per r es onanc e e mi t t e d b y t h e e mp h y s e ma t o u s l u n g ; i t i s i n t e r me d i a t e is b e t w e e n r e s o n a n c e f r o m t h e l u n g , f i l l e d w i t h s ma l l a i r s a c s a n d s e p t a , a n d t y mp a n y f r o m t h e l a r g e u n d i v i d e d b u b b l e i n t h e sDul l nes.s s a d i s t i n c t i v e n o i s e t o ma c h i elicited by percussion over the heart when it is not covered by inflated lung. P e r c u s s i o n o f t h e t h i g h mu s c l e s fy at nes s . l ields

In a n o n t e c h n i c a l s e n s e , t h e p e r c u s s i o n s o u n d s ma y b e r e g a r d e d a s t h e n o t e s o f a scale, which progresses from tissues of high density to tissues of low density in the f o l l o w i n g s e q u e n c e : f l a t n e s s , d u l l n e s s , r e s o n a n c e , h y p e r r e s o n a n c e , a n d t y mp a n y. T h e d u r a t i o n o f e mi t t e d s o u n d c o r r e l a t e s i n v e r s e l y w i t h t h e d e n s i t y p r o d u c i n g i t : flatness is a very short sound and, as the density lessens, each succeeding note in t h e s c a l e i s l o n g e r t h a n i t s p r e d e c e s s o r.

T h e p i t c h a n d t i mb r e o f t h e s o u n d s mu s t b e l e a r n e d b y l i s t e n i n g . L a n g u a g e i s i n a d e q u a t e f o r d e s c r i p t i o n o f s o u n d s , a n d a t t e mp t s t o d e s c r i b e P. 4 5 t h e s e n o t e s a r e f u t i l e a n d c o n f u s i n g . P r o p e r r e c o g n i t i o n o f t h e s e d i s t i n c t i o n s mu s t b g a i n e d b y l i s t e n i n g . S o me c l i n i c i a n s h a v e t r a i n e d t h e ms e l v e s t o f e e l c h a n g e s i n resonance, using vibration sense, as well as to perceive them as sound.

S o n o r o u s p e r c u s s i o n i s e mp l o y e d t o a s c e r t a i n t h e d e n s i t y o f t h e l u n g s , t h e p l e u r a l s p a c e , t h e p l e u r a l l a y e r s , a n d t h e h o l l o w v i s c e r a o f t h e a b d o me n . It r e q u i r e s a s t r o n b l o w, e s t i ma t e d t o v i b r a t e t i s s u e f o r a r a d i u s o f 6 c m i n t h e c h e s t , 3 c m i n t h e t h o r a c i c w a l l , a n d 3 c m i n t h e l u n g p a r e n c h y ma .

Definitiv e Percussion

When the density of an organ is invariable and contrasts with that of the surroundin tissue, the borders of the organ can be identified as the transition site of one sound q u a l i t y t o t h e o t h e r ; t hdef i s t i v e per c us s i F o r e xa mp l e , p e r c u s s i o n o f t h e i s ni on. h e a r t i s e mp l o y e d o n l y t o l o c a t e i t s b o u n d a r i e s w i t h t h e l u n g ; t h e d e n s i t y o f n e i t h e r tissue is in question. A lighter blow should be struck by for definitive percussion tha for sonorous percussion. Mapping of the area of greater density gives an idea of th s i ze o f t h e s t r u c t u r e o r t h e e xt e n t o f i t s b o r d e r.

D e f i n i t i v e p e r c u s s i o n i s c o mmo n l y u s e d t o d e t e r mi n e t h e l o c a t i o n o f t h e l u n g b a s e s ,
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t h e h e i g h t o f f l u i d i n t h e p l e u r a l c a v i t y, t h e w i d t h o f t h e me d i a s t i n u m, t h e s i ze o f t h e h e a r t , t h e o u t l i n e o f d e n s e ma s s e s i n t h e l u n g s , t h e s i ze a n d s h a p e o f t h e l i v e r a n d s p l e e n , t h e s i ze o f a d i s t e n d e d g a l l b l a d d e r a n d u r i n a r y b l a d d e r, a n d t h e l e v e l o f ascitic fluid.

Auscultation

Al t h o u g h a u s c u l t a t i o n l i t e r a l l y me a n s u s i n g h e a r i n g t o o b t a i n p h y s i c a l s i g n s , i t h a s c o me t o me a n h e a r i n g t h r o u g h t h e s t e t h o s c o p e . T h e r e i s n o t e c h n i c a l t e r m f o r hearing the patient speak, cough, groan, or shriek, although all these sounds furnis d i a g n o s t i c c l u e s ; t h i s j u s t e mp h a s i ze s t h e i mp o ir saenie oo t h e p a t i e n t , n o t l t t n c ng f t just the patient's words.

T h e u s e s o f a u s c u l t a t i o n h a v e e xp a n d e d a s t h e c o r r e l a t i o n o f a u s c u l t a t o r y f i n d i n g s to physiologic and pathophysiologic processes has been revealed by u l t r a s o n o g r a p h y, e c h o c a r d i o g r a p h y, a n d o t h e r d i a g n o s t i c s t u d i e s . As e v e r y mu s i c i a n k n o w s , t h e e a r c a n b e t r a i n e d t o r e c o g n i ze s o u n d s mo r e a c c u r a t e l y. E a c h p e r s o n l e a r n s t o r e c o g n i ze t h e v o i c e s o f ma n y a s s o c i a t e s b y p a t t e r n s o f p i t c h a n d overtones.

Use of the Stethoscope

T h e s t e t h o s c o p e c o n t a i n s a v i b r a t i n g a i r c o l u mn c o n n e c t i n g t h e b o d y w a l l t o t h e e a r s . B e c a u s e s t e t h o s c o p e s i n v a r i a b l y mo d i f y s o u n d t o s o me e xt e n t , y o u s h o u l d u s e a s i n g l e i n s t r u me n t w h e n e v e r p o s s i b l e . T h e u s u a l s t e t h o s c o p e d o e s n o t a mp l i f y s o u n d ; i t me r e l y a s s i s t s i n e xc l u d i n g e xt r a n e o u s n o i s e s . E l e c t r o n i c s t e t h o s c o p e s , w h i c h a mp l i f y a n d / o r p r o j e c t t h e s o u n d t h r o u g h a s p e a k e r, a r e p a r t i c u l a r l y u s e f u l f o teaching purposes.

B i n a u r a l i n s t r u me n t s c o n s i s t o f a c h e s t p i e c e , p l a s t i c t u b e s , a n d t w o e a r p i e c e s connected by a spring. Two chest pieces are needed to better detect the full range o f f r e q u e n c i e s . Tbel l i s a h o l l o w c o n e w i t h a r i m he P. 4 6 o f h a r d r u b b e r o r p l a s t i c . T h e b e l l t r a n s mi t s a l l s o u n d s f r o m t h e c h e s t ; t h e l o w p i t c h e d s o u n d s c o me t h r o u g h p a r t i c u l a r l y w e l l . T h e l o w - p i t c h e d mu r mu r o f mi t r a l s t e n o s i s a n d t h e f e t a l h e a r t s o u n d s ma y b e a u d i b l e o n l y w i t h t h e b e l l . A w i d e b e l l c a t r a n s mi t s o u n d s o f l o w e r p i t c h t h a n a n a r r o w d i a me t edi aphr. agms a f l a t r b e l l T hie c u p c o v e r e d w i t h a s e mi - r i g i d d i a p h r a g m t h a t s e r v e s a s a f i l t e r t o e xc l u d e l o w - p i t c h s o u n d s , s o t h e i s o l a t e d h i g h - p i t c h e d s o u n d s s e e m l o u d e r. T h e d i a p h r a g m i s b e s t s u i t e d f o r h i g h - p i t c h e d s o u n d s f r o m t h e h e a r t ( e . g . , r e g u r g i t a n t a o r t i c mu r mu r s ) a n d b r e a t h s o u n d s . C r a c k s i n t h e d i a p h r a g m i mp a i r i t s p r o p e r t i e s . T h e c h e s t p i e c e s h o w i n F i g . 3 - 2s a p o p u l a r a n d c o n v e n i e n t c o n f i g u r a t i o n o f t h e b e l l a n d d i a p h r a g m w i t h a i v a l v e t o d i r e c t t h e a i r c o l u mn f r o m o n e t o t h e o t h e r. T h e t u b i n g s h o u l d b e t h i c k w a l l e d ; t h e i n s i d e d i a me t e r s h o u l d n o t b e s ma l l e r t h a n t h e c a l i b e r o f t h e c o n n e c t i n g t u b e s . F o r o p t i ma l a c o u s t i c s , t h e l e n g t h o f t h e r u b b e r t u b i n g s h o u l d n o t e xc e e d 3 0 c m, a l t h o u g h ma n y p h y s i c i a n s a c c e p t a l o n g e r, mo r e c o n v e n i e n t l e n g t h .

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F i g . 3 - 2 T h e S p r a g u e s t e t h o s c o p ec hes t pi ec e c ombi nes t he bel l and The . di aphr agm, wi t h a v al v e t o di r ec t t he ai r t hr ough ei t her. The ear pi ec es ar e c onnec t ed by a s pr i ng t hat hol ds t hem i n pl ac e.

T he stethoscope should fit the user's ears. T he plastic or rubber earpiece should i mp i n g e o n t h e e xt e r n a l a u d i t o r y me a t u s w i t h o u t d i s c o mf o r t o r p a i n , y e t f i t t i g h t l y w i t h o u t a i r l e a k a g e . T h e s p r i n g , s i ze , a n d d e s i g n o f t h e e a r p i e c e d e t e r mi n e t h e tightness of the fit.

M o r e a r t t h a n me e t s t h e e y e i s r e q u i r e d t o u s e t h e s t e t h o s c o p e . T h e d i a p h r a g m should be pressed tightly against the chest wall; in contrast, the rim of the bell s h o u l d t o u c h t h e c h e s t w a l l l i g h t l y, b u t s e a l c o mp l e t e l y. H e a v y p r e s s u r e w i t h t h e b e s t r e t c h e s t h e u n d e r l y i n g s k i n o v e r t h e b e l l ' s c i r c u mf e r e n c e s o t h e s k i n b e c o me s a d i a p h r a g m e xc l u d i n g l o w - p i t c h e d s o u n d s . T h e e n t i r e r i m o f t h e b e l l mu s t t o u c h t h e s k i n ; a r o a r i n g s o u n d f r o m e xt r a n e o u s n o i s e w a r n s t h e e xa mi n e r o f a l e a k . At f i r s t , t h e l i s t e n e r ma y b e d i s t r a c t e d b y e xt r a n e o u s n o i s e s c o mi n g t h r o u g h t h e w a l l s o f t h e t u b i n g , b u t s o o n l e a r n s t o i g n o r e t h e s e c o mp l e t e l y. T h e b r e a t h o f t h e e xa mi n e r o n t h t u b i n g p r o d u c e s n o i s e ; t r y t h i s , s o t h e s o u n d ma y b e r e c o g n i ze d a n d e l i mi n a t e d . S k or hair rubbing on the chest piece produces sounds like crackles, which can be e l i mi n a t e d b y w e t t i n g t h e h a i r o r b y p l a c i n g a s o f t r u b b e r r i m o n t h e b e l l . M o v e me n t o f mu s c l e s , j o i n t s , o r t e n d o n s s o u n d l i k e f r i c t i o n r u b s ; b e c e r t a i n t h a t y o u c a n r e c o g n i ze t h e m s o t h e y c a n b e e l i mi n a t e d . If y o u d o n o t h e a r t h e e xp e c t e d s o u n d s w i t h y o u r f i r s t a t t e mp t , d o n o t d i s c r e d i t y o u r i n s t r u me n t P. 4 7 o r y o u r e a r s ; t h e y a r e p r o b a b l y n o r ma l , b u t y o u n e e d p r a c t i c e . U s e t h e b e l l f o r narrow spaces such as the supraclavicular fossae. T hin-walled chests present d i f f i c u l t i e s i n f i t t i n g t h e c h e s t p i e c e i n t o t h e i n t e r s p a c e s w i t h o u t l e a k a g e . E xa mi n e t i n s t r u me n t o c c a s i o n a l l y t o e n s u r e t h a t i t h a s n o l e a k s o r p l u g s o f c e r u me n o r o t h e r debris.

Au s c u l t a t i o n i s u s e d t o e xa mi n e t h e h e a r t a n d l u n g s . F r o m t h e l u n g s t h e s t e t h o s c o p conveys breath sounds, whispers, and voice sounds, as well as crackles and frictio r u b s . T h e h e a r t g e n e r a t e s t h e n o r ma l h e a r t s o u n d s , g a l l o p s , mu r mu r s , r h y t h m disturbances, and pericardial rubs and knocks. T he vessels of the neck are e xa mi n e d f o r mu r mu r s i n t h e t h y r o i d , c a r o t i d , a n d s u b c l a v i a n a r t e r i e s a n d f o r v e n o u h u ms . Au s c u l t a t i o n o f t h e a b d o me n r e v e a l s b o w e l s o u n d s a n d mu r mu r s f r o m a n e u r y s ms a n d s t e n o t i c a r t e r i e s . T h e s k u l l c a n b e a u s c u l t a t e d f o r t h e b r u i t o f a n
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a r t e r i o v e n o u s f i s t u l a . C r e p i t u s c a n b e h e a r d i n j o i n t s , t e n d o n s h e a t h s , mu s c l e s , a n d f r a c t u r e d b o n e s , a s w e l l a s i n s u b c u t a n e o u s e mp h y s e ma .

Procedure for the Screening Physical Exam ination

W i t h i n p r a c t i c a l l i mi t s , t h e r e i s n o s u c h t h i n g a s a r o u t i n e p h y s i c a l e xa mi n a t i o n . L i k h i s t o r y t a k i n g , t h e p h y s i c a l e xa mi n a t i o n i s a s t r u c t u r e d me t h o d f o r e l i c i t i n g o b s e r v a t i o n s o f t h e p a t i e n t u s i n g mu l t i p l e t e c h n i q u e s . T h e e mp h a s i s o f e a c h e xa m v a r i e s a s p r o mp t e d b y t h e s y mp t o ms , p h y s i c a l s i g n s , a n d l a b o r a t o r y f i n d i n g s o f e a c p a t i e n t ; f o r e xa mp l e , t h e h e a r t a n d c i r c u l a t i o n w i l l b e e xa mi n e d mo r e c a r e f u l l y a n d t h o r o u g h l y i n a p a t i e n t w i t h e xe r t i o n a l d y s p n e a t h a n i n a p a t i e n t w h o h a s j u s t sustained a fractured ankle.

E i t h e r u n c o n s c i o u s l y o r, p r e f e r a b l y, a f t e r c a r e f u l c o n s i d e r a t i o n , e v e r y p h y s i c i a n a d o p t s a s e q u e n c e o f e xa mi n a t i o n . T h e p h y s i c i a n d e v e l o p s basoc t i n e o r a riu s c r eeni ng ex ami nat it on t i s p e r i o d i c a l l y p e r f o r me d w i t h mo s t p a t i e n t s . If s i g n i f i c a n t ha a b n o r ma l i t i e s a r e e n c o u n t e r e d t h a t f o c u s a t t e n t i o n o n a n a n a t o mi c s i t e o r s o me p h y s i o l o g i c p r o b l e m, a mo r e d e t a i l e d e xa mi n a t i o n o f t h a t a r e a o r s y s t e m s h o u l d b e p e r f o r me d . T h e s c r e e n i n g e xa mi n a t i o n s h o u l d v a r y v e r y l i t t l e f r o m p a t i e n t t o p a t i e n t o f t h e s a me g e n d e r a n d a g e .diT h e agnos t i c ex ami natfi o l l o w i n g u p o n p r o b l e ms on i d e n t i f i e d i n t h e h i s t o r y o r a b n o r ma l i t i e s e l i c i t e d o n t h e s c r e e n i n g e xa mi n a t i o n , i s u n i q u e t o e a c h p a t i e n t a n d p r o b l e m.

H i l l ma n e t a l . s t u d i e d t h e c o mp o n e n t s o f s c r e e n i n g e xa mi n a t i o n s e mp l o y e d b y v a r i o u s f a mi l y p h y s i c i a n s a n d i n t e r n i s t s i n S e a t t l e . T h e y f o u n d t h a t t h e e xa mi n a t i o n v a r i e d f r o m 2 t o 4 5 mi n u t e s , w i t h w i d e v a r i a t i o n i n t h e c o mp o n e n t s e mp h a s i ze d . W e a r e i n d e b t e d t o t h e m f o r ma k i n g t h e i r f i n d i n g s H vlama b l e S , G o o d a l l B W, a i l ilan R [ G r u n d y S M , e t a l : T h e b a s i c o r r o u t i n e p h y s i c a l e xa mi n a t i o n o fCl hni c alu l t , i n t i e ad Sk i l l s N e w Yo r k : M c G r a w - H i l l , 1 9 8 1 : 9 7 11c5h v a r i a t i o n i n t h e s c r e e n i n g . ]. Su e xa mi n a t i o n r e f l e c t s b o t h e xa mi n a t i o n s t h a t a r e t o o c u r s o r y a n d e xa mi n a t i o n s t h a t are probably too detailed for efficient screening. T he clinician P. 4 8 mu s t ma s t e r a s t r u c t u r e d , e f f i c i e n t s c r e e n i n g e xa m, w h i c h , w h e n c o mb i n e d w i t h t h e h i s t o r y, i s l i k e l y t o i d e n t i f y mo s t s e r i o u s a b n o r ma l i t i e s .

F o r c o n v e n i e n c e , a n d f o r t h e p a t i e n t ' s c o mf o r t , w e e xa mi n e t h e b o d y b y r e g i o n s . In c o n t r a s t , w e r e c o g n i ze i l l n e s s a n d d i s e a s e b y t h e p h y s i o l o g i c s y s t e ms i n v o l v e d . C o n s e q u e n t l ex ami ne by r egi ons , but t hi nk by s y s th i s r .e q u i r e s p r a c t i c e , y, T ems r e f l e c t i o n , a n d e xp e r i e n c e . T h e b e g i n n e r s e e s a l l t h e r e g i o n s a n d ma y i d e n t i f y ma n y o r mo s t o f t h e f i n d i n g s , b u t h a s t r o u b l e i n t e g r a t i n g t h o s e f i n d i n g s i n t o a c o mp l e t e p i c t u r e o f t h e a n a t o my a n d p h y s i o l o g y h e h a s o b s e r v e d . T h i s i n t e g r a t i o n o f f i n d i n g s i s c r i t i c a l f o r g e n e r a t i n g u n i f y i n g d i a g n o s t i c h y p o t h eoblsem e e s, t s a g e 3 3 , Pr s e ( s Li p a n d Hy pot hes i s Gener at i on g e 7 ) . , pa A s i n g l e r o u t i n e t h a t e v e r y o n e s h o u l d f o l l o w e xa c t l y i s i mp r a c t i c a l . T h e r e a r e ma n y p o s s i b l e s e q u e n c e s o f e xa mi n a t i o n , e a c h w i t h i t s a d v a n t a g e s a n d d i s a d v a n t a g e s ; n o n e i s p e r f e c t . W e h a v e b a s e d o u r r e c o mme n d a t i o n o n s e v e r a l o b s e r v a t i o n s : 1. M a n y p h y s i c a l s i g n s a r e r e c o g n i ze d a n d e v a l u a t e d d u r i n g h i s t o r y t a k i n g . 2. A w e l l - o r g a n i ze d e xa m r o o m w i t h e a s i l y a c c e s s i b l e i n s t r u me n t s f a mi l i a r t o t h e
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e xa mi n e r e n h a n c e s e f f i c i e n c y. 3. E xa mi n i n g e a c h p a t i e n t f r o m h e a d t o f o o t i n t h e s a me s e q u e n c e a v o i d s mi s s i n g s i g n s a n d d e v e l o p s a n a p p r e c i a t i o n o f n o r ma l v a r i a t i o n . 4. E xc e s s i v e c h a n g e s o f p o s i t i o n b y t h e e xa mi n e r o r p a t i e n t t a k e t i me a n d a r e u n c o mf o r t a b l e f o r b o t h . 5. T h i s s c r e e n i n g e xa mi n a t i o n c a n b e p e r f o r me d i n 1 5 mi n u t e s . Al w a y s k e e p t h e f o l l o w i n g p o i n t s i n mi n d : 1. R e s p e c t i n g y o u r p a t i e n t ' s mo d e s t y a n d r e t a i n i n g a p r o f e s s i o n a l a p p r o a c h e n c o u r a g e s t h e p a t i e n t ' s c o o p e r a t i o n a n d d i mi n i s h e s t h e c h a n c e s f o r mi s i n t e r p r e t a t i o n o f y o u r i n t e n t t o e xa mi n e e mo t i o n a l l y s e n s i t i v e a n a t o my. 2. A s c r e e n i n g e xa mi n a t i o n n o t o n l y d i s c o v e r s d i a g n o s t i c s i g n s b u t a l s o r e a s s u r e s the patient.

3. E xa mi n i n g t h e p r o b l e m a r e a f i r s t r e s p o n d s t o t h e p a t i e n t ' s a n xi e t y b u t s h o u l d n o d i s t r a c t f r o m c o mp l e t i n g a c o mp l e t e e xa mi n a t i o n . 4. D e t a i l e d e v a l u a t i o n o f s p e c i f i c s i g n s r e q u i r e s a d d i t i o n a l t i me .

5. In s o me c i r c u ms t a n c e s , a f u l l s c r e e n i n g e xa mi n a t i o n i s i n a p p r o p r i a t e ; a r e g i o n a l o r s p e c i a l e xa mi n a t i o n ma y b e a l l t h a t i s i n d i c a t e d . T h i s i s p a r t i c u l a r l y t r u e f o r the patient returning for follow up after a short interval or an otherwise healthy p a t i e n t w i t h a n a c u t e l i mi t e d p r o b l e m.

Preparing for the Screening Examination


T h i s e xa mp l e o f a mu l t i s y s t e m s c r e e n i n g e xa mi n a t i o n i s d e s i g n e d t o b e p e r f o r me d w i t h t h e p a t i e n t i n o n l y f o u r o r f i v e p o s i t i o n s . It t a k e s a p p r o xi ma t e l yg 1 5 mi n u t e s ( Fi . 3 - 3) . In t h e f o l l o w i n g s e c t i o n s , w e g i v e y o u a d e s c r i p t i o n o f t h e s e q u e n c e o f t h e e xa mi n a t i o n . T h e me t h o d s f o r e xa mi n a t i o n o f e a c h r e g i o n a r e d e t a i l e d i n t h e i r respective chapters. P. 4 9

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F i g . 3 - 3 T h e o f f i c e s c r e e n i n g p h y s i c a l e xa m i n a t i o n . A . P a t i e n t d r a p e d a n d s i t t i n g phy s i c i an f ac i ng) . P a t i e n t d r a p e d a n d s i t(tphy s i c i an t o r i ght ( B. ing and bac k )C . P a t i e n t d r a p e d a n d s u pphy s i c i an t o r i ght ) . Pl ac e t he pat i ent . ( ine i n t he l ef t l at er al dec ubi t us pos i t i on t o l i s t en at t he c ar.diFacmapex . D e ale p e l vi c e xa m : i ent dr aped and s upi ne, k nees and hi ps f l ex ed ( phy s i c i an at pat f oot ) .

Preparation: Required Equipment

A mi n i mu m l i s t o f e q u i p me n t f o r t h e s c r e e n i n g e xa mi n a t i o n i n c l u d e s a s t e t h o s c o p e , s p h y g mo ma n o me t e r, o t o s c o p e , o p h t h a l mo s c o p e , p e n l i g h t , t o n g u e b l a d e s , r e f l e x h a mme r, t u n i n g f o r k a n d c a l i b r a t e d mo n o f i l a me n t f o r s e n s o r y t e s t i n g , t a p e me a s u r e , l a t e x o r p l a s t i c g l o v e s , l u b r i c a n t f o r r e c t a l a n d v a g i n a l e xa mi n a t i o n s , r e a g e n t f o r o c c u l t b l o o d t e s t , s t e r i l e s w a b s , a n d ma t e r i a l s f o r s p e c i me n c o l l e c t i o n d u r i n g t h e f e ma l e p e l v i c e xa mi n a t i o n . T h e i n s t r u me n t s mu s t b e w i t h i n e a s y r e a c h . W e a r g l o v e s w h e n e xa mi n i n g i n f e c t e d s k i n o r w h e n y o u ma y c o me i n c o n t a c t w i t h b o d y f l u i d s .

Preparation: The Patient


P. 5 0

T h e p a t i e n t u n d r e s s e s i n p r i v a t e , p u t s o n a n e xa mi n a t i o n g o w n , a n d s i t s o n t h e e n d o f t h e e xa m t a b l e w i t h a s h e e t d r a p e d o v e r t h e l a p a n d l e g s .

Performance of the Screening Examination


P has e A:Vital Signs, General Inspection, Close Inspection,

and Palpation of the Head, Ears, Eyes, Nose, and Throat


Pat i ent and Ex ami ner Pos i t i p a t i : n t d r a p e d a n d s i t t i n g f a c i n g t h e e xa mi n e r ons e
To s t a r t t h e e xa m, t h e p h y s i c i a n w a s h e s h e r h a n d s .

Vital S igns .
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O b t a i n t h e v i t a l s i g n s o r, i f p r e v i o u s l y o b t a i n e d b y a n u r s e , r e v i e w t h e m a n d c o n f i r m a n y a b n o r ma l f i n d i n g s b y r e c h e c k i n g t h e m y o u r s e l f .

Ge ne r al I ns pe c tion.
N o t e t h e g e n e r a l a p p e a r a n c e o f t h e p a t i e n t . In s p e c t t h e h e a d a n d f a c e , s c l e r a a n d c o n j u n c t i v a e , e xt e r n a l e a r s , s c a l p , s k i n o f t h e h e a d a n d n e c k , t h e h a n d s a n d f i n g e r n a i l s , a n d t h e s k i n o f t h e a r ms .

C los e I ns pe c tion.
E xa mi n e t h e e a r s w i t h t h e o t o s c o p e , c h e c k h e a r i n g , v i s u a l f i e l d s b y c o n f r o n t a t i o n , e xt r a o c u l a r mo v e me n t s a n d p u p i l l a r y s i ze a n d r e a c t i o n s , e xa mi n e t h e f u n d i , a n d inspect the oral cavity and oropharynx using the tongue blade.

P alpation:
P a l p a t e a n y a r e a s o f h e a d , f a c e , o r n e c k d e f o r mi t y, a n d u s e b i ma n u a l p a l p a t i o n o f i n t r a o r a l p a t h o l o g y. P a l p a t e a n y a r e a s o f d e f o r mi t y o f t h e h a n d , w r i s t , a n d e l b o w joints for synovitis or effusion. Palpate all skin rashes.

P has e B :Inspection of the Back of the Head, Neck, Back,

and Shoulders; Palpation of the Neck, Shoulders, and Back; Percussion of the Spine and Lungs; Auscultation of the Lungs
Pat i ent and Ex ami ner Pos i t i p a t i : n t d r a p e d a n d s i t t i n g ; e xa mi n e r o n t h e ons e patient's right side behind the patient
Yo u ma y e i t h e r s t a n d t o t h e p a t i e n t ' s r i g h t s i d e o r s i t o n t h e e xa m t a b l e b e h i n d t h e p a t i e n t , f o r p a r t o f t h e e xa m.

I ns pe c tion.
E xp o s e t h e p a t i e n t ' s b a c k a n d i n s p e c t f o r s k i n l e s i o n s , s c a r s , r a s h e s , a n d t h e l i k e . O b s e r v e t h e n e c k f r o m t h e s i d e a n d c h e c k r a n g e o f n e c k mo t i o n .

P alpation.

Palpate the anterior neck noting the carotid pulsations, the thyroid, and the positio o f t h e t r a c h e a . S e a r c h e a c h l y mp h n o d e b e d f o r a d e n o p a t h y. Vi s u a l l y a n d b y p a l p a t i o n , d e t e r mi n e t h e p o s i t i o n o f t h e t h o r a c i c a n d l u mb a r v e r t e b r a l s p i n e s ; n o t e a n y s c o l i o s i s o r e xc e s s i v e k y p h o s i s o r l o r d o s i s . P a l p a t e a n y d e f o r mi t i e s o r s w e l l i n g of the neck, back, shoulders, or scapulae.

P e r c us s ion.

Use fist percussion to check for spinal or costovertebral angle tenderness. Percuss t h e c h e s t a n t e r i o r l y a n d p o s t e r i o r l y, c o mp a r i n g r i g h t t o l e f t a n d a p i c e s t o b a s e s .

Aus c ultation.
Au s c u l t a t e t h e c h e s t p o s t e r i o r l y, l a t e r a l l y, a n d a n t e r i o r l y ( u n d e r t h e g o w n ) , c o mp a r i right to left and apices to bases. P. 5 1
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P has e C (Fe m ale P atie nts Only): Sitting Breast Exam The
Pat i ent and Ex ami ner Pos i t i p a t i : n t d r a p e d a n d s i t t i n g f a c i n g t h e e xa mi n e r ons e

Af t e r p r o p e r e xp l a n a t i o n , l o w e r t h e f r o n t o f t h e p a t i e n t ' s g o w n w h i l e t h e p a t i e n t s i t s w i t h t h e a r ms r e l a xe d .

I ns pe c tion.
In s p e c t t h e b r e a s t s f o r s y mme t r y, s k i n d i mp l i n g , a n d n i p p l e r e t r a c t i o n . H a v e t h e patient press her hands to her waist, and then raise her hands over her head, each t i me r e p e a t i n g t h e i n s p e c t i o n .

P alpation.

P e n d u l o u s b r e a s t s ma y b e mo s t e a s i l y e xa mi n e d i n t h i s p o s i t i o n b y u s i n g a b i ma n u a technique.

P has e D :Examination of the Anterior Neck and Chest,

Breasts, Axillae, Abdomen, Legs and Feet


Pat i ent and Ex ami ner Pos i t i p a t i : n t d r a p e d a n d s u p i n e ; e xa mi n e r s t a n d i n g a t ons e the patient's right side
S t a r t a t t h e n e c k a n d w o r k t o w a r d t h e f e e t e xp o s i n g o n e a r e a f o r e xa mi n a t i o n a t a t i me : t h e n e c k , t h e a n t e r i o r c h e s t a n d e a c h b r e a s t s e p a r a t e l y, t h e a b d o me n , t h e g r o i n , a n d t h e l e g s . M o s t l e f t - h a n d e d c l i n i c i a n s a r e a b l e t o e xa mi n e a p a t i e n t f r o m the right side.

Neck.
I n s p e c t i o nO b s e r v e t h e n e c k v e i n s f o r f u l l n e s s a n d p u l s a t i o n s . .

C he s t and P r e c or dium .
I n s p e c t i o nO b s e r v e t h e p r e c o r d i u m f o r a n y d e f o r mi t i e s o f t h e s t e r n u m o r r i b s , a n d . t h e n i d e n t i f y t h e a p i c a l i mp ua sp a t i o nP a l p a t e t h e a p i c a l i mp u l s e a n d a n y l i f t s P l l e. . o r h e a v e s o r o t h e r p a l p a b l e c a r d i a cPs irg n ss s i o nP e r c u s s t h e l u n g f i e l d s e cu . . a n t e r i o r l y a n d i d e n t i f y t h e b o r d e r s o f c a r d i a c A u slc u ls s .t i o n .t a r t dul ne ta S a u s c u l t a t i n g o v e r t h e a p i c a l i mp u l s e t o i d e n t i f y t h e f i r s t h e a r t s o u n d . L i s t e n a t t h e a p e x, t h e l o w e r l e f t a n d u p p e r l e f t s t e r n a l b o r d e r s a n d t h e r i g h t s e c o n d i n t e r c o s t a l s p a c e . Au s c u l t a t e t h e c a r o t i d a r t e r i e s . Au s c u l t a t e l u n g s o u n d s i n t h e a n t e r i o r c h e s t and supraclavicular fossae.

B r e as ts .
E xp o s e e a c h b r e a s t s e p a r a t e l p e c t i o nIn s p e c t t h e b r e a s t s f o r s y mme t r y, s k i n I n s y. . d i mp l i n g , o r n i p p l e r e t r a c t iao n .a t i o nP a l p a t e t h e b r e a s t s a n d n i p p l e s . P lp .

Ax illae .
I n s p e c t i o nL i f t t h e a r ms t o e xp o s e t h e a xi l l a f o r i n s p e c ta oin . nP a l p a t e t h e . Palp i t o . a xi l l a a n d i n f r a c l a v i c u l a r l y mp h n o d e b e d s .

Abdom e n.
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R e p o s i t i o n t h e d r a p e o v e r t h e c h e s t a n d e xp o s e t h e a b d o me n f r o m b e l o w t h e b r e a s t t o t h e s y mp h y s i s p u b i s . As k t h e p a t i e n t t o f l e x t h e h i p s a n d k n e e s t o r e l a x t h e a b d o mi n a l mu s c u l a t u r e .p e c t i o nO b s e r v e t h e s y mme t r y a n d s h a p e o f t h e Ins . a b d o me n . N o t e a n y s c a r s o r s k i n a b n o r ma l i t i e s . H a v e t h e p a t i e n t t e n s e t h e a b d o mi n a l mu s c l e s t o r e v e a l a n a b d o mi n a l w aPl eh e r n i s i. o nP e r c u s s t h e l rcus a . a b d o me n n o t i n g a n y a r e a s o f t y mp a n y o r p a i n w i t h p e r c u s s i o n . U s e d e f i n i t i v e p e r c u s s i o n t o i d e n t i f y t h e l i v e r a n d l o o k f o r s p l eA u s c u la lay.i o n . s c u l t a t e n o me g t t Au o v e r t h e e p i g a s t r i u m, b o t h f l a n k s , a n d b o t h f e mo r a lP t rlip a tgi lo nP e r f o r m a a n e s. superficial and deep palpation P. 5 2 o f t h e a b d o me n . P a l p a t e d e e p l y t o i d e n t i f y t h e a o r t a a n d p a l p a t e b o t h f e mo r a l p u l s e a n d t h e i n g u i n a l l y mp h n o d e s .

Le gs and Fe e t.

C o v e r t h e a b d o me n a n d e xp o s e t h e l e g s aIn d pe e tt.i o nIn s p e c t s k i n , mu s c l e s , ns f ec . a n d j o i n t s , a n d l o o k f o r e d e ma . F l e x e a c h h i p t o 9 0 d e g r e e s a n d p e r f o r m i n t e r n a l a n e xt e r n a l r o t a t i o n . l p a t i o nP a l p a t e d o r s a l i s p e d i s a n d p o s t e r i o r t i b i a l p u l s e s . Pa . P a l p a t e a n y a r e a s o f a s y mme t r y, d e f o r mi t y, o r j o i n t e n l a r g e me n t .

P has e E :Supplementary Neurological Exam, Sittingn( W he I ndic ate d )


Pat i ent and Ex ami ner Pos i t i p a t i : n t d r a p e d a n d s i t t i n g ; e xa mi n e r f a c i n g t h e ons e patient
R e t u r n t h e p a t i e n t t o t h e s i t t i n g p o s i t i o n . N o w i s a g o o d t i me t o d o a n y r e ma i n i n g p a r t s o f t h e n e u r o l o g i c e f t hey ar e i ndi c atb y t h e p a t i e n t ' s h i s t o r y a n d i xa m ed e xa mi n a t i o n t o t h i s p o i n t . F r o m t h i s p o s i t i o n , i t i s e a s y t o d o p r e c i s e t e s t i n g o f t h e c r a n i a l n e r v e s , f o l l o w e d b y t e s t i n g o f mu s c l e t o n e a n d s t r e n g t h i n t h e u p p e r e xt r e mi t i e s , r e f l e xe s , a n d s e n s a t i o n ( p o s i t i o n , v i b r a t i o n , t o u c h , a n d 1 0 - g mo n o f i l a me n t ) , f o l l o w e d b y s t a n c e , g a i t , a n d l o w e r e xt r e mi t y s t r e n g t h i n P h a s e F.

P has e F:Supplemental Neurologic Examination, Standing (W he n I ndic ate)d


Pat i ent and Ex ami ner Pos i t i p a t i : n t s t a n d i n g f a c i n g e xa mi n e r ; s u p p l e me n t a r y ons e n e u r o l o g i c a n d s p i n e e xa ms , w h e n i n d i c a t e d
T h i s p o r t i o n o f t h e e xaim i sc at ed i f t he hi s t or y or ex am s ugges t s neur ol ogi c ndi di s eas e or bac k pr obl ems .

I ns pe c tion.
Have the gowned patient stand in front of you and observe the stance. Perform the R o mb e r g ma n e u v e r. C h e c k t h e r a n g e o f s p i n a l mo t i o n . H a v e t h e p a t i e n t w a l k a w a y from you and then toward you first on his toes, then on his heels. Have the patient h o p o n t h e b a l l s o f b o t h f e e t , a n d t h e n h o p o n o n e f o o t a t a t i me .

P has e G:The Urogenital Exams


Pat i ent and Ex ami ner Pos i t i fons : l e p a t i e n t s i n t h e l i t h o t o my p o s i t i o n , ma l e e ma p a t i e n t s s t a n d i n g ; e xa mi n e r a t t h e f o o t o f t h e t a b l e
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Fe m ale P atie nts .


W i t h t h e h e l p o f a n a s s i s t a n t , p o s i t i o n f e ma l e p a t i e n t s i n t h e l i t h o t o my p o s i t i o n f o r t h e f e ma l e p e l v i c a n d r e c t a l e xa mi n a t i oC h a(p te e 11 a g e 6 2 6 o r a ns s er , p f d e s c r i p t i o n o f t h e e xa mi n a t i o n ) .

M ale P atie nts .

B e g i n t h e e xa m w i t h t h e p a t i e n t s t a n d i n g f a c i n g t h eI n s p e c nie r. In s p e c t e xa mi t o n . t h e p e n i s , s c r o t u m, a n d i n g u i n a l P aep a t i o nP a l p a t e t h e t e s t e s a n d e v a l u a t e ar l as. . f o r i n g u i n a l h e r n i a s . N e xt h a v e t h e p a t i e n t t u r n a n d b e n d o v e r t h e e xa m t a b l e , o r l i e o n t h e t a b l e i n t h e l e f t l a t e r a l p on ist po n .t i o nE xa mi n e t h e p e r i n e u m a n d a n u s I s i ec . a n d p e r f o r m t h e r e c t a l a n d p r o s t a t e e xa mi n a t i o n s . Te s t t h e s t o o l f o r b l o o d i f indicated. P r o v i d e t i s s u e s f o r t h e p a t i e n t t o c l e a n t h e ms e l v e s a t t h e c o n c l u s i o n o f t h e u r o g e n i t a l a n d r e c t a l e xa ms . P. 5 3

P has e H :Concluding the Visit


H a v e t h e p a t i e n t g e t d r e s s e d w h i l e y o u a r e o u t o f t h e e xa m r o o m.

W h e n y o u r e t u r n a n d t h e p a t i e n t i s c o mf o r t a b l e , s h a r e y o u r s y n o p s i s o f t h e p a t i e n t ' s h i s t o r y, a s u mma r y o f y o u r p h y s i c a l f i n d i n g s , y o u r i mp r e s s i o n o f t h e p a t i e n t ' s p r o b l e ms , a n d y o u r r e c o mme n d a t i o n s f o r f u r t h e r d i a g n o s t i c t e s t s a n d / o r t r e a t me n t . Conclude by asking if there are any questions. Be sure to set a follow-up a p p o i n t me n t a p p r o p r i a t e f o r t h e p a t i e n t a n d p r o b l e ms .

T h e p r e c e d i n g r o u t i n e i s a s e q u e n c e t h a t h a s s e r v e d u s w e l l f o r ma n y y e a r s . R e me mb e r t h a t t h e p u r p o s e o f t h e s c r e e n i n g e xa mi n a t i o n i s t o d e t e c t s i g n i f i c a n t a b n o r ma l i t i e s i n a n y o f t h e b o d y r e g i o n s a n d s y s t e ms , t o e s t a b l i s h a b a s e l i n e a g a i n w h i c h f u t u r e f i n d i n g s c a n b e c o mp a r e d , a n d t o c o n t i n u a l l y h o n e y o u r e xa mi n a t i o n s k i l l s b y e xp e r i e n c i n g t h e r a n g e o f n o r ma l f i n d i n g s . T r u n c a t i n g t h e e xa mi n a t i o n i n t h i n t e r e s t o f e xc e s s i v e e f f i c i e n c y ma y l e a d t o o v e r l o o k i n g i mp o r t a n t f i n d i n g s a n d t h e l o s s o f v a l u a b l e c l i n i c a l e xp e r i e n c e . P. 5 4

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 1 - T h e D i a g n o s t i c F r a me w o r k > In t r o d u c t i o n

Introduction
To c ar ef ul l y obs er v e t he phenomena of l i f e i n al l i t s phas es , nor mal and per v er t ed, t o mak e per f ec t t hat mos t di f f i c ul t of al l ar t s , t he ar t of obs er v at i on, t o c al l t o ai d t he s c i enc e of ex per i ment at i on, t o c ul t i v at e t he r eas oni ng f ac ul t y, s o as t o be abl e t o k now t he t r ue f r om t he f al s et hes e ar e our met hods .
- -S i r W i l l i a m O s l e r

Don' t s t r ai n f or ar r angement . Look and put down and l et y our s ens i bi l i t y be t he s i ev e.


- -T h e o d o r e R o e t h k e o e t r y a n d C r a f t P

. . . t he f r ami ng of hy pot hes es i s t he mos t di f f i c ul t par t of s c i ent i f i c wor k , and t he par t wher e gr eat abi l i t y i s i ndi s pens abl e. So f ar, no met hod has been f ound whi c h woul d mak e i t pos s i bl e t o i nv ent hy pot hes es by r ul e. Us ual l y s ome hy pot hes i s i s a nec es s ar y pr el i mi nar y t o t he c ol l ec t i on of f ac t s , s i nc e t he s el ec t i on of f ac t s demands s ome way of det er mi ni ng r el ev anc e. Wi t hout s omet hi ng of t hi s k i nd, t he mul t i pl i c i t y of f ac t s i s baf f l i ng.
- -B e r t r a n d R u s s e lA H i s t o r y o f W e s t e r n P h i l o s o p h y l

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 2 - T h e D i a g n o s t i c E xa m > C h a p t e r 1 0 - T h e U r i n a r y System

Chapter 10 The Urinary System


Urinary System : Overview of Anatom y and Physiology

T h e u r i n a r y s y s t e m c o n s i s t s o f t h e k i d n e y s , c o l l e c t i n g s y s t e ms o f t h e r e n a l p e l v i s , u r e t e r s , u r i n a r y b l a d d e r, a n d u r e t h r a . Imp o r t a n t s p h i n c t e r s a r e f o u n d a t t h e ureterovesical junction, as the ureter passes obliquely through the bladder wall, an a t t h e p r o xi ma l u r e t h r a , a s i t p a s s e s t h r o u g h t h e u r o g e n i t a l s e p t u m. T h e u r e t h r a l s p h i n c t e r h a s a n i n v o l u n t a r y s mo o t h mu s c l e p o r t i o n u n d e r p a r a s y mp a t h e t i c a n d s y mp a t h e t i c c o n t r o l , a n d a v o l u n t a r y s t r i a t e d mu s c l e s p h i n c t e r i n n e r v a t e d v i a t h e l u mb o s a c r a l p l e xu s . T h e u r i n a r y s y s t e m i s d e s i g n e d t o f i l t e r t h e b l o o d a t t h e g l o me r u l u s a n d t o r e a b s o r b a n d t o s e c r e t e s o l u t e s a n d f l u i d a c r o s s t h e r e n a l t u b u l e a n d t h e n t o c o n c e n t r a t e t h e u r i n e i n t h e me d u l l a r y c o l l e c t i n g d u c t s . T h e u r i n e p a s s e down the ureters to the bladder by gravity and by peristaltic contractions. T he b l a d d e r i s a h o l l o w mu s c u l a r s t r u c t u r e t h a t a c t i v e l y r e l a xe s w i t h u r i n a r y d i s t e n t i o n keeping intravesical pressures low until capacity is reached. Further filling occurs b stretching of the bladder wall at rapidly increasing pressures. Continence is ma i n t a i n e d b y t o n i c c o n t r a c t i o n o f t h e s mo o t h mu s c l e s p h i n c t e r a n d a c t i v e i n h i b i t i o n o f d e t r u s o r mu s c l e c o n t r a c t i o n a s t h e b l a d d e r f i l l s . Vo i d i n g i s a c o mp l e x p r o c e s s i n v o l v i n g s i mu l t a n e o u s , c o o r d i n a t e d r e l a xa t i o n o f t h e u r e t h r a l s p h i n c t e r s a n d c o n t r a c t i o n o f t h e p r e v i o u s l y r e l a xe d d e t r u s o r mu s c l e . In ma l e s , t h e p r o xi ma l u r e t h r is surrounded by the prostate gland and receives prostatic secretions from the p r o s t a t e a n d s e mi n a l v e s i c l e s . In t h e f e ma l e t h e u r e t h r a i s q u i t e s h o r t .

T he kidneys lie posteriorly partially under the eleventh and twelfth ribs and lateral L 1 - 4 ( s e e i g . 9 -)2 T h e y a r e e n c l o s e d i n a t i g h t c a p s u l e a n d l i e r e t r o p e r i t o n e a l l y, F . s u r r o u n d e d b y G e r o t a f a s c i a . T h e u r e t e r s c o u r s e r e t r o p e r i t o n e a l l y, a n d d e s c e n d o v e t h e p s o a s mu s c l e a n d i n t o t h e p e l v i s , w h e r e t h e y r u n l a t e r a l l y a n d t h e n a n t e r i o r l y t o e n t e r t h e i n f e r i o r p o r t i o n o f t h e b l a d d e r o n e i t h e r s i d e o f t h e mi d l i n e . T h e b l a d d e r l i a n t e r i o r l y i n t h e p e l v i s b e h i n d a n d b e l o w t h e s y mp h y s i s p u b i s . T h e u r e t h r a e xi t s t h e b l a d d e r a n d r u n s t h r o u g h t h e u r o g e n i t a l d i a p h r a g m o f t h e p e l v i c f l o o r mu s c l e s t o e n t e r t h e ma l e p r o s t a t e a n d p e n i s o r t h e f e ma l e p e r i n e u m. O n l y t h e u r e t h r a l me a t u s i s v i s i b l e o n p h y s i c a l e xa mi n a t i o n a n d n o r ma l l y t h e d e e p e r s t r u c t u r e s c a n n o t b e identified by palpation. P. 6 1 0

Physical Exam ination of the Urinary System


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S e e a l s o h a p t e r :9The Abdomen h a p t e r 11 C ;C : The Femal e Geni t al i a and Repr oduc t i v e Sy s t em dC h a p t e r 1: 2 ; an The M al e Geni t al i a and Repr oduc t i v e Sy s t em.

Determination of the Postvoid Residual Urine Volume.

T h e a d e q u a c y o f b l a d d e r e mp t y i n g i s me a s u r e d b y d e t e r mi n i n g t h e v o l u me o f u r i n e r e ma i n i n g i n t h e b l a d d e r a f t e r a f u l l v o l u n t a r y v o i d i n g : t h e r e s i d u a l v o l u me . F i r s t , h a v e t h e p a t i e n t e mp t y h i s o r h e r b l a d d e r c o mp l e t e l y. R e s i d u a l v o l u me c a n b e e s t i ma t e d b y u l t r a s o n o g r a p h y d e v i c e s o r me a s u r e d d i r e c t l y b y p a s s i n g a s t e r i l e urethral catheter into the bladder to collect the residual urine. T he risk of infection i n c r e a s e s s h a r p l y w i t h r e s i d u a l v o l u me s o f g r e a t e r t h a n 1 0 0 c c .

Urinary Sym ptom s


D i s c o l o r e d Ur i n e : S e e Ur i nar y Si gns : Di s c ol or ed ,Ur ia g e 6 1 3 . p ne Ur e t h r a l D i s c h a r g e : S e e Ur i nar y Si gns : Ur et hr al Di s c,har ge 6 1 6 . page

Re n a l C o l i c : S e e Abdomi nal Pai n a g e s 5 2 9 a n d 5 6 P faf t. h o p h y s i o l o g Vi: g o r o u s c o n t r a c t i o n , p 2 y o f v i s c e r a l s mo o t h mu s c l e i n t h e u r e t e r s a g a i n s t a n o b s t r u c t i o n i s i n t e n s e l y p a i n f u l . O b s t r u c t i n g s t o n e s i n t h e r e n a l p e l v i s , u r e t e r, o r b l a d d e r p r o d u c e a c u t e , o f t e n e xt r e me l y i n t e n s e p a i n , w h o s e l o c a t i o n i s d e p e n d e n t u p o n t h e s i t e o f o b s t r u c t i o n . O b s t r u c t i o n a t t h e r e n a l p e l v i s g i v e s f l a n k a n d u p p e r a b d o mi n a l p a i n . U r e t e r a l o b s t r u c t i o n p r o d u c e s p a i n i n t h e u p p e r a b d o me n , l o w e r a b d o me n , p e l v i s , t e s t i c l e s , a n d p e r i n e u m. B l a d d e r o u t l e t o b s t r u c t i o n l e a d s t o p a i n i n t h e p e l v i s . T h e d i a g n o s i s s u p p o r t e d b y a n a c u t e o n s e t , a b s e n c e o f s y s t e mi c s y mp t o ms o t h e r t h a n n a u s e a a n d a n o r e xi a , a p r e v i o u s o r f a mi l y h i s t o r y o f u r o l i t h i a s i s , a n d t h e p r e s e n c e o f mi c r o s c o p h e ma t u r i a w i t h o u t p y u r i a .


P. 6 11

F r e q u e n t Ur i n a t i o n w i t h o u t P o l y u r i a : P a t h o p h y s i o l o gAl:t h o u g h t h e a v e r a g e a d u l t u r i n a t e s a b o u t f i v e o r s i x t i me s d a i l y, y frequency depends upon fluid balance, renal function, individual habits, and the p r e s e n c e o r a b s e n c e o f i r r i t a t i o n i n t h e g e n i t o u r i F ae y ut ea c t u r i n a t i o n c a n b e nr rq r nt . c a u s e d b y i n c r e a s e d t o t a l u r i n a r y v o l u me ( p o l y u requente Ur i nat i on, Wi t h Fr i a ; s e Pol y ur i ,a b e l o w ) , d e c r e a s e d b l a d d e r c a p a c i t y, o r i n c r e a s e d s t i mu l a t i o n o f t h e mi c t u r i t i o n r e f l e xe s c a u s e d b y i r r i t a t i o n o f t h e g e n i t o u r i n a r y t r a c t . T h e h i s t o r y, p h y s i c a l e xa mi n a t i o n , a n d me a s u r e me n t o f 2 4 - h o u r f l u i d i n t a k e a n d u r i n e v o l u me , v o l u me o f e a c h v o i d i n g , a n d p o s t v o i d r e s i d u a l b l a d d e r v o l u me w i l l u s u a l l y l e a d t o t h c o r r e c t a s s e s s me n t . URI NARY F RE Q UE NC Y C L I NI C AL O C C URRE NC E : Congeni t al ma l l b l a d d e r c a p a c i t y ; u r e t e r o v e s i c a l r e f l u x; u r e t h r a l a n d me a t a l s s t r i c t u r eEndoc r i ne t r o p h i c v a g i n i tI idi ;opat hi c e n i g n p r o s t a t i c h y p e r p l a s i a , p e l v i c ; a s b f l o o r r e l a xa t i o n , c y s t o c e l e , u r e t h I nfcl e l e ; r o ammat or y / I mmunee r s t i t i a l a n d int c h e mi c a l c y s t i t i s , p r o s t a t i t i s , a p p e nnfi ectti isous a c t e r i a l a n d v i r a l p y e l i t i s , I d ci ; b
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c y s t i t i s , u r e t h r i t i s , v a g i n i t i s , s a l p i n gabol i c / Toxc c e mi c a l c y s t i t i s , h i g h l y M et i t i s ; ih a c i d i c u r i n e ; ec hani c al / Tr aumat iecl v i c f l o o r r e l a xa t i o n , c y s t o c e l e , u r e t h r o c e l e , M p b l a d d e r s t o n e , e xt r i n s i c c o mp r e s s i o n o f t h e b l a d d e r o r u r e t h r a , b l a d d e r w a l l f i b r o s i s u r e t h r a l s t r i c t u r e , b l a d d e r n e c k o b s t Neopl n ; t i c l a d d e r c a n c e r, p r o s t a t e r u c t i o as b c a n c e r, l o c a l l y i n v a s i v e c e r v i c a l a n d r e c t aNeur ole r ; c p i n a l c o r d , c a u d a l c a n c ogi s e q u i n a a n d s a c r a l p l e xu s l e s i o n s , a u t o n o mi c n e u r o p a t h y, d e t r u s o r i n s t a b i l i t y ; Ps y c hos oc i al n t r a i n e d b l a d d e r, v o i d i n g h a b i t s . u

F r e q u e n t Ur i n a t i o n , Wi t h P o l y u r i a : P a t h o p h y s i o l o g T : e a d u l t ma l e b l a d d e r h o l d s a b o u t 5 0 0 mL ; t h e a d u l t f e ma l e ' s yh b l a d d e r h o l d s s o me w h a t l e s s . An a v e r a g e o u t p u t o f u r i n e i n 2 4 h o u r s i s 1 2 0 0 1 5 0 0 mL , b u t t h i s v o l u me i s d e p e n d e n t u p o n t h e t y p e a n d v o l u me o f f l u i d i n t a k e , s e n s i b l e ( v o mi t i n g , d i a r r h e a ) a n d i n s e n s i b l e ( s w e a t i n g , r e s p i r a t o r y ) f l u i d l o s s e s , a n d t h e r e n c o n c e n t r a t i n g a b i lIny.r e a s e d u r i n a r y v o l u me ( p o l y u r i a ) c a n r e s u l t f r o m a n it c i n c r e a s e d o s mo t i c l o a d ( e . g . , d i a b e t e s me l l i t u s ) , i n c r e a s e d i n t a k e o f f l u i d s , me d i c a t i o n s , d i e t a r y e xp o s u r e s , a n d d e c r e a s e d r e n a l c o n c e n t r a t i n g a b i l i t y. T h e h i s t o r y, p h y s i c a l e xa mi n a t i o n , a n d u r i n a l y s i s a r e a b l e t o e s t a b l i s h t h e c a u s e i n mo s cases. P O LY URI A C L I NI C AL O C C URRE NC E : Congeni t al e n a l t u b u l a r d e f e c t s ( e . g . , r e n a l t u b u l a r a c i d o sEndoc ei ne ; r is typ r 1) d i a b e t e s me l l i t u s , c e n t r a l o r r e n a l d i a b e t e s iIn s opatu s ;c h r o n i c r e n a l f a i l u r e di i p i d hi o f a n y c a u s enf l ammat or y / I mmunee r s t i t i a l n e p h r iMiet; abol i c / Toxdcu r e t i c I; int t s ii u s e , h y p e r c a l c e mi a , h y p o k a l e mi ahani c al / Tr aumat iocs t o b s t r u c t i v e d i u r e s i s ; M ec ; p Ps y c hos oc i al xc e s s i v e f l u i d i n t a k e , p s y c h o g e n i c p o l y d i p s i a , a l c o h o l a n d c a f f e i n e e ingestion.
P. 6 1 2

No c t u r i a : P a t h o p h y s i o l o g U:r i n e p r o d u c t i o n d e c l i n e s d u r i n g s l e e p a n d s l e e p i s u s u a l l y n o t y i n t e r r u p t e d t o u r i n a t o me p e o p l e h a v e h a b i t u a l n o c t u r i a , w h i c h i s a g g r a v a t e d b y S e. high fluid intakes, especially of caffeinated or alcoholic beverages taken in the e v e n i n g . N o c t u r i a a l s o o c c u r s w i t h mo s t d i s o r d e r s c a u s i n g i n c r e a s e d f r e q u e n c y o f u r i n a t i o n o r p o l y u r i a . E d e ma t o u s s t a t e s ( c o n g e s t i v e h e a r t f a i l u r e , h e p a t i c i n s u f f i c i e n c y, n e p h r o t i c s y n d r o me , a n d c h r o n i c r e n a l f a i l u r e ) a r e a s s o c i a t e d w i t h n o c t u r i a c a u s e d b y mo b i l i za t i o n o f d e p e n d e n t f l u i d f r o m t h e l o w e r e xt r e mi t i e s a n d a b d o me n d u r i n g r e c u mb e n c y. R e c l i n i n g c a n a l s o l e a d t o l o s s o f b l a d d e r s u p p o r t , p a r t i c u l a r l y i n w o me n w i t h p e l v i c f l o o r r e l a xa t i o n o r a h i s t o r y o f h y s t e r e c t o my, l e a d i to increased frequency of urination at night. Ur i n a r y I n c o n t i n e n c e : In v o l u n t a r y l o s s o f u r i n e b y c h i l d r e n a t n i g h t i s r e f enurd t io U rsi n a r y e r r e es s .a i n c o n t i n e n c e i n t h e a d u l t s h o u l d i n i t i a t e a n e v a l u a t i o n f o r a s p e c i f i c c a u s e , mo s t o f w h i c h a r e t r e a t a b l e . Ur ie y Sy ndr omes : I nc ont i nencg e 6 1 7 , f o r f u r t h e r S e nar , pa e discussion. D i f f i c u l t Ur i n a t i o n : P a t h o p h y s i o l o g N:o r ma l u r i n a t i o n o c c u r s w i t h t h e e f f o r t l e s s r e l a xa t i o n o f t h e y b l a d d e r s p h i n c t e r s c o o r d i n a t e d w i t h c o n t r a c t i o n o f t h e d e t r u s o r mu s c l e . D i f f i c u l t y
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i n i t i a t i n g o r ma i n t a i n i n g t h e u r i n a r y s t r e a m i n d i c a t e s a n o b s t r u c t i o n t o f l o w o r a d e c r e a s e i n d e t r u s o r s t r e n g te .p a t i e n t ma y c o mp l a i n o f h e s i t a n c y i n s t a r t i n g t h e Th h u r i n a r y s t r e a m, d e c r e a s e d f o r c e o f u r i n a t i o n , a n d / o r d r i b b l i n g a t t e r mi n a t i o n o f u r i n a t i o n . O c c a s i o n a l l y, s t r a i n i n g i s r e q u i r e d t o ma i n t a i n t h e s t r e a m.

C L I NI C AL O C C URRE NC E : I di opat hi c r o s t a t i c h y p e r p l a s i a , c h r o n i c s t e r i l e p r Ionftect ti it ousa b e s d o r s a l i s , p s a i s ;t p r o s t a t i t i s ; ec hani c al / Tr aumat ir c t h r a l s t r i c t u r e o r v a l v e , b l a d d e r n e c k M u e o b s t r u c t i o n , b l a d d e r s t o n e o r c l o t , p r e g n a n c y, hNeopl as t i; c r e t h r a l e ma t o ma u c a r c i n o ma , p r o s t a t e c a n c e r, u t e r i n e f i b r o i d , v a g i n a l c a n c e r, c e r v i c a l c a n c e r ; Neur ol ogi c e t r u s o r w e a k n e s s , mu l t i p l e s c l e r o s i s , s p i n a l c o r d i n j u r y o r e p i d u r a l d c o mp r e s s i o n , my e l i t i s , s y r i n g o my e l i a .

P a i n f u l Ur i n a t i o n ( D y s u r i a ) : P a t h o p h y s i o l o g In:f l a mma t i o n o f o r b r e a k s i n t h e u r e t h r a l e p i t h e l i u m ( e xp o s i n g t h e y s u b mu c o s a t o t h e a c i d i c u r i n e ) r e s u l t s i n p a i n l o c a t e d i n t h e p e n i s o r t h e f e ma l e u r e t h r a w i t h u r i n a t i o n . T h i s i s u s u a l l y t h e r e s u l t o f i n f e c t i o n k rwth e tu ma . As o r a h e r t h e p a i n i s g r e a t e r o n i n i t i a t i o n o r o n t e r mi n a t i o n o f v o i d i n g . P a i n d u r i n g u r i n a t i o n o c c u r s w i t h u r e t h r a l o b s t r u c t i o n , u r e t h r i t i s , c y s t i t i s , v u l v i t i s a n d me a t a l u l c e r s . P a i n a f t e r u r i n a t i o n i s mo r e t y p i c a l o f b l a d d e r c a l c u l u s , c y s t i t i s , p r o s t a t i t i s a n d s e mi n a l vesiculitis.

Urinary Signs
S e e a l s o h a p t e r :9Abdomi nal Si gns h a p t e r 11 C ;C : Femal e Geni t al and Repr oduc t i v e Si gns dC h a p t e r 1: 2 al e Geni t al and Repr oduc t i v e Si gns . ; an M

Ur i n a r y Re t e n t i o n : S e e Ur i nar y Sy ndr omes : Ur i nar y Ret,ent i g e 6 1 7 . p a on


P. 6 1 3

An u r i a a n d O l i g u r i a : P a t h o p h y s i o l o g O:b s t r u c t i o n o f t h e b l a d d e r o u t l e t i s t h e mo s t c o mmo n c a u s e o f y a n u r i a a n d o l i g u r i a a s me a s u r e d b y v o i d e d u r i n e v o l u me s . D e c r e a s e d u r i n e p r o d u c t i o n me a s u r e d i n t h e b l a d d e r i s a r e s u l t o f a p r o f o u n d d e c l i n e i n g l o me r u l a r filtration from a decrease in renal blood flow and/or intrarenal or ureteral obstructio T h e p r o c e s s mu s t i n v o l v e b o t h k i d n e y s o r o b s t r u c t b oIn o l ri e t e r a . t h e 2 4 th u guri s, h o u r u r i n a r y o u t p u t i s b e t w e e n 5 0 a n d 4 0 0 mL ( 4 2 5 mL / h ) . T h e o u t p u t i s 0 5 0 mL i a n u r i a . E v e n w i t h d e h y d r a t i o n , n o r ma l k i d n e y s c o n t i n u e t o e xc r e t e mo r e t h a n 5 0 0 m d a i l y. T h e r e f o r e , o l i g u r i a a n d a n u r i a i n d i c a t e a d v a n c e d d e g r e e s o f r e n a l d y s f u n c t i o n r e q u i r i n g i mme d i a t e t r e a t me n t . Ac u t e r e n a l f a i l u r e ma y o c c u r u n e xp e c t e d l y d u r i n g t h c a r e o f p a t i e n t s f o r a n o t h e r d i s o r d e r. U s u a l l y p a t i e n t s d o n o t c o mp l a i n o f a l a c k o f u r i n e , t h u s d e l a y i n g r e c o g n i t i o n . O f t e n , t h e c a u s e ma y b e s u s p e c t e d f r o m k n o w l e d g o f t h e p r e e xi s t i n g d i s e a s e , b u t p o s t r e n a l o b s t r u c t i o n w i t h h y d r o n e p h r o s i s mu s t a l w a y s b e e xc l u d e d . C L I NI C AL O C C URRE NC E : S e e Ur i nar y Sy ndr omes : Ac ut e Renal Fai aure 6 1 8 . , pl g e
P. 6 1 4

D i s c o l o r e d Ur i n e :
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P a t h o p h y s i o l o g U:r i n e i s n o r ma l l y c l e a r a n d c o l o r e d y e l l o w b e c a u s e o f u r e a . y D i l u t i o n a n d c o n c e n t r a t i o n o f t h e u r i n e w i l l c h a n g e t h e i n t e n s i t y, b u t n o t t h e c o l o r, o the urine. A true color change results from the presence of colored substances in th u r i n e , e i t h e r f i l t e r e d f r o m t h e b l o o d o r a r i s i n g i n t h e u r i n a r y t r a c t i t s e l f . In c r e a s e d opacity of the urine arises with the precipitation of solutes or the addition of cellula ma t e r i a l o r mu c o u s c o mp l a i n t o f a b n o r ma l u r i n e c o l o r r e q u i r e s f u r t h e r h i s t o r y. A . F i r s t , d e t e r mi n e i f t h e c h a n g e i s o n e o f i n t e n s i t y o f t h e n o r ma l y e l l o w c o l o r o r a t r u c h a n g e i n c o l o r. Al s o , d e t e r mi n e i f t h e c h a n g e i s p e r s i s t e n t o r e p i s o d i c a n d w h e t h e r t h e r e i s a n a s s o c i a t i o n w i t h a c t i v i t i e s , i n t a k e o f f o o d s , me d i c a t i o n s , o r o t h e r s y mp t o ms . In s p e c t i o n a n d a n a l y s i s o f a f r e s h l y v o i d e d u r i n e s p e c i me n t o c o n f i r m t h e patient's observation should precede any further investigation. Note that patients w d e s c r i b e a n y r e d d i s c o l o r a t i o n o f t h e u r i n e a s b l o o d , a c o n c l u s i o n y o u mu s t a v o i d u n t i l i t i s p r o v e n . O f t e n d i s c o l o r a t i o n o f t h e u r i n e i s d i s c o v e r e d b y s o me o n e h a n d l i n s p e c i me n s f o r e xa mi n a t i o n .

D I S C O L O RE D URI NE C L I NI C AL O C C URRE NC E : Col or l es s r i n e o f l o w c o n c e n t r a t i o n f r o m e xc e s s i v e f l u i d i n t a k e , c h r o n i c u g l o me r u l o n e p h r i t i s , d i a b e t e s me l l i t u s , d i a b e t e s Cl oudy u s ; tp h o s p h a t e s i n s i p i d Whi e in an alkaline urine (the cloud disappears with the addition of acid), epithelial cells from the lower genitourinary tract, bacteria, pus, chyle (when the urine is c e n t r i f u g e d , c h y l e r e ma i n s h o mo g e n e o u s l y d i s t r i b u t e d ; mi l k f a t a d d e d f o r ma l i n g e r i n f l o a t s t o t h e t oYel l owH i g h l y c o n c e n t r a t e d n o r ma l u r i n e , t e t r a c y c l i n e , p y r i d i n e ; p); Or angeu r o b i l i n o g e n , p y r i d i u m ( a n t i s p a s mo d i c t h a t i s o r a n g e i n a c i d u r i n e a n d r e d i n alkaline urine), rhubarb (food and purgative), cathartics (senna aloes), a n t h r a c y c l i n eRed b e e t s , b l a c k b e r r i e s , a n i l i n e d y e s f r o m c a n d y, f r e s h l y v o i d e d s; h e mo g l o b i n o r my o g l o b i n , p y r i d i n e , p o r p h y r i n , p h e n o l p h t h a l e i n ( a c a t h a r t i c , r e d i n a l k a l i n e u r i n e , c o l o r l e s s i n a c i d u r i n e ) , c a s c a r a ( c a t h a r t i c ) , r i f a mp i n , d o xo r u b i c i n ; Bl ue- Gr een i l i r u b i n ( u r i n e w i t h y e l l o w f r o t h ) , me t h y l e n e b l u e , p s e u d o mo n a s b i n f e c t i o nBl ac k - Br own i g h l y c o n c e n t r a t e d n o r ma l u r i n e , b i l i r u b i n ( w i t h y e l l o w f r o t h ) , ; h a c i d h e ma t i n ( h e mo g l o b i n s t a n d i n g i n a c i d u r i n e ) , me t h e mo g l o b i n , p o r p h y r i n , p h e n o ( b l a c k i n l a r g e q u a n t i t i e s ) , c r e s o l , h o mo g e n t i s i c a c i d , own-s i nac k Af t er Br t y r o Bl e ; St andi ngp o r p h y r i n ( c h a n g e d f r o m e xp o s u r e t o s u n l i g h t ) , me l a n i n ( c h a n g e d f r o m e xp o s u r e t o s u n l i g h t ) , h o mo g e n t i s i c a c i d ( c h a n g e d f r o m b a c t e r i a l a l k a l i n i za t i o n o f t h urine).
P. 6 1 5
He m a t u r i a :

P a t h o p h y s i o l o g M:i c r o s c o p i c h e ma t u r i a i s d e f i n e d a s > 4 e r y t h r o c y t e s p e r h i g h y p o w e r e d f i e l d ( H P F ) o n a s p u n u r i n e s p e c i me n a n d g r o s s h e ma t u r i a i n d i c a t e s s u f f i c i e n t r e d b l o o d c e l l s t o d i s c o l o r t h e u r i n e . M i c r o s c o p i c h e ma t u r i a i s d e t e c t e d b c h e mi c a l o r mi c r o s c o p i c e xa mi n a t i o n o f t h e u r i n e . G r o s s h e ma t u r i a i s f r e q u e n t l y n o t i c e d b y t h e ma l e d u r i n g mi c t uHie ima t.u r i a i s d i s t i n g u i s h e d f r o m r t on h e mo g l o b i n u r i a a n d my o g l o b i n u r i a b y f i n d i n g e r y t h r o c y t e s i n f r e s h l y v o i d e d u r i n e c o l l e c t e d w i t h i n 1 h o u r a f t e r c o mp l e t e b l a d d e r e mp t y i n g . In a l l t h r e e c a s e s , c h e mi c a t e s t s o f t h e u r i n e a r e p o s i t i v e f o r h e me . S p e c t r o s c o p i c e xa mi n a t i o n d i s t i n g u i s h e s my o g l o b i n f r o m h e mo g l o b i n , b u t i t d o e s n o t d i f f e r e n t i a t e i n t r a c e l l u l a r f r o m e xt r a c e l l u l a r h e mo g l o b i n . T h e p a t t e r n o f g r o s s h e ma t u r i a o b s e r v e d b y t h e p a t i e n t ma y i n d i c a t e t h e s o u r c e o f bi lni oid : hemat ur i ah e u r e t h r aer mi nal o t al t t;
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hemat ur i a s ma l l h e mo r r h a g e f r o m t h e t r i g o n e r e g i o n o f t h t ot ala d d e r ; a e bl hemat ur i h e mo r r h a g e f r o m t h e k i d n e y o r p r o f u s e b l e e d i n g f r o m t h e b l a d d e r ; t h e a p r e s e n c e o f e r y t h r o c y t e c a s t s i n t h e u r i n e p r o v e s a r eC a lh e n uR c e B r o w n n o s o r A, [ R S . M i c r o s c o p i c h e ma t u r i Engl J M ed 0 0 3 ; 3 4 8 : 2 3 3 0 2 3.3 8 N a. 2 ] In mo s t i n s t a n c e s , t h e o c c u r r e n c e o f h e ma t u r i a d e ma n d s a c o mp l e t e i n v e s t i g a t i o n o t h e g e n i t o u r i n a r y t r a c t , i n c l u d i n g u p p e r t r a c t i ma g i n g a n d c y s t o s c o p y. B e d s i d e o b s e r v a t i o n s mu s t s u f f i c e w h e n i n s t r u me n t a t i o n i s c o n t r a i n d i c a t e d , a s i n u r e t h r a l i n f e c t i o n o r h e mo r r h a g i c d i s o r d e r s . HE M AT URI A C L I NI C AL O C C URRE NC E : Congeni t al e mo p h i l i a , s i c k l e c e l l d i s e a s e , p o l y c y s t i c k i d n eEndoc r i s e ; h y d i s e a ne me n s t r u a t i o ndi opat hi c l a d d e r d i v e r t i c u l u m, p o l y p s , p r o s t a t i c h y p e r p l a s i a , I; b e n d o me t r i o s i s , u r e mi a , t h r o mb o c y t o p eln i a ; I nf ammat or y / I mmunee r s t i t i a l c y s t i t i s , int f e v e r, g l o me r u l o n e p h r i t i s , p o l y a r t e r i t i s , mi c r o s c o p i c p o l y a n g i i t i s , G o o d p a s t u r e s y n d r o me , W e g e n e r s y n d r onf ec t i ous r e t h r i t i s , b a c t e r i a l a n d v i r a l ( a d e n o v i r u s I me ; u 11 ) c y s t i t i s , p r o s t a t i t i s , p y e l i t i s , s c h i s t o s o mi a s i s , ma l a r i a , y e l l o w f e v e r ; M et abol i c / Toxc c e mi c a l c y s t i t i s ( e . g . , c y c l o p h o s p h a mi d e o r i f o s f a mi d e ) , a n a l g e s i c ih n e p h r o p a t h y, a n t i c o a g u l a n t s , s c u r v y, v i t a mi n K dM fec hani y ;al / Tr aumat i c e icienc c b l u n t o r p e n e t r a t i n g t r a u ma , u r e t h r a l s t r i c t u r e , i n s t r u me n t a t i o n , p o s t - s u r g i c a l , d e c o mp r e s s i o n o f a d i s t e n d e d b l a d d e r, h e a v y e xe r c i s e ( e . g . , ma r a t h o n r u n n e r s ) , f o r e i g n b o d y, s t o n e s , r u p t u r e , r a d i a t i o n , me d u l l a r y n e c r as t sc i d n e y, Neopl o s i i k ; u r e t e r, b l a d d e r, p r o s t a t e c a n c eyrc hos oc i ala c t i t i o u s ; c ul arb l a d d e r a n d Ps s ; f Vas p r o s t a t i c v a r i c e s , r e n a l i n f a r c t i o n , v a s c u l i t i s , a r t e r i o v e n o u s ma l f o r ma t i o n .

He m o g l o b i n u r i a : P a t h o p h y s i o l o g H:e mo g l o b i n u r i a i s e xt r a c e l l u l a r h e mo g l o b i n i n t h e u r i n e r e s u l t i n g y f r o m f i l t r a t i o n o f p l a s ma - f r e e h e mo g l o b i n o r l y s i s o f r e d b l o o d c e l l s p r e s e n t i n t h e u r i n e . S u f f i c i e n t c o n c e n t r a t i o n s p r o d u c e a r e d c o l o r i d e n t i c a l t o my o g l o b i n u r i a a n d h e ma t u r i a . W h e n h e mo g l o b i n e n t e r s t h e p l a s ma b y t h e i n t r a v a s c u l a r h e mo l y s i s , i t b i n d s t o p l a s ma h a p t o g l o b i n a n d t h e l a r g e h e mo g l o b i n h a p t o g l o b i n c o mp l e x i s n o t f i l t e r e d b y t h e n o r ma l g l o me r u l u s . W h e n t h e b i n d i n g c a p a c i t y o f h a p t o g l o b i n i s e xc e e d e d , f r e e h e mo g l o b i n p a s s e s t h r o u g h t h e g l o me r u l a r b a s e me n t me mb r a n e a n d a f r e s h l y v o i d e d u r i n e s p e c i me n u s u a l l y c o n t a i n s h e mo g l o b i n c a s t s . T h e i r p r e s e n c e e xc l u d e s t h e p o s s i b i l i t y t h a t h e mo l y s i s o c c u r r e d i n t h e mo g l d e r. g i v e s He blad obin p o s i t i v e c h e mi c a l t e s t s w h e t h e r i n t r a c e l l u l a r o r e xt r a c e l l u l a r, s o h e mo g l o b i n u r i a mu s b e d i s t i n g u i s h e d f r o m h e ma t u r i a b y t h e a b s e n c e o f e r y t h r o c y t e s i n f r e s h l y v o i d e d u r i n e . Al t h o u g h my o g l o b i n ( mo l e c u l a r w e i g h t [ M W ] 1 7 , 5 0 0 ) c a n b e d i f f e r e n t i a t e d f r o m h e mo g l o b i n ( M W 6 8 , 0 0 0 ) b y s p e c t r o s c o p i c e xa mi n a t i o n , l o o k f o r a c o n c o mi t a n t r e d c o l o r a t i o n o f t h e b l o o d p l a s ma , w h i c h s u g g e s t s h e mo g l o b i n u r i a b e c a u s e t h e s ma l l e r my o g l o b i n mo l e c u l e s a r e c l e a r e d mo r e r a p i d l y f r o m t h e b l o o d . H e ma t u r i a a n d h e mo g l o b i n u r i a f r o m h e mo l y s i s i n t h e b l a d d e r o c c u r w h e n t h e u r i n e i s s o d i l u t e a s t h e mo l y ze t h e e r y t h r o c y t e s ( s p e c i f i c g r a v i t y l e s s t h a n 1 . 0 0 6 ) . T r a n s f u s i o n o f i mp r o p e r l y s t o r e d o r f r o ze n b l o o d r e s u l t s i n t h e d i r e c t i n f u s i o n o f h e mo g l o b i n f r o m t h e l y ze d r e d b l o o d c e l l s . HE M O G L O B I NURI A C L I NI C AL O C C URRE NC E : Congeni t al - 6 - P D ( g l u c o s e - 6 - p h o s p h a t e d e h y d r o g e n a s e ) d e f i c i e nrc ne G Endoc i y ; p r e g n a n c y a n d t h e p u e r p e rI idi m; hi c a r o xy s ma l n o c t u r n a l h e mo g l o b i n u r i a u opat p ( P N H ) ;I nf l ammat or y / I mmune j o r t r a n s f u s i o n r e a c t i o n , a u t o i mmu n e h e mo l y t i c ma
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a n e mi a , h a p t e n - a s s o c i a t e d h e mo l y s i s ( q u i n i n e , s u l f o n a mi d e s ) , h i g h - t i t e r c o l d a g g l u t i n i n d i s e a snf;ec t i ous l a r i a , b l a c k w a t e r f e v e r, t y p h u s , g a s g a n g r e n e , Ie ma g e n e r a l i ze d a n t h r a x, y e l l o w fM et abol i c / Toxoc d a n t d r u g s o r f a v a b e a n s i n ever; i xi p e r s o n s w i t h G - 6 - P D d e f i c i e n c y ( s u l f o n a mi d e s , s u l f o n e s , p r i ma q u i n e ) , e n v e n o ma t i o n b y s n a k e o r s p i d e r b i t e s , i n f u s i o n o f o u t d a t e d , f r o ze n , o r i mp r o p e r l y s t o r e d b l o o d ; M ec hani c al / Tr aumat i cr c h h e mo g l o b i n u r i a , me c h a n i c a l h e a r t v a l v e s , s e v e r e a o r t i c ma a n d p a r a p r o s t h e t i c mi t r a l r e g u r g i t a t i o n , e xt r a c o r p o r e a l c i r c u l a t i o n , ma j o r b u r n s , i n t r a v a s c u l a r d e v i cPs y c hos oc i al j e c t i o n o f d i s t i l l e d wVasrc; ul ar es; in ate mi c r o a n g i o p a t h i c h e mo l y t i c a n e mi a - t h r o mb o t i c t h r o mb o c y t o p e n i c p u r p u r a ( T T P ) , h e mo l y t i c - u r e mi c s y n d r o me ( H U S ) , a n d ma l i g n a n t h y p e r t e n s i o n ; r e n a l i n f a r c t i o n . P. 6 1 6

M yoglobinur ia: P a t h o p h y s i o l o g E : r e t i o n o f my o g l o b i n r e l e a s e d f r o m d a ma g e d mu s c l e c o l o r s t h e y xc u r i n e r e d a n d g i v e s c h e mi c a l t e s t s f o r h eSi gns :e e me ( s Hemogl obi nur i a v e ) . abo M u s c l e p a i n a n d a h i s t o r y o f c r u s h i n j u r y o r p r o l o n g e d mu s c l e i s c h e mi a a r e u s u a l a l t h o u g h l o s s o f c o n s c i o u s n e s s a s s o c i a t e d w i t h s e v e r e i n j u r y ma y o b s c u r e t h e findings. M Y O G L O B I NURI A C L I NI C AL O C C URRE NC E : Congeni t al c Ar d l e d i s e a sI e ; l ammat or y / I mmunet o i mmu n e h e mo l y t i c a n e mi a , M nf au t r a n s f u s i o n o f i n c o mp a t i b l e b l o o abol i c / Toxs c v e r e h y p o k a l e mi a , i n g e s t i o n o f M et d ; ie q u a i l ( i d i o s y n c r a t i c ) , o p i a t e a n d s e d a t i v e a b u s e , H a f f d i s e a s e ( a n e p i d e mi c my o g l o b i n u r i a e n c o u n t e r e d i n K n i g s b e r g , G e r ma n y, c a u s e d b y t h e i n g e s t i o n o f f i s h f e e d i n g i n a l a g o o n p o l l u t e d w i t h i n d u s t r i a l M ecshani c al / Tr aumat i c s h wa tes); cru i n j u r i e s , c o mp r e s s i o n i n j u r i e s c a u s e d b y p r o l o n g e d i mmo b i l i za t i o n o r i mp a i r e d c o n s c i o u s n e s s , e l e c t r i c a l s h o c k , c o mp a r t me n t s y n d r o me s , i n t r a v a s c u l a r h e mo l y s i s .

Urethral Signs

Ur e t h r a l D i s c h a r g e : P a t h o p h y s i o l o g In:f l a mma t i o n i n t h e u r e t h r a a n d / o r i t s e xo c r i n e g l a n d s d i s t a l t o y the urogenital septum leads to an increase in purulent secretions, which leak from t h e u r e t h r a l o r i f i c e b e t w e e n t i me s o f u rMn a t i ma.y c o mp l a i n s p e c i f i c a l l y a b o u t i en on d i s c h a r g e f r o m t h e p e n i s a c c o mp a n i e d b y s t a i n i n g o f t h e u n d e r w e a r w i t h p u s o r b l o o d . D e t e r mi n e w h e t h e r t h e d i s c h a r g e i s c l e a r o r p u r u l e n t , a c c o mp a n i e d b y p a i n f u a n d / o r f r e q u e n t u r i n a t i o n a n d w h e t h e r t h e p a t i e n t h a s h a d a n y n e w s e xu a l p a r t n e r s . As k s p e c i f i c a l l y a b o u t s a me - s e x c o n t a c t s a n d t h e u s e o f c o n d o ms . In w o me n , urethral discharge is confounded with vulvovaginitis. URE T HRAL D I S C HARG E C L I NI C AL O C C URRE NC E : I nf l ammat or y / I mmune i t e r s y n d r o me , B e h e t s y n dIrnfme ; i ous amy di a Re o ec t Chl t r ac homat i s , Nei s s er i a gonor r hoeae, Ur eapl as ma ur eal y t i c um, Tr i c homonas v agi nal i, so t h e r s e xu a l l y t r a n s mi t t e d d i s e aec hani c al / Tr aumat ir c t h r a l M ses; u e catheter and foreign bodies.

Urinary System Syndrom es


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L o i n P a i n - He m a t u r i a S y n d r o m e : I g A Ne p h r o p a t h y : P a t h o p h y s i o l o g F : r u n k n o w n r e a s o n s , t h e r e a r e d e p o s i t s o f Ig A i n t h e me s a n g i a l yo r e g i o n o f t h e g l o me r uPu st .i e n t s p r e s e n t w i t h p a i n l e s s h e ma t u r i a o r h e ma t u r i a a n d l a l o i n p a i n , o f t e n f o l l o w i n g a mi l d v i r a l i n f e c t i o n . P r o g r e s s i o n i s u n p r e d i c t a b l e , b u t a s i g n i f i c a n t mi n o r i t y d e v e l o p e n d - s t a g e r e n a l D o s e a so J V, G r a n d e J P. Ig A dinani e [ n e p h r o p a t h y. Engl J M ed 0 0 2 ; 3 4 7 : 7 3 8 7 4 8 N 2 ].


P. 6 1 7

Ur i n a r y I n c o n t i n e n c e : P a t h o p h y s i o l o g L o s s o f b l a d d e r c o n t r o l r e s u l t s f r o m a b n o r ma l i t i e s o f y: g e n i t o u r i n a r y s e n s a t i o n a n d / o r s mo o t h mu s c l e f u n c t i o n ( d e t r u s o r i n s t a b i l i t y, u r g e incontinence), inadequate sphincter function (stress incontinence), urinary retentio l e a d i n g t o o v e r f l o w i n c o n t i n e n c e , c o mb i n a t i o n s o f t h e s e ( mi xe d i n c o n t i n e n c e ) , a b n o r ma l i t i e s o f c o g n i t i o n , a n d i n a b i l i t y t o r e s p o n d i n a t i me l y f a s h i o n t o r e a c h a t o i l e t .U r i n a r y i n c o n t i n e n c e i n t h e a d u l t s h o u l d i n i t i a t e a n e v a l u a t i o n f o r a s p e c i f i c c a u s e , mo s t o f w h i c h a r e t r e a t a b l e . T h e o n s e t , p a t t e r n , p r e c i p i t a t i n g f a c t o r s , f l u i d i n t a k e , a n d me a s u r e s t a k e n b y t h e p a t i e n t t o r e d u c e t h e i n c o n t i n e n c e a r e e s s e n t i a l h i s t o r i c a l i n f o r ma t i o n . A d e t a i l e d r e v i e w o f a l l p r e s c r i p t i o n a n d n o n p r e s c r i p t i o n me d i c a t i o n s a n d d i e t a r y s u p p l e me n t s i s ma n d a t o r y. It i s e s p e c i a l l y i mp o r t a n t t o identify whether the patient feels an urge to void prior to the episode and the volum o f u r i n e l o s t a t e a c h e p i s o d e . C o mp l e t i o n o f a b l a d d e r j o u r n a l b y t h e p a t i e n t f o r a t least 2 weeks will greatly facilitate the evaluation. URI NARY I NC O NT I NE NC E C L I NI C AL O C C URRE NC E : I di opat hi c e n i g n p r o s t a t i c h y p e r p l a s i a , c y s t o c e l e u r eItnfrec teous y s t i t i s , b h o c i l e ;c u r e t h r i t i s ; ec hani c al / Tr aumat iecl v i c f l o o r r e l a xa t i o n , s p h i n c t e r i n j u r y f r o m M p childbirth; Neopl as t i c r o s t a t e , b l a d d e r, c e r v i x, a n d r e c t a l c a n c e r s , e s p e c i a l l y w i t h p s a c r a l p l e xu s i n v o l v e me n t , e p i d u r a l c o r d c o mp r e s s i o n , c a u d a e q u i n a s y n d r o me ; Neur ol ogi c t o k e , s p i n a l c o r d i n j u r y, d e me n t i a , a u t o n o mi c a n d p e r i p h e r a l s n e u r o p a t h i e s , n o r ma l p r e s s u r e h y d r o c e p h a l u s , mu l t i p l e s c l e r o s i s , p a r a l y s i s , mu s c u l w e a k n e s s a n d l i mi t e d mo b i l i t y.

Ur i n a r y Re t e n t i o n : P a t h o p h y s i o l o g T : e b l a d d e r i s u n a b l e t o e mp t y b e c a u s e o f me c h a n i c a l yh obstruction of bladder outflow and/or loss of detrusor strength. Rapid increase in b l a d d e r v o l u me l e a d s t o h i g h w a l l t e n s i o n , w h e r e a s s l o w i n c r e a s e s l e a d t o i n c r e a s e b l a d d e r c o mp l i a n c e a n d f l a c i d i t y o f t h e tw a ltli.o n i s mo r e c o mmo n i n me n t h a n Re en i n w o me n . Ac u t e u r i n a r y r e t e n t i o n i n t h e b l a d d e r i s u s u a l l y p a i n f u l , d i s t i n g u i s h i n g i t f r o m p a i n l e s s a n u r i a o r o l i g u r i a . S e r i o u s l y i l l p a t i e n t s ma y b e u n a b l e t o c o mmu n i c a t d i s c o mf o r t . C h r o n i c r e t e n t i o n d e v e l o p s g r a d u a l l y a n d i s p a i n l e s s . T h e o n l y s y mp t o m ma y b e f r e q u e n t u r i n a t i o n o f s ma l l a mo u n t s o r i n c o n t i n e n c e ( o v e r f l o w ) . T h e p a t i e n t ma y h a v e a s e n s a t i o n o f f u l l n e s s i n t h e b l a d d e r, b u t o f t e n t h i s i s a b s e n t . E xa mi n a t i o s h o w s a s u p r a p u b i c s w e l l i n g o f t h e d i s t e n d e d b l a d d e r. H a v e t h e p a t i e n t v o i d , t h e n me a s u r e t h e p o s t v o i d r e s i d u a l u r i n e v o l u me b y c a t h e t e r i za t i o n o r b l a d d e r u l t r a s o n o g r a p h y. URI NARY RE T E NT I O N C L I NI C AL O C C URRE NC E : Congeni t al r e t h r a l v a l v e s ; l ammat or y / I mmune s t a t i t i s ( n o n b a c t e r i a l ) ; u I nf pro I nf ec t i ous r o s t a t i t i s ( b a c t e r i a l ) a n d p r o s t a t e aM s c e s s ; c al / Tr aumat i c p b ec hani
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p r o s t a t e , h y p e r p l a s i a , b l a d d e r s t o n e , o c c l u d e d c a t h e t e r, u r e t h r a l s t r i c t u r e o r c a l c u l u s , r u p t u r e d u r e t h r a l ; as t i c r o s t a t e a n d b l a d d e r c a n c e r, l o c a l l y i n v a s i v e Neopl p c e r v i c a l o r r e c t a l c a nNeur ol ogi c p i n a l c o r d i n j u r y, a u t o n o mi c n e u r o p a t h y, t a b e s cer; s dorsalis. P. 6 1 8 P. 6 1 9


Ac u t e Re n a l F a i l u r e :

P a t h o p h y s i o l o gAc u t e l o s s o f r e n a l f u n c t i o n r e s u l t s f r o m d i s o r d e r s w h i c h c a n b e y: c l a s s i f i e d a s er enal( d e c r e a s e d e f f e c t i v e r e n a l b l o o dr enal ) , pr flow ( g l o me r u l o n e p h r i t i s , me s a n g i a l p r o l i f e r a t i o n , t u b u l a r d y s f u n c t i o n , o r i n t e r s t i t i a l i n f l a mma t i o n ) , pos t r enal b s t r u c t i o n o f t h e u r e t e r s o r b l Ac u te r. r e n a l f a i l u r e or o add e ma y o c c u r u n e xp e c t e d l y d u r i n g t h e c a r e o f p a t i e n t s f o r a n o t h e r d i s o r d e r. U s u a l l y p a t i e n t s d o n o t c o mp l a i n o f l a c k o f u r i n e , d e l a y i n g r e c o g n i t i o n . O f t e n t h e c a u s e ma y b e s u s p e c t e d f r o m k n o w l e d g e o f t h e p r e e xi s t i n g d i s e a s e . T h e p h y s i c a l e xa m, i n c l u d i n g a s s e s s me n t o f i n t r a v a s c u l a r v o l u me s t a t u s , c a r d i a c o u t p u t , a n d t h e p r e s e n c e o f s e v e r e h e p a t i c d i s e a s e , w i l l i d e n t i f y p r e r e n a l c a u s e s . O b s t r u c t i o n mu s t b e e xc l u d e d i n a l l p a t i e n t s b y u l t r a s o n o g r a p h i c i ma g i n g . U r i n a l y s i s h e l p s t o d i s t i n g u i s h b e t w e e n g l o me r u l a r c a u s e s ( mi c r o s c o p i c h e ma t u r i a , r e d b l o o d c e l l c a s t s proteinuria) and tubular disease (cellular and granular casts, decreased c o n c e n t r a t i n g a b i l i t y, s a l t w a s t i n g ) . M e d i c a t i o n s c o mmo n l y c a u s e o r c o n t r i b u t e substantially to acute renal failure. Congenital solitary kidney or the prior n o n f u n c t i o n i n g o f o n e k i d n e y ma y p r e c i p i t a t e a c u t e r e n a l f a i l u r e f r o m u n i l a t e r a l e v e n t s t h a t w o u l d n o t n o r ma l l y b e a s s o c i a t e d w i t h a s u d d e n a n d d r a ma t i c l o s s o f r e n a l f u n c t i o n . T h e f o l l o w i n g i s a c l i n i c a l c l a s s i f i c a t i o n o f c a u s e s t h a t i s mo r e d i a g n o s t i c a l l y u s e f u l t h a n p a t h o l o g i c c a t e g o r i za t i o n s .

AC UT E RE NAL FAI L URE C L I NI C AL O C C URRE NC E : Congeni t al i c k l e c e l l c r i sEndoc r i ne y p e r p a r a t h y r o i d i s m ( s e v e r e h y p e r c a l c e mi a ) , s is; h t h y r o i d s t o r m; opat hi c d v a n c e d c h r o n i c r e n a l f a i l u r e o f a n y c a u s e ; I di a I nf l ammat or y / I mmunes c u l i t i s ( W e g e n e r, p o l y a r t e r i t i s , mi c r o s c o p i c p o l y a n g i i t i s , va h y p e r s e n s i t i v i t y v a s c u l i t i s ) , a n t i b a s e me n t g l o me r u l a r me mb r a n e d i s e a s e ( G o o d p a s t u r e s y n d r o me ) , s y s t e mi c l u p u s e r y t h e ma t o s u s ( S L E ) , p r o g r e s s i v e s y s t e mi s c l e r o s i s ( P S S , s c l e r o d e r ma ) , s e r u m s i c k n e s s , r e t r o p e r i t o nIe aec t bous i s ; nf l f i i r o s p y e l o n e p h r i t i s , s e p t i c e mi a , h e mo r r h a g i c f e v e r s , b l a c k w a t e r f e v e r ( ma l a r i a ) , b a c t e r i a e n d o c a r d i t i s ; et abol i c / ToxM edi c at i ons :n t i b i o t i c s ( a mi n o g l y c o s i d e s , M ic a a mp h o t e r i c i n - B , s u l f o n a mi d e s ) , n o n s t e r o i d a l a n t i i n f l a mma t o r y d r u g s , a n d h y p e r s e n s i t i v i t y t o a n y me d i c Tox i n ; :my o g l o b i n , r a d i o l o g i c c o n t r a s t ma t e r i a l , a t i o ns h e a v y me t a l s ( me r c u r y, b i s mu t h , c o p p e r, u r a n i u m, a r s e n i c ) , o r g a n i c s o l v e n t s ( c a r b o t e t r a c h l o r i d e ) , i n o r g a n i c p h o s p h o r u s , c a r b o n mo n o xi d e , p a r a l d e h y d e , e t h y l e n e g l y c o l , h e r o i n , b i o l o g i c s ( mu s h r o o ms , r a t t l e s n a k e v e n o m) , me t h e mo g l o b i n e mi a ; Bl ood Tr ans f us i on: mo l y s i s f r o m mi s h a n d l e d o r i n c o mp a t i b l e b l o o d ; he M ec hani c al / Tr aumat i aj or Tr auma: y p o v o l e mi c s h o c k , c r u s h s y n d r o me , b u r n s , Mc H h e a t p r o s t r a t i o n , h e ma t o ma , r u p t u r e d k i d n e y s , my o gIl ns ti r ument at i on: o b n e mi a ; r e t r o g r a d e p y e l o g r a p h y a n d c a t h e t e r i za t i o n o Pos ertenal Obs t r uc t i on f ur t ers; ( e s p e c i a l l y i f o n e k i d n e y i s a b s e n t o r p o o r l y f u n c t i o n i n g ) : r e n a l c a l c u l i , c y s t s , t u mo o r ma s s o b s t r u c t i n g t h e u r e t e r s , o b s t r u c t i o n b y c r y s t a l s o f u r i c a c i d , o xa l i c a c i d , c y s t i n e , o r c a l c i u m; Neopl as t i cy mp h o ma , e xt e n s i v e c e r v i c a l c a n c e r c a u s i n g l
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b i l a t e r a l u r e t e r a l o b s t r u c t i o n , t u mo r l y s i s s Vas co meh y p o t e n s i o n o f a n y y n d r ul ar; c a u s e ( s e p s i s , h e mo r r h a g e , o b s t e t r i c a l c o mp l i c a t i o n s ) , p o s t o p e r a t i v e ( e s p e c i a l l y w i ma j o r v a s c u l a r p r o c e d u r e s a o r t i c r e s e c t i o n , c a r d i o t o my, r e p a i r o f i n j u r i e s t o b l o o d v e s s e l s , e t c . o r h e mo r r h a g e ) , v a s c u l i t i s ( p o l y a r t e r i t i s n o d o s a , mi c r o s c o p i c p o l y a n g i i t i s , G o o d p a s t u r e s y n d r o me , W e g e n e r g r a n u l o ma t o s i s , h y p e r s e n s i t i v i t y a n g i i t i s ) , o r v a s c u l o p a t h y ( h e mo l y t i c u r e mi c s y n d r o me , t h r o mb o t i c t h r o mb o c y t o p e n i c p u r p u r a , ma l i g n a n t a n d a c c e l e r a t e d h y p e r t e n s i o n , a b d o mi n a l a o r t i c d i s s e c t i o n , a t h e r o e mb o l i ) .

C h r o n i c Re n a l F a i l u r e : P a t h o p h y s i o l o g C:h r o n i c l o s s o f r e n a l f u n c t i o n c a n o c c u r f r o m p r e r e n a l , r e n a l , o r y p o s t r e n a l c a u s e s . It ma y b e t h e l o n g - t e r m r e s u l t o f a n e p i s o d e o f a c u t e r e n a l f a i l u r e or result from a slowly progressive process that gradually reduces function. When f u n c t i o n i n g n e p h r o n ma s s f a l l s b e l o w a c r i t i c a l l e v e l , t h e i n c r e a s e d f i l t r a t i o n r e q u i r e o f t h e r e ma i n i n g n e p h r o n s t o ma i n t a i n a d e q u a t e s o l u t e c l e a r a n c e r e s u l t s i n p r o g r e s s i v e f a i l u r e o f t h e s e r e ma i n i n g n e p h r o n s . T h i s v i c i o u s c y c l e l e a d s t o e n d s t a g e k i d n e y d i s e a W e a k n e s s , a n o r e xi a , f a t i g u e , a n d n a u s e a a r e c o mmo n se. s y mp t o ms , w h i l e p r u r i t u s a n d d y s p n e a a r e l a t e f i n d i n g s . T h e s l o w p r o g r e s s i o n l e a d s t o a d a p t i v e me t a b o l i c a n d h e mo d y n a mi c c h a n g e s t h a t ma y b e a p p a r e n t o n p h y s i c a l e xa m. H y p e r t e n s i o n , e xp a n s i o n o f t h e e xt r a c e l l u l a r f l u i d v o l u me c a u s i n g e d e ma , mu s c l e w a s t i n g , a n d a n e mi a a r e c o mmo n . L e s s f r e q u e n t l y, p e r i c a r d i t i s o r s o f t - t i s s u e c a l c i f i c a t i o n s ma y b e f o u n d . C HRO NI C RE NAL FAI L URE C L I NI C AL O C C URRE NC E : N O T E :T h e c a u s e s o f a c u t e r e n a l f a i l u r e a r e n o t r e p e a t e d h e r e . Congeni t al p o l y c y s t i c k i d n e y d i s e a s e , Al p o r t s y n d r o mer;i ne i a b e t e s me l l i t u s t h e Endoc d me t a b o l i c s y n d r o me ;l ammat or y / I mmune me r u l o n e p h r i t i s , s y s t e mi c l u p u s I nf glo e r y t h e - ma t o s uIs ; ec t i ous h r o n i c p y e l o n e p h r i t i s , r e n a l t u b e r c u l o s i s ; nf c M et abol i c / Toxnc n s t e r o i d a l a n t i i n f l a mma t o r y d r u g s , a c e t a mi n o p h e n ; io M ec hani c al / Tr aumat il c d d e r n e c k o b s t r u c tVas ;c ul arh y p e r t e n s i o n , b a ion a t h e r o s c l e r o t i c r e n a l a r t e r y s t e n o s i s , a t h e r o e mb o l i , v a s c u l i t i s . Polycystic Kidney Disease: P a t h o p h y s i o l o gAn a u t o s o ma l d o mi n a n t d e f e c t o f r e n a l t u b u l a r d e v e l o p me n t y: p r o d u c e s ma s s i v e e n l a r g e me n t o f t h e k i d n e y s a n d p r o g r e s s i v e r e n a l f a i l u r e . P r e s e n t i n g s y mp t o ms a r e f l a n k p a i n , n a u s e a , ma l a i s e , r e n a l c o l i c , a n d h e ma t u r i a . H y p e r t e n s i o n i s c o mmo n a n d b i l a t e r a l e n l a r g e me n t o f t h e k i d n e y s i s o f t e n d e t e c t e d o n a b d o mi n a l p a l p a t i o n .

Ur e m i a : P a t h o p h y s i o l o gA :c l i n i c a l p i c t u r e a s s o c i a t e d w i t h r e n a l f a i l u r e , i t i n c l u d e s y a zo t e mi a , a l t h o u g h t h e s y mp t o ms d o n o t n e c e s s a r i l y p a r a l l e l t h e d e g r e e o f a zo t e mi a S y mp t o ms i n c l u d e i n c r e a s e d f a t i g a b i l i t y, h e a d a c h e , a n o r e xi a , d y s p n e a , n a u s e a a n d v o mi t i n g , d i a r r h e a , h i c c u p , r e s t l e s s n e s s , a n d d e p r e s s i o n . S i g n s o n p h y s i c a l e xa m include Cheyne-Stokes breathing, fetid breath, dehydration, pericardial friction rub, mu s c l e t w i t c h i n g , c o n v u l s i o n s , d e l i r i u m, c o ma .


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P a t h o p h y s i o l o g D:a ma g e t o t h e g l o me r u l a r c a p i l l a r y e n d o t h e l i u m, b a s e me n t y me mb r a n e , me s a n g i u m, a n d / o r e p i t h e l i a l p o d o c y t e s r e s u l t s i n i n f l a mma t i o n w i t h d e s t r u c t i o n o f n o r ma l g l o me r u l a r a r c h i t e c t u r e . P r o t e i n u r i a a n d h e ma t u r i a w i t h r e d b l o o d c e l l c a s t s r e s u l t f r o m l o s s o f t h e i n t e g r i t y o f t h e If l to me r u l u s . g he g l o me r u l o n e p h r i t i s i s t h e c o n s e q u e n c e o f a s y s t e mi c d i s e a s e , t h e s i g n s a n d s y mp t o ms o f t h e p a r t i c u l a r d i s e a s e w i l l b e t h e c l u e s l e a d i n g t o t h e d i a g n o s i s . P r o c e s s e s l i mi t e d t o t h e k i d n e y w i l l o f t e n o n l y p r e s e n t w i t h t h e o n s e t o f e n d - s t a g e r e n a l d i s e a s e w i t h o l i g u r i a , e d e ma , s e v e r e h y p e r t e n s i o n , a n d e l e c t r o l y t e d i s o r d e r s .

Ne p h r o t i c S y n d r o m e : P a t h o p h y s i o l o g D:a ma g e t o t h e g l o me r u l a r b a s e me n t me mb r a n e i n c r e a s e s t h e y f i l t r a t i o n o f l o w - mo l e c u l a r - w e i g h t p r o t e i n s , p a r t i c u l a r l y a l b u mi n . W h e n t h e c a p a c i t y t h e t u b u l e s t o r e a b s o r b t h i s p r o t e i n i s e xc e e d e d , p r o t e i n u r i a , s o me t i me s ma s s i v e , o c c u r s .Al b u mi n u r i a o f > 3 . 5 g / 2 4 h i s d i a g n o s t i c ; h y p e r t e n s i o n , e d e ma , h y p o a l b u mi n e mi a , a n d e l e v a t e d s e r u m c h o l e s t e r o l a r e f r e q u e n t l y p r e s e n t . C o mp l i c a t i o n s i n c l u d e p r o t e i n ma l n u t r i t i o n a n d i n c r e a s e d r i s k o f t h r o mb o s i s , p a r t i c u l a r l y i n t h e r e n a l v e i n . R e n a l f u n c t i o n a s me a s u r e d b y t h e c r e a t i n i n e a n d b l o o d u r e a n i t r o g e n ( B U N ) ma y r e ma i n n o r ma l . N e p h r o t i c s y n d r o me ma y c o mp l i c a t e ma n y f o r ms o f g l o me r u l a r i n j u r y a n d i s p a r t i c u l a r l y c o mmo n i n d i a b e t i c n e p h r o p a t h y.

Ur o l i t h i a s i s : P a t h o p h y s i o l o g S : o n e s f o r m e i t h e r f r o m s o l u t e s ( u s u a l l y c a l c i u m o xy l a t e , b u t a l s o yt uric acid) that accrete upon a nidus or as a result of chronic urinary tract infections w i t h u r e a - s p l i t t i n g o r g a n i s ms ( s t r u v i t e s tto n e s ) .a r e u s u a l l y a s y mp t o ma t i c u n t i l S ones they lodge at a narrowing in the ureter or bladder outlet. Pain is the presenting s y mp t o m, t h e s i t e d e p e n d i n g u p o n t h e l o c a t i o n o f t h e i mp a c t e d s t o n e ( S e e Renal Col i c p a g e 6 1 0 ) . M i c r o s c o p i c o r g r o s s h e ma t u r i a ma y b e p r e s e n t i n t e r mi t t e n t l y , d u r i n g t h e a s y mp t o ma t i c p h a s e .

Ur o e p i t h e l i a l C a n c e r ( B l a d d e r , Ur e t e r s , Re n a l P e l v i s ) : P a t h o p h y s i o l o g T : e t r a n s i t i o n a l c e l l e p i t h e l i u m b e c o me s n e o p l a s t i c u n d e r yh t h e i n f l u e n c e o f s u b s t a n c e s e xc r e t e d i n t h e u r i n e . R i s k f a c t o r s i n c l u d e t h e c o mb i n a t i o n o f a l c o h o l a n d t o b a c c o , i n d u s t r i a l c h e mi c a l s a n d c e r t a i n c h e mo t h e r a p y a g e n t s ( c y c l o p h o s p h a mi d e , i f o s f a H ed e ) t. u r i a , e i t h e r g r o s s o r mi c r o s c o p i c , i s mi ma t h e o n l y e a r l y s i g n . Ad v a n c e d d i s e a s e p r e s e n t s w i t h d i r e c t e xt e n s i o n t o o t h e r p e l v i c and retroperitoneal organs causing pain, fistulas, and obstructions.


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Kidney Cancer : P a t h o p h y s i o l o g M:o s t r e n a l c a n c e r s a r i s e f r o m t h e e p i t h e l i u m a n d h a v e y mu t a t i o n s o f t h e v o n H i p p e l - L i n d a u g e n e , e i t h e r i n h e r i t e d ( v o n H i p p e l - L i n d a u s y n d r o me ) o r a c q u i r e d . To b a c c o s mo k e i s a ma j o r r i s k f a c t o r f o r a c q u i r e d r e n a l c e l l c a r c i n o maR e n a l c a n c e r s ma y i n v a d e t h e r e n a l v e i n a n d i n f e r i o r v e n a c a v a . T h e y . me t a s t a s i ze t o t h e l u n g s a n d i n v a d e l o c a l r e t r o p e r i t o n e a l s t r u c t u r e s , i n c l u d i n g b o n e a n d C N S , c a u s i n g p a i n . M i c r o s c o p i c h e ma t u r i a ma y b e p r e s e n t . T h e p r e s e n t i n g f l a n p a i n i s o f t e n mi l d a n d f e l t a s a f u l l n e s s o r p r e s s u r e p r i o r t o t h e o n s e t o f p a i n . Ur i n a r y T r a c t I n f e c t i o n : Ur e t h r i t i s a n d Ur e t h r a l S y n d r o m e : P a t h o p h y s i o l o g In:f e c t i o n i n t h e u r e t h r a c a u s i n g p a i n a n d p u r u l e n t d i s c h a r g e i s y


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c a u s e d b y s e xu a l l y t r a n s mi t t e d d i s e a s e s o r c o mp l i c a t e s p r o l o n g e d c a t h e t e r i za t i o n . U r e t h r i t i s i s u s u a l l y c a u s e d b y i n f e c t Nei s sier i a gonor r hoea, Chl amy di a ion w th t r ac homat,i sg e n i t a l my c o p l a s ma s , o r h e r p e s s iB u r ln i x.g d y s u r i a i s u n i f o r m a n d mp e n p u s ma y b e mi l k e d f r o m t h e me a t u s b y u r e t h r a l s t r i p p i n g . M i xe d i n f e c t i o n s a r e n o t unusual. Untreated, progression to upper tract infection is possible. Dysuria, u r g e n c y, a n d f r e q u e n c y w i t h n e g a t i v e c u l t u r e s f o r b a c t e r i a a n d l a c k o f r e s p o n s e t o a n t i b i o t i c s d e f i n e s u he t h r a l s y n d r o mT h e e t i o l o g y i s p o o r l y u n d e r s t o o d a n d tr e e. ma y r e s u l t f r o m v i r a l i n f e c t i o n o r s t e r i l e i n f l a mma t i o n .

Ur i n a r y T r a c t I n f e c t i o n : C y s t i t i s : P a t h o p h y s i o l o gAs c e n d i n g i n f e c t i o n w i t h e n t e r i c f l o r a Ess u a l liy hi a c)oli is y: ( u c her c c o mmo n i n n o r ma l w o me n b e c a u s e o f u r e t h r a l c o l o n i za t i o n w i t h f e c a l a n d v a g i n a l f l o r a a n d a s h o r t u r e t h r a . C y s t i t i s i n me n s u g g e s t s a n a n a t o mi c , u s u a l l y o b s t r u c t i n g a b n o r ma l i t y. R e s i d u a l u r i n e v o l u me > 1 0 0 c c i s a s s o c i a t e d w i t h i n c r e a s e d r i s k o f i n f e c t i o nIn f l a mma t i o n o f t h e b l a d d e r w a l l a n d t r i g o n e e l i c i t s u r i n a r y f r e q u e n c y, . u r g e n c y, d y s u r i a , a n d a s e n s a t i o n o f i n c o mp l e t e v o i d i n g . U n t r e a t e d , i n f e c t i o n c a n a s c e n d t o t h e k i d n eB e n[t S , N a l l a mo t h u B K , S i me l D L , e t a l . D o e s t h i s w o ma n ys h a v e a n a c u t e u n c o mp l i c a t e d u r i n a r y t r a c t i n fAM tAo n ? 2 ; 2 8 7 : 2 7 0 1 2 7.1 0 J ec i 200 ]

Ur i n a r y T r a c t I n f e c t i o n : Ac u t e P y e l o n e p h r i t i s : P a t h o p h y s i o l o g B : c t e r i a a s c e n d f r o m t h e b l a d d e r o r, l e s s c o mmo n l y, r e a c h t h e ya k i d n e y v i a t h e b l o o d s t r e a m. In f e c t i o n i n v o l v e s p r i ma r i l y t h e r e n a l me d u l l a a n d c o l l e c t i n g s y s t e m, b u t ma y e xt e n d t o t h e c o r t e x o r p e r i n e p h r i t i c t i s s u e w i t h a b s c e s s f o r ma t i o nS y mp t o ms a r e f e v e r, c h i l l s , a n d f l a n k p a i n . P h y s i c a l e xa m r e v e a l s . p e r c u s s i o n t e n d e r n e s s a t t h e c o s t o v e r t e b r a l a n g l e . P r o mp t d i a g n o s i s a n d t r e a t me n t p r e v e n t s b a c t e r e mi a , u r o s e p s i s , a n d l o c a l s u p p u r a t i v e c o mp l i c a t i o n s . Ur i n a r y T r a c t I n f e c t i o n : C h r o n i c P y e l o n e p h r i t i s : P a t h o p h y s i o l o g C:h r o n i c k i d n e y i n f e c t i o n i s c a u s e d b y n o n p y o g e n i c b a c t e r i a , y i n c l u d i n g s l o w l y g r o w i n g , o f t e n i n t r a c e l l u l a r o r g a n i s ms , s u c h a s t u b e r c u l o s i s a n d b r u c e l l o s i s .e s i c o u r e t e r a l r e f li u xa s s o c i a t e d w i t h r e c u r r e n t i n f e c t i o n s i n a d d i t i o n V s t o p r o d u c i n g p r e s s u r e i n d u c e d r e n a l i n j u r y. T h i s c o n d i t i o n ma y b e a s y mp t o ma t i c w i t a b n o r ma l i t i e s o n u r i n a l y s i s ( p y u r i a , c e l l u l a r c a s t s , a n d p r o t e i n u r i a ) a n d d e c l i n i n g renal function the only clues.


P. 6 2 2

I n t e r s t i t i a l Ne p h r i t i s : P a t h o p h y s i o l o g In:f l a mma t i o n o f t h e c o r t i c a l a n d me d u l l a r y r e n a l i n t e r s t i t i u m ( a s y d i s t i n c t f r o m t h e g l o me r u l a r a n d v a s c u l a r i n j u r y o f g l o me r u l o n e p h r i t i s ) r e s u l t s i n s c a r r i n g , d e c r e a s e d t u b u l a r f u n c t i o n , a n d p r o g r e s s i v e r e n a l i n s u f f i c i e n c y. In j u r y ma b e a c u t e ( i n f e c t i o n , d r u g i n d u c e d ) o r c h r o n i c ( t o xi n s , d r u g s , i n f e c t i o n , o b s t r u c t i o n ) . T h i s c o n d i t i o n ma y b e a s y mp t o ma t i c w i t h a b n o r ma l i t i e s o n u r i n a l y s i s ( p y u r i a , c e l l u l a casts, and proteinuria) and declining renal function the only clues. I NT E RS T I T I AL NE P HRI T I S C L I NI C AL O C C URRE NC E : Congeni t al o l y c y s t i c k i d n e y d i s e a s e , me d u l l a r y c y s t i c a n d s p o n g e k i d n e y, s i c k l e p c e l l d i s e a s e , v e s i c o u r e t e r a l rIe f ll u x; nf ammat or y / I mmune g a l l e r g y ( p e n i c i l l i n s , dru s u l f o n a mi d e s , e t c . ) , S j g r e n s y n d r o me , G o o d p a s t u r e s y n d r o me , t r a n s p l a n t r e j e c t i o n I nf ec t i ous c u t e a n d c h r o n i c p y e l o n e p h r i t i s , v i r a l i n f e c t i o n ( E p s t e i n - B a r r v i r u s , a
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c y t o me g a l o v i r u s , H IV, h a n t a v i r u s ) , b r u c e l l o s i s , y e r s i n i a , t u b e r c u l o s i s , l e p t o s p i r o s i s , r i c k e t t s i a , my c o p l a s M et abol i c / Toxdc u g s ( n o n s t e r o i d a l a n t i i n f l a mma t o r y d r u g s , ma ; ir d i u r e t i c s , a n t i c o n v u l s a n t s , c y c l o s p o r i n , a n d o t h e r s ) , t o xi n s ( h e a v y me t a l s , l i t h i u m, h e r b a l s , a n d o t h e r s ) , h y p e r c a l c e mi a , h y p e r u r i c e mi a , p r o l o n g e d h y p o k a l e mi a ; M ec hani c al / Tr aumat ihc o n i c o b s t r u c t i o n , u r e t e r o v e s i c a l r e f l u x, r a d i a t i o n ; c r Neopl as t i c l t i p l e my e l o ma , l y mp h o ma , l e u k e mi a ; ara c c o mp a n y i n g mu Vas c ul g l o me r u l o n e p h r i t i s a n d v a s c u l i t i s .

Inter stitial Cystitis: P a t h o p h y s i o l o gA :c o n d i t i o n o f u n k n o w n c a u s e r e s u l t s i n o f t e n p a i n f u l y i n f l a mma t i o n o f t h e b l a d d e r w a l l l e a d i n g t o f i b r o s i s a n d d e c r e a s e d b l a d d e r c a p a c i t y. T h i s c o n d i t i o n i s mo s t c o mmo n i n w o me n w h o p r e s e n t w i t h u r i n a r y f r e q u e n c y a n d b l a d d e r p a i n , b u t n e g a t i v e c u l t u r e s f o r i n f e c t i o n . D i a g n o s i s i s b y e xc l u s i o n o f o t h e r c a u s e s o f b l a d d e r p a i n a n d f r e q u e n c y a n d c o mp l e t e u r o l o g i c e v a l u a t i o n .

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 2 - T h e D i a g n o s t i c E xa m > C h a p t e r 11 - T h e F e ma l e Genitalia and Reproductive System

Chapter 11 The Female Genitalia and Reproductive System


Overview of Fem ale Reproductive Physiology

M a l e a n d f e ma l e e xt e r n a l g e n i t a l i a a r i s e f r o m i d e n t i c a l e mb r y o l o g i c a n l a g e d e p e n d i n on the presence or absence of testosterone. Lack of the SRY gene (typically found o n t h e Y c h r o mo s o me ) l e a d s t o d e v e l o p me n t o f o v a r i e s , w i t h s u b s e q u e n t ma t u r a t i o n o f f e ma l e s e x o r g a n s . T h e l a b i a ma j o r a i s a c o g n a t e o f t h e s c r o t u m a n d t h e c l i t o r i s a n d p e n i s a r e s i mi l a r l y d e r i v e d . Amb i g u o u s g e n i t a l i a o c c u r w h e n d e v e l o p me n t a n d ma t u r a t i o n o c c u r s w i t h a mi xe d h o r mo n a l e n v i r o n me n t o r g e n e t i c s u b s t r a t e . T h e f e ma l e r e p r o d u c t i v e s y s t e m c o n s i s t s o f t h e o v a r i e s o n t h e i r s u s p e n s o r y l i g a me n t s , t h e f a l l o p i a n t u b e s , t h e u t e r i n e c o r p u s a n d c e r v i x, t h e v a g i n a w i t h i t s mu s c u l a r w a l l , t h e v a g i n a l a n d i n t r o i t a l g l a n d s o f C o w p e r a n d B a r t h o l i n , t h e l a b i a mi n o r a a n d ma j o r a , a n d t h e c l i t o r i s w i t h i t s c o v e r i n g p r e p u c e .

T h e o v a r y c y c l i c a l l y ma t u r e s o n e o v u m w i t h i n a f o l l i c l e u n d e r t h e s t i mu l a t i o n o f f o l l i c l e - s t i mu l a t i n g h o r mo n e ( F S H ) f r o m t h e p i t u i t a r y. T h e d e v e l o p i n g f o l l i c l e p r o d u c e s t r o g e n , w h i c h c a u s e s p r o l i f e r a t i o n o f t h e e n d o me t r i u m. W h e n t h e s e r u m e s t r o g e n l e v e l r e a c h e s a t h r e s h o l d , a l u t e i n i zi n g h o r mo n e ( L H ) s u r g e i s t r i g g e r e d f r o m t h e p i t u i t a r y, e f f e c t i n g o v u l a t i o n a n d f o r ma t i o n o f t h e c o r p u s l u t e u m t h a t s e c r e t e s i n c r e a s e d l e v e l s o f p r o g e s t e r o n e , i n d u c i n g t r a n s f o r ma t i o n o f t h e e n d o me t r i u m f r o m its proliferative to its secretory phase. T he released ovum is captured by the f i mb r i a t e d e n d o f t h e f a l l o p i a n t u b e d o w n w h i c h i t t r a v e l s t o t h e u t e r i n e c o r p u s . If f e r t i l i ze d i n t h e t u b e o r u t e r i n e c a v i t y, t h e o v u m ma y i mp l a n t i n t o t h e r e c e p t i v e e n d o me t r i u m e s t a b l i s h i n g a p r e g n a n c y. If n o t , i mp l a n t a t i o n d o e s n o t o c c u r a n d t h e corpus luteum involutes. With the cessation of estrogen and progesterone p r o d u c t i o n , t h e e n d o me t r i u m i s s l o u g h e d a s me n s t r u a l b l e e d i n g , F S H r i s e s a g a i n t o s t i mu l a t e d e v e l o p me n t o f a n o t h e r f o l l i c l e i n i t i a t i n g a n o t h e r r e p r o d u c t i v e c y c l e . Imp l a n t a t i o n o f a f e r t i l i ze d o v u m l e a d s t o t h e d e v e l o p me n t o f t h e p l a c e n t a w h i c h s e c r e t e s b e t a - h u ma n c h o r i o n i c g o n a d o t r o p i n ( b e t a - h C G ) s u p p r e s s i n g p i t u i t a r y F S H a n d L H , l e a d i n g t o c e s s a t i o n o f o v u l a t i o n a n d me n s t r u a t i o n . P. 6 2 4

Anatom y of the Fem ale Genitalia and Reproductive System


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T h e s y mp h y s i s p u b i s i s s u r mo u n t e d a n t e r i o r l y b y a f a t p a d , t h e moF is .p u b i s ( s e e ng 11 - 1 . At p u b e r t y, t h e e mi n e n c e b e c o me s c o v e r e d w i t h h a i r t h a t e xt e n d s o n t o t h e s k i n )

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o f t h e a b d o me n t o f o r m a t r a n s v e r s e b o r d e r l i n e , t h e b a s e o f a n i n v e r t e d t r i a n g l e c a l l e d t h f emal e es c ut c heonh i s h a i r d i s t r i b u t i o n c o n t r a s t s w i t h t h a t o f t h e ma l e e . T e s c u t c h e o n , w h i c h d e s c r i b e s a n u p r i g h t t r i a n g l e w i t h t h e a p e x n e a r t h e u mb i l i c u s .

The Vulva.

T h e v u l v a o r p u d e n d u m c o mp r i s e s t h e e xt e r n a l g e n i t a l i a o f Ftih e 11maBe ( g . f e - 2) .l T h e l abi a maj ora r e e l e v a t e d r i d g e s e xt e n d i n g i n f e r i o r l y a n d p o s t e r i o r l y f r o m t h e a mo n s p u b i s n e a r l y t o t h e a n u s , f o r mi n g t h e s i d e s o f a l e n s - s h a p e d f i g u r e . T h e y c o n t a i n f a t , b l o o d v e s s e l s , n e r v e s , a n d t i s s u e t h a t r e s e mb l e t h e d a r t o s t u n i c i n t h e s c r o t u m. B e t w e e n t h e t w o l a b i a ma j o r a a r e t w o s ma l l e r s k li n f o l d s , nore abi a mi t h, a w h i c h e xt e n d p o s t e r i o r l y f r o m t h e c l i t o r i s t o u n i t e i n f r o n t o f t h e a n u s b y a t r a n s v e r s f o l d , t h eour c het t eT h ec l i t or i s s t h e e r e c t i l e h o mo l o g u e o f t h e p e n i s , c o mp o s e d o f f . i t w o s ma l l c o r p o r a c a v e r n o s a a n d s u r r o u n d e d s u p e r i o r lepuc et h e i n f e r i o r l y pr y b y a n d b y f o l d s o f t h e l a b i a mi n o r ar enul um T h e c l e f t p o s t e r i o r t o t h e c l i t o r i s , b e t w e e n f , the . t h e t w o l a b i a mi n o r a , i s c a l l e d t t i e .eIt i s p i e r c e d b y ur et hr al meat,us v es h bul the a p p r o xi ma t e l y 2 . 5 c m p o s t e r i o r t o t h e c l i t o r i s ,agi nal hor i f i,c emme d i a t e l y v and t e i p o s t e r i o r t o t h e me a t u s . T h e v a g i n a l o p e n i n g i s a me d i a n s l i t , v a r y i n g i n v e r s e l y w i t h t h e s i ze o f t h e h y me n . hyh e i s a t h i n me mb r a n e c o v e r i n g p a r t o f t h e v a g i n a l T men o r i f i c e . C o mmo n l y a p e r f o r a t e r i n g , w i d e s t p o s t e r i o r l y, t h e h y me n ma y b e c r i b r i f o r m, f r i n g e d , o r e v e n i mp e r f o r a t e . Af t e r r u p t u r e , t h e h y me n a l r e mn a n t s h e a l a s i r r e g u l a r f o l d s o f mu c o s a . T w o p a i r e d g l a n d s o p e n o n t o t h e v e s t i b u l a r s u r f a c e : j u s t i n f e r i o r t o t h e u r e t h r a a r e t h e o p e n i n g s partaur et hr al ( Sk ene) gl ,ands a t t h e p o s t e r i o r of he and e d g e o f t h e v a g i n a l o r i f i c e a r e f o u n d t h e o p e n i n geat ert h e t i bul ar gr s o f v es ( Bar t hol i n) gl ands .

The Vagina, Uterus, and Adnexa.

F r o m i t s o r i f i c e , vh e nae xt e n d s p o s t e r i o r l y i n t o t h e p e lgv. i s ( -)1 It i s a t agi Fi 11 . c o l l a p s e d t u b e w i t h a p o s t e r i o r w a l l a p p r o xi ma t e l y 9 c m l o n g a n d a s h o r t e r a n t e r i o r v a g i n a l w a l l ( 6 7 . 5 c m) , w h i c h r e f l e c t o ner i neec er v il x c a t e d mo s t c o mmo n l y ut t o t h o a t i t s a n t e r i o r a p e x. T h e r e c e s s o f t h e v a g i n a b e h i n d t h e c e r v i x i s t e r me d t h e pos t er i or f or ni xe c e s s e s o n e i t h e r s i d e o f t h e c e r v i x a rl e c aale dor ni c. es ; r at er l l f T h e v a g i n a l mu c o s a i s t h r o w n i n t o t r a n s v e r s e r u g a e , s e p a r a t e d b y f u r r o w s o f v a r i a b l e d e p t h s . T h r o u g h t h e v a g i n a , t h e n u l l i p a r o u s c e r v i x a p p e a r s a s a s mo o t h button with its face rounded and pierced by a hole or slit, the cervical os. T he paro c e r v i x ma y b e s o me w h a t i r r e g u l a r. T h e a n t e r i o r a n d p o s t e r i o r l i p s o f t h e o s a r e usually in contact with the posterior vaginal wall. Dorsal to the posterior vaginal wa l i e s t h e ec t um v e n t r a l t o t h e a n t e r i o r v a g i n a l w a l l ur r e hrh a n dbl adder T h e r ; a et t ae . p e r i t o n e a l c a v i t y e xt e n d s i n f e r i o r l y b e h i n d t h e p o s t e r i o r f o r n i x t o f o r m t h e r ec t ov agi nal pouc h ( c ul - de- s ac of Dougl asw;e r p a r t i s i n t e r p o s e d b e t w e e n t h e its lo ) r e c t u m a n d t h e c e r v i x. ut h eusi s a mu s c u l a r o r g a n , s h a p e d l i k e a n i n v e r t e d p e a r T er f l a t t e n e d a n t e r o p o s t e r i o r l y. F r o m P. 6 2 5 e a c h s i d e o f t h e b r o a d u t e r i n e f u n d alsl opi an t ubes e n d f o r a p p r o xi ma t e l y f u the e xt 1 0 c m, c u r v i n g l a t e r a l l y a n d p o s t e r i o r l y i n t h e p e l v i s . T h e t u b e s , s u s p e n d e d b y t h e me s o s a l p i n g e s , f o r m t h e u p p e r b o r d e r s o f t h ei gament h a t s p r e a d f r o m t h e br oad l ts l a t e r a l ma r g i n s o f t h e u t e r u s t o t h e p e l v i c w a l l . T h e u t e r u s w i t h t h e t w o w i n g s o f b r o a d l i g a me n t f o r ms a t r a n s v e r s e s e p t u m d i v i d i n g t h e p e l v i s i n t o a n a n t e r i o r a n d
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p o s t e r i o r f o s s a . O n t h e p o s t e r i o r s u r f a c e o f t h e b r o a d l i g a me n t a r t h e ov ar i ess e suspended P. 6 2 6 me d i a l t o a n d b e l o w t h e f i mb r i a t e d e n d s o f t h e f a l l o p i a n t u b e s b y l i g a me n t s w h i c h a t t a c t t o t h e u t e r ov ar i an l i gament n d t h e p e l v i c ws us ( us ( ) a a l l pens or y l i gament ).

F i g . 11 - 1 A n a t o m y o f t h e U t e r u s a n d A d n e xag i t t a l S e c t i o n o f t h e . A. Sa F e m a l e P e l vi s : e t he angl e of t he v agi na wi t h t he v er t i c al ax i s of t he body, Not and t he ax i s of t he ut er us per pendi c ul ar t o t he v agi nal ax i s . The l i ps of t he c er v i x ut er i ar e s hown t o be i n t he s ame pl ane as t he ant er i or v agi nal wal l , whi c h i s s hor t er t han t he pos t er i or wal l . The r ec t ov agi nal pouc h ( c ul - de- s ac of Dougl as ) l i es ant er i or t o t he r ec t al wal l ; henc e, i t c an be pal pat ed dur i ng t he r ec t al ex am. The ut er i ne f undus i n t he us ual pos i t i on i s i nac c es s i bi l e t o t he r ec t al ex ami ni ng f i nger, but v er y c l os e t o pal pat i on f r om t he l ower abdomen . B. Vi e w o f t h e P e l vi s f r o m A b o ve a n d i n Noto nhow t he r ound l i gament Fr e t: c ur v es ant er i or l y and t he ut er i ne t ubes c ur v e pos.t eroor leyr i o r Vi e w o f . C P i st t h e U t e r u s a n d B r o a d L i g a m e n t s , S p r e a d O utthe s us pens i on of t he Not e : ov ar y near t he f i mbr i at ed end of t he ut er i ne t ube. The ut er i ne t ube f or ms t he upper bor der of t he br oad l i gament .

Physical Exam of the Fem ale Genitalia Reproductive System


In s p e c t i o n a n d p a l p a t i o n o f t h e f e ma l e p e l v i s c a n r e v e a l ma n y d i s o r d e r s o f t h e
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r e p r o d u c t i v e o r g a n s , t h e l o w e r u r i n a r y t r a c t , a n d t h e l o w e r a b d o me n . T h e p e l v i c e xa mi n a t i o n i s a n e xt e n s i o n o f a b d o mi n a l p a l p a t i o n a n d i s ma n d a t o r y f o r e v e r y f e ma l e . N e g l e c t o f t h e p e l v i c e xa mi n a t i o n o f t e n l e a d s t o s e r i o u s e r r o r s i n d i a g n o s i s R o u t i n e P a p a n i c o l a o u s me a r i s e f f e c t i v e i n d e t e c t i n g e a r l y c a n c e r.

The Female Pelvic Examination

T h e p e l v i c e xa mi n a t i o n s h o u l d b e a t t h e e n d o f t h e p h y s i c a l e xa mi n a t i o n b e c a u s e i t r e q u i r e s s p e c i a l p o s i t i o n i n g , e q u i p me n t , a n d a t t e n d a n c e o f a f e ma l e c h a p e r o n e t o a s s i s t . Af t e r e mp t y i n g h e r b l a d d e r, t h e p a t i e n t i s p l a c e d i n t h e l i t h o t o my p o s i t i o n o n t h e e xa mi n a t i o n t a b l e . C o v e r h e r b o d y w i t h a s h e e t , p l a c e h e r f e e t i n s t i r r u p s attached to the table, and wrap the lower corners of the sheet around her legs, l e a v i n g c o n s i d e r a b l e s l a c k f o r t h e c l o t h t o e n v e l o p e t h e t h i g h s a n d l o w e r a b d o me n (F i g . 11 - 2)A W h e n t h e p a t i e n t i s t o o w e a k t o b e e xa mi n e d o n t h e t a b l e , h a v e h e r . a s s u me t h e l i t h o t o my p o s i t i o n i n b e d . E l e v a t e h e r p e l v i s o n a n i n v e r t e d b e d p a n .

F i g . 11 - 2 E xa m i n a t i o n o f t h e V u l va . A . D r a p i n g f o r P e l vi c E xa m i n a t i o n : The pat i ent as s umes t he l i t hot omy pos i t i on wi t h f eet i n s t i r r ups pr oj ec t i ng f r om t he end of t he ex ami ni ng t abl e. A s heet i s s pr ead ov er t he pat i ent s o t he t wo l ower c or ner s ar e wr apped about t he t hi ghs and l egs . The mi ddl e of t he l ower edge of t he s heet i s s l ac k l y dr aped ov er t he l ower. abdomen r a p h i c B . To p o g A n a t o m y o f t h e V u l The r ec es s ed v es t i bul e c ont ai ns a r el at i v el y s mal l va : v agi nal or i f i c e, s ur r ounded by one of t he us ual pat t er ns of unr upt ur ed hy men. Bor der i ng t he v es t i bul e ar e t he t wo pr oj ec t i ng f ol ds of of t en deepl y pi gment ed s k i n, t he l abi a mi nor a. Ant er i or l y, ac c es s or y f ol ds of t he l abi a f or m t he pr epuc e t hat enc l os es t he c l i t or i s . Lat er al t o t he l abi a mi nor a ar e t wo par al l el r i dges of s k i n and f at t hat f or m t he l abi um maj us on ei t her s i de of t he. l abi a mi nor a

P. 6 2 7 S i t o n a l o w s t o o l w i t h i n r e a c h o f a s i d e t a b l e t h a t h o l d s s p e c u l a , f o r c e p s , g a u ze , r u b b e r g l o v e s , l u b r i c a t i n g j e l l y, a n d t h e ma t e r i a l s f o r ma k i n g t h e P a p s me a r a n d b a c t e r i o l o g i c c u l t u r e s . S h i n e a b r i g h t l i g h t o n t o t h eFor ra nc ompl et e p e i e u m. ex ami nat i on, t he f ol l owi ng s equenc e i s s uggesned:e c t i o n o f t h e v u l v a ; ( b ) (a) i t sp i n s e r t i o n o f t h e v a g i n a l s p e c u l u m; ( c ) g a t h e r i n g o f s p e c i me n s f o r c y t o l o g i c e xa mi n a t i o n a n d b a c t e r i o l o g i c t e s t s ; ( d ) i n s p e c t i o n o f t h e v a g i n a l w a l l s a n d c e r v i x; ( e ) d i g i t a l b i ma n u a l e xa mi n a t i o n o f t h e u t e r u s a n d a d n e xa ; ( f ) r e c t o v a g i n a l e xa mi n a t i o n .


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I n s p e c t i o n a n d P a l p a t i o n o f t h e V u l vai g s e e - 2). O b s e r v e t h e s k i n o f t h e F ( . 11 B p e r i n e u m f o r s w e l l i n g , u l c e r s , a n d c h a n g e s i n c o l o r. S e p a r a t e t h e l a b i a w i t h t h e g l o v e d t h u mb a n d f o r e f i n g e r t o i n s p e c t t h e c l i t o r i s a n d v e s t i b u l e . E xa mi n e t h e u r e t h r a l me a t u s f o r d e v e l o p me n t a l a n o ma l i e s , d i s c h a r g e , c a r u n c l e , n e o p l a s m, a n d S k e n e a b s c e s s . In s p e c t t h e v a g i n a l o r i f i c e f o r d i s c h a r g e , g a p i n g o f t h e e d g e s , a n d p r o t r u s i o n o f t h e v a g i n a l w a l l s . P a l p a t e p o s t e r i o r l y a n d l a t e r a l l y t o t h e h y me n f o r e n l a r g e me n t o f t h e B a r t h o l i n g l a n d a n d f o r v e s t i b u l a r t e n d e r n e s s . H a v e t h e p a t i e n t strain as if to defecate and look for bulging of the anterior or posterior vaginal wall through the introitus or leaking of urine.

Va g i n a l S p e c u l u m E xaF i g(. 11 -). U n l u b r i c a t e d v a g i n a l s p e c u l u m e xa m s h o u l d m 3 p r e c e d e d i g i t a l e xa mi n a t i o n b e c a u s e l u b r i c a t i n g j e l l y i n t e r f e r e s w i t h t h e P a p a n i c o l a s me a r. S e p a r a t i n g t h e v a g i n a l w a l l s b y a s p e c u l u m p e r mi t s i n s p e c t i o n o f t h e v a g i n a a n d c e r v i x, a n d s a mp l e c o l l e c t i o n f o r c y t o l o g i c a n d b a c t e r i o l o g i c t e s t s a n d f o r b i o p s i e s w h e n i n d i c t e d . S e l e c t a c l e a n b i v a l v e s p e c u l u m o f s u i t a b l e s i ze a n d e n s u r e i t s p r o p e r t e mp e r a t u r e b y s t o r i n g i t i n a h e a t e d d r a w e r o r b y i mme r s i n g i t i n w a r m w a t e r.

F i g . 11 - 3 U s i n g t h e Va g i n a l S p e.cThe mabi a mi nor a ar e r et r ac t ed l at er al l y ulu l wi t h t he gl ov ed i ndex and mi ddl e f i nger s . The c l os ed bl ades of t he v agi nal s pec ul um ar e i ns er t ed i n t he v agi na wi t h t he wi dt hs of t he bl ades al mos t hor i zont alA. The c l os ed bl ades of t he s pec ul um hav e been wel l i ns er t ed at a . 30- t o 45- degr ee angl e pos t er i or l y and t he bl ades s epar at ed and l oc k ed open . B. A s agi t t al s ec t i on s hows t he open bl ades of t he s pec ul um i n pr oper pos i t i on wi t h t he upper s hor t er bl ade l i f t i ng t he v aul t of t he v agi na t o ex pos e t he c er v i x ut er i on t he ant er i or v agi nal wal l .

P. 6 2 8 With one hand grasp the handle and close the blades of the speculum while s e p a r a t i n g t h e l a b i a mi n o r a a t t h e l e v e l o f t h e p o s t e r i o r f o u r c h e t t e w i t h t h e o t h e r h a n d . In s e r t t h e c l o s e d b l a d e s i n t o t h e v a g i n a l o r i f i c e w i t h s l i g h t d o w n w a r d p r e s s u r t o a v o i d p i n c h i n g t h e u r e t h r a a g a i n s t t h e s y mp h y s i s p u b i s . W h e n t h e s p e c u l u m t i p s r e a c h t h e u p p e r v a g i n a , s e p a r a t e t h e b l a d e s a n d i l l u mi n a t e t h e v a g i n a l c a v i t y w i t h a s u i t a b l e l i g h t . M o v e t h e s p e c u l u m h a n d l e s o t h e b l a d e t i p s erxpi o st e e n e c e v x h th , l o c k t h e b l a d e s o p e n w i t h t h e s e t s c r e w. O b t a i n s p e c i me n s f r o m t h e c e r v i x f o r t h e Pap t es t If t h e c e r v i c a l o s i s o b s c u r e d b y d i s c h a r g e , g e n t l y s p o n g e i t w i t h a l a r g e , .
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s t e r i l e c o t t o n s w a b . T h e c e r v i c a l s a mp l e i s o b t a i n e d b y g e n t l y s c r a p i n g t h e c e r v i x with a wooden spatula and turning a cytobrush in the cervical canal, or by using a special brush for liquid Pap preparation. When indicated, inoculate gonorrheal and c h l a my d i a l ul t ur es r o m a s w a b b i n g o f t h e c e r v i c a l Ic a n a l . t t he c er vf io r c f ns pec x c o l o r, l a c e r a t i o n s , u l c e r s , a n d n e w g r o w t h s . In s p e c t t h e c e r v i c a l o s f o r s i ze , s h a p e , c o l o r, d i s c h a r g e , a n d p o l y p s . L o o s e n t h e s e t si c r epec tntd v agi nal walyl s ns w a he b r o t a t i n g t h e s p e c u l u m t o e xp o s e a l l t h e c a v i t y. L o o k f o r a b n o r ma l r e d n e s s o r b l u e n e s s o f t h e mu c o s a a n d l o s s o f r u g a t i o n . If p r e s e n t , d e t e r mi n e w h e t h e r a d i s c h a r g e e xu d e s f r o m t h e c e r v i c a l o s o r t h e v a g i n a . W h e n i n d i c a t e d , o b t a i n a s a mp l e o f d i s c h a r g e f r o m t h e l a t e r a l a n d a n t e r i o r v a g i n a l w a l l s f o r mi c r o s c o p i c e xa mi n a t i o n . F i n a l l y, c a r e f u l l y w i t h d r a w t h e s p e c u l u m w h i l e i n s p e c t i n g t h e mu c o s a .

Bimanual Pelv ic Exam.


Al w a y s u s e t h e s a me h a n d f o r v a g i n a l p a l p a t i o n , w h i c h , t h e r i g h t o r t h e l e f t , i s a ma t t e r o f p e r s o n a l p r e f e r e n c e . M a n y g y n e c o l o g i s t s p a l p a t e t h e v a g i n a w i t h t h e l e f t h a n d a n d h a n d l e i n s t r u me n t s w i t h t h e r i g h t . T h e i n v a r i a b l e u s e o f t h e s a me h a n d i n t h e b i ma n u a l e xa mi n a t i o n p e r mi t s e a c h h a n d t o b e c o me a c c u s t o me d t o i t s r o l e , a n d t h e s e n s e o f t o u c h i s e d u c a t e d f o r t h e f i n d i n g s e n c o u n t e r e d . In t h e f o l l o w i n g directions, the right hand is arbitrarily assigned to the vagina and the left hand is e mp l o y e d t o p a l p a t e t h e a b d o me n . If o b s t r u c t i o n f r o m a p e r s i s t e n t h y me n o r a c o n s t r i c t e d v a g i n a d o e s n o t i n t e r f e r e , u s e t w o f i n g e r s f o r v a g i n a l e xa mi n a t i o n .

P l a c e t h e g l o v e d r i g h t h a n d i n t h e g y n e c o l o g i c p o s i t i o n : i n d e x a n d mi d d l e f i n g e r s s t r a i g h t a n d c l o s e t o g e t h e r, t h u mb w i d e l y a b d u c t e d , f o u r t h a n d f i f t h f i n g e r s f o l d e d i n t o t h e p a l m. L u b r i c a t e t h e s t r a i g h t f i n g e r s , s p r e a d t h e l a b i a w i t h t h e l e f t t h u mb a n f o r e f i n g e r t o a v o i d t h e d i s c o mf o r t o f p u l l i n g p u b i c h a i r i n t o t h e v a g i n a . In s e r t t h e t w lubricated fingers in the vaginal cavity with the finger pads facing the anterior vagi w a l l F i g . 11 - 4)A E xa mi n e e a c h s t r u c t u r e s y s t e ma t i c a l l y f o r mi n g a me n t a l p i c t u r e o f ( . your observations.

T h e gr eat er v es t i bul ar gl andsl v o v a g i n a l g l a n d s o r B a r t h o l i n g l a n d s ) a r e (vu e xa mi n e d w i t h t h e f o r e f i n g e r i n s i d e t h e v a g i n a a n d t h e t h u mb o p p o s i t e a n d o u t s i d e o n t h e p o s t e r i o r p a r t o f t h e l a b i u m ma j u s f e e l i n g t h e i n n e r w a l l f o r a b s c e s s o r t e n d e r n e s s ( s e eg . 11 - 4)B E v e r t t h a t p a r t o f t h e v a g i n a l mu c o s a t o l o o k f o r a r e d Fi . s p o t o r p u s ma r k i n g t h e o p e n i n g o f a n i n f l a me d d u c t . T h e n o r ma l g l a n d s a n d d u c t s c a n n o t b e s e e n o r f e l t . ur h ehr ai s p a l p a t e d i n t h e mi d l i n e o f t h e a n t e r i o r v a g i n a l T et w a l l n e a r t h e i n t r o i t u s f o r t e n d e r n e s s o r i n d u r a t i o n . of h e adder p a l p a t e d bas e T bl is i n t h e mi d l i n e o f t h e a n t e r i o r v a g i n a l w a l l , h a l f w a y b e t w e e n t h e i n t r o i t u s a n d t h e c e r v i x, f o r t e n d e r n e s s o r i n d u r a t i o n p r o d u c e d b y c y s t i t i s o r P. 6 2 9 n e o p l a s m o f t h e b l a d d e r. P a l p av e t h e walf lo r t e n d e r n e s s , i n d u r a t i o n ( f r o m t agi nal s c a r s , g r a n u l o ma s , o r n e o p l a s m) , s t r i c t u r e s , s e p t a , a n d a d h e s i o n s ( n o t t o b e c o n f u s e d w i t h t h e n o r ma l t r a n s v e r s e r u g a e ) . N e xt e xa mi nx w h ie h n o r ma l l y c er v i ,e t c feels like a button, with a convex face and a central depression, the consistency of t h e t i p o f t h e n o s e . F e e l f o r n o d u l e s a n d u l c e r s a n d n o t e a n y a b n o r ma l i t y o f s h a p e , s i ze , o r c o n s i s t e n c y. D e t e r mi n e t h e a xi s o f t h e c e r v i x; n o r ma l l y i t f a c e s p o s t e r i o r l y i t h e s a me p l a n e a s t h e a n t e r i o r v a g i n a l w a l l . E xa mi n e t h e pus and f undus ut er i ne c or b i ma n u a l l y b y p u s h i n g t h e c e r v i x a n t e r i o r l y w h i l e t h e f i n g e r s o f t h e l e f t h a n d p r e s s
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i n t o t h e a b d o me n p o s t e r i o r l y j u s t a b o v e t h e mo n s p u b i s . E s t i ma t e t h e s i ze o f t h e u t e r u s , i t s a xi s , t e n d e r n e s s , mo b i l i t y, a n d c h a r a c t e r i ze a n y n o d u l e s t h a t ma y b e p r e s e n t . To e xa mi n e adnex a p l a c e t h e v a g i n a l f i n g e r s o n o n e s i d e o f t h e c e r v i x the , and push their tips superiorly and posteriorly as far as possible. With the fingers of t h e l e f t h a n d , l o c a t e a p o i n t o n t h e s a me s i d e o f t h e a b d o me n 2 3 c m me d i a l l y f r o m t h e a n t e r i o r s u p e r i o r i l i a c s p i n e . P u s h t h e a b d o mi n a l f i n g e r s d e e p s o t h e i r t i p s a p p r o a c h t h e v a g i n a l f i n g e r s . T h i s s h o u l d b r i n g t h e a p p r o xi ma t e d h a n d s b a c k t o t h e u t e r i n e t u b e s a n d o v a r i e s . If t h e s t r u c t u r e s a r e n o t f e l t a t t h a t p o i n t , mo v e t h e f i n g e r t i p s o f b o t h h a n d s i n f e r i o r l y t o w a r d t h e p u b i s , s o t h a t t h e a d n e xa p a s s b e t w e e the two P. 6 3 0 h a n d s . E xe r t a b d o mi n a l p r e s s u r e g e n t l y, b u t d e e p l y, p r e s s i n g t h e t w o h a n d s a l i t t l e c l o s e r e a c h t i me t h e p a t i e n t e xp i r e s t o a v o i d a b d o mi n a l g u a r d i n g . T h e r o l e o f t h e a b d o mi n a l h a n d s h o u l d b e t o d i s p l a c e t h e s t r u c t u r e s , w h i l e t h e v a g i n a l h a n d f e e l s t h e m. T h e n o r ma l o v a r y a n d t u b e a r e u s u a l l y n o t p a l p a b l e . W h e n t h e n o r ma l f al l opi an t ube f e l t , i t i s a p p r o xi ma t e l y 4 mm i n d i a me t e r, a b o u t h a l f t h e s i ze o f a is c o mmo n p e n c i l . It h a s t h e c o n s i s t e n c y o f a p i e c e o f r u b b e r t u b i n g . arh e n o r ma l ov T y i s a p p r o xi ma t e l y 3 c m b y 2 c m b y 2 c m; t h e l a t e r a l f a c e i s , t h e r e f o r e , a b o u t t h e s i ze o f t h e d i s t a l p h a l a n x o f t h e e xa mi n e r ' s t h u mb , b u t t h e t h i c k n e s s o f t h e o v a r y i s a b o u half that of the digit. T he ovary is soft and naturally tender to palpation. Look for e n l a r g e me n t o r a s y mme t r y o f t h e a d n e xa , u n u s u a l t e n d e r n e s s , d e c r e a s e d mo b i l i t y, a n d o t h e r ma s s e s o r i n d u r a t i o n . E xa mi n ev t h ef l oorn o t i n g t h e s i ze o f t h e pel i c , i n t r o i t u s , a n d , w i t h t h e e xa mi n i n g f i n g e r s f a c i n g p o s t e r i o r l y, p r e s s t h e p e l v i c f l o o r i n f e r i o r l y a n d p o s t e r i o r l y t o d e t e r mi n e t h e r e s i s t a n c e o r r e l a xa t i o n .

F i g . 11 - 4 B i m a n u a l P e l vi c E xa m i n a t i o n . A . P a l p a t i o n o f t TheU t e r u s : he i ndex and mi ddl e f i nger s of t he gl ov ed r i ght hand ar e i ns er t ed i n t he v agi na wi t h t he t i ps of t he f i nger s f ac i ng ant er i or l y and t ouc hi ng t he c er v i x . The f i nger s of t he l ef t hand ar e pr es s ed deep i nt o t he abdomen abov e t he mons pubi s , pus hi ng t he ut er i ne f undus downwar d and f or war d t owar d t he t wo v agi nal f i nger s . The adnex a ar e ex ami ned s i mi l ar l y, ex c ept t he v agi nal f i nger s ar e pl ac ed t o t he s i de of t he ut er us and t he abdomi nal f i nger s ar e pus hed i nt o t he bel l y at a poi nt 23 c m medi al t o t he ant er i or s uper i or i l i ac s pi ne. At t empt t o appr ox i mat e t he f i nger t i ps of t he t wo ex ami ni ng hands . The abdomi nal f i nger s ar e pul l ed i nf er i or l y t o pus h t he t ube and ov ar y ont o t he t i ps of t he
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v agi nal f i ngerB . P a l p a t i o n o f t h e G r e a t e r Ve s t i b u l a r G l a n d ( B a r t h o l i n . s G l a n d ) :The i ndex f i nger i s i ns er t ed i n t he v agi na near t he pos t er i or i nt r oi t us . The t humb i s pr es s ed out s i de on t he l abi um maj us and t he f i nger and t humb ar e appr ox i mat.ed

Rectov aginal Exam.

C o n c l u d e t h e p e l v i c e xa m w i t h a r e c t a l a n d r e c t o v a g i n a l e xa mi n a t i o n . O r d i n a r i l y, t h e f e ma l e g e n i t a l i a a r e f e l t mu c h mo r e s a t i s f a c t o r i l y t h r o u g h t h e v a g i n a t h a n t h e r e c t u m In t h e v i r g i n , h o w e v e r, v a g i n a l p a l p a t i o n ma y n o t b e f e a s i b l e , a n d e n o u g h ma y b e l e a r n e d b y r e c t a l e xa mi n a t i o n t o ma k e o r e xc l u d e d i a g n o s e s .

F i r s t n o t e a n y d i s t o r t i o n o r d e f e c t s i n t h e c i r c s phi nc t er mus,c ae c o mmo n anal u l a r l c o n s e q u e n c e o f v a g i n a l d e l i v e r y. N e xt , p a lanal c anal o r i n t r i n s i c l e s i o n s pate the f ( s e ep a g e 5 2)6 P a l p a t e t h e a n t er ecrt al wal(l p o s t e r i o r v a g i n a l w a l l ) f o r . io t e n d e r n e s s a n d ma s s e s t h e n s y s t e ma t i c a l l y e xa mi n e t h e l a t e r a l a n d p o s t e r i o r r e c t u m a n d a mp u l l a . W h i l e u s i n g t h e l e f t h a n d t o p r e s s o n t h e l o w e r a b d o me n a s i n t h e b i ma n u a l v a g i n a l e xa mi n a t i o n , p a l p a t e t h e p e l v i s t h r o u g h t h e r e c t u m a n d v a g i n a . T h r o u g h t h e a n t e r i o r r e c t a l w a l l , l o cca t ev it x e t t e mp t t o f e e l body and er ,h a the f undus of t he ut er us i s ma y b e t h e o n l y r o u t e b y w h i c h a r e t r o v e r t e d u t e r u s i s . Th p a l p a b l e . In s e r t y o u r f i n g e r f u l l y a n d p a l p a t e t h e a n t e r i o r r e c t a l w a l l i n t h e r e g i o n o t h e p e r i t o n er ec t ov agi nal poucc u l - d e - s a c o f D o u g l a s ;Fs g .e 11 -)1 Af t e r al (h ie . c h a n g i n g g l o v e s , i n s e r t t h e mi d d l e f i n g e r o f t h e g l o v e d r i g h t h a n d i n t o t h e a n a l c a n a w i t h t h e f o r e f i n g e r i n t h e v a g i n a p a l p artec govh e nal wal e t w e e n t h e t w o i n t t agi bl f i n g e r s . T h i c k e n i n g o f t h e r e c t o v a g i n a l s e p t u m o r p a r a me t r i u m o c c u r s f r o m s p r e a d o c e r v i c a l c a r c i n o ma , p u e r p e r a l i n f e c t i o n , a n d p e l v i c i n f l a mma t o r y d i s e a s e .

Fem ale Genital and Reproductive Sym ptom s General Symptoms


P. 6 3 1

Pelvic Pain: P a t h o p h y s i o l o g P : i n i n t h e p e l v i s i s c o mmo n . P a i n a r i s e s f r o m i n f l a mma t i o n , ya usually as the result of infection, from distention of tubular structures or cysts, t r a c t i o n o n s e r o s a l s u r f a c e s b y ma s s e s o r a d h e s i o n s , h e mo r r h a g e , a n d i n v a s i o n o f s e n s i t i v e s t r u c t u r e s b y n e o p l a s ms o r i mp l a n t a t i o n o f e n d o me t r i a l t i s s u e . Vi s c e r a l p a i n i s p o o r l y l o c a l i ze d w h e r e a s s e r o s a l p a i n i s u s u a l l y w e l l l o c a l i ze .d b y t h e p a t i e n It i s e s s e n t i a l t o o b t a i n a c o mp l e t e h i s t o r y o f t h e p a t i e n t ' s p a i n p a t t e r n , i t s r e l a t i o n s h i p t o me n s e s , o v u l a t i o n , b o w e l mo v e me n t s , u r i n a t i o n , a n d p h y s i c a l a n d s e xu a l a c t i v i t y. D e s c r i b e t h e p a i n q u a l i t y u s i n g t h e p a t i e n t ' s w o r d s . T h e p e l v i c e xa m mu s t b e g e n t l e a n d t h e p a t i e n t r e l a xe d f o r t h e e xa mi n e r t o l o c a l i ze t h e p a i n t o a specific area or structure. P E LV I C PAI N C L I NI C AL O C C URRE NC E : Congeni t almp e r f o r a t e h y me n , p o r p hEndoc r i ne c t o p i c p r e g n a n c y, f u n c t i o n a l i yria; e o v a r i a n c y s t Isdi opat hi c v a r i a n c y s t s , e s p e c i a l l y w i t h h e mo r r h a g e o r r u p t u r e , ; o e n d o me t r i o s i s , d i v e r t i c u l Io s il s ; nf ammat or y / I mmunel a mma t o r y b o w e l d i s e a s e , inf a p p e n d i c i t i snf ec t i ous e r v i c i t i s , e n d o me t r i t i s , s a l p i n g i t i s , t u b o o v a r i a n a b s c e s s , I; c
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c y s t i t i s , d i v e r t i c u l i t i s a n d d i v e r t i c u l a r a b s c e s s , a p pec hanitc s ; / Tr aumat i c M e n d i c i i al o v a r i a n t o r s i o n , t u b a l p r e g nNeopl as t i c n y l o c a l l y i n v a s i v e c a n c e r ( e . g . , ancy; a c e r v i c a l , e n d o me t r i a l , r e c t a l , b l a d d e r ) , me t a s t a s e s , d e g e n e r a t i n g l e i o my o ma ; Ps y c hos oc i al h y s i c a l , e mo t i o n a l , a n d s e xu a l a b u s e ; aro v a r i a n i n f a r c t i o n p Vas c ul ( t o r s i o n ) , b l e e d i n g f o l l o w i n g o v u l a t i o n ( mi t t e l s c h me r z) .

Painful M enstr uation (Dysmenor r hea): Pat hophy s i ol ogy r i ma r y d y s me n o r r h e a r e s u l t s f r o m u t e r i n e i s c h e mi a c a u s e d b y P: my o me t r i a l c o n t r a c t i o n u n d e r t h e i n f l u e n c e o f p r o s t a g l a n d i n s r e l e a s e d d u r i n g me n s t r u a t i o n . P a i n a c c o mp a n y i n g me n s e s b u t a r i s i n g f r o m d i s e a s e i n t h e p e l v i s i s s e c o n d a r y d y s me n o r r hT h e mo s t p r o mi n e n t a n d mo s t f r e q u e n t c o mp l a i n t i s s e v e r e ea. a b d o mi n a l c r a mp s i n t h e s u p r a p u b i c r e g i o n . L e s s s e v e r e a r e a c c o mp a n y i n g b a c k a c h e a n d h e a d a c h e . D y s me n o r r h e a ma y d i s a p p e a r a f t e r a p r e g n a n c y. P r o s t a g l a n d i n i n h i b i t o r s c a n b e q u i t e h e l p f u l a n d ma y b e u s e d p r o p h y l a c t i c a l l y. S e c o n d a r y d y s me n o r r h e a ma y r e s u l t f r o m e n d o me t r i o s i s , p e l v i c n e o p l a s ms , a n d p e l v i c i n f l a mma t i o n s .
P. 6 3 2

Painful Inter cour se: Dyspar eunia: P a t h o p h y s i o l o g P : y s i c a l s t i mu l a t i o n o f p e l v i c s t r u c t u r e s d u r i n g v a g i n a l yh i n t e r c o u r s e c a n l e a d t o p a i n p r e v e n t i n g s e xu a l e n j o y me n t . An xi e t y a n d f e a r i n c r e a s e p e r c e p t i o n o f a l l f o r ms o f p aq n i r e w h e t h e r t h e p a i n i s f e l t s u p e r f i c i a l l y o r d e e p l y . In i u a f t e r p e n e t r a t i o n . As k s p e c i f i c a l l y w h e t h e r t h e p a t i e n t h a s s u f f i c i e n t s t i mu l a t i o n t o b e c o me s e xu a l l y a r o u s e d , a b o u t t h e s u f f i c i e n c y o f v a g i n a l l u b r i c a t i o n , w h e t h e r t h e p a r t n e r i s s o a g g r e s s i v e a s t o c a u s e t r a u ma , a n d a n y b l e e d i n g a f t e r i n t e r c o u r s e . In q u i r e a b o u t s e xu a l p r a c t i c e s , i n c l u d i n g t h e u s e o f f o r e i g n b o d i e s a s s t i mu l a n t s , r e c t a l i n t e r c o u r s e , a n d w h e t h e r p r e v i o u s e xp e r i e n c e s h a v e o c c u r r e d t h a t c a n p r o d u c e a f e a r o f i n t e r c o u r s e , f o r e xa mp l e , r a p e , i n c e s t , mo l e s t a t i o n , a n d p h y s i c a l a n d e mo t i o n a l a b u s e . D Y S PARE UNI A C L I NI C AL O C C URRE NC E : In s u f f i c i e n t f o r e p l a y, i n a d e q u a t e l u b r i c a t i o n , p o s t me n o p a u s a l e s t r o g e n d e f i c i e n c y w i t h d r y n e s s o f v a g i n a l mu c o s a , v a g i n i s mu s ( r e f l e x s p a s m o f mu s c l e s a r o u n d t h e l o w e r v a g i n a l o p e n i n g ) , v u l v a r v e s t i b u l i t i s , l i c h e n p l a n u s , p e r i n e a l t r a u ma a n d l a c e r a t i o n s , p e l v i c a n d p e r i n e a l i n f e c t i o n s , p e l v i c t u mo r s . M enstr ual Disor der s: S e e Femal e Repr oduc t i v e Sy ndr omes : M ens t r ual Di p a gder s 4 f f . , s or e 6 4

Vulvar and Vaginal Symptoms

Vu l v a r P a i n : P a t h o p h y s i o l o g T : e v u l v a i s s o ma t i c a l l y i n n e r v a t e d a n d p a i n p e r c e p t i o n a n d yh l o c a l i za t i o n a r e g.o o df e c t i o n , i n f l a mma t i o n , a n d l o c a l t r a u ma a r e t h e mo s t c o mmo n In i d e n t i f i a b l e c a u s e s o f p a i n . D y s e s t h e t i c v u l v o d y n i a ma y b e n e u r o p a t h i c a n d v u l v a r v e s t i b u l i t i s ma y h a v e a n i n f l a mma t o r y b a s i s . VAG I NAL PAI N: VAG I NI S M US : P a t h o p h y s i o l o g P : i n f u l c o n t r a c t i o n o f t h e p u b o c o c c y g e u s mu s c l e a r o u n d t h e ya l o w e r t h i r d o f t h e v a g i n a r e s u l t s i n s e v e r e p a i n t h a t c a n b e p e r s i s t e n.t o r i n t e r mi t t e n


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T h e c a u s e i s u n k n o w n a n d t r e a t me n t i s d i f f i c u l t . In t e r c o u r s e i s p a i n f u l o r i mp o s s i b l e

Vu l v a r P r u r i t u s : It c h i n g o f t h e v u l v a i s u s u a l l y t h e r e s u l t o f o b v i o u s d i s e a s e o r c h e mi c a l i r r i t a t i o n o f t h e v u l v a r s k i n . C a n d i d a i n f e c t i o n a n d l i c h e n s c l e r o s i s a r e c o mmo n e t i o l o g i e s . Va g i n a l B l e e d i n g : S e e Femal e Repr oduc t i v e Tr ac t Sy ndr omes : M ens t r ual ,Di s or der s f f . page 644

Fem ale Genital and Reproductive Signs Vulvar Signs


Am b i g u o u s G e n i t a l i a : I n t e r s e x u a l i t y : Refer to special works on this subject.
P. 6 3 3

G e n i t a l Ul c e r : P a t h o p h y s i o l o g T : a u ma a n d s e xu a l l y t r a n s mi t t e d d i s e a s e s a r e t h e mo s t c o mmo n yr c a u s e s o f g e n i t a l u l c e r a t i o n . P a i n l e s s u l c e r s a r e mo s t t y p i c aU lo fe r s p h i l i s . l c sy i n c r e a s e t h e r i s k o f t r a n s mi t t i n g a n d a c q u i r i n g s e xu a l l y t r a n s mi t t e d d i s e a s e s ( S T D s i n c l u d i n g H IV. U l c e r s ma y b e b o t h mo r e p a i n f u l a n d s l o w e r h e a l i n g i n w o me n t h a n i n me n b e c a u s e o f p e r s i s t e n t w a r mt h a n d mo i s t u r e . pS e e sa l6s6 6 6 1 . ag o0

G E NI TAL UL C E R C L I NI C AL O C C URRE NC E : I di opat hi ci c h e n s c l e r o sIi nf l ammat or y / I mmuneh e t s y n d r o me , v u l v a r l s; Be v e s t i b u l i t i s , f i xe d d r u g r e a c t i o n , l i c h e nI nflec tuous e r p e s s i mp l e x t y p e s 1 a n d p an i s; h 2 , c h l a my d i a , s y p h i l i s , c h a n c r o i d , l y mp h o g r a n u l o ma v e n e r e u m, H IV, c y t o me g a l o v i r u s E p s t e i n - B a r r v i r u s , g r a n u l o ma i n g u i ec hani c al / Tr aumatn c d e q u a t e M nale; i ia l u b r i c a t i o n d u r i n g i n t e r c o Neopl as t i c q u a mo u s c e l l c a n c e r. urse; s Vu l v a r Ra s h : D e t e r mi n e i f t h e r a s h i s a c u t e o r c h r o n i c , p r u r i t i c , w e e p i n g o r s c a l i n g , a s s o c i a t e d w i t h b l e e d i n g o r p a i n , o r w i t h t h e u s e o f t o p i c a l a n d s y s t e mi c me d i c a t i o n s , c r e a ms , and lotions. V ULVAR RAS H C L I NI C AL O C C URRE NC E : S e e a l s o v ar I nf l ammat i on: Vul, vbte lso w. Vul i i Endoc r i ne t r o p h i c v u l v o v a g i n i t i s ; a I di opat hi ci c h e n s c l e r o sIi nf l ammat or y / I mmunen t a c t d e r ma t i tI inf;ec t i ous l s; co s c a n d i d i a s i s , d e r ma t o p h y t e s , c e l l u l i t i s , a b s c e s s o f s k i n a n d mu c o s a l g l a n d s ; M et abol i c / Toxdca b e t e s me l l i t u sec hani c al / Tr aumat ibcr a s i o n s a n d l a c e r a t i o n s , ii M; a tight-fitting clothing with poor ventilation; ti c owen disease, vulvar Neopl as B c a r c i n o maPs y c hos oc i al r u r i t i s v u l v a e , p r u r i t i s a n i . ; p

Vu l v a r I n f l a m m a t i o n : Vu l v i t i s : T h e s k i n i s o f t e n r e d , w a r m, a n d v a r i a b l y e d e ma t o u s a n d t e n d e r. T h e c o n d i t i o n ma y b e a s s o c i a t e d w i t h v a g i n i t i s a n d d i s c h a r g e , o r o c c u r a l o n e . Al t e r n a t i v e l y, t h e s k i n ma y a p p e a r t h i n n e d , a t r o p h i c o r o p a q u e , a n d w h i t e . T h e l a t t e r c h a n g e s a r e mo r e c o mmo n i n l i c h e n s c l e r o s i s a n d l i c h e n p l a n u s . V ULV I T I S C L I NI C AL O C C URRE NC E :


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I nf l ammat or y / I mmunen t a c t d e r ma t i t i s , v u l v a r v e s t i b u l i t i s , l i c h e n p l a n u s , l i c h e n co s c l e r o s i sI;nf ec t i ous e l l u l i t i s , c Candi da d e r ma t o p h y tM;et abol i c / Toxti o p i c a l , e c i r r i t a n t sM ec hani c al / Tr aumatiig h t - f i t t i n g c l o t h Neopl as t i c i f f u s e B o w e n ; t c ing; d disease. At r o p h i c Vu l v o v a g i n i t i s : P a t h o p h y s i o l o g W:i t h d r a w a l o f e s t r o g e n l e a d s t o s k i n w h i c h i s t h i n n e d , i n e l a s t i c , y a n d e a s i l y i r r i t a t e d a n d i n f l a mme d e f u l h i s t o r y f o c u s i n g o n me n s t r u l p a t t e r n a n d . A car s y mp t o ms o f e s t r o g e n i n s u f f i c i e n c y, e s p e c i a l l y h o t f l u s h e s , p o i n t t o t h e d i a g n o s i s . E xa m s h o w s a b s e n t r u g a e a n d a t h i n d r y mu c p a a e( s e e. o s g 6 3)6
P. 6 3 4

Vu l v a r S w e l l i n g , M a s s e s , a n d G r o w t h s : P a t h o p h y s i o l o gAl:l t h e n o r ma l v u l v a r s t r u c t u r e s a r e s u s c e p t i b l e t o n e o p l a s t i c y c h a n g e . In f e c t i o n w i t h h u ma n p a p i l l o ma v i r u s ( H P V) o r s y p h i l i s c a n p r o d u c e c o n d y l o ma sE v a l u a t i o n i s i d e n t i c a l t o o t h e r s k i n g r o w t h s w i t h s p e c i a l r e s p e c t f o r t h e . s e n s i t i v i t y o f t h e t i s s u e s a n d t h e n e e d t o ma i n t a i n c o s me s i s .

V ULVAR M AS S E S C L I NI C AL O C C URRE NC E : I nf l ammat or y / I mmune n u l o ma t o u s d i s e aI s eec t i ous o n d y l o ma l a t u m ( s y p h i l i s ) , gra nf ; c c o n d y l o ma a c u mi n a t u m ( H P V) , h i s t o p l a s mo s i s ; c al / Tr aumat ibcs t r u c t e d M ec hani o mu c o s a l g l a n d s a n d B a r t h o l i n a n d S k e n e Neopl as t i c o w e n d i s e a s e , glands; B me l a n o ma , i n v a s i v e s q u a mo u s c e l l c a n c e r. D I F F US E S WE L L I NG O F T HE V ULVA: P a t h o p h y s i o l o g O:b s t r u c t i o n o f t h e l y mp h a t i c c h a n n e l s f r o m a n y c a u s e ma y y p r o d u c e l y mp h e d e ma o f t h e l a b i a a n d s u r r o u n d i n g t i s s u e s . L i k e w i s e , t h e l a b i a w i l l b e d e ma t o u s w h e n s y s t e mi c v e n o u s p r e s s u r e i s v e r y h i g h a n d d e p e n d e n t e d e ma r e a c h e s a b o v e t h e i n g u i n a l l i g a me n t s , f o r e xa mp l e , a d v a n c e d r i g h t v e n t r i c u l a r f a i l u r o r c o n s t r i c t i v e p e r i c a r dIrtriis a t i o n ma y p r o d u c e h y p e r t r o p h y o f t h e l a b i a . L o o k f o r . i t l o c a l i r r i t a t i o n a n d h i s t o r y a n d p h y s i c a l f i n d i n g f o r s y s t e mi c d i s e a s e a f f e c t i n g t h e l y mp h a t i c s o r v e n o u s s y s t e m. S WE L L I NG O F A L AB I UM M AJ US : HE M AT O M A: A l a r g e , p a i n f u l , b l u i s h s w e l l i n g o f t h e l a b i u m ma y o c c u r w i t h i n a f e w h o u r s a f t e r l o c a l t r a u ma . W i t h o u t a h i s t o r y o f t r a u ma , t h e c o n d i t i o n ma y b e c o n f u s e d w i t h cellulitis of the vulva. S WE L L I NG O F A L AB I UM M AJ US : L AB I O I NG UI NAL HE RNI A: P a t h o p h y s i o l o g F : i l u r e o f t h e p e r i t o n e a l p o u c h t o o b l i t e r a t e i n t h e f e t u s ma y ya p e r mi t a h e r n i a t o d e s c e n d f r o m t h e a b d o me n i n t o t h e l a b i uim a n a ua g o u s . It s ma j l s t o t h e s c r o t a l h e r n i a i n t h e ma l e a n d p r e s e n t s w i t h v i s i b l e s w e l l i n g .

S w e l l i n g o f a L a b i u m M a j u s : Ab s c e s s o f t h e G r e a t e r Ve s t i b u l a r G l a n d ( B a r t h o l i n G l a n d Ab s c e s s ) : P a t h o p h y s i o l o g B : r t h o l i n g l a n d c y s t s a r e c o mmo n a n d a s y mp t o ma t i c . In f e c t i o n o f ya t h e c y s t l e a d s t o a b c e s s f o r ma t i o n , w h i c h ma y t r a c t t o t h e s k i n o r t o w a r d t h e i s c h i o r e c t a l f o s s ah e n o r ma l g l a n d s a r e n o t p a l p a b l e a n d t h e i r d u c t s a r e n o t . T v i s i b l e . E p i d e r ma l i n c l u s i o n c y s t s a r e a c o mmo n c a u s e o f s w e l l i n g . C y s t s a n d s ma l l e a b s c e s s e s a r e f o u n d o n l y b y v a g i n a l e xa mi ng . t i8 -n ()B In f l a mma t i o n c a u s e s a F i a o 11 . r e d s p o t i n t h e mu c o s a a t t h e s i t e o f t h e d u c t a l o r i f i c e , a n d p u s ma y b e e xp r e s s e d


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f r o m i t . If t h e a b s c e s s i s l a r g e , t h e p o s t e r i o r p o r t i o n o f t h e l a b i u m i s s w o l l e n a n d f l u c t u a n t a n d t h e o v e r l y i n g s k i n i s t e n d e r, h o t , a n d r e d .

Ur e t h r a l M e a t u s Ab n o r m a l i t i e s : Ur e t h r i t i s : S e e a l s o h a p t e r 1 0 i nar y Sy ndr omes , Ur i nar y Tr ac t I nf ec t i ons : ,Ur et hr i t i s C , Ur page 6 2 1 . A p u r u l e n t d i s c h a r g e i s s u e s f r o m t h e me a t u s . T h i s i s u s u a l l y c a u s e d b y t h e i n f l a mma t i o n f r o m s s er i a gonor r hoea amy di a t r ac homatg e n i t a l Nei , Chl , is my c o p l a s ma s o r h e r p e s s i mp l e x. P a l p a t i o n o f t h e a n t e r i o r v a g i n a l w a l l , b e g i n n i n g a t t h e c e r v i x a n d s t r o k i n g t o w a r d t h e me a t u s , r e v e a l s t e n d e r n e s s a n d i n d u r a t i o n a l o n g t h e c o u r s e o f t h e u r e t h r a . P u s ma y b e s q u e e ze d f r o m t h e me a t u s i n t h i s ma n n e r. A u r e t h r a l d i v e r t i c u l u m ma y a l s o p r o d u c e p u s .

P. 6 3 5 Ur e t h r a l M e a t u s Ab n o r m a l i t i e s : I n f l a m m a t i o n o f t h e P e r i u r e t h r a l ( S k e n e ) Gland and Duct: T he periurethral gland (the Skene gland) lies on either side of, and posterior to, th f e ma l e u r e t h r a , j u s t i n s i d e t h e me a t u s . O f t e n i t b e c o me s t h e s i t e o f c h r o n i c i n f e c t i o If i n f l a me d , t h e mo u t h o f t h e d u c t i s v i s i b l e a n d r e d , w h e n r e v i e w e d o n s p r e a d i n g o f t h e me a t u s .

Ur e t h r a l M e a t u s Ab n o r m a l i t i e s : Ur e t h r a l C a r u n c l e : T h i s p a p i l l o ma a p p e a r s a s a s ma l l r e d ma s s i n t h e me a t u s o r t h e v i s i b l e p o r t i o n o f t h e u r e t h r a . It u s u a l l y o c c u r s a s a c o mp l i c a t i o n o f u r e t h r i t i s . It ma y b e t e n d e r a n d painful on urination. Ur e t h r a l M e a t u s Ab n o r m a l i t i e s : P r o l a p s e o f t h e Ur e t h r a : S l i g h t g a p i n g o f t h e me a t u s i s c o mmo n i n t h e mu l t i p a r a . W h e n mo r e s e v e r e , t h e u r e t h r a l mu c o s a ma y p r o t r u d e f r o m t h e me a t u s a n d b e c o me t e n d e r a n d i n f l a me d .

Vaginal Signs
Va g i n a l Ul c e r s : T h e s a me t y p e s t h a t o c c u r o n t h e v u l v a ma y i n v o l v e t h e v a g i n a l pmu c o s a ; s e e age 6 3 2.

Va g i n a l D i s c h a r g e : P a t h o p h y s i o l o gA :c l e a r t o s l i g h t l y w h i t e v a g i n a l d i s c h a r g e c o n t a i n i n g mu c o u s , y e p i t h e l i a l c e l l s , a n d c o mme n s a l b a c t e r i a ( p a r t i c u l a r l y l a c t o b a c i l l i ) a t a p H o f 4 . 0 i s n o r ma l . In f e c t i o n a n d / o r i n f l a mma t i o n l e a d t o i n c r e a s e d mu c o u s p r o d u c t i o n a n d e xu d a t i o n o f w h i t e b l o o d c e l l s f r o m t h e mu c o s a , p r o d u c i n g v a g i n a l d i s c h a r g e s . D e p e n d i n g u p o n e t i o l o g y, d i s c h a r g e s v a r y f r o m t h i c k w h i t e t o t h i n , f r o t h y, a n d b l o o d w i t h v a r i a b l e o d o r, p H , a n d a c c o mp a n y i n g p r u r i t i s . ( F o r a r e v i e w o f v a g i n i t i s , s e e [S o b e l J D . Va g i n i tNs Engl J M ed 9 9 8 ; 3 3 7 : 1 8 9 6 1 9.0 3 i . 1 ] ) VAG I NAL D I S C HARG E C L I NI C AL O C C URRE NC E : Endoc r i ne t r o p h i c v a g i n i tI inf;l ammat or y / I mmunen t a c t d e r ma t i tI inf;ec t i ous a s co s bacterial vaginosis, Candi da, Tr i c homonas abol i c / Toxc c t o l y t i c v a g i n o s i s ; ; M et iy M ec hani c al / Tr aumateca i n e d t a mp o n s , p e s s a r y, f o r e i g n b o d yas t i c a g i n a l rit Neopl ; v and cervical cancers (often bloody).
P. 6 3 6
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P. 6 3 7

Re d d e n e d Va g i n a l M u c o s a : Va g i n i t i s : P a t h o p h y s i o l o g In:f l a mma t i o n o f t h e v a g i n a l mu c o s a f r o m i n f e c t i o n , a l l e r g y, o r y i r r i t a n t s l e a d s t o e r y t h e mat o r y a n d e xa mi n a t i o n o f t h e v a g i n a l s e c r e t i o n s , w h i c h . His are frequently increased to a discharge, will usually yield a diagnosis. VAG I NI T I S C L I NI C AL O C C URRE NC E : I nf l ammat or y / I mmunen t a c t d e r ma t i t i s , B e h e t d i s e a s e ; In fCandiuda co ectio s: , Tr i c homonasb a c t e r i a l v a g i n o s i s , v i r a l e n a n M etms ; i c / Toxc c t o l y t i c , t h e abol iy v a g i n o s i sM ec hani c al / Tr aumateca i n e d f o r e i g n b o d i e s , i n a d e q u a t e l u b r i c a t i o n ; rit during intercourse; Neopl as t i c i f f u s e B o w e n d i s e a s e . d RE D D E NE D VAG I NA: V ULV O VAG I NAL C AND I D I AS I S : It c h i n g , p a i n , d y s p a r e u n i a , w i t h e r y t h e ma a n d e d e ma c h a r a c t e r i ze i n f e c t i o n w i t h Candi da al bi c ans h e d i s c h a r g e h a s a n o r ma l v a g i n a l p H ( 4 . 5 ) a n d p s e u d o h y p h a e . T a n d ma n y n e u t r o p h i l s c a n b e i d e n t i f i e d i n a 1 0 % K O H p r e p a r a t i o n . C u l t u r e ma y b e n e e d e d t o c o n f i r m t h e d i a g n o s i s a n d d i s t i n g u i s h i t f r o m l e s s - c o mmo n n o n i n f e c t i o u s causes. RE D D E NE D VAG I NA: T RI C HO M O NAS VAG I NI T I S : Tr i c homonas v agi nal r s d u c e s a t e n d e r, r e d d e n e d mu c o s a , s t u d d e d w i t h s ma l l pio h e mo r r h a g i c s p o t s . T h e r e s u l t i n g ma l o d o r o u s d i s c h a r g e i s y e l l o w - g r e e n t o g r a y a n d i s f r e q u e n t l y f r o t h y, w i t h a p H o f 5 . 0 6 . 0 . In a mo r e c h r o n i c s t a g e , t h e v a g i n a l mu c o s a c o n t a i n s s c a t t e r e d r e d p a p u l e s , g i v i n g a g r a n u l a r a p p e a r a n c e . R a p i d d i a g n o s i s ma y b e ma d e b y s u s p e n d i n g a b i t o f d i s c h a r g e i n i s o t o n i c s a l i n e s o l u t i o n a n d f i n d i n g ma n y n e u t r o p h i l s a n d mo b i l e t r i c h o mo n a d s b y mi c r o s c o p i c e xa mi n a t i o n . RE D D E NE D VAG I NA: AT RO P HI C VAG I NI T I S : P a t h o p h y s i o l o g T : e v a g i n a l mu c o s a i s e s t r o g e n d e p e n d e n t a n d f o l l o w i n g yh me n o p a u s e b e c o me s t h i n , d r y, a n d s mo o t h w i t h.o u th eutg a e a n d t e n d e r T r hin mu c o s a c o n t a i n s a b r a d e d p a t c h e s a n d a d h e s i o n s t h a t b l e e d e a s i l y. F r e q u e n t l y, a serosanguinous discharge with a pH greater than 6.0 results. RE D D E NE D VAG I NA: B AC T E RI AL VAG I NO S I S : T h i s i s o n e o f t h e mo s t c o mmo n c a u s e s o f v a g i n i t i s i n w o me n o f c h i l d b e a r i n g a g e . T h e y p r e s e n t w i t h a t h i c k , o f f - w h i t e , ma l o d o r o u s d i s c h a r g e w i t h a f i s h y s me l l a n d p H g r e a t e r t h a n 4 . 5 . D i a g n o s i s i s c o n f i r me d b y f i n d i n g c l u e c e l l s ( e xf o l i a t e d v a g i n a l e p i t h e l i a l c e l l s t o w h i c hdner el l a v agi nal ds e r e ) i n v a g i n a l s e c r e t i o n s . Gar ai h C u l t u r e s a r e o f n o v a l u e b e c a u s e nal iis p r e s e n t i n 5 0 6 0 % o f h e a l t h y G. v agi s w o me n . RE D D E NE D VAG I NA: C Y T O LY T I C VAG I NO S I S : P a t h o p h y s i o l o g O:v e r g r o w t h o f t obac i l l us s ppr o d u c e s a l o w v a g i n a l p H y Lac . p l e a d i n g t o b r e a k d o w n o f e p i t h e l i a l c e l l s a n d i n f. l a mma tao nn a l p H i s b e t w e e n T he v i gi 3 . 5 a n d 4 . 5 , a n d mi c r o s c o p i c e xa m s h o w s f e w p o l y mo r p h o n u c l e a r c e l l s , c y t o l y t i c c h a n g e s i n t h e e p i t h e l i a l c e l l s , a n d n o e v iCandi da, Tr i c homonas dence of , or bacterial vaginosis. B l u i s h Va g i n a : C y a n o s i s : T h e mu c o s a b e c o me s c y a n o t i c a s a r e s u l t o f l o c a l v e n o u s e n g o r g e me n t i n p r e g n a n c y o r a p e l v i c t u mo r. T h e g e n e r a l i ze d c y a n o s i s o f c o n g e s t i v e c a r d i a c f a i l u r e i s a l s o v i s i b l e i n t h e mu c o s a l l i n i n g .
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Va g i n a l Te n d e r n e s s : Va g i n i t i s : Te n d e r n e s s o f t h e w a l l s a n d a d i s c h a r g e f r o m t h e i n t r o i t u s ma y b e t h e f i r s t s i g n s o f v a g i n i t i s e n c o u n t e r e d , b e f o r e a s p e c u l u m e xa mi n a t i o n h a s b e e n p e r f o r me d . Va g i n a l M a s s : Ne o p l a s m : N e o p l a s ms i n t h e v a g i n a l mu c o s a ma y b e p r i ma r y o r s e c o n d a r y t o c a r c i n o ma o f t h e u t e r u s , r e c t u m, b l a d d e r, o r e xt e r n a l g e n i t a l i a . Va g i n a l M a s s : Va g i n a l P o l y p : P o l y p s c a n a r i s e f r o m t h e v a g i n a l w a l l o r e xt e n d f r o m t h e c e r v i x. P o l y p o i d d e f o r mi t i o f t h e v a g i n a l a p e x f o l l o w i n g h y s t e r e c t o my a r e c o mmo n .

M a s s e s i n t h e Re c t o v a g i n a l P o u c h : P a t h o p h y s i o l o g B : c a u s e t h e r e c t o v a g i n a l p o u c h i s t h e mo s t d e p e n d e n t p o r t i o n o f ye t h e a b d o mi n a l c a v i t y, i t c o l l e c t s f l u i d , e xf o l i a t e d c e l l s , a n d mo b i l e ma s s e s f r o m w i t h t h e a b d o me nM a s s e s i n c l u d e p r o l a p s e d o v a r y, b o w e l l o o p s , c a r c i n o ma o f t h e c o l o n , . i mp l a n t s o f e n d o me t r i o s i s o r o v a r i a n c a r c i n o ma , a r e c t a l s h e l f f o r me d b y o t h e r i n t r a a b d o mi n a l c a n c e r, o r a n a c c u mu l a t i o n o f p u s , f l u i d , o r b l o o d f r o m a b d o mi n a l lesions. Re c t o v a g i n a l F i s t u l a : P a t h o p h y s i o l o g B : e a k d o w n o f t h e r e c t o v a g i n a l w a l l o c c u r s a f t e r e xt e n s i v e yr r a d i a t i o n , o b s t e t r i c a l t r a u ma , s u r g e r y, C r o h n d i s e a s e , a n d A f ils gu la nfcry m . ma i t n a o r e c t u m t o v a g i n a i s u s u a l l y s u g g e s t e d b y t h e h i s t o r y o f f e c a l c o n t a mi n a t i o n o f t h e v a g i n a . T h e mo u t h o f t h e f i s t u l a ma y b e p a l p a b l e a s a s ma l l p a t c h o f i n d u r a t i o n i n t h e p o s t e r i o r w a l l o f t h e v a g i n a . T h e o p e n i n g ma y b e i d e n t i f i e d t h r o u g h t h e v a g i n a l s p e c u l u m. T h e r e c t a l w a l l ma y b e i n d u r a t e d f r o m s c a r t i s s u e .

P e l v i c F l o o r : Re l a x a t i o n : P a t h o p h y s i o l o g tyh e mu s c u l a r p e l v i c f l o o r i s p i e r c e d b y t h e r e c t u m, v a g i n a , a n d : u r e t h r a . It i s s u b j e c t t o e xt e n s i v e t r a u ma d u r i n g v a g i n a l d e l i v e r y w h i c h s t r e t c h e s a n ma y t e a r t h e mu s c l e s . Te a r i n g o f t h e u r e t h r a l a n d a n a l s p h i n c t e r s ma y a l s o o c c u r . In a d e q u a t e s u p p o r t o f t h e p e l v i c o r g a n s l e a d s t o l o s s o f s p h i n c t e r f u n c t i o n s a n d p r o l a p s e o f t i s s u e s . P a t i e n t s c o mp l a i n o f i n c o n t i n e n c e , f e e l i n g s o f p r e s s u r e a n d fullness, and the occurrence of visible or palpable prolapsing tissues. Pelvic Floor : Enlar ged Intr oitus: W h e n t h e h y me n i s r u p t u r e d , t h e v a g i n a l o r i f i c e n o r ma l l y a d mi t s t h e e xa mi n e r ' s t w o f i n g e r s . W h e n t h r e e f i n g e r s a r e a c c o mmo d a t e d , t h e i n t r o i t u s i s d e f i n i t e l y e n l a r g e d , u s u a l l y i n d i c a t i n g s o me d e g r e e o f p e l v i c r e l a xa t i o n f r o m c h i l d b i r t h .
P. 6 3 8

Pelvic Floor : Cystocele (Bladder Pr olapse): When the patient stands or strains, the anterior vaginal wall containing a portion of t h e b l a d d e r, b u l g e s i n t o t h e v a g i n a a n d ma y e me r g e f r o m t h e i n t r o i t u s a s a s o f t , s p h e r i c t u moF i ( . 11 - 5)B T h i s f i n d i n g u s u a l l y i n d i c a t e s p e l v i c f l o o r l a c e r a t i o n r g . during childbirth.

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F i g . 11 - 5 S o m e P e l vi c S i g n s . A . L e s i o n s o f t h e C e r acx: at i ons of The l vi er c hi l dbi r t h l eav e v ar i ous s c ar s . Pus or a pol y p may be s een c omi ng out f r om t he os. B . C y s t o c e l e a n d R e c t o cWhen t he pat i ent i s as k ed t o s t r ai n as i f t o ele: def ec at e, t he i nt r oi t us wi dens and bul gi ng may dev el op ant er i or l y ( c y s t oc el e) or pos t er i or l y ( r ec t oc el .e) t e r i n e D i s p l a c e m e nft she ax i s of t he ut er us .C U I t: r emai ns s t r ai ght and t he whol e or gan i s t i l t ed, i t i s c al l ed r et r ov er s i on. I f t he ax i s of t he ut er us i s bent , t he c ondi t i on i s c al l ed .r et r of l ex i on

P e l v i c F l o o r : Re c t o c e l e ( Re c t a l P r o l a p s e ) : When the patient stands or strains, the posterior vaginal wall, containing a portion t h e r e c t u m, p r o t r u d e s i n t o t h e v a g i n a a n d ma y e me r g e f r o m t h e Fn t r.o 11 -s ( s e e i ig itu 5 B) . T h i s i s a l s o e v i d e n c e o f p e l v i c f l o o r l a c e r a t i o n d u r i n g c h i l d b i r t h . E xa mi n a t i o n i n t h e l e f t d e c u b i t u s p o s i t i o n ma y b e b e t t e r a b l e t o d e t e c t l a r g e r r e c t o c e l e s t h a n e xa m w i t h t h e p a t i e n t s u p D e l e ma r r e J B , K r u y t R H , D o o r n b o s s J , e t a l . An t e r i o r ine [ r e c t o c e l e : As s e s s me n t w i t h r a d i o g r a p h i c d e f e c o g r a p h y, d y n a mi c ma g n e t i c r e s o n a n c e i ma g i n g , a n d p h y s i c a l e xa mi n a t is n . on Rec t um 9 4 ; 3 7 : 2 4 9 2] 5 9 Di o Col 19 . P e l v i c F l o o r : Ut e r i n e P r o l a p s e : W h e n t h e p a t i e n t s t a n d s o r s t r a i n s , t h e c e r v i x ma y p r o t r u d e f r o m t h e i n t r o i t u s . T h i s r e s u l t s f r o m l o s s o f t h e n o r ma l l i g a me n t o u s s u p p o r t f o r t h e u t e r u s .
P. 6 3 9

Cervical Signs
Cer vix: Cyanosis: B l u i s h d i s c o l o r a t i o n o f t h e c e r v i x i s a s i g n o f e a r l y p r e g n a n c y ( C h a d w i c k s i g n ) . It a l s o o c c u r s i n t u mo r s o f t h e p e l v i s a n d i n c o n g e s t i v e c a r d i a c Hegar e . ( S e e failur Si gn p a g e 6 4 0 . ) , Cer vix: Softening:
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An e a r l y s i g n o f p r e g n a n c y i s s o f t e n i n g o f t h e c e r v i x i n t h e f i r s t t r i me s t e r.

Cer vix: Lacer ations: P a t h o p h y s i o l o g D:u r i n g v a g i n a l d e l i v e r y, t h e c e r v i x n e a r l y a l w a y s s u s t a i n s s o me y l a c e r a t i o n ( s e eg . 11 - 5)A C o mmo n l y, t h e t e a r i s t r a n s v e r s e a n d b i l a t e r a l ; Fi . o c c a s i o n a l l y, t h e l a c e r a t i o n i s u n i l a t e r a l , o r mu l t i p l e t e a r s p r o d u c e a s t e l l a t e l e s i o n . R e c e n t l y t o r n e d g e s a p p e a r r a w. In a f e w w e e k s , h e a l i n g l e a v e s s c a r r e d f i s s u r e s o r n o t c h e s . T h e c l e f t l i p s o f t h e c e r v i x ma y b e c o me e v e r t e d ; h e a l i n g ma y b e i n c o mp l e t e , c a u s i n g a n a r e a o f e r o s i o n . H e a l e d l a c e r a t i o n s o f t h e c e r v i x l e a v e n o t c h e s o r f i s s u r e s i n t h e s u r f a c e o f t h e c e r v i x t h a t c a n b e f e l t w i t h t h e f i n g e r.

Cer vical Dischar ge: Endocer vicitis: P a t h o p h y s i o l o g W:h i l e t h e v a g i n a i s q u i t e r e s i s t a n t , t h e c o l u mn a r e p i t h e l i u m o f y t h e e n d o c e r v i x i s p a r t i c u l a r l y s u s c e p t i b l e t o i n f e c t i o n w i t h g o n n o r r h e a , c h l a my d i a , h e r p e s , a n d g e n i t a l my c o p l a sA mu c o p u r u l e n t o r p u r u l e n t d i s c h a r g e e me r g e s . ma s f r o m t h e c e r v i x o s ( F eg . 11 - 5)A T h e c e r v i c a l l i p s a r e u s u a l l y i n f l a me d a n d si e . eroded. T he absence of tenderness on palpation of the uterine fundus suggests tha t h e i n f e c t i o n i s l i mi t e d t o t h e c e r v i c a l c a n a l . C e r v i c i t i s i s a c u t e a n d i s u s u a l l y c a u s e b y g o n o r r h e a o r c h l a my d i a l i n f e c t i o n . E xt e n s i o n i n t o t h e u t e r i n e c a v i t y a n d t u b e s p r o d u c e s e n d o me t r i t i s a n d p e l v i c i n f l a mma t o r y d i s e a s e , w h i c h c a n l e a d t o t u b o o v a r i a n a b c e s s a n d s t e r i l i t y.

Cer vical Dischar ge: Endometr itis: S e e Ut er i ne Si gns : Endomet rbte so w. , i il Cer vical Ever sion: Ve l v e t y r e d mu c o s a , w i t h o u t u l c e r a t i o n , e xt e n d i n g o u t w a r d f r o m t h e c e r v i c a l o s i s u s u a l l y t h e r e s u l t o f mi g r a t i o n o f t h e e n d o c e r v i c a l t i s s u e o n t o t h e v i s i b l e p o r t i o n s o t h e c e r v i x.
P. 6 4 0

C e r v i c a l Ul c e r : T here is a loss of epithelium and sloughing of underlying tissue. Specific causes ar h e r p e s s i mp l e x, c h a n c r o i d , s y p h i l i s , t u b e r c u l o s i s , a n d c a r c i n o ma . B i o p s y i s i n d i c a t e w h e n t e s t s f o r mi c r o b i a l d i s e a s e s a r e n e g a t i v e . T h i s ma y r e s u l t f r o m t h e a b r a s i o n o a p e s s a r y. C e r v i c a l M a s s : Hy p e r t r o p h y : T h e l i p s o f t h e c e r v i x ma y e n l a r g e a n d e l o n g a t e . T h i s mo s t f r e q u e n t l y o c c u r s i n p a r o u s w o me n . In h y p e r t r o p h y t h e f u n d u s r e t a i n s i t s n o r ma l p o s i t i o n . T h e c e r v i x i s a l s o mo r e v i s i b l e , b u t n o t e n l a r g e d , i n u t e r i n e p r o l a p s e ; h o w e v e r, t h e f u n d u s d e s c e n d s t o w a r d t h e v a g i n a l o r i f i c e . T h e c e r v i x r e t a i n s i t s n o r ma l c o n t o u r i n h y p e r t r o p h y, w h e r e a s n e o p l a s m d i s t o r t s t h e p r o p o r t i o n s . Cer vical M ass: Polyp: A s o f t , b r i g h t - r e d , b e n i g n t u mo r, u s u a l l y p e d u n c u l a t e d , o f t e n e me r g e s f r o m t h e c e r v i c a l o s ( s e eg . 11 - 5)A It ma y c a u s e d i s c h a r g e a n d b l e e d i n g . Fi . Cer vical M ass: Cysts: O c c l u s i o n o f g l a n d s i n t h e c e r v i c a l mu c o s a c a u s e s 1 3 mm c l e a r o r w h i t e r e t e n t i o n c y s t s , c a l l e d n a b o t h i a n c y s t s , t h a t a r e v i s i b l e o n s p e c u l u m e xa m.
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Cer vical M ass: Cer vical Car cinoma: F r e q u e n t l y, a b l o o d y d i s c h a r g e f o l l o w s s t r a i n i n g o r c o i t u s . W h e r e a s a c e r v i c a l p o l y p i s s ma l l a n d s o f t , a h a r d ma s s i n t h e c e r v i x s u g g e s t s a n e o p l a s m, w h i c h s h o u l d p r o mp t P a p s me a r a n d c e r v i c a l b i o p s y. A c h r o n i c u l c e r o f t h e c e r v i x w i t h i n d u r a t i o n a l a t e s i g n o f c a r c i n o ma . In t h e l a t e r s t a g e s , e xt e n s i v e u l c e r a t i o n , i n d u r a t i o n , a n d n o d u l a r i t y ma k e t h e d i a g n o s i s o bS ao ua y a G F, B r o w n AD , Wa s h i n g t o n AE , vi w s [ G a r b e r AM . C u r r e n t a p p r o a c h e s t o c e r v i c a l - c a n c e r s c r e e n i n gM ed N Engl J . 2 0 0 1 ; 3 4 4 : 1 6 0 3 1 6.0 7 ]

Uterine Signs
Uterus: Softening (Hegar Sign):

D u r i n g t h e f i r s t t r i me s t e r o f p r e g n a n c y, t h e f u n d u s u t e r i s o f t e n s a t t h e j u n c t i o n o f t h c e r v i x w i t h t h e b o d y. T h i s c h a n g e i n c o n s i s t e n c y i s e a s i l y p a l p a b l e ; s o me t i me s t h e c o n t r a s t b e t w e e n f u n d u s a n d i s t h mu s i s s o p r o n o u n c e d t h a t t h e c e r v i x s e e ms t o s e p a r a t e f r o m t h e f u n d u s t[i a n L A, P i s c i t e l l i J T. T h e r a t i o n a l c l i n i c a l e xa mi n a t i o n . Bas Is t h i s p a t i e n t p r e g n a n t ? C a n y o u r e l i a b l y r u l e i n o r r u l e o u t e a r l y p r e g n a n c y b y c l i n i c a l e xa mi n a t i o n ? A 1 9 9 7 ; 2 7 8 : 5 8 6 5 9 1 J AM ]. P. 6 4 1

Ut e r i n e Te n d e r n e s s : E n d o m e t r i t i s : T h e a p p e a r a n c e o f t h e c e r v i x i s s i mi l a r t o t h a t i n e n d o c e r v i c i t i s , b u t t e n d e r n e s s o f t h e u t e r i n e b o d y o r f u n d u s i n d i c a t e s i n v o l v e me n t o f t h e e n d o me t r i u m. E n d o me t r i t i s i c a u s e d b y s e xu a l l y t r a n s mi t t e d d i s e a s e s ( g o n o r r h e a , c h l a my d i a , a n d my c o p l a s ma s ) or by infection following childbirth or abortion. Ut e r u s : D i s p l a c e m e n t : ( S e eF i g . 11 - 5.C T h e mo s t c o mmo n p o s i t i o n o f t h e u t e r i n e b o d y i s a n t e r i o r l y i n t h e ) s a me a xi s a s t h e c e rRet r ov er s i on d i s p l a c e me n t o f b o t h f u n d u s a n d c e r v i x i n a v i x. is c o mmo n a xi s a n d i s p r e s e n t i n 2 5 % o f n o r ma l w o me n . T h e a xi s o f t h e f u n d u s a n d cervix is in the direction of the spine and the plane of the cervix faces the anterior w a l l o f t h e v a g i n a . T h e f u n d u s e n c r o a c h e s u p o n t h e r e c t u m. T h e u t e r i n e f u n d u s ma y be felt through the anterior rectal wall when it cannot be palpated per vagina. When f r e e l y mo v a b l e , i t i s s y mp t o ml e s s ; w h e n f i xe d , i t s u g g e s t s e n d o me t r i o s i s . Ret r of l ex i on p o s t e r i o r d i s p l a c e me n t o f t h e f u n d u s . T h e p l a n e o f t h e c e r v i x i s i n t h e is n o r ma l p o s i t i o n b u t t h e f u n d u s i s p a l p a b l e t h r o u g h t h e p o s t e r i o r f o r n i x a n d r e c t u m (F i g . 11 - 5)C Lat er al di s pl ac ement t h e u t e r u s i s f r e q u e n t l y c a u s e d b y a d h e s i o n s . of o r ma s s e s i n t h e a d n e xa .

Ut e r i n e E n l a r g e m e n t : P r e g n a n c y : G e n e r a l i ze d u t e r i n e e n l a r g e me n t i n a w o ma n o f c h i l d b e a r i n g a g e s h o u l d b e c o n s i d e r e d a p r e g n a n c y u n t i l p r o v e n o t h e r w i s e . In t h e f i r s t f e w mo n t h s o f p r e g n a n c y t h e g r a v i d u t e r u s b e c o me s g l o b u l a r o r mo r e r o u n d e d i n s h a p e . O t h e r s y mp t o ms a n d s i g n s o f p r e g n a n c y a r e mo r n i n g s i c k n e s s , t e n d e r n e s s o f t h e b r e a s t s , a me n o r r h e a , c y a n o s i s o f t h e v a g i n a l a n d c e r v i c a l mu c o s a c k s i gn s o f t e n i n g o f t h e Chadwi ( ), c e r v i x, a n d s o f t e n i n g o f t h e u t e r i n e Hegars s(i gn U r i n e p r e g n a n c y t e s t i n g i s fundu ). ma n d a t o r y. T h e g r a v i d u t e r u s ma y b e d i s t i n g u i s h e d f r o m l a r g e o v a r i a n c y s t s b y h e a r i n g t h e f e t a l h e a r t b e a t , r e me mb e r i n g t h a t c o n c u r r e n c e o f o v a r i a n c y s t s w i t h


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p r e g n a n c y i s c o mmo n . T h e h e i g h t o f t h e u t e r u s r e f l e c t s t h e s t a g e s o f p r e g n a n c y : 3 mo n t h s , a t t h e p u b i s ; 4 . 5 mo n t h s , a t t h e u mb i l i c u s ; 9 mo n t h s , a t t h e xi p h o i d .

Ut e r i n e E n l a r g e m e n t : L e i o m y o m a ( F i b r o i d ) : H a r d , o f t e n p a i n l e s s n o d u l e s , f r e q u e n t l y mu l t i p l e , a r e f i r ml y a t t a c h e d t o t h e u t e r u s . T h e n o d u l e s a n d t h e f u n d u s mo v e f r e e l y t o g e t h e r. An a s y mme t r i c g r a v i d u t e r u s i s s o me t i me s mi s t a k e n f o r a u t e r i n e f i b r o i d i n a w o ma n o f c h i l d b e a r i n g a g e . F i b r o i d s a r e t h r e e t o f i v e t i me s mo r e c o mmo n i n b l a c k s t h a n i n w h i t e s . Ut e r i n e E n l a r g e m e n t : Ne o p l a s m o f t h e Ut e r u s : C a r c i n o ma a n d s a r c o ma o f t h e u t e r u s p r o d u c e mo r e - o r l e s s - g e n e r a l i ze d e n l a r g e me n t , w h i c h ma y b e a s s o c i a t e d w i t h b l o o d y d i s c h a r g e . E v a l u a t e w i t h ultrasonography and seek gynecology evaluation.

Adnexal Signs
Pelvic M ass: Endometr iosis: S e e Femal e Geni t al and Repr oduc t i v e Sy ndr omes , Endometg eos 4s . , pa ri 6 i 8
P. 6 4 2

Ad n e x a l Te n d e r n e s s : P a t h o p h y s i o l o g P : i n a r i s e s f r o m i n f l a mma t i o n o f s t r u c t u r e s , u s u a l l y a s t h e r e s u l t ya of infection, and from distention of tubular structures or cysts, traction on serosal s u r f a c e s b y ma s s e s o r a d h e s i o n s , h e mo r r h a g e , a n d i n v a s i o n o f s e n s i t i v e s t r u c t u r e s b y n e o p l a s ms o r i mp l a n t a t i o n o f e n d o me t r i. aIt tiis s u e e n t i a l t o o b t a i n a l s ess c o mp l e t e h i s t o r y o f t h e p a t i e n t ' s p a i n p a t t e r n , i t s r e l a t i o n s h i p t o me n s e s , o v u l a t i o n , b o w e l mo v e me n t s , u r i n a t i o n , a n d p h y s i c a l a n d s e xu a l a c t i v i t y. T h e p e l v i c e xa m mu s t b e g e n t l e a n d t h e p a t i e n t r e l a xe d f o r t h e e xa mi n e r t o l o c a l i ze t h e p a i n t o a s p e c i f i c area or structure. AD NE X AL T E ND E RNE S S C L I NI C AL O C C URRE NC E : Congeni t almp e r f o r a t e h y me n , p o r p hIy r iopat hi c v a r i a n c y s t s , e s p e c i a l l y w i t h i di a ; o h e mo r r h a g e o r r u p t u r e , e n d o me t r i o s i s , d i v e r I nf uammat or y / I mmune tic l losis; i n f l a mma t o r y b o w e l d i s e a s e , a p p e nId i ceci tsi ;ous e r v i c i t i s , e n d o me t r i t i s , nf i t c salpingitis, tuboovarian abscess, cystitis, diverticulitis and diverticular abscess, a p p e n d i c i t i s ; ec hani c al / Tr aumat ivc r i a n t o r s i o n , t u b a l p r e g nNeopl as t i c n y M o a ancy; a l o c a l l y i n v a s i v e c a n c e r, f o r e xa mp l e , c e r v i c a l , e n d o me t r i a l , r e c t a l , b l a d d e r, me t a s t a t i c , a p p e n d i c Vas;c ul aro v a r i a n i n f a r c t i o n ( t o r s i o n ) , b l e e d i n g f o l l o w i n g itis o v u l a t i o n ( mi t t e l s c h me r z) .

Ad n e x a l M a s s : P e l v i c I n f l a m m a t o r y D i s e a s e ( S a l p i n g i t i s , Hy d r o s a l p i n x , P y o s a l p i n x , Tu b o o v a r i a n Ab s c e s s ) : P a t h o p h y s i o l o g In:f e c t i o n a s c e n d s f r o m t h e c e r v i x v i a t h e e n d o me t r i u m. S e xu a l l y y t r a n s mi t t e d o r g a n i s ms ( g o n o r r h e a , c h l a my d i a , my c o p l a s ma s ) i n i t i a t e i n f e c t i o n , b u t a e r o b i c a n d a n a e r o b i c e n t e r i c f l o r a e a r e f r e q u e n t s e c o n d a r y c o mp l i c a t i o n s i n t h e a d v a n c e d s t a g e s o f i n f e.c tWo nh a c u t e i n f e c t i o n s , t h e f a l l o p i a n t u b e s a r e t e n d e r i it a n d s w o l l e n , w h i c h f r e q u e n t l y o b s c u r e s t h e s e p a r a t e s t r u c t u r e s i n t h e a d n e xa . M o v e me n t o f t h e u t e r u s a n d c e r v i x i s e xt r e me l y p a i n f u l . In mo r e c h r o n i c s t a g e s , t h e e xu d a t e a n d f i b r o s i s a r o u n d t h e t u b e s f e e l l i k e a n u n y i e l d i n g ma s s , t e r me d a f r o ze n p e l v i s . W h e n a d h e s i o n s o r i n f l a mma t i o n s e a l a t u b e a t b o t h e n d s i t ma y b e c o me


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f i l l e d w i t h f l u i d o r p u s , f e l t a s a s a u s a g e - s h a p e d ma s hy dr os al d a a n d s , t e r me pi nx py os al pi nxr e s p e c t i v e l y. W h e n t h e o v a r y a n d b r o a d l i g a me n t b e c o me i n v o l v e d a , t u b o o v a r i a n a b s c e s s i s f o r me d . S ep a g es o 4,8 S T D s . e al 6

Tu b a l M a s s : E c t o p i c P r e g n a n c y : S e e p a g e 6 4.3 Ir r e g u l a r v a g i n a l b l e e d i n g a n d p e l v i c p a i n d u r i n g c h i l d b e a r i n g y e a r s i n d i c a t e s e c t o p i c p r e g n a n c y u n t i l p r o v e n o t h e r w i s e . T h i c k e n i n g , o r a ma s s , ma y o r ma y n o t b e a p p r e c i a t e d i n t h e a d n e xa . S o f t e n i n g o f t h e c e r v i x a n d f u n d u s o c c u r s w i t h t u b a l p r e g n a n c y, a s w e l l a s w i t h i n t r a u t e r i n e p r e g n a n c y. M o v e me n t o f t h e u t e r u a n d c e r v i x i s p a i n f u l . O c c a s i o n a l l y, a b u l g i n g ma s s i s f e l t i n t h e r e c t o v a g i n a l p o u c h f r o m a p e l v i c h e ma t o ma . Ovar ian M ass: Oophor itis: Al t h o u g h i n f l a mma t i o n o f a n o v a r y c a u s e s i t t o e n l a r g e , t h e c h a n g e i n s i ze i s u s u a l l n o t d e t e c t e d b y p a l p a t i o n b e c a u s e t h e s a me i n f l a mma t o r y p r o c e s s i n v o l v e s t h e u t e r i n e t u b e s , s o t h a t t h e c o mp o n e n t s t r u c t u r e s i n t h e ma s s c a n n o t b e r e c o g n i ze d .


P. 6 4 3

O v a r i a n M a s s : Ne o p l a s m : A v a r i e t y o f b e n i g n a n d ma l i g n a n t n e o p l a s ms ma y i n v o l v e t h e o v a r i e s w h i c h c a n b e s p e c i f i c a l l y d i a g n o s e d o n l y b y o p e r a t i o n . T h e s e n s i t i v i t y o f p h y s i c a l e xa mi n a t i o n , e v e n i n e xp e r i e n c e d h a n d s , i s n o t g o o d f o r d e t e c t i o n o f a d n e xad i lma s s e s [ P a l l a L A, R a d o s e v i c h D M , M i l a d M P. Ac c u r a c y o f t h e p e l v i c e xa mi n a t i o n i n d e t e c t i n g a d n e xa l ma s s e s . Obs t et Gy nec ol0 0 0 ; 9 6 : 5 9 3 5] 9 8 2 . Ovar ian M ass: Endometr iosis: E n l a r g e me n t o f t h e o v a r i e s i s f r e q u e n t l y e n c o u n t e r e d i n e n d o me t r i o s i s ( p a g e 6 4 8 ) .

Ovar ian M ass: Cyst: S e e Femal e Geni t al and Repr oduc t i v e Sy ndr omes : Ov ar i an gCy6 4s . An , pa e st 7 o f t e n f l u c t u a n t , n o n t e n d e r s p h e r o i d a l ma s s i s f e l t i n t h e r e g i o n o f t h e o v a r y. W h e n t h e ma s s i s r e l a t i v e l y s ma l l , p a l p a t i o n i s d i a g n o s t i c . W h e n t h e c y s t e n l a r g e s s u c h t h a t i t e me r g e s f r o m t h e p e l v i s a n d i n t o t h e a b d o me n , n o d i s t i n c t i v e p e l v i c s i g n s a r e p r e s e n t a n d t h e ma s s mu s t b e d i s t i n g u i s h e d f r o m o t h e r a b d o mi n a l ma s s e s ( s e e C h a p t e r ,9p a g e 5 4 4 ) .

Rectal Signs

He a l e d An a l L a c e r a t i o n : P a t h o p h y s i o l g y :h i s i s u s u a l l y t h e r e s u l t o f c h i l d b i r t h , b u t i t ma y b e e v i d e n c e o f T s e xu a l a b u s e t h e l a c e r a t i o n e xt e n d e d t h r o u g h t h e a n a l c a n a l i t i s e v i d e n c e d b y t h e . If a p p e a r a n c e o f t h e a n u s , w h o s e e d g e s a r e e i t h e r n o t a p p r o xi ma t e d o r f o r m a n irregular line rather than a depression with puckered borders. Palpation reveals w e a k n e s s o f t h e s p h i n c t e r. W h e n t h e s p h i n c t e r a n i i s s e v e r e d , t h e c o n d i t i o n i s t e r me d a t h i r d - d e g r e e l a c e r a t i o n . P a r t i a l s p h i n c t e r l a c e r a t i o n s a r e c o mmo n a n d ma y b e p a l p a b l e o n r e c t a l e xa m.Fec al I nc ont i nenc e a p t e r ,9p a g e 5 3 6 . See , Ch

Fem ale Genital and Reproductive Syndrom es


Ectopic Pr egnancy:
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P a t h o p h y s i o l o g Imp l a n t a t i o n o f t h e f e r t i l i ze d o v u m n o r ma l l y o c c u r s i n t h e y: e n d o me t r i u m. Imp l a n t a t i o n c a n o c c u r i n t h e f a l l o p i a n t u b e s , o v a r y, o r p e r i t o n e u m. P r e s e n t a t i o n d e p e n d s u p o n t h e s i t e o f i mp.l a n t ia t i a n d b l e e d i n g a r e f r e q u e n t . Pa n o T h e s e p r e g n a n c i e s a r e n o t v i a b l e t o t e r m a n d mu s t b e a b o r t e d s u r g i c a l l y o r p h a r ma c o l o g i c a l l y t o p r o t e c t t h e w o ma n f r o m l i f e t h r e a t e n i n g D a r t R r h,a g e [ h e mo r G K a p l a n B , Va r a k l i s K . P r e d i c t i v e v a l u e o f h i s t o r y a n d p h y s i c a l e xa mi n a t i o n i n p a t i e n w i t h s u s p e c t e d e c t o p i c p r e g nAnn y. a n c Emer g M ed9 9 9 ; 3 3 : 2 8 3 2] 9 0 1 .

P. 6 4 4 Ab d o m i n a l P a i n a n d P a l l o r : Ru p t u r e a n d He m o r r h a g e f r o m Tu b a l Pregnancy: P a t h o p h y s i o l o g F : i l u r e o f t h e f e r t i ze d o v u m t o p a s s t h e f a l l o p i a n t u b e w i t h ya i mp l a n t a t i o n i n t h e t u b e r e s u l t s i n t u b a l p r e g n a n c y. T h e g e s t a t i o n a l t i s s u e s t r e t c h e s a n d f i n a l l y r u p t u r e s t h e t u b a l w a l l , w h i c h h a s b e c o me v e r y v a s c u l a r, r e s u l t i n g i n a s u d d e n , l a r g e - v o l u me h e mo r r h a g e i n t o t h e p e r i t o n e a p rce vvi io u s l y h e a l t h y . A l a ty y o u n g w o ma n p r e s e n t s w i t h a g o n i zi n g a b d o mi n a l a n d p e l v i c p a i n t h a t ma y b e p o o r l y l o c a l i ze d . S o me t i me s t h e p a i n b e g i n s i n t h e s u p r a p u b i c o r p e l v i c r e g i o n , p r o b a b l y f r o m s e r o s a l i n f l a mma t i o n a n d p r e mo n a t o r y s ma l l v o l u me b l e e d i n g p r i o r t o f r a n k r u p t u r e . T h e a b d o me n i s q u i e t , i n c r e a s i n g l y t e n d e r, a n d r i g i d i t y d e v e l o p s p r o g r e s s i v e l y. T h e a b d o me n b e c o me s d i s t e n d e d a n d e v i d e n c e o f f r e e f l u i d ma y a p p e a r. S i g n s o f h e mo r r h a g i c s h o c k q u i c k l y d e v e l o p . U t e r i n e b l e e d i n g o r s p o t t i n g i s c o mmo n . B e c a u s e r u p t u r e o f t u b a l p r e g n a n c y u s u a l l y o c c u r s i n t h e f i r s t 8 w e e k s o f g e s t a t i o n , me n s t r u a l i r r e g u l a r i t i e s ma y h a v e b e e n s l i g h t o r u n n o t i c e d . W i t h s u b a c u t h e mo r r h a g e , t h e s y mp t o ms a r e n o t s o s e v e r e . T h e p a t i e n t ma y b e s e e n a f t e r t h e f i r s e p i s o d e h a s s u b s i d e d , w h e n h e mo r r h a g e h a s c e a s e d . B l o o d i n t h e p e l v i s g i v e s a s e n s e o f f u l l n e s s w h e n p a l p a t i n g t h e f o r n i c e s . A d e f i n i t e ma s s o f c l o t o r l i q u i d b l o o d ma y b e p r e s e n t i n t h e r e c t o u t e r i n e p o u c h , w h e r e i t c a n b e i d e n t i f i e d b y u l t r a s o n o g r a p h y. i ne pr egnanc y t es t s mus t be obt ai ned i n al l women of Ur c hi l dbear i ng age wi t h abdomi nal Tpainn v a g i n a l u l t r a s o n o g r a p h y i s d i a g n o s t i c . . ra s T h e s e v e r e a t t a c k mu s t b e d i s t i n g u i s h e d f r o m mo s t o t h e r c a u s e s o f a c u t e a b d o mi n a p a i n . O n e mu s t s u s p e c t e c t o p i c p r e g n a n c y i n a n y f e r t i l e w o ma n w i t h a c u t e a b d o mi n a p a i n . T u b a l p r e g n a n c y o c c u r s mo s t c o mmo n l y a s t h e r e s u l t o f p r e v i o u s p e l v i c i n f l a mma t o r y d i s e a s e w i t h t u b a l s c a r r i n g o r p r e v i o u s t u b a l s u r g e r y. E c t o p i c p r e g n a n c y i n o t h e r l o c a t i o n s ( o v a r y, b r o a d l i g a me n t , a b d o me n ) c a n a l s o p r e s e n t w i t p a i n a n d a b d o mi n a l b l e e d i n g .

Ab d o m i n a l P a i n a n d P a l l o r : F o l l i c u l a r a n d C o r p u s L u t e u m He m o r r h a g e : P a t h o p h y s i o l o g R:u p t u r e o f t h e o v a r i a n s u r f a c e t o r e l e a s e t h e o v u m i n t o t h e y f a l l o p i a n t u b e c a n r e s u l t i n p a i n a s s o c i a t e d w i t h mi n o r b l e e d i n g f r o m t h e f o l l i c l e ( m i t t e l s c h m e r zP e r s i s t a n t b l e e d i n g , e s p e c i a l l y i n w o me n o n a n t i c o a g u l a n t s , c a n . ) o c c u r. T h e c o r p u s l u t e u m ma t u r e s o v e r 7 1 0 d a y s a n d r u p t u r e o f a c o r p u s l u t e u m c y s t u s u a l l y o c c u r s a r o u n d t h e o n s e t o f. me n o e s l e e d i n g ma y b e Mi sr b s y mp t o ml e s s , b u t , w h e n h e a v y, t h e c l a s s i c s i g n s o f i n t r a a b d o mi n a l h e mo r r h a g e result (see discussion of tubal pregnancy above). Sonography will show free fluid ( b l o o d ) i n t h e p e r i t o n e a l c a v i t y a n d ma y d e mo n s t r a t e t h e f o l l i c u l a r o r c o r p u s l u t e u m cyst.
P. 6 4 5
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P. 6 4 6 P. 6 4 7

M enstr ual Disor der s: N o r m a l P h y s i o l o gM : n s t r u a t i o n u s u a l l y b e(g i n s c he) e t w e e n t h e a g e s o f ye menar b 1 2 a n d 1 5 y e a r s i n t e mp e r a t e c l i ma t e s a n d a t 9 o r 1 0 y e a r s i n t h e t r o p i c s . T h e a n t e r i o r p i t u i t a r y g l a n d p r o d u c e s f o l l i c l e - s t i mu l a t i n g h o r mo n e ( F S H ) a n d l u t e i n i zi n g h o r mo n e ( L H ) , i n r e s p o n s e t o p u l s i t i l e h y p o t h a l a mi c s e c r e t i o n o f g o n a d o t r o p i n r e l e a s i n g h o r mo n e ( G n R H ) . F S H c a u s e s t h e ma t u r a t i o n o f a n o v a r i a n g r a a f i a n f o l l i c l e b y g r o w t h o f i t s g r a n u l o s a c e l l s a n d t h e f o r ma t i o n o f f o l l i c u l a r f l u i d . In c o mb i n a t i o n w i t h F S H , L H c a u s e s t h e t h e c a i n t e r n a t o s e c r e t e e s t r o g e n . T h e ma t u r e f o l l i c l e r u p t u r e s t h r o u g h t h e o v a r i a n s u r f a c e , r e l e a s i n g t h e o v u m. It e n t e r s t h e f i mb r i a t e d e n d o f t h e f a l l o p i a n t u b e p a s s i n g d o w n t h e t u b e , a n d i f f e r t i l i ze d , i mp l a n t i n t h e e n d o me t r i u m. T h e r u p t u r e d o v a r i a n f o l l i c l e b e c o me s t h e c o r p u s l u t e u m, w h o s c e l l s s e c r e t e b o t h e s t r o g e n a n d p r o g e s t e r o n e u n d e r t h e i n f l u e n c e o f L H a n d F S H . If t h e o v u m i s n o t f e r t i l i ze d , t h e c o r p u s l u t e u m g r a d u a l l y d e g e n e r a t e s a n d s c a r i f i e s . O v u l a t i o n o c c u r s a b o u t 2 w e e k s b e f o r e me n s t r u a t i o n . D u r i n g t h e t i me w h e n e s t r o g e n i s t h e p r i ma r y s e c r e t i o n ( f o l l i c u l a r p h a s e ) , t h e u t e r i n e e n d o me t r i u m u n d e r g o e s p r o l i f e r a t i o n . L a t e r, w h e n t h e s e c r e t i o n o f p r o g e s t e r o n e p r e d o mi n a t e s ( l u t e a l p h a s e t h e e n d o me t r i u m d i f f e r e n t i a t e s i n t o s e c r e t o r y e n d o me t r i u m. W i t h i n v o l u t i o n o f t h e c o r p u s l u t e u m a n d d e c l i n e i n e s t r o g e n a n d p r o g e s t e r o n e , t h e e n d o me t r i u m d e g e n e r a t e s a n d s l o u g h s a s me n s t r u a l b l o o d . T h e me n s t r u a l c y c l e u s u a l l y r e c u r s i n p e r i o d s o f 2 7 3 2 d a y s , a l t h o u g h g r e a t v a r i a b i l i t y e xi s t s . T h e me n s t r u a l f l o w l a s t s a b o u t 5 d a y s . D u r i n g t h e e n t i r e me n s e s , t h e a v e r a g e b l o o d l o s s i s f r o m 6 0 t o 2 5 0 mL , mo s t d u r i n g t h e f i r s t a n d s e c o n d d a y s . A me n s t r u a l p a d i s c o n s i d e r e d f i l l e d w h e i t c o n t a i n s 3 0 5 0 mL o f b l o o d . T h e me n o p a u s e ma y o c c u r b e t w e e n t h e a g e s o f 4 0 a n d 5 5 y e a r s . M e n s t r u a l d i s t u r b a n c e s ma y b e c a u s e d b y d i s o r d e r s o f t h e a n t e r i o r p i t u i t a r y g l a n d , t h e h y p o t h a l a mu s , t h e t h y r o i d g l a n d , t h e o v a r y, o r t h e u t e r u s . It i s f i r s t n e c e s s a r y t o e s t a b l i s h t h e w o ma n ' s n o r ma l me n s t r u a l p a t t e r n s t a r t i n g a t me n a r c h e , i n c l u d i n g t h e me n s t r u a l c y c l e l e n g t h , t h e a mo u n t a n d d u r a t i o n o f n o r ma l f l o w, a n d h e r h i s t o r y o f c o n c e p t i o n , l i v e b i r t h s , a b o r t i o n s , s t i l l b i r t h s , a n d c o n t r a c e p t i o n . D e t e r mi n e t h e t i me o f t h e l a s t n o r ma l c y c l e a n d t h e n s e e k s p e c i f i c i n f o r ma t i o n a b o u t t h e c u r r e n t p r o b l e m. It i s i mp o r t a n t t o d i f f e r e n t i a t e p r o b l e ms o f c y c l e l e n g t h ( e a r l y o r d e l a y e d me n s e s ) , d u r a t i o n o f f l o w ( p r o t r a c t e d o r s h o r t ) , q u a n t i t y o f f l o w ( t o o mu c h o r t o o l i t t l e ) a n d a s s o c i a t e d s y mp t o ms , f o r e xa mp l e , p a i n ( d y s me n o r r h e a ) . T h e t e r mi n o l o g y f o r t h e s e d i s o r d e r s c a n b e c o n f u s i n g s o u s e c l e a r d e s c r i p t i o n s , a v o i d i n g G r e e k a n d L a t i n o b s c u r a t i o n s . E v a l u a t i o n o f me n s t r u a l a b n o r ma l i t i e s r e q u i r e s a t h o r o u g h h i s t o r y, c o mp l e t e p e l v i c e xa mi n a t i o n , a n d e v a l u a t i o n o f t h e w o ma n ' s h o r mo n a l s t a t u s , f r e q u e n t l y c o mb i n e d w i t h i ma g i n g o f t h e p e l v i s a n d / o r e n d o me t r i a l s a mp l i n g . R e me mb e r t h a t p r e g n a n c y a n d me n o p a u s e a r e t h e mo s t c o mmo n c a u s e s o f me n s t r u a l d i s o r d e r. P RO F US E M E NS T RUAT I O N: M E NO RRHAG I A: M e n o r r h a g i a i s t h e c o n d i t i o n i n w h i c h me n s t r u a t i o n p e r s i s t s l o n g e r o r t h e d a i l y v o l u me o f f l o w i s g r e a t e r t h a n n o r ma l . E xc e s s i v e b l o o d l o s s w i t h me n o r r h a g i a i s a c o mmo n c a u s e o f i r o n - d e f i c i e n c y w i t h o r w i t h o u t a n e mi a . M E NO RRHAG I A C L I NI C AL O C C URRE NC E : Congeni t al o n W i l l e b r a n d d i s e a s e , h e mo p h i l i a ; r i ne e r s i s t e n c e o f t h e c o r p u s v Endoc p
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l u t e u m, a n o v u l a t i o n , p e r i me n o p a u s e , h y p o t h y di opatm, c n d o c e r v i c a l a n d I r o i d i s hi e e n d o me t r i a l p o l y p s , e n d o me t rIi nfsl iammat or y / I mmunes t e mi c l u p u s o s; sy e r y t h e ma t o s uIsnf ec t i ous n d o me t r i t i s , s a l p i n gMt et ; ; e i i s abol i c / Toxs c u r v y ; i Neopl as t i c t e r i n e l e i o my o ma , e n d o me t r i a l h y p e r p l a s i a o r c a r c i n o ma , l e u k e mi a ; u Vas c ul arc o a g u l a t i o n d e f e c t s ( t h r o mb o c y t o p e n i a , v o n W i l l e b r a n d d i s e a s e , h e mo p h i l i a ) .

I NT E RM E NS T RUAL AND I RRE G UL AR B L E E D I NG : M E T RO RRHAG I A: Ir r e g u l a r a n d i n t e r me n s t r u a l b l e e d i n g s u g g e s t s a n a b n o r ma l i t y o f t h e e n d o me t r i u m. Al t h o u g h me t r o r r h a g i a i s c o mmo n l y s y n o n y mo u s w i t h i n t e r me n s t r u a l b l e e d i n g , i t a l s o r e f e r s t o i r r e g u l a r b l e e d i n g . S o me c a u s e s o f h e a v y b l e e d i n g , i n mo r e s e v e r e f o r m, p r o d u c e i r r r e g u l a r b l e e d i n g a s w e l l . T h e mo s t c o mmo n c a u s e s a r e e n d o me t r i t i s , u t e r i n e l e i o my o ma , e n d o me t r i a l p o l y p , c e r v i c a l p o l y p s , c e r v i c a l a n d e n d o me t r i a l c a n c e r, p r e g n a n c y, e c t o p i c p r e g n a n c y, t h r e a t e n e d a b o r t i o n , a n d r e t a i n e d p r o d u c t s o conception. AB S E NT M E NS T RUAT I O N: P RI M ARY AM E NO RRHE A: Pat hophy s i ol ogy r i ma r y a me n o r r h e a i s f a i l u r e t o i n i t i a t e r e g u l a r me n s t r u a l c y c l e s P: a t a c h r o n o l o g i c a l l y a p p r o p r i a t e a g e . It r e s u l t s f r o m g e n e t i c , e n d o c r i n o l o g i c , o r a n a t o mi c a b n o r ma l i t i e s o f s e x c h r o ma t i n , s e xu a l d i f f e r e n t i a t i o n , a n d / o r s e xu a l ma t u r a t i o n . S e v e r e p s y c h o l o g i c s t r e s s c a n r e s u l t i n a me n o r r h e a i n o t h e r w i s e n o r ma i n d i v i d u a.l sT h e e xa mi n a t i o n s h o u l d f o c u s u p o n t h e c o r r e l a t i o n o f s e xu a l a n d s o ma t i c ma t u r a t i o n w i t h c h r o n o l o g i c a l a g e a n d , i f n e c e s s a r y, b o n e a g e . O b t a i n g r o w t h r e c o r d s f r o m b i r t h t o i d e n t i f y l o n g - s t a n d i n g g r o w t h p r o b l e ms . E s t i ma t e t h e s t a g e o f s e c o n d a r y s e xu a l d e v e l o p me n t b y u s i n g t h e Ta n n e r s y s t e m o f c l a s s i f i c a t i o n . In a d d i t i o n t o c o n f i r mi n g n o r ma l e xt e r n a l g e n i t a l i a b y p h y s i c a l e xa m, i ma g i n g s t u d i e s ma y b e n e e d e d t o c o n f i r m t h e p r e s e n c e o f a n o r ma l v a g i n a , u t e r u s , a n d o v a r i e s . P RI M ARY AM E NO RRHE A C L I NI C AL O C C URRE NC E : Congeni t al e l a y e d p u b e r t y, u t e r i n e a g e n e s i s , i mp e r f o r a t e h y me n d ( c r y p t o me n o r r h e a ) , o v a r i a n a g e n e s i s o r d y s g e n e s i s ( T u r n e r s y n d r o me ) , a n d o t h e r d i s o r d e r s o f s e x c h r o mo s oEndoc r i ne y p o - a n d h y p e r t h y r o i d i s m, me s ; h h y p o p i t u i t a r i s m, a n d r o gMn s ; e et abol i c / Toxli e a d , me r c u r y, mo r p h i n e , a l c o h o l , c ma l n u t r i t i o n , c h e mo t h e r a p y, e xc e s s i v e e xe r c i s e , o b e s i t y, d e b i l i t a t i n g d i s e a s e s ; M ec hani c al / Tr aumat iyc t e r e c t o my, o o p h o r e c t o my, p e l v i c i r r a d i a t i oas; t i c h s Neopl n a n d r o g e n - p r o d u c i n g t u mo r s , p r o l a c t i n o ma , c r a n i o p h a r y y c hos oc i al Ps n g i o ma ; a n o r e xi a n e r v o s a , d e p r e s s i o n . G O NAD AL D Y S G E NE S I S : T URNE R S Y ND RO M E , O VARI AN AG E NE S I S : P a t h o p h y s i o l o g T : e r e i s a n i n h e r i t e d d e f i c i e n c y o f o n e X c h r o mo s o me . T h e yh k a r y o t y p e i s XO w i t h n o Y a n d a d i p l o i d n u mb e r o f 4 5 i n 8 0 % o f c a s e s . O n l y c o n g e n i t a l l y f i b r o t i c o v a r i a n a n l a g e n i s a s s o c i a t e d w i t h n e g a t i v e ( ma l e p a t t e r n ) s e x c h r o ma t i n o f b u c c a l mu c o s a l c e l l s a n d n e.u t r h e rhe l ss s h o r t s t a t u r e , w e b b e d T op i i n e c k , a s h i e l d - l i k e c h e s t , c u b i t u s v a l g u s , s h o r t me t a c a r p a l s , l y mp h e d e ma , a n d i n f a n t i l e f e ma l e g e n i t a l i a a n d b r e a s t s . S e xu a l ma t u r a t i o n i s d e l a y e d w i t h p r i ma r y a me n o r r h e a a n d d e l a y e d g r o w t h o f a xi l l a r y a n d p u b i c h a i r. AB S E NT M E NS T RUAT I O N: S E C O ND ARY AM E NO RRHE A: P a t h o p h y s i o l o g S : c o n d a r y a me n o r r h e a i s t h e c e s s a t i o n o f me n s t r u a l c y c l e s a f t e r ye p r e v i o u s me n s t r u a l b l e e d i n g . It r e s u l t s f r o m e n d o c r i n o l o g i c o r a n a t o mi c a b n o r ma l i t i e s . S e v e r e p s y c h o l o g i c s t r e s s c a n r e s u l t i n a me n o r r h e a i n g e n e t i c a l l y,
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e n d o c r i n o l o g i c a l l y, a n d a n a t o mi c a l l y n o r ma l i n d i v i d u a l s . E v a l u a t i o n o f s e c o n d a r y a me n o r r h e a r e q u i r e s a d e t a i l e d p e r s o n a l me d i c a l , p s y c h o l o g i c a n d me n s t r u a l h i s t o r y a f a mi l y h i s t o r y, a n d p h y s i c a l e xa mi n a t i o n w t h a t t e n t i o n t o s i g n s o f e n d o c r i n e d i s e a s e . S e c o n d a r y a me n o r r h e a i s e xp e c t e d i n mi d l i f e , a s s o c i a t e d w i t h o v a r i a n a g i n ( me n o p a u s e ) . P r e g n a n c y i s t h e mo s t c o mmo n c a u s e o f s e c o n d a r y a me n o r r h e a i n w o me n o f c h i l d b e a r i n g a g e .

S E C O ND ARY AM E NO RRHE A C L I NI C AL O C C URRE NC E : Congeni t al o l y c y s t i c o v a r y s y n d r o me , a d r e n a l h y p e r p l a s irai ;ne r e g n a n c y, p Endoc p me n o p a u s e , h y p e r - a n d h y p o t h y r o i d i s m, h y p o p i t u i t a r i s m ( S h e e h a n s y n d r o me , a f t e r i r r a d i a t i o n o r s u r g e r y, p r i ma r y ) , p r i ma r y o v a r i a n f a i l u r e , h o r mo n a l c o n t r a c e p t i v e s ( o r a l , i n j e c t a b l e , a n d i mp l a n t e d ) , e l e v a t e d p r o l a c t i n ( n o r ma l l a c t a t i o n , p r o l a c t i n o ma d i a b e t e s me l l i t unf l ammat or y / I mmunes t e mi c l u p u s e r y t h e ma t o s u s , v a s c u l i t i s ; I s; sy I nf ec t i ous IV, t u b e r c u l o sMset abol i c / Toxli e a d , me r c u r y, mo r p h i n e , a l c o h o l , H i ; c ma l n u t r i t i o n , c h e mo t h e r a p y, e xc e s s i v e e xe r c i s e , o b e s i t y, d e b i l i t a t i n g d i s e a s e s ; M ec hani c al / Tr aumat iyc t e r e c t o my, o o p h o r e c t o my, p e l v i c i r r a d i a t i o n , a f t e r u t e r i n e h s c u r e t t a g eNeopl as t i c n d r o g e n - p r o d u c i n g t u mo r s , p r o l a c tPso ma ; oc i al ; a i n y c hos a n o r e xi a n e r v o s a , d e p r e s s i o n . P O LY C Y S T I C O VARY S Y ND RO M E : P a t h o p h y s i o l o g In:c r e a s e d p r o d u c t i o n o f a n d r o g e n i c s t e r o i d s b y t h e o v a r y, o r, l e s s y c o mmo n l y, t h e a d r e n a l , i s a s s o c i a t e d w i t h i n s u l i n r e s i s t a n c e a n d i mp a i r e d f e r t i l i t y b e c a u s e o f a n o v u l a t i o n . G e n e t i c f a c t o r s a r e i mp o r t a n t , a l t h o u g h t h e g e n e s a n d mo d o f i n h e r i t a n c e a r e u n k n o w n i e n t s ma y p r e s e n t i n a d o l e s c e n c e o r mo r e c o mmo n l y . Pat t h e t h i r d o r f o u r t h d e c a d e o f l i f e w i t h o l i g o me n o r r h e a , a me n o r r h e a , i n f e r t i l i t y, o b e s i a n d e xc e s s i v e h a i r g r o w t h . Ab o u t h a l f t h e w o me n w i t h t h e me t a b o l i c a b n o r ma l i t y h a v e p o l y c y s t i c o v a r i e s . T h e r e i s a n i n c r e a s e d r i s k f o r r a na b eSe s [ F di ks t . P o l y c y s t i c o v a r y s y n d r o me . N Engl J M ed 9 9 5 ; 3 3 3 : 8 5 3 8 6 1 1 ].

Ovar ian Cysts: See also Femal e Repr oduc t i v e Tr ac t Si gns : Ov ar i an a g e t6 4 3 . , p Cy s s P a t h o p h y s i o l o g C:y s t i c c h a n g e i n t h e o v a r y c a n r e s u l t f r o m t h e f o l l i c l e s , t h e y c o r p u s l u t e u m, t h e s t r o ma , a n d t h e o v a r i a n e pCty s t ls uc a n b e d e g e n e r a t i v e o r . i he i m n e o p l a s t i c ( b e n i g n a n d ma l i g n a n t ) o r t e r a t o ma s . S p e c i f i c d i a g n o s i s c a n o n l y b e ma d p a t h o l o g i c a l l y.

Ovar ian Cancer : P a t h o p h y s i o l o g M:a l i g n a n t t u mo r s a r i s e p r e d o mi n a n t l y f r o m t h e e p i t h e l i u m, y a l t h o u g h g e r m c e l l a n d s t r o ma l t u mo r s a r e n o t r a r e . B R C A- 1 a n d B R C A- 2 g e n o t y p e s i n c r e a s e t h e r i s k f o r o v a r i a n c a n c e re n i n g f o r o v a r i a n c a n c e r i s n o t c u r r e n t l y . Scr e f f e c t i v e a n d t h e d i s e a s e o f t e n p r e s e n t s a f t e r g e n e r a l i ze d p e r i t o n e a l s p r e a d a s ascites.


P. 6 4 8

Endometr ial Cancer : P a t h o p h y s i o l o g It : i s mo r e c o mmo n i n w o me n w i t h i n c r e a s e d l e v e l s o f y estrogen in the absence of progesterone-induced cycling. T his is a disease p r e d o mi n a t e l y o f p o s t me n o p a u s a l w o me n w h o p r e s e n t w i t h v a g i n a l s p o t t i n g o r b l e e d i n g . D i a g n o s i s i s b y e n d o me t r i a l b i o p s y. O b e s i t y, u n o p p o s e d e s t r o g e n t h e r a p y,
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a p o s i t i v e f a mi l y h i s t o r y, a n d a t y p i c a l e n d o me t r i a l h y p e r p l a s i a a r e r i s k f a c t o r s .

Va g i n a l C a n c e r : T h i s i s a r a r e d i s e a s e . C l e a r - c e l l v a g i n a l c a n c e r w a s a s s o c i a t e d w i t h t h e e xp o s u r e f e ma l e f e t u s e s t o ma t e r n a l d i e t h y l s t i l b e s t r o l ( D E S ) , g i v e n i n a n a t t e mp t t o p r e v e n t spontaneous abortion. Sexually Tr ansmitted Diseases (ST Ds): S T D s c a n p r e s e n t l o c a l l y a s u l c e r s o r i n f l a mma t i o n , s y s t e mi c a l l y, o r b e a s y mp t o ma t i c . Al l s e xu a l l y a c t i v e w o me n , e s p e c i a l l y t h o s e w i t h n e w o r mu l t i p l e partners, should be screened for ST Ds. T he presence of one ST D increases the ris o f a c q u i r i n g o r t r a n s mi t t i n g o t h e r s . B a r r i e r c o n t r a c e p t i v e s ( c o n d o ms ) a r e s o me w h a t e f f e c t i v e a t d e c r e a s i n g t h e r i s k o f a c q u i r i n g a n S T D . Al l p e r s o n s w i t h a n S T D mu s t b e s c r e e n e d f o r o t h e r t r e a t a b l e S T D s , i n c l u d i n g H IV a n d s y p h i l i s , w h i c h a r e o f t e n a c q u i r e d a s y mp t o ma t i c a l l y. E xt e n s i o n o f i n f e c t i o n t o t h e t u b e s , o v a r i e s a n d b r o a d l i g a me n t r e s u l t s i n p e l v i c i n f l a mma t o r y d i s ep a g e ( s e)e, a f r e q u e n t c a u s e o f ase 642 f e ma l e i n f e r t i l i t y. In a d d i t i o n , s e v e r a l i n f e c t i o u s d i s e a s e s , n o t u s u a l l y d e f i n e d a s S T D s , c a n b e a c q u i r e d s e xu a l l y, f o r e xa mp l e , h e p a t i t i s B . Infer tility: P a t h o p h y s i o l o g T : e c a p a c i t y t o b e c o me p r e g n a n t w i t h a v i a b l e f e t u s r e q u i r e s t h e yh c o o r d i n a t e d f u n c t i o n i n g o f c o mp l e x p h y s i o l o g i c s y s t e ms i n a n a n a t o mi c a l l y n o r ma l w o ma n . F a i l u r e o f a n y c o mp o n e n t o f t h i s s y s t e m c a n r e s u l .t In i ti in f le r t i l i t y in a e xa mi n a t i o n s h o u l d f o c u s o n a n a s s e s s me n t o f g e n e r a l h e a l t h a n d n u t r i t i o n , t h e me n s t r u a l h i s t o r y, a n d a p h y s i c a l e xa m t o c o n f i r m n o r ma l s e xu a l d e v e l o p me n t a n d a n a t o my. E v a l u a t i o n o f t h e s e xu a l p a r t n e r i s a l s o r e q u i r e d . T h e e t i o l o g y a n d e v a l u a t i o n o f i n f e r t i l i t y i s a c o mp l e x s u b j e c t . S e e s p e c i a l i ze d t e xt s f o r f u r t h e r i n f o r ma t i o n .

Endometr iosis: P a t h o p h y s i o l o g N:o r ma l - a p p e a r i n g e n d o me t r i a l t i s s u e f o r ms i mp l a n t s i n e c t o p i c y s i t e s i n c l u d i n g t h e o v a r i e s , p o s t e r i o r s u r f a c e o f u t e r u s , s i g mo i d c o l o n , u t e r o s a c r a l l i g a me n t s , a n d , l e s s o f t e n , d i s t a n t s i t e s s u c h a s p l e u r a . C y c l i c a l b l e e d i n g i s a s s o c i a t e d w i t h p a i n a n d t h e d e v e l o p me n t o f a d hh e ic a u s e i s u n k n o w n . . T es ons P a t i e n t s p r e s e n t w i t h d y s me n o r r h e a a n d a b d o mi n a l o r p e l v i c p a i n t h a t i s o f t e n c y c l i c a l . Te n d e r n o d u l a r ma s s e s s u r r o u n d e d w i t h f i b r o s i s ma y b e f e l t . F r e q u e n t l y, t h o v a r i e s a r e e n l a r g e d . T h e u t e r u s ma y b e f i xe d o r p a i n f u l w i t h mo v e me n t . In f e r t i l i t y i c o mmo n a n d d i a g n o s i s u s u a l l y r e q u i r e s l a p a r o s c o p y.

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 2 - T h e D i a g n o s t i c E xa m > C h a p t e r 1 2 - M a l e G e n i t a l i a and Reproductive Tract

Chapter 12 M ale Genitalia and Reproductive Tract


Overview of Male Reproductive Physiology

M a l e a n d f e ma l e e xt e r n a l g e n i t a l i a a r i s e f r o m i d e n t i c a l e mb r y o l o g i c a n l a g e d e p e n d i n on the presence or absence of testosterone. Lack of the SRY gene (typically found o n t h e Y c h r o mo s o me ) l e a d s t o d e v e l o p me n t o f o v a r i e s , w i t h s u b s e q u e n t ma t u r a t i o n o f f e ma l e s e x o r g a n s . C o n v e r s e l y, t h e p r e s e n c e o f t h i s g e n e l e a d s t o t e s t i c u l a r d e v e l o p me n t , w i t h ma s c u l i n i za t i o n o f t h e r e p r o d u c t i v e t r a c t . T h e s c r o t u m i s a c o g n a t e o f t h e l a b i a ma j o r a a n d t h e p e n i s a n d c l i t o r i s a r e s i mi l a r l y d e r i v e d . Amb i g u o u s g e n i t a l i a o c c u r w h e n d e v e l o p me n t a n d ma t u r a t i o n o c c u r s w i t h a mi xe d h o r mo n a l e n v i r o n me n t o r g e n e t i c s u b s t r a t e .

T h e ma l e r e p r o d u c t i v e o r g a n s a r e t h e t e s t e s , e p i d i d y mi s , v a s d e f e r e n s , s e mi n a l v e s i c l e s , p r o s t a t e , a n d p e n i s . T h e t e s t e s a r i s e i n t r a a b d o mi n a l l y a n d d e s c e n d t h r o u g t h e i n g u i n a l c a n a l i n t o t h e s c r o t u m, u s u a l l y b y b i r t h . T h e s c r o t a l l o c a t i o n i s mo r e c o n d u c i v e t o s p e r ma t o g e n e s i s b e i n g s l i g h t l y c o o l e r t h a n b o d y t e mp e r a t u r e . L e y d i g c e l l s i n t h e t e s t e s p r o d u c e t e s t o s t e r o n e u n d e r t h e c o n t r o l o f l u t e i n i zi n g h o r mo n e p r o d u c t i o n b y t h e p i t u i t a r y g l a n d a n d s p e r ma t o g e n e s i s t a k e s p l a c e i n t h e s e mi n i f e r o u s t u b u l e s u n d e r t h e c o n t r o l o f f o l l i c l e - s t i mu l a t i n g h o r mo n e ( F S H ) a n d l o c a l p a r a c r i n e t e s t o s t e r o n e p r o d u c t i o n . S p e r m a r e c o l l e c t e d i n t h e e p i d i d y mi s a n d t r a v e l u p t h e v a s d e f e r e n s i n t h e s p e r ma t i c c o r d , w h i c h i n c l u d e s t h e t e s t i c u l a r a r t e r a n d v e i n a n d t h e l y mp h a t i c s , t o r e a c h t h e p r o s t a t e a n d s e mi n a l v e s i c l e s . E j a c u l a t e c o n t a i n s s p e r m, p r o s t a t i c , a n d s e mi n a l v e s i c l e s e c r e t i o n s .

Anatom y of the Male Reproductive System


At p u b e r t y, t h e p u b e s b e c o me s c o v e r e d w i t h h a i r t h a t e xt e n d s o n t o t h e s k i n o f t h e a b d o me n t o f o r m tmal e es c ut c heon h i c h d e s c r i b e s a n u p r i g h t t r i a n g l e w i t h t h e he , w a p e x n e a r t h e u mb i l i c u s . P. 6 5 0

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F i g . 1 2 - 1 S t r u c t u r e o f t h e P e n i s . A . T h e S h a f t i n i t s Ve n t r o l a t e r a l A s p e c t , w i t h I n t e g u m e n t R e m o ve d . B . A S a g i t t a l S e c t i o n o f t h e S h a f t w i t h Integument Included. C. A Cross-section of the Shaft .

The Penis

T h e s h a f t o f t h e p e n i s i s f o r me d b y t h r e e c o l u mn s o f e r e c t i l e t i s s u e , t h e t w o d o r s o l a t e r a lor por a c av er nos a d t h e v e n t r a l s macl or r c an l e pus s pongi os um c o n t a i n i n g t h e u r e t h ria .( 1 2 -)1 F i b r o u s t i s s u e b i n d s t h e t h r e e c o l u mn s i n t o a F g . c y l i n d e r. T h e e n d o f t h e s h a f t i s a n o b t u s e c o n e o f e r e c t i l gl ans u e , t h e e t i s s peni s , c o n t a i n i n g t h e u r e t h r a l me a t u s . T h e g l a n s h a s a c o r o n a a t i t s j u n c t i o n w i t h t h e s h a f A f l a p o f s k i n , tpre h epuc eo r f o r e s k i n , c o v e r s t h e g l a n s .r enul um s a f o l d o f f T he i t h e p r e p u c e t h a t e xt e n d s v e n t r a l l y i n t o t h e v e n t r a l n o t c h i n t h e g l a n s . P e n i l e e r e c t i o a n d e j a c u l a t i o n a r e c o mp l e x p h y s i o l o g i c a n d h e mo d y n a mi c p r o c e s s e s t h a t c a n b e d i s r u p t e d b y v a s c u l a r d i s e a s e , d r u g s , i n j u r y t o n e r v e s , e n d o c r i n e a b n o r ma l i t i e s , a n d a n xi e t y. T h e ma l e r e p r o d u c t i v e s y s t e m i s d e s i g n e d t o p r o d u c e a n d s t o r e s p e r m c e l l s w h i c h c a n b e d e p o s i t e d a t t h e e n t r a n c e t o t h e f e ma l e c e r v i x w i t h f o r c e f u l e j a c u l a t i o o f t h e s p e r m a n d s p e r ma t i c f l u i d s v i a t h e e r e c t , p e n e t r a t i n g p e n i s . S u c c e s s f u l r e p r o d u c t i o n i s d e p e n d e n t u p o n t h e c o o r d i n a t e d f u n c t i o n i n g o f t h i s s y s t e m.

The Scrotum

T h i s p o u c h i s f o r me d b y a l a y e r o f t h i n , r u g o u s s k i n o v e r l y i n g t h e t i g h t l y a d h e r e n t d a r t o s t u n i c c o n s i s t i n g o f mu s c l e a n dFfia s c1 a - (2)C T h e s a c h a n g s f r o m t h e g. i 2 . root of the penis. T he scrotal skin is bisected by a P. 6 5 1 me d i a n r a p h e . In t e r n a l l y, t h e t w o h a l v e s o f t h e p o u c h a r e s e p a r a t e d b y a s e p t a l f o l d o f d a r t o s t u n i c . E a c h h a l f c o n t a i n s a t e s t i s w i t h i t s e p i d i d y mi s a n d s p e r ma t i c c o r d . T he scrotal contents slide easily in a fascial cleft between the scrotal wall and the c o v e r i n g o f t h e t e s t i s a n d c o r d s . T h e s k i n o f t h e s c r o t u m i s d e e p l y p i g me n t e d a n d
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contains large, sebaceous follicles that have a tendency to form cysts. T he dartos mu s c l e t o n e d e t e r mi n e s s c r o t a l s i ze , w i t h e xp o s u r e t o c o l d s h r i n k i n g t h e s a c a n d h e a t e n l a r g i n g t h e p o u c h . In a d v a n c e d a g e , t h e d a r t o s mu s c l e b e c o me s r e l a t i v e l y a t o n i c . T h e a c t i o n o f t h e d a r t o s mu s c l e s i s i n d e p e n d e n t o f c o n t r a c t i o n s o f t h e c r e ma s t e r i c mu s c l e s t h a t e l e v a t e t h e t e s t e s . T h e a r t e r i a l , v e n o u s a n d l y mp h a t i c d r a i n a g e o f t h e s c r o t a l c o n t e n t s a r i s e s i n t r a a b d o mi n a l l y a n d r e a c h e s i t s s c r o t a l l o c a t i o n v i a t h e i n g u i n a l c a n a l a n d s p e r ma t i c c o r d . Ly mp h a t i c s f r o m t h e s c r o t a l c o n t e n t s d r a i n t o t h e p e l v i c l y mp h n o d e s . T h e s c r o t a l v a s c u l a r a n d l y mp h a t i c s u p p l y i s i n c o n t i n u i t y w i t h t h e p e r i n e u m a n d i t s l y mp h a t i c s d r a i n t o t h e i n g u i n a l l y mp h nodes.

F i g . 1 2 - 2 A n a t o m y o f t h e S c r o t a l W a l l a n d E p i d i d y m i s . A . C a vi t i e s o f t h e T u n i c a Va g i n a l i s A r e O p e n e d A n t e r i o r l y t o S h o w Te s t i s a n d C o r d . B . P a r t s o f t h e E p i d i d y m i s a n d C o r d . C . L a y e r s o f t h e. S c r o t u m

Testis, Epididymis, Vas Deferens, and Spermatic Cord

To w a r d t h e e n d o f f e t a l d e v e l o p me n t , t h e t e s t i s b e g i n s i t s d e s c e n t f r o m t h e a b d o me t o t h e s c r o t u m. T h e p e r i t o n e u m c o v e r i n g t h e t e s t i s b e c o me s t h e p r o c e s s u s v a g i n a l i s a n d t h e g u b e r n a c u l u m l e a d s t h e t e s t i s i n t o i t s s c r o t a l p o s i t i o n . N o r ma l l y, t h e s p e r ma t i c c o r d p o r t i o n o f t h e p e r i t o n e a l p o u c h i s o b l i t e r a t e d , l e a v i n g a c a v i t y s u r r o u n d i n g t h e t e s t i s a n d e p i d i d y mi s , e xc e p t f o r t h e i r p o s t e r i oF i g .s p e c t ( s e e r a 122 A) . T h i s s e r o u s me mb r a n e i suni e a v agi nal iAb n o r ma l p e r s i s t e n c e o f t h i s t thc . s p e r i t o n e a l c o n n e c t i o n l e a d s t o c o n g e n i t a l h e r n i a s o r f u n i c u l a r h y t es tc e l e s . T h e dro i s P. 6 5 2 P. 6 5 3 i s a s mo o t h , s o l i d o v o i d , c o mp r e s s e d l a t e r a l l y, a n d r o u g h l y 4 c m 2 c m. T h e s p e r ma t i c c o r d s u s p e n d s t h e t e s t i s i n t h e s c r o t u m w i t h t h e l o n g a xi s n e a r l y v e r t i c a l . T h e h e a d o f t h e di dy mi s a p s t h e u p p e r p o l e o f t h e t e s t i s . T h e b o d y o f t h e epi c e p i d i d y mi s f o r ms a n e l o n g a t e d i n v e r t e d c o n e a t t a c h e d v e r t i c a l l y t o t h e p o s t e r i o r s u r f a c e o f t h e t e s t i s . T h e a p e x o f t h e c o n e , o r t a i l o f t h e e p i d i d y mi s , a p p r o a c h e s t h


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l o w e r p o l e o f t h e t e s t i s F sg .e1 2 - 2)B T h e e p i d i d y mi s i s c o n t i n u o u s wv tas t h e (i e . i h def er ens w h i c h j o i n s o t h e r v e s s e l s t o f o r m t h e s p e r ma t i c sc o r d . T hc c or d , per mat i e c o n s i s t s o f t h e v a s d e f e r e n s , a r t e r i e s , v e i n s , n e r v e s , a n d l y mp h a t i c v e s s e l s , a l l h e l t o g e t h e r b y t h e s p e r ma t i c f a s c i a . F r o m t h e t e s t i s , t h e c o r d e xt e n d s u p w a r d , e n t e r i n g t h e e xt e r n a l i n g u i n a l r i n g a n d c o u r s i n g t h r o u g h t h e i n g u i n a l c a n a l t o t h e i n t e r n a l i n g u i n a l r i n g , w h e r e i t s c o mp o n e n t s d i v e r g e . In t h e a b d o mi n a l c a v i t y, t h e v a s deferens continues backward and downward behind the peritoneum until it lies b e h i n d t h e b l a d d e r a n d a n t e r i o r t o t h e r e c t u m, j o i n i n g t h e d u c t o f t h e s e mi n a l v e s i c l t o b e c o me t h e e j a c u l a t o r y d u c t .

F i g . 1 2 - 3 R e c t a l E xa m i n a t i o n o f t h e M a l e G e n i t a l i a . A . R e l a t i o n s h i p o f t h e E xa m i n i n g F i n g e r t o t h e P r o s t a t e a n d S e m i n a l Ve s i cower s ec t i on The l l e s : s hows t he f i nger at t he pr os t at e gl and; t he hi gher s ec t i on s hows t he f i nger bet ween t he t wo s emi nal v es iB .l es S a g i t t a l S e c t i o n o f t h e M a l e P e n i s . c A a n d P e l vi c O r g a n s . C . A P o s t e r i o r Vi e w o f t h e P r o s t a t e , S e m i n a l Ve s i c l e s , a n d Va s a D e f e r e n t i a . D . P a l p a t i o n o f t h e C o w p e r B u l b o u r e t h r a l G l a n d : Ther e i s one gl and on eac h s i de of t he ur et hr a. The di agr am s hows a s agi t t al s ec t i on of t he mal e pel v i s . The t i p of t he i ndex f i nger i s i n t he r ec t um wi t h t he pad f ac i ng t he ant er i or r ec t al wal l , bet ween t he i nf er i or bor der of t he pr os t at e and t he i nner edge of t he anal c anal . The t humb i s out s i de t he r ec t um, pr es s i ng t he per i neum on t he medi al r aphe t owar d t he f i nger t i p. A nor mal gl and i s not pal pabl e, but an i nf l amed gl and i s t ender. I f i t c ont ai ns pus , i t f or ms a pal pabl e mas s , f r om pea t o hazel nut s i ze ( t he r ound .bl ac k s pot )

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The Prostate and Seminal Vesicles

T h e p r o s t a t e c o n t a i n s g l a n d s d i s p e r s e d i n a s t r o ma o f s mo o t h mu s c l e a n d f i b r o u s t i s s u e . It i s s h a p e d r o u g h l y l i k e a t r u n c a t e d c o n e t h e s i ze o f a c h e s t n u t a n d i s p r o n t o h y p e r p l a s i a w i t h a g e . It l i e s i n t h e p e l v i s a p p r o xi ma t e l y 2 c m p o s t e r i o r t o t h e s y mp h y s i s p u b i s ; t h e c o n e i s i n v e r t e d s o t h e b a s e i s s u p e r i o r a n d t h e a p e x i n f e r i o r (F i g . 1 2 - 3 B n dC) . T h e a n t e r i o r a n d p o s t e r i o r s u r f a c e s a r e s o me w h a t f l a t t e n e d . T h e a basal surface is directed superiorly and is overlaid by the bladder; the apical surfac f a c e s i n f e r i o r l y a n d r e s t s o n t h e u r o g e n i t a l d i a p h r a g m. T h e p r o s t a t i c u r e t h r a p i e r c e t h e b a s a l o r s u p e r i o r s u r f a c e , s l i g h t l y a n t e r i o r t o t h e c e n t e r, a n d r u n s i n f e r i o r l y i n a v e r t i c a l a xi s t o e me r g e t h r o u g h t h e a p i c a l o r i n f e r i o r s u r f a c e . T h e o n l y p a l p a b l e portion of the prostate is the slightly vertically convex posterior prostatic surface, w h i c h i s i n c l o s e c o n t a c t w i t h t h e r e c t a l w a l l . A s h a l l o w me d i a n f u r r o w d i v i d e s a l l e xc e p t t h e u p p e r p o r t i o n o f t h e p o s t e r i o r s u r f a c e i n t o a r i g h t a n d l e f t l o b e . N e a r t h e s u p e r i o r e d g e o f t h e p o s t e r i o r s u r f a c e i s a t r a n s v e r s e d e p r e s s i o n ma d e b y t h e ejaculatory ducts which enter the prostate and converge to enter the urethra. T he p a i r e d a mp u l l a e o f t h e v a s d e f e r e n s a n d t h e s e mi n a l v e s i c l e s d i v e r g e s u p e r i o r l y f r o t h e p r o s t a t e b a s e . T h e a mp u l l a o f t h e v a s i s s u p e r i o r a n d me d i a l t o t h e s e mi n a l v e s i c l e s a n d b o t h c o n t a c t t h e p o s t e r i o r w a l l o f t h e b l a d d e r. T h e b u l b o u r e t h r a l g l a n d o f C o w p e r l i e o n e a c h s i d e o f t h e mi d l i n e j u s t i n f e r i o r t o t h e c a u d a l b o r d e r o f t h e prostate.

Physical Exam ination of the Male Genitalia and Reproductive System

In s p e c t i o n a n d p a l p a t i o n r e v e a l ma n y d i s o r d e r s o f t h e e xt e r n a l a n d i n t e r n a l ma l e r e p r o d u c t i v e o r g a n s a n d t h e l o w e r u r i n a r y t r a c t . F a mi l i a r i t y w i t h t h e g e n i t a l d i s o r d e d e mo n s t r a t e d b y i n s p e c t i o n a n d p a l p a t i o n i s n e c e s s a r y f o r a n y p h y s i c i a n p e r f o r mi n g a p h y s i c a l e xa mi n a t i o n . P. 6 5 4

Examination of the Penis

Wearing gloves, view the penis in its usual state, then have the patient retract the p r e p u c e r e v e a l i n g t h e s i ze o f t h e f o r e s k i n o r i f i c e a n d t h e g l a n s . O b s e r v e a n y superficial lesions of the corona or retroglandular sulcus. Palpate lesions for induration and tenderness. Palpate the length of the shaft, ventrally along the corp s p o n g i o s u m, a n d l a t e r a l l y o v e r b o t h c o r p o r a c a v e r n o s a , f e e l i n g f o r n o d u l e s a n d p l a q u e s . C o mp r e s s t h e g l a n s a n t e r o p o s t e r i o r l y b e t w e e n t h e t h u mb a n d f o r e f i n g e r t o o p e n a n d i n s p e c t t h e me a t u s a n d t e r mi n a l u r e t h r a . If u r e t h r a l s y mp t o ms a r e p r e s e n t strip the ventral penis from its base to the glans to collect a drop of urethral d i s c h a r g e f o r mi c r o s c o p i c e xa mi n a t i o n .

Examination of the Scrotum

T h e s c r o t u m i s e xa mi n e d b y i n s p e c t i o n a n d p a l p a t i o n . B e c a u s e r u g a e a r e p r o d u c e d b y c o n t r a c t i o n s o f d a r t o s mu s c l e , t h e w a l l s s h o u l d b e i n s p e c t e d b y s p r e a d i n g t h e l a y e r s b e t w e e n g l o v e d f i n g e r s . T r a n s i l l u mi n a t i o n i s r e a d i l y p e r f o r me d , b u t i t i s mo s t i n f o r ma t i v e f o r e xa mi n i n g t h e s c r o t a l c o n t e n t s .

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Examination of Scrotal Contents

P a l p a t i o n a n d t r a n s i l l u mi n a t i o n i d e n t i f y mo s t s t r u c t u r e s w i t h i n t h e s c r o t a l s a c . E xa mi n e t h e s c r o t u m s y s t e ma t i c a l l y i n t h e f o l l o w i n g s e q u e n c e : ( a ) t e s t e s , ( b ) t u n i c a v a g i n a l i s , ( c ) e p i d i d y mi s ( h e a d , b o d y, a n d t a i l ) , ( d ) s p e r ma t i c c o r d , a n d ( e ) i n g u i n a l l y mp h n o d e s . T h e c o mp l e t e s e q u e n c e s h o u l d b e f o l l o w e d i n e v e r y r o u t i n e p h y s i c a l e xa mi n a t i o n . If t h e s c r o t u m i s s w o l l e n , f i r s t e xc l u d e a n i n g u i n a l h e r n i a d e s c e n d i n g i n t o t h e s c r o t u m, t h e n e xa mi n e f o r t h e s t r u c t u r e s n o r ma l l y i n t h e s c r o t u m.

Examination for Scrotal Hernia

P a l p a t e t h e r o o t o f t h e s c r o t u m t o d e t e r mi n e i f t h e ma s s e xt e n d s t h a t h i g h . If t h e f i n g e r s c a n g e t a b o v e t h e ma s s , a h e r n i a i s e xc l u d e d . In s e r t a f i n g e r i n t o t h e e xt e r n i n g u i n a l r i n g a n d f e e l f o r a c o u g h i mp u l s e f r o m h e r n i a . In g u i n a l h e r n i a s a l w a y s d e s c e n d i n f r o n t o f t h e s p e r ma t i c c o r d a n d t e s t e s , s o i d e n t i f y t h e s e s t r u c t u r e s a n d t h e i r a n a t o mi c r e l a t i o n s t o t h e ma s s . A s w o l l e n s c r o t u m s h o u l d b e t r a n s i l l u mi n a t e d b u s i n g a c o o l l i g h t s o u r c e i n a d a r k e n e d r o o m. W i t h t h e t h u mb a n d f o r e f i n g e r, p u l l t h s c r o t a l w a l l t i g h t l y o v e r t h e ma s s . P l a c e t h e l i g h t i n c o n t a c t w i t h t h e p o s t e r i o r w a l l t h e s c r o t u m, s h i n i n g t h e l i g h t a n t e r i o r l y t h r o u g h t h e ma s s t o d e t e r mi n e w h e t h e r t h e structure is translucent or opaque. Most hernia contents are opaque, although o c c a s i o n a l l y a g a s - f i l l e d l o o p o f g u t w i l l t r a n s mi t l i g h t . L i s t e n w i t h a s t e t h o s c o p e f o peristaltic sounds.

Examination of the Testes

E xa mi n e t h e t e s t e s s i mu l t a n e o u s l y b y g r a s p i n g o n e w i t h e a c h g l o v e d h a n d , u s i n g t h u mb a n d f o r e f i n g e r. D e t e r mi n e t h e i r s i ze , s h a p e , c o n s i s t e n c y, P. 6 5 5 a n d s e n s i t i v i t y t o l i g h t p r e s s u r e . T r a n s i l l u mi n a t e e a c h , e v e n i f t h e y f e e l n o r ma l ; o n e ma y b e a t r o p h i e d a n d t h e n o r ma l s i ze a t t a i n e d b y a h y d r o c e l e . U s e s c r o t a l u l t r a s o n o g r a p h y t o h e l p d i s t i n g u i s h b e t w e e n i n t r a - a n d e xt r a t e s t i c u l a r ma s s e s o r l e s i o n s J [u n n i l a J , L a s s e n P. Te s t i c u l a r ma s s e s . Phy s i c i an 9 8 ; 5 9 : 6 8 5 Am Fam 19 692. ]

Examination of the Epididymis

L o c a t e e a c h e p i d i d y mi s b y p a l p a t i n g t h e s mo o t h t e s t i s t o f i n d a v e r t i c a l r i d g e o f s o f n o d u l a r t i s s u e b e g i n n i n g a t t h e u p p e r p o l e a n d e xt e n d i n g t o t h e l o w e r p o l e . U s u a l l y t h e e p i d i d y mi s i s b e h i n d t h e t e s t i s , b u t i n a p p r o xi ma t e l y 7 % o f ma l e s , t h e s t r u c t u r e d e v e l o p s a n t e r i o r t o t h e t e s t i s , a n t e v e r s i o n o f t h e e p i d i d y mi s . R e c o g n i zi n g t h e a n t e v e r s i o n , t h e e xa mi n e r w i l l e xp e c t t h e c a v i t y o f t h e t u n i c a v a g i n a l i s t o b e p o s t e r t o t h e t e s t i s . C o mp a r e t h e f i n d i n g s f r o m p a l p a t i o n i n b o t h e p i d i d y mi d e s , i n t h e i r c o mp o n e n t s e g me n t s o f h e a d , b o d y, a n d t a i l .

Examination of the Spermatic Cord

Palpation of varicoceles is best done in the upright position, while it is easiest to e xa mi n e t h e s c r o t a l c o n t e n t s i n t h e s u p i n e p o s i t i o n . C o mp a r e t h e s p e r ma t i c c o r d s b s i mu l t a n e o u s l y g r a s p i n g e a c h a t t h e n e c k o f t h e s c r o t u m. W i t h t h e t h u mb i n f r o n t a n t h e f o r e f i n g e r b e h i n d t h e s c r o t u m, g e n t l y c o mp r e s s itg .e 1c o)r4d T( h e n o r ma l F h 2- . vas deferens is felt as a distinct hard cord, which can be separated from other cord
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s t r u c t u r e s . T h e o t h e r, l e s s - d e f i n a b l e s t r a n d s a r e n e r v e s , a r t e r i e s , a n d f i b e r s o f c r e ma s t e r i c mu s c l e . T h e v a s ma y b e c o n g e n i t a l l y a b s e n t . T r a c e t h e c o r d s d o w n t o the testes.

F i g . 1 2 - 4 P a l p a t i o n o f t h e S p e r m a t i c Eac h s ov ed hand s i mul t aneous l y . C o r d gl gr as ps a c or d bet ween t humb and i ndex f i nger, c ompar i ng t he t wo s t r uc t ur es . Nor mal l y, t he v as a def er ent i a f eel l i k e di s t i nc t whi pc or ds . The ot her c omponent s of t he c or d, ar t er i es , v ei ns , v es s el s , and ner v es , f eel l i k e i ndef i ni t e s t r ands .

P. 6 5 6

F i g . 1 2 - 5 E xa m i n a t i o n o f t h e I n g u i n a l R e g i o n s f .oA .HP a np a t i o n o f r erl i t h e I n g u i n a l R i n g i n t h e M a l e . B . Z i e m a n T r i d i g i t a l E xa m i n a t i o n f o r H e r n i a : The l ef t s i de of t he pat i ent i s ex ami ned f r om hi s l ef t and wi t h t he ex ami ner ' s l ef t hand .

Examination of the Inguinal Regions for Hernia


T h e t i p o f t h e i n d e x f i n g e r i s p l a c e d a t t h e mo s t d e p e n d e n t p a r t o f t h e s c r o t u m a n d directed into the subcutaneous inguinal ring by invaginating the slack scrotum with ( s e eF i g . 1 2 - 5)A T h e p a t i e n t c o u g h s o r s t r a i n s s o a n i mp u l s e f r o m t h e h e r n i a l s a c .
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ma y b e f e l t o n t h e f i n g e r t i p .

Zieman Inguinal Examination.

T his procedure reveals direct and indirect inguinal hernias, and hernias of the f e mo r a l t r i a n g l e . W i t h t h e p a t i e n t s t a n d i n g , s t a n d a t t h e p a t i e n t ' s r i g h t s i d e a n d p l a t h e p a l m o f y o u r r i g h t h a n d a g a i n s t t h e r i g h t l o w e r a b d o me n . S p r e a d y o u r f i n g e r s s l i g h t l y s o y o u r l o n g f i n g e r l i e s a l o n g t h e i n g u i n a l l i g a me n t w i t h i t s p u l p i n t h e e xt e r n a l i n g u i n a l r i n g , y o u r i n d e x f i n g e r i s o v e r t h e i n t e r n a l i n g u i n a l r i n g , a n d y o u r r i n g f i n g e r p a l p a t e s t h e r e g i o n o f t h e f e mo r a l c a n a l a n d t h e o p e n i n g o f t h e s a p h e n o u s v e i n ( sF i e . 1 2 - 5)B H a v e t h e p a t i e n t t a k e a d e e p b r e a t h , h o l d i t , a n d eg . b e a r d o w n , a s i f t o h a v e a b o w e l mo v e me n t . T h e n r e p e a t t h e ma n e u v e r, s t a n d i n g a t the patient's left side and palpating his left groin with your left hand. A hernia in an o f t h e t h r e e s i t e s i s p e r c e i v e d e i t h e r a s a g l i d i n g mo t i o n o f t h e w a l l s o f t h e e mp t y s or as a protrusion of a viscus into the sac. When the internal ring is closed by the p a l p a t i n g f i n g e r, a n y h e r n i a t i n g ma s s c a n n o t b e a n i n d i r e c t i n g u i n a l h e r n i a .

Palpation of Prostate and Seminal Vesicles

P l a c e t h e p a t i e n t i n t h e l i t h o t o my p o s i t i o n , t h e k n e e c h e s t p o s i t i o n , t h e l e f t - l a t e r a l p r o n e p o s i t i o n ( S i ms ) , o r b e n t - o v e r - t h e - t a b l e p o s i t i o n . T h r e e o f t h e s e h a v e b e e n c o n s i d e r e d e l s e w h e r e (F ie e 9 - 1,6p a g e 5 2 6 ) . In t h e b e n t - o v e r - t h e t a b l e p o s i t i o n , s g. t h e p a t i e n t s t a n d s w i t h l e g s a p a r t , t h e t r u n k f l e xe d o n t h e P. 6 5 7 t h i g h s , a n d t h e e l b o w s r e s t i n g o n t h e k n e e s o r t h e e xa mi n i n g t a b l e . W h a t e v e r t h e p o s i t i o n , t h e d e t a i l s o f t h e p r o c e d u r e a r e t h e s a me . C o v e r t h e e xa mi n i n g h a n d w i t h r u b b e r g l o v e a n d g e n e r o u s l y l u b r i c a t e t h e f o r e f i n g e r. P l a c e t h e p a d o r p u l p o f t h e forefinger on the anal orifice with light pressure while the patient bears down gentl u n t i l t h e s p h i n c t e r r e l a xe s , a d mi t t i n g t h e c u r v e o f t h e p a d . T h e n i n c l i n e t h e f i n g e r until the tip is also inserted. Gradually ease the tip past the anal canal and into the r e c t a l a mp u l l a . K e e p t h e p a d o f t h e f i n g e r f a c i n g t h e a n t e r i o r r e c t a l w a l l . As t h e f i n g e r mo v e s c e p h a l a d f r o m t h e a n a l c a n a l , i t e n c o u n t e r s t h e e l a s t i c b u l g i n g s u r f a c e o f t h e os t at e s e eF i g . 1 2 - 3)A F e e l t h e me d i a n f u r r o w t h a t s e p a r a t e s t h e pr ( . lateral lobes. When the fingertip reaches the superior edge of the prostate, the me d i a n f u r r o w t h i n s o u t t o t h e f l a t mi d d l e l o b e . S u p e r i o r t o t h e p r o s t a t e , t h e f i n g e r t r e a c h e s t h e s e mi n a l v e s i c l e s o n e i t h e r s i d e o f t h e mi d l i n e . D e t e r mi n e w h e t h e r t h e p r o s t a t i c s u r f a c e i s s mo o t h o r n o d u l a r ; w h e t h e r t h e c o n s i s t e n c y i s e l a s t i c , h a r d , b o g g y, s o f t , o r f l u c t u a n t ; w h e t h e r t h e s h a p e i s r o u n d e d o r f l a t ; w h e t h e r t h e s i ze i s n o r ma l , e n l a r g e d , o r a t r o p h i e d ; w h e t h e r s e n s i t i v i t y t o p r e s s u r e i s a b n o r ma l ; w h e t h e t h e r e i s n o r ma l mo b i l i t y o r f i xa t i o n .

N o r ma l l y, t h e s emi nal v es i c l es e n o t p a l p a b l e b e c a u s e t h e y a r e t o o s o f t ; o n l y ar d i s e a s e d s t r u c t u r e s c a n b e f e l t . T h e s e mi n a l v e s i c l e s a r e a p p r o xi ma t e l y 7 . 5 c m l o n g s o o n l y t h e i r l o w e r p o r t i o n s c a n b e r e a c h e d . E xa mi n e e a c h s e mi n a l v e s i c l e f o r d i s t e n t i o n , s e n s i t i v i t y, s i ze , c o n s i s t e n c y, i n d u r a t i o n , a n d n o d u l e s . P a l p a t e i n t h e r e g i o n o f t h e b u l b o u r e t h r a l g l a n d s , t h e y a r e n o r ma l l y n o t p a l p a b l e . W h e n e n l a r g e d , t h e y a r e f e l t a s r o u n d e d ma s s e s i n t h e a n t e r i o r r e c t a l w a l l . O n c o mp l e t i o n o f t h e e xa m, e i t h e r c l e a n t h e p a t i e n t o r p r o v i d e t i s s u e t o t h e p a t i e n t for this purpose.


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Male Genital and Reproductive Sym ptom s

Scr otal Pr ur itus: P a t h o p h y s i o l o gS: r o t a l s k i n i s t h i n , r u g a t e d , a n d s u s c e p t i b l e t o i r r i t a t i o n a n d yc i n f e c t i o n b e c a u s e i t i s u s u a l l y w a r m a n d o f.t e n umo iusst o f t e n i n d i c a t e s Pr rit i n f l a mma t o r y o r i n f e c t i o u s d e r ma t i t i s , b u t s o me t i me s e xi s t s a n d p e r s i s t s w i t h o u t s k i n changes or evident cause.
P. 6 5 8

P a i n i n t h e Te s t i s a n d E p i d i d y m i s : P a t h o p h y s i o l o g In:n e r v a t i o n o f t h e t e s t i s a n d e p i d i d y mi s i s s o ma t i c a n d y s y mp a t h e t i c a r i s i n g i n t h e l o w e r t h o r a c i c r o o t s . P a i n a r i s i n g f r o m t h e s e s t r u c t u r e s f r e q u e n t l y r a d i a t e s t o t h e e p i g a s t r i u m a n d / o r h y p o g a s t r i u m. If t h e s c r o t a l w a l l o r t u n i c a v a g i n a l i s i s i n v o l v e d , t h e p a i n i s w e l .l lP a ia l ia r i d i n g i n t h e t e s t i s ma y o c n ze s b e mi l d o r e xc r u c i a t i n g a n d i s f r e q u e n t l y a c c o mp a n i e d b y n a u s e a . L o o k f o r a r e l a t i o n s h i p t o a c t i v i t i e s , s e xu a l a c t i v i t i e s , a n d s i g n s o f s y s t e mi c o r s e xu a l l y t r a n s mi t t e d d i s e a s e . A c o mp l e t e s e xu a l h i s t o r y i s e s s e n t i a l . T E S T I C UL AR PAI N C L I NI C AL O C C URRE NC E : Congeni t al e r y l a r g e h y d r o c edi opat hi cn g u i n a l h e r n i a , l a r g e v a r i c o c e l e ; v I le; i I nf ec t i ous c u t e o r c h i t i s ( mu mp s , e c h o v i r u s , l y mp h o c y t i c c h o r i o me n i n g i t i s v i r u s , a a r b o v i r u s g r o u p B ) , c h r o n i c o r c h i t i s ( l e p r o s y, t u b e r c u l o s i s ) , a c u t e e p i d i d y mi t i s ( g o n o r r h e a , c h l a my d i ac her i c hi a c,olmy c o p l a s ma ) , a n d c h r o n i c e p i d i d y mi t i s Es , i ( l e p r o s y, t u b e r c u l o s i s , s y p h i l i s , b r u c e l ecs i s ) ; c al / Tr aumat il c n t a n d M l o hani b u p e n e t r a t i n g t r a u ma , t e s t i c u l a r r u p t u r e , t o r s i o n , u r e tNeopl as ni ee s t i c u l a r e r a l s t o t c; t c a r c i n o ma , l e u k e mi a ; ol ogi c e u r o p a t h y ; c ul art e s t i c u l a r i n f a r c t i o n a n d Neur n Vas h e mo r r h a g e . Penile Cur vatur e: S e e M al e Geni t our i nar y Si gns : Pl as t i c I ndur at i on of , t he gPeni s . pa e 663

Er ectile Dysfunction and Impotence: S e e Sy ndr omes : Er ec t i l e Dy s f unc t i on and I mpot enc e 7 3 . M a n y p a t i e n t s d o , page 6 n o t v o l u n t e e r i n f o r ma t i o n a b o u t t h e i r i n a b i l i t y t o s u s t a i n a n e r e c t i o n o f s u f f i c i e n t r i g i d i t y o r d u r a t i o n s a t i s f a c t o r y f o r i n t e r c o u r s e , a l t h o u g h t h e y ma y a c k n o w l e d g e t h e p r o b l e m o n a q u e s t i o n n a i r e . C o mmo n l y, h o w e v e r, t h i s p r o b l e m w i l l n o t b e i d e n t i f i e d u n l e s s y o u a s k s p e c i f i c a l l y a b o u t s e xu a l p e r f o r ma n c e . Aw a k e n i n g w i t h e a r l y mo r n i n g e r e c t i o n s a r g u e s a g a i n s t n e u r o l o g i c , v a s c u l a r, o r e n d o c r i n o l o g i c c a u s e s , a n d s u g g e s t s a f u n c t i o n a l p r o b l e m.

Male Genital and Reproductive System Signs Penis Signs


Ambiguous Genitalia: Intersexuality:
S e e p a g e 6 3.2

C o n d y l o m a Ac u m i n a t u m ( Ve n e r e a l Wa r t , P a p i l l o m a ) : P a t h o p h y s i o l o g In:f e c t i o n w i t h h u ma n p a p i l l o ma v i r u s ( H P V) p r o d u c e s t h e l e s i o n y .
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T h e c o n d y l o ma i s a v i l l o u s p r o j e c t i o n ( a c u mi n a t a me a n s p o i n t e d ) t h a t ma y b e s i n g l e o r c o n g l o me r a tF i g . 1 2 - 6)E It c a n o c c u r o n t h e c o r o n a , i n t h e r e t r o g l a n d u l a r e ( . s u l c u s , a n d o n t h e s h a f t , a n d f r e q u e n t l y i t i s f o u n d a b o u t t h e a n u s . In t h e p r e s e n c e o f mo i s t u r e , s e c o n d a r y i n f e c t i o n p r o d u c e s u l c e r a t i o n . In i t s u n c o mp l i c a t e d f o r m, t h e v e r r u c o u s a p p e a r a n c e i s q u i t e d i s t i n c t i v e . An e xu b e r a n t g r o w t h w i t h mu c h u l c e r a t i o n mu s t b e d i s t i n g u i s h e d f r o m c a r c i n o ma b y b i o p s y. P. 6 5 9

F i g . 1 2 - 6 P e n i l e L e s i o n s . A . C h a n c r e : der i s s moot h; t her e i s no The bor nec r os i s or s uppur at i on. I ndur at i on s ur r ounds t he l es i on s o i t c an be pi c k ed up l i k e a di s k . C h a n c r o i d : bor der i s i r r egul ar wi t hout i ndur at i on and t he .B The c ent er i s nec r ot i c . Ther e i s pr of us e s uppur atli c e r a t i n g C a r c i n o m a : . C . U on The nec r ot i c ul c er may r es embl e c hanc r oi d, but s oon t he pr oc es s i s s ur r ounded by i ndur at i on and nodul atDonC o n d y l o m a L a t uThi s i s t he f l at , . i. m: nons uppur at i ng nodul e of s ec ondar y s y phi lo n d y l o m a A c u m i n a t u m : . E. C i s The l es i ons ar e moi s t , v i l l ous gr owt hs t hat pr ot r ude abov e t he s k i n and under go s ec ondar y ul c er at. i on

Condyloma Latum: As t h e n a me i mp l i e s , t h e g r o w t h i s f l a t a n d wF irg .y 1 2 e6)D It ma y o c c u r a t (s- e . a b o u t t h e g e n i t a l i a o r a n u s . It i s a s e c o n d a r y s y p h i l i d . T h e f l a t a p p e a r a n c e i s d i a g n o s t i c . W h e n t h e l e s i o n h a s a n e xu b e r a n t g r o w t h , i t mu s t b e d i s t i n g u i s h e d f r o m t h e a c u mi n a t e c o n d y l o ma a n d c a r c i n o ma . Ur e t h r a l D i s c h a r g e : S e e Ur i nar y Sy s t em Si gns : Ur et hr al Di s,c p a gge6 1 6 , a n da l e G e n i t a l a n d har e M R e p r o d u c t i v e S y n d r o me s : U r e,t h ra tgi e 6 7 2 . pi s

P e n i s : Hy p e r p l a s i a : T h i s i s u s u a l l y e v i d e n t o n l y b e f o r e t h e a g e o f n o r ma l p u b e r t y, w h e n a d i s c r e p a n c y b e t w e e n s i ze o f t h e o r g a n a n d a g e i s e v i d e n t . T h e c a u s e s o f h y p e r p l a s i a a r e t u mo r s o f t h e p i n e a l g l a n d o r h y p o t h a l a mu s , t u mo r s a r i s i n g f r o m t h e L e y d i g c e l l s o f t h e t e s t i s , o r t u mo r s o f t h e a d r e n a l g l a n d . P e n i s : Hy p o p l a s i a : W i d e v a r i a t i o n o c c u r s i n t h e n o r ma l s i ze o f t h e p e n i s . T h e n o r ma l r a n g e i s l e a r n e d o n l y b y t h e e xa mi n a t i o n o f ma n y i n d i v i d u a l s . S t r i k i n g d i s c r e p a n c i e s b e t w e e n t h e
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p e n i l e s i ze a n d t h e a g e o f t h e p a t i e n t l e a d t o t h e i n f e r e n c e o f h y p o p l a s i a . P e n i l e h y p o p l a s i a i s e i t h e r a ma n i f e s t a t i o n o f e u n u c h o i d i s m o c c u r r i n g b e f o r e p u b e r t y o r i s f e a t u r e o f i n t e r s e xu a l i t y. In t h e l a t t e r c o n d i t i o n , d i s t i n c t i o n b e t w e e n a h y p o p l a s t i c p e n i s w i t h h y p o s p a d i a s a n d a h y p e r p l a s t i c c l i t o r i s ma y b e d i f f i c u l t o r i mp o s s i b l e w i t h o u t h i s t o l o g i c e xa mi n a t i o n o f t h e g o n a d s . P. 6 6 0

Gener alized Penile Swelling: Edema: P a t h o p h y s i o l o g F : u i d a c c u mu l a t e s i n t h e l o o s e t i s s u e o f t h e p e n i s i n g e n e r a l i ze d yl e d e ma t o u s s t a t e s f r o m a n y c a u s e a n d w i t h o b s t r u c t i o n o f t h e p e n i l e v e i n s o r l y mp h a t i c sT h e p e n i s , a n d u s u a l l y s c r o t u m, a r e d i f f u s e l y s w o l l e n w i t h o u t e r y t h e ma , . w a r mt h , o r t e n d e r n e s s . Gener alized Penile Swelling: Contusion: E s p e c i a l l y d u r i n g e r e c t i o n , t r a u ma t o t h e p e n i s ma y c a u s e e xt r a v a s a t i o n o f b l o o d t h a t i s u s u a l l y p a i n l e s s . In a f e w d a y s , t h e s k i n o f t h e p e n i s a n d s c r o t u m ma y b e s t a i n e d b l u e f r o m d e g r a d e d h e mo g l o b i n .

Gener alized Penile Swelling: Fr actur e of the Shaft: P a t h o p h y s i o l o g T : a u ma d u r i n g e r e c t i o n ma y r u p t u r e o n e o r b o t h c o r p o r a yr c a v e r n o s a p e n i S e v e r e p a i n o c c u r s a t t h e t i me o f i n j u r y, w i t h i mme d i a t e s u b s i d e n c e . s o f t h e e r e c t i o n a n d t e mp o r a r y r e l i e f o f p a i n . S u b s e q u e n t e n g o r g e me n t f r o m e xt r a v a s a t i o n o f b l o o d p r o d u c e s r e c u r r e n c e o f p a i n . T h i s i s a u r o l o g i c e me r g e n c y. R u p t u r e ma y n o t b e d i s t i n g u i s h a b l e f r o m c o n t u s i o n u n l e s s a n o p e r a t i o n i s p e r f o r me d


P. 6 6 1

G e n i t a l Ul c e r : P a t h o p h y s i o l o g U:l c e r a t i o n o f t h e p e n i l e s h a f t , g l a n s , o r f o r e s k i n o c c u r s a t t h e y s i t e o f t r a u ma o r i n o c u l a t i o n o f s e xu a l l y t r a n s mi t t e d i n f e c t i o. uT ho r g a n i s ms s e c h a r a c t e r o f t h e u l c e r i s u s e f u l d i a g n o s t i cF ilgy 1s e)e In s p e c t t h e b a s e a n d a l . ( 2-6 . edges, looking for vesicles preceding ulceration, noting especially the presence of p a i n , w h i c h ma y h a v e a n t e d a t e d t h e v i s i b l e l e s i o n i n h e r p e s s i mp l e x. P a l p a t e f o r i n d u r a t i o n o f t h e s u r r o u n d i n g t i s s u e a n d b a s e o f t h e u l c e r, a n d c a r e f u l l y f e e l f o r r e g i o n a l l y mp h a d e n o p a t h y. B e c a u s e t h e s e a r e u s u a l l y s e xu a l l y t r a n s mi t t e d d i s e a s e s s e r o l o g i c e v a l u a t i o n f o r s y p h i l i s a n d H IV a r e i n d i c a t e d , a s a r e c o u n s e l i n g o n s a f e s e xu a l p r a c t i c e s a n d u s e o f c o n d o ms .

G E NI TAL UL C E R C L I NI C AL O C C URRE NC E : I nf l ammat or y / I mmuneh e t s y n d r o me ; ec t i ous e r p e s s i mp l e x, s y p h i l i s , Be I nf h c h a n c r o i d , l y mp h o g r a n u l o ma v e n eMe u m; c al / Tr aumatri a u ma t i c s e x, t i g h t r ec hani t c fitting clothing; Neopl as t i c e n i l e c a n c e r. p G E NI TAL UL C E R: S Y P HI L I T I C C HANC RE ( HARD C HANC RE ) : T h i s i s t h e p r i ma r y l e s i o n o f s y p h i l i s , t h e f i r s t ma n i f e s t a t i o n o f d i s e a s e . It c o mmo n l y occurs on the glans or the inner leaves of the foreskin but is occasionally on the s h a f t o r s c r o t u m. R a r e l y, i t i s e xt r a g e n i t a l , u s u a l l y o n t h e l i p s . T h e c h a n c r e b e g i n s a silvery papule that gradually erodes to form a superficial ulcer with a serous d i s c h a r g e c o n t a i n Tr g i n eponema pal l i dum eF i g . 1 2 - 6)A B e c a u s e t h e o r g a n i s ms (se . p e n e t r a t e t h e u n b r o k e n s k i n , t h e e xa mi n e r mu s t a l w a y s w e a r g l o v e s . E a r l y i n t h e e v o l u t i o n , t h e r e g i o n a l s u p e r f i c i a l i n g u i n a l l y mp h n o d e s u n d e r g o p a i n l e s s mo d e r a t e
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e n l a r g e me n t . T h e c h a n c r e i s p a i n l e s s , u s u a l l y s i n g l e , r o u n d o r o v a l , w i t h a s mo o t h , s l i g h t l y r a i s e d b o r d e r. T h e u n d e r l y i n g i n d u r a t i o n p e r mi t s t h e s u p e r f i c i a l l e s i o n t o b e l i f t e d a s a s ma l l d i s k b e t w e e n t h e t h u mb a n d f o r e f i n g e r. N e i t h e r t h e u l c e r n o r t h e l y mp h n o d e s s u p p u r a t e . P h y s i c a l s i g n s a r e n o t c o n c l u s i v e a n d b e c a u s e t h e l e s i o n a p p e a r s b e f o r e s e r o l o g i c t e s t s f o r s y p h i l i s b e c o me p o s i t i v e , t h e d i a g n o s i s mu s t b e c o n f i r me d b y d e mo n s t r a t i n g t h e l i dum t h e s e r o u s e xu d a t e w i t h t h e d a r k - f i e l d T. pal in mi c r o s c o p e .

G E NI TAL UL C E R: C HANC RO I D ( S O F T C HANC RE ) : A s u p p u r a t i v e i n f e c t i o n c a u s e d b y t h e Haemophi l us duc r,eyt i u s u a l l y bacillus i i n v o l v e s t h e g e n i t a l i a , a l t h o u g h i t ma y b e e xt r a g e n i t a l . T h e l e s i o n b e g i n s a s a s ma l r e d p a p u l e t h a t q u i c k l y b e c o me s p u s t u l a r a n d e n l a r g e s t o f o r m a p u n c h e d - o u t u l c e r w i t h u n d e t e r mi n e d e d g e s Fsg .e 1 2 - 6)B T h e b a s e i s c o v e r e d w i t h a g r a y s l o u g h , (ie . d i s c h a r g i n g p u s p r o f u s e l y. E xt e n s i v e n e c r o s i s e n s u e s a n d mu l t i p l e u l c e r s f o r m. T h e l e s i o n s a r e q u i t e p a i n f u l . In o n e - t h i r d o f t h e c a s e s , t h e r e g i o n a l l y mp h n o d e s b e c o m swollen and tender (the bubo). T hese frequently suppurate. While the clinical a p p e a r a n c e i s q u i t e t y p i c a l , mi xe d i n f e c t i o n s mu s t b e e xc l u d e d b y e xa mi n a t i o n o f t h e xu d a t e w i t h t h e d a r k - f i e l d mi c r o s c Tr eponema pal l i dum ope for . G E NI TAL UL C E R: LY M P HO G RANUL O M A V E NE RE UM ( LY M P HO G RANUL O M A I NG UI NAL E , L G V ) : P a t h o p h y s i o l o g L G V i s c a u s e d Chl amy di a t r ac homata sr i c k e t t s i a - l i k e y: by , i o r g a n i s m, a n d p r i ma r i l y i n v o l v e s t h e l y mp h a t.i c h y spe m l e s s a n d e v a n e s c e n t T se t ain i n i t i a l l e s i o n , a n e r o s i o n l e s s t h a n 1 mm i n d i a me t e r, i s f r e q u e n t l y o v e r l o o k e d . O c c a s i o n a l l y, t h e p e n i l e l e s i o n b e c o me s v e s i c u l a r, p a p u l a r, o r n o d u l a r. O n e o r 2 w e e k s a f t e r i n f e c t i o n , t h e i n g u i n a l l y mp h n o d e s b e c o me s w o l l e n a n d t e n d e r, ma t t i n g t o g e t h e r w i t h a r e a s o f s o f t e n i n g a n d r e d d e n i n g o f t h e o v e r l y i n g s k i n . M u l t i p l e s ma l l f i s t u l a s f o r m, d i s c h a r g i n g c r e a my p u s o r s e r o s a n g u i n e o u s e xu d a t e . H e a l i n g w i t h mu c h f i b r o s i s o c c u r s o v e r ma n y mo n t h s . A c i c a t r i zi n g p r o c t i t i s ma y b e a l a t e c o mp l i c a t i o n . T h e l a t e c l i n i c a l a p p e a r a n c e i s f a i r l y d i s t i n c t i v e . In t h e e a r l y s t a g e s , s y p h i l i s , c h a n c r o i d , a n d h e r p e s s i mp l e x n e e d t o b e e xc l u d e d . D i a g n o s i s i s c o n f i r me d b y c u l t u r e a n d p o l y me r a s e c h a i n r e a c t i o n ( P C R ) . G E NI TAL UL C E R: HE RP E S S I M P L E X : A s ma l l g r o u p o f v e s i c l e s s u r r o u n d e d b y e r y t h e ma f r e q u e n t l y o c c u r s o n t h e g l a n s o r prepuce. T he vesicles rupture, producing painful superficial ulcers that heal in 5 to d a y s . T h e u l c e r s ma y s e r v e a s p o r t a l s o f e n t r y f o r o t h e r o r g a n i s ms . T h e g r o u p e d vesicles or ulcers are fairly characteristic. Recurrent relapsing painful vesiculation and ulceration is characteristic. G E NI TAL UL C E RAT I O N: B E HC E T S Y ND RO M E : Painful aphthous ulcers with yellowish necrotic bases occur singly or in crops lastin 1 t o 2 w e e k s , a n d r e s e mb l e t h o s e s e e n i n t h e o r a l mu c o s a .

Pr epuce: Phimosis: T h e o r i f i c e o f t h e p r e p u c e i s t o o s ma l l f o r t h e f o r e s k i n t o b e r e t r a c t e d f r o m t h e g l a n (F i g . 1 2 - 7)A T h e c o n g e n i t a l f o r m r e s u l t s f r o m ma l f o r ma t i o n ; t h e a c q u i r e d t y p e ma y . be caused by preputial adhesions to the glans as the result of infection. T he lips of t h e p r e p u c e a r e p a l l i d , s t r i a t e d , a n d t h i c k e n e d . T h e n a r r o w o r i f i c e ma y a c t u a l l y o b s t r u c t u r i n a t i o n . R e t a i n e d s me g ma a n d d i r t l e a d t o i n f l a mma t i o n a n d e v e n c a l c u l u
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f o r ma t i o n . C i r c u mc i s i o n i s c u r a t i v e . P. 6 6 2

Fig. 12-7 Structural Abnormalities of the Prepuce (Foreskin) . A. Phimosis: The pr eput i al or i f i c e i s t oo t i ght t o per mi t r et r ac t i on of t he f or es k i n ov er t he gl ans peni s . P a r a p h i m o s iA :pr epuc e wi t h s mal l or i f i c e has been r et r ac t ed .B s ov er t he gl ans and t he l i ps hav e i mpi nged on t he r et r ogl andul ar s ul c us , pr ev ent i ng r et ur n t o t he nor mal pos i t i on. Edema oc c ur s i n t he pr epuc e, t he s k i n of t he s haf t , and t he glC . H y p o s p a d i a Thi s i s a dev el opment al anomal y . ans s: i n whi c h t he ur et hr al meat us opens on t he under s i de .of .t he s haf t D E p i s p a d i a sA dev el opment al anomal y i n whi c h t he ur et hr al meat us i s on t he : dor s al s i de of t he peni s .

Pr epuce: Par aphimosis: A t i g h t f o r e s k i n , o n c e r e t r a c t e d , ma y b e c o me e d e ma t o u s , s o t h a t i t c a n n o t r e s u me i t n o r ma l p o s i t i o n o v e r t h e g l a n s i(g .e 1 2 - 7)B T h e e d e ma i mp e d e s t h e v e n o u s F s e . d r a i n a g e o f t h e g l a n s c a u s i n g s w e l l i n g . M a n u a l r e p l a c e me n t o f t h e p r e p u c e ma y b e a t t e mp t e d . S u r g i c a l i n c i s i o n ma y b e n e c e s s a r y. Glans: Car cinoma of the Penis: T h i s l e s i o n o c c u r s i n a r e a s o f i r r i t a t i o n o r i n f l a mma t i o n o f t h e f o r e s k i n o r g l a n s . C o mmo n l y, t h e p r i ma r y l e s i o n i n v o l v e s t h e d o r s a l c o r o n a o r t h e i n n e r l i p o f t h e foreskin. A warty growth develops, ulcerates, and discharges watery pus. Parts of t h e t u mo r u n d e r g o n e c r o s i s a n d s l o u g hg(. s 1 2 - 6)C M e t a s t a s i s o c c u r s , mo s t Fi ee . o f t e n t o t h e i n g u i n a l l y mp h n o d e s . O f t e n t h e c l i n i c a l a p p e a r a n c e i s n o t s u f f i c i e n t l y t y p i c a l t o d i s t i n g u i s h t h i s f r o m c o n d y l o ma , s o a b i o p s y i s n e c e s s a r y.
P. 6 6 3

Glans: Er osive Balanitis: T h e s k i n o f t h e g l a n s u n d e r g o e s d e s q u a ma t i o n a n d e r o s i o n ; s ma l l u l c e r s f o r m a n d b e c o me c o n f l u e n t , i n v o l v i n g t h e e n t i r e g l a n s . R a r e l y, t h i s r e s u l t s i n g a n g r e n e . T h e identity of the infective organism is unknown. D o r s a l S h a f t : T h r o m b o s i s o f t h e D o r s a l Ve i n : A t h r o mb u s i n t h e d o r s a l v e i n o f t h e p e n i s c a u s e s a p a l p a b l e c o r d , a p p r o xi ma t e l y 1 mm i n d i a me t e r, i n t h e mi d l i n e d o r s a l l y. T h i s c o n d i t i o n i s u s u a l l y s e c o n d a r y t o


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i n f l a mma t i o n o f t h e g l a n s .

D o r s a l S h a f t : Va r i c o s e Ve i n s : Va r i c o s i t i e s o f t h e d o r s a l v e i n s o f t h e p e n i s ma y b e v i s i b l e a n d p a l p a b l e . T h e y ma y b e s u f f i c i e n t l y l a r g e t o r e q u i r e s u r g i c a l t r e a t me n t . Later al Shaft: Caver nositis: An i r r e g u l a r h a r d ma s s ma y o c c u r i n t h e l a t e r a l o r v e n t r a l c a v e r n o u s c o r p o r a f r o m i n f l a mma t i o n . P r i a p i s m a n d e d e ma u s u a l l y a c c o mp a n y t h i s c o n d i t i o n . S u p p u r a t i o n ma y o c c u r, w i t h d r a i n a g e t h r o u g h t h e s k i n o r t h e u r e t h r a .

Later al Shaft: Plastic Indur ation of the Penis (Peyr onie Disease): P a t h o p h y s i o l o g T : i s i s a c h r o n i c d i s e a s e o f u n k n o w n c a u s e , c h a r a c t e r i ze d b y yh i r r e g u l a r f i b r o s i s o f t h e s e p t u m o r s h e a t h o f t h e c o r p u s c a v e r n o s u m p e n i s , e xt e n d i n i n t o t h e t u n i c a a l b u g i n e a . It n e v e r a f f e c t s t h e c o r p u s s p o n g i o s o m. It i s c o n s i d e r e d a c o mp o n e n t o f D u p u y t r e n d i a t h e s i s a l o n g w i t h p a l ma r a n d s oFarrm,i b r o s i s . li f n o n t e n d e r p l a q u e s ma y b e f e l t l a t e r a l l y i n t h e c o r p o r a c a v e r n o s a p e n i s o r d o r s a l l y o v e r t h e i n t e r c o r p o r e a l s e p t u m. T h e p l a q u e s ma y b e s i n g l e o r mu l t i p l e ; t h e y a r e n o t n e c e s s a r i l y s y mme t r i c a l . T h e p a t i e n t ma y c o mp l a i n o f c u r v a t u r e o f t h e p e n i s d u r i n g e r e c t i o n . T h e f i n d i n g s ma y r e s e mb l e t h o s e i n g u mma , s c a r s f r o m t r a u ma , c a v e r n o s i t i s , s u b c u t a n e o u s g o u t y t o p h i , f i b r o ma s , c h o n d r o ma s , a n d c a r c i n o ma .

Pr iapism: P a t h o p h y s i o l o g E : e c t i o n i s s u s t a i n e d b y r e f l e x o r c e n t r a l n e r v e s t i mu l a t i o n , o r b y yr l o c a l me c h a n i c a l c a u s e s , s u c h a s t h r o mb o s i s , h e mo r r h a g e , n e o p l a s m, i n j e c t i o n o f v a s o a c t i v e a g e n t s , a n d i n f l a mma t i o n i n t.h P r p eo ns e d , p e r s i s t e n t , p e n i l e e ol ni g e r e c t i o n o c c u r s w i t h o u t s e xu a l d e s i r e . T h e c o n d i t i o n i s u s u a l l y p a i n f u l . It ma y c o mp l i c a t e l e u k e mi a a n d s i c k l e c e l l a n e mi a . U r g e n t s u r g i c a l ma n i p u l a t i o n i s u s u a l l y required.

Urethral Signs
P. 6 6 4

M eatus: Str ictur e: N a r r o w i n g o f t h e u r e t h r a l me a t u s ma y b e o b s e r v e d w i t h a n t e r o p o s t e r i o r p r e s s u r e o n t h e g l a n s . It i s u s u a l l y a c o n g e n i t a l ma l f o r ma t i o n . S t r i c t u r e s i n o t h e r p o r t i o n s o f t h e u r e t h r a mu s t b e d e mo n s t r a t e d b y t h e p a s s a g e o f c a t h e t e r s o r s o u n d s . M e a t u s : Hy p o s p a d i a s : T h e u r e t h r a l me a t u s a p p e a r s o n t h e v e n t r a l s u r f a c e o f t h e g l a n s , t h e s h a f t , o r a t t h p e n o s c r o t a l j u n c t i o n (F ie e 1 2 - 7)C s g. . M eatus: Epispadias: M a l d e v e l o p me n t r e s u l t s i n t h e me a t u s o p e n i n g d o r s a l l y o n t h e g l a n s , s h a f t , o r a t t h p e n o s c r o t a l j u n c t i o n (F ie e 1 2 - 7)D T h i s a n o ma l y i s o f t e n a s s o c i a t e d w i t h s g. . e xs t r o p h y o f t h e b l a d d e r. M eatus: M or gagni Folliculitis: T h e f o l l i c l e s o f M o r g a g n i o p e n i n t o t h e u r e t h r a l a t e r a l l y, i mme d i a t e l y b e h i n d t h e me a t a l l i p s . W h e n t h e u r e t h r a l mu c o s a i s i n f l a me d , t h e mo u t h s o f t h e s e d u c t s b e c o me p r o mi n e n t , a n d p u s c a n b e s e e n e xu d i n g w h e n t h e f o l l i c l e s a r e i n v o l v e d . M eatus: Papilloma:
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A b e n i g n t u mo r i n t h e me a t u s ma y b e v i s i b l e w h e n t h e o r i f i c e g a p e s f r o m p r e s s u r e o the glans.

Ve n t r a l P e n i l e S h a f t : Ac u t e Ur e t h r i t i s : S e e a l s oM al e Geni t al and Repr oduc t i v e Sy ndr omes : Urp a hr i t6 s 2 . An , , et g e i 7 acute indurating urethritis, especially as the result of infection from an indwelling c a t h e t e r, ma y c a u s e a p a l p a b l e c o r d t h a t e xt e n d s t h e e n t i r e l e n g t h o f t h e v e n t r a l mi d l i n e o f t h e p e n i s .

Ve n t r a l P e n i l e S h a f t : Ur e t h r a l S t r i c t u r e : A t u n n e l s t r i c t u r e o f t h e u r e t h r a ma y c a u s e a p a l p a b l e , c o r d - l i k e ma s s i n t h e c o r p u s cavernosum urethrae at the penoscrotal junction. Strictures in other parts of the penile urethra are usually not palpable. Ve n t r a l P e n i l e S h a f t : Ur e t h r a l D i v e r t i c u l u m : When located at the penoscrotal junction, a diverticulum frequently produces a v i s i b l e s w e l l i n g , f e l t a s a s o f t mi d l i n e ma s s . Ve n t r a l P e n i l e S h a f t : P e r i u r e t h r a l Ab s c e s s : An a c c u mu l a t i o n o f p u s i n t h e mi d p o r t i o n o f t h e p e n i l e u r e t h r a i n t h e L i t t r e f o l l i c l e w produce visible swelling. Ve n t r a l P e n i l e S h a f t : Ur e t h r a l C a r c i n o m a : O c c a s i o n a l l y, a n e o p l a s m ma y b e f e l t i n a n i n d u r a t e d ma s s i n t h e c o r p u s s p o n g i o s u m.

Scrotum Signs
B l u e P a p u l e s : S c r o t a l Ve n o u s An g i o m a ( F o r d y c e L e s i o n ) : F r e q u e n t l y, v e n o u s a n g i o ma s d e v e l o p i n t h e s u p e r f i c i a l v e i n s o f t h e s c r o t u m i n me n o l d e r t h a n 5 0 y e a r s o f a g e . T h e p a p u l e s a r e u s u a l l y mu l t i p l e , 3 4 mm i n d i a me t e r, a n d f i l l e d w i t h v e n o u s b l o o d t h a t c o l o r s t h e m d a r k r e d , b l u e , o r a l mo s t b l a c k ( s e e F i g . 6 - 1 4,Bp a g e 1 6 5 ) . T h e y a r e o f n o s i g n i f i c a n c e .
P. 6 6 5

Scr otal Swelling: Edema: P a t h o p h y s i o l o gE: r a c e l l u l a r f l u i d c o l l e c t s i n t h e d e p e n d e n t s c r o t u m w h e n v e n o u s y xt o r l y mp h a t i c o u t f l o w i s o b s t r u c t e d a n d w h e n u r i n e e xt r a v a s a t e s f r o m a r u p t u r e d u r e t h r a b e l o w t h e u r o g e n i t a l d i a p h r au tm o b s t r u c t i o n o f t h e l y mp h a t i c s f r o m a n y . Ac g e c a u s e ma y p r o d u c e l y mp h e d e ma t h a t p i t s o n p r e s s u r e ; w h e n l o n g - s t a n d i n g , i t c a n b n o n p i t t i n g . P i t t i n g e d e ma w i l l o c c u r w h e n s y s t e mi c v e n o u s p r e s s u r e i s v e r y h i g h a n d d e p e n d e n t e d e ma r e a c h e s a b o v e t h e i n g u i n a l l i g a me n t s ( e . g . , a d v a n c e d r i g h t v e n t r i c u l a r f a i l u r e o r c o n s t r i c t i v e p e r i c a r d i t i s , t h r o mb o s i s o f t h e p e l v i c v e i n s o r i n f e r i o r v e n a c a v a , n e p h r o t i c s y n d r o me ) a n d o f t e n i n t h e s e t t i n g o f t e n s e a s c i t e s . S c r o t a l S w e l l i n g : He m a t o m a a n d L a c e r a t i o n : T he conditions are usually evident and cause no difficulty in diagnosis. Scr otal Gangr ene: P a t h o p h y s i o l o g T : i s n e c r o t i zi n g p e r i n e a l i n f e c t i o n ( F o u r n i e r g a n g r e n e ) i s c a u s e d yh b y p o l y mi c r o b i a l mi xe d a e r o b i c a n d a n a e r o b i c , g r a m- p o s i t i v e a n d g r a m- n e g a t i v e
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o r g a n i s ms , o f t e n w i t h g a s p r o d u c t i o n . T h e r a p i d p r o g r e s s i o n r e s u l t s f r o m s u b c u t a n e o u s v a s c u l a r t h r o mb o s i s l e a d i n g t o g a n g r e n e o f t h e o v e rIty i s g d e r mi s . l n mo s t c o mmo n i n d i a b e t i c p a t i e n t s b e y o n d t h e s i xt h d e c a d e w h o p r e s e n t c l i n i c a l l y w i t h f e v e r, a t o xi c a p p e a r a n c e , a n d e v i d e n c e o f s e p s i s , a n d w h o h a v e n e c r o t i c , f o u l s me l l i n g , r a p i d l y a d v a n c i n g l e s i o n s o f s c r o t u m w i t h c r e p i t u s . T h e c o n d i t i o n i s l i f e t h r e a t e n i n g u n l e s s a n t i b i o t i c s a n d w i d e s u r g i c a l d e b r i d e me n t o f a l l n o n v i a b l e t i s s u e a r e i n s t i t u t e d p r o mp t l y.

Scr otal Cysts: Sebaceous Cysts: T h i s i s t h e mo s t c o mmo n n o d u l a r l e s i o n o f t h e w a l l a n d i s b e n i g n . It ma y b e s i n g l e o mu l t i p l e . T h e w h i t e c o n t e n t o f t h e c y s t ma y s h o w t h r o u g h t h e s k i n . Scr otal Car cinoma: T h e n e o p l a s m i s s i mi l a r t o t h o s e i n o t h e r a r e a s o f s k i n . It i s p a r t i c u l a r l y c o mmo n i n w o r k e r s w i t h o c c u p a t i o n a l e xp o s u r e t o t a r a n d o i l .

Testis, Epididymis, and Other Intrascrotal Signs


P. 6 6 6

M a l d e s c e n d e d Te s t i s : C r y p t o r c h i d i s m : P a t h o p h y s i o l o g D:u r i n g f e t a l d e v e l o p me n t , t h e d e s c e n t o f t h e t e s t i s ma y b e y a r r e s t e d i n t h e a b d o me n , i n t h e i n g u i n a l c a n a l , o r a t t h e p u b o s c rE itta lejru n c t i o n . o h o r b o t h t e s t e s ma y b e a f f e c t e d . W h e n t h e t e s t i s r e ma i n s i n t h e a b d o me n , i t c a n n o t b p a l p a t e d . In t h e i n g u i n a l c a n a l o r a t t h e p u b o s c r o t a l j u n c t i o n , t h e t e s t i s i s p a l p a b l e b u t f r e q u e n t l y i t i s a t r o p h i e d , s o t h e ma s s i s s ma l l e r t h a n mi g h t b e e xp e c t e d . M o r e c o mp l i c a t e d a n o ma l i e s o f d e v e l o p me n t r e s u l t i n t h e t e s t i s l o d g i n g i n t h e p e r i n e u m n e a r t h e me d i a n r a p h e o f t h e s c r o t u m, i n t h e f e mo r a l c a n a l , o r a n t e r i o r l y a n d d o r s a l a t t h e r o o t o f t h e p e n i s . Te s t i c u l a r ma l d e s c e n t ma y r e s u l t i n d e c r e a s e d f e r t i l i t y. A ma l d e s c e n d e d t e s t i s i s f r e q u e n t l y a s s o c i a t e d w i t h a c o n g e n i t a l i n g u i n a l h e r n i a o n t h s a me s i d e a s a r e s u l t o f p e r s i s t e n c e o f p a r t o f t h e s a c c u s v a g i n a l i s . M a l d e s c e n d e d t e s t i s c a r r i e s a n i n c r e a s e d r i s k o f t e s t i c u l a r c a n c e r.

S m a l l Te s t e s : At r o p h y : T h e t e s t i s ma y b e s ma l l e r t h a n n o r ma l f r o m ma l d e v e l o p me n t . At r o p h y ma y o c c u r a f t e i n f a r c t i o n , t r a u ma , mu mp s o r c h i t i s , c i r r h o s i s , K l i n e f e l t e r s y n d r o me , P r a d e r - W i l l i s y n d r o me , s y p h i l i s , f i l a r i a s i s , o r s u r g i c a l r e p a i r o f a n i n g u i n a l h e r n i a .

No n t e n d e r Te s t i c u l a r S w e l l i n g : Ne o p l a s m : Te s t i c u l a r c a n c e r i s mo s t c o mmo n i n y o u n g me n w h o ma y p r e s e n t w i t h r e g i o n a l o r d i s s e mi n a t e d d i s e a s e . It i s a g g r e s s i v e , y e t c u r a b l e . T h e ma s s i s i n d i s t i n g u i s h a b l e f r o m g u mma o r t u b e r c u l o ma a n d b i o p s y b y t h e t r a n s i n g u i n a l ( n e v e r t r a n s s c r o t a l ) approach is required for diagnosis. T he testis is usually enlarged and harder than n o r ma l , a n d i t f r e q u e n t l y c o n t a i n s s o f t e r c y s t i c i rge g1o n8 D n dH) . A F . i 2- s a ( c a r c i n o ma t o u s t e s t i s i s h e a v i e r t h a n t h a t w i t h o r c h i t i s o r h y d r o c e l e . T h e p r e s e n c e o me t a s t a t i c l e s i o n s e l s e w h e r e i s p r e s u mp t i v e e v i d e n c e t h a t a n o d u l e i n t h e t e s t i s i s neoplastic.

Te n d e r Te s t i c u l a r S w e l l i n g : Te s t i c u l a r To r s i o n : P a t h o p h y s i o l o g T : e t e s t i c l e i s s u s p e n d e d o n t h e s p e r ma t i c c o r d w i t h i n t h e yh s c r o t u m. It i s n o r ma l l y a n c h o r e d a t i t s d i s t a l p o l e . W h e n t h e s p e r ma t i c c o r d b e c o me
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t w i s t e d , v e n o u s a n d l y mp h a t i c o b s t r u c t i o n o c c u r f i r s t b e c a u s e o f t h e n a t u r e o f t h e vessel walls and lower pressures, as contrasted with arterial wall thickness and a r t e r i a l p r e s s u r e . T h i s p r o d u c e s e n g o r g e me n t o f t h e t e s t i c l e , w o r s e n i n g c i r c u l a t i o n a n d l e a d i n g t o a r t e r i a l , a s w e l l a s v e n o u s a n d l y mp h a t i.c , h e cc u s id i ni o n i s T oc l on o t p a i n f u l a n d u r g e n t . It i s f r e q u e n t l y c o n f u s e d w i t h a c u t e e p i d i d y mo o r c h i t i s a n d s t r a n g u l a t e d s c r o t a l h e r n i a . P a l p a t i o n r e v e a l s a t e n d e r, i r r e g u l a r, e d e ma t o u s ma s s t h e s c r o t u m. T h e t e s t i c l e l i e s i n a h o r i zo n t a l p o s i t i o n a n d t h e e p i d i d y mi s l i e s i n a n a n t e r i o r l o c a t i o n . T h e p a i n ma y b e r e f e r r e d t o t h e r i g h t l o w e r q u a d r a n t ( R L Q ) o f t h e a b d o me n , mi mi c k i n g a p p e n d i c i t i s . O c c a s i o n a l l y, t h e t w i s t i n t h e c o r d c a n b e f e l t . F i v d i s t i n g u i s h i n g f e a t u r e s a r e c o mmo n l y n o t e d : ( a ) T h e t e s t i s o n t h e a f f e c t e d s i d e l i e s h i g h e r t h a n n o r ma l f r o m t h e t w i s t i n g o f t h e c o r d a n d t h e s p a s m o f t h e c r e ma s t e r i c mu s c l e s . ( b ) P a l p a t i o n c a n n o t d i s t i n g u i s h b e t w e e n t h e t e s t i s a n d t h e e p i d i d y mi s . In a c u t e e p i d i d y mo o r c h i t i s , t h e e p i d i d y mi s c a n u s u a l l y b e f e l t s e p a r a t e l y f r o m t h e t e s t (c) Elevation and support of the scrotum for an hour usually relieves the pain of e p i d i d y mo o r c h i t i s ; i t d o e s n o t a me l i o r a t e t h e p a i n Pr ehn ss ogn (( d ) In i n t o r i i n. ) t o r s i o n , t h e l e g o f t h e i n v o l v e d s i d e i s o f t e n h e l d i n f l e xi o n . ( e ) W h e n a s e c o n d a r y hydrocele is present, the aspirated contents yield serosanguineous fluid from t o r s i o n , s e r o u s f l u i d i n e p i d i d y mo o r c h i t i s . S o me t i me s s t r a n g u l a t e d h e r n i a c a n n o t b e distinguished from torsion without operation. P. 6 6 7

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F i g . 1 2 - 8 S w e l l i n g s o f t h e S c r o t a l C o n t e n t s . ( S e e t e xt f o r d e s c r i p t i o n s o f A O.)

Te n d e r Te s t i c u l a r S w e l l i n g : Ac u t e O r c h i t i s : P a t h o p h y s i o l o g In:f l a mma t i o n o f o n e o r b o t h t e s t e s o c c u r s f r e q u e n t l y i n mu mp s , y a n d o c c a s i o n a l l y i n o t h e r i n f e c t i o u s d i s e a s e sa n d i s s w o l l e n , t e n d e r, a n d . T he gl u s u a l l y e xt r e me l y p a i n f u l . F r e q u e n t l y, t h e i n f l a mma t i o n c a u s e s a c u t e h y d r o c e l e , b u t t h e i n f l a mma t o r y e d e ma a n d t h e p a i n o f p a l p a t i o n p r e v e n t a c c u r a t e d i s t i n c t i o n . O f t e n , p r i ma r y o r s e c o n d a r y e p i d i d y mi t i s i s a s s o c i a t e d . O r c h i t i s i s s o me t i me s c o n f u s e d w i t h t o r s i o n o f t h e s p e r ma t i c c o r d .


P. 6 6 8

No n - t e n d e r I n t r a - s c r o t a l S w e l l i n g : Hy d r o c e l e : P a t h o p h y s i o l o g S : r o u s f l u i d a c c u mu l a t e s i n t h e c a v i t y o f t h e t u n i c a v a g i n a l i s ye
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c o n g e n i t a l l y o r f r o m i n f e c t i o n o r . t r aa l mat i o n r e v e a l s a p e a r - s h a p e d ma s s w i t h P u pa t h e s ma l l e r p o l e u p w a r d . P i n c h i n g t h e r o o t o f t h e s c r o t u m i n d i c a t e s t h a t t h e ma s s d o e s n o t e xt e n d t h a t h i g h . T h e ma s s f e e l s s mo o t h a n d r e s i l i e n t . T h e t e s t i s a n d e p i d i d y mi s a r e u s u a l l y b e h i n d t h e ma F sg ( s1 2 - 8)B e xc e p t w h e n a n t e v e r s i o n i s s i . ee , p r e s e n t a n d t h e s t r u c t u r e s a r e t h e n a n t e r i io r. (1 2 -e )O T r a n s i l l u mi n a t i o n F g se 8 . s h o w s t h e ma s s t o b e t r a n s l u c e n t ; i t a l s o r e v e a l s t h e o p a q u e s h a d o w o f t h e t e s t i s . T h e t r a n s l u c e n c y o f t h e h y d r o c e l e d i s t i n g u i s h e s i t f r o m t h e o p a q u e h e ma t o c e l e . E xc e p t i n a n t e v e r s i o n o f t h e t e s t i s , t h e l o c a t i o n o f t h e ma s s i n f r o n t o f t h e t e s t i s d i s t i n g u i s h e s i t f r o m s p e r ma t o c e l e t h a t a r i s e s f r o m t h e e p i d i d y mi s a n d i s b e h i n d t h e t e s t i s . H y d r o c e l e o f t h e s p e r ma t i c c o r d o c c u r s a b o v e t h e t e s t i s .

No n - t e n d e r I n t r a - S c r o t a l S w e l l i n g : Hy d r o c e l e o f t h e S p e r m a t i c C o r d : P a t h o p h y s i o l o g W:h e n t h e s a c c u s v a g i n a l i s f a i l s t o b e o b l i t e r a t e d a r o u n d t h e y s p e r ma t i c c o r d , a s e r o u s c a v i t y p e r s i s t s . T h i s c a v i t y ma y b e c o me f i l l e d w i t h f l u i d t o f o r m a h y d r o c e lT y p i c a l l y, t h e r e s u l t i n g ma s s i s s mo o t h , r e s i l i e n t , a n d s a u s a g e . e s h a p e d ; i t i s l o c a t e d a b o v e t h e t e s t i s a n d t r a n s i l l u mi n a t e1 2 ( s)e eW h e n n o Fig. s -8K . o t h e r a b n o r ma l i t i e s a r e p r e s e n t , t h e d i a g n o s i s i s ma d e b y p a l p a t i o n a n d t r a n s i l l u mi n a t i o n . W h e n a s s o c i a t e d w i t h a h e r n i a , s p e r ma t o c e l e , o r t e s t i c u l a r h y d r o c e l e , t h e d i s t i n c t i o n ma y b e d i f f i c u l t o r i mp o s s i b l e w i t h o u t o p e r a t i o n . O c c a s i o n a l l y, t h e r e e xi s t s a c o mmu n i c a t i o n b e t w e e n t h e h y d r o c e l e a n d t h e p e r i t o n e c a v i t y, s o - c a l l e d c o mmu n i c a t i n g h y d r o c e l e . T h i s i s c h a r a c t e r i s t i c a l l y i d e n t i f i e d b y t h v a r i a t i o n i n s i ze f r o m l a r g e t o n o n e xi s t e n t , d e p e n d i n g o n t h e q u a n t i t y o f f l u i d contained. No n - t e n d e r I n t r a - s c r o t a l S w e l l i n g : He m a t o c e l e : T h e c a v i t y o f t h e t u n i c a v a g i n a l i s i s f i l l e d w i t h b l o o d . T h e s w e l l i n g r e s e mb l e s t h a t o a h y d r o c e l e , b u t b l o o d i s o p a q u e t o t r a n s i l l u mi n F t go n1 ( s e)e A h i s t o r y o f ai i . 2-8C . r e c e n t t r a u ma s u g g e s t s h e ma t o c e l e . No n - t e n d e r I n t r a - s c r o t a l S w e l l i n g : He m a t o m a o f t h e C o r d : W h e n t r a u ma c a u s e s b l e e d i n g a r o u n d t h e s p e r ma t i c c o r d , a b o g g y ma s s ma y b e f e l t i n t h e r e g i o n . T h e ma s s i s o p a q u e t o t r a n s i l l u mi nF itgo n 2s 8 L T h e h i s t o r y a i . 1 ( - ee ). o f t r a u ma s h o u l d a s s i s t i n d i a g n o s i s . No n - t e n d e r I n t r a - s c r o t a l S w e l l i n g : C h y l o c e l e : In f i l a r i a s i s , o p a l e s c e n t l y mp h ma y a c c u mu l a t e i n t h e c a v i t y o f t h e t u n i c a v a g i n a l i s . T h e ma s s i s t r a n s l u c e n t a n d d i s t i n c t i o n f r o m h y d r o c e l e c a n b e ma d e o n l y b y aspiration of the fluid.
P. 6 6 9

No n - t e n d e r I n t r a - s c r o t a l S w e l l i n g : Va r i c o c e l e : P a t h o p h y s i o l o g Va r i c o s i t i e s o f t h e p a mp i n i f o r m p l e xu s o f v e i n s f o r m a s o f t , y: i r r e g u l a r ma s s i n t h e s c r. oTu m c o n d i t i o n o c c u r s p r e d o mi n a n t l y o n t h e l e f t s i d e ; t he o c c a s i o n a l l y i t i s b i l a t e r a l ; a l mo s t n e v e r i s t h e r i g h t s i d e i n v o l v e d e xc l u s i v e l y. P a l p a t i o n g i v e s a s e n s a t i o n l i k e n e d t o f e e l i n g a b a g o f w o r ms t h a t i s r a r e l y mi s t a k e f o r a n y t h i n g e l s e ( s eg . 1 2 - 8)N To d i s t i n g u i s h t h e c o n d i t i o n f r o m a n i n d i r e c t Fi e . i n g u i n a l h e r n i a c o n t a i n i n g o me n t u m, h a v e t h e p a t i e n t l i e d o w n ; p l a c e y o u r g l o v e d finger over the subcutaneous inguinal ring. When the patient stands, with your finge in place, the veins refill but the hernia will be held back.
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No n - t e n d e r E p i d i d y m a l S w e l l i n g : S p e r m a t o c e l e : R e t e n t i o n c y s t s o f t h e e p i d i d y mi s , e s p e c i a l l y i n t h e g l o b u s ma j o r, c o n t a i n f l u i d t h a t ma y b e mi l k y o r c l e a r. S p e r ma t o zo a ma y b e p r e s e n t mi c r o s c o p i c a l l y. T h e c y s t s a r e u s u a l l y s ma l l b u t ma y a t t a i n a d i a me t e r o f 8 o r 1 0 c m. T h e c y s t i s u s u a l l y t r a n s l u c e w h e n t r a n s i l l u mi n a t e d ( si e e 1 2 - 8)G F g. . No n - t e n d e r E p i d i d y m a l S w e l l i n g : S o l i d Tu m o r : O p a q u e ma s s e s o f t h e e p i d i d y mi s a r e r a r e ; w h e n p r e s e n t , t h e y a r e u s u a l l y n e o p l a s ms . T h e y s h o u l d b e b i o p s i e d b e c a u s e t h e y a r e f r e q u e n t l y ma l i g n a n t . No n - t e n d e r E p i d i d y m a l S w e l l i n g w i t h No d u l a r i t y : S y p h i l i s : T h e g l o b u s ma j o r i s u s u a l l y f i r s t i n v o l v e d ; t h e n t h e p r o c e s s e xt e n d s t o t h e b o d y o f t h e e p i d i d y mi s ( sF i e . 1 2 - 8 J T h e o r g a n i s u s u a l l y n o t t e n d e r. T h e c a u s e i s eg ). inferred from positive serologic tests for syphilis and the presence of syphilitic lesions elsewhere. No n - t e n d e r E p i d i d y m a l S w e l l i n g w i t h No d u l a r i t y : Tu b e r c u l o s i s : T h e b o d y o f t h e e p i d i d y mi s i s u s u a l l y f i r s t i n v o l v e d . T h e h a r d n o d u l e s a r e n o t t e n d e T h e e p i d i d y mi s b e c o me s a d h e r e n t t o t h e s c r o t u m, a n d s i n u s eF i g . 1 2 f o.r m ( s ma y - 8 I ) T he cause is usually inferred from the presence of tuberculosis in other structures.
P. 6 7 0

Te n d e r E p i d i d y m a l S w e l l i n g : Ac u t e E p i d i d y m i t i s : P a t h o p h y s i o l o g In:f e c t i o n o f t h e e p i d i d y mi s o c c u r s b y e xt e n s i o n f r o m i n f e c t i o n s i n y t h e u r e t h r a , p r o s t a t e , o r s e mi n a l v eInid we sl l i n g u r e t h r a l c a t h e t e r s i n c r e a s e t h e . s cl e r i s k o f e p i d i d y mi t i s . T h e p a i n f u l , t e n d e r s w e l l i n g o f t h e e p i d i d y mi s ma y b e a c c o mp a n i e d b y f e v e r, l e u k o c y t o s i s , a n d p y u r i a . In y o u n g , s e xu a l l y a c t i v e me n w i t h mu l t i p l e o r n e w s e xu a l p a r t n e r s , s e xu a l l y t r a n s mi t t e d o r g a n i s ms a r e e xp e c t e d ; i n me o v e r a g e 4 0 a n d i n t h o s e w i t h c a t h e t e r s , e n t e r i c o r g a n i s ms a r e c o mmo n . T h i c k e n i n g o f t h e Va s D e f e r e n s : D e f e r e n t i t i s : T h i s i s i n f l a mma t i o n o f t h e v a s d e f e r e n s . In a c u t e d i s e a s e s , t h e v a s i s t e n d e r a n d s w o l l e n . T h e i n f l a mma t i o n i s u s u a l l y a n e xt e n s i o n f r o m o t h e r s t r u c t u r e s . W i t h c h r o n i n f l a mma t i o n t h e v a s ma y b e t h i c k e n e d a n d i n d u r a t e d , w i t h s o me n o dg .l a r i t y ( s e e Fi u 1 2 - 8)I , s u g g e s t i n g e i t h e r t u b e r c u l o u s o r s y p h i l i t i c e xt e n s i o n f r o m o t h e r p a r t s o f t h e genitourinary tract.

Prostate and Seminal Vesicle Signs

No n - t e n d e r P r o s t a t e E n l a r g e m e n t : B e n i g n P r o s t a t i c Hy p e r p l a s i a ( B P H) : B P H a f f e c t s a ma j o r i t y o f me n i n t h e i r s e v e n t i e s , b u t o n l y a mi n o r i t y e xp e r i e n c e u r e t h r a l o b s t r u c t i o n w i t h s y mp t o ms o f s t r a i n i n g a t u r i n a t i o n , w e a k u r i n a r y s t r e a m, n o c t u r i a , a n d d r i b b l i n g . W h e n t h e l a t e r a l l o b e s a r e i n v o l v e d , t h e y a r e s y mme t r i c a l l y e n l a r g e d , e l a s t i c t o r u b b e r y o r f i r m, a n d t h e r e c t a l mu c o s a c a n b e ma d e t o s l i d e o v e t h e m r e a d i l y. H y p e r p l a s i a o f t h e me d i a n l o b e ma y b e d i f f i c u l t t o d e t e c t b e c a u s e t h e b u l k o f t h e l o b e ma y p r o t r u d e a n t e r i o r l y t o p r o d u c e u r e t h r a l o b s t r u c t i o n w i t h o u t b e i n p a l p a b l e , s o s i ze c a n n o t b e u s e d t o j u d g e p r o p e n s i t y f o r o b s t r u c t i o n . No n - t e n d e r P r o s t a t i c E n l a r g e m e n t : P r o s t a t e C a n c e r : T h i s i s u s u a l l y a s y mp t o ma t i c ; d y s u r i a a n d s y mp t o ms o f o b s t r u c t i o n ma y o c c u r i n
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a d v a n c e d d i s e a s e . A d i s c r e t e n o d u l e ma y b e p a l p a t e d o n t h e p o s t e r i o r s u r f a c e o f t h p r o s t a t e o r t h e g l a n d my f e e l d i f f u s e l y e n l a r g e d . T h e e n t i r e g l a n d ma y b e c o me s t o n h a r d , o r t h e r e ma y b e s e v e r a l h a r d n o d u l e s . T h e me d i a n f u r r o w b e c o me s o b l i t e r a t e d E a r l y s p r e a d i s o f t e n i n t h e d i r e c t i o n o f t h e s e mi n a l v e s i c l e s . It i s i mp o r t a n t t o n o t e t h e s i ze o f t h e ma s s , w h e t h e r i t i n v o l v e s o n e o r b o t h l o b e s , w h e t h e r n o r ma l a n a t o mi l a n d ma r k s a r e p r e s e r v e d o r o b l i t e r a t e d , a n d w h e t h e r t h e r e i s e xt e n s i o n b e y o n d t h e p r o s t a t e . E xt e n s i o n i s p a l p a b l e o r i n f e r r e d f r o m f i xa t i o n o f t h e r e c t a l mu c o s a t o t h e p o s t e r i o r s u r f a c e o f t h e p r o s t a t e . If t h e d i g i t a l r e c t a l e xa m i s p o s i t i v e , u l t r a s o u n d guided needle biopsy is indicated.

No n - t e n d e r P r o s t a t e E n l a r g e m e n t : C h r o n i c P r o s t a t i t i s : P a l p a t i o n o f t h e p r o s t a t e ma y n o t r e v e a l d i s t i n c t i v e f i n d i n g s . A h i s t o r y s u g g e s t i n g c h r o n i c u r i n a r y t r a c t i n f e c t i o n p r o mp t s t h e f i n d i n g o f l a r g e mu c o u s s h r e d s i n t h e u r i n e s p e c i me n . P r o s t a t i c ma s s a g e i s a c c o mp l i s h e d b y r e p e a t e d l y a n d f i r ml y s t r o k i n t h e p o s t e r i o r s u r f a c e o f t h e p r o s t a t e f r o m t h e l a t e r a l ma r g i n s t o w a r d t h e mi d l i n e , s o me t i me s a p a i n f u l p r o c e d u r e . T h e f l u i d i s mi l k e d f r o m t h e u r e t h r a a n d e xa mi n e d u n d e r t h e mi c r o s c o p e . In p r o s t a t i t i s , t h e f l u i d c o n t a i n s ma n y l e u k o c y t e s . C h r o n i c p r o s t a t i t i s ma y b e e i t h e r i n f e c t i v e o r n o n i n f e c t i v e , a d i s t i n c t i o n s o me t i me s d i f f i c u l t ma k e .
P. 6 7 1

Te n d e r P r o s t a t i c E n l a r g e m e n t : Ac u t e P r o s t a t i t i s : In s e xu a l l y a c t i v e y o u n g me n , c h l a my d i a a n d g o n o r r h e a a r e mo s t l i k e l y, w h e r e a s i n me n o v e r a g e 4 0 o r t h o s e me n w i t h a n i n d w e l l i n g u r e t h r a l c a t h e t e r, e n t e r i c o r g a n i s msEs c her i c hi a c ol ri Kl ebs i el l) aa r e t h e c a u s e . It ma y b e g i n w i t h d y s u r i a , ( o c h i l l s , a n d f e v e r. G e n t l e p a l p a t i o n r e v e a l s a n e n l a r g e d , t e n s e o r b o g g y a n d t e n d e r p r o s t a t e , s u r r o u n d e d b y e d e ma t o u s t i s s u e . T h e u r i n e s p e c i me n c o n t a i n s l a r g e mu c o u s s h r e d s . Vi g o r o u s ma s s a g e o f t h e p r o s t a t e t o o b t a i n f l u i d f o r e xa mi n a t i o n i s c o n t r a i n d i c a t e d b e c a u s e i t ma y i n d u c e b a c t e r e mi a , a n d a u r i n e s p e c i me n c o n t a i n i n g bacteria and white blood cells will be adequate for culture. P a l p a b l e S e m i n a l Ve s i c l e : Ve s i c u l i t i s : T h e n o r ma l s e mi n a l v e s i c l e i s n o t p a l p a b l e . W h e n t h e s t r u c t u r e c a n b e f e l t a s a d i l a t e d o r i n d u r a t e d ma s s , i t i s t h e s i t e o f a c u t e o r c h r o n i c i n f e c t i o n o r o b s t r u c t i o n . T h e f i n g e r i n t h e r e c t u m ma y p r o c u r e f l u i d f o r e xa mi n a t i o n b y ma s s a g i n g t h e v e s i c l e t o w a r d t h e p r o s t a t e , t h e n mi l k i n g t h e u r e t h r a t o e xt r u d e t h e s e mi n a l f l u i d . Palpable Cowper Gland: Inflammation of Bulbour ethr al Gland (Cowper itis): N o r ma l l y t h e b u l b o u r e t h r a l g l a n d s a r e n o t p a l p a b l e . W h e n t h e y a r e i n f l a me d , t h e y a r e e xq u i s i t e l y t e n d e r. In c h r o n i c i n f l a mma t i o n , t h e y e n l a r g e f r o m t h e s i ze o f a p e a t h a t o f a h a ze l n u t . T h e t e n d e r n e s s o r ma s s i s r e a d i l y d e mo n s t r a t e d i f t h e c o n d i t i o n considered and searched for in the proper place. One gland lies on each side of the me mb r a n o u s u r e t h r a b e t w e e n t h e i n f e r i o r e d g e o f t h e p r o s t a t e a n d t h e i n n e r b o r d e r o f t h e a n a l c a n a l . W i t h t h e g l o v e d f o r e f i n g e r i n t h e r e c t u m, e xp l o r e t h e a n t e r i o r r e c w a l l i n f e r i o r t o t h e p r o s t a t e a n d s u p e r i o r t o t h e e d g e o f t h e a n ai lg .c a n a l ( s e e F 123 D) . At t h e s a me t i me , t h e t h u mb i s h e l d o u t s i d e o n t h e me d i a n r a p h e o f t h e s c r o t u m j u s t a n t e r i o r t o t h e a n u s . T h e t i s s u e b e t w e e n t h e t h u mb a n d f o r e f i n g e r i s c o mp r e s s e d t o d e t e c t t e n d e r n e s s o r a ma s s .
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Male Genital and Reproductive Syndrom es


I n g u i n a l He r n i a : S e e C h a p t e r ,9Her ni as p a g e 6 0 2 f f . ,
P. 6 7 2

Sexually Tr ansmitted Diseases (ST Ds): S T D s c a n p r e s e n t l o c a l l y a s u l c e r s o r i n f l a mma t i o n , s y s t e mi c a l l y, o r b e a s y mp t o ma t i c . Al l s e xu a l l y a c t i v e me n , e s p e c i a l l y t h o s e w i t h n e w o r mu l t i p l e partners, should be screened for a history of ST Ds. T he presence of one ST D i n c r e a s e s t h e r i s k o f a c q u i r i n g a n d t r a n s mi t t i n g o t h e r s . B a r r i e r c o n t r a c e p t i v e s ( c o n d o ms ) a r e s o me w h a t e f f e c t i v e a t d e c r e a s i n g t h e r i s k o f a c q u i r i n g a n S T D . Al l p e r s o n s w i t h a n S T D mu s t b e s c r e e n e d f o r o t h e r t r e a t a b l e S T D s , i n c l u d i n g H IV a n d s y p h i l i s , w h i c h a r e o f t e n a c q u i r e d a s y mp t o ma t i c a l l y. In a d d i t i o n , s e v e r a l i n f e c t i o u s d i s e a s e s , n o t u s u a l l y d e f i n e d a s S T D s , c a n b e a c q u i r e d s e xu a l l y, f o r e xa mp l e , hepatitis B. Syphilis (Lues): P a t h o p h y s i o l o g T : e p o n e ma p a l l i d u m a c q u i r e d f r o m s e xu a l c o n t a c t c a u s e s a n yr a c u t e u l c e r ( c h a n c r e ) a t t h e i n o c u l a t i o n s i t e f o l l o w e d b y d i s s e mi n a t i o n t h r o u g h o u t t h e b o d.yPr i mar y s y phi l ps e s e n t s a s a c h a n c r e Fs g .e 1 2 - 6)A a s i n g l e , f i r m, ir ( ie , p a i n l e s s , p u n c h e d - o u t u l c e r o n o r n e a r t h e g e n i t a l i a o r u n c o mmo n l y o n t h e l i p s , mo u t h , o r w o ma n ' s b r e a s t w i t h r e g i o n a l l y mp h a d e n o p a t h y.y s y phi l i s Sec ondar p r e s e n t s w i t h h e a d a c h e , s o r t t h r o a t , my a l g i a , ma l a i s e , a n d i t c h i n g . P h y s i c a l e xa m r e v e a l s a ma c u l o p a p u l a r r a s h o n t h e s o l e s , p a l ms , a n d e xt r e mi t i e s a p p e a r i n g a b o u t w e e k s a f t e r t h e c h a n c r e . T h e r e ma y b e l y mp h a d e n o p a t h y, f e v e r, a n d a l o p e c i a . Ter t i ar y s y phi lp se s e n t s w i t h v a r i o u s c l i n i c o p a t h o l o g i c p i c t u r e s d e p e n d i n g o n ir t i s s u e s i n v o l v e d . F i n d i n g s ma y i n c l u d e a o r t i c i n s u f f i c i e n c y, t a b e s d o r s a l i s , g e n e r a l p a r e s i s , o r g u mma f o r ma t i o n .

M e a t u s : Ur e t h r i t i s : P a t h o p h y s i o l o g In:f e c t i o n , u s u a l l y b y s e xu a l l y t r a n s mi t t e d o r g a n i s ms , r e s u l t s i n y i n f l a mma t i o n a n d p u r u l e n t d i s c h a r g e f r o m t h e u r e t h r a l o r i f i c e a c c o mp a n i e d b y b u r n i n g p a i n w i t h u r i n a tTo n e d g e s o f t h e me a t u s ma y b e r e d d e n e d , e d e ma t o u s , . i he a n d e v e r t e d . A v a r i a b l e a mo u n t o f p u s d i s c h a r g e s f r o m t h e u r e t h r a . T h e l y mp h a t i c c h a n n e l s i n t h e d o r s u m o f t h e p e n i s ma y b e t e n d e r a n d p a l p a b l e . Te n d e r, s w o l l e n , p a l p a b l e l y mp h n o d e s d e v e l o p i n t h e i n g u i n a l r e g i o n s . M i c t u r i t i o n a n d e r e c t i o n ma y be painful. T he diagnosis is usually obvious by direct inspection and the presence mu c o u s s h r e d s a n d p u s i n t h e f i r s t p a r t o f t h e u r i n e s p e c i me n . T h e c h a l l e n g e i s t o d e t e r mi n e t h e c a u s a t i v e a g e n t . In y o u n g , s e xu a l l y a c t i v e me n , c h l a my d i a , g o n o r r h e a a n d t h e g e n i t a l my c o p l a s ma s a r e t h e mo s t c o mmo n p a t h o g e n s . In me n o v e r a g e 4 0 , e n t e r i c b a c t e r i a p r e d o mi n a t e . P r o s t a t i t i s ma y c o mp l i c a t e u r e t h r i t i s b y e xt e n s i o n o f i n f e c t i o n i n t o t h e p r o s t a t i c d u c t s . U r e t h r i t i s ma y c o n s t i t u t e a me mb e r o f t h e t r i a d , along with conjunctivitis and arthritis, in Reiter disease; the urethritis frequently a p p e a r s b e f o r e t h e o t h e r me mb e r s .
P. 6 7 3

Er ectile Dysfunction: Impotence:


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P a t h o p h y s i o l o g S : xu a l a r o u s a l , r i g i d d i s t e n t i o n o f t h e c o r p o r a c a v e r n o s u m o f t h e ye p e n i s , o r g a s m, a n d e f f e c t i v e e j a c u l a t i o n r e q u i r e a n o r ma l a f f e c t a n d i n t a c t e n d o c r i n n e u r o l o g i c , a n d v a s c u l a r f u n c t i o n . D y s f u n c t i o n a n y w h e r e i n t h i s c o mp l e x a n d coordinated process can produce erectile dysfunction, the inability to sustain a p e n i l e e r e c t i o n o f s u f f i c i e n t r i g i d i t y o r d u r a t i o n t o c o n s u mma t e s a t .i sAa c t o r y c o i t u s f t h o r o u g h h i s t o r y f o c u s i n g o n t h e o n s e t a n d p r o g r e s s i o n o f s y mp t o ms , l i b i d o , me d i c a t i o n s , s u r g e r y, a n d p s y c h o s o c i a l i s s u e s i s e s s e n t i a l i n t h e e v a l u a t i o n . E a r l y mo r n i n g e r e c t i o n s mi l i t a t e a g a i n s t n e u r o l o g i c , v a s c u l a r, o r e n d o c r i n o l o g i c c a u s e s , a n d s u g g e s t s a f u n c t i o n a l p r o b l e m. S c r e e n i n g f o r d e p r e s s i o n , h y p o t h y r o i d i s m, hypogonadism and diabetes is rewarding. Full evaluation requires urologic referral [M o r g e n t a l e r A. M a l e i mp o t e n c e . et1 9 9 9 ; 3 5 4 : 1 7 1 3 1 7 1 8 v i s - J o s e p h B , Lanc ; Da T i e f e r L , M e l ma n A. Ac c u r a c y o f t h e i n i t i a l h i s t o r y a n d p h y s i c a l e xa mi n a t i o n t o e s t a b l i s h t h e e t i o l o g y o f e r e c t i l e d y s f Ur olt ogy1 9 9 5 ; 4 5 : 4 9 8 5] 0 2 unc ion. .

E RE C T I L E D Y S F UNC T I O N C L I NI C AL O C C URRE NC E : Congeni t al e n e t i c d i s o r d e r s i mp a i r i n g s e xu a l ma t u r a t i o n ( e . g . , P r a d e r W i l l i g s y n d r o me ) o r l e a d i n g t o h y p o g o n a d i s m ( e . g . , h e mo c h rEndoc r i ine ;r i ma r y o ma t o s s ) p h y p o g o n a d i s m, h y p o t h y r o i d i s m, h y p o p i t u i t a r i s m, d i a b e t edi opat ihiu s ; I s me l l t c h y p e r t e n s i o n , a t h e r o s c l e r Ms i sabol i c / Toxme d i c a t i o n s ( a n t i h y p e r t e n s i v e s , o et ; ic a n xi o l y t i c s , a n t i d e p r e s s a n t s ) , a l c o h o l , o p i a t e s , ma r i j u a n a , c h r o n i c r e n a l f a i l u r e ; M ec hani c al / Tr aumat iocs t r a d i c a l p r o s t a t e c t o my, r a d i a t i o n , l o n g - d i s t a n c e b i c y c l i n g ; p Neur ol ogi c e r i p h e r a l n e u r o p a t h y, my e l i t i s , s p i n a l c o r d c o mp r e s s i o n , mu l t i p l e p s c l e r o s i s , d e me n tPs ;y c hos oc i al e p r e s s i o n , a n xi e t y ; c ul ara t h e r o s c l e r o s i s , ia d Vas vasculitis.

Re i t e r S y n d r o m e : P a t h o p h y s i o l o g T : i s r e a c t i v e a r t h r i t i s s y n d r o me o c c u r s f o l l o w i n g a s e xu a l l y yh t r a n s mi t t e d d i s e a s e o r d i a r r h e a l i l l n e s s e s . It i n v o l v e s c h r o n i c r e c u r r e n t i n f l a mma t i o o f t h e u r e t h r a , c o n j u n c t i v a e , s k i n , p e r i a r t i c u l a r t i s s u e , a n.d Pl a tr ig e tj s i n t s en o present with urethritis, conjunctivitis, arthritis, back pain, and/or characteristic skin d i s e a s e o n t h e f e e t a n d g l a n s p e n i s . D i a g n o s i s r e s t s o n f i n d i n g mu l t i s y s t e m i n v o l v e me n t i n a p a t i e n t w i t h a c o mp a t i b l e h i s t o r y a n d w i t h o u t o t h e r d e mo n s t r a b l e disease. T here is no diagnostic test. Behet Syndr ome: P a t h o p h y s i o l o gA :d i s e a s e o f u n k n o w n c a u s e w i t h i n c r e a s e d f r e q u e n c y i n c e r t a i n y p o p u l a t i o n s ( e a s t e r n M e d i t e r r a n e a n , J a.p S ne rs ee i n f l a mma t i o n i n v o l v e s at e il ) mu l t i p l e o r g a n s s i mu l t a n e o u s l y o r s e q u e n t i a l l y. P a t i e n t s f r e q u e n t l y p r e s e n t w i t h a p h t h o u s u l c e r s o f t h e mo u t h o r g e n i t a l t r a c t . E y e i n v o l v e me n t c a n l e a d t o b l i n d n e s It n e e d s t o b e c o n s i d e r e d i n p a t i e n t s w i t h p a i n f u l g e n i t a l u l c e r a t i o n . P a t h e r g y, s t e r i p u s t u l e s t h a t f o r m a t t h e s i t e o f n e e d l e i n j u r y, i s p a t h o g n o mo n i c . Klinefelter Syndr ome: P a t h o p h y s i o l o gAn a b n o r ma l c o mp l e me n t o f 4 7 c h r o mo s o me s ( XXY a n d v a r i a n t s ) y: p r o d u c e s v a r i a b l e ma s c u l i n i .za t ifo n t e d i n d i v i d u a l s a r e t a l l w i t h l o n g l e g s , Af e c a t r o p h i c t e s t e s a n d g y n e c o ma s t i a . T h e y a r e i n f e r t i l e .
P. 6 7 4

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 2 - T h e D i a g n o s t i c E xa m > C h a p t e r 1 3 - T h e S p i n e a n d E xt r e mi t i e s : T h e M u s c u l o s k e l e t a l a n d S o f t - T i s s u e E xa m

Chapter 13 The Spine and Extremities: The M usculoskeletal and Soft-Tissue Exam

T h e mu s c u l o s k e l e t a l s y s t e m h a s f o u r ma j o r f u n c t i o n a l c o mp o n e n t s : t h e b o n e s a n d l i g a me n t s , t h e s y n o v i a l a n d f i b r o c a r t i l a g i n o u s j o i n t s , t h e mu s c l e s a n d t e n d o n s , a n d t h e n e r v e s i n n e r v a t i n g t h e mu s c l e s . Te n d o n s a n c h o r mu s c l e t o b o n e w h i l e l i g a me n t s anchor bone to bone.

Major System s and their Physiology Bones and Ligaments

B o n e s p r o v i d e me c h a n i c a l s u p p o r t f o r t h e b o d y a n d p r o t e c t i o n f o r t h e v i s c e r a w i t h i n b o d y c a v i t i e s a n d t h e s k u l l . M a t u r e b o n e f o r ms b y mi n e r a l i za t i o n o f o s t e o i d l a i d d o w b y o s t e o b l a s t s o n a c a r t i l a g i n o u s ma t r i x i n t h e e p i p h y s e s o f t h e l o n g b o n e s , endplates of the vertebrae and cartilaginous structures (endochondral bones of the s k u l l a n d f a c e ) . C o r t i c a l b o n e f o r ms a t h i c k c o r t e x s u r r o u n d i n g a c e n t r a l h o l l o w, t h e ma r r o w s p a c e . T r a b e c u l a r b o n e f o r ms a n i n t r i c a t e l a t t i c e l a i d d o w n a l o n g t h e l i n e s o s t r e s s w i t h i n t h e ma r r o w c a v i t y. B o n e i s c o n s t a n t l y r e mo d e l e d b y r e a b s o r p t i o n b y o s t e o c l a s t s c o mb i n e d w i t h n e w b o n e f o r ma t i o n . S t r u c t u r a l s t r e n g t h o f b o n e mu s t b e s u f f i c i e n t t o r e s i s t c o mp r e s s i o n a n d t e n s i o n a p p l i e d b y me c h a n i c a l l o a d i n g f o r c e s a n d mu s c l e t r a c t i o n . T h e s t r e n g t h o f b o n e d e p e n d s u p o n n o r ma l a r c h i t e c t u r e , c o l l a g e n , a n d mi n e r a l i za t i o n ; a b n o r ma l i t y o f e a c h r e s u l t s i n w e a k b o n e s u s c e p t i b l e f r a c t u r e . T h e s h a p e o f ma t u r e b o n e i s i n f l u e n c e d b y t h e p u l l o f t h e mu s c l e s a t t h e i r a n a t o mi c o r i g i n s a n d i n s e r t i o n s d u r i n g s k e l e t a l ma t u r a t i o n . M u s c l e s t h a t i n s e r t o n a s ma l l p o r t i o n o f b o n e a n d e xe r t l a r g e f o r c e s d e f o r m t h e b o n e i n t o p r o mi n e n c e s , f o r e xa mp l e , t h e f e mo r a l t r o c h a n t e r s . Ad j a c e n t b o n e s a r e i n t e r c o n n e c t e d b y l i g a me n t s that are collagenous structures continuous with the collagen of the bone itself. L i g a me n t s s t a b i l i ze t h e b o n e s r e l a t i v e t o o n e a n o t h e r a n d t h e i n t e r v e n i n g j o i n t s .

Joints and Bursae

Joints separate articulated bones. Fibrocartilage separates bones at joints where mo t i o n i s mi n i ma l , f o r e xa mp l e , t h e i n t e r v e r t e b r a l d i s c s . S y n o v i a l ( d i a r t h r o d i a l ) j o i n t s e p a r a t e b o n e s w h e r e mo t i o n i s e xt e n s i v e . T h e b o n e P. 6 7 6 s u r f a c e s o f d i a r t h r o d i a l j o i n t s a r e c o v e r e d w i t h s p e c i a l i ze d h y a l i n e c a r t i l a g e a r c h i t e c t u r a l l y d e s i g n e d t o r e s i s t r e p e a t e d a xi a l l o a d i n g w i t h mi n i ma l d e f o r ma t i o n w h i l e p r o v i d i n g a s mo o t h , v i r t u a l l y f r i c t i o n - f r e e s u r f a c e f o r mo t i o n . T h e a v a s c u l a r


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cartilage derives its nutrition from the synovial fluid by diffusion. T he diarthrodial joints are enclosed within a synovial envelope of collagen lined with a single cell layer of synovium that secretes the proteoglycans necessary for joint lubrication. J o i n t i n t e g r i t y i s ma i n t a i n e d b y l i g a me n t s a n c h o r i n g b o n e t o b o n e a n d t h e f o r c e s e xe r t e d b y mu s c l e s w h o s e t e n d o n s c r o s s t h e j o i n t . T h e o v e r a l l s h a p e o f t h e b o d y i s attributable to its skeletal structures.

M uscles and Tendons

See also hapter 14 C , The Neur ol ogi c Ex ami natSoni a t e d s k e l e t a l mu s c l e e xe r t s . i tr c o n t r a c t i l e f o r c e p r o xi ma l l y o n o n e b o n e a t i t s o r i g i n a n d d i s t a l l y v i a a v a r i a b l y e l o n g a t e d t e n d o n o n t o i t s i n s e r t i o n o n a n o t h e r b o n e . T h e r e f o r e , mu s c u l a r c o n t r a c t i o s e r v e s t o c h a n g e t h e r e l a t i v e p o s i t i o n o f t h e b o n e s . M o s t mu s c l e s o r i g i n a t e d i f f u s e l d i r e c t l y f r o m t h e p e r i o s t e u m, w h i l e s o me a t t a c h b y t e n d o n s a t b o t h t h e i r o r i g i n a n d i n s e r t i o n , f o r e xa mp l e , t h e l o n g h e a d o f t h e b i c e p s . Te n d o n s a r e e l o n g a t e d , r e l a t i v e avascular collagen structures that are continuous at their origin with the interstitial c o l l a g e n o f t h e mu s c l e a n d a t t h e i r i n s e r t i o n w i t h t h a t o f t h e b o n e . Te n d o n s ma y l i e free in the tissue, but are often surrounded by synovial sheaths or bursae where th c r o s s mo b i l e j o i n t s o r p a s s a r o u n d b o n y p r o mi n e n c e s . B u r s a e a r e s y n o v i a l - l i n e d c a v i t i e s s e r v i n g t o r e d u c e f r i c t i o n b e t w e e n t e n d o n s o r mu s c l e s a n d u n d e r l y i n g b o n e M u s c l e s a r e h i g h l y v a s c u l a r r e q u i r i n g h i g h l e v e l s o f o xy g e n d e l i v e r y t o e f f i c i e n t l y c o n v e r t s t o r e d g l y c o g e n a n d f a t t y a c i d s i n t o e f f e c t i v e me c h a n i c a l p o w e r. M u s c l e i s enclosed with an inelastic collagenous fascia. Muscle is susceptible to tearing from t h e f o r c e o f i t s o w n c o n t r a c t i o n . Is c h e mi c n e c r o s i s ma y o c c u r w h e n c o n t r a c t i n g w i t h a c o mp r o mi s e d b l o o d s u p p l y. B o d y c o n t o u r s r e s u l t f r o m mu s c l e s a n d s u b c u t a n e o u s f a t o v e r l y i n g t h e s k e l e t o n . As y mme t r y o r a b n o r ma l i t i e s o f b o d y c o n t o u r s u g g e s t c h a n g e s i n t h e u n d e r l y i n g mu s c l e s , o r l e s s c o mmo n l y, f a t d i s t r i b u t i o n .

T he Spine and Extrem ities: Superficial Anatom y


S e e t h e d e s c r i p t i o n s o f e a c h a n a t o mi c l o c a t i Phyu nc alr Ex ami nat ia n d on si de on t e xt s o n a n a t o my f o r a r t i s t s .

The Axial Skeleton: Spine and Pelvis


The Cerv ical Spine

T h e c e r v i c a l s p i n e ma y b e c o n s i d e r e d a p a r t f r o m t h e r e ma i n d e r o f t h e s p i n a l c o l u mn (F i g . 1 3 - 1)A T h e b o n e s o f t h e s p i n e a r e c o n s i d e r e d a l o n g w i t h t h e i r l i g a me n t o u s . a t t a c h me n t s , i n t e r v e r t e b r a l d i s k s , a n d mu s c u l a t u r e . P. 6 7 7 T h e r e a r e s e v e n c e r v i c a l v e r t e b r a e , t h r e e o f w h i c h a r e s p e c i a l i ze d : C 1 i s t h e a t l a s ( b e a r i n g a g l o b e , l i k e t h e G r e e k g o d a f t e r w h o m i t i s n a me d ) ; C 2 i s t h e a xi s a b o u t w h i c h t h e a t l a s r o t a t e s ; a n d C - 7 i s t h e v e r t e b r a p r o mi n e n s . N o d d i n g o f t h e h e a d o c c u r s c h i e f l y a t t h e a t l a n t o o c c i p i t a l j o i n t . F l e xi o n a n d e xt e n s i o n i n v o l v e t h e o c c i p u C 1 a n d C 3 t o C 7 . Al l v e r t e b r a e p e r mi t l a t e r a l b e n d i n g . H a l f o f r o t a t i o n o c c u r s a t t h e a t l a n t o a xi a l j o i n t , w i t h t h e r e ma i n d e r d i s t r i b u t e d t h r o u g h t h e c e r v i c a l s p i n e . F o r me a s u r e me n t s o f c e r v i c a l mo t i o n ,i gs. e1 3 - 1.B F e

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F i g . 1 3 - 1 A n a t o m y a n d M o t i o n s o f t h e C e r vi c a l S p i n e . A . T h e S k e l e t o n o f t h e C e r vi c a l S p i n e . B . M o t i o n s o f t h e C e r vi c a l Smal er:ange of Nor p i n mot i on ex c eeds t he angl es , whi c h ar e s hown as poi nt s of r ef er enc e .

Thoracolumbar Spine and Pelv is

B e l o w t h e n e c k , t h e v e r t e b r a l c o l u mn h a s 1 2 t h o r a c i c ( d o r s a l ) v e r t e b r a e , 5 l u mb a r v e r t e b r a e , a f u s e d ma s s o f 5 s a c r a l v e r t e b r a e a r t i c u l a t e d w i t h t h e p e l v i c b o n e s a t t h s a c r o i l i a c j o i n t a n d 4 v a r i o u s l y s e p a r a t e d c o c c y g e a l v e r t e b r a e . Vi e w e d l a t e r a l l y, t h e v e r t e b r a l c o l u mn p r e s e n t s f o u r c F irg .e s 3 - 2)A L e a s t p r o n o u n c e d i s t h e c e r v i c a l u v 1 ( . curve, which is concave backwards, beginning at C2 and ending at T 2. T he thoracic c u r v e i s c o n v e x b a c k w a r d s , b e g i n n i n g a t T 2 a n d e n d i n g a t T 1 2 . T h e l u mb a r c u r v e , mo r e p r o n o u n c e d i n t h e f e ma l e , i s c o n c a v e b a c k w a r d s , f r o m T 1 2 t o t h e l u mb o s a c r a l j o i n t . T h e p e l v i c c u r v e , c o n v e x b a c k w a r d s a n d d o w n w a r d , e xt e n d s f r o m t h e l u mb o s a c r a l j o i n t t o t h e t i p o f t h e c o c c y x. T h e s p i n a l mo t i o n s a r e f l e xi o n e xt e n s i o n , l a t e r a l b e n d i n g , a n d r o t a t i o n . F o r me t h o d s o f me a s u rF i me n t3 -s2.B e g. 1 ee

Appendicular Skeleton Including Joints, Ligaments, Tendons, and Soft Tissues


The Hand
T h e h a n d i n c l u d e s t h e c a r p a l , me t a c a r p a l , a n d p h a l a n g e a l b o n e s , t h e i r j o i n t s , a n d t h e c o v e r i n g s o f t t i s s u e s . Ab n o r ma l i t i e s i n s i ze a n d d i s p r o p o r t i o n s i n a p a r t a r e u s u a l l y c a u s e d b y b o n e a b n o r ma l i t i e s . Ture of t he hands u l t s f r o m t h e pos t h e re r e l a t i v e t o n e o f t h e f i n g e r a n d w r i s t f l e xo r s , e xt e n s o r s , a n d i n t r i n s i c h a n d mu s c l e s and the presence or absence of joint disorders. P. 6 7 8

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F i g . 1 3 - 2 B o n e s a n d M o t i o n s o f t h e S p i n e . A . L a t e r a l vi e w o f t h e f o u r s p i n e c u r ve s . B . S p i n a l m o t i o n s : f l e xi o n - e xt e n s i o n , l a t e r a l b e n d i. n g , r o t a t i o n

P. 6 7 9

Fig. 13-3 Bones of the Wrist .

The Wrist

T he wrist includes the radiocarpal joint, the eight carpal bones in two parallel rows a n d t h e o v e r l y i n g t e n d o n s a n d t e n d o n sF ie a t h s -)(3 T h e r a d i o c a r p a l j o i n t i s h g. 13 . t h e a r t i c u l a t i o n o f a c o n c a v e w i t h a c o n v e x s u r f a c e . T h e p r o xi ma l c o n c a v e s u r f a c e i f o r me d b y t h e d i s t a l e n d o f t h e r a d i u s a n d t h e a d j a c e n t t r i a n g u l a r a r t i c u l a r d i s k t h a t caps the distal end of the ulna. T he distal convex surface consists of the curving s i d e s o f t h r e e c a r p a l b o n e s o f t h e p r o xi ma l r o w, f r o m t h e r a d i a l t o t h e u l n a r s i d e , t h n a v i c u l a r, t h e l u n a t e , a n d t h e t r i q u e t r u m. T h e p i s i f o r m d o e s n o t p a r t i c i p a t e b e c a u s e l i e s o n t h e v o l a r a s p e c t o f t h e t r i q u e t r u m. T h e n a v i c u l a r i s mo s t c o mmo n l y f r a c t u r e d because the radius has wider contact with it than with the lunate, and the forces t r a n s mi t t e d f r o m t h e u l n a t o t h e t r i q u e t r u m a r e c u s h i o n e d b y t h e a r t i c u l a r d i s k . T h e ma j o r s y n o v i a l c a v i t y l i e s b e t w e e n r a d i u s a n d t h e n a v i c u l a r. A mi n o r c a v i t y s e p a r a t e
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t h e d i s t a l e n d o f t h e u l n a a n d t h e a r t i c u l a r d i s k , e xt e n d i n g p r o xi ma l l y b e t w e e n t h e radius and ulna.

K n o w l e d g e o f t h e t o p o g r a p h y i s n e c e s s a r y t o e xa mi n a t i o n o fi g .h e 3 -)r.i s t ( F t 1 w4 Vo l a r A s p e c t o f t h e W r iT h : p i s i f o r m b o n e c a n b e p a l p a t e d a s a b o n y ste p r o mi n e n c e o n t h e u l n a r s i d e , j u s t d i s t a l t o t h e p a l ma r c r e a s e a n d p r o xi ma l t o t h e b a s e o f t h e h y p o t h e n a r e mi n e n c e . F o u r t e n d o n s c a n b e p a l p a t e d a n d o f t e n s e e n . W i t h t h e d i g i t s s l i g h t l y f l e xe d a n d mu s c l e s t e n s e d , t h r e e t e n d o n s a r e a p p a r e n t i n mo s t p e r s o n s . F r o m t h e u l n a r t o t h e r a d i a l s i d e , t h e y a r e t h e f l e xo r c a r p i u l n a r i s , p a l ma r i s l o n g u s , a n d f l e xo r c a r p i r a d i a l i s . T h e p a l ma r i s l o n g u s i s a b s e n t i n a p p r o xi ma t e l y 1 0 % o f p e r s o n s . W i t h t h e f i s t c l e n c h e d h a r d , t h e t e n d o n o f t h e f l e xo r d i g i t o r u m s u b l i mi s a l s o a p p e a r s b e t w e e n t h e f l e xo r c a r p i u l n a r i s a n d t h e p a l ma r i s l o n g u s . o r s a l A s p e c t o f t h e W r Ts te mo s t c o n s p i c u o u s p r o mi n e n c e i s t h e u l n a r D i h: s t y l o i d p r o c e s s . E xt e n s i o n o f t h e t h u mb a c c e n t u a t e s t h e b o r d e r s o f t h e a n a t o mi s t ' s s n u f f b o x, a r e c e s s f o r me d b y t h e mo r e p r o mi n e n t l a t e r a l e xt e n s o r p o l l i c i s l o n g u s a n me d i a l l y b y t h e l e s s p r o n o u n c e d e xt e n s o r p o l l i c i s b r e v i s . In t h e i n t e r v e n i n g h o l l o w the radial artery and the radial styloid process can be felt. On the volar side P. 6 8 0 o f t h e e xt e n s o r p o l l i c i s l o n g u s t e n d o n i s a p r o mi n e n c e f o r me d b y t h e a r t i c u l a r ma r g i o f t h e r a d i u s , c a l l e d t h e d o r s a l r a d i a l t u b e r c l e ( L i s t e r t u b e r c l e ) ; t h i s ma r k s t h e l i p o the tendon's groove.

F i g . 1 3 - 4 T h e W r i s t . A . To p o g r a p h y o f t h e W r i s t J o i n t . B . M o t i o n s o f t h e Wrist Joint .

The Forearm

T h e f o r e a r m e xt e n d s f r o m t h e e l b o w t o t h e w r i s t i. on n dpal pat i on r e u s e d I ns pec a a f o r e xa mi n a t i o n . T h e r a d i u s a n d u l n a a r t i c u l a t e w i t h t h e h u me r u s p r o xi ma l l y. T h e y a c o n n e c t e d b y a n i n t e r o s s e o u s me mb r a n e t h r o u g h o u t mo s t o f t h e i r l e n g t h . T h e r a d i u s and ulna are practically subcutaneous, so their entire length can be palpated. T he d o r s a l mu s c l e ma s s i s f o r me d b y t h e w r i s t a n d f i n g e r e xt e n s o r mu s c l e s w h i c h i n s e r t
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o n t h e l a t e r a l e p i c o n d y l e o f t h e h u me r u s . T h e v o l a r ma s s i s t h e f i n g e r a n d w r i s t f l e xo r s i n s e r t i n g o n t h e me d i a l e p i c o n d y l e .

The Elbow

T h e r e a r e t w o a r t i c u l a t i o n s i n t h e e l b o w. T h e h i n g e d h u me r o u l n a r j o i n t i s f o r me d b y t h e s e mi l u n a r n o t c h o f t h e u l n a r o l e c r a n o n p r o c e s s e mb r a c i n g a n d mo v i n g a r o u n d t h e t r a n s v e r s e d r u m o f t h e s p o o l - s h a p e d t r o c h l e a o f t h e d i s Fa g .h u me )A s ( t i l 1 3 - 5r .u W h e n t h e e l b o w i s i n f u l l e xt e n s i o n , t h e o l e c r a n o n p r o c e s s f i t s i n t o t h e o l e c r a n o n f o s s a o f t h e h u me r u s j u s t a b o v e t h e t r o c h l e a . T h e t r o c h l e a f o r ms t h e me d i a l t w o t h i r d s o f t h e l o w e r h u me r a l a r t i c u l a t i o n . T h e l a t e r a l t h i r d i s t h e r o u n d e d c a p i t u l u m o which a cup-shaped depression in the radial head pivots and glides to form the h u me r o r a d i a l j o i n t . T h e r a d i a l h e a d i s a s q u a t c y l i n d e r w h o s e s i d e s r o t a t e i n t h e a n n u l a r l i g a me n t d u r i n g p r o n a t i o n a n d s u p i n a t i o n o f t h e f o r e a r m.

Vi e w e d f r o m t h e b aF ikg .( 1 3 -)6 t h e f l e xe d e l b o w p r e s e n t s t h r e e b o n y p r o mi n e n c e s c , of an inverted equilateral triangle: the two basal P. 6 8 1 P. 6 8 2 p o i n t s a r e t h e me d i a l a n d l a t e r a l e p i c o n d y l e s o f t h e h u me r u s , t h e t i p o f t h e o l e c r a n o p r o c e s s f o r ms t h e a p e x. D u r i n g f u l l e xt e n s i o n , t h e t h r e e p o i n t s f o r m a s t r a i g h t transverse line.

Fig. 13-5 Structure and Motions of the Elbow .

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F i g . 1 3 - 6 To p o g r a p h i c R e l a t i o n s o f t h e IE l b o t ens i on, t he ul nar . n ex w ol ec r anon pr oc es s l i es on a s t r ai ght l i ne bet ween t he medi al and t he l at er al epi c ondy l es of t he el bow. I n f l ex i on, t he ol ec r anon pr oc es s mov es downwar d t o pr oduc e an i nv er t ed equi l at er al t r i angl e bet ween t he t hr ee bony pr omi nenc es . Any di s t or t i on of t hi s t r i angl e af t er t r auma poi nt s t o a f r ac t ur e i nv ol v i ng one or mor e of i t s poi .nt s

The Shoulder

T h e s h o u l d e r g i r d l e i n c l u d e s b o n e s ( h u me r u s , s c a p u l a , c l a v i c l e , s t e r n u m) , j o i n t s ( g l e n o h u me r a l , a c r o mi o c l a v i c u l a r, s t e r n o c l a v i c u l a r, a n d s c a p u l o t h o r a c i c ) , t h e i r l i g a me n t o u s c o n n e c t i o n s , a n d t h e o v e r l y i n g mu s c l e s , t e n d o n s , a n d b u r s a e . T h e s h o u l d e r j o i n t i s a b a l l - a n d - s o c k e t a r t i c u l a t i o n w i t h t h e h e mi s p h e r i c h u me r a l h e a d f i t t i n g i n t o t h e s h a l l o w s c a p u l a r g l e n o i d i c a v1 t y)7 T h e a r t i c u l a t i n g s u r f a c e s F g . i 3 - .( are enclosed by a short tube of joint capsule. T he scapular coracoid process projects P. 6 8 3 a n t e r i o r a n d me d i a l t o t h e j o i n t a n d t h e a c r o mi o n f o r ms a r i g i d f e n d e r a b o v e t h e j o i n T h e y a r e c o n n e c t e d b y t h e c o r a c o a c r o mi a l l i g a me n t . T h e c l a v i c l e i s c o n n e c t e d t o t h a c r o mi o n b y t h e s u p e r i o r a c r o mi o c l a v i c u l a r l i g a me n t a n d t o t h e u n d e r l y i n g c o r a c o i d p r o c e s s b y t h e c o r a c o c l a v i c u l a r l i g a me n t . F r o m i t s o r i g i n w i t h i n t h e j o i n t c a p s u l e , t h t e n d o n o f t h e l o n g h e a d o f t h e b i c e p s e me r g e s a n t e r i o r l y t h r o u g h a c a p s u l a r o p e n i n b e t w e e n t h e g r e a t e r a n d l e s s e r t u b e r c l e s o f t h e h u me r a l h e a d . T h e j o i n t c a p s u l e i s l i n e d b y a s y n o v i a l me mb r a n e w i t h a p r o l o n g a t i o n f o r mi n g a t u b u l a r s h e a t h f o r t h e b i c e p s t e n d o n w h i c h f o l l o w s t h e t e n d o n d i s t a l l y t o t h e s u r g i c a l n e c k o f t h e h u me r u s

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F i g . 1 3 - 7 A n a t o m y o f t h e S h o u l d e r. J o i n ant er i or wi ndow i n t he j oi nt The t c aps ul e ex pos es t he i nner at t ac hment of t he bi c eps br ac hi i mus c l e .

T h e j o i n t c a p s u l e i s l o o s e , e xe r t i n g l i t t l e t e n s i o n e xc e p t i n e xt r e me p o s i t i o n s . T h e r e f o r e , s h o u l d e r s t a b i l i t y i s ma i n t a i n e d b y mu s c l e p u l l . T h e s h o u l d e r j o i n t e n j o y g r e a t f r e e d o m o f mo t i o n f r o m t h e s h a l l o w n e s s o f t h e g l e n o i d c a v i t y a n d t h e l a c k o f r e s t r a i n i n g l i g a me n t s , b u t t h i s a l s o ma k e s i t v u l n e r a b l e t o d i s l o c a t i o n . T h e s c a p u l a h e l d t o t h e t h o r a c i c w a l l e n t i r e l y b y i t s mu s c u l a r a t t a c h me n t s , i t s w i n g g l i d i n g f r e e l y o v e r t h e t h o r a c i c mu s c l e s . S c a p u l a r mo v e me n t s a d d g r e a t l y t o t h e mo b i l i t y o f t h e u p p e r l i mb , s o s c a p u l a r mo t i o n mu s t b e d i s t i n g u i s h e d f r o m mo v e me n t s o f t h e g l e n o h u me r a l j o i n t . T h e s i n g l e l i g a me n t - b o n e c o n n e c t i o n o f t h e s h o u l d e r g i r d l e t o t h a xi a l s k e l e t o n i s v i a t h e a c r o mi o c l a v i c u l a r j o i n t , t h e c l a v i c l e , a n d t h e s t e r n o c l a v i c u l joint.

T h e p r i n c i p a l b o n y l a n d ma r k s o f t h e s h o u l d e r f o r m a r i g h t - a n g l e d t r i a n g l e : t h e t i p o f t h e c o r a c o i d , t h e g r e a t e r t u b e r c l e o f t h e h u me r a l h e a d , a n d t h e a c r o mi o n . T h e r i g h t a n g l e i s a t t h e g r e a t e r t u b e r c l e . T h e a c r o mi o n i s e a s i l y s e e n a n d f e l t b e y o n d t h e e n of the clavicle. T he coracoid is palpated near the anterior border of the deltoid mu s c l e o n a h o r i zo n t a l l i n e w i t h t h e g r e a t e r t u b e r c l e .

The Hip Joint and Thigh

In t h e d i a g n o s t i c e xa mi n a t i o n , t h e h i p j o i n t a n d t h i g h a r e c o n s i d e r e d t o g e t h e r. T h e f e mo r a l a xi s s l a n t s me d i a l l y t o w a r d t h e k n e e . T h e g r e a t e r t r o c h a n t e r o f t h e f e mu r p r e s e n t s a l a t e r a l b o n y ma s s , p a l p a b l e t h r o u g h t h e t h i g h gmu s c l8)A O n F i . 1 3 - e.s ( t h e me d i a l s i d e a n d a l i t t l e d i s t a l i s t h e l e s s e r t r o c h a n t e r, s ma l l e r i n s i ze a n d i n a c c e s s i b l e t o p a l p a t i o n . Ar i s i n g b e t w e e n t h e t r o c h a n t e r s , t h e f e mo r a l n e c k s l a n t s p r o xi ma l l y a n d me d i a l l y, f o r mi n g a n a n g l e w i t h t h e f e mo r a l a xi s o f 1 2 0 1 6 0 d e g r e e s . An i n c r e a s e i n t h e a n g l e p r o d u c e s l a t e r a l d e v i a t i o n o f t h e f e moa av al h, a f t , c ox r l s ga a d e c r e a s e i n t h e a n g l e d e v i a t e s t h e s h a f t c oxd i a lar.aT h e n e c k i s me a v l y, s u r mo u n t e d b y t h e g l o b u l a r f e mo r a l h e a d , w h i c h f i t s i n t o t h e c u p p e d a c e t a b u l u m o f t h e p e l v i s , f o r mi n g a b a l l - a n d - s o c k e t j o i n t . T h i s j o i n t p e r mi t s f l e xi o n - e xt e n s i o n , a b d u c t i o n - a d d u c t i o n , a n d i n t e r n a l - e xt e r n a l F og .a t1 o n8)(. An i mp o r t a n t ri t i3- C t o p o g r a p h i c r e l a t i o n s h i p i s d e f i n e d b y t h e N l a t o n l i n e , e xt e n d i n g f r o m t h e a n t e r o s u p e r i o r i l i a c s p i n e t o t h e i s c h i a l t u b e r o s i t y. W i t h t h e t h i g h f l e xe d , t h e l i n e passes through the tip of the greater trochanter; an upward deviation of 1 cm is c o n s i d e r e d n o r ma li g(. 1 3 - 8)B F .

The Knee
T h e k n e e r e g i o n i n c l u d e s t h e t i b i o f e mo r a l a n d t i b i o f i b u l a r j o i n t s , t h e p a t e l l a , t h e a d j a c e n t s e g me n t s o f t h e f e mu r, t i b i a , a n d f i b u l a , t h e i r l i g a me n t s , P. 6 8 4 P. 6 8 5 me n i s c i , a n d mu s c l e s . Vi e w e d f r o m F ie l .o w3(-)9 t h e a r t i c u l a r s u r f a c e o f t h e bg 1 , f e mu r i s s h a p e d l i k e a h o r s e s h o e w i t h i t s o p e n e n d p o s t e r i o r. T h e t w o a n t e r o p o s t e r i o r l e g s o f t h e s h o e a r e f o r me d b y n e a r l y p a r a l l e l l a t e r a l a n d me d i a l
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f e mo r a l c o n d y l e s , s e p a r a t e d b y t h e i n t e r c o n d y l a r f o s s a . T h e s u r f a c e o f t h e a n t e r i o r b o w i s i n d e n t e d b y a s h a l l o w me d i a n g r o o v e c u r v i n g u p w a r d o n t o t h e a n t e r i o r f e mu r the patellar articular surface. Superior to the articular surfaces of the condyles are t h e me d i a l a n d l a t e r a l e p i c o n d y l e s . Vi e w e d f r o m a b o v e , t h e a r t i c u l a r s u r f a c e o f t h e t i b i a p r e s e n t s t w o l a t e r a l a l mo s t f l a t , o v a l f a c e t s , t h e me d i a l a n d l a t e r a l t i b i a l c o n d y l e s , s e p a r a t e d b y a n i n t e r c o n d y l a r f o s s a w i t h a n t e r i o r a n d p o s t e r i o r s e g me n t s T h e l a t e r a l b o r d e r s o f t h e f o s s a a r e t h e r a i s e d r i ms o f t h e c o n d y l e s , t h e i n t e r c o n d y l a r e mi n e n c e s . O n t h e c e n t r a l a n t e r i o r t i b i a , s l i g h t l y b e l o w t h e j o i n t , i s t h t i b i a l t u b e r o s i t y.

Fig. 13-8 Anatomy and Motions of the Hip Joint. A. Skeleton of the Left Hip J o i n t . B . R e l a t i o n s o f t h e F e m o r a l Theafd : H e emor al gr eat er t r oc hant er l i es on t he Nl at on l i ne bet ween t he ant er i or s uper i or i l i ac s pi ne and t he i s c hi al t uber os i t y. The r el at i v e pos i t i ons of t he f emor al heads wi t h r es pec t t o t he t r oc hant er s c an be c ompar ed on t he t wo s i des as i l l us t r at ed. The t humbs ar e pl ac ed on t he ant er i or s uper i or i l i ac s pi nes , whi l e t he f i nger s r es t on t he gr eat er t r oc hant er s of t he f emor a. Smal l di s par i t i es i n di s t anc e ar e r eadi l y det ec t edC . M o t i o n s o f t h e H i p J. o i n t .

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F i g . 1 3 - 9 A r t i c u l a r S u r f a c e s a n d L i g a m e n t s o f t h e R.i g h t K n e e

T h e k nee j oi nt has t hr ee ar t i c ul at i onsd i a l a n d a l a t e r a l c o n d y l a r a r t i c u l a t i o n a me : a n d a n a n t e r i o r j o i n t w h e r e t h e p a t e l l a g l i d e s o v e r t h eFfi e mu r -(9 e eh e g . 1 3 )s T . f e mo r a l c o n d y l e s ma y b e l i k e n e d t o t w o t h i c k d i s k s w i t h t h e i r e d g e s r e s t i n g o n t h e a l mo s t f l a t t i b i a l c o n d y l e s . T h e P. 6 8 6 s ma l l r a d i u s o f c u r v a t u r e o f t h e f e mo r a l c o n d y l e s p r e s e n t s l i t t l e a p p o s i n g s u r f a c e w i t h t h e t i b i a i n a n y p o s i t i o n . T h e l a t e r a l a n d me d ia rl e f l a t t e n e d c r e s c e n t s meni s c a of fibrocartilage that rim the peripheral borders of the tibial condyles. T heir crosss e c t i o n s a r e w e d g e - s h a p e d , w i t h t h e t h i c k e s t p a r t o u t w a r d . T h i s a r r a n g e me n t deepens the articular surfaces of the tibial condyles and fills the space between the c u r v e d f e mo r a l c o n d y l e s a n d t h e f l a t t e r t i b i a l s u r f a c e . T h e me n i s c i a r e c o v e r e d w i t h s mo o t h s y n o v i a l me mb r a n e s . T h e e n d s o f t h e i r c r e s c e n t s a r e a t t a c h e d t o t h e intercondylar fossa.

T h e p r i n c i p a l i n t e r n a l l i g a me n t s a r e er i e and pos t er i or c r uc i at e l i gament s ant t h or , n a me d f o r t h e p o s i t i o n s o f t h e i r t i b i a l a t t a c h me n t s a n d t h e i r c r o s s i n g a r r a n g e me n t ( s e eF i g . 1 3 -)9 T h e a n t e r i o r c r u c i a t e l i g a me n t b e g i n s i n f r o n t o f t h e a n t e r i o r t i b i a l . i n t e r c o n d y l o i d e mi n e n c e a n d p a s s e s u p w a r d , b a c k w a r d , a n d l a t e r a l w a r d t o t h e b a c k o f t h e l a t e r a l f e mo r a l c o n d y l e . T h e p o s t e r i o r c r u c i a t e l i g a me n t a t t a c h e s t o t h e p o s t e r i o r i n t e r c o n d y l o i d f o s s a , p a s s e s u p w a r d , f o r w a r d , a n d me d i a l l y, t o t h e f r o n t o t h e me d i a l f e mo r a l c o n d y l e .l at er al ( f i bul ar ) c ol l at er al l i gamentt r o n g T he is a s


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fibrous cord ascending vertically from the lateral aspect of the fibular head to the b a c k o f t h e l a t e r a l f e mo r a l c o n d y l e . It s o p p o s i t e i s t hte bi al ) c ol l at er al medi al ( i l i gament s c e n d i n g f r o m t h e me d i a l a s p e c t o f t h e me d i a l t i b i a l c o n d y l e t o t h e me d i a l a f e mo r a l c o n d y l e . T h e f l a t t r i a n g upat el l ,a a s e s a mo i d b o n e , i s e mb e d d e d i n t h e t e n d o n o f t h e lar q u a d r i c e p s f e mo r i s . T h e d i s t a l e xt e n s i o n o f t h i s t e n d o n i s t h e p a t e l l a r l i g a me n t , a t t a c h e d d i s t a l l y t o t h e t i b i a l t u b e r o s i t y. D u r i n g e xt e n s i o n o f t h e k n e e , t h e p a t e l l a r i d e s l o o s e l y i n f r o n t o f t h e d i s t a l f e mu r. In f l e xi o n , t h e p a t e l l a o p p o s e s t h e l a t e r a l p a r t o f t h e me d i a l f e mo r a l c o n dg .l e1 ( - 1 0 A w h i l e w i t h a c t i v e e xt e n s i o n i t i s Fi y 3 ), o f t e n p u l l e d a g a i n s t t h e l a t e r a l f e mo r a l c o n d y l e .

T h e h e a d o f t hie aa r t i c u l a t e s w i t h t h e l a t e r a l t i b i a l c o n d y l e b y a n a r t h r o d i a l j o i n t . f bul T his joint is inferior to the knee joint and entirely separated from it. T he fibula is h t o t h e t i b i a b y t h e j o i n t c a p s u l e a n d a n t e r i o r a n d p o s t e r i o r l i g a me n t s .

T h e j oi nt c aps ul e of t he k nee c o mp l e x o f f i b r o u s s h e e t s r e i n f o r c e d b y b a n d s is a f r o m t h e mu s c l e t e n d o n s c r o s s i n g t h e j o i n t . It i s a s i n g l e s y n o v i a l s a c t h a t e n v e l o p s t h e a r t i c u l a r s u r f a c e s o f b o t h p a i r s o f c o n d y l e s f o r mi n g t h e l a r g e s t j o i n t c a v i t y i n t h b o d y. A l a r g e s u p r a p a t e l l a r p o u c h o f t h e s a c a s c e n d s a n t e r i o r l y, f i r s t b e t w e e n t h e patella and the anterior P. 6 8 7 a s p e c t o f t h e f e mu r, t h e n i n t o a b u r s a b e t w e e n t h e q u a d r i c e p s t e n d o n a n d a f a t p a d i n f r o n t o f t h e f e mu r. A p r e c i s e u n d e r s t a n d i n g o f t h e e xt e n t o f t h i s s a c i s d i a g n o s t i c a l l y i mp o r t a n t .

F i g . 1 3 - 1 0 M o t i o n s a n d D e vi a t i o n s o f t h e K n e e .

T h e pr i nc i pal bur s ae of t he ka r e o f d i a g n o s t i c i mp o r t a n c e : ( a ) a b u r s a l y i n g nee b e t w e e n t h e s k i n a n d t h e p a t e l l a , t h e p r e p a t e l l a r b u r s a ; ( b ) a s ma l l e r b u r s a b e t w e e n t h e s k i n a n d t h e p a t e l l a r l i g a me n t , t h e s u p e r f i c i a l i n f r a p a t e l l a r b u r s a ; ( c ) a b u r s a b e t w e e n t h e s k i n a n d t h e t i b i a l t u b e r o s i t y ; ( d ) t h e a n s e r i n e b u r s a me d i a l a n d i n f e r i o t o t h e k n e e j o i n t b e t w e e n t h e t i b i a a n d t h e t e n d o n s o f t h e s e mi t e n d i n o s u s , g r a c i l i s , a n d s a r t o r i u s mu s c l e s . T h e s u p r a p a t e l l a r p o u c h o f t h e k n e e j o i n t e xt e n d i n g s u p e r i o r l y b e t w e e n t h e q u a d r i c e p s t e n d o n a n d t h e f e mu r i s n o t a t r u e b u r s a , a l t h o u g h i t f u n c t i o n s a s s u c h . It ma y b e e r r o n e o u s l y c a l l e d t h e s u p r a p a t e l l a r b u r s a .

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The Ankle

T he ankle joint is a hinged articulation between the tibia and the talus of the foot. T he articular surface of the talus, the trochlea, is rounded superiorly with a t r a n s v e r s e a xi s t h a t i s t i p p e d s l i g h t l y me d i a l l y, a n d f l a t t e n e d o n i t s me d i a l a n d l a t e r f a c e s F i g . 1 3 - 11 T h e u p p e r c u r v a t u r e a r t i c u l a t e s w i t h t h e f l a t s u r f a c e o f t h e l o w e r ( ). t i b i a . T h e p r o xi ma l s i d e s o f t h e j o i n t a r e f l a t , d o w n w a r d p r o j e c t i o n s , t h e me d i a l ma l l e o l u s o f t h e t i b i a a n d t h e l a t e r a l ma l l e o l u s o f t h e f i b u l a . T h e s e s e r v e a s t h e s i d e s o f a mo r t i s e , a r t i c u l a t i n g w i t h t h e f l a t l a t e r a l s u r f a c e s o f t h e t a l u s a n d s t a b i l i zi n g t h e j o i n t l a t e r a l l y a n d me d i a l l y. D u r i n g a n k l e f l e xi o n a n d e xt e n s i o n , t h e tibial surface glides over the curved surface of the talus changing the angle betwee l e g a n d f o o t a n d r o t a t i n g t h e l e g me d i a l l y P. 6 8 8 P. 6 8 9 o n t h e f o o t w i t h i n c r e a s i n g d o r s i f l e xi o n h e l p i n g t o t r a n s f e r w e i g h t t o w a r d t h e me d i a l foot and great toe during stance and push-off phases of gait. T he lower ends of the tibia and fibula are bound together by the anterior and posterior tibiofibular l i g a me n t s . T h e me d i a l ma l l e o l u s i s a t t a c h e d t o t h e t a l u s a n d c a l c a n e u s b y a t r i a n g u l a r b a n d , t h e t oi d l i gament h e l a t e r a l ma l l e o l u s i s a t t a c h e d b e l o w t o t h e del . T t a l u s a n d t h e c a l c a n e u s b y t h e c a l c a n e o f i b u l a r l i g a me n t a n d t h e a n t e r i o r a n d p o s t e r i o r t a l o f i b u l a r l i g a me n t s . T h e j o i n t c a p s u l e s u r r o u n d s t h e a r t i c u l a t i o n a n d i s l i n e d w i t h s y n o v i a l me mb r a n e .

F i g . 1 3 - 11 S t r u c t u r e o f t h e A n k l e J o i n t a.n d F o o t

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Fig. 13-12 Motions of the Ankle .

T h e mo t i o n s o f t h e a n k l e j o i n t a r e d o r s i f l e xi o n ( e xt e n s i o n ) a n d p l a n t a r f l e xi o n ( f l e xi o n )F ( g . 1 3 - 1 2 T h e o n l y b o n y l a n d ma r k s a r e t h e l a t e r a l a n d me d i a l ma l l e o l i ; i ). t h e l a t e r a l i s l o w e r t h a n t h e me d i a l .

The Foot

T h e f o o t i s a c o mp l e x s t r u c t u r e d e s i g n e d t o w i t h s t a n d t h e e n o r mo u s f o r c e s t r a n s mi t t e d f r o m t h e b o d y t o t h e g r o u n d d u r i n g w a l k i n g , r u n n i n g , a n d j u mp i n g . It i s b o t h f l e xi b l e a n d s t r o n g , a n d a b l e t o a d a p t t o v i r t u a l l y a n y g r o u n d s u r f a c e . It i s d i v i d e d i n t o t h endf oot t a l u s a n d c a l c a n e u s )df oot( n a v i c u l a r, c u b o i d a n d hi ( mi , me d i a l , i n t e r me d i a t e a n d l a t e r a l c u n e i f o r ms )f,or efd t h e t a t a r s a l s , a n oot me ( p h a l a n g e s , a n d s e s a mo i d s ) . T h e h i n d f o o t a n d mi d f o o t a r e s e p a r a t e d b y t h e transverse tarsal joint between the talus and the navicular and the calcaneus and th cuboid. T he transverse tarsal joint is responsible for inversion and eversion. T he mi d f o o t i s s e p a r a t e d f r o m t h e f o r e f o o t a t t h e t a r s o me t a t a r s a l j o i n t . T h e f o o t h a s t w o p r o mi n e n t a r c h e s : t h e l o n g i t u d i n a l a r c h f o r ms t h e i n s t e p me d i a l l y f r o m t h e t u b e r c l e s o f t h e c a l c a n e u s t o t h e h e a d s o f t h e me t a t a r s a l s ; a n d t h e me d i o l a t e r a l me t a t a r s a l a r c h f r o m t h e f i r s t t o t h e f i f t h me t a t a r s a l h e a d s . T h e c a l c a n e u s i s p a l p a b l e o n a l l b u i t s s u p e r i o r a n d d i s t a l s u r f a c e s . T h e b o n e s o f t h e mi d f o o t a n d f o r e f o o t a r e b e s t p a l p a t e d d o r s a l l y w h e r e t h e y a r e n o t c o v e r e d b y mu s c l e . T h e r e i s a b o n y p r o mi n e n c o n t h e mi d l a t e r a l ma r g i n j u s t a b o v e t h e s o l e f o r me d b y t h e t u b e r o s i t y o f t h e f i f t h me t a t a r s a l . T h e f o o t c a n b e v i s u a l i ze d a n a t o mi c a l l y a s a s e r i e s o f t r i a n g l e s , e a c h with an apex and a base. T he first has its apex at the calcaneus and its base along t h e me t a t a r s a l h e a d s . T h i s t r i p o d a l l o w s s t a b l e w e i g h t b e a r i n g o n u n e v e n g r o u n d . T he second is the longitudinal arch with its apex at the transverse tarsal joint and i b a s e t h e c a l c a n e u s a n d f i r s t me t a t a r s a l h e a d . T h e t h i r d i s t h e me t a t a r s a l a r c h , w i t h i t s b a s e t h e f i r s t a n d f i f t h me t a t a r s a l h e a d s a n d i t s a p e x t h e t h i r d me t a t a r s a l h e a d . L a s t l y, e a c h t o e f o r ms a t r i a n g l e w i t h t h e a p e x a t t h e p r o xi ma l i n t e r p h a l a n g e a l j o i n t
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a n d t h e b a s e a t t h e p a d o f t h e t o e a n d t h e me t a t a r s a l h e a d .

Physical Exam ination of the Spine and Extrem ities

B e c a u s e t h e e xa mi n a t i o n o v e r l a p s t h e i mp r e c i s e d i v i s i o n s b e t w e e n i n t e r n a l me d i c i n e n e u r o l o g y, a n d o r t h o p e d i c s , mo s t e xa mi n e r s f o l l o w a r o u t i n e i n w h i c h a n a t o mi c r e g i o n s a r e e xa mi n e d i n a s e q u e n c e d i c t a t e d P. 6 9 0 b y t h e me c h a n i c a l c o n v e n i e n c e o f t h e d o c t o r a n d p a t i e n t , r a t h e r t h a n a l o g i c a l e xp l o r a t i o n o f p h y s i o l o g i c a l s y s t e ms . An y a t t e mp t t o p r e s e n t d i a g n o s t i c f i n d i n g s a s t h e y a r e e n c o u n t e r e d i n a n a n a t o mi c r e g i o n n e c e s s i t a t e s c o n s i d e r a b l e c r o s s r e f e r e n c e t o t h e e xa mi n a t i o n o f t h e n e r v o u s a n d t h e p e r i p h e r a l v a s c u l a r s y s t e ms .

Examination of the Axial Skeleton: Spine and Pelvis


EXAMINATION OF THE CERVICAL SPINE
Fol l owi ng t r auma or s us pec t ed c er v i c al i nj ur y, t he c er v i c al s pi ne mus t ALWAYS be i mmedi at el y I M M OBI LI ZED i n a r i gi d c ol l ar PRI OR TO ANY M OVEM ENT or ex ami nat i on of t he pat i ent .

Ab s e n t t h i s s i t u a t i o n , e xa mi n e t h e p a t i e n t i n t h e s e a t e d p o s i t i o n . Vi e w t h e n e c k f r o m t h e f r o n t , s i d e s , a n d b a c k f o r d e f o r mi t i e s a n d u n u s u a l p o s t u r e . As k t h e p a t i e n t t o p o i n t t o t h e s i t e o f p a i n . Te s t a c t i v e mo t i o n s o f t h e n e c k w i t h t h e i n s t r u c t i o n s : c h i n t o c h e s t , c h i n t o r i g h t a n d l e f t s h o u l d e r, e a r t o r i g h t a n d l e f t s h o u l d e r, a n d h e a b a c k . W i t h t h e f l a t o f t h e h a n d , p a l p a t e t h e p a r a v e r t e b r a l mu s c l e s f o r t h e h a r d e n i n o f mu s c l e s p a s m, a n d w i t h t h e f i n g e r t i p f o r t e n d e r p o i n t s o r t r i g g e r p o i n t s . Te s t f o r tenderness of the spinous processes by palpation and by percussion with the finger o r r u b b e r h a mme r.

GENERAL EXAMINATION OF THE THORACOLUMBAR SPINE AND PELVIS


Fol l owi ng t r auma or s us pec t ed s pi nal i nj ur y, t he s pi ne mus t ALWAYS be i mmedi at el y i mmobi l i zed on a bac k boar d PRI OR TO ANY M OVEM ENT or ex ami nat i on of t he pat i ent .

A ma n s h o u l d b e u n d r e s s e d t o h i s u n d e r s h o r t s . A w o ma n ' s c l o t h e s s h o u l d b e r e p l a c e d b y a s h o r t - s l e e v e d e xa mi n i n g g o w n t h a t t i e s i n b a c k s o i t ma y b e o p e n e d t r e v e a l t h e s p i n e . t h t h e P a t i e n t S t a n d iO b s e r v e f r o m b e h i n d a n d t h e s i d e Wi ng: n o t i n g d e f o r mi t y, mu s c l e a t r o p h y, l o c a l s w e l l i n g , a b n o r ma l c u r v a t u r e o r l a t e r a l d e v i a t i o n s o f t h e s p i n e . If t h e s p i n a l p r o c e s s e s a r e h i d d e n b y mu s c l e o r f a t , p a l p a t e e a c h a n d ma r k w i t h a s k i n ma r k e r ; t h e r e s u l t i n g b r o k e n l i n e w i l l d i s c l o s e a n y d e v i a t i o n s f r o m t h e mi d l i n e . W h e n l a t e r a l d e v i a t i o n i s p r e s e n t , h a v e t h e p a t i e n t l e a n f o r w a r d o b s e r v i n g w h e t h e r t h e s p i n e s t r a i g h t e n s . At t h e s a me t i me , e xa mi n e t h e c h e s t w a l l b e s i d e t h e s p i n e . In s t r u c t u r a l s c o l i o s i s , o n e s i d e w i l l b e h i g h e r t h a n t h e o t h e r F i g . 1 3 - 1 3w h i l e w i t h c u r v a t u r e f r o m mu s c l e s p a s m o r d i s e a s e o f l i g a me n t s o r ( ) j o i n t s , t h e l a t e r a l ma s s e s w i l l b e l e v e l . H a v e t h e p a t i e n t t e n s e t h e g l u t e i t o r e v e a l a t r o p h y. P e r c u s s e a c h s p i n o u s p r o c e s s w i t h f i n g e r o r r u b b e r h a mme r t o e l i c i t tenderness. Have the patient walk and note the gait. Have the patient hop on each f o o t t o f i n d mu s c l e w e a k n e s s a n d p a i n . D i r e c t t h e p a t i e n t t o f l e x, e xt e n d , a n d l a t e r a
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b e n d t h e s p i n e w i t h o u t a s s i s t a n c e . Te s t r o t a t i o n b y g r a s p i n g t h e h i p s w h i l e t h e p a t i e n t t u r n s f i r s t o n e s h o u l d e r, t h e n t h e o t h e r. P a l p a t e P. 6 9 1 f o r t e n d e r n e s s , f o r mu s c l e s s p a s m o r t e n d e r o r t r i g We r h ohn t s . a t i e n t g it p t i e P S u p i n e :H a v e t h e p a t i e n t l i e f a c e - u p w a r d o n t h e e xa mi n i n g t a b l e , t h e h e a d p i l l o w e d a n d t h e k n e e s s l i g h t l y f l e xe d f o r c o mf o r ts t r ai ghte l eg- r ai s i ng t(F i g . 1 3 . Do th es t 1 4 A b y g r a s p i n g t h e a n k l e , w i t h t h e k n e e h e l d i n e xt e n s i o n , a n d l i f t i n g t h e l o w e r l i m ) t o i t s l i mi t . N o t e t h e l o c a t i o n o f p a i n e l i c i t e d , e s p e c i a l l y c o n t r a l a t e r a l r a d i a t i o n i n d i c a t i n g n e r v e r o o t c o mp r e(sLas n s i o que s i gn) i t h t h e s t r a i g h t l e g e l e v a t e d a t a . W l i t t l e - l e s s - t h a n - c o mp l e t e f l e xi o n , d o r s i f l e x t h e f o o t f o r a g g r a v a t i o n o f p a i n . An a l t e r n a t i v e t e s t i s t o g r a d u a l l y e xt e n d t h e f l e xe d k n e e , w i t h t h e f i n g e r p r e s s i n g o n t tibial nerve in the popliteal fossa; this produces pain if there is irritation of the low l u mb a r n e r v e r o oW i.t h t h e P a t i e n t P r o As k t h e p a t i e n t t o t u r n f r o m t h e s u p i n e ts ne: t o t h e p r o n e p o s i t i o n a n d n o t e t h e a mo u n t o f g u a r d i n g a s a n i n d i c a t i o n o f p a i n s e v e r i t y. F o r c o mf o r t , p l a c e a p i l l o w b e t w e e n t h e t a b l e a n d t h e p a t i e n t ' s p e l v i s . N o t i c e i f t h e mu s c l e s p a s m a n d s p i n a l d e f o r mi t y o b s e r v e d w h i l e e r e c t p e r s i s t s i n t h e p r o n e p o s i t i o n . R e e xa mi n e f o r a r e a s o f t e n d e r n e s s a n d d e f o r mi t y. A s t e p d e f o r mi t y between L5 and S1 indicates spondylolisthesis. With the heel of the hand, press a l o n g t h e s p i n o u s p r o c e s s e s . P a i n f r o m l i g h t p r e s s u r e s u g g e s t s a p p r o xi ma t i n g s p i n e with an intervening bursa; pain from deep pressure arises from intervertebral facets o r d i s k sW i t h t h e P a t i e n t S i t t iL o o k f o r d i mi n i s h e d t e n d o n r e f l e xe s a n d a t r o p h y . ng: o f mu s c l e ma s s e s i n t h e l o w e r l i mb a s e v i d e n c e o f n e r v e i n j u r y i n t h e b a c k .

F i g . 1 3 - 1 3 S t r u c t u r a l S c o l.i I nsipec t i on of t he f l ex ed s pi ne f r om behi nd os s s hows t he unequal el ev at i on of t he t wo er ec t or s pi nae mus c l e mas s es .

S c hobe r Te s t for Lum bar Fle x ion.

H a v e t h e p a t i e n t s t a n d e r e c t w i t h h e e l s t o g e t h e r. M a r k t h e l u mb o s a c r a l j u n c t i o n a t t h e L 5 s p i n o u s p r o c e s s o r t h e p o i n t w h e r e a h o r i zo n t a l l i n e b e t w e e n t h e p o s t e r i o r s u p e r i o r i l i a c s p i n e s i n t e r s e c t s t h e s p i n e . P l a c e a ma r k o n t h e s p i n e 1 0 c m a b o v e a n d 5 c m b e l o w t h e l u mb o s a c r a l j u n c t i o n . H a v e t h e p a t i e n t b e n d f o r w a r d t r y i n g t o t o u c h t h e f i n g e r s t o t h e t o e s . N o r ma l l y, t h e d i s t a n c e b e t w e e n t h o s e t w o ma r k s i n c r e a s e s b y 5 c m o r mo r e w i t h ma xi mu m f l e xi o n . If t h e d i s t a n c e i n c r e a s e s l e s s t h a n 4 c m, mo b i l i t y i s r e s t r i c t e d .
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P. 6 9 2

F i g . 1 3 - 1 4 Te s t s a t t h e H i p a n d S a c r o i l i a c J o i n t . A . S t r a i g h t - L e g - R a i s i n g Te s t :The ex ami ner l i f t s t he s upi ne pat i ent ' s l ower l i mb when t he k nee i s hel d i n ex t ens i on . P a t r i c k Te sLat er al r ot at i on of t he hi p i s as s es s ed by hav i ng .B t: t he k nee f l ex ed and t he f oot of t hat l eg pl ac ed on t he oppos i t e pat el l a. The ex ami ner t hen pus hes t he f l ex ed k nee down and out t o r ot at e t he head of t he f emur C . P a s s i ve H y p e r e xt e n s i o n o f t h e T h i g h ( G a e n s l e n Te s t ) : . Whi l e s upi ne, t he pat i ent f l ex es t he k nee and f emur on t he af f ec t ed s i de and hol ds t he k nee wi t h t he hands t o el i mi nat e l umbar l or dos i s . The ex ami ner t hen hy per ex t ends t he unaf f ec t ed t hi gh by l et t i ng i t s i nk ov er t he s i de of t he t abl e. I n di s eas e of t he s ac r oi l i ac j oi nt , t hi s maneuv er evD . es tpai n . ok A c i ve H y p e r e xt e n s i o n : t h t he pat i ent pr one and t he abdomen r es t i ng on a pi l l ow, Wi t he pat i ent l i f t s t he s pi ne agai ns t t he r es i s t anc e of f er ed by t he ex ami ner ' s hand; s ac r oi l i ac di s eas e c aus es. pai n

Additional E x am s for H e r niate d D is k .

Te s t n e u r o s e n s o r y f u n c t i o n b y a s s e s s i n g k n e e a n d a n k l e t e n d o n r e f l e xe s , f l e xi o n a n e xt e n s i o n s t r e n g t h a t t h e k n e e a n d a n k l e , g r e a t t o e e xt e n s i o n s t r e n g t h , a n d s e n s a t i o n t o t o u c h .o s s e d - S t r a i g h t - L e g - R a i s i n g H as t : t h e p a t i e n t l i e s u p i n e Cr Te v e a n d l i f t t h e u n a f f e c t e d l i mb w i t h t h e k n e e h e l d s t r a i g h t . In t h e p r e s e n c e o f h e r n i a t e d d i s k , t h i s ma n e u v e r w i l l e xa c e r b a t e t h e p a i n i n t h e a f f e c t e d l i mb , a n d ma y c a u s e s c i a t i c p a i n i n t h e h i t h e r t o u n a f f e c t e d l i mb . T h i s i s c o n s i d e r e d b y s o me w r i t e r s t o b p a t h o g n o mo n i c o f h e r n i a t e d R es k .r s e S t r a i g h t - L e g - R a i s i n g Te s t f o r d i ve I n t e r ve r t e b r a l D i s ki:t h t h e p a t i e n t l y i n g p r o n e a n d t h e k n e e f l e xe d ma xi ma l l y o n W t h e t h i g h , t h e n o r ma l p e r s o n c o mp l a i n s o f q u a d r i c e p s t i g h t n e s s i n t h e a n t e r i o r t h i g h With true disk disease, the pain is felt in the back or in the sciatic distribution on t affected side. T his pain is evoked by the root tightening over the involved disk, whi a b d o mi n a l c o mp r e s s i o n i n c r e a s e s t h e p r e s s u r e i n t h e s u b a r a c h n o i d s p a c e .

Te s ting the S ac r oiliac J oint.

Have the patient seated with the patient's back toward you. Locate the sacroiliac j o i n t s b y t h e d i mp l e s i n t h e o v e r l y i n g s k i n . If d i mp l e s a r e l a c k i n g , p l a c e y o u r t h u mb s o n t h e i l i a c c r e s t s w i t h y o u r h a n d s a r o u n d t h e p a t i e n g'.s 1 3u 1 5 f(o l l o w Fi t tr - nk ); P. 6 9 3
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t h e c r e s t s me d i a l l y w i t h y o u r t h u mb s t o l o c a t e t h e p o s t e r o s u p e r i o r i l i a c s p i n e s ; mo v y o u r t h u mb s o n e f i n g e r b r e a d t h me d i a l t o t h e s p i n e s f o r t h e a r e a o f t h e j o i n t s mo s t a c c e s s i b l e t o p a l p a t i o n . W i t h y o u r t h u mb s i n p l a c e , h a v e t h e p a t i e n t b e n d f o r w a r d s l o w l y, a n d p r e s s d e e p l y a l o n g t h e j o i n t c l e f t s t o e l i c i t t e n d e r n e s s . en t h e Gaens l In t es t of t he s ac r oi l i ac j(oie eF i g . 1 3 - 1 4)C h a v e t h e s u p i n e p a t i e n t h o l d t h e k n e e s nt , o f t h e a f f e c t e d s i d e w i t h b o t h h a n d s , f l e xi n g t h e k n e e a n d t h e h i p t o f i x t h e l u mb a r s p i n e a g a i n s t t h e t a b l e ; t h e n h y p e r e xt e n d t h e o t h e r t h i g h b y p u s h i n g i t d o w n w a r d o v e r t h e s i d e o f t h e t a b l e . An a f f e c t e d s a c r o i l i a c j o i n t w i l l b e p a i n f u l w i t h t h i s ma n e u v e r. Ac t i v e p r o n e h y p e r e xt e n s i o n o f t h e sF i g .e 1(3 -e1 4)Dma y p n s e a g g r a v a t e s a c r o i l i a c p a i n w h e n t h e p a t i e n t a t t e mp t s t o l i f t t h e s p i n e a g a i n s t t h e r e s i s t a n c e o f t h e e xa mi n e r ' s h a n d h e l d i n t h e l u mb a r r e g i o n .

Fig. 13-15 Palpation of the Sacroiliac Joints .

Low B ac k P ain: P ointing Te s t for M alinge r ing.

L o w b a c k p a i n i s a f a v o r i t e c o mp l a i n t o f ma l i n g e r e r s . O n e me t h o d o f e xp o s u r e i s t h e M agnus on t es W h e n t h e p a t i e n t i n d i c a t e s a p a i n f u l s p o t i n t h e l o w e r b a c k , i t i s . t ma r k e d w i t h a s k i n p e n c i l . As a d i v e r s i o n , t h e e xa mi n e r p r o c e e d s w i t h t e s t s e l s e w h e r e i n t h e b o d y ; l a t e r, t h e e xa mi n e r a g a i n p a l p a t e s t h e b a c k a n d e l i c i t s a d i f f e r e n t p a i n f u l s i t e . T h e p a t i e n t w i t h o r g a n i c d i s e a s e i d e n t i f i e s t h e s a me p o i n t e a c t i me .

Examination of the Appendicular Skeleton Including Joints, Ligaments, Tendons, and Soft Tissues
GENERAL EXAMINATION OF JOINTS

E xa mi n e a l l j o i n t s s y s t e ma t i c a l l y f r o m h e a d t o f o o t o r i n r e v e r s e s e q u e n c e . P l a c e t h p a t i e n t s o t h e j o i n t t o b e e xa mi n e d i s s u p p o r t e d a t r e s t w i t h t h e l e a s t p a i n a n d mu s c l e s p a s m. C o mp a r e j o i n t s , r i g h t a n d l e f t , w h e n o n e Ii nsipec tfl v e d . s nvo or n o r ma l b o n y l a n d ma r k s , j o i n t d e f o r mi t y f r o m s w e l l i n g , a n g u l a t i o n , r o t a t i o n , s u b l u xa t i o n , c o n t r a c t u r e , o r a n k y l o s i s . N o t e t h e s i ze a n d c o n t o u r o f t h e j o i n t , k e e p i i n mi n d t h e l o c a t i o n o f t h e j o i n t c a p s u l e , a n d t h e c o l o r o f t h e oPalrpatn g s k i n . ve lyi e g e n t l y f o r s k i n t e mp e r a t u r e a n d t o l o c a t e a r e a s o f t e n d e r n e s s i n t h e s k i n , mu s c l e s , b u r s a e , l i g a me n t s , t e n d o n s , f a t p a d s , a n d j o i n t c a p s u l e . P a l p a t e P. 6 9 4


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t h e j o i n t c a p s u l e . T h e n o r ma l s y n o v i u m i s n o t p a l p a b l e , w h i l e a t h i c k e n e d s y n o v i u m f e e l s d o u g h y o r b o gTes t he j oi nt f or ef f us i y c o mp r e s s i n g l a t e r a l l y w i t h g y. t b on the fingers of one hand while the fingers of the other hand rest on the opposite side o f t h e j o i n t ; f l u i d i n t h e j o i n t c a v i t y w i l l d i s p l a c e t h e r e c e i v i n g f i n g e r s . E f f u s i o n ma y b e i n t h e j o i n t c a v i t y a n d / o r i n a b u r s a , t h e b o r d e r s a n d o t h e r a n a t o mi c r e l a t i o n s ma d i s t i n g u i s h t h eTes t ac t i v e r ange of mot i y d i r e c t i n g t h e p a t i e n t t o mo v e t h e m. b on j o i n t t h r o u g h i t s f u l l r a n gte . To es t pas s i v e r ange of motaon h o r t h e j o i n t , i nc p r o xi ma l l y w i t h o n e h a n d w h i l e t h e o t h e r h a n d mo v e s t h e d i s t a l me mb e r g e n t l y t o i t s f u l l l i mi t s . D e t e r mi n e i f t h e l i mi t a t i o n o f mo t i o n i s f r o m mu s c l e s p a s m, g e l l i n g t h a t i mp r o v e s w i t h r e p e a t e d mo v e me n t , e f f u s i o n i n t h e j o i n t , l o c k i n g f r o m l o o s e b o d i e s i n the joint, fibrosis ( soft arrest ), or bony ankylosis ( hard arrest ). Palpate over the j o i n t f o r c r e p i t u s o n a c t i v e mo t i o nf.or l i gament i nt egr iyt y o t i n g t h e Tes t b n r e s i s t a n c e t o j o i n t d i s p l a c e me n t w h e n a n c h o r i n g t h e b o n e p r o xi ma l t o t h e j o i n t w h i l e g e n t l y d i s p l a c i n g t h e d i s t a l b o n e i n t h e p l a n e t o b e t e s t e d . T h e mu s c l e s mu s t b e r e l a xe d w h e n t e s t i n g l i g a me n t s t a b i l i t y. Al w a y s c o mp a r e r i g h t a n d l e f t s i n c e n o r ma l l i g a me n t t i g h t n e s s i s q u i t e v a r i a b l e , f r o m t i g h t t o l o o s e ( d o u b l e j o i n t e d ) .

The Upper Limb

T h i s a n a t o mi c r e g i o n i n c l u d e s t h e s t r u c t u r e s o f t h e n e c k , s h o u l d e r g i r d l e , u p p e r a r m f o r e a r m a n d h a n d . T h e e xa mi n a t i o n u s u a l l y b e g i n s w i t h t h e h a n d s a n d w o r k s u p w a r d the sequence used here.

EXAMINATION OF THE HAND

T h e s t r u c t u r e s o f t h e h a n d a r e r e l a t i v e l y s u p e r f i c i a l a n d e a s i l y e xa mi n e d , c o mp a r i n g r i g h t t o l e fI tn s p e c t i o nT h e f i n g e r t i p s i n e xt e n s i o n f o r m a n a r c w i t h t h e a p e x a t t h e . : mi d d l e f i n g e r. In me n , t h e f o u r t h f i n g e r i s l o n g e r t h a n t h e i n d e x; i n w o me n , t h e i n d e f i n g e r i s u s u a l l y l o n g e r. W i t h f l e xi o n t h e f i n g e r t i p s a l i g n a t t h e b a s e o f t h e t h e n a r e mi n e n c e w i t h t h e n a i l s i n t h e s a me p l a n e ; i f t h e r e i s s h o r t e n i n g o r c r o s s i n g o f t h e fingertips prior injury with shortening and/or rotation of the affected phalanges or me t a c a r p a l i s p r e s e n t . H a v e t h e p a t i e n t g e n t l y ma k e a f i s t a n d o b s e r v e t h e p r o xi ma l k n u c k l e s , w h i c h a r e t h e d i s t a l me t a c a r p a l h e a d s . T h e r e s h o u l d b e a s mo o t h a r c between the index and little fingers. Depression of one knuckle from its proper plac i n t h e a r c i n d i c a t e s s h o r t e n i n g o f t h e me t a c a r p a l , e i t h e r c o n g e n i t a l o r p o s t t r a u ma t i c O b s e r v e t h e d o r s u m o f t h e h a n d a n d t h e w e b s p a c e b e t w e e n t h e t h u mb a n d i n d e x f i n g e r f o r t h e b u l k o f t h e i n t r i n s i c h a n d mu s c l e s . P r o mi n e n c e o f t h e t e n d o n s a n d b o n e s o c c u r s w i t h l o s s o f mu s c l e ma s s , u s u a l l y r e s u l t i n g f r o m a n u l n a r n e r v e l e s i o n In s p e c t t h e p a l ma r a s p e c t o f t h e h a n d f o r n o r ma l s k i n c r e a s e s , t h e b u l k o f t h e t h e n a a n d h y p o t h e n a r mu s c l e ma s s e s , c a l l o s i t i e s o r t h i c k e n i n g o f t h e p a l ma r f a s c i a . In s p e c t t h e n a i l s a n d f i n g e r t i p s f o r d e f o r mi t i e s , u l c e r s , a n d s i g n s o f p r e v i o u s t r a u m P a l p a t i o nE xa mi n e e a c h j o i n t f o r b o n y p r o mi n e n c e s , s y n o v i a l t h i c k e n i n g , o r : e f f u s i o n . P a l p a t e t h e t h e n a r, h y p o t h e n a r a n d f i r s t w e b s p a c e mu s c l e s b o t h r e l a xe d a n d w i t h c o n t r a c t i o n . If b o n e i n j u r y i s s u s p e c t e d , p a l p a t e t h e e n t i r e P. 6 9 5 l e n g t h o f t h e b o n e . S q u e e ze t h e p a l m f r o m f r o n t t o b a c k a n d l a t e r a l l y a c r o s s t h e knuckles to detect tenderness.

Functional Tests of Fingers


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C o mp l e t e f u n c t i o n a l e xa mi n a t i o n o f t h e h a n d r e q u i r e s a n i n - d e p t h u n d e r s t a n d i n g o f t h e a n a t o my o f t h e b o n e s , mu s c l e s , t e n d o n s , l i g a me n t s , a n d n e r v e s o f t h e h a n d a n d f o r e a r m. T h i s i s b e y o n d t h e s c o p e o f t h i s t e xt . H e r e , w e p r e s e n t a s c r e e n i n g e xa mi n a t i o n . T h e f i n g e r s a r e n a me d t h u mb , i n d e x, l o n g o r mi d d l e , r i n g , a n d l i t t l e , o r t h e y a r e n u mb e r e d o n e t h r o u g h f i v e . T h e p h a l a n g e a l j o i n t s a r e t e r me d d i s t a l i n t e r p h a l a n g e a l ( D IP ) , p r o xi ma l i n t e r p h a l a n g e a l ( P IP ) , a n d me t a c a r p o p h a l a n g e a l ( M C P ) . T h e a s p e c t s o f t h e f i n g e r s a r e d o r s a l ( e xt e n s o r s u r f a c e ) a n d v o l a r ( f l e xo r o r p a l ma r s u r f a c e )i.g u r e 1 3 - 1i6l u s t r a t e s t h e f u n c t i o n a l a s s e s s me n t o f t h e j o i n t s . T h e F l n o r ma l l i mi t s o f mo t i o n a r e i n d i c a t e d b y zo n e s w i t h i n d e f i n i t e b o r d e r s t o e mp h a s i ze i n d i v i d u a l v a r i a t i o n a n d c h a n g e s f r o m a g i n g . T h e t e s t i n g o f mu s c l e s i s d e s c r i b e d o n p a g e 8 0 5 . Te s t a c t i v e f l e xi o n a n d e xt e n s i o n a g a i n s t r e s i s t a n c e a t t h e D IP a n d P IP j o i n t s . T h e s u p e r f i c i a l f l e xo r s a t t a c h o n t h e mi d d l e p h a l a n x a s s i s t i n g f l e xi o n o f t h e M C P a n d P IP. F l e xi o n a t t h e D IP i s p e r f o r me d s o l e l y b y t h e d e e p f l e xo r s . N e xt , t e s t a b d u c t i o n a n d a d d u c t i o n o f t h e f i n g e r s ; t h e s e mo v e me n t s a r e p o w e r e d b y t h e i n t e r o s s e u s a n d l u mb r i c a l mu s c l e s i n n e r v a t e d b y t h e u l n a r n e r v e . L a s t , t e s t t h e t h u mb f o r f l e xi o n a n d e xt e n s i o n p o w e r a t t h e M C P a n d IP, a s w e l l a s a b d u c t i o n a n d a d d u c t i o n . T h e l a t t e r mo v e me n t s a r e p e r f o r me d b y t h e t h e n a r mu s c l e s i n n e r v a t e d b y t h e me d i a n n e r v e .

EXAMINATION OF THE WRIST

I ns pec ta n dpal pat et h e w r i s t f o r s w e l l i n g , t e n d e r n e s s , a n d d e f o r mi t i e s . As s e s s w e a k n e s s a n d a t r o p h y i n t h e mu s c l e s o f t h e f o r e a r m t h a t s u p p l y t h e h a n d . P a l p a t e t h e mo v i n g w r i s t f o r c r e p i t u s . L i s t e n w i t h t h e s t e t h o s c o p e t o t h e v o l a r s u r f a c e o f t h e j o i n t f o r a r uTe s t i n g W r i s t M o t i o n :e p r i ma r y mo t i o n s o f t h e w r i s t a r e b. Th e xt e n s i o n - f l e xi o n ( d o r s i f l e xi o n a n d p a l ma r f l e xi o n ) a n d r a d i a l - u l n a r d e v i a t i o n . T h e d i a g r a ms iF i g . 1 3 - 4 e p i c t t h e me t h o d s o f me a s u r e me n t . W h e n o n l y o n e w r i s t i s n d a f f e c t e d , c o mp a r e i t w i t h t h e o t h e r, b e c a u s e a v e r a g e v a l u e s v a r y b e t w e e n p e r s o n s and with age.

EXAMINATION OF THE FOREARM


In s p e c t t h e mu s c l e ma s s e s f o r s y mme t r y ; o f t e n t h e d o mi n a n t a r m i s b e t t e r mu s c l e d . B o t h t h e r a d i a l a n d u l n a r a r t e r i a l p u l s e s a r e p a l p a b l e p r o xi ma l t o t h e w r i s t . T h e mo t i o n s o f t h e f o r e a r m a r e p r o n a t i o n a n d s uF i g .a t1 o n1 (. Te s t f o r a c t i v e a n d p n i 3 - )7 p a s s i v e r a n g e o f mo t i o n a n d p o w e r a g a i n s t r e s i s t a n c e . P a i n w i t h r e s i s t e d mo t i o n i s e s p e c i a l l y i mp o r t a n t a n d t h e s i t e s o f p a i n s h o u l d b e p a l p a t e d .

EXAMINATION OF THE ELBOW


I ns pec ta n dpal pat et h e r e g i o n f o r d e f o r mi t y, t e n d e r n e s s , a n d s w e l l i n g . S w e l l i n g s a r e mo r e c o mmo n o n t h e e xt e n s o r s u r f a c e . S u b c u t a n e o u s n o d u l e s P. 6 9 6 P. 6 9 7 are often found in the olecranon bursa and distally in the ulnar region.

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Fig. 13-16 Motions of Fingers and Thumb .

F i g . 1 3 - 1 7 F o r e a r m M o t .i o n s
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Te s ting E lbow M otion.

T h e mo v e me n t s o f t h e h u me r o u l n a r j o i n t a r e e xt e n s i o n - f l e xi o n . P r o n a t i o n - s u p i n a t i o n p r i n c i p a l l y i n v o l v e s t h e h u me r o r a d i a l a n d t h e d i s t a l r a d i o u l n a r j o i n t s . M e a s u r e me n t s o f t h e s e mo t i o n s a r e i n d i c a tF i d . i n 3 - 5.BTe s t p a s s i v e a n d a c t i v e mo t i o n a n d eg 1 s t r e n g t h b y r e s i s t i n g a c t i v e mo t i o n .

INSPECTION AND PALPATION OF THE SHOULDER JOINT

E xa mi n e t h e d i s r o b e d p a t i e n t , s i t t i n g w i t h t h e a r ms r e l a xe d , f r o m f r o n t a n d b a c k ( Fig. 1 3 - 1 8 . I ns pec tt h e s h o u l d e r a n t e r i o r l y a n d t h e s c a p u l a p o s t e r i o r l y f o r d e f o r mi t i e s ) a n d mu s c l e a t r o p h y, r e a l i zi n g t h a t n e a r l y e v e r y o n e c a r r i e s o n e s h o u l d e r h i g h e r t h a n t h e o t h e r. pat et h e s c a p u l a r s p i n e , f o l l o w i n g i t f o r w a r d t o t h e a c r o mi o n a n d Pal p a l p a t e t h e a c r o mi o c l a v i c u l a r j o i n t . P a l p a t e t h e s t e r n o c l a v i c u l a r j o i n t f o r d e f o r mi t y t e n d e r n e s s . N e xt p a l p a t e t h e s u b a c r o mi a l s p a c e a n d t h e d e l t o i d mu s c l e a n d i t s subdeltoid bursa. Palpate the tendons of the rotator cuff for defects or tenderness a n d t h e i r i n s e r t i o n s o n t h e g r e a t e r ( s u p r a s p i n a t u s , i n f r a s p i n a t u s , a n d t e r e s mi n o r t e n d o n s ) a n d l e s s e r ( s u b s c a p u l a r i s t e n d o n ) t u b e r o s i t i e s o f t h e h u me r u s . F e e l t h e bicipital groove between greater and lesser tuberosities for tenderness in the bicipital tendon sheath. Stand behind and to the side of the patient to palpate the s u p r a s p i n a t u s t e n d o n a n d t h e s u b a c r o mi a l b u r s a . F o r t h e r i g h t s h o u l d e r, p l a c e y o u r left hand over the shoulder so your index finger palpates the tendon just behind its a t t a c h me n t o n t h e g r e a t e r t u b e r c l e o f t h e h u me r a l h e a d , a n d P. 6 9 8 y o u r mi d d l e f i n g e r p a l p a t e s t h e s u b a c r o mi a l b u r s a . W i t h y o u r r i g h t h a n d o n t h e p a t i e n t ' s f l e xe d e l b o w, mo v e t h e a r m b a c k w a r d a n d f o r w a r d a f e w t i me s t o d e t e c t c r e p i t u s o r t e n d e r n e s s a t e i t h e r p o i n t . F i n a l l y, p l a c e y o u r f i n g e r s i n t h e a xi l l a w i t h t p u l p s f a c i n g l a t e r a l l y a n d p a l p a t e t h e h u me r a l h e a d a n d t h e l a t e r a l a s p e c t o f t h e glenoid synovial sac.

F i g . 1 3 - 1 8 E xa m i n a t i o n o f t h e S h o u l d e r J o i n t . A . To p o g r a p h y o f t h e
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S h o u l d e r The bony pr omi nenc es of t he humer al gr eat er t uber c l e and t he : c or ac oi d and ac r omi al pr oc es s es of t he s c apul a f or m a r i ght - angl .ed t r i angl e .B I m m o b i l i z a t i o n o f t h e S c a p u l a t o Te s t S h o u l d e r M o t i o n . C . F l u i d i n t h e S h o u l d e r J o i nThe heav i l y s t i ppl ed s t r uc t ur es ar e t he j oi nt c aps ul es t: di s t ended wi t h f l.ui d R u p t u r e o f S u p r a s p i n a t u s Te n d o n D. .

M e as ur e m e nts of S houlde r M otion.

Ima g i n e t h e s h o u l d e r j o i n t a s t h e c e n t e r o f a s p h e r e , ma r k e d a s a g l o b e w i t h a n o r t h a n d s o u t h p o l e a n d me r i d iF in s 1 3 - 1 9 T h e n a n a n t e r i o r - p o s t e r i o r ( p a r a s a g i t t a l ) a g. ( ). p l a n e t h r o u g h t h e s h o u l d e r j o i n t d e s c r i b e s a n a n t e r i o r me r i d i a n o n t h e s p h e r e ' s s u r f a c e t h a t 0 sdegr ees of abduc t i on- adducM e r i d i a n s l a t e r a l t o i t ma r k i . t i on d e g r e e s oabduc t i on n d t h o s e me d i a l t o i t a r e d e g r adducft i onW h e n t h e a r m f a ees o . h a n g s a t t h e p a t i e n t ' s s i d e , i0 idegr ees of el ev at i on and of abduc th e a r m t s in . T i on c a n b e l i f t e d f r o m t h e s o u t h p o l e t o t h e n o r t h p o 0e , oo r f r o m l t 180 degr ees of el ev at i onW h i l e e l e v a t i n g , t h e a r m mu s t f o l l o w i n a me r i d i a n t h a t d e s i g n a t e s . a b d u c t i o n o r a d d u c t i o n . If t h e a r m i s r a i s e d d i r e c t l y f o r w a r d t o t h e h o r i zo n t a l , t h e p o s i t i o n i90 degr ees of el ev at i on wi t h 0 degr ees of abduc t i ont h e c a r d i n a l s ; this s mo t i o n o f F L E XIO N . W h e n t h e a r m i s r a i s e d l a t e r a l l y t o t h e h o r i zo n t a l , t h e p o s i t i o n 90 degr ees of el ev at i on wi t h 90 degr ees of abduc t i s t h e c a r d i n a l ; t h i s on P. 6 9 9 mo t i o n o f AB D U C T IO N . W h e n t h e a r m i s r a i s e d d i r e c t l y p o s t e r i o r l y, t h e p o s i t i o n i s el ev at i on wi t h 180 degr ees of abduc tiisons t h e c a r d i n a l mo t i o n o f E XT E N S IO N . ; th i If , h o w e v e r, t h e a r m i s r a i s e d t o t h e h o r i zo n t a l i n a me r i d i a n 2 0 d e g r e e s me d i a l t o 0 d e g r e e s , t h e p o s i t i o90i s n degr ees of el ev at i on wi t h 20 degr ees of adduc t i on .

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F i g . 1 3 - 1 9 M o t i o n s a t t h e S h o. u l d e re has been muc h c onf us i on i n Ther t er mi nol ogy about s houl der mot i on. The s y s t em pr es ent ed her e l eav es no r oom f or mi s i nt er pr et at i on. El ev at i on i s a mov ement of t he ar m al ong any mer i di an, meas ur ed f r om pos i t i on at t he s out h pol e. El ev at i on al ong t he mer i di an i n t he par as agi t t al pl ane pas s i ng t hr ough t he s houl der j oi nt ar e f l ex i on ( f or war d) and ex t ens i on ( bac k war ds ) . M ov ement medi al t o t hi s i s adduc t i on; mov ement l at er al t o t he pl ane i s abduc t i on. When t he ar m i s el ev at ed i n any mer i di an ot her t han t he par as agi t t al one, t he mot i on i s ex pr es s ed as el ev at i on i n abduc t i on or el ev at i on i n abduc t i on. The amount of dev i at i on f r om t he par as agi t t al pl ane i s not ed i n degr ees , f or ex ampl e, el ev at i on i n 70 degr ees of abduc t i on.

Te s ting M obility of the S houlde r.

S h o u l d e r mo b i l i t y i n c l u d e s s c a p u l o t h o r a c i c a n d g l e n o h u me r a l j o i n t mo t i o n s . Te s t t h e u n a f f e c t e d s h o u l d e r f i r s t a n d c o mp a r e t h e a f f e c t e d s i d e w i t h i t . T h e c a r d i n a l mo v e me n t s o f t h e s h o u l d e r a r e a b d u cev at i (on at 90 degr ees abduc t i on el t i o n ), a d d u c t i o nat 90 degr ees el ev at,i one xi o n (ev at i on at 0 degr ees abduc t i on ( ) fl el ), e xt e n s i o npos t er i or el ev at i on at 0 degr ees abduc tdon t e r n a l a n d e xt e r n a l ( ) an i in rotation. P. 7 0 0 R a n g e o f mo t i o n s h o u l d b e a s s e s s e d b o t h a c t i v e l y a n dAc ais s i vmot i on p t v e e l y. i s a c c o mp l i s h e d b y t h e p a t i e n t a n d a s s e s s e s j o i n t mo b i l i t y a n d mu s c l e a n d t e n d o n i n t e g r i t y a n d r e v e a l s l i mi t a t i o n s o f mo t i o n a s a r e s u l t o f p a i n . T h e e xa mi n e r p r o v i d e t h e p o w e r d u r i n g s i v e mot i onh i l e t h e p a t i e n t r e l a xe s , e l i mi n a t i n g mu s c l e a n d pas w t e n d o n l i mi t a t i o n s , t o r e v e a l t h e f u l l r a n g e o f mo t i o n a v a i l a b l e Eloev atci h j o i n t . t e a on wi t h abduc t i on v o l v e s b o t h s c a p u l o t h o r a c i c a n d g l e n o h u me r a l mo v e me n t . H a v e t h e in patient slowly raise the arm laterally from the side to straight overhead; the scapula s h o u l d b e g i n t o mo v e w h e n e l e v a t i o n o f t h e a r m a t t a i n s 6 0 des tr e e s . To t e g gl enohumer al mot i on al one s p t h e s c a p u l a r w i n g a n d h o l d i t f a s t t o t h e t h o r a x , gra w i t h o n e h a n d w h i l e t h e p a t i e n t ' s a r m i s r e s t i n g a t h iF i g .i d1 3 - 1 e e s s e (s8B ). Al t e r n a t i v e l y, p l a c e o n e h a n d o n t o p o f t h e a c r o mi o n t o s t a b i l i ze t h e s c a p u l a . H a v e the patient raise the arm laterally (90 degrees of abduction) and let the patient c o mp l e t e t h e mo t i o n a s f a r a s p o s s i b l e , w i t h t h e s c a p u ladduc di.onatr 90 a f i xe t F o ( degr ees el ev at i) on e s t t h e f i n g e r s o f o n e h a n d o n t h e t o p o f t h e p a t i e n t ' s s h o u l d e r , r w i t h y o u r t h u mb b e h i n d , f i xi n g t h e p a t i e n t ' s s c a p u l a . H a v e t h e p a t i e n t mo v e t h e a r m across the front of the patient's chest as far as the patient can, to place the patien w r i s t o v e r t h e o p p o s i t e s h o u l d e r.on(el ev at i on at 0 degr ees abducits on Fl ex i ) i tested by having the patient elevate the arm forward from rest to straight overhead t h e a n t e r i o r - p o s t e r i o r p l a n e . Fens i onpos t er i or el ev at i on at 0 degr ees ex t o r ( abduc t i on h a v e t h e p a t i e n t p u s h t h e a r m s t r a i g h t b a c k w a r d i n t h e s a me p l a n e t o t h e ) l i mi t o f mo t i o n . Te s ter nal and ex t er nal r ot at i on t h e a r m a t 9 0 d e g r e e s o f i nt w th a b d u c t i o n a n d 9 0 d e g r e e s o f e l e v a t i o n , s t a r t i n g w i t h t h e e l b o w f l e xe d a t 9 0 d e g r e e s a n d t h e p a l m f a c i n g t h e f l o oir. F onal r ot at i, ons k t h e p a t i e n t t o l o w e r t h e h a n d , nt er r a p a l m d o w n , a s f a r a s p o s s i b l e w i t h o u t mo v i n g t h e e l b o w. F orrot at i, ont a r t ex t er nal s from the neutral position and have the patient raise the hand, palm forward, as far a p o s s i b l e w i t h o u t mo v i n g t h e e l b o w. W h e n t h e r e i s a d e f i c i t i n a c t i v e mo t i o n , t e s t
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p a s s i v e r a n g e o f mo t i o n b y r e p e a t i n g t h e ma n e u v e r w i t h t h e p a t i e n t r e l a xe d a n d t h e e xa mi n e r s u p p o r t i n g t h e a r m a n d g e n t l y p u t t i n g i t t h r o u g h t h e mo t i o n . Te s t f o r abduction strength and pain by resisting abduction at 30 degrees (supraspinatus) and 90 degrees (deltoid).

Aus c ultation of B ony C onduc tion Thr ough the S houlde r.

T h e o l e c r a n o n ma n u b r i u m p e r c u s s i o n s i g n i s u s e f u l i n e v a l u a t i n g p a t i e n t s w i t h p o s s i b l e s h o u l d e r d i s l o c a t i o n s , c l a v i c u l a r f r a c t u r e s , o r h u me r a l f r a c t u r e s . P l a c e t h e b e l l o f t h e s t e t h o s c o p e o v e r t h e ma n u b r i u m w i t h t h e p a t i e n t ' s e l b o w s f l e xe d a t 9 0 d e g r e e s a n d p e r c u s s t h e o l e c r a n o n . N o r ma l l y, w i t h n o d i s r u p t i o n o f b o n y c o n d u c t i o n percussion of both sides will produce equal crisp sounds. When dislocation or fracture disrupts bony conduction, the affected side will have decreased intensity and duller pitch.

The Lower Limb

T his region includes the pelvis, buttocks, hip joint, thigh, knee, leg, ankle, foot, an t o e s . It s p r i n c i p a l f u n c t i o n i s ma i n t e n a n c e o f a n u p r i g h t s t a n c e a g a i n s t g r a v i t y a n d p r o v i d i n g l o c o mo t i o n . P. 7 0 1

EXAMINATION OF THE HIP AND THIGH


T he patient should be disrobed from the waist down, covering the genitalia but not the buttocks.

S ite s of P ain.

H a v e t h e p a t i e n t p o i n t t o t h e s i t e o f p a i n . An a f f e c t e d h i p j o i n t c o mmo n l y c a u s e s p a i n t h e i n g u i n a l r e g i o n o r i n t h e b u t t o c k s p o s t e r i o r t o t h e g r e a t Paitn ofc h a n t e r. e r r r om t he hi p j oi nt may be f el t onl y i n t he k nee; t hi s has l ed t o many di agnos t i c er r or s .

B e gin the E x am ination with the P atie nt S tanding.


H a v e t h e p a t i e n t w a l k l o o k i n g f o r a b n o r ma l i t i e s o f g a i t : s w i n g i n g t h e l e g f r o m t h e l u mb a r s p i n e s u g g e s t s a n k y l o s i s ; a w a d d l i n g g a i t i s t y p i c a l o f b i l a t e r a l h i p d i s l o c a t i o n ; t h e g l u t e a l Tra i t ( enbur g gai t i t h t h e t r u n k l i s t i n g t o t h e a f f e c t e d g endel ), w side with each step, suggests unilateral hip dislocation. With the patient standing s t i l l , l o o k f o r a l i s t t o o n e s i d e , a s y mme t r y o f t h e b u t t o c k s o r o t h e r mu s c l e ma s s e s , and scars or sinuses.

Late r al Tilting of the P e lvis .

To d e t e r mi n e i f t h e p e l v i s i s l e v e l , s i t i n f r o n t o f t h e s t a n d i n g p a t i e n t , w i t h y o u r t h u mb s o n t h e a n t e r i o r s u p e r i o r i l i a c s p i n e s ; t h e i n t e r s p i n o u s l i n e s h o u l d b e h o r i zo n t a l . L a t e r a l t i l t i n g r e s u l t s e i t h e r f r o m a d d u c t i o n o f o n e t h i g h o r f r o m s h o r t e n i o f t h e l i mb . N e xt , me a s u r e t h e d i s t a n c e b e t w e e n t h e g r e a t e r t r o c h a n t e r s a n d t h e a n t e r i o r s u p e r i o r i l i a c s p i n e s : w i t h y o u r mi d d l e f i n g e r s , f i n d t h e t i p s o f t h e g r e a t e r t r o c h a n t e r s a n d p a l p a t e t h e d i s t a n c e s t o t h e s p i n e s . S ma l l d i s p a r i t i e s c a n b e d e t e c t e d i n t h i s ma n n e r Fsg .e 1 3 - 8)B If t h e p e l v i s i s n o t h o r i zo n t a l , p l a c e b o o k s (ie . o r b l o c k s u n d e r t h e f o o t o f t h e s h o r t e r l i mb u n t i l t h e p e l v i s b e c o me s h o r i zo n t a l ; t h i s


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p r o v i d e s a n a c c u r a t e me a s u r e me n t o f s h o r t e n i n g . N e xt ,hav e t he pat i ent l i e on t he ex ami ni ng t abl e f o l l o w i n g t e s t s e xc e p t . All the t h a t f o r e xt e n s i o n a r e m a d e i n t h e s u p i n e . p o s i t i o n

Te s t for R otation with E x te ns ion.

T h i s mo t i o n s h o u l d b e t e s t e d f i r s t b e c a u s e i t i s g e n t l e s t ; i f i t i s p a i n f u l , a l l o t h e r ma n e u v e r s s h o u l d b e c a r r i e d o u t c a u t i o u s l y. W i t h t h e p a t i e n t s u p i n e , p l a c e a h a n d o each side of the lower thigh and rock it from side to side, watching the patella or th f o o t f o r t h e r a n g e o f r o t aF i o n 1 3 - 2 0 A Al t e r n a t i v e l y, t h e f o o t ma y b e r o c k e d f r o m t g. ( ). side to side.

Te s t for R otation with Fle x ion.


F l e x t h e k n e e a n d h i p t o 9 0 d e g r e e s , t h e n mo v e t h e f o o t ma xi ma l l y b o t h me d i a l l y ( e xt e r n a l r o t a t i o n ) a n d l a t e r a l l y ( i n t e r n a l r o t aF i o n )1 ( s e)e t g. 3-8C .

Te s t for Abduc tion.

H a v e t h e p a t i e n t l i e s u p i n e w i t h t h e l e g s t o g e t h e r. P l a c e a h a n d o n t h e i l i a c c r e s t a grasp the ankle with your other hand; gradually abduct the patient's thigh until you f e e l t h e p e l v i s mo v e , a n d n o t e t h e a n g l e a titg .i n e d 8(C F a 13- ).

Te s t for Adduc tion.


W i t h e a c h h a n d , g r a s p a n a n k l e , h o l d i n g o n e l e g d o w n i n e xt e n s i o n w h i l e y o u mo v e t h e o t h e r t h i g h a c r o s s i t F is e e1 3 - 8)C N o t e t h e a n g l e a t t a i n e d f r o m t h e n e u t r a l ( g. . p o s i t i o n . N o r ma l l y, t h e t h i g h s h o u l d c r o s s t h e o t h e r a t mi d t h i g h . P. 7 0 2

F i g . 1 3 - 2 0 Te s t s o f t h e H i p J o i n t a n d T h i g h . A . G e n t l e R o t a t i o n o f T h i g h . B . A n vi l Te s t . C . H u g h O w e n T h o m a s S i g n f o r L u m b a r L oex io s i s : t he Fl r d on of unaf f ec t ed hi p pr es s es t he l umbar s pi ne agai ns t t he t abl e. I f ex t ens i on of t he oppos i t e hi p i s s hown t o be i mpai r ed when el i mi nat i ng l umbar l or dos i s , i t i s a
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pos i t i v e Hugh Owen Thomas. Di. gn e a s u r e m e n t o f t h e G i r t h o f t h e T h i g h : s M M ar k s i mi l ar l ev el s on bot h l i mbs , meas ur ed down f r om t he ant er i or s uper i or i l i ac s pi nes . M eas ur e t he gi r t h at eacE . l ev el s u r e m e n t o f L e n g t h o f . h Mea L i m b s :Hav e t he t wo l i mbs appr ox i mat ed, or i n t he s ame r el at i v e pos i t i ons f r om t he mi dl i ne. M eas ur e f r om t he ant er i or s uper i or i l i ac s pi ne t o t he medi al mal l eol us , wi t h t he t ape r unni ng medi al t o t he pat el l a .

Te s t for H ip Fle x ion C ontr ac tur e .

P a t h o p h y s i o l o g y : e xi o n c o n t r a c t u r e o f t h e h i p i s c o mp e n s a t e d f o r b y a l u mb a r Fl l o r d o s i s , a l l o w i n g a n u p r i g h t s t a n c e t h a t ma s k s t h e .c o narca c tyu ru r h a n d Pl t e o e u n d e r t h e l u mb a r s p i n e f l e xi n g t h e u n a f f e c t e d t h i g h u n t i l t h e s p i n e p r e s s e s y o u r h a n a g a i n s t t h e t a b l e t o i n d i c a t e t h a t t h e l u mb a r l o r d o s i s h a s b e e n s t r a i g h t e n e d . N o w, e xt e n d t h e o t h e r t h i g h . It s h o u l d b e a b l e t o l i e f l a t o n t h e e xa m t a b l e . L a c k o f f u l l e xt e n s i o n r e v e a l s a f l e xi o n c o n t r a c t u r e o n t h e a f f e c t e d s i dHughpOwen e e, a ositiv Thomas s i gns e eF i g . 1 3 - 2 0)C ( .

The Anvil Te s t.

If o t h e r ma n e u v e r s h a v e n o t b e e n p a i n f u l , r a i s e t h e l e g f r o m t h e t a b l e w i t h t h e k n e e i n e xt e n s i o n a n d s t r i k e t h e c a l c a n e u s w i t h y o u r f i s t , u s i n g a mo d e r a t e b l o w i n t h e d i r e c t i o n o f t h e h i p j o i n t F(is e e1 3 - 2 0 B T h i s ma y e l i c i t p a i n i n e a r l y d i s e a s e o f g. ). the joint. P. 7 0 3

D ir e c tion P alpation of the H ip J oint.

F a c i n g t h e p a t i e n t , e xa mi n e t h e l e f t h i p w i t h y o u r r i g h t h a n d , a n d t h e r i g h t h i p w i t h y o u r l e f t h a n d . H o o k y o u r f i n g e r s a b o u t t h e g r e a t e r t r o c h a n t e r w i t h y o u r t h u mb p l a c e d o n t h e a n t e r i o r s u p e r i o r i l i a c s pFn g . ( 1 3 - 8)B W i t h y o u r t h u mb , f o l l o w i i e see . t h e i n g u i n a l l i g a me n t me d i a l l y u n t i l y o u f e e l t h e f e mo r a l a r t e r y, t h e n mo v e y o u r t h u m j u s t b e l o w t h e i n g u i n a l l i g a me n t a n d l a t e r a l t o t h e a r t e r y ; t h i s s h o u l d b r i n g y o u r t h u mb o v e r t h e s ma l l p o r t i o n o f t h e f e mo r a l h e a d t h a t i s e xt r a a c e t a b u l a r. E xe r t i n c r e a s i n g l y f i r m p r e s s u r e t o e l i c i t p a i n f r o m a r t h r i t i s . R o c k t h e f e mu r g e n t l y, t o f e e c r e p i t u s . If t h e h e a d d o e s n o t mo v e , f r a c t u r e o f t h e n e c k i s p r o b a b l e . If t h e h e a d cannot be felt, dislocation is suggested.

P atr ic k Te s t.
Passively flex the knee to a right angle and place the foot on the opposite patella. P u s h t h e f l e xe d k n e e t o w a r d s t h e t a b l e a s f a r a s t h e h i p j o i n t Fpg .r mi3 - ( s e e i e 1 ts 1 4 B) . P a i n l e s s a n d f u l l e xt e r n a l r o t a t i o n ( n e g a t i v e P a t r i c k s i g n ) e xc l u d e s s y mp t o ma t disease of the hip joint.

Te s t for E x te ns ion.
Wi t h t he pat i ent pr,one a d y t h e p e l v i s w i t h o n e h a n d w h i l e y o u r a i s e t h e l i mb ste p o s t e r i o r l y ( s e eg . 1 3 - 8)C N o r ma l e xt e n s i o n i s a b o u t 1 5 d e g r e e s . Fi .

M e as ur e m e nt of the Lowe r Lim bs .


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T h e g i r t h o f t h e t h i g h s a n d l e g s i s a s c e r t a i n e d b y me a s u r i n g t h e c i r c u mf e r e n c e s w i t a t a p e me a s u r e a t s y mme t r i c a l l e v e l s , d e t e r mi n e d b y me a s u r i n g d i s t a n c e s f r o m t h e a n t e r i o r s u p e r i o r i l i a c s p i n e s a n d ma r k i n g t h e m w i t h a s k i n ip e n1 3l- 2 s)e e F g. ci (0D . T h e l e n g t h o f t h e l o w e r l i mb s i s me a s u r e d i n s t r a i g h t l i n e s f r o m t h e a n t e r i o r s u p e r i o i l i a c s p i n e s t o t h e me d i a l ma l l e o l i o f t h e t i F i a e 1 3 e2 0 E C a r e s h o u l d b e b g. (s- e ). t a k e n t o h a v e t h e t a p e i n a s t r a i g h t l i n e r u n n i n g me d i a l t o t h e p a t e l l a e . B o t h e xt r e mi t i e s s h o u l d l i e e xa c t l y e q u i d i s t a n t f r o m t h e mi d l i n e . If o n e l i mb c a n n o t b e p l a c e d i n n o r ma l p o s i t i o n , i t s o p p o s i t e s h o u l d b e me a s u r e d i n a s i mi l a r p o s i t i o n . A d i f f e r e n c e o f > 1 . 5 c m s u g g e s t s h i p d e f o r mi t y i n t h e s h o r t e r l e g .

EXAMINATION OF THE KNEE


T h e n o r ma l mo v e me n t s o f t h e k n e e a r e f l e xi o n a n d e xt e n s i o n . F o r me a s u r e me n t s , seeFig. 13-10B .

Ge ne r al E x am ination of the Kne e .

I n s p e c t i o nH a v e t h e l e g s a n d t h i g h s u n c o v e r e d a n d t h e p a t i e n t s t a n d i n g . In s p e c t : t h e k n e e r e g i o n f o r d e f o r mi t i e s , s w e l l i n g , r e d n e s s , a n d mu s c l e a t r o p h y. N o t e t h e p o s i t i o n o f t h e p a t e l la l .p a t i o nTe s t s w e l l i n g s f o r f l u c t u a n c e , j o i n t e f f u s i o n , P a : c r e p i t a t i o n w i t h mo t i o n , a n d p o i n t s o f l o c a l i ze d t e n d e r n e s s i n t h e l i g a me n t s , b o n e s , and along the joint line. Palpate for doughy thickening of the synovium with o b s c u r a t i o n o f b o n y l a n d ma r k s . W i t h t h e p a t i e n t s u p i n e , t e s t t h e r a n g e o f f l e xi o n a n e xt e n s i o n , t e s t f o r a b n o r ma l a n t e r i o r a n d p o s t e r i o r mo b i l i t y o f t h e t i b i a o n t h e f e mu r a n d s t r e s s t h e me d i a l a n d c o l l a t e r a l l i g a me n t s f o r l a xi t y o r p a i n . Al w a y s c o mp a r e r i g t o l e f t b e c a u s e c o n s i d e r a b l e i n d i v i d u a l v a r i a t i o n e xi s t s f o r j o i n t s t a b i l i t y. P. 7 0 4 With a history of pain in the knee or locking, test for internal disorders of the knee joint, as described on page 706ff.

E x am ination for Kne e E ffus ion.

Inspection y reveal bulging on both sides of the patellar tendon and in the ma suprapatellar pouch, obliterating the natural hollows in these regions. T he swelling ma y a s s u me t h e s h a p e o f a h o r s e s h o e a r o u n d t h e i p a t1 3 l-a 4 A a g e 7 5 8 ) . F g. el 4 ( p , P a l p a t ew i t h t h e p a t i e n t s u p i n e a n d t h e k n e e s e xt e n d e d . G e n t l y p r e s s t h e t h u mb a n d f i n g e r s o f t h e r i g h t h a n d a g a i n s t t h e a n t e r i o r f e mo r a l c o n d y l e s a t t h e me d i a l a n d l a t e r a l s i d e s o f t h e k n e e s l i g h t l y p r o xi ma l t o t h e j o i n t l i n e a t t h e l o w e r e n d o f t h e patella. Slide the left hand down the distal thigh with constant pressure until the p a t e l l a r e s t s i n t h e s p a c e b e t w e e n t h e t h u mb a n d f i r s t f i n g e r ; y o u w i l l b e c o mp r e s s i n g t h e s u p r a p a t e l l a r p o u c h . If e f f u s i o n i s p r e s e n t y o u w i l l p a l p a t e a n d o f t e s e e a b u l g e o f f l u i d a p p e a r u n d e r t h e p a l p a t i n g r i g h t t h u mb a n d / o r f i n g e r s a s t h e f l u i s mo b i l i ze d o u t o f t h e s u p r a p a t e l l a r b u r s a b y t h e l e f t h a n d . S ma l l a mo u n t s o f f l u i d c a n b e d e t e c t e d v i s u a l l y b y c o mp r e s s i n g t h e s w e l l i n g i n o n e o f t h e o b l i t e r a t e d hollows beside the patella then watching for the hollow to slowly refill spontaneous o r w i t h c o mp r e s s i o n o f t h e s u p r a p a t e l l a r p o u c hpat elsl tar obal l ot t ement . Te f r ( p a t e l l a r t a p o r f l o a t i n g p a t e l l a ) b y c o mp r e s s i n g t h e s u p r a p a t e l l a r p o u c h , a s described above, while the fingers of the other hand push the patella sharply again t h e f e mu rF ( g . 9 - 4 4,B a g e 7 5)8 If f l u i d i s p r e s e n t i n s u f f i c i e n t q u a n t i t y t o e l e v a t e i p . t h e p a t e l l a f r o m t h e f e mu r, b r i s k p r e s s u r e o n t h e p a t e l l a w i l l f o r c e i t d o w n a g a i n s t t
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f e mo r a l c o n d y l e s w i t h a p a l p a b l e t a p , elh e bal l ot t ement .s i gn pat t l ar

E x am ination of the Kne e Ligam e nts .

T h i s i s p a r t o f t h e r o u t i n e k n e e e xa m. D e t e r mi n e t h e d e g r e e o f t i g h t n e s s o r l a xi t y o f t h e a n t e r i o r a n d p o s t e r i o r c r u c i a t e s a n d b o t h c o l l a t e r a l l i g a me n t s .

C o l l a t e r a l L i g a m e n W i:t h t h e p a t i e n t s u p i n e , f l e x t h e k n e e t o 1 0 d e g r e e s . P a l p a t e ts t h e i n s e r t i o n s p r o xi ma l l y a n d d i s t a l l y a n d e a c h l i g a me n t a t t h e j o i n t l i n e . T h e r o p e l i k e l a t e r a l l i g a me n t i s e a s i l y i d e n t i f i e d a t t h e j o i n t l i n e p o s t e r o l a t e r a l l y. T h e b r o a d e me d i a l l i g a me n t i s mo r e d i f f i c u l t t o i d e n t i f y. G r a s p i n g t h e c a l f w i t h o n e h a n d w h i l e t o t h e r h a n d s u p p o r t s a n d s t a b i l i ze s t h e f e mu r f r o m b e h i n d w i t h t h e t h u mb a n d f i n g e r t i p s o n o p p o s i t e j o i n t ma r g i n s o v e r l y i n g t h e c o l l a t e r a li g i. g1 3 - 2n t s ( F l a me) 1 . S t r e s s f i r s t t h e l a t e r a l , t h e n t h e me d i a l c o l l a t e r a l l i g a me n t s b y e xe r t i n g a v a r u s t h e n v a l g u s f o r c e o n t h e c a l f w h i l e p a l p a t i n g o v e r t h e l i g a me n t s a t t h e j o i n t ma r g i n . F e e l f o r s e p a r a t i o n o f t h e t i b i a f r o m t h e f e mu r w h i l e o b s e r v i n g t h e a mo u n t o f me d i a l o r l a t e r a l d i s p l a c e me n t o f t h e t i b i a .

C r u c i a t e L i g a m e n tTe:s t t h e a n t e r i o r c r u c i a t e w iLact hman t es t i g . 1 3 - 2 2 A s th he (F ). Have the patient lie supine and flex the affected knee to an angle of 30 degrees. Si on the patient's foot to fix it. Grasp the upper part of the leg with your fingers in th p o p l i t e a l f o s s a a n d y o u r t h u mb s o n t h e a n t e r i o r j o i n t l i n e . P u l l t h e h e a d o f t h e t i b i a t o w a r d y o u s o i t g l i d e s o n t h e f e mo r a l c o n d y l e s . F o r w a r d mo v e me n t o f mo r e t h a n 1 c m i s a p o s i t i v e L a c h ma n t e s t , i n d i c a t i n g r u p t u r e o f t h e a n t e r i o r c r u c i a t e l i g a me n t . T t e s t t h e p o s t e r i o r c r u c i a t e , s t a r t a s i n t h e L a c h ma n t e s t a n d o b s e r v e f o r s a g g i n g o f t h e t i b i a p o s t e r i o r l y. T h e n p u s h t h e h e a d o f P. 7 0 5 t h e t i b i a p o s t e r i o r l y. D i s p l a c e me n t s h o u l d b e l e s s t h a n 5 mm. Al w a y s c o mp a r e t h e t w o k n e e s b e c a u s e c o n s i d e r a b l e i n d i v i d u a l v a r i a b i l i t y i n l i g a me n t t i g h t n e s s i s n o r ma a d i s c r e p a n c y b e t w e e n t h e t w o s i d e s i s a s i g n o f p r e v i o u s i n j u r y.

F i g . 1 3 - 2 1 Te s t s f o r L a t e r a l S t a b i l i t y o f t h e K n e e J o i n t .

E X A M I N AT I O N O F T H E PA I N F U L K N E E O b t a i n a d e t a i l e d a c c o u n t o f p r e v i o u s t r a u ma , i n c l u d i n g t h e e xa c t me c h a n i s m o f i n j u r y. T h i s i s e s s e n t i a l t o u n d e r s t a n d i n g w h i c h s t r u c t u r e s P. 7 0 6
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mi g h t h a v e b e e n i n j u r e d . As k w h i c h mo t i o n s c a u s e d i s c o mf o r t o r l o c k i n g , a n d a s c e r t a i n w h e t h e r u n l o c k i n g i s s u d d e n o r g r a d u a l ( a s i n mu s c l e s p a s m) . H a v e t h e p a t i e n t p o i n t t o s i t e s o f p a i n a n d d e mo n s t r a t e t h e p o s i t i o n o f f i xa t i o n i f l o c k i n g h a s o c c u r r e dI.n s p e c t i o nE xa mi n e t h e p a t i e n t s u p i n e o n t h e t a b l e . N o t e e v i d e n c e o f : j o i n t e f f u s i o n a n d mu s c l e a t rP a lh y. t i o nF e e l t h e k n e e c a r e f u l l y f o r p o i n t op pa : tenderness, especially over the quadriceps tendon, patellar tendon, collateral l i g a me n t s , a n s e r i n e b u r s a , a n d a l o n g t h e j o i n t l i n e . P a l p a t e t h e s u r f a c e o f t h e p a t e l a n d u n d e r i t s e d g e s , t h e n p u s h t h e p a t e l l a a s i d e a n d p a l p a t e t h e u n d e r l y i n g f e mo r a condyles. Feel for a click with pain while putting the knee through a full range of mo t i o n . A p a i n l e s s c l i c k i s r e l a t i v e l y u n i mp o r t a n t a s i t ma y b e c a u s e d n o r ma l l y b y t e n d o n s mo v i n g o v e r a b o n y p r o mi n e n c e . H a v e t h e p a t i e n t p u t t h e k n e e t h r o u g h a f u r a n g e o f a c t i v e mo t i o n a n d c o mp a r e w i t h t h e r a n g e o f p a s s i v e mo t i o n b y t h e e xa mi n e r. R e me mb e r t h a t j o i n t e f f u s i o n l i mi t s f l e xi o n a n d f u l l e xt e n s i o n . Imme d i a t e l y a f t e r i n j u r y, mu s c l e s p a s m a n d s w e l l i n g ma y ma k e f u l l e xa mi n a t i o n i mp o s s i b l e , i n w h i c h c a s e , i mmo b i l i ze t h e k n e e f o r a d a y o r t w o a n d t h e n rS o lxa mi n eDiH ,[ e e o mo t S i me l D L , B a t e s D W, e t a l . T h e r a t i o n a l c l i n i c a l e xa mi n a t i o n . D o e s t h i s p a t i e n t h a v e t o r n me n i s c u s o r l i g a me n t o f t h e k n e e ? Va l u e o f t h e p h y s i c a l J AMmi n a t i o n . e xa A 2 0 0 1 ; 2 8 6 : 1 6 1 0 1 6.2 0 ]

F i g . 1 3 - 2 2 Te s t i n g t h e C r u c i a t e L i g a m e n t s a n d A c h i l l e s Te n d o n . A . L a c h m a n Te s t f o r To r n C r u c i a t e L i g a m e n t : i ent i s s upi ne wi t h t he k nee f l ex ed at The pat 30 degr ees and t he f oot f l at on t he t abl e. The ex ami ner s i t s on t he f oot t o anc hor i t , t hen pul l s t he head of t he t i bi a t owar d hi ms el f t o t es t t he ant er i or c r uc i at e l i gament . For war d mot i on of mor e t han 1 c m i s pos i t i v e. Pus hi ng t he k nee bac k war d wi t h t he k nee f l ex ed at 90 degr ees t es t s t he pos t er i or c r uc i at e l i gamentB . E xa m i n a t i o n f o r R u p t u r e d A c h i l l e s Te n d opr:one pat i ent . The n hangs t he f eet ov er t he end of t he t abl e. I ns pec t i on s hows l es s nat ur al pl ant ar f l ex i on on t he s i de of r upt ur e. o n d s Te s Squeeze t he c al f mus c l es Simm t: t r ans v er s el y ; a nor mal or par t i al l y r upt ur ed t endon wi l l pr oduc e pl ant ar f l ex i on; c ompl et e r upt ur e wi l l not r es pond .

Te s ting for M e nis c us I nj ur y.


S e v e r a l t e s t s c a n b e p e r f o r me d t o i d e n t i f y me n i s c u s i n j u r y. M c M u r r a y Te s t i(g . 1 3 - 2 3)A W i t h t h e p a t i e n t p r o n e o n t h e t a b l e , g r a s p t h e F : p a t i e n t ' s k n e e w i t h o n e h a n d s o t h a t y o u r f i n g e r s p r e s s t h e me d i a l a n d l a t e r a l
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aspects of the joint. Grasp the patient's heel with your other hand so that the plant s u r f a c e o f t h e f o o t r e s t s a l o n g y o u r w r i s t a n d f o r e a r m. F i r s t , f l e x t h e k n e e u n t i l t h e h e e l n e a r l y t o u c h e s t h e b u t t o c k . To t e s t t h e p o s t e r i o r h a l f o f t h e me d i a l me n i s c u s , r o t a t e t h e f o o t l a t e r a l l y, a n d t h e n s l o w l y e xt e n d t h e k n e e f u l l y. If a c l i c k i s f e l t o r h e a r d d u r i n g t h e e xt e n d i n g mo t i o n , a n d t h e p a t i e n t r e c o g n i ze s i t a s t h e s e n s a t i o n p r e c e d i n g p a i n o r l o c k i n g , t h e me d i a l me n i s c u s i s t o r n . To t e s t t h e l a t e r a l me n i s c u s r e p e a t t h e ma n e u v e r w i t h t h e f o o t r o t a t e d me d i a l l y.

F i g . 1 3 - 2 3 Te s t s f o r Te a r o f t h e M e d i a l M e n i s c u s . A . M c M u r r a y Te s t . B . A p l e y Te s t . C . C h i l d r e s s . Te s t

P. 7 0 7 A p l e y G r i n d i n g Te s t ( S eg . 1 3 - 2 3)B H a v e t h e p a t i e n t l i e p r o n e o n a l o w c o u c h , Fi e : a b o u t 2 f e e t ( 6 0 c m) h i g h , w i t h t h e p a t i e n t ' s a f f e c t e d l i mb t o w a r d y o u . G r a s p t h e f o o w i t h b o t h y o u r h a n d s , f l e x t h e k n e e t o 9 0 d e g r e e s , a n d r o t a t e t h e f o o t l a t e r a l l y. T h i s s h o u l d c a u s e l i t t l e d i s c o mf o r t . N o w, r e s t y o u r k n e e o n t h e p a t i e n t ' s h a ms t r i n g s t o f i t h e f e mu r, a n d p u l l t h e l e g t o f u r t h e r f l e xi o n w h i l e t h e f o o t i s h e l d i n l a t e r a l r o t a t i o n p a i n i n d i c a t e s a l e s i o n o f t h e me d i a l c o l l a t e r a l l i g a me n t . N e xt , c o mp r e s s t h e t i b i a l c o n d y l e s o n t o t h e f e mo r a l c o n d y l e s b y p l a c i n g y o u r b o d y w e i g h t o n t o t h e p l a n t a r s u r f a c e o f t h e f o o t , s t i l l i n l a t e r a l r o t a t i o n . P a i n f r o m t h i s ma n e u v e r i n d i c a t e s t e a r o t h e me d i a l me n i s c u s .

C h i l d r e s s D u c k - W a d d l e Te s t F S e. e1 3 - 2 3)C T h i s t e s t i s s t r e n u o u s a n d i s (ig : reserved for athletes. Have the patient squat and waddle on the toes, swinging from s i d e t o s i d e . W i t h r u p t u r e o f t h e p o s t e r i o r h o r n o f t h e me n i s c u s , c o mp l e t e f l e xi o n c a n n o t b e a t t a i n e d ; t h e ma n e u v e r e l i c i t s p a i n o r c l i c k i n g i n t h e p o s t e r o me d i a l p o r t i o of the joint.

EXAMINATION OF THE ANKLE JOINT

W i t h t h e p a t i e n t s u p i n e pec ta n dpal pat et h e a n k l e f o r e d e ma , e f f u s i o n , o r ns , t e n d e r n e s s . Te s t d o r s i f l e xi o n a n d p l a n t a r f l e xi o n b y g r a s p i n g t h e h e e l f i r ml y w i t h y o u l e f t h a n d t o i mmo b i l i ze t h e s u b t a l a r j o i n t s w h i l e y o u r r i g h t h a n d g r a s p s t h e mi d f o o t a n d mo v e s t h e a n k l e t h r o u g h t h e f u l l r a n g e o f f l e xi o n a n d e xt e n s i o n . Te s t a n t e r i o r s t a b i l i t y ( d r a w e r t e s t ) b y s t a b i l i zi n g t h e d i s t a l t i b i a w i t h o n e h a n d w h i l e g r a s p i n g t h h e e l a n d p u l l i n g i t d i r e c t l y f o r w a r d w i t h t h e o t h e r. Te s t i n v e r s i o n a n d e v e r s i o n s t a b i l i t y b y s t a b i l i zi n g t h e t i b i a a s a b o v e w h i l e a l t e r n a t e l y f i r ml y i n v e r t i n g a n d


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e v e r t i n g t h e h e e l . In c r e a s e d mo b i l i t y w i t h e a c h t e s t i n d i c a t e s i n j u r y t o t h e a n k l e l i g a me n t s s t a b i l i zi n g t h a t mo t i o n .

EXAMINATION OF THE FOOT

In s p e c t t h e s h o e s f o r u n e v e n w e a r. N o r ma l w e a r i s o n t h e l a t e r a l e d g e o f h e e l a n d s o l e . W e a r o n t h e me d i a l s i d e o f t h e h e e l a n d t i l t i n g o f t h e v e r t i c a l h e e l s e a m i n d i c a t e s a b n o r ma l f o o t me c h a n i c s . W i t h t h e p a t i e n t b a r e f o o t a n d s t a n d i n g i n s p e c t t h e h e e l s f r o m b e h i n d , t h e s i d e s a n d t h e f r o n t . Al w a y s c o mp a r e r i g h t t o l e f t . L o o k f o t h e n o r ma l s l i g h t o u t w a r d a n g u l a t i o n o f t h e h e e l w h i c h s h o u l d r o t a t e me d i a l w h e n s t a n d i n g o n t h e t o e s . N o t e a n y d e f o r mi t i e s ( e . g . , h a mme r t o e s o r b u n i o n ) , t h e h e i g h t o f t h e p e d a l a r c h e s , a n d a l i g n me n t ( a p l u mb l i n e h a n g i n g f r o m t h e mi d - p a t e l l a s h o u l p o i n t b e t w e e n t h e f i r s t a n d s e c o n d me t a t a r s a l b o n e s ) . H a v e t h e p a t i e n t p o i n t t o t h e site of pain and palpate the site for tenderness or crepitus. With the patient supine i n s p e c t t h e s o l e f o r t h e p o s i t i o n o f c a l l u s f o r ma t i o n a n d p a l p a t e t h e f a t p a d s u n d e r t h e c a l c a n e u s a n d me t a t a r s a l h e a d s . Te s t mo t i o n b y s u p p o r t i n g t h e h e e l w i t h t h e s u p i n e h a n d a n d g r a s p i n g t h e f o o t w i t h t h e o t h e r h a n d , t o mo v e i t i n d o r s i f l e xi o n , p l a n t a r f l e xi o n , e v e r s i o n , a n d i n v e r s i F ng .( s1 3 - 1 2 A W h e n t e n d o n i n f l a mma t i o n oi ee ). i s s u s p e c t e d , l i s t e n w i t h t h e s t e t h o s c o p e f o r a r u b o v e r t h eAdaen f R lHs i t e [ pl ir u , G e r t s c h M . T h e s t e t h o s c o p e a s a d i a g n o s t i c a i d i n t e n o s y n oNi tEngl l e t t e r ) v is. ( J M ed 1 9 9 9 ; 3 4 0 : 1 5.6 ] P. 7 0 8

E XAM I N ATI ON FOR FLATFOOT:

H a v e t h e p a t i e n t s t a n d w i t h t h e f e e t p a r a l l e l a n d s e p a r a t e d b y a b o u t 1 0 c m. N o t e t h h e i g h t o f t h e me d i a l l o n g i t u d i n a l a r c h . If i t i s f l a t t e n e d , s e e i f i t r e s u me s a n o r ma l h e i g h t w h e n w e i g h t i s r e mo v e d . Te s t s t r e n g t h o f t h e a n t e r i o r l e g mu s c l e s b y h a v i n g t h e p a t i e n t s t a n d o n t h e h e e l s . Te s t f o r s h o r t e n i n g o f t h e Ac h i l l e s a n d p e r o n e a l t e n d o n s b y d o r s i f l e xi o n a n d i n v e r s i o n , r e s p e c t i v e l y, i n t h e s u p i n e p o s i t i o n . Te s t e v e r s i o n , w h i c h i s l i mi t e d i n r i g i d f l a t f o o t .

MUSCLE EXAMINATION
SeeChapter 14, The Neur ol ogi c Ex ami natpi a g e 8 0 5 . , on

BRIEF EXAMINATION FOR SKELETAL INJURIES

I f pai n or ot her s y mpt oms or s i gns l ead y ou t o s us pec t i nj ur y t o t he s pi ne, I M M EDI ATELY I M M OBI LI ZE t he pat i ent and obt ai n r adi ogr aphi c c onf i r mat i on of s t abi l i t y bef or e mov i ng t he nec k or s pi ne or pr oc eedi ng wi t h t he ex am. Tr auma of s uf f i c i ent f or c e t o c aus e i nj ur y t o maj or s k el et al s t r uc t ur es i s f r equent l y ac c ompani ed by i nt er nal v i s c er al i nj ur i es , whi c h ALWAYS t ak e pr ec edenc e ov er t he s k el et al i nj ur .i es

T h e f o l l o w i n g p r o c e d u r e i s r e c o mme n d e d f o r t h e r a p i d e xa mi n a t i o n o f i n j u r e d b u t c o n s c i o u s p e r s o n s t o u n c o v e r s k e l e t a l l e s i o n s i n t h e a b s e n c e o f s p e c i f i c c o mp l a i n t s

H e a d : H a v e t h e p a t i e n t o p e n a n d c l o s e h i s mo u t h a n d b i t e d o w n w h e n y o u r f i n g e r t i p s a r e o n t h e ma s s e t e r mu s c l e s ; i f n o p a i n i s e l i c i t e d , t h e f a c i a l b o n e s a r e n a f f e c t e d . P a l p a t e t h e zy g o ma t i c a r c h a n d n o s e f o r t e n d e r n e s s . P a l p a t e t h e s c a l p f o r b r u i s e s a n d l u mp s . W i t h y o u r h a n d s p r e s s f r o m o p p o s i t e s i d e s o f t h e p a t i e n t ' s h e a d
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for the pain of a skull fracture. N e c k : P a l p a t e t h e s p i n e s o f t h e c e r v i c a l v e r t e b r a e w i t h y o u r f i n g e r s b e f o r e mo v i n g the neck. Have the patient roll his head gently from side to side while your fingers p a l p a t e t h e n e c k mu s c l e s f o r t e n d e r n e s s o r s p a s m. As k t h e p a t i e n t t o l i f t h i s h e a d w h i l e y o u p l a c e y o u r h a n d u n d e r i t . As k t h e p a t i e n t t o p u s h d o w n w i t h h i s h e a d t o e s t i ma t e h i s s t r e n g t h a n d d i s c o mf o r t .

I f PAI N i s el i c i t ed wi t h any of t hes e maneuv er s , I M M EDI ATELY I M M OBI LI ZE t he nec k and c eas e f ur t her mov ement or ex ami nat i on unt i l t he nec k i s c l ear ed by adequat e r adi ol ogi c ex am .
C h e s t :As k t h e p a t i e n t t o t a k e a d e e p b r e a t h ; i f t h i s i s p a i n f u l , p l a c e y o u r h a n d s o n o p p o s i t e s i d e s o f t h e p a t i e n t ' s c h e s t a n d s q u e e ze t o l o c a t e t h e p o i n t o f t e n d e r n e s s of a rib fracture. Palpate the length of each clavicle. S p i n e :W i t h t h e p a t i e n t s u p i n e , s l i p y o u r h a n d u n d e r t h e p a t i e n t ' s b a c k , l i f t t h e p a t i e n t ' s c h e s t s l i g h t l y, a n d r u n y o u r f i n g e r s o v e r t h e s p i n o u s P. 7 0 9 p r o c e s s e s f o r t e n d e r n e s s a n d a n g u l a t i o n . D e t e r mi n e i f t h e r e i s l i mi t a t i o n o f s p i n a l mo t i o n .

I f PAI N i s el i c i t ed wi t h any of t hes e maneuv er s , I M M EDI ATELY I M M OBI LI ZE t he s pi ne and c eas e f ur t her mov ement or ex ami nat i on unt i l t he s pi ne i s c l ear ed by adequat e r adi ol ogi c ex am .

A r m s a n d H a n d s :a v e t h e p a t i e n t mo v e h i s a r ms , h a n d s , a n d f i n g e r s i n s u c c e s s i o n H a n d t h r o u g h a f u l l r a n g e o f mo t i o n . P a l p a t e e a c h f i n g e r f o r p h a l a n g e a l a n d me t a c a r p a l i n j u r i e s . S h a k e h a n d s , b o t h r i g h t a n d l e f t , a n d a s k t h e p a t i e n t t o t w i s t h a r m, w i t h e l b o w b o t h s t r a i g h t a n d f l e xe d . P e r f o r ma n c e o f t h e s e mo t i o n s , w i t h n o r ma s t r e n g t h a n d p a i n l e s s l y, e xc l u d e s i n j u r i e s o f h a n d , w r i s t , f o r e a r m, e l b o w, a r m, s h o u l d e r, c l a v i c l e , a n d s c a p u l a . P e l vi s :P l a c e d o w n w a r d p r e s s u r e me d i a l l y w i t h a h a n d o n e a c h a n t e r i o r i l i u m, t h e n o n t h e s y mp h y s i s p u b i s . P l a c e y o u r c l e n c h e d f i s t b e t w e e n t h e p a t i e n t ' s k n e e s a n d a s k t h e p a t i e n t t o s q u e e ze i t ; l a c k o f p a i n e xc l u d e s f r a c t u r e s o f p e l v i s a n d f e mo r a .

L e g s a n d F e e As k t h e p a t i e n t t o mo v e f i r s t o n e l e g , t h e n t h e o t h e r, t h r o u g h a f u l l t: r a n g e o f mo t i o n . P a l p a t e e a c h t o e . H a v e t h e p a t i e n t s t r e t c h h i s l e g s f l a t o n t h e t a b l Press his feet together and have him rotate them laterally against your resistance. t h e p a t i e n t e mp l o y s n o r ma l s t r e n g t h w i t h o u t p a i n , y o u h a v e e xc l u d e d ma j o r i n j u r i e s of legs and pelvis.

Musculoskeletal and Soft Tissue Sym ptom s

J o i n t P a i n : Ar t h r a l g i a : Ar t h r a l g i a me a n s j o i n t p a i n w i t h o r w i t h o u t o b j e c t i v e s i g n s o f i n f l a mma t i o n . T h e o n s e t , l o c a t i o n , s e v e r i t y, a n d t e mp o r a l p a t t e r n o f p a i n a r e i mp o r t a n t c l u e s t o t h e d i a g n o s i s . It i s e s p e c i a l l y h e l p f u l t o i n q u i r e w h e t h e r a c t i v i t y ma k e s t h e p a i n b e t t e r o w o r s e , a n d w h e t h e r mo r n i n g s t i f f n e s s i s p r e s e n t . In a p a t i e n t w i t h a r t h r a l g i a a n d arthritis, the differential diagnosis is based upon the pattern of the arthritis. R e c o g n i ze t h a t e a r l y i n t h e c o u r s e o f d i s e a s e , a r t h r a l g i a s ma y p r e c e d e a r t h r i t i s b y w e e k s o r mo n t h s .
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P. 7 1 0

Bone Pain: P a t h o p h y s i o l o g y : i n i n b o n e i s c a u s e d b y me c h a n i c a l i n j u r y, i n f l a mma t i o n , Pa i n f a r c t i o n , i n c r e a s e d i n t r a o s s e o u s p r e s s u r e , o r s t r e t c h i n g o f t h e p e r i o s t e u m. S o ma t a f f e r e n t n e r v e s c a r r y t h e p a i n f i b e r s a n d t h e p a i n i s w e l l l o c a l i ze d , e s p e c i a l l y w h e n t h e p e r i o s t e u m o r e n d o s t e u m i s i n vB ov e d p a i n i s o f t e n t h e o n l y s y mp t o m o f . ol ne d i s e a s e i n b o n e , a l t h o u g h i t ma y b e a c c o mp a n i e d b y l o c a l i ze d t e n d e r n e s s a n d s w e l l i n g . C h a r a c t e r i s t i c a l l y, b o n e p a i n i s c o n s t a n t , w e l l l o c a l i ze d , w o r s e a t n i g h t a n o f t e n i n t e n s i f i e d b y mo v e me n t o r w e i g h t b e a r i n g . B o n e p a i n ma y b e r e f e r r e d t o t h e n e a r e s t j o i n t , b u t c a r e f u l e xa mi n a t i o n c a n u s u a l l y d i s t i n g u i s h b e t w e e n a r t i c u l a r a n d b o n e p a i n . S q u e e zi n g t h e o v e r l y i n g mu s c l e s b e t w e e n t h u mb a n d i n d e x f i n g e r s h o u l d e xc l u d e t e n d e r mu s c l e s a s t h e s o u r c e o f p a i n . T h e o c c u r r e n c e o f b o n e p a i n s h o u l d p r o mp t x- r a y e xa mi n a t i o n . B O NE PAI N C L I NI C AL O C C URRE NC E : Congeni t al e mo g l o b i n S a n d C ( b o n e i n f a r c t i o n ) , a s e p t i c n e c r o s i s ( L e g g - C a l v h P e r t h e s d i s e a s e ) o f t h e f e mo r a l Endoc; r i ne y p e r p a r a t h y r o i d i s m ( o s t e i t i s head h f i b r o s a c y s t i c adi opat hi c s t e i t i s d e f o r ma n s ( P a g e t d i s e a s e o f b o n e ) , h y p e r t r o p h i c I ); o o s t e o a r t h r o p a t h y, o s t e o a r t h nftliammat or y / I mmunes i n o p h i l i c g r a n u l o ma o f I ri s; eo b o n e ;I nf ec t i ous s t e o my e l i t i s , B r o d i e a b s c e s s ( l o c a l i ze d s t a p h y l o c o c c a l i n f e c t i o n o f o t h e me t a p h y s i s o f a l o n g b o n e ) , u n t r e a t e d s y p h i l i s o f mo r e t h a n 3 y e a r s , s y p h i l i t i c o s t e o p e r i o s t i t i s , t u b e r c u l o s i s o fM etn e ; i c / Toxoc t e o p o r o s i s , o s t e o ma l a c i a , b o abol is d r u g s ( g r a n u l o c y t e c o l o n y - s t i mu l a t i n g f a c t o r, e r y t h r ec hani ic al / Tr aumat i c M opoiet n; f r a c t u r e s ( s p o n t a n e o u s o r p a t h o l o g i c ) , t e n d o n a v u l s i o n s a n d r u p t u r e s , l i g a me n t avulsions, epiphyseal plate injuries (e.g., Osgood-Schlatter disease of the tibial t u b e r o s i t y Neopl as t i c s t e o s a r c o ma , mu l t i p l e my e l o ma , g i a n t c e l l t u mo r, l a r g e c e l l ); o l y mp h o ma , E w i n g t u mo r, me t a s t a s e s t o b o n e , f i b r o s a r c o ma , c h o n d r o s a r c o ma ; Vas c ul ara v a s c u l a r n e c r o s i s ( w i t h g l u c o c o r t i c o i d s , h e mo g l o b i n S a n d C d i s e a s e s ) .
P. 7 11

M uscle Pain: M yalgia: P a t h o p h y s i o l o g M:u s c l e p a i n i s c a r r i e d o n s o ma t i c s e n s o r y n e u r o n s a n d i s y g e n e r a l l y w e l l l o c a l i ze d . P a i n c a n r e s u l t f r o m e xt e r n a l t r a u ma , r e p e t i t i v e o r s u s t a i n e c o n t r a c t i o n , i n f l a mma t i o n , i s c h e mi a , a n d me t a b o l i c d i s t u r b a n c e s . C h r o n i c my o f a s c i a p a i n i s o f u n k n o w n e t i o l o g y, b u t p r o b a b l y r e p r e s e n t s a l t e r a t i o n s i n t h e p e r i p h e r a l o r c e n t r a l n e u r a l c i r c u i t s . P a i n i s f r e q u e n t l y r e f e r r e d f r o m a n d t o mu s c l e f r o m r e g i o n a l s t r u c t u r e sH i s t o r y i s t h e k e y t o d i a g n o s i s n o t i n g t h e o n s e t , d u r a t i o n , a n d c h a r a c t e r . o f t h e p a i n , i t s r e l a t i o n s h i p t o a c t i v i t y, r e s t , a n d s y mp t o ma t i c t h e r a p y. M y a l g i a s f r e q u e n t l y a c c o mp a n y s y s t e mi c i n f l a mma t o r y i l l n e s s e s w i t h o r w i t h o u t f e v e r. In ma n y c h r o n i c i n f l a mma t o r y d i s o r d e r s , t h e mu s c l e p a i n i s mo r e s e v e r e a t n i g h t o r w i t h p r o l o n g e d i n a c t i v i t y. N e u r o mu s c u l a r e xa m i s p e r f o r me d l o o k i n g f o r s i g n s o f a t r o p h y, h y p e r t r o p h y, s p a s m, t e n d e r n e s s , t r i g g e r p o i n t s , t e n d e r p o i n t s , w e a k n e s s , o r fasciculations. M YAL G I A C L I NI C AL O C C URRE NC E : Thes e ar e ex ampl es , .onl y Congeni t al c Ar d l e d i s e a s e ( p a r o xy s ma l my o g l o b i n u r i a ) ; M Endoc r i ne y p e r - / h y p o p a r a t h y r o i d i s m, h y p o t h y rIo i dopat hi c s t e o a r t h r i t i s ; h di i s m; o I nf l ammat or y / I mmune u ma t i c f e v e r, r h e u ma t o i d a r t h r i t i s , d e r ma t o my o s i t i s , rhe
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p o l y my o s i t i s , s y s t e mi c l u p u s e r y t h e ma t o s u s , v a s c u l i t i s , p o l y my a l g i a r h e u ma t i c a ; I nf ec t i ous y a c u t e i n f e c t i o n , f o r e xa mp l e , i n f l u e n za , ( u n c o mmo n b u t i mp o r t a n t t o An r e me mb e r : ma l a r i a , r u b e l l a , d e n g u e , r a t - b i t e f e v e r, t r i c h i n o s i s , l e p t o s p i r o s i s , t y p h u s r i c k - e t t s i o s iBar t onel l) a e p i d e mi c p l e u r o d y n i a ( B o r n h o l m d i s e a s e , d e v i l ' s g r i p ) , s, , p y o my o s i t i s ; et abol i c / Toxfi e v e r, a c u t e h y p o n a t r e mi a , h y p o c a l c e mi a , M c h y p o p h o s p h a t e mi a , h y p o ma g n e s e mi a , d e h y d r a t i o n , d i u r e s i s , ma l a b s o r p t i o n , d r u g s ( s t a t i n s a n d o t h e rM ) ; hani c al / Tr aumatri a u ma , s t r a i n , h e ma t o ma , ma r c h s ec t c my o g l o b i n u r i a , t o n i c c o n t r a c t i o n s ( s u c h a s t e n s i o n h e a d a c h e s ) , s p i n a l s t e n o s i s ; Neopl as t i c a r a n e o p l a s t i c my o p a t h y a n d d e r ma t o my o s i tolsogi ci b r o my a l g i a , p Neur i ; f n e u r o g e n i c c l a u d i c a t Psn ;c hos oc i al b u s e ; io y a Vas c ul arc o mp a r t me n t s y n d r o me s , i s c h e mi a , a t h e r o e mb o l i , v a s c u l i t i s .

T RI C HI NO S I S : P a t h o p h y s i o l o g H:e a v y i n f e c t i o n w i t ih hi nel l a s pi r al if se r i n g e s t i o n o f y Tr c a t i n c o mp l e t e l y c o o k e d i n f e c t e d me a t ( p o r k , b e a r me a t ) ma y c a u s e s e v e r e d i s e a s e a n d i n f r e q u e n t l y, d e a t h . T h e o r g a n i s ms l o c a l i ze .i n mu s c l e d a y s a f t e r i n g e s t i o n , One to 4 t h e p a t i e n t c o mp l a i n s o f n a u s e a a n d v o mi t i n g , d i a r r h e a , a n d a b d o mi n a l p a i n . W i t h i n 1 0 d a y s t h e r e a r e f e v e r, d y s p n e a , a n o r e xi a , my a l g i a , a n d a s t h e n i a . P h y s i c a l f i n d i n g i n c l u d e p e r i o r b i t a l e d e ma , s c a r l a t i n i f o r m r a s h , s p l i n t e r h e mo r r h a g e s u n d e r n a i l s , t r e mo r s , a n d i n v o l u n t a r y mo v e me n t s .


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Back Pain: In c o mmo n u s a g e , b a c k a c h e r e f e r s t o t h e s p i n a l r e g i o n i n f e r i o r t o t h e s e v e n t h c e r v i c a l v e r t e b r a . Ac h i n g d i s c o mf o r t i n t h e b a c k ma y b e a c u t e a n d / o r c h r o n i c . It i s u s e f u l t o t h i n k o f b a c k a c h e i n t e r ms o f t h e a n a t o mi c s t r u c t u r e s t h a t c a u s e b a c k p a i n a n d p a i n r a d i a t i n g t o t h e b a c k . Ac u t e p a i n i s u s u a l l y t h e r e s u l t o f me c h a n i c a l t r a u m f r o m e xc e s s i v e f o r c e s a p p l i e d t o t h e b a c k o r r e p e t i t i v e u s e i n j u r y. C h r o n i c p a i n c a n b e t h e c o n s e q u e n c e o f a n y a c u t e i n j u r y o r r e p e t i t i v e u s e d i s o r d e r. It i s e s s e n t i a l t o r e me mb e r t h a t p a i n f r o m i n t e r n a l o r g a n s c a n b e r e f e r r e d t o t h e b a c k s o d i s o r d e r s n o o f mu s c u l o s k e l e t a l o r g i n mu s t b e c o n s i d e r e d i n p a t i e n t s w i tD eb a c k A,a i n [ h yo R p W e i n s t e i n J N . L o w b a c k p a iEngl J M ed 0 0 1 ; 3 4 4 : 3 6 3 3 7 0e y o R A, R a i n v i l l e N n. 2 ;D J , D e n t D L . T h e r a t i o n a l c l i n i c a l e xa mi n a t i o n . W h a t c a n t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n t e l l u s a b o u t l o w b a c k AMi A ? 9 9 2 ; 2 6 8 : 7 6 0 7 6 5 J pa n1 ]. B AC K PAI N C L I NI C AL O C C URRE NC E : A c u t eB o n e s a n d L i g a m e n t sa c t u r e s , d i s l o c a t i o n s , t o r n o r a v u l s e d l i g a me n t s ; fr : C a r t i l a g e sh e r n i a t e d i n t e r v e r t e b r a l d i s k , dJs k in it s ;:r e a c t i v e a r t h r i t i s ; : i oi t s M u s c l e s :mu s c l e s t r a i n , my o s i t i s , h e maNo ma ; s :r a d i c u l o p a t h y ( d i s k t e r ve c o mp r e s s i o n , d i a b e t e s ) , e p i d u r a l ma s s o r a b s c e s s , a f t e r my e l o g r a p h y, s u b a r a c h n o i d h e mo r r h a g e , p o l i o my e l i t i s , t e tR e fue r;r e d P a i n :i s s e c t i n g a o r t i c a n e u r y s m, an s d angina pectoris, retrocecal appendicitis, pancreatitis, cholecystitis, biliary colic, p n e u mo t h o r a x, p l e u r i s y, n e p h r o l i t h i a s i s , p y e l o n e p h r i t i s . C h r o n i c o n e s a n d L i g a m e n t s :t e o p o r o s i s , o s t e o ma l a c i a , o s t e o my e l i t i s , d i f f u s e B os i d i o p a t h i c s k e l e t a l h y p e r o s t o s i s ( D IS H ) , s p o n d y l o a r t h r i t i d e s ( a n k y l o s i n g s p o n d y l i t i s reactive and psoriatic arthritis, etc.), Pott disease (tuberculous spondylitis), osteiti o f s y p h i l i s , P a g e t d i s e a s e ( o s t e i t i s d e f o r ma n s ) , p r i ma r y o r s e c o n d a r y n e o p l a s m o f b o n e , s p i n a b i f i d a ;r t i l a g eh e r n i a t e d i n t e r v e r t e b r a l J os n ;t s :o s t e o a r t h r i t i s ; Ca : di i k M u s c l e s :c h r o n i c mu s c l e s t r a i n , f i b r o my a l g i a , mye rs i t is :;s y r i n g o my e l i a , N o ve s
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C h i a r i ma l f o r ma t i o n , a r a c h n oR e t ie r;r e d P a i n :s o p h a g e a l c a r c i n o ma , p e p t i c idif s e u l c e r, c h r o n i c p a n c r e a t i t i s , p a n c r e a t i c c a r c i n o ma , r e n a l c e l l c a r c i n o ma , r e t r o p e r i t o n e a l l y mp h o ma , h e p a t o me g a l y f r o m a n y c a u s e , s p i n a l c o r d t u mo r, a o r t i c a n e u r y s m.

P a i n i n t h e Up p e r Ar m , F o r e a r m , a n d Ha n d : W h e n p a i n i s w e l l l o c a l i ze d t o o n e p a r t o f a n e xt r e mi t y, t h e d i a g n o s i s i s r e l a t i v e l y s i mp l e . H o w e v e r, o f t e n t h e p a i n i s mo r e o r l e s s d i f f u s e t h r o u g h o u t t h e u p p e r l i mb , s a n a n a t o mi c c l a s s i f i c a t i o n o f c a u s e s i s u s e f u l . L i mb p a i n d o e s n o t a l w a y s a r i s e i n mu s c u l o s k e l e t a l s o u r c e s , f o r e xa mp l e , p a i n ma y b e r e f e r r e d t o t h e u p p e r a r m f r o m my o c a r d i a l i s c h e mi a . ARM , F O RE ARM , AND HAND PAI N C L I NI C AL O C C URRE NC E : W e l l - L o c a l i z e d P a i rn h r i t i s , b u r s i t i s , b o n e f r a c t u r e , t e n d o n r u p t u r e , t e n o s y n o v i t i s , a t c e l l u l i t i s , mu s c l e s t r a i n , n e o p l a s m, i s c h e mi a a n d c l a ufdfiu s ei o n . i n Di cat Pa h e r n i a t e d c e r v i c a l i n t e r v e r t e b r a l d i s k , p o l y my a l g i a r h e u ma t i c a , s p o n d y l i t i s , P o t t d i s e a s e , n e o p l a s m o f b o n e , P a n c o a s t t u mo r, s y r i n g o my e l i a , r a d i c u l i t i s , c a r p a l t u n n e s y n d r o me , u l n a r t u n n e l s y n d r o me , c o mp l e x r e g i o n a l p a i n s y n d r o me ( r e f l e x s y mp a t h e t i c d y s t r o p h y ) .

Pain in the Shoulder : P a i n i n t h e s h o u l d e r i s a c o mmo n c o mp l a i n t , w h i c h t h e p a t i e n t ma y h a v e d i f f i c u l t y l o c a l i zi n g . S p e c i f i c d i a g n o s i s d e p e n d s u p o n i d e n t i f y i n g t h e p r o v o c a t i v e a n d p a l l i a t i v c i r c u ms t a n c e s , t h e q u a l i t y o f t h e p a i n , t h e a n a t o mi c r e g i o n o f t h e p a i n , i t s s e v e r i t y, a n d t i mi n g . It i s h e l p f u l t o c o n s i d e r t h e c o mmo n c o n d i t i o n s a r r a n g e d b y a n a t o mi c l o c a t i o nS[t e i n f e l d R , Va l e n t e R M , S t u a r t M J . A c o mmo n s e n s e a p p r o a c h t o s h o u l d e r p r o b l e msM ay o Cl i n Pr oc 9 9 ; 7 4 : 7 8 5 7] 9 4 . 19 .

S HO UL D E R PAI N C L I NI C AL O C C URRE NC E : S h o u l d e r J o i n tas t h r i t i s o f s t e r n o c l a v i c u l a r, a c r o mi o c l a v i c u l a r, a n d g l e n o h u me r a l r j o i n t s ; s u b l u xa t i o n s o f h u me r a l h e a d , a c r o mi o c l a v i c u l a r j o i n t , s t e r n o c l a v i c u l a r j o i n t ; B u r s a es u b a c r o mi a l a n d s u b d e l t o i d b uTe in dso n ss u p r a s p i n a t u s t e n d o n i t i s , t e a r rs ti . o f s u p r a s p i n a t u s t e n d o n ( p a r t i a l o r c o mp l e t e ) , o t h e r r o t a t o r c u f f t e a r s , r u p t u r e o f l o n g t e n d o n o f t h e b i c e p s , b i c i p i t a l t e n o sMn o v iltes mu s c l e s t r a i n , y u s c i s; f i b r o my a l g i a ( t e n d e r p o i n t s ) , my o s i t i s , h e ma t o ma , r u p t u r e o f mu s c l e ( c o mp l e t e o r i n c o mp l e t e ) , p o l y my a l g i a r h e u maoin e sf r a c t u r e s o f h u me r a l n e c k , s c a p u l a r B t ca; n e c k , c l a v i c lN ; r ve sn e r v e c o mp r e s s i o n b y t h e s c a l e n u s a n t i c u s mu s c l e ( s c a l e n u s ee a n t i c u s s y n d r o me ) , f i r s t r i b a n d c l a v i c l e ( c o s t o c l a v i c u l a r s y n d r o me ) ; c o mp l e x r e g i o n p a i n s y n d r o me ( s h o u l d e r h a n d s y n d r o me , r e f l e x s y mp a t h e t i c Vay s t uoa r y ) ; d sc r l ph a n e u r y s m o r t h r o mb o s i s o f t h e s u b c l a v i a n a r t e r y.
P. 7 1 3

P a i n Re f e r r e d t o t h e S h o u l d e r : P a t h o p h y s i o l o g P : i n i s r e f e r r e d t o t h e s h o u l d e r f r o m ma n y s i t e s i n t h e c h e s t , ya e s p e c i a l l y t h o s e i n n e r v a t e d b y t h e p h r e n i c o r v a g u s n e r v e s o r c e r v i c a l s y mp a t h e t i c chain When the diaphragm is involved (phrenic nerve) patients present with aching . o r s h a r p p a i n u s u a l l y f e l t o v e r t h e t o p o f t h e s h o u l d e r o r i n t h e t r a p e zi u s a t t h e b a s o f t h e n e c k . An g i n a i s mo s t o f t e n r e f e r r e d t o t h e i n n e r a r ms , j a w, a n d s h o u l d e r. P a i n f r o m n e r v e i n v o l v e me n t i s o f t e n b u r n i n g i n q u a l i t y a n d f o l l o w s t h e a p p r o p r i a t e
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d e r ma t o me . T h e f o l l o w i n g a n a t o mi c s i t e s a n d c o n d i t i o n s mu s t b e c o n s i d e r e d .

RE F E RRE D S HO UL D E R PAI N C L I NI C AL O C C URRE NC E : C a r d i o va s c u l a rn g i n a p e c t o r i s ( t o e i t h e r o r b o t h s h o u l d e r s ) , a o r t i c a n e u r y s m o r a d i s s e c t i o n ; l e u r ap l e u r i t i s o f t h e c e n t r a l p a r t o f d i a p h r a g m, p n e u mo n i a , P t u b e r c u l o s i s , p n e u mo t h o r a x, o r c a r c i n o ma o f t h e s u p e r i o r s u l c u s ( P a n c o a s t s y n d r o me )S p l e e n( l e f t s h o u l d e r o n l y ) i n f a r c t i o n , r Dpau rh r;a g m u b p h r e n i c ; uitp e s a b s c e s s , l e a k i n g p e p t i c uSc e r ; a c h a n d D u o d e n u ms t r i t i s , p e p t i c u l c e r, l tom ga g a s t r i c c a r c i n o ma ; r a n d G a l l b l a d dce ro l e l i t h i a s i s , c h o l e c y s t i t i s , h e p a t i t i s , L i ve h h e p a t i c c i r r h o s i s o r c a r c i n o ma , h e p a t i c a ba n c r e a s h r o n i c p a n c r e a t i t i s , P scess; c c a r c i n o ma , c a l c u l u s , o r p s e u d o c y s t ; sh e r p e s zo s t e r, b r a c h i a l p l e xi t i s , N e r ve n e o p l a s m o f c e r v i c o t h o r a c i c v e r t e b r a e , my e l i t i s , s p i n a l c o r d t u mo r.

P a i n i n t h e Hi p , T h i g h , o r L e g : P a i n i n t h e l o w e r e xt r e mi t y f r e q u e n t l y p r e s e n t s t h e p r o b l e m o f d i s t i n g u i s h i n g b e t w e e n t h e p r i ma r y l e s i o n a n d p a i n r e s u l t i n g f r o m r e d i s t r i b u t i o n o f w e i g h t b e a r i n g f a v o r t h e o r i g i n a l d i s o r d e r. F o r e xa mp l e , l i mp i n g o n a c h r o n i c a l l y p a i n f u l f o o t c a u s e mu s c l e s t r a i n i n t h e b a c k , p e l v i c g i r d l e , a n d b o t h l o w e r l i mb s . P a i n f u l s t r u c t u r e s a r e i d e n t i f i e d b y l o c a l i za t i o n o f p a l p a b l e t e n d e r n e s s a n d a c c e n t u a t i o n o f t h e p a i n w i t h s p e c i f i c mo v e me n t s . P a i n a r i s i n g i n s o ma t i c t i s s u e s ( mu s c l e , b o n e , t e n d o n , l i g a me n i s u s u a l l y w e l l l o c a l i ze d b y t h e p a t i e n t . P a i n a l s o i s f r e q u e n t l y r e f e r r e d t o r e g i o n a l s t r u c t u r e s i n n e r v a t e d b y t h e s a me s p i n a l s e g me n t . As a n e xa mp l e , l e s i o n s i n v o l v i n g t h e h i p j o i n t f r e q u e n t l y p r o d u c e p a i n i n t h e me d i a l a s p e c t o f t h e k n e e . An a n a t o mi c o r g a n i za t i o n f o r d i a g n o s t i c p u r p o s e s i s u s e f u l .

HI P, T HI G H, AND L E G PAI N C L I NI C AL O C C URRE NC E : M u s c l es t r a i n s a n d t e a r s , h e ma t o ma , p o l y my a l g i a r h e u ma t i c a , f i b r o my a l g i a , i s c h e mi a a n d i n f a r c t i o n , i n f e c t i o n , t uS o frts ;T i s s u eh e r n i a t i o n o f f a t t h r o u g h mu s c l e mo s f a s c i a , b u r s i t Te; n d o n st e n o s y n o v i t i s , t e n d o n s t r a i n a n d r J o t u r ea r t h r i t i s is u p i n t s; ( i n f l a mma t o r y, s e p t i c , c r y s t a l - i n d u c e d , o s t e o a r t h r i t i s ) , d i s l o c a tBo n se ss p r a i n s ; i on , f r a c t u r e s , n e o p l a s ms , o s t e o my e l i t i s , o s t e o p o r o s i s , o s t e o ma l a c i a , a s e p t i c n e c r o s i s , s p o n d y l o l i s t h e sAsr;t e r i e s h r o mb o s i s , e mb o l i s m ( t h r o mb u s , a t h e r o ma , f a t , s e p t i c i t v e g e t a t i o n s ) , v a s c u l i t i s , a n e uVe sn st h r o mb o s i s , t h r o mb o p h l e b i t i s , v e n u l i t i s , r y i m; v e n o u s i n s u f f i c i e nN y ;r ve sh e r n i a t e d i n t e r v e r t e b r a l d i s k , e p i d u r a l ma s s , c o n t u s i o n , ce v a s c u l i t i s ( mo n o n e u r i t i s mu l t i p l e x) , t a b e s d o r s a l i s , n e o p l a s ms ( e s p e c i a l l y n e u r o f i b r o ma s ) , p o s t h e r p e t i c n e u r a l g i a , p e r i p h e r a l n e u r o p a t h i e s ( e . g . , d i a b e t e s a n d others).
P. 7 1 4

Musculoskeletal and Soft Tissue Signs

Fr ac t ur es ar e di s c us s ed i n t hi s s ec t i on f or t he pur pos e of i l l us t r at i ng r el at i v el y c ommon phy s i c al f i ndi ngs . Thi s t ex t s houl d not be us ed as a gui de f or t he def i ni t i v e di agnos i s of t r aumat i c mus c ul os k el et al i nj ur i es . Or t hopedi c t ex t s s houl d be c ons ul t ed f or det ai l s , di f f er ent i al di agnos i s , and as a gui de t o di agnos i s and management .

General Signs
P a i n l e s s No d u l e s Ne a r J o i n t s o r Te n d o n s :
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S e v e r a l d i s e a s e s p r o d u c e p a i n l e s s n o d u l e s i n j o i n t c a p s u l e s , t e n d o n s , l i g a me n t s , o t h e s u r r o u n d i n g c o n n e c t i v e t i s s u e . S u b c u t a n e o u s n o d u lm s to fi d a r t h r i t i s rhe e a o a r e u s u a l l y o v e r b o n y p r o mi n e n c e s , w h e r e t h e y a r e l o o s e l y a t t a c h e d t o a r t i c u l a r capsules. T hey are also found in the periosteum or the deeper layers of the skin. G o u t y t o p h ia l t h o u g h u s u a l l y i n b u r s a e , a r e a l s o f o r me d i n t h e Ac h i l l e s t e n d o n a n d , t h e p i n n a o f t h e e a r. S u b c u t a n e o u s n o d u le u m a t i c f e ve r e f r e e l y mo v a b l e rh es of ar a n d o c c u r e s p e c i a l l y o v e r b o n y p r o mi n e n c e s o r t e n d o n s . T h e d i tah o ms ts c xa n g n o a i o f h y p e r c h o l e s t e r o l e mi a o c c u r i n t e n d o n s o f t h e h a n d s a n d i n t h e Ac h i l l e s t e n d o n a n d p a t e l l a r t e n d o n . J u xt a a r t i c u l a r n o d e s ( J e a n s e l me n o d u l e s ) o c c u r n e a r j o i n t s i n s y p h i l i s , y a w s , a n d o t he p o n e m a l d i s e a s e se r i a r t i c u l c a l c i u m d e p o s i t s r er . P ar o c c u r i n t h e C R E S T s y n d r o me a n d t u mo r a l c a l c i n o s i s .

No n t e n d e r F l u c t u a n t S w e l l i n g Ne a r J o i n t s a n d Te n d o n s : S y n o v i a l C y s t , M ucoid Cyst: P a t h o p h y s i o l o gT : e s e a r e e i t h e r b u r s a e o r t e n d o n s h e a t h s d i s t e n d e d b y f l u i d o r yh p r o t r u s i o n c y s t s h e r n i a t e d b y h y d r o s t a t i c p r e s s u r e f r o m j o i n th e a pa ru l e s . T cy s e u s u a l l y n o n t e n d e r a n d f l u c t u a n t . T h e p r o t r u s i o n c y s t s ma y c o l l a p s e u n d e r p r e s s u r e . S y n o v i a l c y s t s o c c u r i n t h e c o urrheumat oi d ar t hr,i tus u a l l y o n t h e d o r s a l se of i a s p e c t s o f t h e p r o xi ma l i n t e r p h a l a n g e a l j o i n t s . In o s t e o a r t h r i t i s , t h e y c o mmo n l y o c c over the distal interphalangeal joints of the hands and feet. When cysts arise from t h e e xt e n s o r s h e a t h s o f t h e w r i s t s , t h e y c a u s e o v a l s w e l l i n g s o n t h e d o r s a o f t h e h a n d s . In t h i s r e g i o n , t h e s y n o v i a l c y s t s a r e o fgangl aonsT h e p r o t r u s i o n ten c i lled . c y s t o f t h e k n e e i s k n o w n Bak er o r popl i t eal c y. s t as a
P. 7 1 5

Bur sitis: P a t h o p h y s i o l o gB: r s a e a r e s y n o v i a l c a v i t i e s u n d e r p e r i a r t i c u l a r t e n d o n s o r yu b e t w e e n t h e s k i n a n d b o n y p r o mi n e no me p e r i a r t i c u l a r b u r s a e c o mmu n i c a t e . S ces w i t h t h e j o i n t s p a c e . E f f u s i o n s o c c u r a s a r e s u l t o f r e p e t i t i v e u s e t r a u ma , d i r e c t b l u o r p e n e t r a t i n g t r a u ma , c r y s t a l d e p o s i t i o n , o r i n f e c t i o n . T h e h i s t o r y a n d e xa m c o mb i n e d w i t h k n o w l e d g e o f t h e l o c a l a n a t o my i s e s s e n t i a l f o r d i a g n o s i s .

Cr epitation: P a t h o p h y s i o l o g N:o r ma l j o i n t s u r f a c e s p r o d u c e a s mo o t h , g l i d i n g mo t i o n w i t h o u t y p a l p a b l e o r a u d i b l e f r i c t i o n o r n of il s e . In a mma t i o n , c a r t i l a g e i n j u r y, a n d l o o s e b o d i e s a r e o f t e n a s s o c i a t e d w i t h d e mo n s t r a b l e f r i c t i o n a n d c r e p i t a t i o n o n mo v e me n t . M o v i n j o i n t s ma y e mi t s e v e r a l t y p e s o f s o u n d s t h a t p r o mp t me d i c a l c o n s u l t a t i o n . T h e k n e e o r h i p s e s p e c i a l l y ma y p r o d u c e c r e a k i n g . C r e p i t u s i s a g r a t i n g s o u n d w h o s e v i b r a t i o n s ma y a l s o b e p a l p a t e d . It i s p r o d u c e d b y t h e r o u g h e n e d s u r f a c e s o f c a r t i l a g e r u b b i n g t o g e t h e r a n d i n d i c a t e s s i g n i f i c a n t d a ma g e t o t h e s u r f a c e o f t h e j o i n t . S o me p e r s o n s h a v e a p p a r e n t l y n o r ma l j o i n t s t h a t c r a c k l e o r p o p u n d e r c e r t a i n conditions.

M u s c l e Te n d e r n e s s : P a i n i n t h e mu s c l e s i s d i s t i n g u i s h e d f r o m a r t i c u l a r o r n e u r i t i c p a i n b y e l i c i t i n g mo d e r a t e t e n d e r n e s s w h e n t h e mu s c l e i s s q u e e ze d b e t w e e n t h e e xa mi n e r ' s t h u mb a n d f i n g e r s . To n i c mu s c l e c o n t r a c t i o n i s i d e n t i f i e d a s p a l p a b l e p e r s i s t e n t f i r mn e s s i t h e mu s c l e . B o t h mu s c l e a n d j o i n t p a i n a r e i n t e n s i f i e d b y mo v e me n t . N e u r i t i c p a i n i s
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associated with tenderness over the nerve trunk and intensification of the pain in th d i s t r i b u t i o n o f i t s b r a n c h e s . C h r o n i c n e u r i t i c p a i n ma y s t i mu l a t e s e c o n d a r y t o n i c mu s c l e c o n t r a c t i o n s .

Incr eased Joint M obility: P a t h o p h y s i o l o g P : s s i v e j o i n t mo t i o n i s r e s t r a i n e d b y t h e l i g a me n t s a t t a c h i n g t h e ya b o n e s o n e i t h e r s i d e o f t h e j o i n t . Ac t i v e mo t i o n i s a l s o r e s t r a i n e d b y mu s c u l a r c o n t r a c t i o nE xc e s s i v e mo t i o n i mp l i e s d i s o r d e r s o f t h e l i g a me n t s . Ab n o r ma l i t i e s c a n . b e c o n g e n i t a l o r a c q u i r e d . Ac q u i r e d l a xi t y r e s u l t s f r o m a c u t e o r c h r o n i c i n j u r y t o t h e l i g a me n t ( s ) l e a d i n g t o d i s r u p t i o n a n d l o s s o f s u p p o r t . It i s l i mi t e d t o t h e a f f e c t e d j o i a n d i n v o l v e s o n l y t h e mo t i o n u s u a l l y r e s t r a i n e d b y t h e a f f e c t e d l i g a me n t . T h e r e i s a s y mme t r y b e t w e e n t h e a f f e c t e d a n d t h e u n a f f e c t e d s i d e . D i f f u s e j o i n t l a xi t y r e s u l t s f r o m c o n g e n i t a l d i s o r d e r s o f c o n n e c t i v e t i s s u e i n t h e E h l e r s - D a n l o s s y n d r o me s . In c r e a s e d l a xi t y o f t h e s k i n , e a s y b r u i s i n g , a n d p o o r s c a r f o r ma t i o n a r e a mo n g t h e mo r e c o mmo n ma n i f e s t a t i o n s o f t h e s e s y n d r o me s .

Axial M usculoskeletal Signs


Neck Signs
P. 7 1 6

Ne c k P a i n : Nu c h a l He a d a c h e : Onset of dull pain is unilateral in the occipital region, progressing in a few hours to t h e b a c k o f t h e e y e , w h e r e i t ma y p e r s i s t f o r h o u r s t o d a y s a n d b e c o me t h r o b b i n g . P a l p a t i o n o f t h e p o s t e r i o r c e r v i c a l mu s c l e s ma y d i s c l o s e o n e o r mo r e t r i g g e r p o i n t s t h a t r e p r o d u c e t h e p a i n , a l t h o u g h t h e mu s c l e i t s e l f i s n o t t e n d e r. T h e p a i n ma y b e reproduced or accentuated by pressing on the vertex of the skull when the neck is b e n t l a t e r a l l y. P a s s i v e e xt e n s i o n o f t h e n e c k ma y r e l i e v e t h e p a i n . T h e p h y s i c a l s i g i n t h e n e c k d i s t i n g u i s h t h e c o n d i t i o n f r o m mi g r a i n e , o c c i p i t a l n e u r i t i s , t r i g e mi n a l n e u r a l g i a , a n d b r a i n t u mo r.

P a i n i n t h e Ne c k a n d S h o u l d e r : P a n c o a s t S y n d r o m e ( S u p e r i o r S u l c u s Syndr ome): P a t h o p h y s i o l o gL u n g c a n c e r a t t h e t h o r a c i c a p e x i n v a d e s l o c a l l y t o i n v o l v e t h e y: p l e u r a , t h o r a c i c mu s c l e s , a n d n e u r o v a s c u l a r b u n d l e s , i n c l u d i n g t h e b r a c h i a l p l e xu s a n d c e r v i c a l s y mp a t h e t i c .c h a iin i s f e l t i n l o c a l s t r u c t u r e s a n d i s r e f e r r e d i n t h e Pa n distribution of the involved nerves. Severe pain is present in the posterior part of t s h o u l d e r a n d a xi l l a , o f t e n s h o o t i n g d o w n t h e a r m, w i t h p a r e s t h e s i a o f t h e a r m a n d h a n d . P a r e s i s o r a t r o p h y o f a r m mu s c l e s ma y o c c u r. In a d d i t i o n t o n e c k a n d s h o u l d e p a i n , t h e c o mp l e t e s y n d r o me i n c l u d e s H o r n e r s y n d r o me ( u n i l a t e r a l mi o s i s , p t o s i s , a n d a b s e n c e o f s w e a t i n g o n t h e i p s i l a t e r a l f a c e a n d n e c k ) . It ma y b e c o n f u s e d w i t h rupture of the supraspinatus tendon, cervical spondylosis, and peripheral neuritis. P a i n i n t h e Ne c k a n d S h o u l d e r : C e r v i c a l S p o n d y l o s i s ( C e r v i c a l Osteoar thr itis): P a t h o p h y s i o l o gS: o n d y l o s i s r e s u l t s f r o m d e g e n e r a t i o n o f t h e v e r t e b r a e a n d yp i n t e r v e r t e b r a l d i s k s . O s t e o p h y t e s f o r mi n g a b o u t t h e d e g e n e r a t i n g t i s s u e ma y e n c r o a c h o n t h e i n t e r v e r t e b r a l n e u r a l f o r a mi n a o r p r o t r u d e i n t o t h ePs pnn a l c a n a l . ai i i s u s u a l l y p r e s e n t i n t h e n e c k o r s c a p u l a a n d f r e q u e n t l y e xt e n d s t o t h e s h o u l d e r, t h
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o c c i p u t , o r d o w n t h e a r m w i t h r a d i c u l o p aNuc hal e gi di t y wi t h Ar m Pai n: t h y ( s e Ri Cer v i c al Sy ndr ome l o w ) . N u mb n e s s a n d t i n g l i n g o f t h e h a n d s a r e f r e q u e n t , b u t be mu s c l e a t r o p h y i s r a r e . Ac t i v e a n d p a s s i v e mo t i o n s o f t h e n e c k a r e r e s t r i c t e d a n d ma y b e p a i n l e s s , b u t o f t e n p r o d u c e s u b j e c t i v e a n d o b j e c t i v e c r e p i t u s . C o u g h i n g w i t h t h e h e a d h e l d i n e xt e n s i o n ma y r e p r o d u c e t h e p a i n . T h e b i c e p s t e n d o n r e f l e x i s f r e q u e n t l y d i mi n i s h e d o r a b s e n t w i t h a r a d i c u l o p a t h y o f C 5 o r C 6 . T h e t r i c e p s r e f l e x i s d e c r e a s e d w i t h a r a d i c u l o p a t h y o f C 7 . At t r i b u t i o n o f t h e s y mp t o ms t o s p o n d y l o s i s d e p e n d s o n e xc l u s i o n o f o t h e r c a u s e s , s u c h a s i n c o mp l e t e r u p t u r e o f t h e s u p r a s p i n a t u s , P a n c o a s t t u mo r, a n d p e r i p h e r a l n e u r o p a t h y. P. 7 1 7

Nu c h a l Ri g i d i t y w i t h Ar m P a i n : C e r v i c a l S y n d r o m e : P a t h o p h y s i o l o g C:o n t u s i o n o f a c e r v i c a l r o o t i n t h e n e u r a l f o r a me n p r o d u c e s y s e v e r e p a i n a n d d i s a b i l i t y i n t h e n e r v e d i s t r i b u t i o n . C o mmo n l y, t h e c a u s e i s n a r r o w i n g o f i n t e r v e r t e b r a l f o r a mi n a o r c o mp r e s s i o n o f n e r v e r o o t s b y o s t e o p h y t e s . U n c o mmo n l y, t h e l e s i o n i s c a u s e d b y p r o t r u s i o n o f a n i n t e r v e r t e b r a l d i s k o r b y C 1 - C i n s t a b i l i t y f r o m r h e u ma t o i d a .r t U r iuia l l y mi n o r t r a u ma p r e c e d e s t h e o n s e t o f hs t s p a i n . P a i n f u l s p a s m o f t h e n e c k mu s c l e s c a u s e s t e mp o r a r y t o r t i c o l l i s , w i t h t h e h e a d tilted away from the painful side. Sharp, shooting pains spread slowly down the s h o u l d e r, t h e l a t e r a l a s p e c t o f t h e u p p e r a r m, a n d t h e r a d i a l a s p e c t o f t h e f o r e a r m, t h e w r i s t . T h e n e c k mu s c l e s a r e r i g i d o n t h e a f f e c t e d s i d e . Te n d e r n e s s i s o f t e n p r e s e n t i n t h e t r a p e zi u s , b r a c h i o r a d i a l i s , p e c t o r a l i s ma j o r, a n d t h e f o r e a r m e xt e n s o r T h e b i c e p s a n d t r i c e p s j e r k s a r e f r e q u e n t l y d i mi n i s h e d o r a b s e n t . T h e h a n d i s o c c a s i o n a l l y i n v o l v e d w i t h t i n g l i n g a n d n u mb n e s s i n t h e t h u mb , i n d e x a n d mi d d l e f i n g e r s . S y mp t o ms r e mi t g r a d u a l l y o v e r d a y s t o w e e k s . S t i f f Ne c k , Wi t h o r Wi t h o u t P a i n : Tu b e r c u l o u s S p o n d y l i t i s ( C e r v i c a l P o t t Diseases): P a t h o p h y s i o l o g T : b e r c u l o s i s o f t h e s p i n e i s a n i n d o l e n t o s t e o my e l i t i s o f t h e yu a n t e r i o r v e r t e b r a l e n d p l a t e s w i t h e xt e n s i o n t o t h e p a r a v e r t e b r a lTs o f t t i s s u e s . he n e c k i s h e l d s t i f f l y a n d s p o n t a n e o u s r o t a t i o n o f t h e h e a d i s a b s e n t . T h e r e ma y b e p a i n i n t h e n e c k , b u t o f t e n t h e n e c k i s p a i n l e s s . W h e n s e a t e d , t h e p a t i e n t ma y s u p p o r t h e r h e a d w i t h t h e h a n d s ( i gn An a b s c e s s o f t h e c e r v i c a l v e r t e b r a Rus t s ) . ma y t r a c k t o t h e r e t r o p h a r y n g e a l s p a c e .
P. 7 1 8

P o s t - t r a u m a t i c Ne c k P a i n : Fol l owi ng t r auma or s us pec t ed c er v i c al i nj ur y, t he c er v i c al s pi ne mus t ALWAYS be i mmedi at el y I M M OBI LI ZED i n a r i gi d c ol l ar PRI OR TO ANY M OVEM ENT or ex ami nat i on of t he pat i ent . P O S T - T RAUM AT I C NE C K PAI N AND HE AD AC HE : WHI P L AS H C E RV I C AL I NJ URY: P a t h o p h y s i o l o g S : d d e n , f o r c e f u l h y p e r e xt e n s i o n o f t h e n e c k w i t h f l e xi o n r e c o i l yu c o mmo n l y o c c u r s t o a p a s s e n g e r i n a n a u t o mo b i l e t h a t i s s t r u c k Ff irg .m b e h i n d ( o 1 3 - 2 4. P o s t e r i o r n e c k p a i n d e v e l o p s s l o w l y o v e r h o u r s o r d a y s . N e r v e - r o o t i r r i t a t i o n ) p r o d u c e s s p a s m o f t h e n e c k mu s c l e s a n d t o r t i c o l l i s . O c c i p i t a l h e a d a c h e d e v e l o p s , s o me t i me s w i t h b l u r r i n g o f v i s i o n . T h e c h i n i s t u r n e d t o w a r d t h e p a i n f u l s i d e o f t h e n e c k . P a l p a t i o n o v e r t h e l o w e r c e r v i c a l s p i n o u s p r o c e s s e s e l i c i t s t e n d e r n e s s . An
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e f f u s i o n w i t h s o f t c r e p i t u s c a n s o me t i me s b e f e l t o v e r t h e l o w e s t p a r t o f t h e l i g a me n t u m n u c h a e . T h e b i c e p s r e f l e x ma y b e d i mi n i s h e d o r a b s e n t o n o n e o r b o t h s i d e s . O c c a s i o n a l l y, t h e p u p i l i s d i l a t e d o n t h e a f f e c t e d s i d e .

F i g . 1 3 - 2 4 E xt e n s i o n I n j u r y ( W h i p l a s h ) o f t h e C e r vi c a olS p i ni e . Vi l ent mpac t f r om behi nd pr oduc es r api d t r ans l at i on bet ween t hr ee s equent i al pos i t i ons , c aus i ng r upt ur e of t he l i gament um .nuc hae

P O S T - T RAUM AT I C NE C K PAI N: F RAC T URE O F A S P I NO US P RO C E S S : P a t h o p h y s i o l o gT : e l o n g , t h i n , s p i n o u s p r o c e s s o f v e r t e b r a e n e a r t h e yh c e r v i c o t h o r a c i c j u n c t i o n b r e a k r e a d i l y f r o m a d i r e c t b l o w o r f r o m v i o l e n t mu s c u l a r c o n t r a c t i o n , s u c h a s r a i s i n g a h e a v y l o a d w i t h S us h o v e l s e v e r e p a i n . a dden, e xt e n d s f r o m t h e n e c k t o t h e s h o u l d e r, a c c e n t u a t e d b y f l e xi o n a n d r o t a t i o n o f t h e n e c k . Te n d e r n e s s i s e xq u i s i t e o v e r t h e f r a c t u r e s i t e . S o me t i me s t h e f r a c t u r e d p r o c e s s i s mo b i l e l a t e r a l l y a n d c r e p i t u s c a n b e f e l t . P O S T - T RAUM AT I C NE C K PAI N: F L E X I O N F RAC T URE O F T HE NE C K : P a t h o p h y s i o l o g T : e C 5 v e r t e b r a l b o d y i s mo s t f r e q u e n t l y f r a c t u r e d w h e n t h e r e i s yh f o r c e f u l h y p e r f l e xi o n o f t h e n e c k , f o r e xa mp l e , w h e n a d i v e r s t r i k e s h i s h e a d o n t h e b o t t o m T h e p a t i e n t w h o e s c a p e s i mme d i a t e d e a t h o r q u a d r i p l e g i a ma y b e u n a b l e t o . w a l k w i t h o u t s u p p o r t i n g h i s h e a d w i t h h i s h a n d s . P a i n r e s t r i c t s a l l mo t i o n s o f t h e n e c k . T h e s p i n o u s p r o c e s s o f t h e a f f e c t e d v e r t e b r a i s t e n d e r a n d ma y b e s o me w h a t p r o mi n e n t . P O S T - T RAUM AT I C NE C K PAI N: PART I AL D I S L O C AT I O N F RO M HY P E RE X T E NS I O N: P a t h o p h y s i o l o gA :f a l l o r b l o w o n t h e f o r e h e a d ma y h y p e r e xt e n d t h e n e c k a n d y r u p t u r e t h e a n t e r i o r l o n g i t u d i n a l l i. gT h e rn t i s i n t e n s e p a i n i n t h e n e c k . O n e a me e s p i n o u s p r o c e s s ma y s e e m mo r e p r o mi n e n t . P a r a p l e g i a f r e q u e n t l y o c c u r s .

P O S T - T RAUM AT I C NE C K PAI N: F RAC T URE O F T HE AT L AS ( C 1 ) O R T HE O D O NT O I D P RO C E S S ( C 2 ) : P a t h o p h y s i o l o g L o s s o f i n t e g r i t y o f t h e v e r t e b r a l r i n g o f b o n e a n d l i g a me n t y: restraining the odontoid process on fracture at the base of the odontoid produce i n s t a b i l i t y o f C 1 o n C 2 l e a d i n g t o c o mp r e s s i o n o f t h e c e r v i c a lIfs p i n a l c o r d . i mme d i a t e d e a t h d o e s n o t r e s u l t , t h e p a t i e n t s u p p o r t s h i s h e a d w i t h h i s h a n d s ; h e i s unwilling to nod his head. T here is severe occipital headache. T he patient cannot r o t a t e t h e h e a d . If t h e c l i n i c a l d i a g n o s i s i s n o t ma d e i mme d i a t e l y a n d t h e n e c k
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c o mp l e t e l y i mmo b i l i ze d , s u d d e n d e a t h ma y e n s u e . In r h e u ma t o i d a r t h r i t i s , p a n n u s ma y e r o d e t h e t r a n s v e r s e l i g a me n t o f C 1 t h a t s u p p o r t s t h e p o s t e r i o r o d o n t o i d l e a d i n g t o C 1 - C 2 i n s t a b i l i t y w i t h t r i v i a l t r a u ma . A h i g h i n d e x o f s u s p i c i o n i s r e q u i r e d t o ma k e t h e d i a g n o s i s .

Thoracolumbar Spine and Pelv is Signs


P. 7 1 9

Dor sal Pr otr usion fr om the Spine: Spina Bifida Cystica: P a t h o p h y s i o l o g F : i l u r e i n f u s i o n o f t h e n e u r a l a r c h o f a v e r t e b r a i s .s p i n a b i f i d a ya In s p i n a b i f i d a o c c u l t a , t h e r e i s n o p r o t r u s i o n o f t h e me n i n g e s ; t h e o n l y e xt e r n a l ma n i f e s t a t i o n ma y b e a d i mp l e i n t h e s k i n , a p a t c h o f h a i r, o r a l i p o ma t o u s n e v u s . W h e n t h e me n i n g e s f o r m a s a c p r o t r u d i n g t h r o u g h t h e d e f e c t i v e a r c h , i t i s a me n i n g o c e l e i(g . 1 3 - 2 5 A W h e n t h e s a c c o n t a i n s s p i n a l c o r d o r c a u d a e q u i n a , i t i s F ). t e r me d a my e l o me n i n g o c e l e . T h e s a c i s c o v e r e d b y h e a l t h y s k i n ; t h e l o c a l s w e l l i n g f i l l e d w i t h s p i n a l f l u i d , s o i t i s f l u c t u a n t a n d t r a n s l u c e n t . W i t h my e l o me n i n g o c e l e t h e o v e r l y i n g s k i n i s f r e q u e n t l y d e f e c t i v e a n d t r a n s i l l u mi n a t i o n ma y s h o w c o r d o r n e r v e f i b e r s . T r a n s mi s s i o n o f p r e s s u r e f r o m t h e o p e n f o n t a n e l l e t o t h e me n i n g o c e l e s h o w s t h e c o mmu n i c a t i o n t o b e w i d e . S o me t i me s a s i n u s l e a d s f r o m a s p i n a b i f i d a o c c u l t a t o t h e s k i n o f t h e s a c r a l r e g i o n , a c o n g e n i t a l s a c r o c o c c y g e a l s i n u s , o f t e n mi s t a k e n for a pilonidal sinus.

F i g . 1 3 - 2 5 S p i n a l D i s o r d e r s . A . M e n i n g o c e l e . B . C u r va t u r e s o f t h e S p i n e .

P. 7 2 0

S p i n a l D e f o r m i t y, L a t e r a l D e v i a t i o n : S c o l i o s i s : P a t h o p h y s i o l o g L a t e r a l c u r v a t u r e o f t h e t h o r a c i c s p i n e i s u s u a l l y a c c o mp a n i e d b y y: s o me r o t a t i o n o f t h e v e r t e b r a l b o d i e s , b u t o n l y t h e l a t e r a l d e v i a t i o n s o f t h e s p i n o u s p r o c e s s e s a r e v i s i b l e . M i n o r f u n c t i o n a l s c o l i o s i s f o r ms a s i n g l e l a t e r a l c u r v e , u s u a l w i t h c o n v e xi t y t o t h e r i g h t . W i t h s t r u c t u r a l c h a n g e s , t h e l a t e r a l c u r v e i n t h e t h o r a x p r o d u c e s a n o p p o s i t e c o mp e n s a t o r y c u r v e i n f e r i o r l y, s o t h e l i n e o f s p i n o u s
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p r o c e s s e s f o r ms a n S - s h a p e d c u r v e . T h e s p i n o u s p r o c e s s e s a l w a y s r o t a t e t o w a r d the concave side. On the convex side, rotation of the vertebral bodies causes f l a t t e n i n g o f t h e r i b s a n t e r i o r l y a n d b u l g i n g o f t h e c h e s t p o s t e r i o r l y, e l e v a t i o n o f t h e s h o u l d e r, a n d l o w e r i n g o f t h e h iw e d f r o m t h e p a t i e n t ' s b a c k , t h e p o s t e r i o r b u l g e . Vi e p i s a u g me n t e d w i t h a n t e f l e xi o n o f t h e s p iF i e . ( s e e2 L a t e r a l d e v i a t i o n w i t h a n g 1 3 -) . s i n g l e c u r v e i s u s u a l l y p o s t u r a l , a s p r o v e d b y i t s d i s a p p e a r a n c e i n e xt r e me s p i n a l f l e xi o n . An S - s h a p e d o r o t h e r c o mp l e x c u r v e ma y b e c o mp e n s a t o r y F i r .s t r u c t u r a l ( og 1 3 - 2 5 B. C o mp e n s a t o r y s c o l i o s i s o c c u r s w i t h t o r t i c o l l i s , t h o r a c o p l a s t y, c o n g e n i t a l ) d i s l o c a t i o n o f t h e h i p , a n d s h o r t e n e d l o w e r l i mb . S t r u c t u r a l s c o l i o s i s o c c u r s i n c o n g e n i t a l d e f o r mi t i e s a n d p a r a l y s i s o f b a c k o r a b d o mi n a l mu s c l e s . It i s mo s t o f t e n i d i o p a t h i c , o c c u r r i n g mo s t c o mmo n l y i n a d o l e s c e n t g i r l s .

For war d Spinal Cur vatur e: Kyphosis: T he forward concavity of the thoracic curve is accentuated, producing a hunch-back ( s e eF i g . 1 3 - 2 5 B A s mo o t h c u r v e r e s u l t s f r o m f a u l t y p o s t u r e , r i g i d k y p h o s i s o f ). a d o l e s c e n c e ( S c h e u e r ma n n d i s e a s e ) , a n k y l o s i n g s p o n d y l i t i s ( M a r i e - S t r mp e l l d i s e a s e ) , P a g e t d i s e a s e ( o s t e i t i s d e f o r ma n s ) , o s t e o p o r o s i s ( d o w a g e r ' s h u mp ) , a c r o me g a l y, a n d s e n i l e k y p h o s i s ( d o r s u m r o t u n d u m) . O f t h e s e , o n l y t h e c u r v e o f f a u l t y p o s t u r e d i s a p p e a r s w i t h s p i n a l e xt eGi bbus In or mi ta n a b r u p t n s i o n . def , y a n g u l a r c u r v e c a u s e d b y t h e c o l l a p s e o f o n e o r mo r e c o n t i g u o u s v F irge b r a e ( s e e e t. 1 3 - 2 5 B, r e s u l t s f r o m o s t e o p o r o t i c c o mp r e s s i o n f r a c t u r e , t u b e r c u l o s i s ( P o t t d i s e a s e ) ) n e o p l a s m ( e . g . , mu l t i p l e my e l o ma ) , t r a u ma , o r s y p h i l i s . In e i t h e r c u r v e d o r a n g u l a r k y p h o s i s , t h e s p i n a l f l e xi o n ma y f o r c e t h e t h o r a x t o p e r ma n e n t l y a s s u me t h e i n s p i r a t o r y p o s i t i o n , w i t h i n c r e a s e d a n t e r o p o s t e r i o r d i a me t e r a n d h o r i zo n t a l r i b s . T h t h o r a c i c d i s t o r t i o n i s i d e n t i c a l w i t h t h e b a r r e l c h e s t o f p u l mo n a r y e mp h y s e ma , b u t t h a u s c u l t a t o r y s i g n s o f e mp h y s e ma a r e a b s e n t . Spinal Defor mity: Kyphoscoliosis: T h e t h o r a c i c d e f o r mi t y o f s c o l i o s i s i s a c c e n t u a t e d a n d c o mp o u n d e d w h e n k y p h o s i s i s a l s o p r e s e n t . T h e t h o r a c i c c a v i t y ma y b e s o r e d u c e d a s t o c o mp r o mi s e t h e h e a r t and lungs.

Backwar d Spinal Cur vatur e: Lor dosis: T h e n o r ma l p o s t e r i o r c o n c a v i t y o f t h e l u mb a r c u r v e i s a c c e n tiu a t 1 3 - ( s e e F g. ed 2 5 B) . W e a k n e s s o f t h e a n t e r i o r a b d o mi n a l mu s c l e s i s a c o mmo n c a u s e . T h i s ma y o c c u r t o c o u n t e r b a l a n c e a p r o t u b e r a n t a b d o me n i n p r e g n a n c y a n d o b e s i t y o r c o mp l i c a t e r i c k e t s . It c o mp e n s a t e s f o r o t h e r s p i n a l d e f o r mi t i e s i n s p o n d y l o l i s t h e s i s , t h o r a c i c k y p h o s i s , f l e xi o n c o n t r a c t u r e o f t h e h i p j o i n t , c o n g e n i t a l h i p d i s l o c a t i o n , c o xa v a r a , a n d s h o r t e n i n g o f t h e Ac h i l l e s t e n d o n s . Ac c e n t u a t i o n o f t h e l u mb a r c u r v e t h r o w s t h e t h o r a c i c s p i n e b a c k w a r d a n d t h e t h o r a c i c c a g e b e c o me s f l a t t e n e d f r o m t h e p u l l o f t h e a b d o me n , c a u s i n g a n e xp i r a t o r y p o s i t i o n t o b e a s s u me d .


P. 7 2 1

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F i g . 1 3 - 2 6 L e s i o n s o f a S i n g l e Ve r t e b r a . A . S p o n d y l o l i s t h e s i s . B . H e r n i a t e d I n t e r ve r t e b r a l D i s k . C . S t a b l e C o m p r e s s i o n Ve r t e b r a l F r a c t u r e . D . U n s t a b l e C o m p r e s s i o n Ve r t e b r a l F r a c t u r e . E . I n t e r l o c k i n g o r S u b l u xa t i o n o f Ve r t e b r a .

Low Back Pain with Spinal Indentation: Spondylolisthesis: P a t h o p h y s i o l o g U:s u a l l y L 5 s l i p s f o r w a r d o n i S.1 1(3 - 2 6 Ab e c a u s e o f f r a c t u r e y F g ) o r d e g e n e r a t i o n o f t h e a r t i c u l a r p r o c e s s e s o f t h e n e u r a l a r c h ; o c c a s i o n a l l y, a d e f e c o f t h e l a mi n a ma y b e i n h e rIft e d mp t o ms o c c u r, t h e r e i s l o w b a c k p a i n , o f t e n . i sy r e f e r r e d t o t h e c o c c y x o r t h e l a t e r a l a s p e c t o f t h e l e g ( L 5 d e r ma t o me ) . In s p e c t i o n f r e q u e n t l y d i s c l o s e s a t r a n s v e r s e l o i n c r e a s e . P a l p a t i o n o f t h e l u mb a r s p i n e r e v e a l s a d e e p r e c e s s i o n o f t h e s p i n o u s p r o c e s s o f L 5 . T h e r e i s r e s t r i c t e d f l e xi o n o f t h e lower spine.

Post-tr aumatic M id-Back Pain: Stable Compr ession Fr actur e of Ve r t e b r a l B o d y ( w i t h I n t a c t S p i n a l L i g a m e n t s ) : P a t h o p h y s i o l o g T : e t h o r a c i c o r l u mb a r v e r t e b r a e a r e f r a c t u r e d b y t r a u ma t h a t yh c r u s h e s t h e i r b o d i e s , s u c h a s f o r c e f u l h y p e r f l e xi o n o f t h e s p i n e , f a l l i n g a n d l a n d i n g o n t h e f e e t o r b u t t o c k s , o r a d o w n w a r d b l o w o n t h e s h oF il g .e r1s3 - 2 e). u d (s6e C P a i n a n d t e n d e r n e s s a t t h e f r a c t u r e s i t e ma y b e mi l d o r e v e n a b s e n t f o r w e e k s , s o f r a c t u r e ma y n o t b e s u s p e c t e d u n t i l a r a d i o g r a p h i s o b t a i n e d . O c c a s i o n a l l y, s l i g h t kyphosis is present.
P. 7 2 2 P o s t - t r a u m a t i c M i d - B a c k P a i n : Un s t a b l e C o m p r e s s i o n F r a c t u r e o f Ve r t e b r a l B o d y ( w i t h To r n S p i n a l L i g a m e n t s ) : P a t h o p h y s i o l o g R:u p t u r e o f t h e i n t e r s p i n a l a n d s u p r a s p i n a l l i g a me n t s , y a c c o mp a n y i n g t h e c o mp r e s s i o n f r a c t u r e , p e r mi t s t h e a r t i c u l a r f a c e t s o f t w o a d j a c e n v e r t e b r a e t o s l i d e a p a r t ; o n r e c o i l , t h e y ma y i n t eF il g .c k 3 s2 6 E T h i s r o 1 (- ee ). d a n g e r o u s c o n d i t i o n ma y b e s u g g e s t e d c l i n i c a l l y b y p a l p a t i n g a g a p b e t w e e n t w o s p i n o u s p r o c e s s e s ( s eg . 1 3 - 2 6)D Fi e .
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P o s t - t r a u m a t i c B a c k P a i n : F r a c t u r e D i s l o c a t i o n o f Ve r t e b r a e : P a t h o p h y s i o l o g Vi: o l e n t h y p e r f l e xi o n o f t h e s p i n e , i n a d d i t i o n t o f r a c t u r i n g t h e y v e r t e b r a e , ma y t e a r t h e s u p p o r t i n g l i g a me n t s , p e r mi t t i n g v e r t e b r a l d i s l o c a t i o n a n d c o n s e q u e n t d a ma g e t o t h e s p i n a l Tch i r d i s a p o t e n t i a l l y u n s t a b l e c o n d i t i o n . os r e q u i r i n g i mme d i a t e i mmo b i l i za t i o n a n d e v a l u a t i o n . T h i s s h o u l d b e s u s p e c t e d w h e n the palpating finger finds a gap between two spinous processes.

Post-tr aumatic Low Back Pain: Fr actur e of a Tr ansver se Pr ocess: P a t h o p h y s i o l o g U:s u a l l y, t h e t r a n s v e r s e p r o c e s s o f a l u mb a r v e r t e b r a i s f r a c t u r e d y f r o m v i o l e n t c o n t r a c t i o n o f t h e a t t a c h e d. mu s c le s s s e v e r e p a i n i n t h e l u mb a r T her e i r e g i o n , w i t h i n t e n s e mu s c l e s p a s m. T h e s p i n o u s p r o c e s s e s a r e n o t t e n d e r. If c a u s e d b y a d i r e c t b l o w, l o o k f o r b l o o d i n t h e u r i n e t o i d e n t i f y a c o n c o mi t a n t k i d n e y i n j u r y.

C h r o n i c B a c k P a i n : An k y l o s i n g S p o n d y l i t i s ( M a r i e - S t r m p e l l - B e c h t e r e w Syndr ome): N o n - s p e c i f i c s y mp t o ms o f t e n b e g i n i n a d o l e s c e n c e a n d o c c u r i n t e r mi t t e n t l y f o r 5 o r 1 0 y e a r s . In t h e l a t e t e e n s o r e a r l y t w e n t i e s , p a i n a n d s i g n i f i c a n t mo r n i n g s t i f f n e s s a r e f e l t i n t h e l u mb a r r e g i o n , b u t t o c k s , a n d s a c r o i l i a c r e g i o n . T h e s p i n e l o s e s i t s f l e xi b i l i t y : t h e n o r ma l l u mb a r l o r d o s i s i s s t r a i g h t e n e d w i t h d i mi n i s h e d a n t e r i o r f l e xi o a n d s p i n a l r o t a t i o n a n d l a t e r a l b e n d i n g a r e i mp a i r e d . S l o w l y t h e p r o c e s s a s c e n d s t h l u mb a r a n d t h o r a c i c s p i n e , t h e c e r v i c a l r e g i o n ma y b e i n v o l v e d l a t e . F a t i g u e , f e v e r, a n d w e i g h t l o s s ma y o c c u r. E p i s o d e s o f a c u t e o r s u b a c u t e a r t h r i t i s ma y i n v o l v e h i p , k n e e , s h o u l d e r, s t e r n o c l a v i c u l a r, o r ma n u b r i o s t e r n a l j o i n t s . Te n d e r n e s s i s f o u n d o v e t h e i n v o l v e d j o i n t s . Ir i d o c y c l i t i s o c c u r s i n o n e - f i f t h o f t h e c a s e s . Ao r t i c r e g u r g i t a t i o n i s a l a t e c o mp l i c a t i o n i n 3 % o f p a t iD X:t Id. i o p a t h i c a n k y l o s i n g s p o n d y l i t i s n e e d s D en s to be distinguished from psoriatic arthritis and reactive spondyloarthritis (Crohn disease, ulcerative colitis, Reiter disease), Whipple disease, and diffuse idiopathic s p i n a l h y p e r o s t o s i s ( D IS H ) .
P. 7 2 3

Appendicular Skeleton, Joint, Ligament, Tendon, and Soft-Tissue Signs


Finger Signs

S o me a b n o r ma l i t i e s o f t h e f i n g e r s h a v e b e e n i n c l u d e d i n c o n s i d e r a t i o n o f t h e e n t i r e h a n d ; t h e mo r e l o c a l i ze d d i s o r d e r s a r e d i s c u s s e d h e r e .

M alfor m ation: P olydac tyly (S upe r num e r ar y Finge r s ):

T h e c o n d i t i o n ma y b e c o n g e n i t a l , f a mi l i a l , o r a s s o c i a t e d w i t h c e r t a i n s y n d r o me s . In t h e L a w r e n c e - M o o n - B i e d l s y n d r o me , p o l y d a c t y l y i s a s s o c i a t e d w i t h j u v e n i l e o b e s i t y, r e t i n a l d e g e n e r a t i o n , g e n i t a l h y p o p l a s i a , a n d me n t a l r e t a r d a t i o n ; a p p r o xi ma t e l y 8 0 % o f t h e c a s e s o f t h i s s y n d r o me a r e f a mi l i a l .

M alfor m ation: S yndac tyly (W e bbe d Finge r s ):


T h i s c o n g e n i t a l d e f o r mi t y ma y b e h e r e d i t a r y. T h e w e b ma y b e o n l y s o f t t i s s u e , o r i t ma y c o v e r f u s e d b o n e s . S c a r t i s s u e f r o m b u r n s ma y f o r m a n a c q u i r e d w e b .

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D ive r ge nt Finge r s : Tr ide nt H ands :


A characteristic of achondroplasia, the fingers approach uniform length and radiate f r o m t h e h a n d l i k e t h e s p o k e s i n a w h e e l w i t h a i f a t 1h u b 7(D F g. 3-2 ).

F i g . 1 3 - 2 7 C o n g e n i t a l l y D i s p r o p o r t i o n a t e H a n d s . A . A N o rIm a l H a n d : n pr ac t i c al l y al l nor mal mal e hands , t he r i ng f i nger i s l onger t han t he i ndex f i nger ; mos t women hav e l onger i ndex f i nger s , al t hough a f ew ex c ept i ons oc c ur.B . A r a c h n o d a c t y lThe f i nger s ar e r emar k abl e f or t hei r l engt h and y: s l ender nes s ; t he j oi nt s ar e abnor mal l y hy per ex t ens i bl e. Thi s oc c ur s i n M ar f an s y ndr ome. . D o w n S y n d r o mThe di gi t s ar e s hor t and t he l i t t l e f i nger of t en C e: has a pec ul i ar r adi al war d cD . vT r i d e n t H a n d : s oc c ur s i n ur e. Thi ac hondr opl as i a. The f i nger s ar e s hor t and al mos t equal i n l engt h; t he i ndex and mi ddl e f i nger s ar e wi del y s epar at ed .

P. 7 2 4 T h u m b P a i n F o l l o w i n g a F a l l : Ul n a r C o l l a t e r a l L i g a m e n t S p r a i n : T h e r e i s a h i s t o r y o f a f a l l o n t o t h e p a l m, o f t e n w h i l e g r a s p i n g a n o b j e c t w i t h t h e t h u mb . T h e p a t i e n t c o mp l a i n s o f p a i n i n t h e me t a c a r p o p h a l a n g e a l ( M C P ) j o i n t o f t h e t h u mb a n d a n i n a b i l i t y t o e xe r t s i g n i f i c a n t p r e s s u r e o n t h e p a d o f t h e t h u mb t i p w i t h o u t p a i n o r g i v i n g w a y. E xa m s h o w s t e n d e r n e s s a n d l a xi t y o f t h e u l n a r c o l l a t e r a l i g a me n t .

P a i n l e s s No d u l e s o n t h e I n t e r p h a l a n g e a l J o i n t s : He b e r d e n a n d B o u c h a r d No d e s : P a t h o p h y s i o l o g T : e s e f i n d i n g s a r e a r e s u l t o f ma r g i n a l o s t e o p h y t e s o n t h e d i s t a l yh i n t e r p h a l a n g e a l ( D IP ) a n d p r o xi ma l i n t e r p h a l a n g e a l .( P IPb ej rod n t s n o d e s o f He ) ien t h e D IP j o i n t s a r e h a r d n o d u l e s , 2 3 mm i n d i a me t e r, o n e o n e i t h e r s i d e o f t h e d o r s a mi d l i n e F(i g . 1 3 - 2 8 K T h e y a r e u s u a l l y p a i n l e s s , mo t i o n i s s l i g h t l y l i mi t e d , a n d ). d e f o r mi t y i s p r o g r e s s i v e , b u t f u n c t i o n i s p r e s e r v e d . T h e y a r e mo r e p r o n o u n c e d o n t h e d o mi n a n t h a n d . In v o l v e me n t b e g i n s i n s e v e r a l j o i n t s mo s t c o mmo n l y i n p e r i - o r p o s t me n o p a u s a l w o me n . T h e c o n d i t i o n i n w o me n i s u s u a l l y h e r e d i t a r y a n d t h e p r o c e s s i s a r e s u l t o f o s t e o a r t h r i t i s . A s i n g l e H e b e r d e n n o d e ma y r e s u l t f r o m t r a u ma N o d u l e s o n t h e P IP j o i n t s a r e c a l l e d B o u c h a r d n o d e s . T h e y o c c u r t o g e t h e r w i t h H e b e r d e n n o d e s , b u t s o me w h a t l e s s f r e q u e n t l y t h a n t h e l a t t e r.


P. 7 2 5
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P. 7 2 6

Clubbing of the Finger s Clubbing has intrigued physicians since Hippocrates because of its association with s e r i o u s s y s t e mi c d i s o r d e r s . T h e me c h a n i s m i s u n k n o w n , b u t c l u b b i n g i s r e v e r s i b l e w h e n t h e c a u s e i s r e mo v e d . T h e t h r e e k e y o b s e r v a t i o n s a r e f l o a t i n g o f t h e n a i l b a s e l o s s o f t h e u n g u o p h a l a n g e a l a n g l e , a n d i n c r e a s e d l o n g i t u d i n a l c o n v e xi t y o f t h e n a i l plate. Clubbing is painless and usually bilateral. With long-standing clubbing, the s o f t t i s s u e a n d t e r mi n a l p h a l a n x b e c o me t h i c k e n e d , t h e c o n v e xi t y o f t h e n a i l p l a t e i s e xt r e me , a n d t h e f i n g e r s a r e b u l b o u s ; a p p r o p r i a t e t e r ms a r e d r u ms t i c k f i n g e r s o r p a r r o t ' s b e a k . In t h e l i t e r a l s e n s e , t h e t e r m c l u b b i n g s h o u l d b e r e s e r v e d f o r t h i s l a t stage, but it is now applied to the general process in all stages, from the first sign floating nail. T he floating nails and alteration of the unguophalangeal angle d i s t i n g u i s h c l u b b i n g f r o m a l l o t h e r c o n d i t i o n s . C o n v e xi t y a l o n e i s s e e n i n o t h e r c o n d i t i o n s o r a s a n o r ma l v a r i a n t ( c e r t a i n o c c u p a t i o n s , i n h e r i t e d f o r ms ) . Demonstr ating Clubbing O b l i t e r a t i o n o f t h e U n g u o p h a l a n g e a l An g l e ( L o v i b o n d An g l e ) : In s p e c t t h e p r o f i l e o f t h e t e r mi n a l d i g i t . N o r ma l l y, t h e n a i l ma k e s a n a n g l e o f 2 0 d e g r e e s o r mo r e w i t h t h e p r o j e c t e d l i n e o f t h e d i g i t . W i t h c l u b b i n g , t h i s a n g l e i s d i mi n i s h e d o r ma y b e o b l i t e r a t e d o r e xt e n d b e l o w t h e p r o j e c t e d l i n e o fF it g .e 1d i - 2 t9 F l o a t i n g N a i l : h 3 g i) . ( P a l p a t e t h e p r o xi ma l n a i l w i t h t h e t i p o f y o u r f i n g e r. Yo u c a n f e e l a n d s e e t h e s p r i n g s o f t n e s s a s t h e r o o t o f t h e n a i l i s d e pF eg .s 1 3 - () 9 T h i s ma y b e s i mu l a t e d a s ri s ed 2 . f o l l o w s : w i t h y o u r r i g h t i n d e x f i n g e r p r e s s t h e ma n t l e o f y o u r l e f t mi d d l e f i n g e r ; t h e p l a t e r e s t s s n u g l y a g a i n s t t h e b o n e w i t h o u t mo v e me n t . N o w d e p r e s s t h e f r e e e d g e o t h e n a i l w i t h y o u r l e f t t h u mb a n d t e s t t h e ma n t l e a g a i n w i t h y o u r r i g h t i n d e x f i n g e r ; t h e p l a t e r o o t n o w s i n k s w i t h p r e s s u r e a n d s p r i n g s b a c k w h e n ne l exi s y d . C o r ve a t e o f t h e N a i lA mo n t h o r s o a f t e r t h e f l o a t i n g n a i l a n d n a i l a n g l e c h a n g e s o c c u r, a : t r a n s v e r s e r i d g e a p p e a r s i n t h e p l a t e f r o m b e n e a t h t h e ma n t l e . T h e r i d g e ma r k s t h e c h a n g e f r o m t h e n o r ma l d i s t a l c u r v e t o a n e w c u r v e o f s ma l l e r r a d i u s i n t h e p r o xi ma nail.

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F i g . 1 3 - 2 8 D e f o r m i t i e s o f t h e H a n d . A . C l u b h s n d :a c ongeni t al l es i on Thi a i s i n whi c h t he hand dev el opment i s r udi ment ar y ; t he s t ub may be s ur mount ed by r udi ment ar y or nor mal di B . t s .l n a r D e vi a t i oAl:s o c al l ed ul nar dr i f t . gi U n C. P o s i t i o n o f A n a t o m i c R e s t . D . C l a w h a n d E . A p e H a n d F. C a r p a l S p a s m G . Benediction Hand H. Wrist-drop I. Dupuytren Contracture J. Athetoid Hand K . H e b e r d e n N o d e s L . H a y g a r t h N o d e ss:pi ndl e- s haped enl ar gement s of The t he mi ddl e i nt er phal angeal j oi nt s oc c ur i n r heumat oi d ar t hr i t i s .

T h e f l o a t i n g n a i l a n d f l a t t e n e d a n g l e o c c u r r a p i d l y, f o r e xa mp l e , w i t h i n 1 0 d a y s a f t e a t o n s i l l e c t o my c o mp l i c a t e d b y l u n g a b s c e s s . W i t h c h r o n i c i l l n e s s o f o v e r 6 mo n t h s t h e e n t i r e n a i l h a s a b n o r ma l c o n v e xi t y. T h e s e q u e n c e o f c h a n g e s c a n o c c a s i o n a l l y be observed in a patient with subacute bacterial endocarditis. When first seen with 3 - mo n t h h i s t o r y o f i l l n e s s , a t r a n s i t i o n r i d g e i s vFs gb l e 3(-s ) 9eAf t e r i i i . 1 2e. t r e a t me n t o f t h e i n f e c t i o n a s e c o n d r i d g e a p p e a r s , t h i s o n e ma r k i n g t h e t r a n s i t i o n b e t w e e n d i s t a l a b n o r ma l c u r v a t u r e a n d p r o xi ma l n o r ma l p r o f i l e .

F i g . 1 3 - 2 9 C h a r a c t e r i s t i c s o f C l u b b e d .FTher e sar e t hr ee pr i nc i pal inger


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s i gns of c l ubbi ng of t he f i nger s : g u l a t i o n ( 2 ) c u r va t u r e o f t hand a i l (1) an e n (3) floating nail root

C L UB B I NG C L I NI C AL O C C URRE NC E : Congeni t al y a n o t i c c o n g e n i t a l h e a r t d i s e a s e , f a mi l i a l , c y s t Endoc ois i s ; c i c f i b r r ne h y p o t h y r o i d i s m; opat hi c h r o n i c o b s t r u c t i v e l u n g d i s e a s e , b r o n c h i e c t a s i s ; I di I nf l ammat or y / I mmunel a mma t o r y b o w e l d i s e a s e , b i l i a r y c i r r h o s i s , a l c o h o l i c inf c i r r h o s i sI;nf ec t i ousn f e c t i v e e n d o c a r d i t i s , l u n g a b s c e s s , p u l mo n a r y t u b e r c u l o s i s ; i Neopl as t i cu n g c a n c e r, me t a s t a t i c c a n c e r t o l u n g , me s oVaslc o ma ; l t h e i ul ar h y p e r t r o p h i c o s t e o a r t h r o p a t h y, p u l mo n a r y a r t e r i o v e n o u s ma l f o r ma t i o n s ( i n c l u d i n g dialysis shunts). C L UB B I NG WI T H P E RI O S T O S I S : HY P E RT RO P HI C P UL M O NARY O S T E O ART HRO PAT HY: H y p e r t r o p h i c o s t e o a r t h r o p a t h y ( H O A) i s r e c o g n i ze d b y c l u b b i n g a n d p e r i o s t e a l n e w b o n e f o r ma t i o n . Ac q u i r e d H O A r e s u l t s f r o m s y s t e mi c d i p a g e e7 ( s .e e s e a s 9)2 P r i ma r y h e r e d i t a r y H O A ( M a r i e - B a mb e r g e r s y n d r o me ) i s a n a u t o s o ma l d o mi n a n t s y n d r o me , w h i c h i s e xp r e s s e d mu c h mo r e c o mmo n l y i n ma l e s . It h a s c l u b b i n g , g r e a s thickening of the skin, especially noticeable on the face, and hyperhidrosis of the hands and feet.
P. 7 2 7

Swelling of the Finger s: Dactylitis, Sausage Digits: In f l a mma t i o n o f t h e e n t h e s e s o f o n e o r mo r e f i n g e r s p r o d u c e s f u s i f o r m s w e l l i n g w i t h or without joint effusion in patients with reactive and psoriatic arthritis. Dactylitis i a l s o s e e n i n t h e h a n d f o o t s y n d r o me o f s i c k l e c e l l o r s i c k l e t h a l a s s e mi a d i s e a s e . Fusifor m M onar ticular Swelling: Spr ain of an Inter phalangeal Joint: A p a i n f u l f u s i f o r m j o i n t s w e l l i n g ma y p e r s i s t f o r s e v e r a l mo n t h s . In mo s t c a s e s , t h e r i s a h i s t o r y o f t r a u ma . Localized Swelling Over a Joint: Synovial or M ucous Cyst: A s y n o v i a l c y s t r e s u l t s f r o m my xo ma t o u s d e g e n e r a t i o n o f a j o i n t c a p s u l e . A s ma l l , t e n s e n o d u l e a p p e a r s o v e r a n i n t e r p h a l a n g e a l j o i n t ; f r e q u e n t l y i t i s mi s t a k e n f o r a s e s a mo i d b o n e . It ma y b e s o t e n s e t h a t i t f e e l s b o n y h a r d ; u s u a l l y i t i s n o t f l u c t u a n P r e s s u r e ma y e l i c i t s l i g h t t e n d e r n e s s . O f t e n t h e r e i s s l i g h t t r a n s v e r s e mo b i l i t y. Flexion Defor mity of Distal Finger Joint: M allet Finger : P a t h o p h y s i o l o g T : i s i s c a u s e d b y r u p t u r e o f t h e e xt e n s o r t e n d o n t h a t i n s e r t s o n yh t h e t e r mi n a l p h a l a n x o r a v u l s i o n f r a c t u r e o f t h e d i s t a lh p hta lra n x a l p h a l a n x . T e e mi n o f t h e f i n g e r i s f l e xe d a t t h e d i s t a l i n t e r p h a l a n g e a l ( D IP ) j o i n t a n d c a n n o t b e v o l u n t a r i l y e xt e n d F dg .( 1 3 - 3 0 A ei ).

E x t e n s i o n D e f o r m i t y o f t h e P I P J o i n t : S w a n Ne c k D e f o r m i t y : P a t h o p h y s i o l o g F : xe d e xt e n s i o n o f t h e p r o xi ma l i n t e r p h a l a n g e a l ( P IP ) j o i n t o c c u r s yi w h e n t h e f l e xo r t e n d o n s a r e i n j u r e d o r s u b l u x t o t h e d o r s u m o f t h e j o i n t , h o l d i n g t h e j o i n t i n e xt e n s.i o nh i s d e f o r mi t y i s c o mmo n i n r h e u ma t o i d a r t h r i t i s a n d s y s t e mi c T l u p u s e r y t h e ma t o s u s . In t h e l a t t e r, i t i s u s u a l l y r e d u c ioud- t a pe def or mi t y J ac b l e , y .

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F i g . 1 3 - 3 0 A c q u i r e d F l e xi o n D e f o r m i t i e s o f t h e F i n g e r s . A . M a l l e t F i n g e r B . B o u t o n n i r e D e f o r m iTher e i s per manent f l ex i on of t he pr ox i mal ty: i nt er phal angeal j oi nt f r om r upt ur e of t he ex t ens or t endon i ns er t i ng on t he mi ddl e phal anx , gi v i ng a pos i t i on s i mi l ar t o t hat empl oy ed when us i ng a t y pewr i t er or c omput er k ey boarS a l u t i n g H a n The t humb i s l i mpl y C . d. d: f l ex ed i n t he pal m and c annot be v ol unt ar i l y ex.t ended. r F i n g eThe D Trigge r: f our t h or r i ng f i nger mov es i nt o f l ex i on pai nl es s l y, but at t empt ed ex t ens i on i s t empor ar i l y i mpeded. Ex t ens i on i s ac c ompl i s hed wi t h a pal E . e s nap. pabl F l e xu r e C o n t r a c t u r e s o f t h e F i nWi trh :s heat h adhes i ons , pas s i v e mot i on ge s of t he t endon i s ni l , ev en wi t h wr i s t f l ex i on .

P. 7 2 8 F l e x i o n D e f o r m i t y o f t h e P I P J o i n t : B o u t o n n i r e D e f o r m i t y, Ty p e w r i t e r Finger : P a t h o p h y s i o l o g T : i s r e s u l t s f r o m r u p t u r e o f t h e c e n t r a l b a n d o f t h e e xt e n s o r yh t e n d o n t h a t i n s e r t s o n t h e mi d d l e p h a l a n x. Vo l a r s u b l u xa t i o n o f t h e i n t a c t l a t e r a l b a t o t h e d i s t a l p h a l a n x h o l d s t h e f i n g e r i.nTfhe xif on g e r i s f l e xe d a t i t s p r o xi ma l le i n i n t e r p h a l a n g e a l ( P IP ) a n d l a c k s v o l u n t a r y e xt e nF iig .n 1(3 -e e) B E xt e n s i o n s o s 30 . f o l l o w e d b y f l e xi o n o f t h e P IP j o i n t ma y p r o d u c e a p a l p a b l e o r a u d i b l e d i a g n o s t i c c l i c k , a s t h e l a t e r a l s l i p s o f t h e d i s t a l e xt e n s o r t e n d o n s d i v e r g e a n d s l i p l a t e r a l l y o v t h e h e a d o f t h e p r o xi ma l p h a l a n x, h e n c e , b u t t o n h o l e r u p t u r e .

F l e x i o n D e f o r m i t y o f t h e T h u m b : S a l u t i n g Ha n d : P a t h o p h y s i o l o g E : e n s i o n a t t h e t h u mb me t a c a r p o p h a l a n g e a l ( M C P ) a n d y xt i n t e r p h a l a n g e a l j o i n t i s p e r f o r me d b y t h e e xt e n s o r p o l l i c i s l o n g u s t e n d o n ; r u p t u r e l e a d s t o l o s s o f f u n c t Toh i s i s a p p r o xi ma t e l y t h e p o s i t i o n o f t h e h a n d i n a n . i n Ame r i c a n mi l i t a r y s a l u t e F sg .e1 3 - 3 0)C T h e t h u mb i s l i mp l y f l e xe d i n t h e p a l m (i e . a n d c a n n o t b e v o l u n t a r i l y e xt e n d e d . T h e t e n d o n i s o f t e n w o r n t h r o u g h b y mo v i n g o v e r t h e f r a g me n t s o f a C o l l e s f r a c t u r e ; r u p t u r e ma y o c c u r f r o m 3 w e e k s t o 4 mo n t h after the fracture has been reduced. Snapping or Locking of Finger : Tr igger Finger : P a t h o p h y s i o l o gA :n o d u l a r t h i c k e n i n g f o r ms i n t h e l o n g f l e xo r t e n d o n j u s t p r o xi ma l y t o t h e me t a c a r p a l h e a d a s a r e s u l t o f i n f l a mma t i o n o r r e p e t i t i v e t r a u ma . W i t h f i n g e r e xt e n s i o n , t h e n o d u l e l i e s w i t h i n t h e t e n d o n s h e a t h ; d u r i n g f l e xi o n , i t i s p u l l e d w i t h o u t d i f f i c u l t y f r o m t h e p r o xi ma l e n d o f t h e s h e a t h b y t h e f l e xo r mu s c l e s . D u r i n g
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f i n g e r e xt e n s i o n b y t h e w e a k e r e xt e n s o r mu s c l e s , t h e c o n s t r i c t e d mo u t h o f t h e sheath resists reentry of the nodule. Entry is suddenly achieved with a noticeable c l i c k E i t h e r t h e mi d d l e o r r i n g f i n g e r i s u s u a l l y i n v o li v e d 3s 3 0)D F l e xi o n o f . F g. 1 ( - ee . t h e f i n g e r f e e l s n o r ma l , b u t e xt e n s i o n i s a c c o mp a n i e d b y a s n a p t h a t t h e p a t i e n t s o me t i me s r e f e r s t o t h e r e g i o n o f t h e p r o xi ma l i n t e r p h a l a n g e a l ( P IP ) j o i n t . T h e n o d u l e c a n b e p a l p a t e d mo v i n g w i t h t h e t e n d o n o n a c t i v e o r p a s s i v e f l e xi o n e xt e n s i o n . T r i g g e r i n g ma y o r ma y n o t b e p a i n f u l .

C o n t r a c t u r e o f a F l e x o r Te n d o n : Te n d o n Ad h e s i o n s o r Te n d o n Shor tening: P a t h o p h y s i o l o gAd h e s i o n s b e t w e e n a t e n d o n a n d i t s s h e a t h a r e c a u s e d b y y: t e n o s y n o v i t. i s i b r o t i c s h o r t e n i n g o f t h e t e n d o n w i t h o u t s y n o v i a l a d h e s i o n s o c c u r s i n F Vo l k ma n n i s c h e mi c c o n t r a c t u r e ( p a g e 7 4 0 ) . D i s t i n c t i o n b e t w e e n t h e t w o me c h a n i s ms c a n b e ma d e w i t h t h e w r i s t f l e xe d . G r a s p t h e t i p o f t h e f l e xe d f i n g e r a n d p u l l i t i n t o e xt e n s i o n . W i t h t h e s l a c k p r o v i d e d b y w r i s t f l e xi o n , t h e s h o r t e n e d t e n d o n p e r mi t s p a r t i a l e xt e n s i o n ; a d h e s i o n s t o t h e s h e a t h o r p a l ma r f a s c i a e n t i r e l y p r e v e n t e xt e n s i ( s e eF i g . 1 3 - 3 0 E ).


P. 7 2 9

Flexion Defor mity fr om T ight Skin: Scler odactyly: P a t h o p h y s i o l o g In: s c l e r o d e r ma , t h e s k i n a n d u n d e r l y i n g t i s s u e s b e c o me y c o n t r a c t e d a n d f i b r o s e d . M o v e me n t s o f t h e d i g i t s a r e i n h i b i t e d b y t h e t i g h t e n v e l o p e b u t t h e r e i s n o a n k y l o s i s o r s w e l l i n g o f l j o i n tt s a r e u s u a l l y i n v o l v e d , R a y n a u d . Al d g i p h e n o me n o n i s n e a r l y a l w a y s p r e s e n t , a n d c a l c i n o s i s o f t h e s k i n ma y o c c u r. S k i n i n o t h e r a r e a s o f t h e b o d y i s p r o g r e s s i v e l y i n v o l v e d i n t h e s c l e r o d e r ma t o u s p r o c e s s w i t h t h i c k e n i n g , s t i f f e n i n g , h y p e r p i g me n t a t i o n , a n d l i mi t e d mo t i o n . O p e n i n g t h e mo u t h , s w a l l o w i n g , a n d r e s p i r a t o r y mo v e me n t s ma y b e l i mi t e d . W i t h mu s c l e c o n t r a c t u r e o r t e n d o n a d h e s i o n s , t h e s k i n i s n o r ma l .


P. 7 3 0

Digital Infection: D e e p t i s s u e i n f e c t i o n s i n t h e f i n g e r s a r e i n i t i a l l y l i mi t e d t o s p e c i f i c t i s s u e c o mp a r t me n t s g i v i n g c h a r a c t e r i s t i c s i g n s . Par onychia: T h e s k i n o v e r t h e ma t r i x o f t h e n a i l a n d t h e l a t e r a l n a i l f o l d s i s s w o l l e n , r e d d e n e d , p a i n f u l , a n d t e n dF irg ( 1 3 - 3 1 A W h e n i n f e c t i o n i s o v e r t h e n a i l r o o t , l i g h t p a l p a t i o n e . ). o f t h e i n f l a me d a r e a p r o v o k e s e xq u i s i t e p a i n . P a i n f r o m p r e s s u r e o n t h e n a i l p l a t e i n d i c a t e s s u b u n g u a l a b s c e s s , b e t w e e n n a i l p l a t e a n d p e r i o s t e u m.

Digital Inflammation: Chr onic Par onychia: Candi dap a r o n y c h i a i s mi n i ma l l y t e n d e r a n d d o e s n o t d r a i n . C h r o n i c u l c e r a t i o n o f t h e n a i l ma n t l e a n d l a t e r a l f o l d s o c c u r s i n o c c u p a t i o n s r e q u i r i n g f r e q u e n t i mme r s i o n o f t h e h a n d s i n w a t e r o r c o n t a mi n a t e d o i l . T h e u l c e r s a r e i n d o l e n t ; a b s c e s s f o r ma t i o n rare.

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Fig. 13-31 Common Locations for Finger Abscesses. A. Paronychia B. A b s c e s s o f t h e A p i c a l S p aThe :api c al s pac e i s l oc at ed i n t he nai l bed ces near t he f r ee mar gi n of t he nai l C . atb s c e s s o f t h e Te r m i n a l P u l p S p a c e pl A e. ( F e l o n ) :The s t i ppl ed r egi on on t he v ol ar s ur f ac e r epr es ent s t he s i t e of r upt ur e t hr ough t he s k iD . A b s c e s s o f t h e Vo l a r S p a c e s : s t i ppl ed r egi ons ar e n. The t he s i t es of abs c es s es ; t he ar r ows poi nt i n t he di r ec t i on of bur r owi ng t o r eac h t he f l ex or c r eas es of t he f.i nger

D i g i t a l I n f e c t i o n : Ab s c e s s o f t h e Te r m i n a l P u l p S p a c e ( F e l o n ) : In f l a mma t i o n o f t h e t e r mi n a l f i n g e r p a d i s c o n f i n e d w i t h i n s ma l l f a s c i a l c o mp a r t me n t a t t a c h e d t o t h e p e r i o s t e u mF(is e e1 3 - 3 1)C T h e o n s e t i s h e r a l d e d b y s w e l l i n g o f g. . t h e f i n g e r t i p a n d d u l l p a i n . T h e p a i n g r a d u a l l y h e i g h t e n s a n d b e c o me s i n t e n s e a n d t h r o b b i n g a n d t h e t i p e xq u i s i t e l y t e n d e r. T h e p r e s e n c e o f p u s i s i n d i c a t e d b y induration of the pulp and loss of resilience. T he great pressure in the confined s p a c e ma y c a u s e t h e a b s c e s s t o b u r s t t h r o u g h t h e v o l a r s u r f a c e o f t h e f i n g e r p a d . O s t e o my e l i t i s ma y o c c u r.

D i g i t a l I n f e c t i o n : Ab s c e s s o f t h e Ap i c a l S p a c e : S y mp t o ms f o l l o w a p u n c t u r e w o u n d b e n e a t h t h e n a i l , a s t h e d i s t a l q u a r t e r o f n a i l b e b e c o me s e xt r e me l y p a i n f u l w i t h o u t mu c h sF i e l. l i1 3 - 3 1 B T h e n a i l b e d s h o w s wg ng ( ). r e d t h r o u g h t h e p l a t e . M a xi mu m t e n d e r n e s s i s p r o xi ma l t o t h e f r e e e d g e o f t h e p l a t e unlike a felon, which produces tenderness at the fingertip. When the abscess ruptures, drainage is at the free edge of the nail plate. D i g i t a l I n f e c t i o n : Ab s c e s s o f t h e M i d d l e Vo l a r P u l p S p a c e : T h e f i n g e r i s h e l d i n p a r t i a l f l e xi o n t o r e d u c e t h e p a i n . A p a i n f u l , t e n d e r s w e l l i n g o c c u r s o n t h e v o l a r a s p e c t o f t h e f i n g e r b e t w e e n t h e d i s t a l i n t e r p h a l a n g e a l ( D IP ) a n p r o xi ma l i n t e r p h a l a n g e a l ( P IP ) j o i nFs g(. s 1 3 - 3 1)D T h e s y mp t o ms r e s e mb l e ti ee . t h o s e o f t h e f e l o n . O s t e o my e l i t i s ma y o c c u r o r t h e a b s c e s s ma y b u r s t a f t e r b u r r o w i n t o t h e d i s t a l f l e xo r c r e a s e . D i g i t a l I n f e c t i o n : Ab s c e s s o f t h e P r o x i m a l Vo l a r P u l p S p a c e : An a b s c e s s f o r ms o n t h e v o l a r a s p e c t b e t w e e n t h e mi d d l e a n d p r o xi ma l j o i n t s ( s e e F i g . 1 3 - 3 1)D T h e s y mp t o ms a n d s i g n s a r e s i mi l a r t o t h o s e i n t h e mi d d l e s p a c e , . e xc e p t t h e i n f e c t i o n b u r r o w s p r o xi ma l l y t o i n v o l v e t h e w e b s p a c e . No d u l e s i n t h e F i n g e r We b : B a r b e r ' s P i l o n i d a l S i n u s : S h o r t h a i r s h a f t s ma y p e n e t r a t e t h e s k i n o f t h e f i n g e r w e b s a n d p r o d u c e i n f l a mma t i o n . O n e o r mo r e n o d u l e s ma y b e f e l t i n t h e s o f t s k i n ; t h e y a r e d r a i n e d b y
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sinuses, which are seen as black dots between the fingers. P. 7 3 1

No d u l e s i n F i n g e r P a d s : O s l e r ' s No d e s : P a t h o p h y s i o l o g S : p t i c e mb o l i f r o m i n f e c t i v e e n d o c a r d i t i s l o d g e i n t h e c u t a n e o u s ye v e s s e l s p r o d u c i n g mi c r o s c o p i c a b s.c e s s e s a r e p e a - s i ze d , t e n d e r b l u i s h o r T hese p i n k n o d u l e s , s o me t i me s w i t h a b l a n c h e d c e n t e r, w h i c h o c c u r o n t h e p a d s o f t h e f i n g e r s , p a l ms o f t h e h a n d s , a n d s o l e s o f t h e f e e t i n s o me p a t i e n t s w i t h i n f e c t i v e endocarditis.

Digital Fr actur es and Dislocations: G i v e n a n a p p r o p r i a t e h i s t o r y, t h e p h y s i c a l s i g n s o f t e n d e r n e s s a n d d e f o r mi t y a r e sufficient to indicate the diagnosis. Cir culator y Disor der s of the Finger s: S e e C h a p t e r ,8p a g e s 4 4 0 4 4 3 a n d 4 8 5 4 9 0 . Janeway Spots: J a n e w a y s p o t s a r e o n l y a f e w mi l l i me t e r s i n d i a me t e r. T h e y a p p e a r o v e r a f e w h o u r s o r d a y s a s c r o p s o f e r y t h e ma t o u s o r h e mo r r h a g i c , ma c u l a r o r n o d u l a r l e s i o n s . T h e y o c c u r i n t h e p a l ms , s o l e s , o r d i s t a l f i n g e r p a d s . Al t h o u g h p a i n l e s s a n d n o n t e n d e r, t h e y ma y u l c e r a t e . M o s t w r i t e r s c o n s i d e r t h e m h a l l ma r k s o f b a c t e r i a l e n d o c a r d i t i s o my c o t i c a n e u r y s m. T h e c a u s a t i v e o r g a n i s ms h a v e b e e n i s o l a t e d f r o m t h e l e s i o n s . Finger nail Signs: S e e C h a p t e r ,6p a g e s 1 5 2 1 5 8 .

Palm Signs

Ye l l o w P a l m s : C a r o t e n e m i a : P a t h o p h y s i o l o g T : e y e l l o w s k i n c o l o r i s i mp a r t e d b y f a t - s o l u b l e c a r o t e n e yh c o n c e n t r a t e d i n t h e s t r a t u m c o r n e u m o f t h e c r e a s e s o n t h e p a l ms a n d s o l e s . T h e p i g me n t i s e xc r e t e d i n t h e s e b u m b y t h e s e b a c e o u s g l a n d s . T h e w a t e r - s o l u b l e p i g me n t s o f b i l i r u b i n e mi a a r e mo r e u n i f o r ml y d i s t r i b u t e d , i n c l u d i n g c o l o r a t i o n o f t h e s c l e r a e a n d t h i n s kEn e s s i v e c a r o t e n e e xc r e t i o n o c c u r s f r o m c h r o n i c i n g e s t i o n o f . i xc large quantities of carrots, squash, oranges, peaches, apricots, and leafy v e g e t a b l e s . B e c a u s e c a r o t e n e i s c o n v e r t e d t o v i t a mi n A i n t h e l i v e r w i t h t h e a s s i s t a n c e o f t h y r o i d h o r mo n e , c a r o t e n o d e r ma i s mo r e c o mmo n i n h y p o t h y r o i d i s m. G r a n u l a r P a l m s : Hy p e r k e r a t o s e s : P a l p a t i o n w i t h t h e f i n g e r t i p s d i s c l o s e s r o u g h g r a n u l a r e xc r e s c e n c e s i n t h e h o r n y l a y e r. T h e mo s t c o mmo n c a u s e i s c h r o n i c a r s e n i c p o i s o n i n g . A r a r e c a u s e i s hy per k er at os i s ( t y l os i s ) pal mar i s et pl ant ar i ts s o ma l d o mi n a n t d i s e a s e . , an au o T h e n a r At r o p h y : P a t h o p h y s i o l o g T : e t h e n a r e mi n e n c e i s f o r me d b y t h e b opponens yh ellies of pol l i c i s , abduc t or pol l i c i s br ev i rsv a t e d b y t h e me d i a n n e r v e ; d e n e r v a t i o n l e a d s inne t o a t r o p h yAt r o p h y s u g g e s t s a l e s i o n o f t h e me d i a n n e r v e , mo s t c o mmo n l y c a r p a l . t u n n e l s y n d r o me , o r s e v e r e o s t e o a r t h r i t i s a t t h e b a s e o f t h e t h u mb . D i mi n u t i o n i n s i ze o f t h e e mi n e n c e ma y a c c o mp a n y g e n e r a l a t r o p h y o f a l l i n t r i n s i c h a n d mu s c l e s (F i g . 1 3 - 3 2 B ).
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P. 7 3 2

F i g . 1 3 - 3 2 A t r o p h y o f t h e I n t r i n s i c M u s c l e s o f .t h e H a n d of at r ophy Regi ons ar e i ndi c at ed by s t i ppl i ng .

Hy p o t h e n a r At r o p h y : P a t h o p h y s i o l o g T : e h y p o t h e n a r e mi n e n c e i s f o r me d b y t h e b e l l mar io f yh pal i e s s br ev i s , abduc t or di gi t i qui nt i , f l ex or di gi t i nqui nt i , a dopponens di gi t i qui nt i i n n e r v a t e d b y t h e u l n a r n e r v e ; d e n e r v a t i o n l e a d s . t At ao r o p h s u g g e s t s o r t phy y d a ma g e t o t h e u l n a r n e r v e F is e e1 3 - 3 2)C If b o t h t h e n a r a n d h y p o t h e n a r a t r o p h y ( g. . a r e p r e s e n t , c o n s i d e r c e r v i c a l my e l o p a t h y. Localized T hickening of Palmar Fascia: Dupuytr en' s Contr actur e: S e e p a g e 7 3.8 An e a r l y f i n d i n g , a n t e d a t i n g t h e c o n t r a c t u r e , i s t h e p a l p a t i o n o f a t h i c k , n o n t e n d e r, n o d u l a r t h i c k e n i n g i n t h e p a l ma r fF i s c i a 3(-s e e a g . 1 2)8. I

P a i n f u l P a l m a r S w e l l i n g : We b S p a c e I n f e c t i o n : F e v e r, ma l a i s e , a n d d i f f u s e p a i n i n t h e h a n d , w i t h d o r s a l e d e ma o c c u r e a r l y. W h e n l o c a l i za t i o n h a s o c c u r r e d , t h e t w o i n v o l v e d f i n g e r s a r e s e p a r a t e d b y s w e l l i n g a t t h e b a s e s . T h e s k i n o v e r t h e w e b , b o t h b a c k a n d f r o n t , i s r e d d e n e d . M a xi ma l t e n d e r n e s i s l o c a t e d o n t h e p a l ma r s u r f a c e n e a r t h e b a s e o f t h e i n v o l iv e d1 f3i - 3 3 A ( F g. n g e.r ) Painful Palmar Swelling: Infection of the T henar Space: T h e a f f e c t e d t h e n a r e mi n e n c e i s s w o l l e n , t e n d e r, a n d ma y s h o w e r y t h e ma a n d w a r mt h . T h e i n t e r p h a l a n g e a l j o i n t o f t h e t h u mb ma y b e f l e xe d , b u t e xt e n s i o n i s n o t r e s i s t e d a s i t i s i n t e n o s y n o v i t i s o f t h e f l e xo r p o l l i c i s l o n g u s .

P a i n f u l P a l m a r S w e l l i n g : D e e p Ab s c e s s o f t h e P a l m : In a d d i t i o n t o s e v e r e d o r s a l e d e ma , t h e c o n c a v i t y o f t h e p a l m i s o b l i t e r a t e d , o r e v e n e l e v a t e d ; t h e r a i s e d a r e a i s t e n d e r. P a i n f u l P a l m a r S w e l l i n g : Ab s c e s s o f t h e Ul n a r B u r s a : T h e r e i s d o r s a l e d e ma a n d f u l l n e s s o n t h e u l n a r s i d e o f t hF i g .a1m - ( s )e. e e p l 3 33A T h e p o i n t o f ma xi mu m t e n d e r n e s s i s h a l f w a y b e t w e e n t h e l u n a t e a n d t h e f i f t h me t a c a r p o p h a l a n g e a l j o i n t .


P. 7 3 3
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F i g . 1 3 - 3 3 S w e l l i n g s o f t h e H a n d . A . P a l m a r The s a e : i ons of t he B u r l oc at bur s ae ar e i ndi c at ed by s t i ppl i ng. Not e t he t endon s heat hs endi ng pr ox i mal l y near t he pal mar c r eas e; t her e i s a c onnec t i on bet ween t he r adi al and ul nar bur s ae. The r adi al bur s a i s c ont i nuous f r om t he t humb t o t he r egi on of t he t henar emi nenc e. The web s pac es ar e i ndi c at ed as s i t es ofBabs c es s es . . F r a c t u r e o f a M e t a c a r p a l B Di agr am s hows di s pl ac ement of t he f r agment s one: i nt o t he pal m, wher e an abnor mal pr omi nenc e may be not ed .

P a i n f u l P a l m a r S w e l l i n g : Ab s c e s s o f t h e Ra d i a l B u r s a : T h e i n t e r p h a l a n g e a l j o i n t o f t h e t h u mb i s f l e xe d a n d p a s s i v e e xt e n s i o n p r o d u c e s p a i n . T h e r e i s t e n d e r n e s s a n d s w e l l i n g o v e r t h e s h e a t h o f t h e f l e xo r p o l l i c i s l o n g u s

P a i n f u l P a l m a r a n d D i g i t a l S w e l l i n g : Ac u t e S u p p u r a t i v e F l e x o r Te n o s y n o v i t i s : T h r o b b i n g p a i n ma y b e g i n i n a f i n g e r a n d p r o g r e s s t o w a r d t h e p a l m. D o r s a l e d e ma appears and the entire finger swells. T he affected finger is held in the posture of r e s t , s l i g h t l y f l e xe d , a n d t h e p a t i e n t w i l l n o t mo v e t h e f i n g e r. G e n t l e p a s s i v e e xt e n s i o n o f a d j a c e n t f i n g e r s i s p a i n f u l , s o t h e e xa mi n e r s h o u l d n o t a t t e mp t t o t e s t t h e a f f e c t e d f i n g e r. To f i n d t h e p o i n t o f ma xi mu m t e n d e r n e s s , h a v e t h e p a t i e n t r e s t t h e s u p i n a t e d h a n d o n a t a b l e . Te s t f o r t e n d e r n e s s b y g e n t l y p a l p a t i n g w i t h t h e b l u n e n d o f a n a p p l i c a t o r o r t o n g u e d e p r e s s o r. If t h e p o i n t i s l o c a t e d a t t h e p r o xi ma l e n d o f t h e t e n d o n s h e a t h o f t h e i n d e x, mi d d l e , o r r i n g f i n g e r, i n v o l v e me n t o f t h e s h e a t h c e r t a i n . If t h e r e i s n o l o c a l i za t i o n , t h e s h e a t h ma y h a v e r u p t u r e d .
P. 7 3 4

Painful Palmar Swelling: Fr actur e of a M etacar pal Bone: In a t r a n s v e r s e f r a c t u r e , t h e f r a g me n t s o f t h e me t a c a r p a l b o n e a r e b o w e d i n t o t h e p a l m t o p r o d u c e a p a i n f u l p r o mi n e n c e g(.s e e - 3 3 B T h e p r o mi n e n c e ma y b e Fi 13 ). o b s c u r e d b y s o f t - t i s s u e s w e l l i n g , b u t d o r s a l p a l p a t i o n w i l l l o c a l i ze t e n d e r n e s s a t t h f r a c t u r e s i t e . In a s p i r a l f r a c t u r e , p r o xi ma l s l i p p a g e o f t h e d i s t a l f r a g me n t p r o d u c e s s h o r t e n i n g r e v e a l e d b y l o s s o f p r o mi n e n c e i n t h e c o r r e s p o n d i n g k n u c k l e w h e n t h e f i s t i s c l o s e d . R o t a t i o n o f t h e d i s t a l f r a g me n t i s p r e s e n t i f t h e a f f e c t e d f i n g e r i s n o t a l i g n e d w i t h t h e u n a f f e c t e d f i n g e r s w h e n t h e t i p s a r e f l e xe d o n t o t h e b a s e o f t h e t h e n a r e mi n e n c e . B e n n e t t f r a c t u r e i s a n o b l i q u e b r e a k t h r o u g h t h e b a s e o f t h e f i r s t me t a c a r p a l , f r e q u e n t l y w i t h s u b l u xa t i o n o f t h e c a r p a l me t a c a r p a l j o i n t . T h e t h u mb i s s e mi f l e xe d , a n d i t c a n n o t b e o p p o s e d t o t h e r i n g o r l i t t l e f i n g e r a n d t h e f i s t c a n n o t


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clenched.

Hand and Wrist Signs

S w e l l i n g o f t h e Wr i s t : T h e a n a t o mi c l o c a t i o n o f s w e l l i n g i s i d e n t i f i e d b y t h e p h y s i c a l s i g n s . P e r i a r t i c u l a r e d e ma i n t h e s u b c u t a n e o u s t i s s u e s a r o u n d t h e j o i n t , b u t o u t s i d e t h e s y n o v i u m, p i t s with pressure. With thickening of the joint capsule and synovium the tissues feel b o g g y. W h e n t h e s y n o v i a l e n v e l o p e i s b u l g i n g a n d f l u c t u a n t , f l u i d i s p r e s e n t . E f f u s i o n , p u s , o r b l o o d a r e i d e n t i f i e d b y a s p i r a t i o n . W i t h b o n y e n l a r g e me n t , p a l p a t i o ma y d i s t i n g u i s h b e t w e e n o s t e o p h y t e s a t t h e j o i n t ma r g i n s , l o c a l b o n e t u mo r s , o r a c r o me g a l i c h y p e r p l a s i a . P a i n f u l S w e l l i n g o r L i m i t e d M o t i o n o f t h e Wr i s t : C h r o n i c Ar t h r i t i s : W i t h a c t i v e i n f l a mma t i o n , t h e r e i s e n l a r g e me n t o f t h e w r i s t j o i n t , a c c o mp a n i e d b y v a r i a b l e d e g r e e s o f p a i n a n d t e n d e r n e s s . T h e o v e r l y i n g s k i n ma y b e w a r m a n d r e d d e n e d . In r h e u ma t o i d a r t h r i t i s , t h e r e i s l i mi t e d mo t i o n . T h e j o i n t i s s w o l l e n , r e d , h o t , a n d t e n d e r w i t h g o u t , p s e u d o g o u t , a n d s e p t i c a r t h r i t i s . P r i ma r y o s t e o a r t h r i t i s does not affect the wrist. P a i n f u l S w e l l i n g i n t h e An a t o m i c S n u f f b o x : Ac u t e Te n o s y n o v i t i s : P a i n i s e xp e r i e n c e d i n t h e r e g i o n o f t h e s n u f f b o x. A s a u s a g e - l i k e s w e l l i n g , a b o u t 4 c m l o n g F(i g . 1 3 - 3 4)C i n v o l v e s t h e t e n d o n s h e a t h o f t h e e xt e n s o r p o l l i c i s b r e v i s a n d , a b d u c t o r p o l l i c i s l o n g u s a t t h e r a d i a l b o r d e r o f t h e s n u f f b o x. W i t h t h u mb e xt e n s i o n c r e p i t u s c a n b e f e l t o v e r t h e s h e a t h . T h e c a u s e i s u s u a l l y t r a u ma , a l t h o u g h i n f l a mma t i o n c a n b e p r o d u c e d b y g o u t o r g o n o c o c c a l i n f e c t i o n .

C h r o n i c P a i n i n t h e An a t o m i c S n u f f b o x : C h r o n i c S t e n o s i n g Te n o s y n o v i t i s ( D e Q u e r v a i n Te n o s y n o v i t i s ) : T h e t e n d o n s h e a t h o f t h e e xt e n s o r p o l l i c i s b r e v i s i s ma xi ma l l y p a i n f u l o n p a l p a t i o n o v e r t h e r a d i a l s t y l o i d . In l o n g s t a n d i n g c a s e s , o n e o r t w o s w e l l i n g s t h e s i ze o f orange seeds are palpable in the snuffbox near the radial styloid process. Chronic i n f l a mma t i o n i n v o l v e s a l l l a y e r s o f t h e t e n d o n s h e a t h . W h e n t h e f i s t i s c l e n c h e d o v e t h e f l e xe d t h u mb , g e n t l e b u t f i r m u l n a r d e v i a t i o n o f t h e h a n d b y t h e e xa mi n e r e l i c i t s p a i n a t t h e r a d i a l s t y l o i d p r oFie s s (s t ei n t es te eF i g . 1 3 - 3 4 B T h i s p a i n ma y c nk el , s ). b e t r a n s mi t t e d d o w n t h e t h u mb o r t o w a r d t h e e l b o w. P a s s i v e e xt e n s i o n o f t h e t h u mb is painless.
P. 7 3 5

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F i g . 1 3 - 3 4 S o m e D i s o r d e r s o f t h e W r i s t . A . S h e a t h s o f t h e W r i s t Te n d o n s : Thi s s hows t he s heat h, whi c h s wel l s t o obs t r uc t t he mot i on of t he t endons of ex t ens or pol l i c i s br ev i s and abduc t or pol l i c i s l ongus i n c hr oni c s t enos i ng t enos y nov i t i B. F i n k e l s t e i n Te s t f o r Te n o s y n oThei spat i ent c l enc hes hi s s vi t : f i s t on hi s t humb whi l e t he ex ami ner pus hes t he f i s t t owar d t he ul na. A pos i t i v e t es t el i c i t s pai n at t he r adi al s t y l oi d pr.oc esesl.l i n g f r o m A c u t e C Sw N o n s u p p u r a t i ve Te n o s y n o vi t i s . D . F r e q u e n t S i t e o f G a n g l i o n o f t h e W r i s t : The s wel l i ng i s pai nl es s and s omet i mes t r ans l uc ent .

Localized Painless Swelling on the Dor sum: Ganglion: A c y s t f r o m my xo ma t o u s d e g e n e r a t i o n o f t h e j o i n t c a p s u l e u s u a l l y o c c u r s o n t h e d o r s u m o f t h e n a v i c u l o l u n a t e j o i n ti g s e e - 3 4)D T h e s w e l l i n g i s r o u n d , s e s s i l e , F (. 13 . t e n s e , a n d t r a n s l u c e n t . F l e xi o n o f t h e w r i s t b r i n g s i t i n t o p r o mi n e n c e , e xt e n s i o n obscures it.

P. 7 3 6 Nu m b n e s s , T i n g l i n g , a n d P a i n i n t h e Ha n d : C a r p a l Tu n n e l S y n d r o m e ( C o m p r e s s i o n Ne u r o p a t h y o f t h e M e d i a n Ne r v e i n t h e C a r p a l Tu n n e l ) : P a t h o p h y s i o l o g T : e me d i a n n e r v e i s c o mp r e s s e d i n t h e c h a n n e l b e n e a t h t h e yh v o l a r t r a n s v e r s e c a r p a l l i g a me n t o f t hF i g . r i1s3 - () 5 P r o g r e s s i v e c o mp r e s s i o n e w t 3. of the nerve initially produces dysesthesia and pain, then loss of fine (two-point) s e n s a t i o n , a n d , f i n a l l y, t h e n a r mu s c l e a t r o p h y a n d. w e a kp a ts s n t c o mp l a i n s T he ne ie o f n u mb n e s s a n d t i n g l i n g i n t h e h a n d , p a r t i c u l a r l y a t n i g h t . T h e r e ma y b e a s s o c i a t e p a i n , l i mi t e d t o t h e h a n d o r r u n n i n g u p t h e f o r e a r m. U l t i ma t e l y, t h e r e i s p r o g r e s s i v e w e a k n e s s a n d a w k w a r d n e s s i n t h e f i n e r mo v e me n t s o f t h e f i n g e r s . It ma y b e u n i l a t e r a l o r b i l a t e r a l . Al t h o u g h p a t i e n t s f r e q u e n t l y d e s c r i b e t i n g l i n g o f t h e e n t i r e h a n d , h y p o e s t h e s i a i s d i s t r i b u t e d o n t h e p a l ma r a s p e c t s o f t h e 3 . 5 r a d i a l d i g i t s a n d t h e d i s t a l t w o - t h i r d s o f t h e d o r s a l a s p e c t s o f t h e s a me f i n g e r s . L i g h t p e r c u s s i o n o n t h e r a d i a l s i d e o f t h e p a l ma r i s l o n g u s t e n d o n ma y p r o d u c e a t i n g l iTig s e n s a t i o n ( n nel s i gn F i g . 1 3 - 3) 5 F l e xi o n o f t h e w r i s t s a t 9 0 d e g r e e s w i t h t h e d o r s a l s u r f a c e s o f t h e , . h a n d s i n a p p o s i t i o n f o r 6 0 s e cPhalsen t es tma y r e p r o d u c e t h e pF i g . ( 1 3 ond ( ) a n 3 5) . N e i t h e r ma n e u v e r i s p a r t i c u l a r l y s e n s i t i v e o r s p e c i f i c f o r t h e f i n d i n g o f n e r v e i n j u r y b y n e r v e c o n d u c t i o n s t u d i e s . T h e c o n d i t i o n i s mo s t c o mmo n w i t h r e p e t i t i v e u s i n j u r y, f o r e xa mp l e , me a t - p a c k i n g w o r k e r s , g r o c e r y c l e r k s , a n d k e y b o a r d o p e r a t o r s [K a t z J N , S i mmo n s B P. C a r p a l t u n n e l s y n d rEngl . J M ed 0 0 2 ; 3 4 6 : 1 8 0 7 N o me 2
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1 8 1 2 D ' Ar c y C A, M c G e e S . T h e r a t i o n a l c l i n i c a l e xa mi n a t i o n . D o e s t h i s p a t i e n t ; h a v e c a r p a l t u n n e l s y n d r o me ?A 2 0 0 0 ; 2 8 3 : 3 11 0 3 ]11 7 J AM .

F i g . 1 3 - 3 5 C a r p a l T u n n e l S y n d r o m e . 1 . T h e C a r p a l T u nln e lor The f ex : r et i nac ul um i n t he wr i s t c ompr es s es t he medi an ner v e t o pr oduc e hy per es t hes i a i n t he r adi al di gi2t.s . i n e l S i g n : c us s i on on t he r adi al s i de of t he pal mar i s T Per l ongus t endon pr oduc es t i ngl i ng i n t he di gi t al. rP h aon. Te s t : 3 egi l e n Hy per f l ex i on of t he wr i s t f or 60 s ec onds pr oduc es pai n i n t he medi an ner v e di s t r i but i on, whi c h i s r el i ev ed by ex t ens i on of t he wr i s t .

C ARPAL T UNNE L S Y ND RO M E C L I NI C AL O C C URRE NC E : C o n g e n i t ac o n g e n i t a l l y s ma l l c a r p a l t u n n e l ; r i ne y p o t h y r o i d i s m, d i a b e t e s , l Endoc h a c r o me g a l y, p r e g n a nIc y opat hi c s t e o a r t h r i t iIs ; l ammat or y / I mmune u ma t o i d di ; o nf rhe a r t h r i t i s , a my l o i d o s i s , s a r c o i Mo s iabol i c / Toxgc u t , P a g e t d i s e a s e ; d et s ; io M ec hani c al / Tr aumatec e t i t i v e w r i s t f l e xi o n a n d e xt e n s i o n , p o s t t r a u ma t i c a r t h r i t i s ; rip Neopl as t i c l t i p l e my e l o ma , M G U S . mu Ab n o r m a l Ha n d P o s t u r e : P o s i t i o n o f An a t o m i c Re s t : In i n f l a mma t i o n o f t h e h a n d , t h e p a r t s a r e h e l d i n t h i s p o s i t i o n t o e a s e t h e p a i n , w i t f i n g e r s a n d t h u mb f l e xe d , t h e i n d e x f i n g e r l e s s b e n t t h a n t h e io t.h 1 3s ( s e e F g er 2 8 C, p a g e 7 2 5 ) .

Ab n o r m a l Ha n d P o s t u r e : Ul n a r D e v i a t i o n o r D r i f t o f F i n g e r s : M o s t c o mmo n i n r h e u ma t o i d a r t h r i t i s , p r i ma r i l y a s a r e s u l t o f mu s c l e a t r o p h y a n d t h e mu s c l e p u l l o n s u b l u xa t e d j o i n t s . T h e f i n g e r s d e v i a t e a t t h e me t a c a r p o p h a l a n g e a l j o i n t s t o w a r d t h e u l n a . T h e r e ma y a l s o b e s u b l u xa t i o n s o f t h e me t a c a r p o p h a l a n g e a l ( M C P ) j o i n t ( s e eg . 1 3 - 2 8 Bp a g e 7 2 5 ) . Fi ,

P. 7 3 7 Ab n o r m a l Ha n d P o s t u r e : D i a b e t i c Ha n d , D i a b e t i c C h e i r o p a t h y : In l o n g - s t a n d i n g d i a b e t e s , t h e s o f t t i s s u e s o f t h e h a n d b e c o me t h i c k a n d c o n t r a c t e d b e n d i n g t h e f i n g e r s i n t o a s l i g h t l y f l e xe d p o s i t i o n . H a v e t h e p a t i e n t a t t e mp t t o p l a c e t h e p a l ms t o g e t h e r ; a s p a c e w i l l r e ma i n b e t w e e n t h e p a l ms a n d f i n g e r s i n a p r a y e r sign.
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Ab n o r m a l Ha n d P o s t u r e : C l a w h a n d : P a t h o p h y s i o l o g T : i s o c c u r s f r o m t h e p r e d o mi n a n t p u l l o f t h e e xt e n s o r c o mmu n i s yh d i g i t o r u m a n d t h e f l e xo r d i g i t o r u m a g a i n s t w e a k o r p a r a l y ze d i n t e r o s s e u s a n d l u mb r i c a l mu s c .l eT h e c l a w i s c a u s e d b y h y p e r e xt e n s i o n o f t h e s me t a c a r p o p h a l a n g e a l j o i n t s a n d f l e xi o n o f t h e i n t e r p h a l a n g e a l a r t i F ug a t i o n s ( s e e ci l. 1 3 - 2 8 D p a g e 7 2 5 ) . P a r a l y s i s ma y r e s u l t f r o m b r a c h i a l p l e xu s , u l n a r a n d me d i a n , n e r v e i n j u r i e s , s y r i n g o my e l i a , t h e mu s c u l a r a t r o p h i e s , o r a c u t e p o l i o my e l i t i s . Ab n o r m a l Ha n d P o s t u r e : Ap e Ha n d : T h e t h u mb i s h e l d i n e xt e n s i o n b y i t s i n a b i l i t y t o i fgl .e x 3 s2 8 E T h i s ma y F 1 ( - e e. ) o c c u r i n s y r i n g o my e l i a , p r o g r e s s i v e mu s c u l a r a t r o p h y, o r a my o t r o p h i c l a t e r a l sclerosis.

Ab n o r m a l Ha n d P o s t u r e : C a r p a l S p a s m : T h e c h a r a c t e r i s t i c p o s i t i o n o c c u r s i n Ft ie t.a n y - (2 8 Fp a g e 7 2 5 ) a n d h a n d g 13 , dystonia associated with repetitive hand activities. T his is also called obstetrician's h a n d b e c a u s e i t s o me w h a t r e s e mb l e s t h e p o s i t i o n o f t h e p h y s i c i a n ' s h a n d i n p e r f o r mi n g a p e l v i c e xa mi n a t i o n . T h e t h u mb i s f l e xe d o n t h e p a l m, t h e w r i s t a n d me t a c a r p o p h a l a n g e a l j o i n t s a r e f l e xe d , w h i l e t h e i n t e r p h a l a n g e a l j o i n t s a r e h y p e r e xt e n d e d a n d t h e f i n g e r s a r e a d d u c t e d i n t h e s h a p e o f a c o n e . Al l t h e h a n d mu s c l e s a r e r i g i d . T h e s p a s m i s i n v o l u n t a r y a n d u s u a l l y p a i n l e s s . T h i s p o s t u r e occurs in tetany; when present, it is involuntary and cannot be altered by the patien Ab n o r m a l Ha n d P o s t u r e : B e n e d i c t i o n Ha n d ( P r e a c h e r ' s Ha n d ) : T h e r i n g a n d l i t t l e f i n g e r s c a n n o t b e e xt e n d e d w h i l e t h e o t h e r d i g i t s mo v e n o r ma l l y a n d ma y b e e xt e n d e d t o p r o d u c e t h e p o s t u ri e . ( s e e2 8,Gp a g e 7 2 5 ) . T h i s F g 13o c c u r s i n u l n a r n e r v e p a l s y, s y r i n g o my e l i a , a n d e xt e n s o r t e n d o n r u p t u r e i n r h e u ma t o i d a r t h r i t i s . It i s n a me d f r o m t h e e c c l e s i a s t i c a l g e s t u r e o f p r o n o u n c i n g b e n e d i c t i o n . D o n o t c o n f u s e w i t h D u p u y t r e n c o n t r a c t u r e o f t h e p a l ma r f a s c i a . Ab n o r m a l Ha n d P o s t u r e : Wr i s t - D r o p : T h i s r e s u l t s f r o m w e a k n e s s o f t h e w r i s t e xt e n s o r s . W h e n t h e p r o n a t e d h a n d i s h e l d h o r i zo n t a l l y w i t h o u t s u p p o r t f r o m b e n e a t h , i t d r o p s f r o m t h e w r i s t b e c a u s e o f w e a k n e s s o f t h e e xt e n s o r s F is e e1 3 - 2 8, Hp a g e 7 2 5 ) , w h i c h a r e u n a b l e t o ( g. o v e r c o me g r a v i t y. C o mmo n c a u s e s a r e r a d i a l n e r v e p a l s y, p o l i o my e l i t i s , n e u r o p a t h y f r o m l e a d o r a r s e n i c p o i s o n i n g a n d r a d i a l n e r v e c o mp r e s s i o n .
P. 7 3 8 Ab n o r m a l Ha n d P o s t u r e : D u p u y t r e n C o n t r a c t u r e ( P a l m a r F i b r o s i s ) : P a t h o p h y s i o l o g T : i s d i s o r d e r i s a p a i n l e s s n o d u l a r t h i c k e n i n g o f t h e p a l ma r yh a p o n e u r o s i s f r o m h y a l i n i za t i o n o f c o l l a g e n f i b e r s b e g i n n i n g n e a r t h e b a s e o f t h e d i g i t . It e xt e n d s t o f o r m a p l a q u e o r b a n d a d h e r i n g t o t h e p a l ma r f a s c i a a n d p r o d u c i n g r e t r a c t i o n a n d d i mp l i n g o f t h e p a l ma r s k i n a n d f l e xi o n c o n t r a c t u r e o f t h e f i n g e r .s It u s u a l l y b e g i n s a f t e r t h e a g e o f 4 0 y e a r s a s a n i n c o n s p i c u o u s n o d u l e , w h i c h i s o f t e n n o t n o t e d b y t h e p a t i e n t u n t i l f i n g e r d e f o r mi t y o c c u r s . O n e o r b o t h h a n d s ma y b e i n v o l v e d . T h e r i n g f i n g e r i s mo s t o f t e n a f f e c t e d , b u t o t h e r s ma y b e i n v o l v e d , i n o r d e r o f d i mi n i s h i n g f r e q u e n c y, t h e l i t t l e , l o n g , i n d e x, a n d t h u mb . R e t r a c t i o n o f t h e f a s c i a f o r c e s t h e a f f e c t e d f i n g e r i n t o p a r t i aF i f l .e xi3 -n ,8 s e e l g 1 o 2 (I page 725). Palpation of the palm reveals a hard cord over the tendon. Passive
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dgdiagnexam

e xt e n s i o n o f t h e f i n g e r r a i s e s t h e c o r d t a u t , w h e r e i t c a n b e r e a d i l y s e e n . W i t h p r o g r e s s i o n , a p a i n l e s s c o n t r a c t u r e o f t h e d i g i t r e s u l t s t h a t ma y r e q u i r e s u r g i c a l c o r r e c t i o n . T h e c o n t r a c t u r e , n a me d a f t e r t h e F r e n c h s u r g e o n B a r o n G u i l l a u me D u p u y t r e n , i s c o n s i d e r e d b y s o me w r i t e r s a s t h e p r o t o t y p i c a l ma n i f e s t a t i o n o f D u p u y t r e n d i s e a s e . L e s s - c o mmo n ma n i f e s t a t i o n s , o c c u r r i n g s i n g l y o r i n c o mb i n a t i o n a r e p l a n t a r f i b r o s i s ( L e d e r h o s e n s y n d r o me ) , k n u c k l e p a d s , p l a s t i c i n d u r a t i o n o f t h e p e n i s ( P e y r o n i e d i s e a s e ) , a n d f i b r o s i s o f t h e ma l e b r e a s t ( f i b r o s i s ma mma e v i r i l i s ) . Ap p r o xi ma t e l y 4 0 % o f t h e p a t i e n t s h a v e a f f e c t e d k i n ; o n l y w h i t e s a r e s u s c e p t i b l e . M e n a r e a f f e c t e d t w i c e a s o f t e n a s w o me n . T h e ma n i f e s t a t i o n s a r e mo r e c o mmo n i n p e r s o n s w i t h a l c o h o l i s m, e p i l e p s y, o r d i a b e t e s me l l i t u s ; t h e c a u s e f o r t h e s e associations is unknown.

Ab n o r m a l Ha n d P o s t u r e : At h e t o i d Ha n d : A g r o t e s q u e p a t t e r n i s s e e n i n a t h e t o s i s i n w h i c h i n v o l u n t a r y mu s c l e c o n t r a c t i o n s p r o d u c e s i mu l t a n e o u s f l e xi o n o f s o me d i g i t s a n d h y p e r e xt e n s i o n o f o t h e r s , r e s e mb l i n g t h e w r i t h i n g o f a s n a kF i g s e e - 2 8 Jp a g e 7 2 5 ) . e (. 13 ,

L a r g e Ha n d s : Ac r o m e g a l y a n d G i g a n t i s m : S e e p a g e 7 7.4 T h e b o n e s o f t h e h a n d s a r e p e r f e c t l y p r o p o r t i o n e d , b u t s o f t - t i s s u e o v e r g r o w t h i n c r e a s e s t h e f i n g e r g i r t h , ma k i n g t h e m p o n d e r o u s , a p a w h a n d o r s p a d e h a n d . Ac r o me g a l i c a r t h r i t i s i s f r e q u e n t l y p r e s e n t .

L a r g e Ha n d s : Hy p e r t r o p h i c O s t e o a r t h r o p a t h y : S e e p a g e 7 9.2 Al l d i me n s i o n s o f t h e h a n d s a r e i n c r e a s e d , a s i n a c r o me g a l y, b u t t h e c o n d i t i o n i s i n v a r i a b l y a c c o mp a n i e d b y c l u b b i n g o f t h e f i n g e r s a n d p a r r o t - b e a k n a i l s E n l a r g e m e n t o f O n e Ha n d : He m i h y p e r t r o p h y a n d L o c a l G i g a n t i s m : An e n t i r e s i d e o f t h e b o d y ma y b e e n l a r g e d i n a c o n g e n i t a l d e f o r mi t y k n o w n a s h e mi h y p e r t r o p h y. L o c a l g i g a n t i s m i s o f t e n t h e r e s u l t o f a c o n g e n i t a l a r t e r i o v e n o u s f i s t u l a o f t h e u p p e r l i mb . In e i t h e r c a s e , t h e h a n d i s p e r f e c t l y p r o p o r t i o n e d .

P. 7 3 9 L o n g , S l e n d e r Ha n d s : S p i d e r F i n g e r s ( Ar a c h n o d a c t y l y, M a r f a n Syndr ome): Al l t h e l o n g b o n e s o f t h e h a n d s a r e s l e n d e r a n d e l o n g a t e d , o f t e n w i t h h y p e r e xt e n s i b l e j o i n t s Fs g .e 1 3 - 2 7 Bp a g e 7 2 3 ) . T h e i s t s i gns u s e f u l t o ( ie , wr i d i s t i n g u i s h e l o n g a t e d f i n g e r s f r o m l o n g , n o r ma l f i n g e r s o f t a l l , t h i n i n d i v i d u a l s . T h e p a t i e n t e n c i r c l e s h i s o w n w r i s t , w i t h h i s t h u mb a n d l i t t l e f i n g e r p r o xi ma l t o t h e s t y l o p r o c e s s o f t h e u l n a . In n o r ma l p e r s o n s , t h e e n c i r c l i n g d i g i t s s c a r c e l y t o u c h , b u t i n a r a c h n o d a c t y l y t h e y ma y o v e r l a p b y 1 2 c m. T h e p o s i t i v e s i g n r e s u l t s f r o m t h e c o mb i n a t i o n o f l o n g d i g i t s a n d n a r r o w w r i s t . T h e h a n d s i n M a r f a n s y n d r o me ma y a l s s h o w a p o s i t i v e t h u mb sSt ei nber g s i gn w h e n t h e f i n g e r s a r e c l e n c h e d o v e r t h e ign ( ): t h u mb , t h e e n d o f t h e t h u mb p r o t r u d e s b e y o n d t h e u l n a r ma r g i nFo fl kt h e h a n d [ a R H . T h e t h u mb s i g n i n M a r f a n ' s s y nN rEngl . J M ed 9 9 5 ; 3 3 3 : 4 3 0 ( p i c t]u r e ) d o me 1 . N e i t h e r t h e t h u mb s i g n n o r t h e w r i s t s i g n i s p r o o f o f M a r f a n s y n d r o me .

L o n g , S l e n d e r Ha n d s : E u n u c h o i d i s m : T h e s e ma y b e s i mi l a r t o t h e s p i d e r f i n g e r s i n M a r f a n s y n d r o me . S h o r t , T h i c k Ha n d s : C o n g e n i t a l Hy p o t h y r o i d i s m ( C r e t i n i s m ) : T h e h a n d s a r e s h o r t , t h i c k , a n d f a t . T h e r a d i u s ma y b e s h o r t e n e d .
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S h o r t , T h i c k Ha n d s : T r i s o m y 2 1 ( D o w n S y n d r o m e ) : T h e h a n d s a r e s h o r t a n d t h i c k ; t h e t h u mb d i v e r g e s f r o m n e a r e r t h e w r i s t t h a n n o r ma t h e l i t t l e f i n g e r i s c u r v e dF(i s e e 3 - 2 7, Cp a g e 7 2 3 ) . g. 1

I n t e r o s s e o u s At r o p h y : P a t h o p h y s i o l o g Wa s t i n g s u g g e s t s i n j u r y t o t h e u l n a r Tn e r v e n d s a p p e a r y: . he ha s h r u n k e n w i t h p r o mi n e n c e o f t h e e xt e n s o r t e n d o n s a n d me t a c a r p a l s o n t h e d o r s u m ( s e eF i g . 1 3 - 3 2 A a g e 7 3 2 ) . P a l p a t i o n d i s c l o s e s l o s t o f mu s c l e ma s s , mo s t e a s i l y , p d e t e c t e d i n t h e f i r s t d o r s a l i n t e r o s s e o u s b e t w e e n t h e t h u mb a n d i n d e x f i n g e r. Ad d u c t i o n o f t h e f i n g e r s i s w e a k . C o mmo n c a u s e s a r e u l n a r n e r v e e n t r a p me n t a t t h e e l b o w, r h e u ma t o i d a r t h r i t i s , a n d d i a b e t i c n e u r o p a t h y. Painless Swelling of the Dor sum: P a t h o p h y s i o l o g E : e ma a r i s i n g f r o m t h e d e e p s p a c e s o f t h e h a n d a c c u mu l a t e s i n yd t h e l o o s e s u b c u t a n e o u s t i s s u e d o r s a l l y, r a t h e r t h a n t h e p a l ma r s u r f a c e , b e c a u s e o f t h e r e s t r i c t i n g p a l ma r f .a s ca a s e s i n c l u d e i n f e c t i o n , o b s t r u c t i o n o f t h e s u p e r i o r C iu v e n a c a v a , a n a s a r c a , a n d r e l a p s i n g s y mme t r i c a l s e r o n e g a t i v e s y n o v i t i s w i t h p i t t i n g e d e ma ( R S 3 P E ) . U n i l a t e r a l e d e ma ma y a l s o o c c u r f r o m o c c l u s i o n o f t h e v e n o u s o r l y mp h a t i c d r a i n a g e o f t h e u p p e r a r m.


P. 7 4 0

Painful Dor sal Swelling: In f e c t i o n a n d e xt e n s o r t e n o s y n o v i t i s c a u s e e d e ma , e r y t h e ma , a n d l o c a l i ze d t e n d e r n e s s . F l u c t u a t i o n ma y n o t b e p r e s e n t w i t h a n a b s c e s s .

P a i n i n Ul n a r S i d e o f Ha n d : Ul n a r Tu n n e l S y n d r o m e : P a t h o p h y s i o l o g T : e u l n a r n e r v e p a s s e s p o s t e r i o r t o t h e me d i a l h u me r a l yh e p i c o n d y l e i n t h e u l n a r g r o o v e , a n d t h e n d e e p t o t h e s u p e r f i c i a l f l e xo r s a n d a b o v e t h e d e e p f l e xo r s o f t h e f o r e a r m, w h e r e i t i s s t r e t c h e d a n d c o mp r e s s e d d u r i n g v i g o r o u s mu s c u l a r a c t. i v i tjy r y t o t h e u l n a r n e r v e a t t h e e l b o w c a u s e s p a i n i n t h e In u l i t t l e f i n g e r, t h e u l n a r h a l f o f t h e r i n g f i n g e r, a n d t h e u l n a r s i d e o f t h e p a l m. At r o p h y o f t h e h y p o t h e n a r e mi n e n c e a n d i n t e r o s s e u s mu s c l e s ma y r e s u l t f r o m p r o l o n g e d c o mp r e s s i o n . T h e s e f i n d i n g s s h o u l d d i r e c t a t t e n t i o n t o t h e e l b o w. T h e u l n a r n e r v e ma y b e s t r e t c h e d o r i n j u r e d b y a c u b i t u s v a l g u s d e f o r mi t y o r a n o l d e l b o w f r a c t u r e . O t h e r r i s k f a c t o r s f o r u l n a r e n t r a p me n t i n c l u d e a l c o h o l i s m a n d d i a b e t e s . P r e s s o n t h u l n a r n e r v e i n i t s g r o o v e b e h i n d t h e me d i a n e p i c o n d y l e ; t i n g l i n g i n t h e u l n a r d i s t r i b u t i o n o f t h e h a n d s u g g e s t s u l n a r t u n n e l s y n d r o me .

Forearm and Elbow Signs

F o r e a r m P a i n a n d We a k n e s s : F l e x o r C o m p a r t m e n t S y n d r o m e a n d Vo l k m a n n I s c h e m i c C o n t r a c t u r e : P a t h o p h y s i o l o g Is:c h e mi c n e c r o s i s o f mu s c l e r e s u l t s f r o m e i t h e r p r i ma r y a r t e r i a l y e v e n t s ( c o mp r e s s i o n , v a s c u l a r s p a s m, a r t e r i a l i n j u r y o r e mb o l i s m) o r s e c o n d a r y t o h e mo r r h a g e o r s w e l l i n g w i t h i n t h e c o n f i n i n g f a s c i a o f t h e f l e xo r mu s c l e c o mp a r t me n ( c o mp a r t me n t s y n d r o me , p a g e 7 9 4k)ma n n c o n t r a c t u r e , t h e f i b r o s i s a n d . Vo l s h o r t e n i n g o f t h e mu s c l e s , i s a l a t e f i n d i n g . E a r l y r e c o g n i t i o n o f t h e i n i t i a l i s c h e mi c p h a s e ma y p r e v e n t d a ma g e l e a d i n g t o c o n t r a c t u r e . T h e o n s e t o f i s c h e mi a i s i n d i c a t e d b y t h e f i v e P s : p a i n , p u f f i n e s s , p a l l o r, p u l s e l e s s n e s s , a n d p a r a l y s i s .
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P a s s i v e e xt e n s i o n o f t h e f i n g e r s p r o d u c e s p a i n i n t h e f o r e a r m. T h e f i n g e r s ma y b e c y a n o t i c a n d a r e o f t e n e d e ma t o u s . T h e r a d i a l p u l s e i s a b s e n t , t h e s k i n o v e r t h e h a n d s i s c o o l a n d me d i a n n e r v e s e n s a t i o n i s d i mi n i s h e d . M e a s u r e c o mp a r t me n t p r e s s u r e s i f s i g n s o f c o mp a r t me n t s y n d r o me a p p e a r. In Vo l k ma n n c o n t r a c t u r e , t h e f i n g e r s a r e h e l d i n f l e xi o n b y s h o r t e n i n g o f t h e f i b r o t i c b e l l i e s o f t h e d i g i t a l f l e xo r s t h e f o r e a r m. B e c a u s e t h e f l e xo r t e n d o n s a r e f r e e t o mo v e i n t h e i r s h e a t h s , s l i g h t e xt e n s i o n o f t h e f i n g e r s i s p e r mi t t e d w i t h p a s s i v e mo t i o n w h e n t h e w r i s t i s h e l d i n f l e xi o n . T h i s d i s t i n g u i s h e s i t f r o m a d h e s i o n s o f f l e xo r t e n d o n s t o t h e i r s h e a t h s ; b o t h p r e v e n t a n y e xt e n s i o n . P r e c i p i t a t i n g e v e n t s a r e f o r e a r m a n d s u p r a c o n d y l a r f r a c t u r e a n d c i r c u mf e r e n t i a l b a n d a g e s o r c a s t s a p p l i e d s h o r t l y a f t e r t r a u ma .

Smooth For ear m Cur vatur e: Diseases of Osseous Gr owth: S mo o t h c u r v e s o f t h e r a d i u s a n d u l n a a r e u s u a l l y a t t r i b u t a b l e t o s y p h i l i s , r i c k e t s , o s t e o ma l a c i a , o r o s t e i t i s d e f o r ma n s .


P. 7 4 1

Fig. 13-36 Traumatic Deformities of the Forearm .

Silver -For k Defor mity: Colles Fr actur e: T h e mo s t c o mmo n c a u s e i s a f a l l o n t h e o u t s t r e t c h e d h a n d . T h e r a d i u s i s f r a c t u r e d w i t h i n 2 . 5 c m o f i t s d i s t a l Feg .d 1(3 - 3 6 A F r a c t u r e o f t h e u l n a r s t y l o i d p r o c e s s in ). occurs in half the cases. When the pronated arm is laid on the table, its profile r e s e mb l e s a d i n n e r f o r k l y i n g h o r i zo n t a l l y w i t h t h e t i n e s p o i n t i n g d o w n w a r d , s o t h e b a s e o f t h e t i n e s f o r ms a n u p w a r d c u r v e . T h e c o r r e s p o n d i n g h u mp i n t h e f r a c t u r e d a r m o c c u r s f r o m d o r s a l d i s p l a c e me n t o f t h e d i s t a l r a d i a l f r a g me n t . To e xc l u d e a h u m f r o m s o f t - t i s s u e s w e l l i n g , p a l p a t e t h e v o l a r a s p e c t o f t h e r a d i u s a n d c o mp a r e i t t o t o p p o s i t e s i d e . T h e n o r ma l a n t e r i o r c o n v e xi t y o f t h e s h a f t i s o b l i t e r a t e d b e l o w t h e fracture.

P. 7 4 2 Re v e r s e d S i l v e r - F o r k D e f o r m i t y : S m i t h F r a c t u r e ( Re v e r s e d C o l l e s Fr actur e): Like the Colles fracture, this is a break of the distal end of the radius, but the dista f r a g me n t i s d i s p l a c e d v o l a r w a r d , ma k i n g a d e f o r mi t y s o me w h a t r e s e mb l i n g t h e s i l v e f o r k w i t h i t s t i n e s p o i n t i n g u p w a rF i g .s e e - 3 6 B T h e f r a c t u r e u s u a l l y r e s u l t s d ( 13 ). f r o m a b l o w o r f a l l o n t h e h y p e r f l e xe d h a n d .
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D o r s a l An g u l a t i o n o f t h e Wr i s t : M a d e l u n g D e f o r m i t y : T h e p r o n a t e d h a n d p r e s e n t s a p r o f i l e i n w h i c h t h e w r i s t i s d e f o r me d b y a s h a r p p r o t r u s i o n u p w a r d ( d o r s a l l y ) o f t h e l o w e r u l in a ( s e e 6)C T h i s i s c a u s e d b y a F g. 13-3 . d o r s a l s u b l u xa t i o n o f t h e d i s t a l e n d o f t h e u l n a . P a i n a n d Te n d e r n e s s i n t h e B o n y S h a f t s : Ra d i a l a n d Ul n a r F r a c t u r e s : In f r a c t u r e s o f t h e u l n a r s h a f t , t h e b o n e i s w e l l s p l i n t e d b y t h e r a d i u s , s o d i s p l a c e me n t a n d d e f o r mi t y a r e r a rF i g .s e e - 3 6)D T h e o n l y p h y s i c a l s i g n s a r e e ( 13 . l o c a l i ze d t e n d e r n e s s a n d s w e l l i n g . U l n a r f r a c t u r e s a c c o mp a n i e d b y v o l a r d i s l o c a t i o n o f t h e r a d i a l h e a d ( M o n t e g g i a f r a c t u r e / d i s l o c a t i o n ) , e s p e c i a l l y c o mmo n i n c h i l d r e n , p e r mi t c o n s i d e r a b l e b o w i n g o f t h e f r a c t u r e d u l n a . A f r a c t u r e d r a d i a l s h a f t p r e s e n t s v a r i a b l e d e g r e e s o f b o w i n g , e s p e c i a l l y w i t h c o n c o mi t a n t d i s l o c a t i o n o f t h e l o w e r radioulnar joint. P a i n f u l An g u l a r D e f o r m i t y : F r a c t u r e s o f B o t h F o r e a r m B o n e s : G r e e n s t i c k f r a c t u r e s p r o d u c e l i t t l e d e f o r mi t y, b u t c o mp l e t e f r a c t u r e s o f t h e r a d i u s a u l n a p r e s e n t e a s i l y r e c o g n i za b l e d e f o r mi t y. Post-tr aumatic Elbow Pain: Fr actur e of the Cor onoid Pr ocess of the Ul n a : F r a c t u r e o f t h e u l n a r c o r o n o i d p r o c e s s , w h i c h f o r ms t h e d i s t a l p a r t e l b o w j o i n t , i s e a s i l y mi s s e d i f n o t c o n s i d e r e d a n d s e a r c h e d f o r. Post-tr aumatic Elbow Pain: Fr actur e of the Olecr anon Pr ocess: P r o n o u n c e d s w e l l i n g r e s u l t s , p a r t i c u l a r l y a r o u n d t h e d o r s u m o f t h e e l b o w. T h e o l e c r a n o n p r o c e s s i s t e n d e r. W h e n t h e f r a c t u r e i s c o mp l e t e , t h e p a t i e n t c a n n o t e xt e n d t h e f l e xe d f o r e a ri m. (1 3 - 3 7 A T h e b o n y e q u i l a t e r a l t r i a n g l e ma y b e F g ). flattened.
P. 7 4 3

P o s t - t r a u m a t i c E l b o w P a i n : Hu m e r a l S u p r a c o n d y l a r F r a c t u r e : T he injury is usually caused by falling on the outstretched hand in children younger than 10 years of age. T he patient supports the forearm with the opposite hand. U s u a l l y t h e d i s t a l f r a g me n t i s d i s p l a c e d p o s t e r i o r l y, s o e l b o w a n g u l a t i o n i s u n u s u a l l p r o mi n e n t ( s e e g . 1 3 - 3 7 B T h e e l b o w ' s b o n y e q u i l a t e r a l t r i a n g l e i s i n t a c t . Fi ). Te n d e r n e s s a n d s w e l l i n g a r e p r e s e n t a t t h e f r a c t u r e s i t e . To p r e v e n t i n j u r y t o t h e a n t e c u b i t a l s t r u c t u r e s a v o i d mo v i n g t h e f r a g me n t s . S e e k t h e e a r l y s i g n s o f c o mp a r t me n t s y n d r o me ( s e e a b o v e ) . In t h e u n c o mmo n a n t e r i o r d i s p l a c e me n t o f t h e d i s t a l f r a g me n t , t h e s i g n s a r e l e s s d i s t i n c t i v e .

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Fig. 13-37 Fractures and Dislocations about the Elbow .

P o s t - t r a u m a t i c E l b o w P a i n : L o w e r T - S h a p e d Hu m e r a l F r a c t u r e : A b l o w o n t h e e l b o w ma y r e s u l t i n t h e h u me r a l s h a f t b e i n g d r i v e n b e t w e e n t h e t w o c o n d y l e s , p r o d u c i n g w i d e n i n g o f t h e e l bF iw .( s e e 3 7)C C r e p i t u s o f t h e o g 13. f r a g me n t s o c c u r s w i t h l i g h t p a l p a t i o n w h e n t h e f r a g me n t s a r e n o t s e p a r a t e d . S w e l l i n g ma y o b s c u r e t h e d i s t o r t i o n o f t h e b o n y e q u i l a t e r a l t r i a n g l e , b u t b l o o d i n t h joint cavity produces fluctuation and bulging on both sides of the olecranon process Post-tr aumatic Elbow Pain: Dislocation of the Elbow: F a l l i n g o n t h e o u t s t r e t c h e d h a n d u s u a l l y c a u s e s a p o s t e r i o r d i sFog .a t i 3 -n ( s e e li c 1o 3 7 D) . T h e o l e c r a n o n p r o c e s s i s u n u s u a l l y p r o mi n e n t . T h e a r m i s h e l d i n 4 0 d e g r e e s o f f l e xi o n , a n d i s i mmo v a b l e , a c t i v e l y o r p a s s i v e l y. T h e f o r e a r m i s n o t s u p p o r t e d b y the opposite hand. T he height of the bony triangle is shortened. T he last two features distinguish it from supracondylar fracture.

D e f o r m i t y o f t h e E l b o w : C u b i t u s Va l g u s a n d Va r u s : T h e c a r r y i n g a n g l e o f t h e e l b o w i s n o t n o r ma l , a n d d i f f e r s mo r e t h a n 1 0 d e g r e e s b e t w e e n r i g h t a n d l e f t . B e c a u s e t h e n o r ma l a n g l e i s a p p r o xi ma t e l y 1 7 0 d e g r e e s a s me a s u r e d o n t h e l a t e r a l s i d e o f t h e a r m a n d f o r e a r m, a n a n g l e l e s s t h a n 1 6 5 d e g r e e i s a v a l g u s d e f o r mi t y, a n d o n e g r e a t e r t h a n 1 7 5 d e g r e e s i s a v a rF i s .d e f o r mi t y ( ug 1 3 - 3 8 A. )
P. 7 4 4

Swelling of the Elbow: Effusion in the Elbow Joint: T he synovial sac of the elbow joint is very loose. Fluid distention produces fluctuan b u l g i n g p o s t e r i o r l y, o n b o t h s i d e s o f t h e o l e c r a n o n p r o c e s s a n d t h e a t t a c h e d t r i c e p s b r a c h i i t e n d o n ( sF i e . 1 3 - 3 8 B It i s mo s t a c c e s s i b l e t o p a l p a t i o n l a t e r a l l y i n t h e eg ). sulcus between the lateral epicondyle, radial head, and olecranon. T he elbow is he i n s e mi f l e xi o n t o a c c o mmo d a t e ma xi ma l f l u i d v o l u me . C a r e f u l n o t e o f t h e b o r d e r s o f t h e s a c iF i g . 1 3 - 3 8 B i l l a s s i s t i n d i s t i n g u i s h i n g w h e t h e r t h e f l u i d i s i n t h e j o i n t n w c a v i t y o r i n t h e o l e c r a n o n b u r s a . T h e j o i n t ma y b e d i s t e n d e d b y s y n o v i a l f l u i d , p u s , or blood.

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F i g . 1 3 - 3 8 D i s o r d e r s o f t h e I n t a c t .E l b o w

S w e l l i n g o f t h e E l b o w : O l e c r a n o n B u r s i t i s ( M i n e r ' s E l b o w, S t u d e n t ' s Elbow): T r a u ma , i n f l a mma t i o n , i n f e c t i o n o r g o u t p r o d u c e s a n a c c u mu l a t i o n o f f l u i d i n t h e o l e c r a n o n b u r s a , a s u b c u t a n e o u s s p a c e o v e r l y i n g t h e o l e c r a n o n F irg .c e s s ( s e e p o 1 3 - 3 8 C. T h e s w e l l i n g i s f l u c t u a n t . T h e l o c a t i o n o f t h e b u l g e r e a d i l y d i s t i n g u i s h e s i t ) from fluid in the joint.

L a t e r a l E l b o w P a i n : L a t e r a l a n d M e d i a l E p i c o n d y l i t i s ( Te n n i s E l b o w ) : P a t h o p h y s i o l o g R:e p e t i t i v e f o r c e f u l w r i s t a n d / o r f i n g e r f l e xi o n a n d e xt e n s i o n f o c u s y t e n s i o n o n t h e c o mmo n p r o xi ma l t e n d o n i n s e r t i o n s a t t h e l a t e r a l ( e xt e n s o r s ) a n d me d i a l ( f l e xo r s ) h u me r a l e p i c o nL a t e s a l E p i c o n d y l ic i s s e s p a i n i n t h e dyl r . tau l a t e r a l a s p e c t o f t h e e l b o w, a c c e n t u a t e d b y u s e o f t h e h a n d d u r i n g a p o w e r g r i p ( w h e n t h e w r i s t e xt e n s o r s a r e a l s o c o n t r a c t i n g ) , a s i n l i f t i n g o b j e c t s . P a l p a t i o n d i s c l o s e s t e n d e r n e s s o v e r t h e l a t e r a l e p i c o n d y l e a n d 1 c m d iCozen tIn t h e s t a l l y. es ( r e s i s t e d w r i s t e xt e n s i o n ) , t h e p a t i e n t i s a s k e d t o k e e p t h e f i s t c l e n c h e d w h i l e e xt e n d i n g t h e w r i s t a g a i n s t r e s i s t a n c e r e p r o d u c i n g t h e p a t i e n t ' s l a t e r a l e p i c o n d y l a r p a i n . In t hM i l l maneuv erh a v e t h e e l b o w h e l d i n e xt e n s i o n w i t h t h e w r i s t f l e xe d ; e , when you pronate the forearm against the patient's resistance, epicondylar pain is e l i c i t e dM e d i a l E p i c o n d y l i its sl e s s c o mmo n . T h e p a i n i s l o c a t e d j u s t d i s t a l t o t h e . i me d i a l e p i c o n d y l e i n t h e f l e xo r t e n d o n s a n d i s r e p r o d u c e d b y ma n e u v e r s r e q u i r i n g w r i s t a n d f i n g e r f l e xi o n o r a r m p r o n a t i o n a g a i n s t r e s i s t a n c e . Ar t h r i t i s o f t h e E l b o w : An y t y p e o f a r t h r i t i s ma y i n v o l v e t h e e l b o w j o i n t . S u p p u r a t i v e a r t h r i t i s p r o d u c e s p a i n f u l s w e l l i n g , w i t h p u s i n t h e j o i n t . R h e u ma t i c f e v e r a n d r h e u ma t o i d a r t h r i t i s c a u p a i n f u l s w e l l i n g ; t h e c h r o n i c s t a g e o f r h e u ma t o i d a r t h r i t i s o f t e n r e s u l t s i n l i mi t e d e xt e n s i o n . A l o o s e b o d y i n t h e j o i n t i s s u g g e s t e d b y a h i s t o r y o f l o c k i n g . An e n l a r g e p a i n l e s s j o i n t , s u g g e s t i n g o s t e o a r t h r i t i s b u t u n i l a t e r a l , ma y b e n e u r o g e n i c a r t h r o p a t h y ( C h a r c o t j o i n t ) ; w h e n e n c o u n t e r e d i n t h e e l b o w, s y r i n g o my e l i a i s t h e mo s t l i k e l y c a u s e .
P. 7 4 5

P o s t - t r a u m a t i c E l b o w P a i n : S u b l u x a t i o n o f t h e Ra d i a l He a d : T h i s u s u a l l y o c c u r s i n c h i l d h o o d ( t h e p u l l e d e l b o w ) . T h e r e i s n o d e f o r mi t y o f t h e e l b o w a n d t e n d e r n e s s i s ma xi mu m n e a r t h e r a d i a l h e a d . F l e xi o n e xt e n s i o n e l i c i t s
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pain, but pronation and supination are painless.

P o s t - t r a u m a t i c E l b o w P a i n : F r a c t u r e o f t h e Ra d i a l He a d : U s u a l l y t h i s r e s u l t s f r o m a f a l l o n t h e o u t s t r e t c h e d h a n d . S w e l l i n g i s mi n i ma l a n d t h e r e i s n o d e f o r mi t y ; t h e b o n y e q u i l a t e r a l t r i a n g l e i s n o r ma l . F l e xi o n a n d e xt e n s i o n are painless, but there is severe restriction of pronation-supination and the radial h e a d i s t e n d e r.

Upper Arm Signs


T h i s r e g i o n i n c l u d e s t h e s h a f t o f t h e h u me r u s a n d i t s c o v e r i n g mu s c l e s , p r i n c i p a l l y the biceps brachii and the triceps brachii.

P a i n i n t h e Up p e r Ar m : B i c i p i t a l Te n o s y n o v i t i s : P a t h o p h y s i o l o gA :d a y o r s o a f t e r e xc e s s i v e u s e o f t h e b i c e p s b r a c h i i , y i n f l a mma t i o n o c c u r s i n t h e t e n d o n s h e a t h o f t h e b i c e p s w h e r e i t e me r g e s a n t e r i o r l y f r o m t h e c a p s u l e o f t h e s h o u l d e rPja iin ti s l o c a t e d n e a r t h e i n s e r t i o n o f t h e . o n p e c t o r a l i s ma j o r o n t h e h u me r u s a n d ma y s h o o t d o w n t h e a r m. S h o u l d e r mo t i o n s a r e s o me w h a t l i mi t e d , e s p e c i a l l y f l e xi o n o f t h e a r m ( e l e v a t i o n a t 0 d e g r e e s a b d u c t i o n ) . Te n d e r n e s s i s e l i c i t e d b y p a l p a t i n g t h e t e n d o n i n t h e b i c i p i t agasron v e .gn: Yer l g o o Si H a v e t h e p a t i e n t f l e x t h e e l b o w t o 9 0 d e g r e e s a n d p r o n a t e t h e f o r e a r m. G r a s p t h e h a n d a n d a s k t h e p a t i e n t t o s u p i n a t e a g a i n s t y o u r r e s i s t a n c e . It i s p o s i t i v e w h e n t h i p r o d u c e s p a i n i n t h e a n t e r o me d i a l a s p e c t o f t h e s h o u l d e r.

B i c i p i t a l Hu m p s : Ru p t u r e o f t h e B i c e p s B r a c h i i : T h e u s u a l l y s mo o t h p r o f i l e o f t h e b i c e p s i s i n t e r r u p t e d b y o n e o r t w o h u mp s . O n e h u mp r e s u l t s w i t h r u p t u r e o f t h e t e n d o n o r mu s c l e s F eg . t h 3 -s3 7 F R u p t u r e h i a 1 ( e e. ) o f t h e b e l l y c a u s e s t w o h u mp s . R u p t u r e o c c u r s d u r i n g l i f t i n g e xc e s s i v e w e i g h t a n d i u s u a l l y p a i n f u l . Ab s e n c e o f t h i s h i s t o r y s u g g e s t s d e g e n e r a t i o n o f t h e b i c i p i t a l l o n g h e a d t e n d o n i n t h e s h o u l d e r j o i n t , o f t e n a s s o c i a t e d w i t h c h r o n i c i mp i n g e me n t o r s h o u l d e r s y n o v i t i s . R u p t u r e o f t h e l o n g - h e a d t e n d o n i s mo s t c o mmo n , r e s u l t i n g i n mi l d w e a k n e s s . R u p t u r e o f t h e mu s c l e ma y n o t g r e a t l y i mp a i r s t r e n g t h .

P. 7 4 6 P a i n f u l I m m o b i l i t y o f t h e Up p e r Ar m : F r a c t u r e o f t h e Hu m e r a l S h a f t : T hese are painful injuries, and the arm is useless, being held in the opposite hand. T r a n s v e r s e f r a c t u r e i s u s u a l l y c a u s e d b y a d i r e c t b l o w a n d t h e r e i s u n mi s t a k a b l e d e f o r mi t y. S p i r a l f r a c t u r e , c o mmo n l y f r o m a f a l l o n t h e h a n d , ma y n o t c a u s e d e f o r mi t y. L a c k i n g d e f o r mi t y, g e n t l y p a l p a t e t h e l a t e r a l a n d me d i a l a s p e c t s o f t h e h u me r u s f o r l o c a l t e n d e r n e s s a n d s w e l l i n g . S h a f t f r a c t u r e s c a n l a c e r a t e t h e r a d i a l nerve and distal brachial artery as they lie in contact with the posterior upper third t h e h u me r u s . In a l l c a s e s o f f r a c t u r e d h u me r u s , f e e l t h e r a d i a l a r t e r i a l p u l s e a n d t e f o r r a d i a l n e r v e i n j u r y. Te s t t h e mo t o r f u n c t i o n o f t h e n e r v e b y h a v i n g t h e p a t i e n t f l e t h e e l b o w w i t h t h e f o r e a r m p r o n a t e d a n d l o o k f o r w r i s t - d r o p . An e s t h e s i a o n t h e r a d i dorsum of the hand is evidence of sensory loss of the radial nerve.

Shoulder Signs
D e f i c i t s o f Ar m Ab d u c t i o n : S e e F i g . 1 3 - 3 9F u l l p a i n l e s s a b d u c t i o n e f f e c t i v e l y e xc l u d e s s e r i o u s i n j u r y t o t h e .
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s h o u l d e r. P a i n w i t h e l e v a t i o n o r l i mi t e d a c t i v e r a n g e o f mo t i o n s u g g e s t p a t h o l o g y i n t h e s h o u l d e r. P a i n b e t w e e n 6 0 d e g r e e s a n d 1 2 0 d e g r e e s o f e l e v a t i o n , w i t h t h e r e ma i n d e r o f t h e a r c p a i n l e s s , s u g g e s t s p a r t i a l r u p t u r e o f t h e s u p r a s p i n a t u s t e n d o n s u p r a s p i n a t u s t e n d i n i t i s , o r s u b a c r o mi a l b u r s i t i s . M i n i ma l e l e v a t i o n a n d s u p p o r t o f t h e a r m w i t h t h e o p p o s i t e h a n d p o i n t t o f r a c t u r e , d i s l o c a t i o n , o r c o mp l e t e r u p t u r e o f t h e s u p r a s p i n a t u s ; i n t h e l a t t e r c a s e , p a s s i v e mo t i o n s o f t h e j o i n t a r e n o r ma l . P a i n throughout the range of elevation indicates arthritis. Descriptions of these conditio f o l l o w.

P. 7 4 7 P. 7 4 8 P. 7 4 9 PAI N B E T WE E N 6 0 D E G RE E S AND 1 2 0 D E G RE E S O F AB D UC T I O N ( PAI NF UL ARC , I M P I NG E M E NT S I G N) : PART I AL RUP T URE O F T HE S UP RAS P I NAT US T E ND O N, S UP RAS P I NAT US T E ND I NI T I S , AND S UB AC RO M I AL B URS I T I S : P a t h o p h y s i o l o g D:u r i n g a r m a b d u c t i o n t h e s u p r a s p i n a t u s t e n d o n a n d i t s i n s e r t i o n y o n t h e p r o xi ma l ma r g i n o f t h e g r e a t e r h u me r a l t u b e r o s i t y mu s t p a s s b e n e a t h t h e a c r o mi o n . T h e s u b a c r o mi a l b u r s a i s p o s i t i o n e d t o d e c r e a s e t h e f r i c t i o n , o r i mp i n g e me n t , w h i c h o c c u r s w i t h t h i s mo t i o n . R e p e t i t i v e f o r c e f u l mo t i o n c a u s e s me c h a n i c a l i r r i t a t i o n t o t h e t i s s u e s e l i c i t i n g i n f l a mma t i o n o f t h e t e n d o n a n d b u r s a . S u d d e n o r s e v e r e l o a d i n g o f t h e s h o u l d e r ma y r e s u l t i n i n c o mp l e t e o r c o mp l e t e t e a r o f t h e s u p r a s p i n a t u s t e.n d o n s e t h r e e c o n d i t i o n s p r e s e n t w i t h s i mi l a r s i g n s a n d T he s y mp t o ms . A h i s t o r y o f s u d d e n o n s e t f a v o r s p a r t i a l t e a r o f t h e t e n d o n , w h e r e a s r e p e t i t i v e s h o u l d e r mo t i o n a n d s u b a c u t e o r c h r o n i c o n s e t f a v o r t e n d o n i t i s o r b u r s i t i Al l h a v e p a i n f u l a b d u c t i o n b e t w e e n 6 0 d e g r e e s a n d 1 2 0 d e g r e e s , o f t e n p r o h i b i t i n g f u l l a c t i v e r a n g e o f mo t i o n . P a s s i v e r a n g e , t h o u g h p a i n f u l , i s p r e s e r v e d . P r e c i s e d i s t i n c t i o n b e t w e e n t h e t h r e e i s n o t p o s s i b l e w i t h p h y s i c a l P xa t i an a t i o n . e a r mi l R u p t u r e o f t h e S u p r a s p i n a t u s Te n dh en : t h e t e n d o n i s o n l y i n c o mp l e t e l y t o r n , W o n t h e r o t a t o r c u f f i s i n t a c t . P a i n i s r e f e r r e d t o t h e h u me r a l i n s e r t i o n o f t h e d e l t o i d mu s c l e , b u t t h e r e i s n o t e n d e r n e s s a t t h a t p o i n t . S o me t i me s t h e p a i n e xt e n d s d o w n t h e a r m t o t h e e l b o w o r b e y o n d . Te n d e r n e s s i s e l i c i t e d j u s t b e n e a t h t h e a c r o mi a l t i p o r i n t h e n o t c h b e t w e e n g r e a t e r a n d l e s s e r h u me r a l D u b e Ifc lw e a k n e s s o f t D X: r e s . t h e s u p r a s p i n a t u s , w e a k e xt e r n a l r o t a t i o n a n d i mp i n g e me n t s i g n s a r e a l l p r e s e n t , a r o t a t o r c u f f t e a r i s l i k eu y r e l l G A, Wa l t o n J R . D i a g n o s i s o f r o t a t o r c u f f t e a r s . M lr [ Lanc et2 0 0 1 ; 3 5 7 : 7 6 9 7 7A c u t e S u p r a s p i n a t u s Te n d i nT t iis : u s u a l l y o c c u r s ]. 0 ih s in a person 25 to 45 years of age, with a dull ache developing in the shoulder w i t h o u t a n t e c e d e n t t r a u ma . T h e p a i n s t e a d i l y w o r s e n s a n d ma y b e e xc r u c i a t i n g . T h e diagnostic test is abduction to 90 degrees and then full internal rotation, which r e p r o d u c e s p a i n . Te n d e r n e s s i s p r o n o u n c e d b e n e a t h t h e aC ho mi a c t i p . cr roni l S u p r a s p i n a t u s Te n d i n i Diu l:l s h o u l d e r p a i n d e v e l o p s i n a p a t i e n t w h o i s u s u a l l y t s b e t w e e n 4 5 a n d 6 0 y e a r s o l d a n d w i t h o u t p r e c e d i n g t r a u ma . Ab d u c t i o n i s p a i n l e s s t o 60 degrees, where the patient feels a jerk with pain in the region of the deltoid mu s c l e . P r o n o u n c e d t e n d e r n e s s c a n b e e l i c i t e d i n t h e n o t c h b e t w e e n t h e g r e a t e r a n l e s s e r t u b e r c l e s o f t h e h u me r a l h e a d o r b e n e a t h t h e a c r o mi a l t i p . C r e p i t u s ma y a l s o b e p r e s e n t . Ly i n g o n t h e s h o u l d e r p r o d u c e s p a i n t h a t p r e v e n t s s l e e p i n g o n t h e a f f e c t e d s i d e f o r mo nSh s . a c r o m i a l B u r s i t Ts :i s c a n b e a c u t e o r c h r o n i c a n d t ub ih
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o f t e n a c c o mp a n i e s s u p r a s p i n a t u s t e n d o n i t i s . T h e p a i n i s c o n s t a n t a n d a g g r a v a t e d b elevation in abduction. T here is often a history of heavy arm use.

F i g . 1 3 - 3 9 C a u s e s o f P a i n a n d L i m i t e d M o t i o n w i t h E l e va t i o n o f t h e A r m i n A b d u c t i o.n

M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H T HE O P P O S I T E HAND : C O M P L E T E RUP T URE O F T HE S UP RAS P I NAT US T E ND O N, T O RN RO TAT O R C UF F : P a t h o p h y s i o l o g T : e s u p r a s p i n a t u s mu s c l e i n i t i a t e s a r m a b d u c t i o n f r o m 0 t o 4 5 yh d e g r e e s , w h e r e t h e d e l t o i d b e c o me s e n g a g e d . In a b i l i t y t o i n i t i a t e e l e v a t i o n i n 9 0 a b d u c t i o n i n d i c a t e s r u p t u r e o f t h e s u p r a s p i n a t.u T h ie n d o u a l l y o c c u r s a f t e r s t s us n a g e 4 0 . T h e p a t i e n t c a n n o t e l e v a t e t h e a r m a g a i n s t mi n i ma l r e s i s t a n c e a t 3 0 d e g r e e e l e v a t i o n a n d 9 0 d e g r e e s a b d u c t i o n , b u t p a s s i v e mo t i o n i s f r e e a n d p a i n l e s s . In i t i a l s h o u l d e r mo t i o n i s mo s t l y w i t h t h e s c a p u l a . T h e r e i s r e s i s t a n c e t o e xt e r n a l r o t a t i o n w h e n t h e a r m i s h e l d a t t h e s i d e w i t h e l b o w f l e xe d . As t h e a r m i s mo v e d f o r w a r d , o n ma y p a l p a t e a j e r k , f i n e c r e p i t u s , o r a n i n d e n t a t i o n i n t h e s u b a c r o mi a l r e g i o n b e t w e e n t h e g r e a t e r a n d l e s s e r h u me r a l t u b e r F li e s 1 s e1 8, Dp a g e 6 9 8 ) . Af t e r c g. ( 3- e 3 weeks, atrophy of the supraspinatus and infraspinatus occurs. M I NI M AL ARM E L E VAT I O N WI T H S UP P O RT O F O P P O S I T E HAND : S HO UL D E R D I S L O C AT I O N: P a t h o p h y s i o l o g W:h e n t h e h a n d o r a r m a r e f o r c e f u l l y a b d u c t e d a n d e xt e r n a l l y y r o t a t e d , t h e h u me r a l h e a d d i s l o c a t e s o u t o f t h e g l e n o i d t e a r i n g t h r o u g h t h e a n t e r i o r r o t a t o r c u f f . T h e h u me r a l h e a d i s u s u a l l y d i s p l a c e d a n t e r i o r l y a n d me d i a l l y f r o m i t s n o r ma l l o c a t i o n i mme d i a t e l y b e l o w t h e a c r o mi a l t i p a n d l a t e r a l t o t h e c o r a c o i d t o a p o s i t i o n u n d e r t h e c o r a c o i d p r o ci e s s 3 - 4 0 A T h e s h o u l d e r p r o f i l e i s f l a t t e n e d F g. 1 ( ). a n d t h e b o n y t r i a n g l e i s d i s r u p t e d . T h e b o n y h a r d n e s s o f t h e h u me r a l h e a d c a n b e p a l p a t e d me d i a l l y i n t h e n o r ma l l y s o f t b e l l y o f t h e u p p e r t h i r d o f t h e d e l t o i d . W i t h t h r ul er t es t of Hami l ,t on s t r a i g h t e d g e c a n r e s t s i mu l t a n e o u s l y o n t h e a c r o mi a l t i p a a n d t h e l a t e r a l e p i c o n d y l e o f t h e e l b o w ; n o r ma l l y, t h e h u me r a l h e a d i n t e r v e n e s . T h e t e s t i s a l s o p o s i t i v e i n f r a c t u r e o f t h e h u me r a l Cal lk . T h et es t s e f u l i n n e c oway , u o b e s e p a t i e n t s , c o n s i s t s o f me a s u r i n g t h e g i r t h o f t h e t w o s h o u l d e r j o i n t s . A t a p e me a s u r e i s l o o p e d t h r o u g h t h e a xi l l a a n d t h e g i r t h me a s u r e d a t t h e a c r o mi a l t i p ; t h e
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g i r t h o f t h e a f f e c t e d j o i n t i s i n c r e a s e d . In t hte , tt h e p a t i e n t c a n n o t a d d u c t Dugas es t h e a r m s u f f i c i e n t l y t o p l a c e t h e h a n d o n t h e o p p o s i t e s h o u l d e r. P o s t e r i o r d i s l o c a t i o n s a r e r a r e . T h e h u me r a l h e a d i s f e l t p o s t e r i o r l y u n d e r t h e s p i n e o f t h e s c a p u l a n e a r t h e b a s e o f t h e a c r o mi a l p r o c e s s . A c o mmo n c a u s e o f t h i s u n c o mmo n d i s l o c a t i o n i s a ma j o r mo t o r ( g r a n d ma l ) s e i zu r e . S h o u l d e r d i s l o c a t i o n c a n b e i d e n t i f i e d b y a s c a p u l a r Y- v i e w x- r a y w i t h o u t ma n i p u l a t i o n o f t h e s h o u l d e r. D i s l o c a t i o n o f t h e h u me r a l h e a d c a n d a ma g e a d j a c e n t s t r u c t u r e s i n c l u d i n g t h e l a b r u m o f t h e g l e n o i d a n d t h e a xi l l a r y n e r v e ( c a u s i n g p a r a l y s i s a n d l a t e r a t r o p h y o f t h e d e l t o i d ) . P a l p a t e t h e p u l s e s o f t h e a r m t o d e t e c t c o mp r e s s i o n o f t h e a xi l l a r y vessels.

F i g . 1 3 - 4 0 T r a u m a t i c D i s o r d e r s o f t h e S h o u l d e r. A . A n t e r i o r D i s l o c a t i o n o f t h e H u m e r a l H e a d . B . F r a c t u r e o f t h e H u m e r a l N e c k . C . M i d c l a vi c u l a r F r a c t u r e . D . A c r o m i o c l a vi c u l a r S u b l u xa t i o n . E . F r a c t u r e o f t h e S c a p u l a r Neck .

M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H O P P O S I T E HAND : HUM E RAL NE C K F RAC T URE : Usually this results from a fall on the outstretched hand. Pain is present in the s h o u l d e r, w i t h i mmo b i l i t y o f t h e a r m, w h i c h i s s u p p o r t e d b y t h e o p p o s i t e h a n d . Vi e w e d l a t e r a l l y, t h e p r o f i l e ma y s h o w a n a n t e r i o r a n g u l a r d e fi o r. mi 3y ( s e e F g 1t4 0 B) . T h e a xi l l a r y a s p e c t o f t h e a r m a n d t h e c h e s t w a l l ma y b e e c c h y mo t i c . R o t a t e t h e a r m g e n t l y, w h i l e p a l p a t i n g t h e h u me r a l h e a d ; i f t h e f r a c t u r e i s n o t i mp a c t e d , t h h e a d w i l l n o t mo v e w i t h t h e s h a f t , c o n f i r mi n g t h e d i a g n o s i s . W h e n d i s p l a c e me n t i s p r e s e n t , t h e r u l e r t e s t o f H a mi l t oShoul e n ( s e der Di s l oc at i a b o v e ) ma y b e on p o s i t i v e . If a b r e a k i s n o t o b v i o u s , c o n s i d e r i mp a c t e d f r a c t u r e a n d me a s u r e t h e
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d i s t a n c e f r o m a c r o mi a l t i p t o e p i c o n d y l e o n t h e t w o s i d e s ; t h e i mp a c t e d s i d e s h o u l d b e s h o r t e r.

M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H O P P O S I T E HAND : C L AV I C UL AR F RAC T URE : F r a c t u r e s a t t h e c e n t e r o f t h e s h a f t a r e mo s t c o mmo n . B e c a u s e t h e f r a g me n t s a r e u s u a l l y d i s p l a c e d , d i a g n o s i s c a n b e ma d e b y i n s p e c t i o n a n d p a lip a t 1o n ( s e e F g. i 34 0 C) . G r e e n s t i c k o r i mp a c t e d f r a c t u r e s ma y b e d e t e c t e d b y t e n d e r n e s s a n d s w e l l i n g M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H O P P O S I T E HAND : AC RO M I O C L AV I C UL AR S UB L UX AT I O N: T h e r e i s p a i n i n t h e s h o u l d e r w i t h r e l u c t a n c e t o e l e v a t e t h e a r m. In s p e c t i o n ma y disclose elevation of the distal clavicular tip. Have the patient place the hand of th a f f e c t e d s i d e o n t h e o p p o s i t e s h o u l d e r a n d p r e s s f i r ml y o n t h e d i s t a l e n d o f t h e c l a v i c l e . T h e e n d o f t h e c l a v i c l e mo v e s d o w n w a r d a n d t h e ma n e u v e r i s p a i n f u l ( s e e F i g . 1 3 - 4 0)D W h e n t h e p a t i e n t h o l d s a w e i g h t i n b o t h a r ms , o b s e r v e t h e d o w n w a r d . d i s p l a c e me n t o f t h e a c r o mi o n r e l a t i v e t o t h e e n d o f t h e a f f e c t e d c l a v i c l e .

M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H O P P O S I T E HAND : S T E RNO C L AV I C UL AR S UB L UX AT I O N: T h e mo r e c o mmo n i n j u r y i s f o r w a r d d i s l o c a t i o n a n d s u b l u xa t i o n , c a u s i n g p a i n f u l c l i c k i n g i n t h e j o i n t w i t h e l e v a t i o n o f t h e a r m i n a b d u c t i o n . T h e d e f o r mi t y i s u s u a l l y obvious to inspection. T he rarer backward dislocation is seen as a hollow where the n o r ma l c l a v i c u l a r h e a d p r o t r u d e s . If t h e me d i a s t i n u m i s i n v a d e d , d y s p n e a a n d c y a n o s i s ma y o c c u r. M I NI M AL ARM E L E VAT I O N AND S UP P O RT WI T H O P P O S I T E HAND : S C AP UL AR F RAC T URE : T h e r e i s p a i n i n t h e s h o u l d e r p r e v e n t i n g e l e v a t i o n o f t h ega r1 3 -( 4 0 E S i t Fi . m see ). a t t h e p a t i e n t ' s a f f e c t e d s i d e s u p p o r t i n g t h e f o r e a r m w h i l e p a l p a t i n g t h e s h o u l d e r. Ab d u c t t h e f o r e a r m t o 9 0 d e g r e e s ; c r e p i t u s i n t h e j o i n t s t r o n g l y s u g g e s t s f r a c t u r e o the scapular neck when the clavicle is intact.
P. 7 5 0

Re s t r i c t i o n o f Al l S h o u l d e r M o t i o n s : T r a u m a a n d Ar t h r i t i s : Al l t y p e s o f a r t h r i t i s ma y i n v o l v e t h e s h o u l d e r. In t h e e a r l y s t a g e s o f i n f l a mma t o r y p r o c e s s e s , mo t i o n s a r e i n h i b i t e d b y p a i n ; l a t e r, a d h e s i o n s r e s t r i c t mo t i o n . O s t e o a r t h r i t i s ma y b e a s s o c i a t e d w i t h c r e p i t u s i n t h e j o i n t , b u t e f f u s i o n s a r e r e l a t i v e l y r a r e . O v e r t i me t h e r e i s p r o g r e s s i v e l o s s o f g l e n o h u me r a l mo t i o n . W i t h c h r o n i c a l l y l i mi t e d mo t i o n , g e n e r a l i ze d mu s c l e a t r o p h y o c c u r s . J o i n t e f f u s i o n s u g g e s t s r h e u ma t o i d a r t h r i t i s , c r y s t a l a r t h r i t i s ( c a l c i u m p y r o p h o s p h a t e d i h y d r a t e d e p o s i t i o n [ C P P D ] ) o r l e s s - c o mmo n d i s o r d e r s s u c h a s v i l l o n o d u l a r s y n o v i t i s . RE S T RI C T I O N O F AL L S HO UL D E R M O T I O NS : AD HE S I V E C AP S UL I T I S ( F RO ZE N S HO UL D E R) : P a t h o p h y s i o l o g C:h r o n i c i n f l a mma t i o n o f t h e r o t a t o r c u f f a n d j o i n t c a p s u l e l e a d s y t o s h o r t e n i n g o f t h e u s u a l l y l o o s e t e n d i n o u s c u f f a n d t o p r o g r e s s i v e. l o s s o f mo t i o n T h i s o f t e n f o l l o w s u n r e s o l v e d s u b a c r o mi a l b u r s i t i s o r s u p r a s p i n a t u s t e n d i n i t i s . At o n s e t , p a i n i s t h a t o f t h e o r i g i n a l i n j u r y. P r o g r e s s i v e l i mi t a t i o n o f mo t i o n e n s u e s u n c a p s u l a r c o n t r a c t i o n a n d f i b r o s i s a b a t e t h e p a i n w i t h a s s o c i a t e d mu s c l e a t r o p h y.


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Pain in the Shoulder : Cor acoiditis: P a t h o p h y s i o l o g R:e p e a t e d a c u t e o r c h r o n i c a r m w o r k ma y p r o d u c e i n f l a mma t i o n a t y t h e o r i g i n o f t h e s h o r t h e a d o f t h e b i c e p s a n d t h e c o r a c o b r a c h i a l i s mu s c l e s o n t h e t o f t h e c o r a c o i d p r o c eT h e r e i s a h i s t o r y o f t r a u ma w i t h p a i n a n d t e n d e r n e s s a t t h e . ss t i p o f t h e c o r a c o i d p r o c e s s . T h e p a i n i s r e p r o d u c e d b y a d d u c t i o n a n d e xt e r n a l r o t a t i o n o f t h e h u me r u s , o r h a v i n g t h e p a t i e n t p e r f o r m a g a i n s t r e s i s t a n c e e i t h e r s u p i n a t i o n o f t h e f o r e a r m w i t h t h e e l b o w f l e xe d , f o r w a r d f l e xi o n o f t h e s h o u l d e r, o r a d d u c t i o n o f t h e f l e xe d s h o u l d e r.

Pain in Deltoid M uscle: Subdeltoid Bur sitis (Subacr omial Bur sitis): S o me t i me s r e g a r d e d a s a s i n g l e c l i n i c a l e n t i t y, i n f l a mma t i o n o f t h e s u b d e l t o i d b u r s a u s u a l l y o c c u r s i n a s s o c i a t i o n w i t h i n f l a mma t i o n o r t e a r s o f t h e s u p r a s p i n a t u s t e n d o n

P a i n f u l No d u l e s i n S h o u l d e r M u s c l e s : T r i g g e r P o i n t s : P a i n i s u s u a l l y p r e s e n t o n a r i s i n g o r a f t e r i n a c t i v i t y, w h i l e e xe r c i s e d i mi n i s h e s o r a b o l i s h e s t h e p a i n . S ma l l n o d u l e s ma y b e p a l p a t e d o n t h e s u r f a c e o f t h e t r a p e zi u s o o t h e r mu s c l e . P r e s s u r e o n t h e n o d u l e r e p r o d u c e s t h e p a i n , o f t e n w i t h r a d i a t i o n t o t h n e c k a n d u p p e r a r m. S h o u l d e r - P a d S i g n : Am y l o i d o s i s : Bilateral anterolateral swelling of the shoulder joints is a conspicuous, although u n c o mmo n , s i g n o f a my l o i d d i s e a s e . T h e p e r i a r t i c u l a r s w e l l i n g s f e e l h a r d a n d r u b b e r y, s u g g e s t i n g t h e s h o u l d e r p a d s w o r n b y Ame r i c a n f o o t b a l l p l a y e r s .
P. 7 5 1

Wi n g e d S c a p u l a : P a r a l y s i s o f t h e L o n g T h o r a c i c Ne r v e : P a t h o p h y s i o l o g P : r a l y s i s o f t h e s e r r a t u s a n t e r i o r p e r mi t s t h e s c a p u l a t o b e ya s e p a r a t e d p o s t e r i o r l y f r o m t h e t h o r a c i c w a l l , a w i n g eH as c a ph e ap a t i e n t . d ve t ul s t a n d a n d p u s h t h e h a n d s a g a i n s t a w a l l w h i l e y o u o b s e r v e t h egs c1 3 -u l a e ( Fi . ap 4 1 A . In j u r y t o t h e l o n g t h o r a c i c n e r v e i s c a u s e d b y s t r e t c h i n g d u r i n g h e a v y l i f t i n g o ) s u r g i c a l t r a u ma .

F i g . 1 3 - 4 1 D i s o r d e r s o f t h e I n t a c t S h o u l d e r. A . W i n g e d S c a ptu l a : When he pat i ent pus hes t he hands agai ns t a wal l t he i nv ol v ed s c apul a pr ot r ude pos t er i or l y, f or mi ng a wi nged s cB . F la.i l A r mThe ar m hangs l i mpl y at apul a : t he s i de wi t h pal m pos t er i or and f i nger s par t i alC y Slp a s t i c A r m : l . f ex ed. The ar m as s umes f l ex i on at t he el bow wi t h t he upper ar m at el ev at i on, f l ex i on at t he wr i s t and f i nger s , wi t h s l i ght adduc t i on of t he humer us ; t he f or ear m i s i n
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pr onat i on . Wi n g e d S c a p u l a : S p r e n g e l D e f o r m i t y : T h i s i s a c o n g e n i t a l c o n d i t i o n w i t h u n i l a t e r a l o r b i l a t e r a l w i n g e d s c a p u l a e . It i s s o me t i me s a s s o c i a t e d w i t h a s h o r t , w e b b e d n e c k .

Conditions of the Entire Upper Limb


Flain Ar m :
P a t h o p h y s i o l o g L o w e r mo t o r n e u r o n o r p e r i p h e r a l n e r v e i n j u r i e s p r o d u c e y: mu s c u l a r d e n e r v a t i o n w i t h f l a c c i d p a r a l y s i s a n d mu s c u l Afr t e rt r io p u r i e s t o . a a nj hy t h e b r a c h i a l p l e xu s o r p o l i o my e l i t i s , t h e a r m ma y h a n g l i mp l y a t t h e s i d e w i t h t h e f l e xe d p a l m f a c i n g b a c k w a r dF(i s e e 3 - 4 1 B g. 1 ).

S p a s t i c Ar m : P a t h o p h y s i o l o g In:j u r y t o u p p e r mo t o r n e u r o n s l e a d s t o u n i n h i b i t e d mu s c u l a r y c o n t r a c t i o n w i t h t h e a n t i g r a v i t y f l e xo r s o v e r p o w e r i n g t h e w e a.k e r i teh e n s o r s W xt h e mi p l e g i a , t h e a r m i s c a r r i e d i n e l e v a t i o n w i t h f l e xi o n o f t h e e l b o w, w r i s t , a n d f i n g e r s ( s eF i g . 1 3 - 4 1)C e .

Hip, Buttock, and Thigh Signs


P. 7 5 2

Sacr al Pain: Lesions of the Cauda Equina: P a t h o p h y s i o l o g C:o mp r e s s i o n o f t h e c a u d a e q u i n a ( h o r s e ' s t a i l : t h e s p i n a l r o o t s y b e l o w t h e l e v e l o f t h e s p i n a l c o r d t e r mi n a t i o n , o r c o n u s ) , r e s u l t s i n c o mp r o mi s e o f n e r v e f u n c t i o n i n o n e o r mo r e l u mb a r o r s p i n a l n e r v e s , o f t e n a c c o mp a n i e d b y p a i n . P a i n i s l o c a l i ze d t o t h e s a c r u m a n d i n n e r t h i g h a n d t h e s k i n ma y b e a n e s t h e t i c . B l a d d e r s y mp t o ms ( i n c l u d i n g d e c r e a s e d u r i n a r y s t r e a m, h e s i t a n c y, a n d u r i n a r y r e t e n t i o n ) , a n a l s p h i n c t e r l a xi t y, a b s e n t a n a l w i n k , a n d i mp o t e n c e a r e c o mmo n . C o mp r e s s i o n o c c u r s f r o m a h e r n i a t e d i n t e r v e r t e b r a l d i s k w i t h p o s t e r i o r p r o t r u s i o n , e p i d u r a l h e ma t o ma o r a b s c e s s , a n d n e o p l a s ms .

S a c r o i l i a c P a i n : S a c r o i l i a c Ar t h r i t i s : O n a r i s i n g , t h e r e i s p a i n f u l s t i f f n e s s i n t h e u p p e r me d i a l b u t t o c k s , w h i c h i mp r o v e s w i t h e xe r c i s e . P a i n ma y b e r e f e r r e d t o t h e u p p e r o u t e r q u a d r a n t o f t h e b u t t o c k , o r t h e p o s t e r o l a t e r a l a s p e c t o f t h e t h i g h . S o me t i me s t h e r e i s a l i mp . S p i n a l r o t a t i o n accentuates pain. T he joint is tender to palpation or percussion. Sacroiliac arthritis i s c h a r a c t e r i s t i c o f t h e s p o n d y l o a r t h r o p a t h ia g e( s e e. p e s 7 8)2 Sacr oiliac Pain: Sacr oiliac Str ain: P a t h o p h y s i o l o g M:e c h a n i c a l s t r a i n o r p o s t p a r t u m r e l a xa t i o n o f t h e l i g a me n t s a b o u t y t h e j o i n t i s f o l l o w e d b y i n f l a mmahie n a t i e n t c o mp l a i n s o f p a i n i n t h e j o i n t o r i n . Tt op the upper inner quadrant of the buttock or the posterolateral aspect of the thigh ( d e r ma t o me s L 4 , L 5 , S 1 ) . T h e j o i n t i s t e n d e r. T h e p a i n i s a c c e n t u a t e d b y c o mp r e s s i n g t h e a n t e r i o r i l i a c c r e s t s w h i l e t h e p a t i e n t l i e s s u p i n e . T h e t e n d o n r e f l e xe s i n t h e l o w e r l i mb s a r e n o r ma l . S a c r o i l i a c P a i n : Tu b e r c u l o u s Ar t h r i t i s :
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F r e q u e n t l y t h e r e i s p a i n i n t h e l o w e r mi d l i n e o f t h e s p i n e , i n t h e i n g u i n a l r e g i o n , o r s o me t i me s i n t h e s c i a t i c d i s t r i b u t i o n . Al t h o u g h t h e a b s c e s s i s e xt r a a r t i c u l a r, j o i n t p a a n d t e n d e r n e s s a r e i n t e n s e . T h e a b s c e s s ma y b u r s t a n d d r a i n t h r o u g h t h e s k i n o v e r the joint posteriorly or in the inguinal region along the iliopsoas. P. 7 5 3

P a i n i n t h e B u t t o c k : I s c h i o g l u t e a l B u r s i t i s ( We a v e r B o t t o m ) : P a t h o p h y s i o l o g W:h e n s t a n d i n g , t h e g l u t e a l mu s c l e s c o v e r t h e i s c h i a l y t u b e r o s i t i e s ; h o w e v e r, w h e n s i t t i n g , t h e mu s c l e s s l i d e u p w a r d , e xp o s i n g t h e tuberosities to pressure, protected only by intervening skin, subcutaneous tissue, and the ischiogluteal bursa, which is not always present. Prolonged sitting on a har s u r f a c e w i t h t h e t h i g h s f l e xe d ma y c a u s e i r r i t a t i o n o f t h e b u r s a . In f l a mma t i o n o f t h e b u r s a ma y p r o d u c e s e c o n d a r y i r r i t a t i o n o f t h e a d j a c e n t s cCa tri tca in e r v e . ie n o c c u p a t i o n s a r e a s s o c i a t e d w i t h t h i s d i s o r d e r, a s i n d i c a t e d b y t h e a n c i e n t n a me d e r i v e d f r o m C h a u c e r ' s w e a v e rh a n R F. W e a v e r ' s b o t Jo m. A 1 9 7 4 ; 2 2 8 : 5 6 7 Buc [ t AM 5 6 8 . T h e p a i n ma y b e s p o n t a n e o u s o r c a u s e d b y s i t t i n g o n a v i b r a t i n g , p o o r l y ] c u s h i o n e d s e a t , f o r e xa mp l e , a t r a c t o r. T h e o n s e t i s s u d d e n w i t h e xq u i s i t e , u n r e l e n t i n g p a i n i n t h e b u t t o c k t h a t p e r s i s t s t h r o u g h o u t t h e n i g h t d e s p i t e a t t e mp t s t f i n d a c o mf o r t a b l e p o s i t i o n . M i l d a n a l g e s i c s g i v e n o r e l i e f a n d t h e p a i n i s a g g r a v a t e by sitting, although the patient prefers a hard seat to a soft one. Coughing induces pain down the posterior aspect of the thigh to the knee. Often the patient needs assistance with dressing and undressing. T he patient stands and walks with a list toward the affected side and the stride is shortened on the affected side with c i r c u md u c t i o n o f t h e f o o t . S t a n d i n g o n t i p t o e i s p a i n f u l l y i mp o s s i b l e . T h e p a t i e n t s i t o n t h e e xa m t a b l e w i t h h i s a f f e c t e d b u t t o c k c a r e f u l l y e l e v a t e d a n d t o l i e d o w n h e supports his pelvis with the hand on the unaffected side, suggesting sciatic nerve irritation. Point tenderness in the region of the ischial tuberosity is a cardinal sign. W h e n s u p i n e , t h e s t r a i g h t - l e g - r a i s i n g t e s t c a uLas gue s i gn T h ePat r i c k ses pain ( ). Faber e s i gn p r e s e n t a n d c a u s e s s e v e r e p a i n ( t h e h e e l o f t h e a f f e c t e d s i d e i s is placed on the opposite patella and the knee is pushed downward to rotate the hip e xt e r n a l l y ) . O n r e c t a l e xa mi n a t i o n a r e g i o n o f t e n d e r, b u l g i n g , d o u g h y t i s s u e ma y b e p a l p a t e d i n t h e l a t e r a l r e c t a lD w a l lP a t i e n t s w i t h h e r n i a t e d d i s k a n d l u mb o s a c r a l D X: . d i s e a s e l i e q u i e t l y a n d l a c k t h e P a t r i c k F a b e r e s i g n . T h e b u r s a ma y a l s o b e a f f e c t e by gout.
P. 7 5 4

P a i n l e s s L i m p i n g : Hi p D i s l o c a t i o n : P a t h o p h y s i o l o g D:i s l o c a t i o n o f t h e h i p ma y b e c o n g e n i t a l o r a c q u i r e d . Ac q u i r e d y w e a k n e s s o f t h e s u p p o r t i n g mu s c l e s ( f r o m n e r v e o r mu s c l e i n j u r y ) , h i p j o i n t i n f e c t i o n s , a n d t r a u ma p r o d u c e h i p d i s l o c a t i o n Sn ra d u l it n g b y p h y s i c a l e xa m . i c een s for congenital hip dislocation should begin at birth. A child who has not begun to w a l k b y 1 8 mo n t h s s h o u l d b e s u s p e c t e d o f h a v i n g c o n g e n i t a l h i p d i s l o c a t i o n . T h e b u t t o c k s a n d p e r i n e u m ma y b e u n u s u a l l y b r o a d a n d a d d u c t o r f o l d s ma y b e p r e s e n t o n t h e me d i a l a s p e c t s o f t h e t h i g h s . E xa mi n a t i o n s h o w s i n a b i l i t y t o a b d u c t t h e t h i g h t o 9 0 d e g r e e s i n f l e xi o n . P a t h o g n o mo n i c f o r s u b l u xa t i ool anit h er k s i gn Or t n i s j e , which is elicited with the baby supine on the table. Stand at its head and grasp the thighs in your hands. Fix the opposite side of the pelvis to the table by encircling th t h i g h w i t h y o u r h a n d s o t h a t t h e t h u mb p r e s s e s a l o n g t h e s u b c u t a n e o u s a s p e c t o f
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the tibia. On the side to be tested, grasp the thigh with your hand so that your thum i s o n t h e me d i a l a s p e c t , j u s t b e l o w t h e i n g u i n a l f o l d , a n d y o u r f i n g e r s a r e o v e r t h e t r o c h a n t e r i c r e g i o n . W h i l e s l o w l y a b d u c t i n g t h e t h i g h , p u s h d o w n w a r d o n t h e f l e xe d knee with your palm and pull upward with your fingers near the trochanter until you f e e l a c l i c k a s t h e f e mo r a l h e a d e n g a g e s t h e a c e t a b u l u m. C o n g e n i t a l h i p d i s l o c a t i o n i s s o me t i me s n o t n o t i c e d u n t i l a l i mp o r o t h e r a b n o r ma l g a i t i s n o t i c e d w h e n t h e c h i s t a r t s w a l k i n g . In c h i l d h o o d a n d a d o l e s c e n c e , s i g n s i n c l u d e a f e ma l e c o n t o u r t o t h e p e l v i s ( b o t h s e xe s h a v e a ma l e c o n t o u r a t t h i s a g e ) , a n d p r o mi n e n c e o f t h e b u t t o c k s a n d a b d o me n . A g l u t e a l o r T r e n d e l e n b u r g g a i t i n w h i c h t h e h i p l u r c h e s u p w a r d a n d the shoulder dips downward on the weight-bearing side is present. With the patient supine, observe the thigh length from the foot of the table with the knees and thigh f l e xe d . T h e k n e e o f t h e a f f e c t e d l e g w i l l b e l o w e r t h a n t h e o t h e r i n u n i l a t e r a l d i s e a s H a v e t h e p a t i e n t u n d r e s s e d a n d s t a n d i n g w h i l e y o u i n s p e c t t h e b u t t o c k s . As k t h e p a t i e n t t o s t a n d o n o n e l e g ; n o r ma l l y, t h e f r e e b u t t o c k i s r a i s e d w h e n t h e p e l v i s t i l t s (F i g . 1 3 - 4 2 A In t h e endel enbur g s i gn e f r e e b u t t o c k f a l l s b e c a u s e t h e mu s c l e s ). Tr , th a r e n o t s t r o n g e n o u g h t o s u s t a i n t h e p o s i t i o n w h e n t h e f e mu r i s n o t e n g a g e d i n t h e a c e t a b u l u m. T h e s i g n i s a l s o p o s i t i v e w i t h d i s e a s e o f t h e g l u t e i , f r a c t u r e o f t h e f e mo r a l h e a d , a n d i n s e v e r e d e g r e e s o f c o xa v a r a . In a d u l t s , i n a d d i t i o n t o t h e c h i l d h o o d s i g n s , t h e r e a r e h i p p a i n a n d p r e ma t u r e o s t e o a r t h r i t i s o f t h e a f f e c t e d j o i n

F i g . 1 3 - 4 2 L e s i o n s o f t h e H i p a n d G r o i n . A . T r e n d e l e n b u r g Sti he : When g n pat i ent s t ands on one f oot , t he but t oc k. fS ulb i.n g u i n a l P a i n l e s s B al s Swelling: Swel l i ng bel ow t he i ngui nal l i gament may be ei t her a ps oas abs c es s or an ef f us i on i n t he ps oas bur s a .

P a i n l e s s L i m p i n g : O s t e o n e c r o s i s , As e p t i c Hi p Ne c r o s i s : P a t h o p h y s i o l o g Is:c h e mi a o f t h e f e mo r a l h e a d l e a d s t o n e c r o s i s o f b o n e a n d t o y t h e c o l l a p s e a n d mu s h r o o mi n g o f t h e f e mo r a l h e a d . It ma y b e u n i l a t e r a l o r b i l a t e r a l . Al t h o u g h t h e c a u s e ma y b e u n k n o w n , u s e o f c o r t i c o s t e r o i d s , d i a b e t e s , o b e s i t y, a n d a l c o h o l a r e e a c h a s s o c i a t e d w i t h a n i n c r e .a s e d a il sy i t b e g i n s w i t h a p a i n l e s s Usu r l k l i mp a n d a l l mo t i o n s o f t h e h i p a r e s l i g h t l y i mp a i r e d . L a t e r, t h e r e i s s e v e r e l i mi t a t i o o f a b d u c t i o n a n d r o t a t i o n . M u s c l e a t r o p h y a n d s h o r t e n i n g o f t h e l i mb a r e c o mmo n .


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T he waddling gait suggests dislocation of the hip. Osteonecrosis of the epiphysis in childhood (Legg-Calv-Perthes disease) is relatively painless, whereas o s t e o n e c r o s i s i n a d u l t s ma y b e p a i n f u l . P. 7 5 5

P a i n i n t h e Hi p : S e p t i c Ar t h r i t i s o f t h e Hi p : U s u a l l y, t h e r e i s g r o i n p a i n , f e v e r, l e u k o c y t o s i s , a n d p r o s t r a t i o n . Al l mo t i o n o f t h e h i s p a i n f u l . R a r e l y, f l u c t u a t i o n c a n b e f e l t i n t h e j o i n t . B e c a u s e p a i n ma y b e r e f e r r e d o n l y t o t h e k n e e , k n e e p a i n s h o u l d a l w a y s p r o mp t e xa mi n a t i o n o f t h e h i p . E a r l y d i a g n o s i s i s u r g e n t b e c a u s e t h e j o i n t c a r t i l a g e ma y b e i r r e p a r a b l y d a ma g e d i n a f e w hours without proper drainage and antibiotics. P a i n i n t h e Hi p : Tu b e r c u l o u s Ar t h r i t i s : T h e o n s e t i s i n s i d i o u s , w i t h t h e a p p e a r a n c e o f a l i mp . P a i n i n t h e h i p o r t h i g h ma y o c c u r o n l y a f t e r e xe r t i o n , s u b s i d i n g w i t h r e s t . T h e r e i s e a r l y f l e xi o n o f t h e h i p ma s k e d b y l u mb a r l o r d o s i s , a s d e t e c t e d b y H u g h O w e n T h o ma s s i g n ( p a g e 7 0 3 ) . T h e t h i g h ma y b e h e l d i n s l i g h t a b d u c t i o n a n d l a t e r a l r o t a t i o n t o b e s t a c c o mmo d a t e t h e j o i n t e f f u s i o n . W h e n t h e f l u i d i s a b s o r b e d , t h e p o s t u r e c h a n g e s t o f l e xi o n , a d d u c t i o n , a n d i n w a r d r o t a t i o n . F i n a l l y, e r o s i o n o f t h e j o i n t c a u s e s s h o r t e n i n g o f t h l i mb . P a i n i n t h e Hi p : S l i p p e d C a p i t a l F e m o r a l E p i p h y s i s : P a t h o p h y s i o l o g T : e f e mo r a l h e a d d i s l o c a t e s o n t h e f e mo r a l n e c k a t t h e g r o w t h yh p l a t e d u r i n g r a p i d g r o w t h w h e n t h i s a r e a i s s t r u c t u rA l li y w e ai kh h i p p a i n . a mp w t develops during adolescence, usually in boys who are either obese or unusually tal a n d t h i n . T h e d i s t i n g u i s h i n g f e a t u r e i s p a i n f u l l i mi t a t i o n o f i n t e r n a l r o t a t i o n w h e n t h i g h a n d k n e e a r e b o t h f l e xe d . T h i s ma y b e s u c c e e d e d b y s h o r t e n i n g a n d o u t w a r d r o t a t i o n f r o m a n t e r o s u p e r i o r d i s p l a c e me n t o f t h e f e mo r a l n e c k .

P a i n i n t h e Hi p : O s t e o a r t h r i t i s : P a t h o p h y s i o l o g O:s t e o a r t h r i t i s i s a d i s e a s e o f c a r t i l a g e l e a d i n g t o d e s i c c a t i o n , y f i b r i l l a t i o n o f t h e s u r f a c e , t h i n n i n g o f t h e j o i n t s p a c e , a n d , u l t i ma t e l y, c o mp l e t e l o s s o f t h e c a r t i l a g e w i t h b o n e - o n - b o n e a r t .i cO lca tao no n a l l y p a i n l e s s , t h e c h i e f u c i si s y mp t o m i s u s u a l l y b o r i n g p a i n i n t h e j o i n t , f r e q u e n t l y f e l t i n t h e g r o i n a n d b u t t o c k s s o me t i me s w i t h r e f e r r a l t o t h e k n e e . In i t i a l l y, t h e r e ma y b e < 3 0 mi n u t e s o f s t i f f n e s s a f t e r r e s t , w h i c h d i s a p p e a r s w i t h e xe r c i s e . T h e p a t i e n t ma y b e u n a w a r e o f a l i mp , b u t l a t e r, w a l k i n g i s l i mi t e d b y p a i n . Ab d u c t i o n a n d i n t e r n a l r o t a t i o n a r e r e s t r i c t e d b p a i n . In u n i l a t e r a l d i s e a s e , t h e t h i g h i s h e l d i n a d d u c t i o n , w i t h e v e r s i o n o f t h e f o o t a n d t h e p e l v i s i s t i l t e d u p w a r d o n t h e a f f e c t e d s i d e . P a s s i v e mo t i o n i s mo s t c o mmo n l y r e s t r i c t e d i n i n t e r n a l r o t a t i o n a n d ma y b e r e s t r i c t e d i n a l l d i r e c t i o n s . Capsular swelling from thickening and effusion is rarely palpable. Motion of the join ma y c a u s e p a l p a b l e a n d a u d i b l e c r e p i t u s .
P. 7 5 6

M a s s i n t h e F e m o r a l T r i a n g l e : P s o a s Ab s c e s s : P a i n l e s s a b s c e s s i s u s u a l l y a n e xt e n s i o n o f s p i n a l t u b e r c u l o s i s . P a i n f u l a b s c e s s s u g g e s t s p u r u l e n t i n f e c t i o n f r o m a n i n t r a a b d o mi n a l s o u r c e . T h e ma s s a p p e a r s b e n e a t h t h e i n g u i n a l l i g a me n t i n a c o n i c a l fF irg . 1s e e 2 BD D X: P a l p a t i o n o m ( 3-4 ). d i s c l o s e s a s i mi l a r s w e l l i n g i n t h e i l i a c f o s s a d i s t i n g u i s h i n g i t f r o m e f f u s i o n i n t h e
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p s o a s b u r s a . Ab s c e s s mu s t b e d i s t i n g u i s h e d f r o m f l u c t u a n t l y mp h a d e n o p a t h y.

M ass in the Femor al Tr iangle: Psoas Bur sitis: A painless effusion in the psoas bursa, occasionally associated with osteoarthritis o t h e h i p , p r o d u c e s t e n s e , n o n f l u c t u a n t , i mmo b i l e c o n i c a l s w e l l i n g b e n e a t h t h e i n g u i n l i g a me n t ( s e ei g . 1 3 - 4 2 B T h e a b s e n c e o f a ma s s i n t h e i l i a c f o s s a e xc l u d e s p s o a s F ). abscess. M a s s i n t h e F e m o r a l T r i a n g l e : Ly m p h a d e n o p a t h y : S e e F i g . 9 - 3,7p a g e 6 0 5 . M a s s i n t h e F e m o r a l T r i a n g l e : F e m o r a l He r n i a : S e e p a g e s 4 a n d6 0 4. 11

P o s t - t r a u m a t i c Hi p P a i n : T r a u m a t i c D i s l o c a t i o n o f t h e Hi p : P a t h o p h y s i o l o gA :b l o w o n t h e k n e e w h i l e a p e r s o n i s s i t t i n g d r i v e s t h e f e mo r a l y head posteriorly out of its socket, frequently fracturing the rim of the acetabulum (F i g . 1 3 - 4 3 A T h e r a r e a n t e r i o r t r a u ma t i c d i s l o c a t i o n o c c u r s f r o m l a n d i n g o n t h e f e e t ). i n a f a l lP o s t e r i o r D i s l o c a t i o ng u i n a l a n d t h i g h p a i n i s s e v e r e a n d c o n s t a n t . T h e . In : t h i g h l i e s i n e xt r e me i n t e r n a l r o t a t i o n , a d d u c t i o n , a n d s lF gg .t 1 l3e xi3, C ( i i h f -4 on r i ght p a n e l ) a n d o n l y t h e f o o t c a n b e a c t i v e l y mo v e d w i t h o u t p a i n . T h e g r e a t e r t r o c h a n t e r i s a b n o r ma l l y p r o mi n e n t , w h i l e p a l p a t i o n f o r t h e f e mo r a l h e a d b e n e a t h t h i n g u i n a l l i g a me n t y i e l d s a n i n d e n t a t i o n . T h e l i mb i s s h o r t e n e d a n d p a s s i v e r o t a t i o n t h e f e mu r i s a b s eA n.t e r i o r D i s l o c a t i o n :e j o i n t i s f i xe d i n a b d u c t i o n , o u t w a r d nt Th r o t a t i o n , a n d s l i g h t f l e xiio n 1 3 - 4 3, Cef t p a n e l ) . T h e r e i s n o s h o r t e n i n g o f t h e F g. ( l l i mb , b e c a u s e t h e h e a d i s i mp a l e d a n t e r i o r l y i n t h e i l i o f e mo r a l l i g a me n t .
P. 7 5 7

P o s t - t r a u m a t i c Hi p P a i n : F r a c t u r e o f t h e F e m o r a l Ne c k : T h e f e mo r a l n e c k ma y b e f r a c t u r e d b e l o w t h e c a p s u l e , a l o w f r a c t u r e , o r w i t h i n t h e c a p s u l e , a h i g h f r a c t u r e F sg .e1 3 - 4 3 A In t h e t r ac aps ul ar f r ac t, urh e f e mu r i s (i e ). ex te s h o r t e n e d a n d e xt e r n a l l y r o t a t e d i n t h e s u p i n e p o s iitg o n 3 s4 3, Cef t p a n e l ) . F i . 1 (- ee l W i t h a n nt r ac aps ul ar f r ac t ur e t e n s e j o i n t c a p s u l e r e s t r a i n s r o t a t i o n a n d s w e l l i n g i th o f t h e u p p e r t h i g h i s c o n s i d e r a b l e . If t h e p a t i e n t c a n l i f t t h e f o o t o f f t h e b e d , t h e f r a c t u r e i s i mp a c t e di .mpac t ed f r ac t ur es e p a t i e n t c a n s o me t i me s w a l k w i t h l i t t l e In , th p a i n , s o a f r a c t u r e ma y n o t b e s u s p e c t e d . H o w e v e r, p a s s i v e r o t a t i o n o f t h e t h i g h w i u s u a l l y y i e l d s o me p a i n .

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F i g . 1 3 - 4 3 F e m o r a l D i s l o c a t i o n s a n d F r.a c t u r e s

P o s t - t r a u m a t i c Hi p P a i n : Av u l s i o n F r a c t u r e o f t h e L e s s e r T r o c h a n t e r : T h i s u s u a l l y o c c u r s i n mu s c u l a r p o s t p u b e r t a l me n . T h e s i t t i n g p a t i e n t c a n n o t f l e x t h t h i g h Ludl of f s i gn ( ). Post-tr aumatic T high Pain: Fr actur e of the Femor al Shaft: T h i s ma y l e a d t o s h o c k b e c a u s e o f b l o o d l o s s , s o c a r e f u l o b s e r v a t i o n i s r e q u i r e d . T h e t h i g h i s r o t a t e d e xt e r n a l l y, o f t e n w i t h o b v i o u s d e f o r mi t y a n d s h o r t e n i n g a s a c o n s e q u e n c e o f mu s c l e s p a s m a n d o v e r l a p o f t h e p r o xi ma l a n d d i s t a l f e mu r.

Knee Signs

P a i n l e s s Un i l a t e r a l K n e e D e f o r m i t y : Ne u r o g e n i c Ar t h r o p a t h y ( C h a r c o t Joint): S e e F i g . 1 3 - 4 4 C n dChar c ot J oi ntn p a g e 7 7 9 . a o K n e e D e f o r m i t y : G e n u Va r u m ( B o w l e g ) : T h e l e g s d e v i a t e t o w a r d t h e mi d l i n e s o t h a t t h e k n e e s a r e f a r t h e r a p a r t t h a n n o r ma l w h e n t h e me d i a l ma l l e o l i a r e a p p r o xi ma tF id .( s e e 9)C T h e d e f o r mi t y i s e g 13- . me a s u r e d b e t w e e n t h e k n e e s w h e n t h e p a t i e n t i s s u p i n e w i t h t h e me d i a l ma l l e o l i t o g e t h e r. T h e f e e t a r e t u r n e d i n w a r d w h e n w a l k i n g . T h e mo s t c o mmo n c a u s e i s o s t e o a r t h r i t i c n a r r o w i n g o f t h e me d i a l k n e e c o mp a r t me n t . O t h e r c a u s e s a r e r i c k e t s a f f e c t i n g t h e u p p e r t i b i a l a n d l o w e r f e mo r a l e p i p h y s e s , P a g e t d i s e a s e , o r occupational stress. K n e e D e f o r m i t y : G e n u Va l g u m ( K n o c k - K n e e ) : T h e l e g s d e v i a t e a w a y f r o m t h e mi d l i n e , o f t e n b i l a t F irg .l l 1 3(-s e.e e a y 9)C C o n g e n i t a l e n l a r g e me n t o f t h e me d i a l f e mo r a l c o n d y l e s p r o d u c e s g e n u v a l g u m i n c h i l d r e n . T h e mo s t c o mmo n c a u s e i s o s t e o a r t h r i t i c n a r r o w i n g o f t h e l a t e r a l k n e e c o mp a r t me n t . T h e d e v i a t i o n i s me a s u r e d b e t w e e n t h e me d i a l ma l l e o l i w i t h t h e p a t i e n s t a n d i n g a n d t h e k n e e s t o g e t h e r.
P. 7 5 8

K n e e S w e l l i n g : F l u i d Wi t h i n t h e J o i n t : P a t h o p h y s i o l o gAn e xc e s s o f s y n o v i a l f l u i d i n t h e k n e e j o i nftuss onn l o o d y: ef i i a B . in the joint space is hemar t hr os.i s h e p r e s e n c e o f p u s i n d i c a t e s s u p p u r a t i v e T a r t h r i t i. s F l u i d s i g n s a r e i n d e p e n d e n t o f f l u i d t y p e , s o s p e c i f i c d i a g n o s i s c a n o n l y b e ma d e b y a s p i r a t i o n . E f f u s i o n i s c o mmo n l y c a u s e d b y t r a u ma , r h e u ma t o i d a r t h r i t i s , osteoarthritis, gout, other crystalline arthritides (calcium pyrophosphate, basic c a l c i u m p h o s p h a t e ) o r i n t e r mi t t e n t h y d r a r t h r o s i s . T r a u ma t i c h e ma r t h r o s i s s u g g e s t s i n t r a c a p s u l a r f r a c t u r e o r l i g a me n t d i s r u p t i o n . N o n t r a u ma t i c h e ma r t h r o s i s o c c u r s w i t h h e mo p h i l i a a n d n e o p l a s ms .

An t e r i o r K n e e S w e l l i n g : P r e p a t e l l a r B u r s i t i s : A fluctuant subcutaneous swelling occurs anterior to the lower patella and patellar l i g a me n t , t h e d i s t r i b u t i o n o f t h e p r e p a t e l l a ri gb u1 3 a4 ( )D It i s o f t e n f o u n d F . rs- 4 . a s s o c i a t e d w i t h o c c u p a t i o n a l t r a u ma t o t h e t i s s u e o v e r l y i n g t h e p a t e l l a . T h i s d i f f e r s f r o m f l u i d i n t h e j o i n t c a v i t y t h a t p r o d u c e s s w e l l i n g o n t h e me d i a l s i d e o f t h e p a t e l l a
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P. 7 5 9

An t e r i o r K n e e S w e l l i n g : I n f r a p a t e l l a r B u r s i t i s : S w e l l i n g o c c u r s i n a b u r s a o n b o t h s i d e s o f t h e p a t e l l a r l i g a me n t n e a r t h e t i b i a l t u b e r o s i t y ( s e eg . 1 3 - 4 4 E F l u c t u a t i o n c a n b e d e mo n s t r a t e d f r o m o n e s i d e o f t h e Fi ). l i g a me n t t o t h e o t h e r. T h i s o f t e n r e s u l t s f r o m o c c u p a t i o n s r e q u i r i n g k n e e l i n g , s u c h a roofing and floor laying.

Fig. 13-44 Swellings of the Knee and their Diagnosis. A. Knee Effusion.B. Signs of Knee Effusions. C. Charcot Knee. D. Prepatella Bursitis. E. I n f r a p a t e l l a r B u r s. i t i s

An t e r i o r K n e e S w e l l i n g : I n f r a p a t e l l a r F a t P a d : T h e i n f r a p a t e l l a r f a t p a d b e c o me s i n f l a me d , c a u s i n g t e n d e r n e s s a n d s w e l l i n g o n b o t s i d e s o f t h e p a t e l l a r l i g a me n t . T h e t e n d e r n e s s a n d l a c k o f f l u c t u a n c e d i s t i n g u i s h i t from bursitis and synovitis. Popliteal Swelling: Semimembr anosus Bur sitis: F l u i d a c c u mu l a t e s i n t h e b u r s a b e t w e e n t h e h e a d o f t h e g a s t r o c n e mi u s a n d t h e t e n d o n o f t h e s e mi me mb r a n o s u s , f o r mi n g t h e u p p e r me d i a l b o r d e r o f t h e d i a mo n d s h a p e d p o p l i t e a l f o sF ia .( 1 3 - 4 5 E xt e n s i o n o f t h e k n e e c a u s e s p a i n f u l t e n s i n g o f sg ). t h e b u r s a , w h i l e f l e xi o n r e l a xe s i t . F l u c t u a t i o n i s d i f f i c u l t t o d e mo n s t r a t e .
P. 7 6 0

Popliteal Swelling: Baker Cyst: T he cyst is a pressure diverticulum of the synovial sac protruding through the p o s t e r i o r j o i n t c a p s u l e o f t h e k n e e . S o me t i me s d u l l p a i n i s p r e s e n t . T h e c y s t i s b e s s e e n b y i n s p e c t i o n o f t h e f o s s a w h e n t h e p a t i e n t i s s t a n d i n g . In c o n t r a s t t o t h e s e mi me mb r a n o s u s b u r s i t i s , t h e s w e l l i n g i s i n t h e mi d l i n e a t o r b e l o w t h e t i b i o f e mo r a j u n c t i o n ( s e ei g . 1 3 - 4 5 T h e c y s t p r o t r u d e s w h e n t h e k n e e i s e xt e n d e d a n d , u n l e s s F ).
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i t i s v e r y l a r g e , i s n o t v i s i b l e w i t h f l e xi o n . W h e n t h e c y s t f r e e l y c o mmu n i c a t e s w i t h t h e j o i n t , g r a d u a l , s t e a d y p r e s s u r e o n t h e s a c f o r c e s s o me f l u i d b a c k i n t o t h e j o i n t c a v i t y, t e mp o r a r i l y r e d u c i n g t h e s w e l l i n g . T h e s w e l l i n g ma y b e t r a n s l u c e n t . B a k e r c y s t s o f t e n c o mp l i c a t e r h e u ma t o i d a r t h r i t i s a n d o s t e o a r t h r i t i s . L a r g e c y s t s c a n c o mp r e s s t h e p o p l i t e a l v e s s e l s . If t h e a r t e r y i s c o mp r e s s e d , f o r c e d e xt e n s i o n o f t h e k n e e o r s t r o n g d o r s i f l e xi o n o f t h e f o o t ma y o b l i t e r a t e t h e p e d a l p u l s e .

F i g . 1 3 - 4 5 T h e P o p l i t e a l F. o s s a

P o p l i t e a l S w e l l i n g : P o p l i t e a l Ab s c e s s : T h e r e i s t e n d e r i n d u r a t i o n i n t h e p o p l i t e a l f o s s a . S w e l l i n g ma y b e mi n i ma l a n d f l u c t u a t i o n i s a l a t e o c c u r r e n c e . T h e k n e e i s h e l d i n p a r t i a l f l e xi o n t o r e d u c e t h e p a c a u s e d b y e xt e n s i o n . E xa mi n e t h e f o o t f o r t h e p o t e n t i a l s o u r c e s o f i n f e c t i o n .

P o p l i t e a l C y s t : P o p l i t e a l An e u r y s m : T his feels like a cyst and only a conscious effort to detect pulsation will identify it. M e d i a l K n e e S w e l l i n g : An s e r i n e B u r s i t i s : T h e a n s e r i n e b u r s a l i e s s u p e r f i c i a l t o t h e t i b i a l c o l l a t e r a l l i g a me n t a n d d e e p t o t h e p e s a n s e r i n a ( g o o s e f o o t ) f o r me d b y t h e t e n d o n s o f t h e s a r t o r i u s , g r a c i l i s , a n d s e mi t e n d i n o s u s ( sF i e . 1 3 - 4 5 T h e p a t i e n t c o mp l a i n s o f p a i n i n t h e a n t e r i o r eg ). me d i a l a s p e c t o f t h e k n e e 2 3 c m d i s t a l t o t h e j o i n t l i n e . P a i n i s a g g r a v a t e d b y w a l k i n g , e s p e c i a l l y u p s t a i r s . Te n d e r n e s s , u s u a l l y w i t h o u t s w e l l i n g , i s p a l p a t e d o n t h e me d i a l a s p e c t o f t h e k n e e . M edial Knee Swelling: Cyst of the M edial M eniscus: T h e c y s t i s a d e v e l o p me n t a l a n o ma l y o f t h e me d i a l me n i s c u s , w h i c h p r o t r u d e s me d i a l l y. D u l l p a i n ma y b e p r e s e n t o n s t a n d i n g . It i s f e l t a s a f l u c t u a n t j o i n t l i n e , swelling slightly above the anserine bursa. T he oval, transversely elongated cyst ma y p r o t r u d e e i t h e r a n t e r i o r o r p o s t e r i o r t o t h e t i b i a l c o l l a t e r a l l i g a me n t . F l e xi o n o f t h e k n e e ma k e s i t mo r e p r o mi n e n t . Later al Knee Swelling: Cyst of the Later al M eniscus:
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T h i s c o n g e n i t a l c y s t o c c u r s a t t h e t i b i o f e mo r a l j u n c t i o n , p o s t e r i o r t o t h e f i b u l a r c o l l a t e r a l l i g a me n t . F l e xi o n a c c e n t u a t e s t h e t r a n s v e r s e f l u c t u a n t s w e l l i n g . It ma y b e p a i n f u l a n d , o c c a s i o n a l l y, p r o t r u d e s i n t o t h e p o p l i t e a l f o s s a .

P o s t - t r a u m a t i c P a i n P r o x i m a l t o t h e P a t e l l a : Ru p t u r e o f t h e Re c t u s Femor is M uscle: T h e mu s c l e f i b e r s o f t h e r e c t u s f e mo r i s a t t a c h t o t h e t e n d o n w e l l a b o v e t h e p a t e l l a . T r a u ma t i c mu s c u l a r t e a r s o f t e n o c c u r a t t h i s mu s c u l o t e n d i n o u s j u n c t i o n . T h e i n j u r y p a i n f u l a n d t h e k n e e i s h e l d i n s e mi f l e xi o n . Ab n o r ma l s h o r t e n i n g o f t h e t o r n f i b e r s f o r ms a l u mp t h a t e n l a r g e s w h e n t h e p a t i e n t t e n s e s t h e t h i g h mu s c l e s . A h o l l o w i s f e l t d i s t a l t o t h e l u mp ; t h e n o r ma l mu s c l e ma s s i s n o t f e l t i n t h e s u p r a p a t e l l a r r e g i o
P. 7 6 1

Post-tr aumatic Patellar Pain: Patellar Fr actur e: T h i s r e s u l t s f r o m a d i r e c t b l o w t o t h e p a t e l l a , u s u a l l y f r o m f a l l i n g o n t o t h e f l e xe d k n e e . S t e l l a t e f r a c t u r e s a r e o f t e n n o t d i s p l a c e d a n d a r e e a s i l y mi s s e d w i t h o u t p r o p e r a d i o l o g i c e xa mi n a t i o n . W i t h n o n d i s p l a c e d f r a c t u r e s , a c t i v e e xt e n s i o n i s p r e s e r v e d b u t p a i n f u l . T r a n s v e r s e f r a c t u r e s a r e mo s t l i k e l y t o b e d i s p l a c e d . If t h e r e i s s e p a r a t i o n o f t h e b o n e f r a g me n t s , t h e j o i n t i s s e mi f l e xe d a n d a c t i v e e xt e n s i o n i s i mp o s s i b l e i(g . 1 3 - 4 6 A To i d e n t i f y a s e p a r a t i o n , p a l p a t e d o w n t h e s u r f a c e o f t h e F ). p a t e l l a f e e l i n g f o r a c r e v i c e . H e ma r t h r o s i s a l w a y s o c c u r s w i t h d i s p l a c e d f r a c t u r e s .

F i g . 1 3 - 4 6 S o m e T r a u m a t i c I n j u r i e s t o t h e A n t e .r i o r K n e e

P o s t - t r a u m a t i c P a t e l l a r P a i n : Ru p t u r e o f t h e P a t e l l a r L i g a m e n t : T h e p a t h o g n o mo n i c s i g n i s a n u p w a r d s h i f t o f t h e p a t e l l a . Af t e r t h e s w e l l i n g s u b s i d e s , t h e r u p t u r e d l i g a me n t ma y b e p a l p a tie d 1s e e 6 A Te n d e r n e s s a t F g. ( 3-4 ). t h e t i b i a l t u b e r o s i t y s u g g e s t s c o n c o mi t a n t a v u l s i o n o f t h e t u b e r o s i t y.

An t e r i o r K n e e P a i n : C h o n d r o m a l a c i a P a t e l l a e : D e g e n e r a t i o n o f t h e a r t i c u l a r s u r f a c e o f t h e p a t e l l a o c c u r s f r o m u n k n o w n c a u s e . It i mo r e c o mmo n i n w o me n t h a n me n . P a i n i s f e l t a n t e r i o r l y a n d i s a g g r a v a t e d b y p r o l o n g e d s i t t i n g a n d w a l k i n g d o w n s t a i r s . A s ma l l e f f u s i o n ma y b e p r e s e n t . P a s s i v e j o i n t mo t i o n i s p a i n l e s s . R o c k i n g t h e p a t e l l a i n t h e f e mo r a l g r o o v e f r e q u e n t l y e l i c i t s pain, often with palpable crepitation. Sudden Collapse with Locking Knee: Patellar Dislocation:
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T h i s i s f r e q u e n t l y a r e c u r r e n t p r o b l e m a n d t h e d i a g n o s i s ma y b e ma d e f r o m t h e h i s t o r y. T h e p a t i e n t c o mp l a i n s t h a t t h e k n e e a b r u p t l y g i v e s w a y w i t h p a i n a n d s u b s e q u e n t s w e l l i n g . Ac u t e l y, t h e p a t e l l a i s d i s p l a c e d l a t ie r.a 1l 3 - ( s )e. e F g l y 46B B e t w e e n e p i s o d e s , t h e r e i s i n c r e a s e d l a t e r a l mo b i l i t y o f t h e p a t e l l a a n d q u a d r i c e p s a t r o p h y ma y b e s e e n . P. 7 6 2

K n e e P a i n a n d Re c u r r e n t L o c k i n g : L o o s e B o d y i n t h e J o i n t : A h i s t o r y o f i n t e r mi t t e n t j o i n t p a i n w i t h r e c u r r e n t e f f u s i o n s o r l o c k i n g s u g g e s t s a l o o s e b o d y i n t h e j o i n t . C r e p i t u s ma y b e p r e s e n t ; r a r e l y, t h e e xa mi n e r ma y b e a b l e t p a l p a t e a ma s s . L o o s e b o d i e s a r e u s u a l l y a c h i p o f b o n e r e s u l t i n g f r o m p r e v i o u s i n j u r y.
P. 7 6 3 P. 7 6 4

Post-tr aumatic Knee Pain: T he evaluation of patients with knee injuries starts with a detailed history of the me c h a n i s m o f i n j u r y a n d t h e t r u e c a u s e o f p a i n , s w e l l i n g a n d d i s a b i l i t y. A c o mp l e t e k n e e e xa m s h o u l d b e a t t e mp t e d , b u t ma y b e l i mi t e d b y a g en 7 0 6 n d t h e p p a i . Sa e e f o l l o w i n g r e f e r e n c e f o r f u r t h e r d i s c u st seoln IG , G r e e n b e r g G H , W e l l s G A, e t a l . S iil . [ Prospective validation of a decision rule for the use of radiography in acute knee i n j u r i e sJ AM A 1 9 9 6 ; 2 7 5 : 6 11 6 1 5 . ]

Post-tr aumatic Knee Pain: Femor al Supr acondylar Fr actur e: A d i r e c t b l o w a b o v e t h e p a t e l l a ma y p r o d u c e a f r a c t u r e 2 . 5 5 c m a b o v e t h e f e mo r a l c o n d y l e s ( s e ei g . 1 3 - 4 6)C Ac t i v e mo t i o n o f t h e k n e e i s i mp o s s i b l e . E xt r e me F . t e n d e r n e s s w i t h s w e l l i n g i s i d e n t i f i e d j u s t a b o v e t h e p a t e l l a . D i s p l a c e me n t i s u s u a l l a b s e n t . If d i s p l a c e me n t o c c u r s , t h e d i s t a l f r a g me n t i s p u l l e d b a c k w a r d b y t h e g a s t r o c n e mi u s . Al w a y s e xa mi n e t h e d i s t a l p u l s e s a n d s e n s a t i o n f o r e v i d e n c e o f n e u r o v a s c u l a r d a ma g e . Post-tr aumatic Knee Pain: Femor al Condylar Fr actur e: T h e t w o c o n d y l e s ma y b e s e p a r a t e d b y a T f r a c t u r e , w i t h w i d e n i n g o f t h e k n e e . Al t e r n a t i v e l y, o n l y o n e c o n d y l e ma y b e f r a c t u ri e d 1 s e4 6)Cw i t h u p w a r d F g. ( 3- e d i s p l a c e me n t o f t h e a f f e c t e d c o n d y Poss - teaumat i c Knee Pai n: Femor al le ( t e r Supr ac ondy l ar Fr ac t a be v e ) . ur o

Post-tr aumatic Knee Pain: T ibial Infr acondylar Fr actur e: A f a l l w i t h t h e k n e e e xt e n d e d a n d b e n t me d i a l l y ma y c a u s e f r a c t u r e o f o n e o r b o t h t i b i a l c o n d y l e s . P a i n , s w e l l i n g , a n d h e ma r t h r o s i s o c c u r. A v a l g u s d e f o r mi t y ma y r e s u l t . O c c a s i o n a l l y, a c o n c o mi t a n t f r a c t u r e o f t h e f i b u l a r h e a d i s f o u n d . P o s t - t r a u m a t i c M e d i a l K n e e P a i n : Ru p t u r e o f t h e M e d i a l M e n i s c u s : T h e me n i s c u s i s u s u a l l y i n j u r e d w h e n t h e f e mu r i s t w i s t e d me d i a l l y w h i l e t h e k n e e i f l e xe d a n d t h e f o o t a n d t i b i a a r e f i xe d b y b e a r i n g w e i g h t . T h e c a r t i l a g e ma y b e s p l i t l o n g i t u d i n a l l y, o r e i t h e r t h e a n t e r i o r o r p o s t e r i o r h o r n ma y b e t o r n . M o s t c o mmo n l y, t h e r e i s a b u c k e t - h a n d l e t e a r i n w h i c h t h e h o r n s r e ma i n a t t a c h e d w h i l e t h e c u r v e d p o r t i o n i s t o r n f r o m i t s f i xa t i o n o n t h e t i b i a l s u r f a c e , s o t h e l o o p i s f r e e t o mo v e l a t e r a l l y i n t o t h e j o i n t . L o c k i n g ma y o c c u r. T h e mo s t c o n s t a n t s i g n i s t e n d e r n e s s o v t h e t i b i a l c o l l a t e r a l l i g a me n t a t t h e j o i n t l i n e , w h e n t h e k n e e i s f l e xe d . Te a r i n g o f t h


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p o s t e r i o r h o r n c a u s e s t e n d e r n e s s p o s t e r i o r t o t h e t i b i a l c o l l a t e r a l l i g a me n t . T i b i a l ( me d i a l ) c o l l a t e r a l l i g a me n t i n j u r i e s a r e o f t e n c o e xi s t e n t .

P o s t - t r a u m a t i c M e d i a l K n e e P a i n : Ru p t u r e o f t h e M e d i a l ( T i b i a l ) C o l l a t e r a l Ligament: In j u r i e s o f t h e me d i a l c o l l a t e r a l l i g a me n t o c c u r f r o m v a l g u s s t r e s s t o t h e k n e e , s u c h a s a b l o w t o t h e l a t e r a l s i d e o f t h e k n e e d u r i n g w e i g h t b e a r i n g . U s u a l l y t h e f e mo r a l a t t a c h me n t i s t o r n . T h e r e g i o n o f t h e l i g a me n t i s t e n d e r a n d s o me w h a t s w o l l e n . B e c a u s e t h e me d i a l me n i s c u s a t t a c h e s t o t h e mi d p o r t i o n o f t h e l i g a me n t , me d i a l c o l l a t e r a l l i g a me n t i n j u r y o f t e n a c c o mp a n i e s me d i a l me n i s c u s i n j u r y. W i t h i n c o mp l e t r u p t u r e , p a i n i n t h e r e g i o n i s s e v e r e , b u t f u n c t i o n i s n o t c o mp l e t e l y l o s t a n d mo v e me n t i s r e s u me d i n a f e w h o u r s ; me d i a l s t a b i l i t y i s p r e s e n t , a l t h o u g h s t r e s s o n t h e l i g a me n t e l i c i t s p a i n . W h e n c o mp l e t e r u p t u r e o c c u r s t h e r e i s me d i a l i n s t a b i l i t y d e mo n s t r a t e d w h e n a v a l g u s s t r e s s o n t h e j o i n t p r o d u c e s p a l p a b l e s e p a r a t i o n o f t h e t i b i a f r o m t h e me d i a l f e mo r a l c o n d y l e . In a d d i t i o n t o p a i n a n d s w e l l i n g , p a l p a t i o n o f t h e l i g a me n t a t t a c h me n t ma y d i s c l o s e a mo v a b l e f r a g me n t o f b o n e . Al w a y s c o mp a r e the injured to the uninjured side because there is considerable individual variation t h e b a s e l i n e d e g r e e o f j o i n t s t a b i l i t y.

P o s t - t r a u m a t i c L a t e r a l K n e e Te n d e r n e s s : Ru p t u r e o f t h e L a t e r a l M eniscus: T h e t r a u ma ma y b e s o s l i g h t a s t o e s c a p e a t t e n t i o n . P a i n ma y b e f e l t e i t h e r l a t e r a l l o r me d i a l l y. Te n d e r n e s s i s f o u n d i n t h e l a t e r a l j o i n t l i n e . M c M u r r a y a n d Ap l e y t e s t s a r e p o s i t i v e w h e n t h e p r o c e d u r e s a r e mo d i f i e d b y p r o d u c i n g i n w a r d r o t a t i o n o f t h e f o o t i n s t e a d o f o u t w a r d r o t a t i o n . L o c k i n g o f t h e j o i n t i s u n c o mmo n . P o s t - t r a u m a t i c L a t e r a l K n e e Te n d e r n e s s : Ru p t u r e o f t h e L a t e r a l ( F i b u l a r ) Collater al Ligament: T h i s i n j u r y i s p r o d u c e d b y v a r u s f o r c e o n t h e k n e e w i t h e xt e r n a l r o t a t i o n o f t h e f e m o n t h e f i xe d t i b i a . U s u a l l y t h e f i b u l a r a t t a c h me n t i s t o r n a n d t h e h e a d o f t h e f i b u l a ma y b e a v u l s e d . Te n d e r n e s s i s f o u n d o n t h e l a t e r a l a s p e c t o f t h e k n e e b e t w e e n t h e l a t e r a l f e mo r a l e p i c o n d y l e a n d t h e f i b u l a r h e a d . W i t h a c o mp l e t e t e a r, t h e d e f e c t i n t h e l i g a me n t ma y b e p a l p a b l e . C r e p i t u s i n d i c a t e s a v u l s i o n o f t h e f i b u l a r h e a d . Stability is tested by placing a varus stress on the knee while palpating for opening o f t h e l a t e r a l j o i n t l i n e . T h e c o mmo n p e r o n e a l n e r v e ma y b e i n j u r e d s i mu l t a n e o u s l y, s o t e s t t h e s t r e n g t h o f t h e a n t e r i o r a n d l a t e r a l mu s c l e s o f t h e l e g a n d t h e s h o r t e xt e n s o r s o f t h e t o e s . P o s t - t r a u m a t i c P a i n a n d I n s t a b i l i t y o f t h e K n e e J o i n t : Ru p t u r e o f t h e An t e r i o r C r u c i a t e L i g a m e n t : R u p t u r e o f t h e a n t e r i o r c r u c i a t e l i g a me n t o c c u r s a s t h e r e s u l t o f h i g h - i mp a c t i n j u r y w h e r e t h e t i b i a i s d r i v e n a n t e r i o r r e l a t i v e t o t h e f e mu r. At t h e t i me o f i n j u r y, t h e r e i s s e v e r e p a i n a n d t h e j o i n t i s h e l d i n s l i g h t f l e xi o n . P h y s i c a l e xa mi n a t i o n o f t h e l i g a me n t i s d i f f i c u l t o r i mp o s s i b l e a c u t e l y b e c a u s e o f p a i n a n d l i mi t e d mo b i l i t y s e c o n d a r y t o t e n s e h e ma r t h r o s i s . Af t e r a s p i r a t i o n o r r e s o l u t i o n o f t h e h e ma r t h r o s i s , e xa mi n a t i o n s h o w s a p o s i t i v e L a c h ma n t e s t f o r a n t e r i o r i n sp a g el i 7y )5 s e e t b i t 0 (. P o s t - t r a u m a t i c P a i n a n d I n s t a b i l i t y o f t h e K n e e J o i n t : Ru p t u r e o f t h e Poster ior Cr uciate Ligament: Posterior cruciate injury results from a direct blow on the head of the tibia while th k n e e i s f l e xe d . T h e t i b i a ma y s a g p o s t e r i o r l y w h e n c o mp a r e d t o t h e u n i n j u r e d k n e e
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w h i l e b o t h k n e e s a r e f l e xe d a t 9 0 d e g r e e s . T h e a c u t e a n d l a t e s i g n s a r e s i mi l a r t o i n j u r y o f t h e a n t e r i o r c r u c i a t e l i g a me n t e xc e p t t h a t t h e r e posa eroor t i v e is t p i si d r a w e r s i g n . T h i s i s e l i c i t e d b y p u s h i n g t h e t i b i a l h e a d b a c k w a r d o n t h e f e mo r a l c o n d y l e s w i t h t h e k n e e f l e xe d a t 9 0 d e g r e e s . Al s o , a s h a r p b l o w t o t h e p r o xi ma l a n t e r i o r t i b i a , w i t h t h e k n e e i n 9 0 d e g r e e s o f f l e xi o n , w i l l e l i c i t p a i n .

Leg Signs

Calf Pain: Inter mittent Claudication: P a t h o p h y s i o l o gT : e a r t e r i a l p e r f u s i o n i n t h e l e g s i s s u f f i c i e n t a t r e s t , b u t d u r i n g yh w a l k i n g t h e i n c r e a s e d c i r c u l a t o r y d e ma n d s o f t h e mu s c l e s c a n n o t b e me t , l a c t a t e a c c u mu l a t e s , a n d p a i n , a s i n a n g i n a p e c t o r i s , o c c u r s i n t h e a f f e c t e d mu s c l e s . T h e b a l a n c e o f a r t e r i a l s t e n o s i s a n d c o l l a t e r a l c i r c u l a t i o n d e t e r mi n e s t h e d i s t a n c e o f a s y mp t o ma t i c w a l k i n g . An e mi a i n c r e a s e s s y mp t o ms b y l o s s o f o xy g e n - c a r r y i n g c a p a c i t y, w h i l e p o l y c y t h e mi a d o e s s o b y i n c r e a s i n g t h e b l o o d v i s c o s i t y, w h i c h s l o w s t h e f l o w r a.t e h e L a t ic l audi c at i me a n s l i mp i n g o r l a me n e s s . T h e r e a r e n o T n o s y mp t o ms a t r e s t , b u t t h e p a t i e n t b e g i n s t o l i mp f r o m p a i n o r w e a k n e s s i n t h e c a l f o f o o t o f o n e o r b o t h l e g s a f t e r w a l k i n g a c e r t a i n f i xe d d i s t a n c e . If t h e p a t i e n t s t o p s , s y mp t o ms s u b s i d e w i t h i n a f e w mi n u t e s , p e r mi t t i n g w a l k i n g f o r a n o t h e r s i mi l a r d i s t a n c e b e f o r e s y mp t o ms r e c u r. W i t h c o n t i n u e d w a l k i n g , d e s p i t e s y mp t o ms , mu s c l e c r a mp s a r e l i k e l y t o o c c u r, a l t h o u g h o c c a s i o n a l l y t h e p a i n s u b s i d e s w h i l e w a l k i n g . P u l s e s a r e d i mi n i s h e d o r a b s e n t i n t h e p o p l i t e a l , d o r s a l i s p e d i s , a n d / o r p o s t e r i o r t i b i a l a r t e r i e s o f t h e a f f e c t e d l e g . C o mmo n c a u s e s a r e a t h e r o s c l e r o s i s o f t h e a r t e r i e i n t h e l e g s , t h r o mb o s i s , a t h e r o e mb o l i s m, t h r o mb o a n g i i t i s o b l i t e r a n s , a n d , r a r e l y, p r e ma t u r e c a l c i f i c a t i o n o f a r t e r i e s i n p s e u d o xa n t h o ma e l a s t i c u m. P r e d i s p o s i n g factors are tobacco use and diabetes. UNI L AT E RAL C L AUD I C AT I O N I N T HE Y O UNG : P O P L I T E AL ART E RY E NT RAP M E NT S Y ND RO M E : P a t h o p h y s i o l o g yn t r a p me n t o f t h e p o p l i t e a l a r t e r y b y t h e me d i a l h e a d o f t h e E g a s t r o c n e mi u s mu s c l e i s a c o n g e n i t a l a n oy o ul n g p e r s o n d e v e l o p s u n i l a t e r a l . A ma y c l a u d i c a t i o n , w i t h a b s e n c e o f o r d i mi n i s h e d p u l s e s i n t h e i p s i l a t e r a l p o p l i t e a l a n d dorsalis pedis arteries. P o s t - t r a u m a t i c M i d c a l f P a i n : S o l e u s Te a r : T r a u ma c a u s i n g e xt r e me d o r s i f l e xi o n o f t h e f o o t ma y t e a r t h e s o l e u s mu s c l e . T h i s p r o d u c e s s e v e r e p a i n a n d t e n d e r n e s s i n t h e mi d c a l f .
P. 7 6 5

P o s t - t r a u m a t i c Ac h i l l e s P a i n : Ru p t u r e o f t h e Ac h i l l e s Te n d o n : T h e i n j u r y i s mo s t c o mmo n i n me n o v e r a g e 4 5 a t t e mp t i n g u n u s u a l a n d v i g o r o u s a c t i v i t i e s r e q u i r i n g s u d d e n a c c e l e r a t i o n s o r j u mp i n g . C o mp l e t e r u p t u r e u s u a l l y o c c u r s a b o u t 5 c m a b o v e t h e c a l c a n e a l i n s e r t i o n . T h e r e i s s u d d e n e xc r u c i a t i n g p a i n a n d w a l k i n g i s n o t p o s s i b l e . E xa mi n e t h e p a t i e n t i n t h e p r o n e p o s i t i o n , w i t h t h e f e e t h a n g i n g o v e r t h e e n d o f t h e t a b l F i gs e e - 2 2 Bp a g e 7 0 5 ) . T h e a f f e c t e d f o o t i s e ( . 13 , l e s s p l a n t a r f l e xe d a n d p a s s i v e d o r s i f l e xi o n i s e xc e s s i v e . W i t h i n c o mp l e t e r u p t u r e , s q u e e zi n g t h e c a l f mu s c l e s t r a n s v e r s e l y p r o d u c e s p l a n t a r f l e xi o n o f t h e f o o t . T h i s mo t i o n i s a b s e n t w h e n t h e t e n d o n i s s e v e r e d c oSi mmonds t es t In mp l e t e l y ( ) . c o mp l e t e r u p t u r e , a g a p c a n b e f e l t i n t h e t e n d o n , t h e d i s t a l p o r t i o n o f t h e t e n d o n i s


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t h i c k e r a n d l e s s t a u t , a n d t h e c a l f mu s c l e s a r e s h o r t e n e d i n t o a v i s i b l e l u mp .

P o s t - t r a u m a t i c An t e r i o r L e g P a i n : F r a c t u r e o f t h e T i b i a l S h a f t : T h e i n j u r y ma y b e a r e s u l t o f a f a l l o n t h e l e g o r a d i r e c t b l o w t o t h e a n t e r i o r t i b i a . P a i n i s s e v e r e , a n d t h e l e g c a n n o t b e a r w e i g h t . P a l p a t i o n d i s c l o s e s l o c a l i ze d tenderness at the fracture site. Rolling a pencil over the subcutaneous aspect of th tibia will discover local tenderness. P o s t - t r a u m a t i c An t e r i o r L e g P a i n : F r a c t u r e o f t h e F i b u l a r S h a f t : A d i r e c t b l o w o n t h e a n t e r o l a t e r a l a s p e c t o f t h e l e g i s t h e mo s t c o mmo n c a u s e . F r a c t u r e p r o xi ma l t o t h e a n k l e ma y a l s o a c c o mp a n y s e v e r e i n v e r s i o n a n k l e i n j u r i e s . T h e r e i s p a i n a t t h e s i t e o f i n j u r y, b u t , u s u a l l y, t h e p a t i e n t c a n w a l k . C o mp r e s s i n g t tibia and fibula together causes pain at the fracture site.

Post-tr aumatic Leg Pain: Fr actur e of Both T ibia and Fibula: T h i s i n j u r y i s t h e mo s t c o mmo n c a u s e o f c o mp o u n d f r a c t u r e . F r e q u e n t l y, t h e f o o t i s t u r n e d o u t w a r d i n o b v i o u s d e f o r mi t y ; ma n i p u l a t i o n s h o u l d b e a v o i d e d , b u t a l w a y s p a l p a t e t h e d o r s a l i s p e d i s p u l s e f o r e v i d e n c e o f a r t e r i a l d a ma g e . W h e n d e f o r mi t y i s a b s e n t , a s c e r t a i n i f t h e n o r ma l s t r a i g h t l i n e i s p r e s e n t b e t w e e n t h e me d i a l a s p e c t o t h e g r e a t t o e , t h e me d i a l ma l l e o l u s , a n d t h e me d i a l p a t e l l a r b o r d e r.

Ab r u p t C a l f P a i n : Te a r o f G a s t r o c n e m i u s ( Te n n i s L e g ) : A v i o l e n t c o mb i n a t i o n o f k n e e e xt e n s i o n a n d d o r s i f l e xi o n a t t h e a n k l e c a u s e s a s e n s a t i o n l i k e a b l o w t o t h e p o s t e r i o r c a l f , s o me t i me s a c c o mp a n i e d b y a n a u d i b l e s n a p . U n a s s i s t e d w a l k i n g i s i mme d i a t e l y i n t e n s e l y p a i n f u l i n t h e p o s t e r o me d i a l mi d c a l f . T h e r e i s t e n d e r n e s s a n d a p a l p a b l e d e f e c t i n t h e me d i a l b e l l y o f t h e g a s t r o c n e mi u s . Af t e r a f e w h o u r s , s w e l l i n g o b s c u r e s t h e d e f e c t f o r a f e w d a y s . T h e p o w e r o f p l a n t a r f l e xi o n i s d i mi n i s h e d a n d mu s c l e t o n e i s a b s e n t i n t h e me d i a l h e a d o f t h e g a s t r o c n e mi u s f o r a f e w w e e k s . E c c h y mo s e s d e v e l o p s o v e r d a y s e xt e n d i n g f r o m t h e me d i a l c a l f t o t h e h e e l , a n k l e a n d f o o t .
P. 7 6 6

Post-exer cise T ibial Pain: Str ess Fr actur e of the T ibia: An i n c o mp l e t e c o r t i c a l f r a c t u r e o f t h e t i b i a r e s u l t s f r o m r e p e a t e d s t r e n u o u s u s e o f t h e l e g . P a i n i s g r a d u a l i n o n s e t ; i t i s d u l l a n d a c h i n g . It o c c u r s w i t h p r o g r e s s i v e l y s h o r t e n i n g i n t e r v a l s a f t e r e xe r c i s e a n d p e r s i s t s f o r h o u r s . T h e r e i s l o c a l i ze d t e n d e r n e s s o v e r t h e t i b i a , f r e q u e n t l y a l o n g t h e me d i a l b o r d e r. P a i n a t t h e f r a c t u r e s i t e ma y b e e l i c i t e d b y s p r i n g i n g t h e t i b i a : w i t h t h e p a t i e n t s u p i n e , p l a c e o n e h a n d the knee and the other on the heel; pull the tibia laterally against your knee as a f u l c r u m.

P o s t - e x e r c i s e An t e r i o r L e g P a i n : M a r c h G a n g r e n e ( An t e r i o r T i b i a l Compar tment Syndr ome): S e e p a g e 7 9.4 S e v e r a l h o u r s a f t e r u n u s u a l l y s t r e n u o u s l e g e xe r c i s e , s t i f f n e s s f o l l o w e d b y s e v e r e p a i n o c c u r s i n t h e a n t e r i o r t i b i a l mu s c u l a r c o mp a r t me n t . T h e r e g i o n b e c o me s s w o l l e n , t e n s e , t e n d e r, a n d w a r m. Is c h e mi c n e c r o s i s o f t h e mu s c l e s ma y o c c u r i f t h e p r e s s u r e i s n o t r e l i e v e d b y f a s c i o t o my. P o s t - e x e r c i s e S u b p a t e l l a r P a i n : O s t e o c h o n d r i t i s o f T i b i a l Tu b e r c l e (Osgood-Schlatter Disease):


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R e p e t i t i v e v i g o r o u s e xe r c i s e d u r i n g a d o l e s c e n c e , b e f o r e c l o s u r e o f t h e e p i p h y s i s o f the tibial tubercle, produces chronic traction injury with partial avulsion of the t u b e r c l e . P a i n o c c u r s a f t e r e xe r c i s e a n d a t e n d e r, h a r d s w e l l i n g i s s e e n a n d f e l t a t t h e a t t a c h me n t o f t h e p a t e l l a r t e n d o n .

T h i c k e n e d Ac h i l l e s Te n d o n : T h i c k e n i n g i s mo s t e a s i l y d e t e c t e d b y i n s p e c t i o n a n d p a l p a t i o n w h e n t h e f o o t i s d o r s i f l e xe d . S e v e r a l d i s e a s e s ma y p r o d u c e i n f l a mma t i o n ( e . g . , s e r o n e g a t i v e s p o n d y l o a r t h r o p a t h i e s , r h e u ma t o i d a r t h r i t i s ) o r d e p o s i t s i n t h e t e n d o n ( e . g . , xa n t h o ma s ) .

Ankle Signs
S w e l l i n g o f t h e An k l e J o i n t : J o i n t E f f u s i o n : T h e f o o t i s h e l d i n s l i g h t d o r s i f l e xi o n a n d i n v e r s i o n . T h e d i s t e n d e d j o i n t p r o d u c e s b u l g i n g b e n e a t h t h e e xt e n s o r t e n d o n s , n e a r t h e t a l o t i b i a l j u n c t i o n a n d i n f r o n t o f t h l a t e r a l a n d me d i a l ma l l e o l a r l i g a me n t s .
P. 7 6 7

P o s t - t r a u m a t i c An k l e P a i n : An k l e t r a u ma i s c o mmo n a n d t h e e xa mi n e r n e e d s a p r a c t i c a l a p p r o a c h t o t h e e v a l u a t i o n . T h e mo s t c o mmo n me c h a n i s m o f i n j u r y i s i n v e r s i o n i n j u r y o f t h e f l e xe d a n k l e w h i l e r u n n i n g o r j u mp i n g . L i g a me n t i n j u r i e s a r e e xp e c t e d , b u t f r a c t u r e s ma y o c c u r ; t h i s i s t h e d i a g n o s t i c d i l e mma . C a r e f u l p r o s p e c t i v e s t u d i e s i n d i c a t e t h a t r a d i o g r a p h s o f t h e a n k l e a r e n e c e s s a r y o n l y i f t h e r e i s p a i n n e a r t h e ma l l e o l i a n d t h p a t i e n t i s o l d e r t h a n 5 5 y e a r s o f a g e , i s u n a b l e t o b e a r w e i g h t i mme d i a t e l y a f t e r t h e i n j u r y o r t a k e f o u r s t e p s w h e n e xa mi n e d , o r h a s b o n e t e n d e r n e s s a t t h e p o s t e r i o r e d g e o r t i p o f e i t h e r ma l l eS tl iu s l [ IG , G r e e n b e r g G H , M c K n i g h t R D , e t a l . o el D e c i s i o n s r u l e s f o r t h e u s e o f r a d i o g r a p h y i n a c u t e a n k lAM n j u r i e s . J e iA 1 9 9 3 ; 2 6 9 : 11 2 7 11 3 2 c h ma n n L M , K o l b E , K o l l e r M T, e t a l . Ac c u r a c y o f O t t a w a ; Ba a n k l e r u l e s t o e xc l u d e f r a c t u r e s o f t h e a n k l e a n d mi d - f o o t : S y s t e maJ i c r e v i e w. BM t 2 0 0 3 ; 3 2 6 : 4 1.7 If t h e s e c o n d i t i o n s a r e n o t me t , f r a c t u r e i s v e r y u n l i k e l y. ]

P O S T - T RAUM AT I C L AT E RAL ANK L E PAI N: RUP T URE O F T HE J O I NT C AP S UL E : F o r c e f u l p l a n t a r f l e xi o n w i t h e v e r s i o n o f t h e f o o t ma y d i s r u p t t h e a n t e r o l a t e r a l p o r t i o of the articular capsule. Pain and tenderness occur just anterior to the lateral ma l l e o l a r l i g a me n t s ( c a l c a n e o f i b u l a r a n d t a l o f i b u l a r ) . A h e ma t o ma i n t h e s i t e r a p i d l y a p p e a r s , a c c o mp a n i e d b y s o me e d e ma . P O S T - T RAUM AT I C L AT E RAL ANK L E PAI N: RUP T URE O F T HE C AL C ANE O F I B UL AR L I G AM E NT, C O M M O N ANK L E S P RAI N: T his results from forced inversion of the foot. T he tenderness is anterior and inferi t o t h e l a t e r a l ma l l e o l u s . W i t h c o mp l e t e r u p t u r e , c a r e f u l p a s s i v e i n v e r s i o n o f t h e f o o d e mo n s t r a t e s t i l t i n g o f t h e t a l u s . W h e n t h e l a t e r a l ma l l e o l u s i s f r a c t u r e d , t h e p o s t e r i o r - l a t e r a l ma l l e o l u s i t s e l f i s t e n d e r. P O S T - T RAUM AT I C M E D I AL ANK L E PAI N: RUP T URE O F T HE D E LT O I D L I G AM E NT: T h i s l i g a me n t i s r a r e l y i n j u r e d i n i s o l a t i o n . It ma y o c c u r a s p a r t o f s e v e r e f r a c t u r e dislocation of the ankle.
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P a i n o r C l i c k D u r i n g D o r s i f l e x i o n w i t h E v e r s i o n : Re c u r r e n t S l i p p i n g o f P e r o n e a l Te n d o n s : T he tendons of the peroneus longus and brevis curve behind and under the lateral ma l l e o l u s , h e l d i n a g r o o v e b y t h e a l i g a me n t o u s b a n d , t h e s u p e r i o r p e r o n e a l r e t i n a c u l u m. R e l a xa t i o n o f t h e r e t i n a c u l u m ma y p e r mi t s l i p p i n g o f t h e t e n d o n s d u r i n d o r s i f l e xi o n w i t h e v e r s i o n . P a i n o r c l i c k o c c u r s w i t h t h e s l i p p i n g . P h y s i c a l e xa mi n a t i o n a t r e s t i s n o r ma l b u t a c t i v e mo t i o n ma y p r o d u c e p a l p a b l e t e n d o n s u b l u xa t i o n .

P a i n o n I n v e r s i o n o f t h e F o o t : C h r o n i c S t e n o s i n g Te n o s y n o v i t i s o f t h e P e r o n e a l Te n d o n S h e a t h : T h i s c a u s e s p a i n o n l y o n i n v e r s i o n o f t h e f o o t . Te n d e r n e s s a n d s w e l l i n g o c c u r i n t h s h e a t h b e h i n d a n d b e l o w t h e l a t e r a l ma l l e o l u s .

Foot Signs
P. 7 6 8

D e f o r m e d F o o t : Ta l i p e s : T he five principal varieties are talipes varus (inversion), talipes valgus (eversion), t a l i p e s e q u i n u s ( p l a n t a r f l e xi o n ) , t a l i p e s c a l c a n e u s ( d o r s i f l e xi o n ) , a n d t a l i p e s o r p e c a v u s ( h o l l o w i n g t h e i n s t e p ) 1 3 - 4 7 C o mb i n e d d e f o r mi t i e s a r e t a l i p e s Fig. ( ). equinovarus (clubfoot), talipes equinovalgus, talipes calcaneovarus, and talipes c a l c a n e o v a l g u s . T h e d i a g n o s i s i s u s u a l l y ma d e b y i n s p e c t i o n .

F i g . 1 3 - 4 7 D e f o r m i t i e s o f t h e. F o o t

Defor med Foot: Pes Planus (Flatfoot): ( S e eF i g . 1 3 - 4 7 O n e o r mo r e o f t h e p e d a l a r c h e s a r e l o w e r e d . A f u n c t i o n a l .) c l a s s i f i c a t i o n i n c l u d e s r e l a xe d f l a t f o o t , i n w h i c h t h e a r c h i s l o w e r e d o n l y w h i l e b e a r i n g w e i g h t ; r i g i d f l a t f o o t , c a u s e d b y b o n y o r f i b r o u s a n k y l o s i s ; s p a s mo d i c flatfoot, from contraction of the peronei; and transverse flatfoot, from flattening of the transverse arch. P o s t - t r a u m a t i c He e l P a i n : C a l c a n e a l F r a c t u r e : L a n d i n g o n t h e h e e l d u r i n g a f a l l ma y c a u s e f r a c t u r e o f t h e c a l c a n e u s ( o s c a l c i s ) (F i g . 1 3 - 4 8 A T h e h e e l a p p e a r s b r o a d e r t h a n n o r ma l f r o m t h e b a c k a n d t h e h o l l o w s ).
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b e n e a t h t h e ma l l e o l i a r e o b l i t e r a t e d . Te n d e r n e s s i s ma xi ma l i n t h e c a l c a n e u s n e a r t h e i n s e r t i o n o f t h e Ac h i l l e s t e n d o n . P a l p a t i o n b e l o w t h e ma l l e o l u s d i s c l o s e s t h e s i d e s o f t h e c a l c a n e u s t o b e f l u s h w i t h t h e ma l l e o l u s , r a t h e r t h a n i n d e n t e d . Al l mo t i o n s o f t h e a n k l e a r e r e s t r i c t e d b y p a i n . A h e ma t o ma f o r ms i n t h e s o l e o f t h e h e e l . S i g n s o f f r a c t u r e ma y b e s u b t l e , s o a h i g h i n d e x o f s u s p i c i o n i s r e q u i r e d .

P a i n i n t h e He e l : Re t r o c a l c a n e a l B u r s i t i s : T h e b u r s a b e t w e e n t h e Ac h i l l e s t e n d o n a n d t h e c a l c a n e u s ma y b e i n f l a me d , c a u s i n g p a i n , s w e l l i n g , a n d t e n d e r n e s s n e a r t h e t e n d o n i n s e ri tgi .o n 3 -s4 8 B T h e F 1 ( e e. ) l e s i o n i s c a u s e d b y p r e s s u r e f r o m f o o t w e a r, e s p e c i a l l y h i g h - h e e l e d s h o e s o r s t i f f backed boots.


P. 7 6 9

Fig. 13-48 Lesions of the Foot. A. Calcaneal Fracture. B. Bursae in the Heel. C. March Fracture of a Metatarsal Bone. D. Deep Fascial Spaces of the F o o t . E . H a l l u x Va l gThi:s def or mi t y s hows l at er al dev i at i on of t he gr eat t oe, us wi t h pr omi nenc e of t he 1s t met at ar s ophal angealHja mnt e r To e : . F. oi m The s ec ond t oe i s al way s af f ec t ed. Ther e i s per manent f l ex i on of t he pr ox i mal i nt er phal angeal j oi nt .

P a i n i n t h e He e l : P l a n t a r F a s c i i t i s : P a t h o p h y s i o l o gT : e p l a n t a r f a s c i a i s a t h i c k b a n d o f f i b r o u s t i s s u e a r i s i n g f r o m yh t h e me d i a l t u b e r o s i t y o f t h e c a l c a n e u s a n d s p r e a d i n g l i k e a f a n a c r o s s t h e s o l e t o i n s e r t o n t h e p r o xi ma l p h a l a n g e s o f t h e t o e s . U n u s u a l o r p r o l o n g e d w e i g h t - b e a r i n g a c t i v i t y l e a d s t o mi c r o t r a u ma , w h i c h i s c o n c e n t r a t e d a t t h e c a l c a nP a iln i n s e r t i o n . ea is present in the plantar aspect of the heel and is usually worst with the first steps t h e mo r n i n g . P a i n i mp r o v e s w i t h a c t i v i t y, o n l y t o r e c u r a f t e r r e s t . Te n d e r n e s s i s e l i c i t e d a t t h e i n s e r t i o n o f t h e p l a n t a r f a s c i a o n t h e d i s t a l c a l c a n e u s s o me w h a t me d i a l l y. P a i n i n t h e He e l : I n f l a m m a t i o n o f t h e C a l c a n e a l F a t P a d : P a t h o p h y s i o l o g F : b r o u s b a n d s e xt e n d f r o m t h e c a l c a n e a l p e r i o s t e u m t o t h e s k i n ; yi
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t h e i r i n t e r s t i c e s a r e f i l l e d w i t h f a t . In f e c t i o n o r i n f l a mma t i o n i s c o mp a r t me n t a l i ze d b t h e f i b r o u s b a n d s l e a d i n g t o i n c r e a s e d t i s s u e p r e s s u r e a n d . i n th e s e gpo nn T en r i ai i s t o o t e n d e r t o p e r mi t w e i g h t b e a r i n g . U s u a l l y e d e ma a c c u mu l a t e s a r o u n d t h e a n k l e fluctuation occasionally is present. P. 7 7 0

P a i n i n t h e He e l : Ta r s a l Tu n n e l S y n d r o m e : P a t h o p h y s i o l o g T : e t a r s a l t u n n e l i s b e h i n d a n d i n f e r i o r t o t h e me d i a l ma l l e o l u s o f yh t h e t i b i a . It s b o n y f l o o r i s r o o f e d b y t h e f l e xo r r e t i n a c u l u m e xt e n d i n g f r o m t h e me d i a ma l l e o l u s t o t h e c a l c a n e u s . T h r o u g h t h e t u n n e l p a s s s e v e r a l t e n d o n s a n d t h e posterior tibial nerve, which divides into the calcaneal nerve to the skin of the heel t h e me d i a l p l a n t a r n e r v e t o t h e s k i n a n d mu s c l e s o f t h e me d i a l a s p e c t o f t h e s o l e , a n d t h e l a t e r a l p l a n t a r n e r v e t o t h e l a t e r a l p o r t i o n. o f otmp r s o lse o n o f t h e C he es i n e r v e s i n t h e t u n n e l c a u s e s n u mb n e s s , b u r n i n g p a i n , o r p a r e s t h e s i a s i n p o r t i o n s o f t h e s o l e . P a r e s i s o r p a r a l y s i s o f s o me s ma l l mu s c l e s o f t h e f o o t ma y o c c u r. O c c a s i o n a l l y, a t e n d e r a r e a i s p a l p a t e d a t t h e p o s t e r i o r ma r g i n o f t h e me d i a l ma l l e o l u s . T h e d i a g n o s i s i s c o n f i r me d b y n e r v e c o n d u c t i o n s t u d i e s . P r e c i p i t a t i n g c o n d i t i o n s i n c l u d e f r a c t u r e o r d i s l o c a t i o n o f t h e b o n e s n e a r t h e t u n n e l , t r a u ma t i c e d e ma , t e n o s y n o v i t i s , c h r o n i c s t a s i s o f t h e p o s t e r i o r t i b i a l v e i n a n d f o o t s t r a i n .

M etatar sal Pain: M etatar salgia: P a t h o p h y s i o l o g L o s s o f t h e n o r ma l t r a n s v e r s e me t a t a r s a l a r c h f r o m t h e f i r s t t o y: t h e f i f t h me t a t a r s a l h e a d s l e a d s t o a b n o r ma l w e i g h t b e a r i n g o n t h e s e c o n d t o f o u r t h me t a t a r s a l h e a d s , w h i c h a r e i n s u f f i c i e n t l y p a d d e d t o b e a r As k tw e i g h t i e n t . the h pa t o p o i n t t o t h e s i t e o f t h e p a i n . P a i n o c c u r s i n t h e r e g i o n o f t h e d i s t a l me t a t a r s a l h e a d s . E xa mi n a t i o n ma y s h o w c a l l u s u n d e r t h e s e c o n d t o f o u r t h me t a t a r s a l s a n d decreased callus under the first and fifth. Pressure on the callus reproduces the p a i n . S y mme t r i c a l b i l a t e r a l me t a t a r s a l g i a ma y b e a n e a r l y s y mp t o m o f r h e u ma t o i d a r t h r i t i s . F i b r o n e u r o ma ma y a l s o b e t h e c a u s e , s o s q u e e ze t h e f o o t t r a n s v e r s e l y t o see if the pain is reproduced. M etatar sal Pain: M etatar sal Str ess Fr actur e (M ar ch Fr actur e): E xc e s s i v e w a l k i n g o r s t a n d i n g ma y c a u s e a f r a c t u r e o f t h e me t a t a r F ag . s h a f t ( s e e si l 1 3 - 4 8 C. P a i n d e v e l o p s g r a d u a l l y. M u s c l e c r a mp s a n d s l i g h t s w e l l i n g ma y o c c u r. ) M o t i o n o f t h e c o r r e s p o n d i n g t o e i s p a i n f u l . P a i n i s u s u a l l y l o c a l i ze d s e v e r a l c e n t i me t e r s p r o xi ma l t o t h e me t a t a r s a l h e a d .

M etatar sal Pain: Infection in the Inter digital Space: P u n c t u r e o f t h e s o l e ma y c a u s e i n f e c t i o n o f o n e o f t h e f o u r i n t e r d i g i t a l s u b c u t a n e o u s p a c e s . T h e r e s u l t i n g a b s c e s s ma y r e ma i n u n d e r t h e s o l e , o r i t ma y p o i n t b e t w e e n t h e t w o me t a t a r s a l s t o t h e d o r s u m o f t h e f o o t , f o r mi n g a c o l l a r - s t u d a b s c e s s . Wa l k i n p r o d u c e s p a i n b e t w e e n t h e me t a t a r s a l s . Te n d e r n e s s i s l o c a l i ze d t o t h e i n t e r d i g i t a l space. Swelling of the dorsum occurs when the abscess has penetrated through the foot.
P. 7 7 1

Pain in the Instep: Infection in the Deep Fascial Spaces: T h e c e n t r a l p l a n t a r s p a c e h a s f o u r c o mp a r t me n t s b e t w e e n t h e s o l e a n d t h e p e d a l a r c h ( s e e i g . 1 3 - 4 8)D In f e c t i o n o f t h e s p a c e s o c c u r s f r o m d i r e c t p u n c t u r e o r F .


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b a c k w a r d e xt e n s i o n f r o m a n i n t e r d i g i t a l s p a c e . T h e r e i s t e n d e r n e s s i n t h e i n s t e p ( mi d f o o t ) , d o r s a l e d e ma , a n d t h e c u r v e o f t h e i n s t e p b e c o me s o b l i t e r a t e d .

Localized Swelling on the Dor sum: Ganglion: T h i s i s a c y s t a r i s i n g f r o m a t a r s a l j o i n t c a p s u l e o r a n e xt e n s o r t e n d o n . Contr actur e of Plantar Fascia: Leder hosen Syndr ome: T h e p l a n t a r f a s c i a b e c o me s t h i c k e n e d , b u t i t i s u s u a l l y s y mp t o ml e s s . C o n t r a c t u r e ma y o c c u r u n i l a t e r a l l y o r o n b o t h s i d e s ; o c c a s i o n a l l y, i t i s a s s o c i a t e d w i t h D u p u y t r e c o n t r a c t u r e o f t h e p a l ms a n d P e y r o n i e s y n d r o me .

L a t e r a l D e v i a t i o n o f t h e G r e a t To e : Ha l l u x Va l g u s : L a t e r a l d e v i a t i o n a n d r o t a t i o n o f t h e g r e a t t o e p r o d u c e s a b n o r ma l p r o mi n e n c e o f t h e f i r s t me t a t a r s o p h a l a n g e a l j o i nF i (gs. e1 3 - 4 8 E T h e s e c o n d t o e ma y o v e r l a p t h e t e ). f i r s t , o r i t ma y b e a h a mme r t o e . T h e g r e a t t o e r e t a i n s g o o d mo t i o n . P a i n i s c a u s e d b y a c c o mp a n y i n g h a mme r t o e , a n i n f l a me d b u r s a o v e r t h e p r o mi n e n t me t a t a r s o p h a l a n g e a l j o i n t ( b u n i o n ) , o r me t a t a r s a l g i a f r o m t r a n s v e r s e f l a t f o o t ( s p l a y f o o t ) . T h e mo s t c o mmo n c a u s e s a r e i mp r o p e r s h o e s a n d p r i ma r y o s t e o a r t h r i t i s .

S t i f f e n e d G r e a t To e : Ha l l u x Ri g i d u s : P a t h o p h y s i o l o g C:h r o n i c a r t h r i t i s o r e p i p h y s i t i s o f t h e f i r s t me t a t a r s o p h a l a n g e a l y ( M T P ) j o i n t f r o m i n j u r y, o r f r o m w e a r i n g s h o r t s h o e s , ma y c a u s e a n k y l o s i s , u s u a l l y i e xt e n s i o n ; o c c a s i o n a l l y t h e r e i s f i xa t i o n i n t h e mo r e a w k w a r d f l e xi o n . A p r o mi n e n t o s t e o p h y t e i s u s u a l l y p r e s e n t o n t h e d o r s a l a s p e c t . oP a hn i jn itn te j o i n t f ti e o h o c c u r s w i t h w a l k i n g a n d c l i mb i n g . E xt e n s i o n o f t h e M T P i s s e v e r e l y l i mi t e d a n d f l e xi o n i s p r e s e n t ma i n l y i n t h e i n t e r p h a l a n g e a l j o i n t . O s t e o p h y t e s ma y c a u s e palpable irregularity on the joint edges. D e f o r m i t y o f t h e S e c o n d t o F i f t h To e s : Ha m m e r To e s : T h e p r o xi ma l j o i n t ( me t a t a r s o p h a l a n g e a l [ M T P ] ) i s f i xe d i n d o r s i f l e xi o n a n d t h e p r o xi ma l i n t e r p h a l a n g e a l ( P IP ) j o i n t i s f i xe d i n p l a n t a r f l e xi o n , w h i l e t h e d i s t a l i n t e r p h a l a n g e a l ( D IP ) j o i n t i s f r e e l y mo v aF i lg . (1 3 -e 8 F A c o r n o r i n f l a me d b e se 4 ). b u r s a f r e q u e n t l y o c c u r s o v e r t h e P IP j o i n t . H a mme r t o e s a r e u s u a l l y b i l a t e r a l w i t h s e v e r a l t o e s o n e a c h f o o t i n v o l v e d . It o f t e n a c c o mp a n i e s h a l l u x v a l g u s . S h o r t e n e d F i f t h To e : Ab s e n c e o f M i d d l e P h a l a n x : T h i s i s a f r e q u e n t d e v e l o p me n t a l a n o ma l y. P a i n f u l S w e l l i n g o f a To e : F r a c t u r e d P h a l a n x : N o ma t t e r h o w t r i v i a l t h e t r a u ma s e e ms , c o n s i d e r t h e p o s s i b i l i t y t h a t t h e b o n e h a s been fractured.
P. 7 7 2

Painful Swelling of the M etatar sal Phalangeal Joint: Gout: T his is the classic lesion (podagra) of early gout, described on page 776.

Toenail Signs
S e e C h a p t e r ,6The Sk i n and Nai lpsa g e 1 5 7 . ,

M uscle Signs
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See also hapter 14 C , The Neur ol ogi c Ex ami nat i on .

M u s c u l a r At r o p h y : L o s s o f mu s c l e s u b s t a n c e o c c u r s f r o m d i s u s e o r f r o m d a ma g e t o mu s c l e t i s s u e o r mo t o r n e r v e s . F a s c i c u l a t i o n o f t h e mu s c l e s i n d i c a t e s d e n e r v a t i o n , w h i l e t h e h i s t o r y will disclose injury and disuse. M uscle Contr actur e: P a t h o p h y s i o l o g P : o l o n g e d d i s u s e , i mmo b i l i za t i o n , i s c h e mi a l e a d i n g t o mu s c l e yr n e c r o s i s , o r i n f l a mma t o r y p r o c e s s e s , a s i n d e r ma t o my o s i t i s , r e s u l t i n f i b r o s i s o f mu s c l e w i t h i n e l a s t i c s h o r t.eOin g a l p a t i o n t h e mu s c l e i s f i r m t o h a r d a n d n np a t r o p h i c . T h e s h o r t e n e d mu s c l e d o e s n o t p e r mi t f u l l r a n g e o f j o i n t mo v e me n t . T h e j o i n t s , h o w e v e r, a r e n o r ma l a s d i s t i n c t f r o m j o i n t c o n t r a c t u r e . M u s c l e Hy p e r t r o p h y : P a t h o p h y s i o l o g In:c r e a s e d mu s c l e v o l u me r e s u l t s f r o m e n l a r g e me n t o f n o r ma l y mu s c l e s o r i n f i l t r a t i o n o f t h e mu s c l e b y c e l l u l a r o r e xt r a c e l. l u l e s i ma tn c ea l R ar sta eri e xe r c i s e i n c r e a s e s mu s c l e b u l k a n d p o w e r. H y p e r t r o p h y ma y a l s o o c c u r w i t h a n a b o l i c s t e r o i d u s e , i n h y p o t h y r o i d i s m, c o n g e n i t a l my o t o n i a , D u c h e n n e mu s c u l a r d y s t r o p h y, a n d f o c a l my o s i t i s .

M uscle M asses: To p r o v e t h a t a ma s s i s i n t r a mu s c u l a r t h e ma s s mu s t b e f r e e l y mo v a b l e t r a n s v e r s e l y t o t h e l o n g a xi s , w i t h t h e mu s c l e r e l a xe d . Te n s i n g t h e mu s c l e mu s t l i mi t t h e t r a n s v e r s e mo b i l i t y. A ma s s ma y r e s u l t f r o m r u p t u r e o f a mu s c l e , h e r n i a t i o n o f a mu s c l e t h r o u g h i t s s h e a t h , i n t r a mu s c u l a r h e mo r r h a g e , n e o p l a s m, o r l o c a l i ze d my o s i t i s o s s i f i c a n s .
P. 7 7 3

Tr igger Points: M yofascial Pain: P a i n f u l f i r m n o d u l e s o r b a n d s o c c u r i n mu s c l e s u n d e r f r e q u e n t t o n i c c o n t r a c t i o n . T h p a t i e n t c o mp l a i n s o f p a i n , o f t e n w i t h p r o j e c t i o n o f p a i n i n a n o n d e r ma t o ma l p a t t e r n around the area and distally into the arm from trigger points in the upper back and neck, or into the leg from trigger points in the pelvic girdle. T he pain often has a b u r n i n g q u a l i t y. M o t o r s t r e n g t h a n d s e n s a t i o n a r e n o r ma l . T r i g g e r p o i n t s a r e c h a r a c t e r i s t i c o f my o f a s c i a l p a i n s y n d r o me s . T h e y o c c u r mo s t c o mmo n l y i n l a r g e mu s c l e s o f t h e b a c k a n d i n p r o xi ma l e xt r e mi t i e s . In j e c t i o n o f l o c a l a n e s t h e t i c , h e a t , ma s s a g e , a n d s t r e t c h i n g , c o mb i n e d w i t h a v o i d a n c e o r c h a n g e s i n p r e c i p i t a t i n g p o s t u r a l a c t i v i t i e s , i s e f f e c t i v e t h e r a p y. L e f t u n t r e a t e d , c h a n g e s ma y o c c u r i n c e n t r a a n d p e r i p h e r a l p a i n p a t h w a y s l e a d i n g t o c h r o n i c p e r s i s t e n t p a i n s y n d r o me s .

Te n d e r P o i n t s : F i b r o m y a l g i a : P e r s i s t e n t r e p r o d u c i b l e p a i n i s e l i c i t e d b y p a l p a t i o n o f s p e c i f i c mu s c l e s . T h e p a t i e n d o e s n o t c o mp l a i n s p e c i f i c a l l y o f p a i n i n t h e s e s i t e s , u n l i k e t r i g g e r p o i n t s . E i g h t e e n s y mme t r i c a l l y l o c a t e d s i t e s i n t h e n e c k , b a c k , a n d e xt r e mi t i e s h a v e b e e n s t a n d a r d i ze d f o r t h e d i a g n o s i s o f f i b r o my a pg i g e( s e e [B e n n e t t R M . l a a 7 9)3 E me r g i n g c o n c e p t s i n t h e n e u r o b i o l o g y o f c h r o n i c p a i n : E v i d e n c e o f a b n o r ma l s e n s o r y p r o c e s s i n g i n f i b r o myMlay a . Cl i n Pr oc 9 9 : 7 4 : 3 8 5 3] 9 8 a gi o 19 .

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Musculoskeletal and Soft-Tissue Syndrom es General Syndromes


C o m p l e x Re g i o n a l P a i n S y n d r o m e : Re f l e x S y m p a t h e t i c D y s t r o p h y : P a t h o p h y s i o l o g M:i n o r i n j u r y, u s u a l l y t o a n e xt r e mi t y, i n i t i a t e s a c o mp l e x s e r i e s o f y s p i n a l a n d c e n t r a l n e r v o u s s y s t e m r e s p o n s e s t h a t r e s u l t i n a l t e r e d a u t o n o mi c f u n c t i o n a n d p a i n p e r c e.p tT o n p a t i e n t i n i t i a l l y c o mp l a i n s o f p a i n , o f t e n b u r n i n g o r i he t h r o b b i n g i n q u a l i t y, d i s p r o p o r t i o n a t e t o v i s i b l e i n j u r y. E xa mi n a t i o n ma y r e v e a l h y p e r a l g e s i a , h y p e r e s t h e s i a , e d e ma , e r y t h e ma , a n d c h a n g e s i n s k i n t e mp e r a t u r e . P r o g r e s s i o n l e a d s t o v a s c u l a r c h a n g e s , i n c l u d i n g c y a n o s i s a n d mo t t l i n g , a t r o p h y o f s k i n , mu s c l e a n d s u b c u t a n e o u s t i s s u e , c o n t r a c t u r e s , a n d a l t e r e d s w e a t i n g . T h e a f f e c t e d p a r t i s c o o l a n d p a i n f u l a t r e s t a n d w i t h a n y a c t i v i t y. E a r l y r e c o g n i t i o n a n d t r e a t me n t i s e s s e n t i a l t o a v o i d l o n g - t e r m d i s a bClhta p t(e r e4p a g e 9 7 ) . i i y. S , e
P. 7 7 4

Ne c r o t i z i n g S o f t - T i s s u e I n f e c t i o n : P a t h o p h y s i o l o g R:a p i d e xp a n s i o n o f i n f e c t i o n i n s u b c u t a n e o u s t i s s u e p l a n e s y p r o d u c e s i s c h e mi a o f f a t , c o n n e c t i v e t i s s u e , s k i n , a n d u n d e r l y i n g mu s c l e a s a c o n s e q u e n c e o f l o c a l v a s c u l a r t h r o mb o s i s . T h e i n f e c t i o n s p r e a d s p r o xi ma l l y a n d distally along tissue planes and invades deeper structures along neurovascular b u n d l e s t h a t p e n e t r a t e t h e s e p lWn e s t h e mu s c u l a r f a s c i a i s i n v o l v e d t h e t e r m . a hen nec r ot i zi ng f as c i iitsi sa p p l i e d . P a i n a n d f e v e r a c c o mp a n i e d b y s i g n s o f i n f l a mma t i o n ( e r y t h e ma , w a r mt h , t e n d e r n e s s ) r e s u l t f r o m i n f e c t i o n w i t h g r o u p A s t r e p t o c o c c i o r p o l y mi c r o b i a l ( mi xe d a e r o b i c / a n a e r o b i c ) s o f t - t i s s u e i n f e c t i o n s . S y s t e mi c h y p o t e n s i o t a c h y c a r d i a , a n d d e l i r i u m d e v e l o p r a p i d l y, a n d o u t c o me i s f a t a l w i t h o u t c o mp l e t e s u r g i c a l d e b r i d e me n t . P r e d i s p o s i n g f a c t o r s i n c l u d e d i a b e t e s me l l i t u s , i mmu n o s u p p r e s s i o n , a n d t r a u ma ( o f t e n mi n o r ) . Ur gent s ur gi c al debr i dement i s mandat or y t o s av e l i mb and l i f e . C T a n d M R I h e l p t o a s s e s s t h e e xt e n t o f i n v o l v e H o as sl u e sD[J , M a r k E J . d ti d ey W e e k l y c l i n c o p a t h o l o g i c a l e xe r c i s e s : C a s e 2 8 - 2 0 0 2 : A 3 5 - y e a r - o l d l o n g - t e r m t r a v e l e t o t h e C a r i b b e a n w i t h a r a p i d l y p r o g r e s s i v e s o f t - t i s s uN iEngl tJ oM .ed e nfec i n 2 0 0 2 ; 3 4 7 : 8 3 1 8] 3 7 .

Ac r o m e g a l y a n d G i g a n t i s m : P a t h o p h y s i o l o gT : e h a n d s e n l a r g e f r o m o v e r g r o w t h o f b o n e a n d s o f t t i s s u e s , yh s t i mu l a t e d b y a n e xc e s s o f g r o w t h h o r mo n e , u s u a l l y f r o m a n a d e n o ma o f t h e a n t e r i o pituitary gland. When the condition occurs before the epiphyses close, the enlarged s k e l e t o n i s w e l l p r o p o r t i o n e d a n d t h e c o n d i t i o n i s t e r me d g i g a n t i s m. W h e n g r o w t h o c c u r s a f t e r e p i p h y s e a l c l o s u r e , t h e s k e l e t a l p a t t e r n i s c a l l e d a c r o me g a l y, i n w h i c h t h e h a n d s , f e e t , f a c e , h e a d , a n d s o f t t i s s u e s a r .e P a tlia rn te do f t e n h a v e en e g s d i f f u s e mu s c u l a r o r j o i n t s t i f f n e s s a n d ma y c o mp l a i n o f h e a d a c h e s a n d b a c k p a i n . E xa mi n a t i o n s h o w s t h i c k e n i n g o f t h e s o f t t i s s u e s , p a r t i c u l a r l y a p p a r e n t i n t h e f a c e , h a n d s , a n d f e e t . W i d e n i n g w i t h o u t l e n g t h e n i n g o f t h e b o n e s l e a d s t o p r o mi n e n c e o f t h e j a w, w i d e s p a c i n g o f t h e t e e t h , p r o mi n e n t s u p r a o r b i t a l r i d g e , a n d e n l a r g e d h a n d a n d f e e t . O s t e o a r t h r i t i s i s c o mmo n . In a d v a n c e d d i s e a s e w i t h s u p r a s e l l a r e xt e n s i o n o f t h e t u mo r, s i g n s o f h y p o p i t u i t a r i s m a n d b i t e mp o r a l h e mi a n o p s i a ma y b e p r e s e n t . M ar fan Syndr ome:
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M ar fan Syndr ome: P a t h o p h y s i o l o gT : i s i s a c o n g e n i t a l d i s e a s e , f r e q u e n t l y i n h e r i t e d a s a n yh a u t o s o ma l d o mi n a n t , b u t s p o r a d i c c a s e s d o o c c u r. It a f f e c t s t h e d e v e l o p me n t o f b o n e , l i g a me n t s , t e n d o n s , a r t e r i a l w a l l s , a n d s u p p o r t i n g s t r u c t u r e s i n t h e h e a r t a n d e y e s M a n y p e r s o n s s h o w o n l y a f e w s t i g ma s , w h i l e t h e c o mp l e t e s y n d r o me p r e s e n t s . a striking portrait. T he long, slender phalanges, spider fingers, have given the nam a r a c h n o d a c t y l y t o t h e d i s e a s e , a l t h o u g h s o me p a t i e n t s w i t h M a r f a n s y n d r o me l a c k t h i s s i g n . T h e s k u l l i s l o n g a n d n a r r o w, a n d t h e p a l a t e i s h i g h a n d a r c h e d . T h e l o n g b o n e s a r e t h i n a n d e l o n g a t e d , s o t h e f i n g e r - t o - f i n g e r s p a n w i t h t h e o u t s p r e a d a r ms e xc e e d s t h e b o d y h e i g h t . T h o r a c i c d e f o r mi t i e s ma y b e e i t h e r p e c t u s e xc a v a t u m ( f u n n e l b r e a s t ) o r p e c t u s c a r i n a t u m ( p i g e o n b r e a s t ) . T h e s p i n e ma y e xh i b i t f u s e d v e r t e b r a e o r s p i n a b i f i d a . J o i n t l a xi t y p e r mi t s h y p e r e xt e n s i o n ( d o u b l e - j o i n t e d n e s s ) , d i s l o c a t i o n s , k y p h o s c o l i o s i s , p e s p l a n u s , o r p e s c a v u s . T h e e a r s ma y b e l o n g a n d p o i n t e d , s a t y r e a r. W e a k n e s s o f t h e s u p p o r t i n g s t r u c t u r e s o f t h e e y e p r o d u c e s e l o n g a t i o n o f t h e g l o b e ( my o p i a ) , r e t i n a l d e t a c h me n t , l e n t i c u l a r d i s l o c a t i o n , a n d b l u s c l e r a e . D e g e n e r a t i o n o f t h e v a s c u l a r e l a s t i c me d i a l e a d s t o a n e u r y s ma l d i l a t a t i o n o t h e a o r t a o r p u l mo n a r y a r t e r y. S u b s e q u e n t d i s s e c t i o n o r r u p t u r e a r e c o mmo n c a u s e s o f e a r l y d e a t h . D e f o r mi t i e s o f t h e c a r d i a c v a l v e c u s p s a r e s i t e s f o r b a c t e r i a l e n d o c a r d i t i s . T h e f o r a me n o v a l e ma y r e ma i n p a t e n t .
P. 7 7 5

Conditions Primarily Affecting Joints

Ar t h r i t i s : I n f l a m m a t o r y a n d No n i n f l a m m a t o r y J o i n t D i s e a s e : T h e d i a g n o s i s arft hr i t i s e q u i r e s t h e e xa mi n e r t o c o n f i r m s i g n s o f a c u t e o r c h r o n i c o r j o i n t i n f l a mma t i o n : r e d n e s s , w a r mt h , t e n d e r n e s s , s y n o v i a l t h i c k e n i n g , e f f u s i o n , b o n y e n l a r g e me n t , o r e r o s i v e c h a n g e s o n x- r a y. T h e mo s t d i a g n o s t i c a l l y u s e f u l d e s c r i p t i v classification of joint diseases is based upon the history and physical findings. Firs t h e n u mb e r o f j o i n t s a c t i v e l y i n v o l v e d i s a s smonar t iacsul ar1 j o i n t ) , essed ( ol i goar t i c ul ar 4 j o i n t s ) pol y ar t i c ul ar> 4 j o i n t s ) . F o r p a t i e n t s w i t h o l i g o - o r (2 or ( p o l y a r t h r i t i s , n o t e t h e p a t t e r n o f j o i n t i n v o l v e me n t : ( a ) l a r g e mo r e p r o xi ma l j o i n t s o r d i s t a l s ma l l j o i n t s ; ( b ) a xi a l j o i n t s a n d / o r p e r i p h e r a l j o i n t s ; a n d ( c ) w h e t h e r i n v o l v e me n t ss mmet r i c r as y mmet r i cW i d e s p r e a d a n d s y mme t r i c a l j o i n t iy o . i n v o l v e me n t i n c r e a s e s t h e l i k e l i h o o d o f a s y s t e mi c i n f l a mma t o r y d i s e a s e p r i ma r i l y i n v o l v i n g t h e j o i n t s ( e . g . , r h e u ma t o i d a r t h r i t i s , s y s t e mi c l u p u s e r y t h e ma t o s u s ) . C a r e f u l a t t e n t i o n d u r i n g t h e p h y s i c a l e xa m i s n e c e s s a r y t o d i s t i n g u i s h i n v o l v e me n t o t h e j o i n t ( s y n o v i u m a n d a r t i c u l a r c aar itlhrg t i):s f r o m i n f l a mma t i o n o f t h e rt a i e p e r i a r t i c u l a r t e n d o n a n d l i g a me n t i n s e r t i o n s i n t o b o n e ( t h e e n t h ei s i sh e ent hes i t ) s t : , t e n d o n s a n d t h e i r s h e attendoni t i s n dt enos y nov i t)i s r t h e u n d e r l y i n g b o n e hs ( a o ( os t ei t i)s . N o c l a s s i f i c a t i o n s y s t e m i s p e r f e c t a n d t h e e xa mi n e r mu s t a l w a y s b e a l e r t t o evolution of the pattern over periods ranging from days to weeks or years. R e me mb e r t h a t p o l y a r t h r i t i c d i s e a s e s ma y i n i t i a l l y p r e s e n t w i t h s i n g l e j o i n t i n v o l v e me n t . C o r r e c t r h e u ma t o l o g i c d i a g n o s i s r e q u i r e s p a t i e n c e a n d a n o p e n mi n d .

M o n a r t i c u l a r Ar t h r i t i s : Ar t h r i t i s i n v o l v i n g a s i n g l e j o i n t i s l i k e l y c a u s e d b y l o c a l me c h a n i c a l , i n f l a mma t o r y, i n f e c t i o u s f a c t o r s . L e s s c o mmo n l y, i t i s t h e i n i t i a l ma n i f e s t a t i o n o f a s y s t e mi c p r o c e
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t h a t w i l l i n v o l v e o t h e r j o i n t s . S e q u e n t i a l i n v o l v e me n t o f s i n g l e j o i n t s w i t h i n t e r v e n i n r e mi s s i o n s s u g g e s t a n u n d e r l y i n g s y s t e mi c d i s o r d e r ( c o n g e n i t a l o r a c q u i r e d ) w i t h s u p e r i mp o s e d l o c a l p r e c i p i t a t i n g e v e n t s , f o r e xa mp l e , t r a u ma i n h e mo p h i l i a .

M O NO ART HRI T I S C L I NI C AL O C C URRE NC E : Congeni t al e mo p h i l i a ; h Endoc r i ne y p e r p a r a t h y r o i d i s m, h y p o t h y r oIidii opat hi c h d s m; o s t e o a r t h r i t iIs ; l ammat or y / I mmunes t i n f e c t i o u s r e a c t i v e a r t h r i t i s ( e . g . , R e i t e r nf po s y n d r o me , v i r a l e xa n t h e ms ) , p s o r i a s i s , r h e u ma t o i d a r t h r i t i s ( i n i t i a l p r e s e n t a t i o n ) , s y s t e mi c l u p u s e r y t h e ma t o s u s ( S L E ) , a my lIo i d o s i s ; a c u t e s e p t i c a r t h r i t i s nf ec t ous ( St aphy l oc oc c us aur,eus n o c o c c e mi a , o t h e r s ) , Ly me d i s e a s e , my c o b a c t e r i a , go o s t e o my e l i t i s , v i r a l ( e . g . , H IV, p a r v o v i r u s ,Mo t h e r s )i ;c / Toxc c y s t a l - i n d u c e d et abol ir d i s e a s e s ( e . g . , g o u t , c a l c i u m p y r o p h o s p h a t e d e p o s i t i o n , c a l c i u m h y d r o xy a p a t i t e , c a l c i u m o xa l a t e ) , s c uM ec hani c al / Tr aumat il c n t t r a u ma , h e ma r t h r o s i s , f r a c t u r e , rvy; b u r e p e t i t i v e u s e / o v e r u s e ; as t i c a r c o ma ( b o n e , s y n o v i u m, o r c a r t i l a g e ) , Neopl s me t a s t a s e s t o b o n e , b e n i g n t u mo r s ( e . g . , o s t e o c h o n d r o ma , o s t e o i d o s t e o ma , p i g me n t e d v i l l o n o d u l a r s y n o v i t i s ) , l e u k e mi aogi c e u r o p a t h y p r o d u c i n g a Neur ol ; n C h a r c o t j o i nVas c ul aro s t e o n e c r o s i s . t;
P. 7 7 6

AC UT E M O NART HRI T I S : S UP P URAT I V E ART HRI T I S : P a t h o p h y s i o l o g B : c t e r i a l i n f e c t i o n , mo s t c o mmo nSt aphy l oc oc c us ya ly with aur eus r e s u l t s f r o m d i r e c t e xt e n s i o n ( f r o m s k i n , s o f t t i s s u e , o r p e r i a r t i c u l a r b o n e ) o r , f r o m h e ma t o g e n o u s s p r e a d ( e . g . , b a c t e r i a l e n d o c a r d i t i s , g o n o r r h e a b a c t e r e mi a ) . R e l e a s e o f l y s o s o ma l e n zy me s c a n r a p i d l y d e s t r o. y Ut s u ajl oy no n e j o i n t i s he l i t involved, often the knee, but in gonococcal arthritis, three-fourths of the patients h a v e a n i n i t i a l t r a n s i e n t ( 2 4 d a y s ) mi g r a t o r y o l i g o a r t h r i t i s a n d / o r t e n o s y n o v i t i s . S y mp t o ms o f t e n b e g i n s u d d e n l y w i t h c h i l l s a n d f e v e r. T h e j o i n t s w e l l s r a p i d l y, t h e o v e r l y i n g s k i n i s r e d a n d w a r m, a n d t h e j o i n t i s p a i n f u l a n d t e n d e r t o t o u c h . T h e s w e l l i n g b e c o me s f l u c t u a n t , i n d i c a t i n g f l u i d i n t h e s y n o v i a l c a v i t y. S i g n s o f i n f e c t i o n i n i mmu n o s u p p r e s s e d p a t i e n t s a r e f r e q u e n t l y a b s e n t . J o i n t a s p i r a t i o n d i s c l o s e s p u r u l e n t f l u i d t h a t mu s t b e c u l t u r e d a n d g r a m s t a i n e d t o i d e n t i f y t h e c a u s a t i v e o r g a n i s m. S E P T I C ART HRI T I S C L I NI C AL O C C URRE NC E : In a d d i t i o n S. aur eus n d g o n o r r h e a , l e s s - c o mmo n o r g a n i s ms t o c o n s i d e r a r e to a s t r e p t o c o c c i , me n i n g o c o c c i , Haemophi l us i nf l uenzaep e c i a l l y i n u n i mmu n i ze d (es i n f a n t s a n d c h i l d r e n ) , a n d , r a r e l y, b r u c e l l o s i s , t y p h o i d f e v e r, g l a n d e r s , b l a s t o my c o s g r a n u l o ma i n g u i n a l e , t u b e r c u l o s i s , a n d f u n g i , a s w e l l a s o t h e r s .

AC UT E M O NART HRI T I S : G O UT: P a t h o p h y s i o l o g U:r i c a c i d a c c u mu l a t e s i n t i s s u e a n d e xt r a c e l l u l a r f l u i d a s a r e s u l t y o f g e n e t i c ( p r i ma r y g o u t ) o r a c q u i r e d ( s e c o n d a r y g o u t ) c a u s e s o f u r i c a c i d o v e r p r o d u c t i o n o r u n d e r e xc r e t i o n . W h e n t h e f l u i d b e c o me s s u p e r s a t u r a t e d , c r y s t a l s form in the tissue. When crystals are shed into the joint fluid and phagocytosed by p o l y mo r p h o n u c l e a r n e u t r o p h i l s ( P M N s ) , a c u t e i n f l a mma.t iL a r g e stu sts u e on r il s d e p o s i t s o f u r i c a c i d ( t o p h i ) o c c u r r i n g a r o u n d j o i n t s o v e r b o n y p r o mi n e n c e s a r e n o t u s u a l l y i n f l a me d . T h e i n i t i a l a t t a c k p r e s e n t s t h e c h i e f d i a g n o s t i c p r o b l e m b e c a u s e a h i s t o r y o f r e c u r r e n t s t e r e o t y p i c e p i s o d e s i s v e r y s u g g e s t i v e o f g o u t . F r e q u e n t l y, t h e p a t i e n t i s a w a k e n e d f r o m s l e e p b y s e v e r e b u r n i n g p a i n , t i n g l i n g , n u mb n e s s , o r
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w a r mt h i n a j o i n t . T h e j o i n t r a p i d l y s w e l l s a n d b e c o me s e xc r u c i a t i n g l y t e n d e r, i n t o l e r a n t t o t h e p r e s s u r e o f t h e b e d c l o t h e s . T y p i c a l l y, t h e o v e r l y i n g s k i n b e c o me s r e d o r v i o l a c e o u s . T h e r e ma y b e ma l a i s e , h e a d a c h e , f e v e r, a n d t a c h y c a r d i a . U n t r e a t e d , t h e a t t a c k l a s t s f o r 1 2 w e e k s . In mo r e t h a n h a l f t h e c a s e s , t h e me t a t a r s o p h a l a n g e a l j o i n t o f t h e g r e a t t o e i s a f f e c t e d i n i t i a l l y ( p o d a g r a ) . O t h e r s i t e a r e t h e mi d f o o t ( i n s t e p ) , a n k l e , k n e e , e l b o w, o r w r i s t . Ac u t e g o u t i n t h e mi d f o o t r e s e mb l e s c e l l u l i t i s . T h e a t t a c k s ma y b e t r i g g e r e d b y t r a u ma , s u r g e r y, a c i d o s i s , i n f e c t i o n , e xp o s u r e t o c o l d , c h a n g e s i n a t mo s p h e r i c p r e s s u r e , o v e r i n d u l g e n c e i n alcoholic beverages, or any acute illness.

P. 7 7 7 AC UT E M O NART HRI T I S : C AL C I UM P Y RO P HO S P HAT E D I HY D RAT E D E P O S I T I O N D I S E AS E ( C P P D D , P S E UD O G O UT, C HO ND RO C AL C I NO S I S ) : P a t h o p h y s i o l o g C:a l c i u m p y r o p h o s p h a t e d i h y d r a t e , s h e d f r o m a r t i c u l a r c a r t i l a g e , y c r y s t a l i ze s w i t h i n t h e j o i n t i n t o s ma l l , r h o mb o i d a l , w e a k l y p o s i t i v e b i r e f r i n g e n t c r y s t a l s t h a t t r i g g e r t h e i n f l a mma t i o n . Ar t i c u l a r f i b r o c a r t i l a g e ma y c a l c i f y a n d b e d e t e c t e d b y x- r a y ( c hondr oc al c i nos ii s t h e k n e e o r w r Tsh i s d i s o r d e r i s q u i t e ) n . i t s i mi l a r t o t r u e g o u t i n b o t h i t s a c u t e a n d c h r o n i c f o r ms . T h e a t t a c k b e g i n s a b r u p t l y w i t h p a i n f u l s w e l l i n g a n d h e a t , u s u a l l y i n a s i n g l e j o i n t , o c c a s i o n a l l y i n t w o o r mo r e j o i n t s . T h e k n e e , a n k l e , a n d w r i s t a r e mo s t c o mmo n l y a f f e c t e d . U n t r e a t e d , t h e p a i n and tenderness are intense for 24 days, then they gradually subside during the ne 1 2 w e e k s . It i s c o mmo n l y a s s o c i a t e d w i t h i n c r e a s i n g a g e a n d o s t e o a r t h r i t i s a n d ma b e a c l u e t o h y p e r p a r a t h y r o i d i s m o r h e mo c h r o ma t o s i s ( a p p r o xi ma t e l y 5 % o f C P P D D )

C HRO NI C M O NART HRI T I S : T UB E RC UL O S I S : T h e r e i s c h r o n i c s w e l l i n g o f a s i n g l e j o i n t w i t h o n l y mo d e r a t e p a i n . J o i n t e f f u s i o n ma y b e p r e s e n t w i t h t h i c k e n i n g o f t h e s y n o v i u m. M o s t c o mmo n l y a f f e c t e d a r e t h e hips, knees, and spine. Previous intraarticular or oral corticosteroids and i mmu n o s u p p r e s s i v e d r u g s a r e ma j o r r i s k f a c t o r s . C u l t u r e s o f a s p i r a t e d j o i n t f l u i d o r s y n o v i a l b i o p s y y iMly c obac t er i um t uber c ul. os i s e d C HRO NI C M O NART HRI T I S : S Y P HI L I S : C l i n i c a l l y, t h i s ma y b e i d e n t i c a l t o t u b e r c u l o u s a r t h r i t i s . N e g a t i v e c u l t u r e s a n d p o s i t i v e s e r o l o g i c t e s t s f o r s y p h i l i s ma k e t h e d i s t i n c t i o n . M O NART HRI T I S : E P I S O D I C PAI NL E S S E F F US I O NS O F T HE K NE E S : T h e p a t i e n t e xp e r i e n c e s e p i s o d e s o f p a i n l e s s s w e l l i n g a n d j o i n t e f f u s i o n i n o n e o r b o t h k n e e s , w i t h n o c o n s t i t u t i o n a l s y mp t o ms o v e r a n u mb e r o f y e a r s , w i t h a n a v e r a g e d u r a t i o n o f 3 5 d a y s . T h e c a u s e i s u n k n o w n , t h o u g h , o c c a s i o n a l l y, t h e c o n d i t i o n p r e s a g e s t h e o n s e t o f r h e u ma t o i d a r t h r i t i s .

M O NART HRI T I S : T RAUM A: P a t h o p h y s i o l o g M:e c h a n i c a l t r a u ma a s a r e s u l t o f f a l l s , s p o r t s , o r o t h e r a c t i v i t i e s y c a u s e s b l e e d i n g ( h e ma r t h r o s i s ) o r e f f u s i o n w i t h p a i n a s a c o n s e q u e n c e o f d a ma g e t t h e j o i n t c a p s u l e , i n t r a - o r p e r i a r t i c u l a r l i g a me n t s , c a r t i l. aT h e o rn e e n e d ge, k bo an a n k l e a r e c o mmo n l y a f f e c t e d , b u t a n y j o i n t c a n b e i n j u r e d . T h e e xa c t me c h a n i s m o f i n j u r y, t i me c o u r s e o f p a i n ( i mme d i a t e v e r s u s d e l a y e d ) , a n d p h y s i c a l e xa mi n a t i o n w i a s s i s t i n s u g g e s t i n g t h e t y p e a n d d e g r e e o f i n j u r y. G u i d e l i n e s f o r t h e p r o p e r u s e o f r a d i o l o g i c e xa m f o r i n j u r i e s t o t h e a n k l e a n d k n e e h a v e b e e n d e v e l o p e d . M O NART HRI T I S : C HARC O T J O I NT:
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S e e p a g e 7 7.9 P. 7 7 8

Oligoar thr itis and Polyar thr itis: Ar t h r i t i s i n v o l v i n g s e v e r a l j o i n t s , e i t h e r s i mu l t a n e o u s l y o r s e q u e n t i a l l y, i s t e r me d o l i g o a r t h r i t i s a n d p o l y a r t h r i t i s . T h e p a t t e r n o f i n v o l v e me n t c a n b e u s e f u l i n h e l p i n g i d e n t i f y t h e e xa c t d i a g n o s i s . G e n e r a l l y, o l i g o a r t h r i t i s i n v o l v e s l a r g e r j o i n t s a n d i s as y mmet r i c h i l e t h e c l a s s i c p o l y a r t h r i t i s s y n d r o me s ( r h e u ma t o i d a r t h r i t i s [ R A] , w s y s t e mi c l u p u s e r y t h e ma t o s u s [ S L E ] ) sn v o l v e r i co i n t s , i n c l u d i n g t h e s ma l l i y mmet j j o i n t s o f t h e h a n d s a n d f e e t . T h e s e a r e o n l y g u i d e l i n e s a n d mu s t n o t b e i n t e r p r e t e d as hard-and-fast rules.

O L I G O - AND P O LYART HRI T I S C L I NI C AL O C C URRE NC E : Congeni t al e mo p h i l i a , f a mi l i a l M e d i t e r r a n e a n f e v e r, h e mo c h r o ma t o s i s , s i c k l e c e l l h d i s e a s eEndoc r i ne y p e r p a r a t h y r o i d i s m, h y p o t h y r o i d i s m, a c r o di opaty ; c ; h I me g a l hi i n f l a mma t o r y o s t e o a r t h r infi lsammat or y / I mmunes t i n f e c t i o u s r e a c t i v e a r t h r i t i s I t ; po ( e . g . , R e i t e r s y n d r o me , v i r a l e xa n t h e ms , i n f l a mma t o r y b o w e l d i s e a s e ) , p s o r i a s i s , r h e u ma t o i d a r t h r i t i s , S L E , r h e u ma t i c f e v e r, a n k y l o s i n g s p o n d y l i t i s , s y s t e mi c s c l e r o s ( s c l e r o d e r ma ) , p o l y my o s i t i s / d e r ma t o my o s i t i s , S t i l l d i s e a s e , B e h e t s y n d r o me , r e l a p s i n g p o l y c h o n d r i t i s , a my l o i d o s i s , s a r c o i d o s i s , e r y t h e ma mu l t i f o r me , e r y t h e ma n o d o s u m, d r u g r e a c t i o n s , s e r u m s i cIk n e s si;ous e p t i c a r t h r i t i s ( b a c t e r i a l nf ec t s e n d o c a r d i t i s , aphy l oc oc c us aur,eus n o c o c c e mi a , o t h e r s ) , Ly me d i s e a s e , v i r a l St go ( e . g . , H IV, p a r v o v i r u s , r u b e l l a , mu mp s , o t h e r s ) , W h i p p l e d i s e a s e , my c o s e s ( c o c c i d i o i d o my c o s i s , h i s t o p l a s mo s i s , b l a s t o my c o s i s , c r y p t o c o c c o s i s ) , a c t i n o my c o s i s s e c o n d a r y s y p h i l i s , b r u c e l l o s i s , t y p h o iM et abol; i c / Toxc c y s t a l - i n d u c e d d fever ir d i s e a s e s ( e . g . , g o u t , c a l c i u m p y r o p h o s p h a t e d e p o s i t i o n , c a l c i u m h y d r o xy a p a t i t e , c a l c i u m o xa l a t e ) , s c uNeopl as t i c a r c o ma ( b o n e , s y n o v i u m, o r c a r t i l a g e ) , rvy; s me t a s t a s e s t o b o n e , b e n i g n t u mo r s ( e . g . , o s t e o c h o n d r o ma , o s t e o i d o s t e o ma , p i g me n t e d v i l l o n o d u l a r s y n o v i t i sc)ul aro s t e o n e c r o s i s , s y s t e mi c v a s c u l i t i s , Vas ; h y p e r t r o p h i c o s t e o a r t h r o p a t h y.

M I G RAT O RY O L I G O ART HRI T I S : G O NO C O C C AL ART HRI T I S : P a t h o p h y s i o l o gNei s s er i a gonor r hoeaee c t s t h e u r e t h r a o r u t e r i n e c e r v i x a n d y: inf t h e n d i s s e mi n a t e s h e ma t o g e n o u s l y t o s y n o v i a l me mb r a n e s a n d s k i n , c a u s i n g l o c a l i n f l a mma t i o n . In f e c t i o u s a r t h r i t i s , t e n o s y n o v i t i s , a n d s k i n l e s i o n s a r e t h e mo s t c o mmo n e xt r a g e n i t a l c o mp l i c a t i o n s o f g o nO nreh eo 4 w e e k s a f t e r t h e o n s e t o f . or t a u r e t h r i t i s , i n f l a mma t i o n ma y s u d d e n l y o c c u r i n t h e k n e e s , w r i s t s , a n d a n k l e s , a l t h o u g h o t h e r j o i n t s ma y b e a f f e c t e d . T h e mo s t c o mmo n p a t t e r n i s a mi g r a t o r y o l i g o a r t h r i t i s a n d t e n o s y n o v i t i s . S ma l l a mo u n t s o f t h i n f l u i d ma y a c c u mu l a t e i n j o i n t c a v i t i e s , f r o m w h i c h o r g a n i s ms a r e d i f f i c u l t t o i s o l a t e . In o t h e r c a s e s , s u p p u r a t i v e a r t h r i t i s d e v e l o p s , w i t h i n f l a mma t i o n o f a s i n g l e j o i n t a n d p r o d u c t i o n o f p u r u l e n t e xu d a t e i n w h i c h t h e g o n o c o c c u s c a n b e i d e n t i f i e d . Te n o s y n o v i t i s i n t h e h a n d s , w r i s t s , o r a n k l e i s mo r e c o mmo n i n g o n o r r h e a t h a n i n a r t h r i t i s f r o m a n y o t h e r c a u s e T h e d i a g n o s i s ma y n o t b e e a s y b e c a u s e t h e g o n o c o c c u s i s d i f f i c u l t t o c u l t u r e f r o m t h e j o i n t s . P u s t u l a r s k i n l e s i o n s o n a n e r y t h e ma t o u s b a s e a r e s e e n w i t h g o n o c o c c a l b a c t e r e mi a a n d h e l p t o d i s t i n g u i s h g o n o c o c c a l a r t h r i t i s f r o m o t h e r c o n d i t i o n s . G e n i t a l , r e c t a l a n d t h r o a t s p e c i me n s f o r c u l t u r e o r p o l y me r a s e c h a i n r e a c t i o n ( P C R ) t e s t i n g o f u r i n e f o r g o n o c o c c u s a n d c h l a my d i a s h o u l d b e o b t a i n e d . R e i t e r s y n d r o me (nonspecific urethritis, arthritis, and conjunctivitis) following nongonococcal urethri
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(nonspecific urethritis, arthritis, and conjunctivitis) following nongonococcal urethri ma y c a u s e c o n f u s i o n , b e c a u s e c o n j u n c t i v a l i n f e c t i o n i s p r e s e n t i n u p t o 1 0 % o f patients with gonorrhea.

O L I G O ART HRI T I S : ANK Y L O S I NG S P O ND Y L I T I S : S e e p a g e 7 2.2


P. 7 7 9 O L I G O ART HRI T I S : RE AC T I V E ART HRI T I S ( RE I T E R S Y ND RO M E ) : F o l l o w i n g i n f e c t i o n o f t h e u r e t h r a ( c h l a my d i a ) ogel lua, ( Sal monel l a, Yer s i ni a, Shi r g t Campy l obac t ) a n o l i g o a r t h r i t i s , p r e d o mi n a t e l y o f t h e l o w e r e xt r e mi t i e s , d e v e l o p s . It er ma y b e a c c o mp a n i e d b y e n t h e s i t i s o f t h e h a n d s , a n k l e s , a n d f e e t , c o n j u n c t i v i t i s , u r e t h r i t i s , a n d r a s h o n t h e g l a n s p e n i s ( c i r c i n a t e b a l a n i t i s ) a n d f e e t ( k e r a t o d e r ma b l e n o r r h a g i c a ) . S a c r o i l i i t i s a n d s p i n e i n v o l v e me n t ma y o c c u r. In a d d i t i o n , 8 5 % o f p a t i e n t s a r e H L AB 2 7 p o s i t i v e .

O L I G O ART HRI T I S : E NT E RO PAT HI C ART HRI T I S : In f l a mma t o r y a s y mme t r i c a r t h r i t i s p r e d o mi n a t e l y o f t h e a n k l e s a n d k n e e s ma y o c c u r i n a s s o c i a t i o n w i t h i n f l a mma t o r y b o w e l d i s e a s e ( u l c e r a t i v e c o l i t i s a n d C r o h n d i s e a s e )Ent hes i t i ss c o mmo n , e s p e c i a l l y a t t h e Ac h i l l e s t e n d o n i n s e r t i o n , a n d . i s y mme t r i c a l s a c r o i l i a c a n d s p i n a l i n v o l v e me n t o c c u r s . T h e a r t h r i t i s ma y p r e c e d e c l i n i c a l ma n i f e s t a t i o n s o f t h e i n f l a mma t o r y b o w e l d i s e a s e .

O L I G O ART HRI T I S : P S O RI AT I C ART HRI T I S : T h e j o i n t d i s e a s e i s u s u a l l y a n a s y mme t r i c a l o l i g o - o r p o l y a r t h r i t i s o f s ma l l a n d l a r g j o i n t s . It i s o c c a s i o n a l l y a s y mme t r i c a l p o l y a r t h r i t i s r e s e mb l i n g r h e u ma t o i d a r t h r i t i s ( R A) . D e s t r u c t i v e a r t h r i t i s o f t h e d i s t a l i n t e r p h a l a n g e a l j o i n t s i s s e e n i n p s o r i a t i c a r t h r i t i s b u t n o t i n R A. S p o n d y l i t i s a n d s a c r o i l i i t i s o c c u r i n u p t o 2 5 % o f p a t i e n t s w i p s o r i a t i c a r t h r i t i s , e s p e c i a l l y t h o s e w i t h H L AB 2 7 . E n t h e s i t i s ma y p r e d o mi n a t e i n s o me p a t i e n t s . T h e a r t h r i t i s ma y p r e c e d e , a c c o mp a n y, o r f o l l o w o n s e t o f t h e s k i n r a s h . P h y s i c a l e xa mi n a t i o n s h o u l d i n c l u d e a c a r e f u l s k i n e xa mi n a t i o n , e s p e c i a l l y o f t h e s c a l p ( t h e r a s h ma y b e h i d d e n b y h a i r o r d i s mi s s e d a s s e b o r r h e a ) a n d f i n g e r n a i (looking for pits and onycholysis).

O L I G O ART HRI T I S : T O P HAC E O US G O UT: S e e p a g e 7 7.6P a t h o p h y s i o l o g To p h i a r e ma s s e s o f s o d i u m u r a t e c r y s t a l s y: d e p o s i t e d i n t h e t i s s u e s o f t e n o v e r b o n y p r o mi n e n c e s a n d a r o u n d j o i n t s w h e r e t h e y e r o d e b o n e . Ac t i n g a s f o r e i g n b o d i e s , t h e y s t i mu l a t e l o w - g r a d e i n f l a mma t i o n t h a t ma e xt r u d e t h e t o p h i t h r o u g h t h.e Tsh ena s y mme t r i c a l n o d u l a r s w e l l i n g s a n d c a r t i l a g e ki d e g e n e r a t i o n ma y i mp a i r j o i n t f u n c t i o n . C l i n i c a l s i g n s o f i n f l a mma t i o n a r e v a r i a b l e , f r o m mi l d t o mo d e r a t e l y s e v e r e . T h e o l e c r a n o n , b u n i o n a n d p r e p a t e l l a r b u r s a e , a n d h a n d s a r e mo s t f r e q u e n t l y a f f e c t e d .
P. 7 8 0

O L I G O ART HRI T I S : C HARC O T J O I NT: P a t h o p h y s i o l o gAb s e n c e o f p a i n o r p r o p r i o c e p t i v e s e n s a t i o n i n a j o i n t l e a d s t o y: l o s s o f j o i n t i n t e g r i t y. R e p e a t e d i n j u r i e s c a u s e s u c c e s s i v e l y t h r e e s t a g e s o f a r t i c u l a d a ma g e : s w e l l i n g , j o i n t d e g e n e r a t i o n , a n d f o r ma t i o n o f n e w b o n e . In t h e i n i t i a l s t a g e r y t h e ma a n d s w e l l i n g a r e t h e o n l y f i n d i n g s . T h e c o u r s e i s p r o g r e s s i v e w i t h h y p e r mo b i l i t y, t r a u ma t i c o s t e o p h y t e f o r ma t i o n , a n d s u b l u xa t i o n l e a d i n g t o p a i n l e s s d e f o r mi t i e s a n d c r e p i t u s o n mo v eIn an t y s t a g e , t h e d i a g n o s t i c c l u e i s t h e . me n


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a b s e n c e o f t h e e xp e c t e d p a i n w i t h mo v e me n t a n d l o s s o f p a i n s e n s a t i o n a n d p r o p r i o c e p t i o n i n t h e i n v o l v e d l i mb . A s i n g l e j o i n t ma y b e a f f e c t e d , o r, c o mmo n l y, a l t h e j o i n t s i n a n a n a t o mi c r e g i o n ( e . g . , t h e mi d f o o t j o i n t s ) a r e i n v o l v e d . P h y s i c a l e xa s h o u l d t r y t o d e t e r mi n e i f t h e n e u r o p a t h y i s p a r t o f a l o c a l o r s y s t e mi c n e u r o p a t h i c process. Classic clinical conditions causing Charcot joints include tabes dorsalis ( k n e e mo s t c o mmo n l y i n v o lF ie d 1 3 - 4 4] C h i p , a n k l e , l o w e r s p i n e , l e s s f r e q u e n t l y v g. [ ; i n v o l v e d ) , d i a b e t e s me l l i t u s ( t a r s a l a n d me t a t a r s a l j o i n t s mo s t c o mmo n l y, a n k l e o c c a s i o n a l l y, k n e e r a r e l y ) , s y r i n g o my e l i a ( u s u a l l y j o i n t s o f t h e u p p e r l i mb s ) , a n d l e p r o s y H[ a r t e ma n n - H e u r t i e r A, Va n G H , G r i ma l d i A. T h e C h a r c o t eto o t . Lanc f 2 0 0 2 ; 3 6 0 : 1 7 7 6 1 7.7 9 ] P. 7 8 1

S Y M M E T RI C I NF L AM M AT O RY P O LYART HRI T I S : RHE UM AT O I D ART HRI T I S ( RA) : P a t h o p h y s i o l o g R:A i s c h a r a c t e r i ze d b y p r o l i f e r a t i o n o f i n f l a me d s y n o v i a l t i s s u e y (pannus) that enters the joint cavity in tongue-like projections. T he pannus erodes c a r t i l a g e , p e r i a r t i c u l a r b o n e , a n d s o f t t i s s u e s , i n c l u d i n g t e n d o n s a n d l i g a me n t s . Untreated, the result is destruction of the joint surfaces and supporting structures p r o d u c i n g s u b l u xa t i o n , d e f o r mi t y, a n d l o s s o f j o i.n T hu no nis e t ma y b e t f e ct on i n s i d i o u s w i t h mo r n i n g s t i f f n e s s a n d p a i n f o l l o w e d b y s w e l l i n g a n d t e n d e r n e s s o f t h e j o i n t s , p r o c e e d i n g o v e r w e e k s t o mo n t h s i n t o a s ma l l a n d l a r g e j o i n t p o l y a r t h r i t i s . L e s s c o mmo n l y, t h e o n s e t i s s u d d e n w i t h p a i n a n d s w e l l i n g o c c u r r i n g s i mu l t a n e o u s l y i n s e v e r a l j o i n t s a c c o mp a n i e d b y f e v e r a n d p r o s t r a t i o n . S ma l l e r j o i n t s o f t h e h a n d s ( me t a c a r p o p h a l a n g e a l [ M C P ] , p r o xi ma l i n t e r p h a l a n g e a l [ P IP ] ) , f e e t ( me t a t a r s o p h a l a n g e a l [ M T P ] ) , w r i s t s , a n d a n k l e s a r e t y p i c a l l y i n v o l v e d e a r l y a n d s y mme t r i c a l l y, a l t h o u g h o n s e t i n a s i n g l e l a r g e r j o i n t , u s u a l l y a k n e e , i s n o t r a r e . In t e r p h a l a n g e a l j o i n t s b e c o me f u s i f o r m f r o m j o i n t e f f u s i o n ( f l u c t u a n t ) o r t h i c k e n i n g the joint capsule (palpable as thickening of tissue over the joint). Distal i n t e r p h a l a n g e a l j o i n t s a r e i n v a r i a b l y s p a r e d . Te n d e r n e s s i s c o n f i n e d t o t h e r e g i o n o t h e c a p s u l e . E a r l y, j o i n t mo t i o n i s l i mi t e d b y p a i n o r f l u i d ; l a t e r, i t i s l i mi t e d b y f i b r o o r mu s c l e s h o r t e n i n g . M u s c l e w e a k n e s s a n d a t r o p h y ma y b e r a p i d a n d d i s p r o p o r t i o n a t e t o t h e d e g r e e o f d i s u s e . Al t h o u g h r e mi s s i o n s ma y o c c u r, t h e disease is usually progressive over a period of years. Joint contracture and s u b l u xa t i o n s a r e f r e q u e n t , w i t h s u b l u xa t i o n o f t h e me t a c a r p o p h a l a n g e a l j o i n t s p r o d u c i n g c h a r a c t e r i s t i c u l n a r d e v i a t i o n o f t h e f i n g e r s . Te n o s y n o v i t i s i s ma n i f e s t a s s w e l l i n g o f t h e t e n d o n s h e a t h s . In 2 0 3 5 % o f c a s e s , s u bheumato ud r c u t a n e oi s nodul esd e v e l o p o v e r b o n y p r o mi n e n c e s a n d t e n d o n s h e a t h s . T h e y a r e p a i n l e s s , f i r m, a n d f r e e l y mo v a b l e o v e r b o n e s , s i mi l a r t o t h o s e i n r h e u ma t i c f e v e r ( R F ) . A s e r i o u s l a t e c o mp l i c a t i o n i s i n s t a b i l i t y o f t h e c e r v i c a l s p i n e a s a c o n s e q u e n c e o f s u b l u xa t i o n o f C 1 o n C 2 , w h i c h ma y p r e s e n t a s n e c k p a i n o r u p p e r mo t o r n e u r o n signs. T here is no specific diagnostic test and diagnosis is based upon clinical and l a b o r a t o r y c r i t e r i a . Al t h o u g h r h e u ma t o i d f a c t o r c a n b e d e mo n s t r a t e d i n 8 0 % o f c a s e i t i s n e i t h e r s e n s i t i v e n o r s p e c i f i c . F r e q u e n t l y, t h e p a t i e n t mu s t b e o b s e r v e d f o r ma n mo n t h s b e f o r e t h e d i a g n o s i s i s s D c u r e . A f r e q u e n t l y i n v o l v e s t h e e D X: R t e mp o r o ma n d i b u l a r j o i n t u n l i k e R F. In r h e u ma t i c f e v e r, t h e a r t h r i t i s i s mi g r a t o r y, w h i i t i s p e r s i s t e n t i n R A. R e a c t i v e a r t h r i t i s ( R e i t e r s y n d r o me , p o s t d y s e n t e r y, o r u r e t h r i t i s ) i s u s u a l l y o l i g o a r t i c u l a r a n d ma i n l y a f f e c t s l a r g e j o i n t s , e s p e c i a l l y a n k l e s a n d k n e e s . An i n i t i a l mo n a r t h r i t i s ma y s u g g e s t a n i n f e c t i o u s o r c r y s t a l l i n e a r t h r i t i s ;
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h o w e v e r, a s p i r a t i o n o f j o i n t f l u i d e xc l u d e s t h e s e p o s s i b i l i t i e s .

Va r i a n t s o f Rh e u m a t o i d Ar t h r i t i s . F e l t y ' s s y n d r o ms t h e t r i a d o f r h e u ma t o i d a r t h r i t i s , s p l e n o me g a l y, a n d l e u k o p e n i a . ie P a l i n d r o m i c r h e u m a t ip rm s e n t s a s mu l t i p l e a f e b r i l e a t t a c k s o f p o l y a r t h r i t i s se l a s t i n g f o r o n l y 2 o r 3 d a y s , l e a v i n g n o r e s i d u a . S e g r e n 'rs s y n d r o m e j conda y is d i a g n o s e d w h e n k e r a t o c o n j u n c t i v i t i s s i c c a a n d xe r o s t o mi a a c c o mp a n y r h e u ma t o i d a r t h r i t i sVa s c u l i t i s y a c c o mp a n y R A a n d i n v o l v e t h e s k i n ( n e c r o s i s a n d n o d u l e s ) . ma a n d l u n gJ u ve n i l e r h e u m a t o i d a r t h irs t as g r o u p o f d i s o r d e r s w h i c h ma y o v e r l a p . i i w i t h t h e a d u l t d i s e a s e . S e e p e d i a t r i c t e xt s f o r d e s c r i p t i o n s a n d d e t a i l s .

I NF L AM M AT O RY P O LYART HRI T I S : S Y S T E M I C L UP US E RY T HE M AT O S US (SLE): P a t h o p h y s i o l o g T : e c a u s e i s u n k n o w n , b u t t h e d i s e a s e i n v o l v e s i n f l a mma t i o n o f yh mu l t i p l e t i s s u e s a n d o r g a n s a c c o mp a n i e d b y a n t i b o d i e s t o s p e c i f i c n u c l e a r a n t i g e n s t h a t a r e d e t e c t a b l e i n t h e s e r u m. T h e r o l e o f t h e s e a n t i b o d i e s i n t h e p a t h o g e n e s i s o t h e s y n d r o me i s u n c.l e ah i s i s a c h r o n i c i n f l a mma t o r y mu l t i s y s t e m d i s e a s e , mo r e T r c o mmo n i n w o me n t h a n me n . L u p u s , t h e L a t i n w o r d f o r w o l f , w a s a p p l i e d b e c a u s e t h e ma l a r e r y t h e ma o n t h e c h e e k s r e s e mb l e d a w o l f ' s f a c e . N o o n e s y mp t o m o r s i g n i s p a t h o g n o mo n i c o f S L E ; r a t h e r, t h e d i a g n o s i s i s e s t a b l i s h e d b y c l i n i c a l c r i t e r i a . T mo s t c o mmo n s y mp t o ms a n d s i g n s a r e f a t i g u e , ma l a i s e , o r f e v e r ( 9 0 % o f c a s e s ) , a r t h r i t i s o r a r t h r a l g i a s ( 9 0 % ) , a n d s k i n r a s h e s ( 5 0 6 0 % ) . T h e a r t h r a l g i a s , my a l g i a s , a n d j o i n t i n f l a mma t i o n r e s e mb l e mi l d r h e u ma t o i d a r t h r i t i s , b u t w i t h o u t t h e d e f o r mi t i e a n d s u b l u xa t i o n s s e e n i n R A. T h e ma l a r ( b u t t e r f l y ) r a s h i s a ma c u l a r t o ma c u l o p a p u l a r, s o me t i me s s c a l y, e r y t h e ma t o u s p r o c e s s f o r mi n g t h e w i n g s o f t h e b u t t e r f l y o n e a c h ma l a r p r o mi n e n c e , w i t h t h e t r u n k o f t h e i n s e c t o n t h e b r i d g e o f t h e n o s e . It ma y b e mo r e i n t e n s e a f t e r e xp o s u r e t o s u n l i g h t . In a d d i t i o n , t h e r e ma y b s k i n a t r o p h y, t e l a n g i e c t a s i a , a n d mu c o s a l u l c e r s . S e r o s i t i s i s c o mmo n , p r e s e n t i n g a p l e u r i s y ( w i t h e f f u s i o n a n d / o r p l e u r a l r u b s ) , a b d o mi n a l p a i n , o r p e r i c a r d i t i s . N o n b a c t e r i a l e n d o c a r d i t i s w i t h v a l v u l a r i n s u f f i c i e n c y ( u s u a l l y mi t r a l ) , C N S d i s e a s e ( w i t h p e r s o n a l i t y c h a n g e , p s y c h o s i s , o r s e i zu r e s ) a n d g l o me r u l o n e p h r i t i s c a n o c c u r a t a n y t i me i n t h e c o u r s e o f t h e d i s e a s e , a n d ma y b e t h e p r e s e n t i n g s y n d r o me s . O t h e r s i g n s a r e r e c u r r e n t u r t i c a r i a , mo n o n e u r i t i s mu l t i p l e x a n d l y mp h a d e n o p a t h y. F e t a l w a s t a g e a n d t h r o mb o e mb o l i c d i s e a s e a r e a s s o c i a t e d w i t h a n t i p h o s p h o l i p i d antibodies.
P. 7 8 2

NO NI NF L AM M AT O RY P O LYART HRI T I S : O S T E O ART HRI T I S ( D E G E NE RAT I V E J O I NT D I S E AS E ) : P a t h o p h y s i o l o gT : i s i s a d i s e a s e o f a r t i c u l a r c a r t i l a g e w i t h d e g r a d a t i o n o f t h e yh p r o t e o g l y c a n ma t r i x l e a d i n g t o f i s s u r i n g , t h i n n i n g , a n d l o s s o f a r t i c u l a r c a r t i l a g e , a n s e c o n d a r y t h i c k e n i n g o f s u b c h o n d r a l b o n e . In l a t e s t a g e s , t h e b o n e e n d s r u b d i r e c t l o n e a c h o t h e r s o t h e i r s u r f a c e s b e c o me w o r n a n d p o l i s h e d . T h e j o i n t c a p s u l e s a r e l i t t l e a f f e c t e d , s o a d h e s i o n s a r e n o t f o r me d , a n d a l t h o u g h j o i n t mo t i o n i s r e s t r i c t e d , a n k y l o s i s d o e s n o t r e s u l t . T h e b o n y ma r g i n s p r o l i f e r a t e t o f o r m s p u r s , l i p p i n g , a n d e xo s t o s e s . G e n e t i c a n d a c q u i r e d f a c t o r s ( t r a u ma , s u r g e r y, o b e s i t y, e xc e s s i v e u s e ) c o n t r i b u t e t o t h e p a t h o g e.n e s imp t o ms a r e u s u a l l y f i r s t n o t i c e d i n t h e w e i g h t Sy s b e a r i n g j o i n t s a f t e r a g e 4 0 a n d s i g n s o f i n f l a mma t i o n a r e r e l a t i v e l y s l i g h t . S y mp t o m


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c o r r e l a t e p o o r l y w i t h t h e o b j e c t i v e e xt e n t o f j o i n t d i s e a s e . T h e mo s t c o mmo n s y mp t o m i s p a i n w i t h u s e t h a t d i s a p p e a r s w i t h r e s t . T h e p a t i e n t ma y n o t e g r a t i n g d u r i n g mo t i o n . In i t i a l l y, t h e r a n g e o f mo t i o n i s n o r ma l , w i t h a g r a d u a l d e c r e a s e o c c u r r i n g a s t h e d i s e a s e p r o g r e s s e s . E n l a r g e me n t o f t h e d i s t a l a n d p r o xi ma l interphalangeal joints of the fingers (Heberden and Bouchard nodes, respectively), i s f r e q u e n t l y e n c o u n t e r e d . P a i n l e s s k n e e e f f u s i o n i s f r e q u e n t a s i s a s y mme t r i c l o s s o f k n e e c a r t i l a g e l e a d i n g t o v a l g u s o r v a r u s d e f o r mi t y.

NO NI NF L AM M AT O RY P O LYART HRI T I S : HE M O C HRO M AT O S I S : T h e s e c o n d a n d t h i r d me t a c a r p a l p h a l a n g e a l j o i n t s a n d t h e r a d i o c a r p a l j o i n t o f t h e w r i s t a r e mo s t c o mmo n l y a f f e c t e d . C h o n d r o c a l c i n o s i s i s p r e s e n t . S y mme t r i c n o n i n f l a mma t o r y a r t h r i t i s o f t h e me t a c a r p o p h a l a n g e a l j o i n t s s h o u l d i n i t i a t e a s e a r c h f o r a n i r o n - s t o r a g e d i s o r d e r.


P. 7 8 3

M I G RAT O RY P O LYART HRI T I S : RHE UM AT I C F E V E R: P a t h o p h y s i o l o g T : i s d i s e a s e i s a d e l a y e d i n f l a mma t o r y r e a c t i o n f o l l o w i n g yh i n f e c t i o n w i t h s p e c i f i c L a n c e f i e l d g r o u p s o f g r o u p A b e t a - h e mo l y t i c s t r e p t o c o c c i . T i s s u e s a f f e c t e d i n c l u d e t h e h e a r t , j o i n t s , s k i n , a n d c e n t r a l n e rT h e s s y s t e m . vou d i s e a s e i s p r o t e a n i n i t s c l i n i c a l ma n i f e s t a t i o n s . T h e c l a s s i c p r e s e n t a t i o n b e g i n s f r o 1 t o 4 w e e k s a f t e r s t r e p t o c o c c a l p h a r y n g i t i s , w i t h g r a d u a l o n s e t o f ma l a i s e , f a t i g u e , a n o r e xi a , a n d f e v e r. A s i n g l e l a r g e j o i n t b e c o me s p a i n f u l , t e n d e r, a n d s w o l l e n , a n d t h e o v e r l y i n g s k i n i s r e d a n d h o t . An e f f u s i o n f o r ms t h a t i s t u r b i d a n d s t e r i l e . W h i l e t h e f e v e r a n d o t h e r s i g n s o f i l l n e s s p e r s i s t , t h e j o i n t i n f l a mma t i o n s p o n t a n e o u s l y subsides in a few days, only to reappear in another joint, and later in another joint a mi gr at or y pol y ar t hr i Jio i n t i n v o l v e me n t ma y b e s o mi l d t h a t p a i n i s . t s u n a c c o mp a n i e d b y p h y s i c a l s i g n s o f i n f l a mma t i o n . M o n t h s o f o b s e r v a t i o n ma y b e r e q u i r e d t o d i s t i n g u i s h i t f r o m r h e u ma t o i d a r t h r i t i s ; i n v o l v e me n t o f t h e t e mp o r o ma n d i b u l a r j o i n t o f t e n o c c u r s i n r h e u ma t o i d a r t h r i t i s , p r a c t i c a l l y n e v e r i n r h e u ma t i c f e v e r. R h e u ma t i c f e v e r l e a v e s n o r e s i d u a l j o i n t d e f o r mi t y. At o n s e t , t h e i n f l a mma t i o n o f a s i n g l e j o i n t w i t h e f f u s i o n r e q u i r e s d i s t i n c t i o n f r o m s u p p u r a t i v e a r t h r i t i sCar di t i s s ma n i f e s t a s t a c h y c a r d i a , mu f f l e d h e a r t s o u n d s , h e a r t . i e n l a r g e me n t , v a l v u l a r i n s u f f i c i e n c y mu r mu r s , p e r i c a r d i a l f r i c t i o n r u b , o r g a l l o p r h y t h o n e xa mi n a t i o n . T h e e l e c t r o c a r d i o g r a m ma y s h o w P R p r o l o n g a t i o n . T w o d i s t i n c t t y p e s os k i n l es i ons y b e a s s o c i a t e d w i t h r h e u ma t i c f e v e r, a l t h o u g h n e i t h e r i s f ma p a t h o g n o mo n i c . E r y t h e ma ma r g i n a t u m o r c i r c i n a t u m i s c h a r a c t e r i ze d b y c o a l e s c i n g c i r c u l a r e r y t h e ma t o u s a r e a s o v e r t h e t r u n k a n d e xt r e mi t i e s , mi g r a t o r y a n d t r a n s i t o r y c h a n g i n g w i t h i n t h e h o u r. W i t h c h r o n i c d i s e a s e , s u b c u t a n e o u s r h e u ma t i c n o d u l e s ma y a p p e a r a s f i r m, n o n t e n d e r ma s s e s o v e r t h e j o i n t p r o mi n e n c e s a n d t e n d o n s h e a t h s o f t h e l i mb s , s c a l p , a n d s p i n e . T h e y a r e l o o s e l y a t t a c h e d t o t h e u n d e r l y i n g t i s s u e ; w h e n n u me r o u s , t h e i r d i s t r i b u t i o n t e n d s t o b e sSy denham l . hor ea y mme t r i c a c ma y a p p e a r s e v e r a l mo n t h s a f t e r o n s e t . T h e r e a r e n o d i a g n o s t i c l a b o r a t o r y t e s t s , b the full clinical picture is fairly distinctive. Diagnosis is based upon the Jones crite o f ma j o r a n d mi n o r ma n i f e s t a t i o n s . P O LYART HRI T I S : RE L AP S I NG S Y M M E T RI C AL S E RO NE G AT I V E S Y NO V I T I S WI T H P I T T I NG E D E M A ( RS 3 P E ) : T h i s c o n d i t i o n o f u n k n o w n c a u s e p r e s e n t s w i t h r e c u r r e n t e p i s o d e s o f s y mme t r i c a l s y n o v i t i s o f t h e h a n d s a n d w r i s t s w i t h p i t t i n g e d e ma a n d e r y t h e ma o f t h e d o r s u m o f
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t h e h a n d s . P a i n i s r e l a t i v e l y mi l d a n d t h e c o n d i t i o n r e mi t s a f t e r s e v e r a l d a y s t o a couple of weeks.

Spondyloar thr itis: P a t h o p h y s i o l o g In:f l a mma t i o n a t t h e i n s e r t i o n o f l i g a me n t s a n d t e n d o n s i n t o b o n e y (the enthesis, enthesitis) leads to joint and tendon sheath effusions and calcificatio o f p e r i a r t i c u l a r s t r u c t u r e s . G e n e s ( H L A- B 2 7 ) a n d a c q u i r e d i l l n e s s ( i n f l a mma t o r y bowel disease, infectious colitis, nongonococcal urethritis, psoriasis) predispose to t h e s e d i s o r d e rAs y mme t r i c o l i g o a r t h r i t i d e s o f t h e l a r g e j o i n t s w i t h p r o mi n e n t . s i n v o l v e me n t o f t h e s p i n e a n d s a c r o i l i a c j o i n t s a n d n e g a t i v e t e s t s f o r r h e u ma t o i d f a c t o r a r e d e s c r i b e d a ss eh e n e g a t i ve s p o n d y l o a r t h r i. t i d e se n t s p r e s e n t t ro Pati w i t h b a c k p a i n a n d s t i f f n e s s , a n d o c c a s i o n a l l y w i t h f e v e r, ma l a i s e , a n d w e i g h t l o s s . L o o k f o r e xt r a a r t i c u l a r d i s e a s e , s u c h a s g e n i t o u r i n a r y o r g u t s y mp t o ms , e y e i n v o l v e me n t ( u v e i t i s ) , a n d s k i n d i s e a s e . S P O ND Y L O ART HRI T I S C L I NI C AL O C C URRE NC E : Congeni t al c h r o n o s i s di opat hi c i s k d i s e a s e , d i f f u s e i d i o p a t h i c s k e l e t a l o I; d h y p e r o s t o s i s ( D IS I nf;l ammat or y / I mmunek y l o s i n g s p o n d y l i t i s , r e a c t i v e a r t h r i t i s H) an ( e . g . , R e i t e r ) , e n t e r o p a t h i c a r t h r i t i s ( i n f l a mma t o r y b o w e l d i s e a s e ) , p s o r i a s i s ; I nf ec t i ous f t e r d i a r r h e a l a n d g e n i t o u r i n a r y i n f e c t i o n s ( s e e r e a c t i v e a r t h r i t i s , R e i t e r a s y n d r o me ) . S P O ND Y L O ART HRI T I S : ANK Y L O S I NG S P O ND Y L I T I S : S e e p a g e 7 2.2 T h i s i s a c h r o n i c , p r o g r e s s i v e a r t h r i t i s o f t h e s p i n e o f t e n l e a d i n g t o s e v e r e a n k y l o s i s . It b e g i n s w i t h s a c r o i l i a c i n v o l v e me n t a n d p r o g r e s s e s p r o xi ma l l y. D e c r e a s e d l u mb a r s p i n a l mo t i o n i s a n e a r l y s i g n . In 2 0 % o f c a s e s , t h e r e i s a n a c c o mp a n y i n g l a r g e j o i n t o l i g o a r t h r i t i s o f h i p s a n d s h o u l d e r s . S P O ND Y L O ART HRI T I S : RE AC T I V E ART HRI T I S ( RE I T E R S Y ND RO M E ) : S e e p a g e 7 7.8 S P O ND Y L O ART HRI T I S : P S O RI AT I C ART HRI T I S : S e e p a g e 7 7.9 S P O ND Y L O ART HRI T I S : D I F F US E I D I O PAT HI C S K E L E TAL HY P E RO S T O S I S ( D I S H) : A c o n d i t i o n o f u n k n o w n c a u s e t h a t a f f e c t s w o me n mo r e o f t e n t h a n me n . As y mme t r i c o s t e o p h y t e s d e v e l o p a t mu l t i p l e l e v e l s o f t h e s p i n e l e a d i n g t o b r i d g i n g o f mu l t i p l e i n t e r v e r t e b r a l s p a c e s a n d i r r e g u l a r a n k y l o s i s w i t h d e c r e a s e d s p i n a l mo t i o n , e s p e c i a l l y i n t h e c e r v i c a l a n d l u mb a r r e g i o n s . T h e d i s k s p a c e s a r e p r e s e r v e d .

Conditions Primarily Affecting Bone


P. 7 8 4

Osteopor osis: P a t h o p h y s i o l o g B : n e r e s o r p t i o n e xc e e d s b o n e f o r ma t i o n , l e a d i n g t o d e c r e a s e d yo b o n e ma s s a n d d e c r e a s e d me c h a n i c a l s t r e n g t h . T r a b e c u l a r b o n e i s a f f e c t e d mo r e t h a n c o r t i c a l b o n e . In c r e a s e d r e s o r p t i o n o f b o n e r e s u l t s f r o m i mmo b i l i za t i o n , i n f l a mma t i o n , mu l t i p l e my e l o ma , a n d h y p e r p a r a t h y r o i d i s m. D e c r e a s e d b o n e f o r ma t i o r e s u l t s f r o m g o n a d a l h o r mo n e d e f i c i e n c y a n d g l u c o c o r t i c o i d s t e r o i d e xc e s s , a n d w i t a d v a n c e d a g e . T r a b e c u l a r b o n e d e f i c i e n c y i s e s p e c i a l l y i mp o r t a n t i n t h e v e r t e b r a e a n d p e l v i c b o n e s , w h i l e c o r t i c a l b o n e l o s s i s p r e d o mi n a n t i.n l o n g b o n e s


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O s t e o p o r o s i s i s a s y mp t o ma t i c u n t i l i n s u f f i c i e n c y f r a c t u r e s o c c u r, u s u a l l y i n t h e t h o r a c i c o r l u mb a r s p i n e a n d p e l v i s . T h o r a c i c k y p h o s i s r e s u l t s f r o m a n t e r i o r w e d g i n o f t h o r a c i c v e r t e b r a e . B o n e mi n e r a l d e n s i t y i s a s s e s s e d b y d u a l x- r a y a b s o r p t i o me t r ( D E XA) s c a n .

O S T E O P O RO S I S C L I NI C AL O C C URRE NC E : Congeni t al i t a mi n D - r e s i s t a n t r i c k e t s , M a r f a n s y n d r o me , h e mo c h r o ma t o s i s , E h l e r s v D a n l o s s y n d r o me , h e mo p h i l i a , t h a l a s s e mi a , p o s i t i v e f a mi l y h i s it ney ; Endoc r o r p o s t me n o p a u s a l e s t r o g e n d e f i c i e n c y, p r e ma t u r e me n o p a u s e , h y p o g o n a d i s m, h y p e r t h y r o i d i s m, h y p e r p a r a t h y r o i d i s m, C u s h i n g s y n d r o me , g l u c o c o r t i c o i d u s e , d i a b e t e s me l l i t u s , p r e g n a n c y, a d r e n a l i n s u f f i c i e n c y, a c r o me g a l y, h y p e r p r o l a c t i n e mi a I di opat hi c d v a n c e d a g I nf l ammat or y / I mmuner c o i d o s i s , a my l o i d o s i s , a e; sa r h e u ma t o i d a r t h r i t i s , a n k y l o s i n g s p o n detl abol i c / Toxv ct a mi n D d e f i c i e n c y, M y itis; ii ma l n u t r i t i o n , c h r o n i c r e n a l i n s u f f i c i e n c y, h e p a r i n , c i r r h o s i s , p o s t g a s t r e c t o my, p a r e n t e r a l n u t r i t i o n , c i g a r e t t e s mo k i n g , l o w b o d yec hani c;al / Tr aumat i c M weight i mmo b i l i za t i o n , d i s u s e , a n d n o n w e i g h t b e a r i nas t i c l t i p l e my e l o ma , Neopl g ; mu p a r a n e o p l a s t i c ( p a r a t h y r o i d h o r mo n e - r e l a t e d p r o t e i n s e c r e t i o n ) , l y mp h o ma , p r o l a c t i n o ma ; Neur ol ogi c a r a l y s i s , s t r o k e , mu l t i p l e s c l e r oysci hos oc i al n o r e xi a p Ps s ; a n e r v o s aVas c ul arh y p e r e mi a o f b o n e . ;

Osteogenesis Imper fecta (Br ittle Bones): P a t h o p h y s i o l o g D:e c r e a s e d me c h a n i c a l s t r e n g t h o f a l l b o n e s c a u s e d b y a n y inherited disorder of type I collagen results in pathologic fractures during the first d e c a d e o f l i f e . Au t o s o ma l d o mi n a n t i n h e r i t a n c e o c c u r s i n 6 0 % o f c a s e s , b u t f o u r d i f f e r e n t t y p e s h a v e b e e n r e c o.g n ih e d o n e s a r e h a r d e r a n d mo r e b r i t t l e t h a n T ze b n o r ma l , s o s p o n t a n e o u s o r p a t h o l o g i c f r a c t u r e s a r e c o mmo n . T h e f r a c t u r e s a r e s o me t i me s p a i n l e s s . B l u e s c l e r a e ma y b e o b s e r v e d . S h o r t s t a t u r e i s u s u a l a n d s k u l l d e f o r mi t y i s o f t e n p r e s e n t . H y p e r mo b i l i t y o f j o i n t s i s c o mmo n .
P. 7 8 5

Osteomalacia: P a t h o p h y s i o l o g Vi: t a mi n D d e f i c i e n c y, h y p o c a l c e mi a , o r h y p o p h o s p h a t e mi a a f t e r y t h e e p i p h y s e s a r e c l o s e d p r e v e n t s c a l c i f i c a t i o n o f n e w l y f o r me.dEb o ny ma t r i x arl y t h e r e a r e n o s y mp t o ms o r s i g n s , w h i l e l a t e r, b o n e p a i n a n d t e n d e r n e s s o c c u r. L o w b a c k p a i n a n d s t r i k i n g mu s c l e w e a k n e s s a r e c o mmo n . L o w s e r u m c a l c i u m l e v e l s ma y produce spontaneous carpopedal spasm with the Chvostek and Trousseau signs. In s u f f i c i e n c y ( s t r e s s ) f r a c t u r e s a r e c o mmo n a n d p s e u d o f r a c t u r e s ma y b e s e e n b y xr a y.

O S T E O M AL AC I A C L I NI C AL O C C URRE NC E : Congeni t al i t a mi n D - r e s i s t a n t r i c k e t s ; r i ne y p e r p a r a t h y r o i d i s m, r a p i d v Endoc h deposition of calcium and phosphorus in the tissues after ablation of the parathyroi g l a n d s i n o s t e i t i s f i b r o s a c y s t i c a , h y p o p a r a t hIy r oammat or y / I mmunel i a c nf l i d i s m; ce d i s e a s eM et abol i c / Toxv ct a mi n D d e f i c i e n c y, h y p o c a l c e mi a , h y p o p h o s p h a t e mi a , ; ii ma l a b s o r p t i o n , p a n c r e a t i c i n s u f f i c i e n c y, ma l n u t r i t i o n , c h r o n i c r e n a l i n s u f f i c i e n c y, r e n a l t u b u l a r a c i d o s i s , F a n c o n i s y n d r o me , u r e t e r o s i g mo i d o s t o my, e s s e n t i a l hypercalciuria, drugs (anticonvulsants, e.g., phenytoin, glucocorticoids, etidronate) f l u o r i d e a n d a l u mi n u m i n t o xi c a t i o n . RI C K E T S :
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P a t h o p h y s i o l o g v i:t a mi n D d e f i c i e n c y i n c h i l d h o o d b e f o r e e p i p h y s e a l c l o s u r e y r e s u l t s i n i n a d e q u a t e c a l c i f i c a t i o n o f c a r t i l a g e a n d S e eC h a p tee r ,8F i g . 8 . n w bon 2 8, p a g e 3 8 5 . S o f t e n i n g o f b o n e p r o d u c e s w i d e n i n g o f t h e c r a n i a l s u t u r e s a n d f o n t a n e l l e s ( c r a n i o t a b e s ) , P a r r o t b o s s e s , r a c h i t i c r o s a r y, H a r r i s o n g r o o v e s , t h o r a c i c k y p h o s i s o r l o r d o s i s , g e n u v a l g u m o r v a r u m, a n d a c o n t r a c t e d p e l v i s . W i t h t h e s o l e e xc e p t i o n o f t h e r o s a r y, a l l d e f o r mi t i e s a r e p e r ma n e n t s t i g ma s o f c h i l d h o o d d i s e a s e P. 7 8 6

Paget Disease of Bone: Osteitis Defor mans: P a t h o p h y s i o l o g In:c r e a s e d r e s o r p t i o n o f b o n e c o mb i n e s w i t h r a p i d g r o w t h o f n e w y b o n e w i t h d i s o r d e r e d a r c h i t e c t u r e w i t h d e c r e a s e d me c h a n i c a l s t r e n g t h . T h e c a u s e i u n k n o w .n B o n e p a i n i s i n c o n s t a n t a n d s e l d o m s e v e r e . W i t h t h e e xc e p t i o n o f t h e h a n d s a n d f e e t , a n y b o n e s ma y b e i n v o l v e d . T h e s k i n o v e r a f f e c t e d b o n e s ma y b e w a r m. T h e c l a s s i c o s s e o u s d e f o r mi t i e s a r e i n c r e a s e d g i r t h o f t h e c a l v a r i u m, t h o r a c i k y p h o s i s , g e n u v a r u m, a n d s h o r t e n i n g o f t h e s p i n e b y f l a t t e n i n g o f t h e v e r t e b r a e , g i v i n g t h e a p p e a r a n c e o f d i s p r o p o r t i o n a t e l y l o n g . a1 3 - 4 9 S p o n t a n e o u s o r Fi r ms ) .( s t r e s s f r a c t u r e s c a n o c c u r a n d r a r e l y o s t e o g e n i c s a r c o ma d e v e l o p s . In c r e a s e d b l o o d f l o w t h r o u g h t h e s p o n g y b o n e ma y p r o d u c e a n a r t e r i o v e n o u s f i s t u l a l e a d i n g t o h i g h output cardiac failure.

Fig. 13-49 Bony Signs of Osteitis Deformans (Paget Disease of Bone) . The c hi ef f eat ur es of Paget di s eas e ar e t he enl ar ged c al v ar i um ( c ont r as t i ng wi t h t he nor mal - s i zed f ac e under neat h) , k y phos i s and s hor t eni ng of t he s pi ne, s hor t eni ng of t he s pi ne s o t he ar ms l ook pr opor t i onat el y l onger t han t he t r unk , and bowed l egs . The f i gur e r epr es ent s a c ol l ec t i on of f eat ur es , whi c h ar e unl i k el y t o oc c ur t oget her i n t he s ame per s on .

P. 7 8 7 Hy p e r p a r a t h y r o i d i s m , P r i m a r y : O s t e i t i s F i b r o s a C y s t i c a G e n e r a l i s a t a , Re c k l i n g h a u s e n D i s e a s e : P a t h o p h y s i o l o g In:c r e a s e d p r o d u c t i o n o f p a r a t h y r o i d h o r mo n e ( P T H ) c a u s e s b o n e y r e s o r p t i o n t o e xc e e d n e w b o n e f o r ma t i o n , l e a d i n g t o h y p e r c a l c e mi a , h y p e r c a l c i u r i a , h y p e r p h o s p h a t u r i a , a n d h y p o p h o s p h aTe mi a i s e a s e ma y b e a s y mp t o ma t i c , . t he d a l t h o u g h d i f f u s e mu s c u l o s k e l e t a l a c h i n g a n d f a t i g u e i s s e e n i n ma n y p a t i e n t s . L a t e
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f i n d i n g s a r e b o n e t e n d e r n e s s , mu s c l e w e a k n e s s , a n d w a d d l i n g g a i t . S u b p e r i o s t e a l cysts in the skull and long bones can cause visible and palpable swellings. Peptic u l c e r a n d u r o l i t h i a s i s s h o u l d p r o mp t a s e a r c h f o r h y p e r p a r a t h y r o i d i s m.

HY P E RPARAT HY RO I D I S M , S E C O ND ARY AND T E RT I ARY: P a t h o p h y s i o l o g H:y p e r p h o s p h a t e mi a a n d h y p o c a l c e mi a c o mb i n e d w i t h d i s o r d e r e d y v i t a mi n D me t a b o l i s m i n c h r o n i c r e n a l f a i l u r e ( r e n a l o s t e o d y s t r o p h y ) , o r o s t e o ma l a c f r o m o t h e r c a u s e s , l e a d s t o i n c r e a s e d p r o d u c t i o n o f p a r a t h y r o i d h o r mo n e ( P T H ) , h y p e r p l a s i a o f t h e p a r a t h y r o i d g l a n d s , a n d p r o g r e s s i v e b.o Ce mbs n a tsi e n s n o di i e o o f d i e t a r y, h o r mo n a l , a n d r e n a l r e p l a c e me n t t h e r a p i e s c a n h e l p c o n t r o l t h e d i s o r d e r. W h e n P T H p r o d u c t i o n i s n o t s u p p r e s s i b l e w i t h a p p r o p r i a t e t r e a t me n t , i t i s t e r me d t e r t i a r y h y p e r p a r a t h y r o i d i s m.

Fibr ous Dysplasia of Bone: Osteitis Fibr osa Cystica Disseminata: P a t h o p h y s i o l o gT : e c a u s e o f t h i s d i s e a s e i s u n k n o w n . T h e a r c h i t e c t u r e o f o n e o r yh mo r e b o n e s i s d i s t o r t e d b y f i b r o s i s ; t h e c r a n i u m a n d l o n g b o n e s a r e e s p e c i a l l y i n v o l v e.d T h e r e i s a s y mp t o ma t i c b o w i n g o f t h e a f f e c t e d l o n g b o n e s . T h e s k i n o f t e n c o n t a i n s me l a n o t i c s p o t s w i t h j a g g e d b o r d e r s . In y o u n g g i r l s , p r e c o c i o u s p u b e r t y ma o c c u r. He r e d i t a r y M u l t i p l e E x o s t o s e s : O s t e o c h o n d r o m a t o s i s : P a t h o p h y s i o l o g T : e a u t o s o ma l d o mi n a n t d i s e a s e i s c h a r a c t e r i ze d b y e xo s t o s e s yh a r i s i n g f r o m t h e b o n y c o r t e x, d e f o r mi n g t h e me t a p h y s e a l r e g i o n o f s o. me l o n g b o n e s In v o l v e me n t i s u s u a l l y b i l a t e r a l b u t n o t s y mme t r i c a l . T h e u l n a ma y b e s h o r t e n e d , p r o d u c i n g u l n a r d e v i a t i o n o f t h e h a n d . Va l g u s d e f o r mi t i e s o f t h e a n k l e a r e c o mmo n . T h e o n l y s y mp t o m ma y b e me c h a n i c a l i n t e r f e r e n c e w i t h n o r ma l j o i n t f u n c t i o n .

Ac h o n d r o p l a s i a : C h o n d r o d y s t r o p h i a F o e t a l i s : P a t h o p h y s i o l o gT : e r e i s a d i s t u r b a n c e i n t h e e p i p h y s e a l c a r t i l a g e a n d yh e n c h o n d r a l b o n e f o r ma t i o n t h a t p r o d u c e s s h o r t l i mb s , a l a r g e h e a d , a n d a s p i n e o f n o r ma l l e n g t h c l a s s i c a c h o n d r o p l a s t i c d w a r f i s m. An a u t o s o ma l d o mi n a n t i n h e r i t e d o r s p o n t a n e o u s mu t a t i o n i n f i b r o b l a s t g r o w t h f a c t o r r e c e p t o r 3 Tsh eh e c a u s e . i t s t a t u r e i s f o r e s h o r t e n e d , w i t h t h e s h o r t l o w e r l i mb s s u p p o r t i n g a r e l a t i v e l y l a r g e t r u n k , s o t h e c e n t r a l p o i n t o f t h e f i g u r e i s n e a r t h e xi p h o i d p r o c e s s , r a t h e r t h a n t h e s y mp h y s i s p u b i s . T h e h u me r i a n d f e mo r a a r e r e l a t i v e l y s h o r t e r t h a n t h e f o r e a r ms a n l e g s . T h e h e a d i s b r a c h y c e p h a l i c a n d e xa m ma y s h o w a s a d d l e n o s e , t h i c k l i p s , protruding tongue, high-arched palate, trident hands (short, thick fingers diverging f r o m t h e b a s e s l i k e s p o k e s o f a w h e e l ) , r e s t r i c t e d e xt e n s i o n o f t h e e l b o w s , t h o r a c i c k y p h o s i s , a n d l u mb a r l o r d o s i s w i t h a t i l t e d p e l v i s .

M ultiple M yeloma: P a t h o p h y s i o l o g T : i s ma l i g n a n t c l o n a l p r o l i f e r a t i o n o f i mmu n o g l o b u l i n - p r o d u c i n g yh p l a s ma c e l l s ( t e r mi n a l l y d i f f e r e n t i a t e d B c e l l s ) i n t h e b o n e ma r r o w c a u s e s d e s t r u c t i o o f b o n e b y a c t i v a t i o n o f o s t e o c l a s t s l e a d i n g t o h y p e r c a l c e mi a . N o r ma l i mmu n o g l o b u l i n p r o d u c t i o n i s s u p p r e s s e d , t h e r e i s p r o d u c t i o n o f mo n o c l o n a l p l a s ma p r o t e i n s ( h e a v y c h a i n s , l i g h t c h a i n s , a n d i n t a c t i mmu n o g l o b u l i n ) , a n d a n e mi a a n d t h r o mb o c y t o p e n i a d e v e l o p . R e n a l i n s u f f i c i e n c y r e s u l t s f r o m t u b u l a r t o xi c i t y o f l i g h t c h a i n s ( B e n c e - J o n e s p r o t e i n s ) , h y p e r u r i c e mi a , a n d h y p e r h asl ci e miha mo s t . T ci s t e c o mmo n ma l i g n a n t t u mo r p r i ma r i l y a f f e c t i n g b o n e . F a t i g u e o r g e n e r a l i ze d a c h i n g d i s c o mf o r t ma y b e t h e o n l y e a r l y s y mp t o ms . T h e mo s t c o mmo n s p e c i f i c s y mp t o m i s


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b o n e p a i n . W i t h s p i n a l c o mp r e s s i o n f r a c t u r e s , l o c a l i ze d p a i n i n t h e b a c k w i t h r a d i c u l a r d i s t r i b u t i o n o c c u r s . T h e p r e s e n t i n g c o mp l a i n t s ma y b e r e f e r a b l e t o a n e mi a r e n a l f a i l u r e , o r a p a t h o l o g i c f r a c t u r e . M u l t i p l e my e l o ma s h o u l d b e c o n s i d e r e d i n p a t i e n t s o v e r a g e 4 5 w i t h b a c k p a i n a n d a n e mi a .

M etastasis to Bone: M e t a s t a t i c d i s e a s e p r e s e n t s a s a l o c a l i ze d s w e l l i n g o r p a i n i n a b o n e , a pathologic fracture, or is found incidentally on radiographs taken for another reaso T h e mo s t f r e q u e n t p r i ma r y l e s i o n s a r e c a r c i n o ma s o f t h e b r e a s t , l u n g , a n d p r o s t a t e .
P. 7 8 8

Fr actur es: P a t h o p h y s i o l o g F : a c t u r e s a r e me c h a n i c a l d i s r u p t i o n s o f t h e mi n e r a l i ze d b o n e a n d yr i t s c o l l a g e n o u s ma t r i x. F o r c e f u l l o c a l i ze d t r a u ma f r a c t u r e s t h e e n t i r e b o n e . F r a c t u r e o f t h e mi n e r a l i ze d b o n e l e a v i n g t h e c o l l a g e n o u s ma t r i x i n t a c t r e s u l t s f r o m t r a u ma i n c h i l d r e ngr eens t i c k f r ac t)ur e d r e p e t i t i v e a c t i v i t i e s i n a d r ess (f r ac t ur e ( an st ult s ). If t h e b o n e i s i n h e r e n t l y w e a k b e c a u s e o f l o c a l d e s t r u c t i v e d i s e a s e , i t ma y f r a c t u r e a t u s u a l l o a d s ( hol ogi c al f r ac t)urW h e n f r a c t u r e f r a g me n t s p e n e t r a t e t h e s k i n , i t i s pat . e a n open f r ac t ur e h e n f r a c t u r e i s s u s p e c t e d , i mmo b i l i ze t h e p a r t a n d a s s e s s . W n e u r o v a s c u l a r f u n c t i o n d i s t a l t o t h e i n j u r y. In s p e c t i o n a n d u n a v o i d a b l e mo v e me n t o f t e n r e v e a l s d e f o r mi t y, a b n o r ma l mo b i l i t y, a n d b o n e c r e p i t u s , t w o d i s t i n c t i v e s i g n s f r a c t u r e ( s i g n s o n e d o e s n o t d e l i b e r a t e l y t r y t o e l i c i t ) . M u s c l e c o n t r a c t i o n a t t e mp t i n t o s p l i n t t h e f r a c t u r e o f t e n a g g r a v a t e s p a i n . L o c a l i ze d b o n e t e n d e r n e s s i n d i c a t e s t h s i t e o f t h e f r a c t u r e . S h o r t e n i n g o f a l o n g b o n e ma y b e t h e c r u c i a l s i g n o f a n i mp a c t e d f r a c t u r e . S P O NTANE O US O R PAT HO L O G I C F RAC T URE : T h i s i s a f r a c t u r e t h a t o c c u r s w i t h t r a u ma i n s u f f i c i e n t t o b r e a k a n o r ma l b o n e . J u d g i n g t h e a mo u n t o f t r a u ma i s d i f f i c u l t a n d d i s e a s e d b o n e ma y b e s u b j e c t e d t o mu c h t r a u ma , h e n c e s p o n t a n e o u s f r a c t u r e s a r e e a s i l y mi s t a k e n f o r t r a u ma t i c f r a c t u r e s a n d a h i g h i n d e x o f s u s p i c i o n i s w a r r a n t e d . X- r a y s i g n s o f g e n e r a l i ze d o r l o c a l b o n e d i s e a s e s h o u l d b e s o u g h t i f p a t h o l o g i c f r a c t u r e i s s u s p e c t e d . S o me t i me s s p o n t a n e o u s f r a c t u r e s a r e l e s s p a i n f u l t h a n t h o s e o f h e a l t h y b o n e . O s t e o ma l a c i a , o s t e o p o r o s i s , o s t e i t i s d e f o r ma n s , o s t e i t i s f i b r o s a c y s t i c a g e n e r a l i s a t a , mu l t i p l e my e l o ma , o s t e o g e n e s i s i mp e r f e c t a , a n d p r i ma r y a n d me t a s t a t i c n e o p l a s ms i n b o n e a r e c o mmo n u n d e r l y i n g c o n d i t i o n s . F RAC T URE S : FAT E M B O L I S M : P a t h o p h y s i o l o gAf: t e r t r a u ma t o l a r g e b o n e s , a n d e s p e c i a l l y a f t e r f r a c t u r e s , f a t y g l o b u l e s e mb o l i ze v i a t h e v e i n s t o t h e l u n g s , b r a i n , a n d o t h e r t i s s u e s . T h e p a t h o g e n e s i s r e ma i n s c o n t r o v eT s ie lo n s e t o f f a t e mb o l i s m i s s u d d e n , w i t h . rh a r e s t l e s s n e s s a n d v a g u e p a i n i n t h e c h e s t . S y mp t o ms r e a c h a ma xi mu m i n a b o u t 4 8 h o u r s . D y s p n e a a n d c y a n o s i s a r e c o mmo n a n d p u r u l e n t s p u t u m o c c a s i o n a l l y c o n t a i n i n g d i a g n o s t i c f a t d r o p l e t s ma y b e p r o d u c e d . F e v e r o c c u r s w i t h a d i s p r o p o r t i o n a t e l y h i g h p u l s e r a t e . C e r e b r a l s y mp t o ms a n d s i g n s a r e e xt r e me l y v a r i a b l e ; d e l i r i u m a n d c o ma i n d i c a t e a g r a v e p r o g n o s i s . F a t d r o p l e t s ma y b e s e e n i n r e t i n a l o r c o n j u n c t i v a l v e s s e l s . O n t h e s e c o n d o r t h i r d d a y, p e t e c h i a e a p p e a r o v e r t h e s h o u l d e r s a n d c h e s t a s w e l l a s i n t h e c o n j u n c t i v a e a n d r e t i n a e . F a t e mb o l i s m s h o u l d b e c o n s i d e r e d i n a c u t e l y i l l p a t i e n t s w i t h t r a u ma t o l o n g b o n e s o r s k u l l ,
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i n s e r t i o n o f p r o s t h e s e s , c h r o n i c a l c o h o l i s m, d i a b e t e s me l l i t u s , a n d s i c k l e c e l l disease.

Ac u t e O s t e o m y e l i t i s : P a t h o p h y s i o l o gB:o o d b o r n e b a c t e r i a f r o m s u p e r f i c i a l i n f e c t i o n s a r e c a r r i e d t o t h e yl t e r mi n a l c a p i l l a r y l o o p s o f t h e me t a p h y s e a l c o r t e x, c a u s i n g a n e c r o s i n g i n f e c t i o n t h e r o d e s t o t h e p e r i o s t e u m. T h e i n i t i a l i n f e c t i o n i s i n t h e me t a p h y s i s , n e a r b u t n o t i n v o l v i n g t h e e p i p h ySt s . s i aphy l oc oc c us aur eus h e mo s t c o mmo n o r g a n i s m is t . O s t e o my e l i t i s i s mo s t c o mmo n i n c h i l d r e n . T h e o n s e t i s u s u a l l y s u d d e n , w i t h f e v e r a n d p a i n . O l d e r c h i l d r e n ma y b e a b l e t o p o i n t t o t h e p a i n f u l s i t e , a l t h o u g h t h e p a i n ma y b e r e f e r r e d t o t h e n e a r e s t j o i n t w h e r e s y mp a t h e t i c e f f u s i o n ma y b e n o t e d . In s p e c t i o n f r e q u e n t l y d i s c l o s e s l o c a l i ze d s w e l l i n g a n d r e d n e s s o f t h e o v e r l y i n g s k i n w i t h i n c r e a s e d w a r mt h . L i g h t p e r c u s s i o n o n t h e b o n e w i t h t h e f i n g e r t i p s f r e q u e n t l y d i s c o v e r s t h e s i t e o f t e n d e r n e s s . L o c a l i ze t h e a f f e c t e d a r e a w i t h f i r m f o r e f i n g e r p r e s s u r e o n t h e b o n e , b e g i n n i n g i n a n o r ma l r e g i o n a n d mo v i n g t o w a r d t h e s u s p e c t e d s i t e u n t i l t h e p o i n t o f ma xi mu m t e n d e r n e s s i s f o u n d . T h e p r o xi ma l f e mo r a me t a p h y s i s i s w i t h i n t h e h i p j o i n t i n c h i l d r e n , s o t h e y p r e s e n t w i t h a s e p t i c h i p . S o me t i me s d e e p c e l l u l i t i s c a n n o t b e d i s t i n g u i s h e d c l i n i c a l l y f r o m o s t e o my e l i t i s .


P. 7 8 9

Chr onic Osteomyelitis: Pathogenesis: ter the acute phase, the purulent discharge from the necrosing Af bone breaks through the periosteum and drains through sinuses in the skin. T he c i r c u l a t i o n o f t h e c o r t e x b e c o me s i mp a i r e d , p r o d u c i n g i s l a n d s o f d e a d b o n e , s e q u e s t r.aA s e q u e s t r u m ma y b e a b s o r b e d o r d i s c h a r g e d t h r o u g h t h e s i n u s o r s u r r o u n d e d b y n e w b o n e , t h e i n v o l u c r u m. C o n t i n u i n g n e c r o s i s o f b o n e a n d r e t e n t i o n of sequestra cause persistence of the infection.

Bony Swellings: Swelling is detected by inspection and palpation, but the signs are rarely diagnosti T h e l o c a t i o n o f t h e s w e l l i n g i n a l o n g b o n e ma y b e d i s t i n c t i v e . H a mi l t o n B a i l e y f o r mu l a t e d t h e f o l l o w i n g d i a g n o s t i c a i d s : ( a ) S w e l l i n g i n a l l d i a me t e r s o f t h e b u l b o u e n d o f a l o n g b o n e i s mo s t l i k e l y c a u s e d bc el l t umorb ) S w e l l i n g o n o n e gi ant y . ( a s p e c t o f a b o n e , n e a r t h e e p i p h y s e a l l i n e , i s mo s t l iphyy eal ex os t os i s epi k e l s a n . ( c ) S w e l l i n g i n a l l d i a me t e r s , b e g i n n i n g a t t h e me t a p h y s i s a n d e xt e n d i n g t o w a r d t h e c e n t e r o f g r a v i t y, ma y b e e abs c es s , os t eoi d os t,eoma t eos ar c oma d ) Br odi o r os . ( S w e l l i n g i n a l l d i a me t e r s , a t t h e c e n t e r o f g r a v i Ewi ma yt umor, eos i nophi l i c t y, ng b e gr anul omao r bone c y s t ( e ) C o n s i d e r t h a t a n y l o c a l i ze d b o n e t u mo r ma y b e , . met as t at i c f r om a di s t ant pr,i marc o mp l e t e e xa mi n a t i o n i s i n d i c a t e d . X- r a y so y f i n d i n g s ma y b e d i s t i n c t i v e , b u t b i o p s y i s o f t e n i n d i c a t e d . B o n y No d u l e s ( O c c u p a t i o n a l ) : R e p e a t e d t r a u ma t o a l i mi t e d r e g i o n o f s o f t t i s s u e a n d u n d e r l y i n g b o n e d u r i n g w o r k o r s p o r t ma y c a u s e b o s s e s o f t h e b o n e s w i t h o v e r l y i n g c a l l u s e s . E xa mp l e s a r e s ur f er ' s nodul es t h e d o r s a o f t h e f e e t ( f r o m p r e s s u r e o n t h e s u r f b o a r d a s t h e on s u r f e r s i t s c r o s s - l e g g e d )pai nt er ' s bos s es t h e s u b c u t a n e o u s s u r f a c e o f t h e and on t i b i a a t t h e j u n c t i o n o f t h e u p p e r a n d mi d d l e t h i r d s ( f r o m s t a n d i n g o n a l a d d e r a n d r e s t i n g t h e t i b i a e a g a i n s t t h e n e xt h i g h e r r u n g ) .
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Axial Skeleton: Spine and Pelvis Syndromes


P. 7 9 0

Infectious Spondylitis: P a t h o p h y s i o l o g S : i n a l i n f e c t i o n mo s t c o mmo n l y a f f e c t s t h e d i s k s ( d i s k i t i s ) a n d yp a n t e r i o r e n d p l a t e s o f t h e v e r t e b r a e . U n t r e a t e d t h e i n f e c t i o n ma y e xt e n d a n t e r i o r l y into the psoas or posteriorly into the epidural space leading to spinal cord c o mp r e s s i o n t h e s i t e o f t h e l e s i o n , p a i n a n d t e n d e r n e s s o f t h e s p i n o u s v e r t e b r a l . At processes are usually present, although not invariably in tuberculosis, often with s p a s m o f t h e s a c r o s p i n a l i s . T h e p a i n ma y b e r e f e r r e d a l o n g a s p i n a l n e r v e t o b e mi s t a k e n f o r a p p e n d i c i t i s , p l e u r i s y, o r s c i a t i c a , i f t h e b a c k i s n o t e xa mi n e d . C o l l a p s o f t h e v e r t e b r a l b o d y c a u s e s a g i b b u s a n d p a r a p l e g i a ma y r e s u l t . P s o a s a b s c e s s , c l a s s i c i n t u b e r c u l o s i s , ma y f o r m a l o n g t h e s h e a t h o f t h e p s o a s a n d p o i n t b e n e a t h t h e i n g u i n a l l i g a me n t . P a i n i n t h e s p i n e ma y b e l o c a lheel - b y op eesh a v e i ze d dr t h t t : the patient rise onto tiptoes, and then drop onto the heels.

I NF E C T I O US S P O ND Y L I T I S C L I NI C AL O C C URRE NC E : In f e c t i o n s w i t h p y o g e n i c o r g a n i s ms , s u c h a sl oc oc c us aur,euse mo s t St aphy ar c o mmo n . T u b e r c u l o s i s , t y p h o i d f e v e r, b r u c e l l o s i s , c o c c i d i o i d o my c o s i s , a n d a c t i n o my c o s i s a r e r a r e c a u s e s . T UB E RC UL O S I S O F T HE S P I NE : P O T T D I S E AS E : P a t h o p h y s i o l o g In:f e c t i o n i n v o l v e s t h e v e r t e b r a l b o d i e s w i t h s p r e a d t o t h e e p i d u r a l y space or prevertebral space. T here is progressive destruction of the vertebrae l e a d i n g t o p a t h o l o g i c f r a.c Pu rte e n t s p r e s e n t w i t h f e v e r, n i g h t s w e a t s , a n d b a c k t a i p a i n , a n d ma y h a v e s i g n s o f s p i n a l c o r d c o mp r e s s i o n w i t h e p i d u r a l e xt e n s i o n . R a r e l c o l d a b s c e s s ma y p r e s e n t a s a n i n g u i n a l ma s s f r o m p r e v e r t e b r a l e xt e n s i o n .

Epidur al Spinal Cor d Compr ession: P a t h o p h y s i o l o g T : mo r ma s s e s i n t h e c l o s e d e p i d u r a l s p a c e ma y e r o d e yu b o n e , c o mp r e s s s p i n a l n e r v e s , a n d c o mp r e s s t h e s p i n a l c o r d . M o s t e p i d u r a l ma s s e s e xt e n d f r o m t h e a d j a c e n t v e r t e b r a e o r f r o m r e t r o p e r i t o n e a l ma l i g n a n c y t o p r e s s o n t h e a n t e r i o r o r a n t e r o l a t e r a. l P roo g r e s s i v e a xi a l , r a d i c u l a r, o r r e f e r r e d b a c k p a i n , c rd u n r e l i e v e d b y r e c u mb e n c y, s h o u l d p r o mp t a n i mme d i a t e s e a r c h f o r s p i n a l c o r d c o mp r e s s i o n b y me t a s t a t i c e p i d u r a l n e o p l a s m. P a i n i s t h e mo s t c o mmo n p r e s e n t i n g s y mp t o m f o l l o w e d b y l e g w e a k n e s s , c o n s t i p a t i o n , i n c o n t i n e n c e , a n d s e n s o r y d i s t u r b a n c e s . T h e l a t t e r i n d i c a t e a d v a n c i n g c o r d c o mp r e s s i o n , f r o m w h i c h t h e r e i s l e s s c h a n c e f o r c o mp l e t e r e c o v e r y. P a r a p l e g i a ma y o c c u r i n a ma t t e r o f h o u r s a f t e r t h e o n s e t o f n e u r o l o g i c s i g n s . T h e p a i n ma y o c c u r a t a n y l e v e l a n d i s i n c r e a s e d b y s t r a i g h t - l e g r a i s i n g , Va l s a l v a ma n e u v e r, n e c k f l e xi o n , a n d mo v e me n t . M R I o f t h e e n t i r e v e r t e b r a l c o l u mn a n d c o r d i s t h e mo s t s e n s i t i v e a n d s p e c i f i c t e s t . E P I D URAL S P I NAL C O RD C O M P RE S S I O N C L I NI C AL O C C URRE NC E : B r e a s t , p r o s t a t e , o r l u n g c a n c e r a r e t h e mo s t f r e q u e n t c a u s e s . O t h e r c a n c e r s i n a d u l t s i n c l u d e mu l t i p l e my e l o ma , ma l i g n a n t l y mp h o ma , r e n a l c a r c i n o ma , s a r c o ma , a n d me l a n o ma . In c h i l d r e n , c o n s i d e r l y mp h o ma , s a r c o ma , a n d n e u r o b l a s t o ma . E p i d u r a l a b c e s s c o mp l i c a t e s i n f e c t i o u s s p o n d y l i t i s .
P. 7 9 1

Sciatica:
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P a t h o p h y s i o l o g C:o mp r e s s i o n o r d i r e c t i n j u r y t o t h e s c i a t i c n e r v e p r o d u c e s p a i n , y a l t e r e d s e n s a t i o n ( d e r ma t o me s L 4 - S 3 ) , l o s s o f mu s c l e r e f l e xe s ( a n k l e j e r k ) , a n d , i f s e v e r e , mu s c l e p o w e r a n d i n t h e d i s t r i b u t i o n o f t h e n e r v e ( e . g . , a n k l e f l e xi o n , e xt e n s i o n , i n v e r s i o n a n d e v e r s i o n , g r e a t t o e e xt e na tiio n ) i s p a i n i n t h e . Sci s ca distribution of the sciatic nerve. Pain is initially felt in the buttock and posterior t h i g h , a n d ma y e xt e n d t o i n v o l v e t h e p o s t e r o l a t e r a l a s p e c t o f t h e l e g t o t h e l a t e r a l ma l l e o l u s , t h e l a t e r a l d o r s u m o f t h e f o o t a n d t h e e n t i r e s o l e . W h e n n e r v e f u n c t i o n i s c o mp r o mi s e d , p a r e s t h e s i a s a r e f e l t i n t h e s a me d i s t r i b u t i o n . P a i n a n d p a r e s t h e s i a s are intensified by coughing or straining at defecation. T he nerve trunk is tender when palpated at the sciatic notch. Pain is also elicited by stretching the nerve whe t h e l e g i s e xt e n d e d w h i l e t h e t h i g h i s f l e xe d ( L a s g u e s i g n o r s t r a i g h t - l e g r a i s i n g ) . R e c t a l e xa mi n a t i o n s h o u l d a l w a y s b e d o n e t o l o o k f o r p e l v i c ma s s e s . A p u l s a t i n g r e c t a l ma s s a s s o c i a t e d w i t h s c i a t i c a s u g g e s t s a n e u r y s m o f t h e i n t e r n a l i l i a c o r c o mmo n i l i a c a r t e r y c o mp r e s s i n g t h e n e r v e . T h e g r e a t ma j o r i t y o f t h e c a s e s a r e attributable to herniated intervertebral disk, spondylosis, or sacroiliac disease.

Lumbosacr al Str ain: P a t h o p h y s i o l o g M:e c h a n i c a l i n j u r y c o mmo n l y o c c u r s t o t h e s o f t t i s s u e s ( mu s c l e s , y t e n d o n s , a n d l i g a me n t s ) o f t h e l o w b a c k w h e r e t h e mo b i l e l u mb a r s p i n e me e t s t h e f i xe d s a c r u m, c o n c e n t r a t i n g me c h a n i c a l f o r c e s a t t h e t r a n s i t i o n zo n e . In j u r y c a n b e t h e r e s u l t o f a s i n g l e , l a r g e l o a d i n g f o r c e o r o f a r e p e t i t i v e l o a d i n g w .i t h l e s s e r f o r c e U s u a l l y t h e p a t i e n t i s b e t w e e n 2 5 a n d 5 0 y e a r s o f a g e a n d c o mp l a i n s o f a c h i n g p a i n n e a r L 5 o r S 1 . T h e p a i n ma y r a d i a t e l a t e r a l l y o r t o t h e l a t e r a l a s p e c t o f t h e t h i g h . T h e r e i s a n i n c r e a s e d l u mb a r l o r d o s i s a n d a t t e mp t e d s p i n a l mo t i o n i s a c c o mp a n i e d b y mu s c l e s p a s m. S p i n a l f l e xi o n i s l i mi t e d a n d p a i n f u l . T h e p a t i e n t c a n n o t l i e f l a t w i t h o u t f l e xi n g t h e k n e e s a n d h i p s t o r e l i e v e p a i n . T h e s t r a i g h t - l e g - r a i s i n g t e s t i s n e g a t i v e e xc e p t t h a t l u mb o s a c r a l p a i n o c c u r s a t e xt r e me f l e xi o n . H a v e t h e p a t i e n t l i p r o n e w i t h t h e p e l v i s r e s t i n g o n f o u r p i l l o w s t o s e p a r a t e t h e s p i n o u s p r o c e s s e s . In t h i s p o s i t i o n , p a l p a t i o n o f t h e s u p r a s p i n o u s l i g a me n t ma y r e v e a l t e n d e r n e s s a b o v e o b e l o w t h e s p i n e o f L 5 ; s o me t i me s a d e p r e s s i o n i s f o u n d a t t h a t s i t e .


P. 7 9 2

He r n i a t e d I n t e r v e r t e b r a l D i s k : P a t h o p h y s i o l o g H:e r n i a t i o n o f a d e s i c c a t e d n u c l e u s p u l p o s u s t h r o u g h t e a r s i n t h e y a n n u l o s e f i b r o s a ma y p r o d u c e p r e s s u r e o n n e r v e r o o t s i n t h e n e u r a l f o r a mi n a l a t e r a l l y o r d i r e c t l y o n t h e c a u d a e q u i n a , c o n u s o r s p i n a l c o r d i f t h e e xt r u s i o n i s d i r e c t l y p o s t e r i F r g(. 1 3 - 2 6 Bp a g e 7 2 1 )T h e o n s e t o f l o w b a c k p a i n ma y b e oi , . g r a d u a l o r s u d d e n a n d i s p a r t i a l l y r e l i e v e d i n r e c u mb ec a y. y b e t h e Sc i at i n c ma p r e s e n t i n g s y mp t o m w i t h p a i n i n t h e b u t t o c k r a d i a t i n g t o t h e t h i g h . In s e v e r e c a s e s , t h e p a i n i n v o l v e s t h e l e g , u s u a l l y t h e l a t e r a l a s p e c t , a n d s o me o r a l l o f t h e t o e s ( d e r ma t o me s L 4 t o S 3 ) . C o u g h i n g , s n e e zi n g , o r t h e Va l s a l v a ma n e u v e r a c c e n t u a t e s t h e p a i n . C h r o n i c h e r n i a t e d d i s k i s a t t e n d e d b y s y mp t o m- f r e e p e r i o d s ; c o n t i n u o u s b a c k p a i n i s u s u a l l y c a u s e d b y s o me o t h e r l e s i o n . O n e xa mi n a t i o n , t h e s p i n e ma y b e f l e xe d , f r e q u e n t l y w i t h a l a t e r a l d e v i a t i o n t o w a r d t h e a f f e c t e d s i d e . Ac t i v e f l e xi o n a n e xt e n s i o n o f t h e s p i n e a r e l i mi t e d , mo r e s o t h a n l a t e r a l b e n d i n g a n d r o t a t i o n . M u s c l s p a s m i s mo s t s e v e r e o v e r t h e i p s i l a t e r a l s a c r o s p i n a l i s w i t h l o c a l d e e p t e n d e r n e s s , mo s t p r o n o u n c e d o n t h e a f f e c t e d s i d e , p r e s e n t 5 c m l a t e r a l t o t h e mi d l i n e . P a l p a t e f o r mu s c l e r i g i d i t y, a r e a s o f t e n d e r n e s s , t e n d e r f i b r o s i t i c p o i n t s , a n d t r i g g e r p o i n t s .
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L o o k f o r w e a k n e s s b y h a v i n g t h e p a t i e n t h e e l - a n d - t o e w a l k , a n d e xt e n d t h e g r e a t t o against resistance. With the straight-leg-raising test, record the angle at which pain i s e xp e r i e n c e d , t h e n r e p e a t t h e ma n e u v e r, d o r s i f l e xi n g t h e f o o t s h a r p l y, a s t h e p a i n f u l a n g l e i s a p p r o a c h e d , t o s t r e t c h t h e s c i a t i c n e r v e a n d t e s t i t s i r r i t a b i l i t y. P a i o f t e n o c c u r s a t l e s s t h a n 4 0 d e g r e e s w h e n t h e r e i s a c t u a l i mp i n g e me n t o f a p r o l a p s e d d i s k ; w h e n p a i n o c c u r s o n l y a t mu c h g r e a t e r a n g l e s , t h e n e r v e s e n s i t i v i t y ma y b e f r o m o t h e r c a u s e s . C h e c k s e n s a t i o n n o t i n g t h e d e r ma t oVr o o n v o l v e d [ me i me n P C , d e K r o m M C , K n o t t n e r u s J A. D i a g n o s t i c v a l u e o f h i s t o r y a n d p h y s i c a l e xa mi n a t i o n i n p a t i e n t s s u s p e c t e d o f s c i a t i c a d u e t o d i s c h e r n i a t i o n . J Neur ol 1 9 9 9 ; 2 4 6 : 8 9 9 9; 0 6 o o me n P C , d e K r o m M C , K n o t t n e r u s J A. C o n s i s t e n c y o f h i s t o r y Vr t a k i n g a n d p h y s i c a l e xa mi n a t i o n i n p a t i e n t s w i t h s u s p e c t e d l u mb a r n e r v e r o o t i n v o l v e me nSpi ne2 0 0 0 ; 2 5 : 9 1 ]9 6 t. .

Spinal Stenosis: P a t h o p h y s i o l o g C:o mp r e s s i o n o f t h e l o w e r l u mb a r a n d s a c r a l r o o t s o c c u r s f r o m y overgrowth of bony tissue from congenital narrowing or degenerative disk disease that narrows the spinal canal . Ps eudoc l audi c at i ion p a i n i n t h e b u t t o c k s , b i l a t e r a l s posterior thighs, and calves while standing or walking upright, which is relieved by s i t t i n g o r b e n d i n g f o r w a r d ( r e v e r s i n g t h e l u mb a r l o r d o s i s a n d d e c r e a s i n g t h e d e g r e e o f s t e n o s i s ) . U n l i k e i n t e r mi t t e n t c l a u d i c a t i o n f r o m v a s c u l a r i n s u f f i c i e n c y, p a i n o c c u r w h i l e s t a n d i n g w i t h o u t w a l k i n g , t h a t i s , l e g e xe r t i o n i s n o t r e q u i r e d . S i t t i n g g i v e s r e l i e f , i n c o n t r a s t t o l u mb a r d i s k d i s e a s e . O s t e o p o r o s i s , s p o n d y l o l i s t h e s i s , t r a u ma , l a mi n e c t o my, s p i n a l f u s i o n , s p o n d y l o s i s , s c o l i o s i s , a c r o me g a l y, a n d P a g e t d i s e a s e are all potential contributors. Congenital narrowing of the canal also occurs.

Appendicular Skeletal Syndromes (Including Joints, Tendons, Ligaments, and Soft Tissues)

Hy p e r t r o p h i c O s t e o a r t h r o p a t h y : P a t h o p h y s i o l o g T : i s s y n d r o me , b e g i n n i n g a s a p e r i o s t i t i s o f u n k n o w n c a u s e , yh consists of (a) clubbing of the fingers, (b) new subperiosteal bone in the long bone ( c ) s w e l l i n g a n d p a i n s i n t h e j o i n t s , a n d ( d ) a u t o n o mi c d i s t u r b a n c e s o f t h e h a n d s a n f e e t , s u c h a s f l u s h i n g , s w e a t i n g , a n d b.l a nh e ie a r l i e s t s i g n i s c l u b b i n g o f t h e T ch ng f i n g e r s . W i t h p r o g r e s s i o n , b o n e p a i n o c c u r s w h i l e s w e l l i n g a n d p a i n i n t h e j o i n t s ma b e c o me s e v e r e a n d t e n d e r n e s s i s e l i c i t e d b y p a l p a t i o n o v e r t h e d i s t a l f o r e a r ms a n d l e g s . In a d v a n c e d c a s e s , s w e a t i n g a n d f l u s h i n g o f t h e h a n d s a n d f e e t ma y a l t e r n a t e w i t h t h e R a y n a u d p h e n o me n o n . T h e c o n d i t i o n ma y b e c o n g e n i t a l , w i t h s i g n s appearing in childhood, or acquired. Onset of hypertrophic osteoarthropathy in the adult should initiate a search for an underlying disease. HY P E RT RO P HI C O S T E O ART HRO PAT HY C L I NI C AL O C C URRE NC E : Congeni t al a mi l i a l , c y a n o t i c c o n g e n i t a l h e a r t d i s e a s e , c y s t Endoc ois i s ; f i c f i b r r ne G r a v e d i s e a s e , p r e g n a ndiy ; I c opat hi c mp h y s e ma , c i r r h o snf l; ammat or y / I mmune e I is u l c e r a t i v e c o l i t i s , C r o h n d i s e a s e , c h r o n i c i n t e r s t i t i a l p n e u mo n i t i s , s a r c o i d o s i s , d y s p r o t e i n e miIa ; ec t i ousu n g o r l i v e r a b s c e s s , b r o n c h i e c t a s i s , t u b e r c u l o s i s , nf l b a c t e r i a l e n d o c a r d i t i s , d y s e n t et abol i c / Toxma l a b s o r p t i o n , c h r o n i c M ery; ic h y p o xe mi aNeopl as t i cu n g , p l e u r a l , a n d g a s t r o i n t e s t i n a l c a n c e r, me t a s t a t i c d i s e a s e ; l t o l u n gVas c ul ara o r t i c a n e u r y s m. ;
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P. 7 9 3

Chr onic Painless Enlar gement of the Legs: S e v e r a l c a u s e s mu s t b e d i s t i n g u i s h e d . A d i p o s i t.yAl t h o u g h s o me e v i d e n c e o f o b e s i t y i s p r e s e n t e l s e w h e r e i n t h e b o d y, t h e f a t a b o u t t h e a n k l e s ma y b e d i s p r o p o r t i o n a t e l y g r e a t , b u t t h e f e e t a r e s p a r e d . T h e t i s s u e h a s t h e c o n s i s t e n c y o f f a t , a n d p i t t i n g e d e ma i s a b s e n t . C h r o n i c d e e p v e n o u s o b s t r u c ts u a l l y i s p r e c e d e d b y a h i s t o r y s u g g e s t i n g u ion t h r o mb o p h l e b i t i s . T h e v e n o u s d e f i c i t ma y p r o d u c e p a i n i n t h e l e g s . S o me p i t t i n g e d e ma i s u s u a l l y p r e s e n t , a l t h o u g h i t ma y b e o b s c u r e d b y t h i c k e n i n g o f t h e s k i n f r o c h r o n i c i n f l a mma t ( o n mat ol i pos c l er os iT h e s k i n i s h e mo s i d e r i n s t a i n e d - a n d i der . s) c y a n o t i c . S u p e r f i c i a l v e i n s ma y b e d i l a t e d . P o s t p h l e b i t i c s y n d r orm e u l t s f r o m p r e v i o u s o c c l u s i o n o f t h e d e e p v e i n s e i t h e r es w i t h o u t r e c a n a l i za t i o n o r r e s u l t i n g i n d e s t r u c t i o n o f t h e v a l v e s w i t h p e r s i s t e n t v e n o u i n c o mp e t e n c e . O n e - t h i r d o f p a t i e n t s w i t h a c u t e d e e p v e i n t h r o mb o s i s w i l l d e v e l o p p o s t p h l e b i t i c s y n d r o me . T h e l e g i s p e r s i s t e n t l y e n l a r g e d , u s u a l l y w i t h p i t t i n g e d e ma Sensations of fullness and pain occur with prolonged sitting or standing and chroni s t a s i s c h a n g e s a r e c o mmo n . E a r l y t r e a t me n t d e c r e a s e s l o n g - t e r m d i s a b i l i t y. V a r i c o s e v e i n s e r e a d i l y r e c o g n i ze d w h e n t h e y a r e a s s o c i a t e d w i t h e d e ma . ar Ly m p h e d e m a a u s e s a f i r m, n o n p i t t i n g s w e l l i n g w i t h n o v e n o u s e n g o r g e me n t o r c cyanosis.

M uscle Syndromes
See also hapter 14 C , The Neur ol ogi c Ex ami nat i on .

Fibr omyalgia: S e e Tender Poi nt s a g e 7 7 3 . F i b r o my a l g i a i s mo r e c o mmo n i n w o me n t h a n me n . It , p i s c h a r a c t e r i ze d b y w i d e s p r e a d , d i f f u s e , a c h i n g mu s c u l o s k e l e t a l p a i n , s t i f f n e s s , n o n r e s t o r a t i v e s l e e p , a n d f a t i g u e . Al t h o u g h t h e c a u s e a n d p a t h o g e n e s i s a r e u n k n o w n , i t h a s b e e n a s s o c i a t e d w i t h a n t e c e d e n t t r a u ma , s u r g e r y, me d i c a l i l l n e s s , a n d e mo t i o n a l s t r e s s . T h e d i a g n o s i s i s b a s e d u p o n c l i n i c a l c r i t e r i a ; l a b o r a t o r y s t u d i e s a r e n o r ma l . T h e Ame r i c a n C o l l e g e o f R h e u ma t o l o g y c r i t e r i a f o r d i a g n o s i s i n c l u d e a h i s t o r y o f p a i n i n t h e a l l f o u r b o d y q u a d r a n t s f o r a t l e a s t 3 mo n t h s w i t h a t l e a s t 11 o f 1 8 p a i r e d , b i l a t e r a l t e n d e r p o i n t s e l i c i t e d o n p h y s i c a l e xa mi n a t i o n : s u b o c c i p i t a l mu s c l e i n s e r t i o n , l o w c e r v i c a l , t r a p e zi u s , s u p r a s p i n a t u s , s e c o n d r i b , l a t e r a l e p i c o n d y l e , g l u t e a l , g r e a t e r t r o c h a n t e r, F in d k n e5 0( a g . 1 3 - e. )


P. 7 9 4

M yofascial Pain Syndr ome: P a t h o p h y s i o l o gAf: f e r e n t s i g n a l s f r o m t h e t r i g g e r a r e a s a r e b e l i e v e d t o r e mo d e l y s p i n a l a n d p o s s i b l y t h a l a mi c p a i n p a t h w a y s t o c a u s e r e f l e x mu s c l e s p a s ms a n d d i mi n i s h e d b l o o d f l o w, w h i c h , i n t u r n , i n c r e a s e t h e s e n s i t i v i t y o f t.h S et ei g g e r a r e a e r Tr i gger Poi nt s a g e 7 7 2 . C h r o n i c r e c u r r e n t p a i n o c c u r s r o u g h l y i n t h e d i s t r i b u t i o n o f , p o n e o r mo r e mu s c l e s a n d t h e i r d i s t r i b u t i o n o f r e f e r r e d p a i n . T h e p a i n ma y b e l a n c i n a t i n g , a c h i n g , b o r i n g , o r a f e e l i n g o f mu s c u l a r s t i f f n e s s . O f t e n , t h e p a t i e n t r e l a t e s t h e o n s e t t o s o me s p e c i f i c t r a u ma o r a c t i v i t y. T h e d i s t i n g u i s h i n g f e a t u r e i s t p r e s e n c e o f o n e o r mo r e t r i g g e r p o i n t s , w i t h o r w i t h o u t p a l p a b l e mu s c l e s p a s m. T h e e xa mi n e r s h o u l d p a l p a t e t h e e n t i r e r e g i o n c a r e f u l l y w i t h f i r m p r e s s u r e o f t h e


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f i n g e r t i p s . O f t e n , t h e t r i g g e r p o i n t i s d i s c o v e r e d s o me d i s t a n c e f r o m t h e r e f e r r e d p a a r e a . T h e d i a g n o s i s i s c o n f i r me d w h e n t h e p a i n i s r e l i e v e d b y i n j e c t i o n o f t h e p r i ma r y t r i g g e r p o i n t w i t h a l o c a l a n e s t h e t i c .

F i g . 1 3 - 5 0 T h e Te n d e r P o i n t s o f F i b r o m y a l g i a . T h e r e s h o u l d b e t e n d e r n e s s i n a t l e a s t 11 o f t h e 1 8 p o i n t s t o d i a g n o s e f i b r o m y a l g i a .

P. 7 9 5

P o l y m y a l g i a Rh e u m a t i c a ( P M R) : P a t h o p h y s i o l o g T : i s i n f l a mma t o r y d i s e a s e o f u n k n o w n o r i g i n i s c h a r a c t e r i ze d b y yh p a i n i n p r o xi ma l mu s c l e g r o u p s , w i t h i n f l a mma t i o n d e mo n s t r a b l e b y M R I i n t h e s h o u l d e r g i r d l e t e n d o n s h e a t h s a n d b u r s a e , a n d l e s s c o mmo n l y t h e s h o u l d e r j o i n t i t s e l.f It u s u a l l y o c c u r s a f t e r t h e s i xt h d e c a d e o f l i f e a n d i s mo s t c o mmo n i n w o me n . P r o n o u n c e d mo r n i n g s t i f f n e s s o f t h e n e c k , s h o u l d e r, a n d u p p e r b a c k mu s c l e s u s u a l l b e g i n s g r a d u a l l y. S o me p a t i e n t s h a v e r a t h e r s u d d e n o n s e t a n d c a n n o t e t h e d a y a n d t i me o f t h e i r f i r s t s y mp t o ms . M u s c l e s o f t h e l o w b a c k , p e l v i c g i r d l e a n d t h i g h s a r e l e s s p r o mi n e n t l y i n v o l v e d a n d / o r ma y d e v e l o p l a t e r. It i s c o mmo n i n p a t i e n t s w i t h t e mp o r a l a r t e r i t i s , b u t o n l y 1 5 % o f p a t i e n t s p r e s e n t i n g w i t h P M R d e v e l o p t e mp o r a l a r t e r i t i s . Al t h o u g h s p o n t a n e o u s l y p a i n f u l , t h e mu s c l e s a r e s e l d o m v e r y t e n d e r, t r i g g p o i n t s a r e n o t c h a r a c t e r i s t i c , a n d t h e s t i f f n e s s i s i mp r o v e d b y a c t i v i t y. T h e e r y t h r o c y t e s e d i me n t a t i o n r a t e ( E S R ) i s u s u a l l y 8 0 a n d s y mp t o ms a r e p r o mp t l y relieved by low-dose corticosteroids.

Compar tment Syndr ome: P a t h o p h y s i o l o g In:j u r y t o mu s c l e e n c l o s e d w i t h i n c o n s t r i c t i n g f a s c i a l y c o mp a r t me n t s l e a d s t o s w e l l i n g f r o m e d e ma , h e mo r r h a g e a n d i n f l a mma t i o n . W h e n t h e p r e s s u r e w i t h i n t h e c o mp a r t me n t e xc e e d s 3 0 c m o f w a t e r, p r o g r e s s i v e i s c h e mi a e n s u e s l e a d i n g t o f u r t h e r .i n j u riy h i n d e x o f s u s p i c i o n i s r e q u i r e d t o r e c o g n i ze A h g t h i s s e r i o u s d i s o r d e r b e f o r e i r r e v e r s i b l e mu s c l e i n j u r y o c c u r s . T h e p a t i e n t c o mp l a i n o f s e v e r e p a i n o f t e n d i s p r o p o r t i o n a t e t o a p p a r e n t i n j u r y. P a l p a t i o n o f t h e a f f e c t e d mu s c l e c o mp a r t me n t r e v e a l s t e n s e d i s t e n t i o n o f t h e f a s c i a w i t h s e v e r e p a i n . If ma j o a r t e r i e s o r n e r v e s p a s s t h r o u g h t h e c o mp a r t me n t , d i s t a l p u l s e s ma y b e d i mi n i s h e d a n d s e n s a t i o n i mp a i r e d . W i t h o u t r e l i e f o f p r e s s u r e , mu s c l e n e c r o s i s l e a d s t o c h r o n i


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f i b r o s i s , s h o r t e n i n g , a n d l o s s o f f u n c t i o n . D i a g n o s i s i s ma d e b y me a s u r i n g c o mp a r t me n t p r e s s u r e a n d t r e a t me n t i s s u r g i c a l f a s c i o t o my.

ADDIT IONAL READING


1 . M e n s e S , S i mo n s D Gus c l e Pai nP h i l a d e l p h i a , L i p p i n c o t t W i l l i a ms & M. . Wilkins, 2001. 2 . S h e o n R P, M o s k o w i t z R W, G o l d b e rSof t Ti s s ue Rheumat i c Pai n. g VM . Rec ogni t i on, M anagement and Pr ev entd ond . B a l t i mo r e , W i l l i a m a n d . 3r i e Wilkins, 1996. 3 . Wa l t e r B . G r e e n e ( eEs)s ent i al s of M us c ul os k el et al, Car e e d i t i o n . d. . 2nd R o s e mo n t , IL , Ame r i c a n Ac a d e my o f O r t h o p e d i c S u r g e o n s , 2 0 0 1 . 4 . Pr i mer of t he Rheumat i c Di s eas es n t a , G A, T h e Ar t h r i t i s F o u n d a t i o n , . At l a 2001. 5 . T r a v e l l J G , S i mo n s D G .of as c i al Pai n and Dy s f unc t i on. The Tr i gger Poi nt My M anual B a l t i mo r e , W i l l i a ms & W i l k i n s , 1 9 8 3 . .

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E d i t o r s : L e B l o n d , R i c h a r d F. ; D e G o w i n , R i c h a r d L . ; B r o w n , D o n a l d D . T i t l e : D e G o w i n ' s D i a g n o s t i c E xa m i n a t i o n , 8 t h E d i t i o n Copyright 2004 McGraw-Hill > Ta b l e o f C o n t e n t s > P a r t 2 - T h e D i a g n o s t i c E xa m > C h a p t e r 1 4 - T h e N e u r o l o g i c E xa mi n a t i o n

Chapter 14 The Neurologic Examination


Diagnostic testing of the nervous system is based upon specific tests of its f u n c t i o n a l c h a r a c t e r i s t i c s , n o t o n t h e t r a d i t i o n a l p h y s i c a l e xa mi n a t i o n mo d a l i t i e s o f inspection, palpation, percussion, and auscultation.

In t h e r o u t i n e p h y s i c a l e xa mi n a t i o n , mo s t c l i n i c i a n s t e s t t h e c o mp o n e n t s o f t h e n e r v o u s s y s t e m a s t h e y e l i c i t t h e h i s t o r y a n d e xa mi n e t h e b o d y b y r e g i o n s . T h e p a t i e n t ' s s p e e c h a n d b e h a v i o r ma y i n d i c a t e a b n o r ma l i t i e s o f c e r e b r a l f u n c t i o n . W h e e xa mi n i n g t h e h e a d , s o me , i f n o t a l l , o f t h e c r a n i a l n e r v e s a r e t e s t e d . M u s c u l a r s t r e n g t h i s a s s e s s e d b y i n s p e c t i o n o f g a i t a n d mo v e me n t . Te n d o n r e f l e xe s a r e e l i c i t e d d u r i n g e xa mi n a t i o n o f t h e e xt r e mi t i e s . W h e n e v i d e n c e o f n e r v o u s s y s t e m ma l f u n c t i o n i s e n c o u n t e r e d , a mo r e c o mp l e t e a n d s y s t e ma t i c n e u r o l o g i c e xa mi n a t i o n is required.

T h e f i r s t o b j e c t i v e o f t h e s y s t e ma t i c n e u r o l o g i c e xa mi n a t i o n i s t o d i s c o v e r a l l c o g n i t i v e , s e n s o r y, mo t o r, a n d c o o r d i n a t i o n d e f i c i t s . F r o m a c o mp l e t e i n v e n t o r y, t h e c l i n i c i a n d e d u c e s t h e s i t e o f t h e l e s i o n f r o m k n o w l e d g e o f n e r v o u s s y s t e m a n a t o my a n d p h y s i o l o g y. S e v e r a l g e n e r a l p r i n c i p l e s h e l p t o o r g a n i ze a n a p p r o a c h t o l o c a l i zi n t h e p r o b l e m: 1. Def i c i t s of i nt el l ec t , memor y, or hi gher br ai n i fmp l yt i lon i o n s o f t h e unc e s c e r e b r a l h e mi s p h e r e s . 2. Def i c i t s of c ons c i ous nes si c a t e l e s i o n s o f t h e b r a i n s t e m r e t i c u l a r a c t i v a t i n g ind s y s t e m o r b i l a t e r a l c e r e b r a l d a ma g e .

3. Par al y s i s wi t h l os s of deep t endon r ef ld i c ese s a l o w e r mo t o r n e u r o n i n ex a t lesion interrupting the reflex arc. T his can be at the spinal cord, spinal root, p l e xu s o r p e r i p h e r a l n e r v e l e v e l . Ac u t e u p p e r mo t o r n e u r o n l e s i o n s c a n b e a s s o c i a t e d w i t h d e c r e a s e d r e f l e xe s i n i t i a l l y, b u t p r o d u c e i n c r e a s e d r e f l e xe s a f t e hours to days. 4. Par al y s i s wi t h an ac c ent uat ed deep t endon (rs p laex esi t y ) i n d i c a t e s a n ef s t i c u p p e r mo t o r n e u r o n l e s i o n . T h i s ma y r e f l e c t d i s e a s e o f t h e h e mi s p h e r e , b r a i n s t e m, o r s p i n a l c o r d . 5. Uni l at er al l os s of t ouc h and pos i t i on s ens at i on and c ont r al at er al l os s of t emper at ur e and pai n s ens at idon a t e a u n i l a t e r a l l e s i o n o f t h e s p i n a l c o r d in ic ipsilateral to the loss of touch and position. T his happens because the a s c e n d i n g t r a c t s f o r t o u c h a n d p o s i t i o n s e n s a t i o n d e c u s s a t e i n t h e me d u l l a ,
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w h i l e t h e a s c e n d i n g t r a c t s f o r p a i n a n d t e mp e r a t u r e s e n s a t i o n c r o s s n e a r w h e r e they enter the spinal cord. P. 7 9 8 6. Par al y s i s i s c ont r al at er al t o l es i ons abov e t he medul l a and i ps i. l at er al bel ow T h i s i s b e c a u s e t h e d e s c e n d i n g mo t o r t r a c t s , l i k e t h e t r a c t s f o r d i s c r i mi n a t i v e s e n s e , d e c u s s a t e i n t h e me d u l l a . 7. A l ower mot or neur on par al y s i s ac c ompani ed by anes t hes i a i n an appr opr i at e di s t r i but i on us ual l y i ndi c at es a per i pher al ner v e c es ison ma n y n e r v e s , be l au e c a r r y b o t h mo t o r a n d s e n s o r y f i b e r s . S o me t i me s s p i n a l r o o t o r s e g me n t a l c o r d l e s i o n s c a u s e s i mi l a r s i g n s . 8. M us c l e at r ophy wi t h f as c i c ul at i on r es ul t s f r om a l ower mot or neur on l es i on ; w i t h o u t f a s c i c u l a t i o n , a t r o p h y i s o f t e n a t t r i b u t a b l e t o i n t r i n s i c mu s c l e d i s e a s e .

Overview of the Major Neurologic System Com ponents and their Function
An a c c u r a t e d i a g n o s t i c n e u r o l o g i c e xa mi n a t i o n r e q u i r e s c o mp r e h e n s i v e u n d e r s t a n d i n g o f n e r v o u s s y s t e m a n a t o mi c a n d f u n c t i o n a l o r g a n i za t i o n . A f u l l u n d e r s t a n d i n g o f t h e r e l a t i o n s h i p s b e t w e e n t h e a n a t o my a n d t h e f u n c t i o n a l c o mp o n e n t s o f t h e n e r v o u s s y s t e m i s b e y o n d t h e s c o p e o f t h i s b o o k . T h e r e a d e r s h o u l d c o n s u l t a n a t o my a n d n e u r o l o g y t e xt s f o r d e t a i l e d d i s c u s s i o n s o f n e u r o a n a t o my a n d f u n c t i o n a l p h y s i o l o g y.

Anatomic Organization
F o r d i a g n o s t i c p u r p o s e s , t h e n e r v o u s s y s t e m i s d i v i d e d a n a t o mi c a l l y i n t o t h e b r a i n , the spinal cord and the peripheral nerves.

The Central Nerv ous System (CNS).


T h e b r a i nc o n s i s t s o f t h e c e r e b r u m, t h e b r a i n s t e m, a n d t h e c e r e b e l l u m. T h e c er ebr um e r f o r ms c o g n i t i v e f u n c t i o n s , i s t h e s i t e o f e mo t i o n a n d mo o d f o r ma t i o n p a n d d e t e r mi n e s p e r s o n a l i t y a n d b e h a v i o r. T h e d e e p c e r e b r a l s t r u c t u r e s mo d u l a t e mo t o r a n d s e n s o r y f u n c t i o n a n d c o n t r o l e n d o c r i n e a n d a p p e t i t i v e f u n c t i o n s . T h e br ai ns t em o n s i s t s o f t h e mi d b r a i n , t h e p o n s a n d t h e me d u l l a a n d c o n t a i n s n u c l e i o f c c r a n i a l n e r v e s III t o XII.c erh e l ums i n v o l v e d i n ma n y mo t o r a n d s e n s o r y T ebel i p a t h w a y s a n d c o n t r o l s t h e c o o r d i n a t i o n o f c o mp l e x mo t o r a c t i v i t i e s . T h e s p i n a l c o r do n t a i n s t h e a s c e n d i n g s e n s o r y c a u t o n o mi c t r a c t s a n d t h e l o w e r mo t o r n e u r o n s d o r s a l a n d v e n t sa l nal r ootc o n t a i n t h e s e n s o r y r pi s T h e dor s al r oot ganglci o n t a i n t h e c e l l b o d i e s o f a t r a c t s , t h e d e s c e n d i n g mo t o r a n d w h i c h a c t i v a t e s k e l e t a l mu s c l e s . T h e a n d mo t o r t r a c t s r e s p e c t i v e l y. afferent sensory nerves.

The Peripheral Nerv ous System.


T h e p e r i p h e r a l n e r v o u s s y s t s m q u a l l y c o mp l e x. C r a n i a l a n d s p i n a l n e r v e s ie e c o me t o g e t h e r t o f o r m i aa n dpl ex us es b r a c h i a l , l u mb a r, s a c r a l ) w h e r e t h e gangl ( s e n s o r y a n d mo t o r c o mp o n e n t s o f t h e c r a n i a l a n d s p i n a l s e g me n t s a r e r e d i s t r i b u t e d i n t o p e r i p h e r a l n e r v e s w h i c h s e r v e s p e c i f i c a n a t o mi c a r e a s o f t h e p e r i p h e r y.
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P. 7 9 9

Functional Organization of the Nervous System

It i s a l s o n e c e s s a r y t o h a v e a n u n d e r s t a n d i n g o f t h e f u n c t i o n a l o r g a n i za t i o n o f t h e n e r v o u s s y s t e m. F u n c t i o n c a n b e s y s t e ma t i c a l l y d e s c r i b e dc a s n otl il o w s : og f i n ( i n t e l l e c t , l a n g u a g e , r e g i s t r a t i o n , me mo r y, a t t e n t i o n , o r i e n t a t i o n , s p a t i a l d i s c r i mi n a t i o n ) ;o o d a n d a f f e c t ; s p e c i a l s e n ( s i r y t , h e a r i n g , b a l a n c e , t a s t e , m sogh s me l l ) ; o m a t i c a n d vi s c e r a l s e n s a(ttio u c h , p o s i t i o n , p a i n , t e mp e r a t u r e , s on v i b r a t i o n , p r e s s u r e , t w o - p o i n t d i s c r i mima ttio r )f;u n c t i o(n y r a mi d a l t r a c t s a n d n o on p e xt r a p y r a mi d a l s y s t ep o s t u r e , b a l a n c e , a n d c o o r d i n ( c eoe b e l l a r, v e s t i b u l a r, m) ; ati r n a n d b a s a l g a n g l i a f u n c t i o n )a u tn d o m i c f u n c t i oT h e a u t o n o mi c n e r v o u s ; a on . n s y s t e m i s d i v i d e d i n t opare y mpat hetac ds y mpat het i s y s t e ms . T h e t h as in c p a r a s y mp a t h e t i c o u t f l o w i s f r o m t h e c r a n i a l , c e r v i c a l , a n d s a c r a l r o o t s , w i t h g a n g l i a c l o s e t o t h e o r g a n s t h e y i n n e r v a t e . T h e s y mp a t h e t i c o u t f l o w i s f r o m t h e t h o r a c i c a n d l u mb a r r o o t s v i a t h e s y mp a t h e t i c s p i n a l g a n g l i a .

Superficial Anatom y of the Nervous System

T he brain is encased within the rigid skull and the spinal cord within the spinal can o f t h e v e r t e b r a l c o l u mn . T h e s e g me n t a l o r g a n i za t i o n o f t h e n e r v o u s s y s t e m i s mo s t e v i d e n t i n t h e c h e s t a n d a b d o me n , mu c h l e s s s o i n t h e h e a d a n d e xt r e mi t i e s . T h e g a n g l i a , p l e xu s e s , a n d n e r v e t r u n k s a r e i n a c c e s s i b l e t o p h y s i c a l e xa mi n a t i o n l y i n g d e e p t o t h e mu s c l e s a n d b o n e s o f t h e s p i n e , c h e s t , a b d o me n , a n d p e l v i s . T h e p e r i p h e r a l n e r v e s , h o w e v e r, a r e d i s t r i b u t e d i n t h e n e u r o v a s c u l a r b u n d l e s , a l o n g w i t t h e i r c o r r e s p o n d i n g a r t e r i e s a n d v e i n s , a n d ma y b e a c c e s s i b l e t o p a l p a t i o n w h e r e t h e y e xi t t h e t r u n k a n d i n t h e e xt r e mi t i e s .

T he Neurologic Exam ination CRANIAL NERVE EXAM INATION


T h e 1 2 p a i r s o f c r a n i a l n e r v e s ( C N ) e me r g e f r o m t h e b r a i n a n d p a s s t h r o u g h f o r a mi n a i n t h e b a s e o f t h e s k u l l . T h e y a r e d e s i g n a t e d b y R o ma n n u me r a l s I t o XII. T h e p h y s i c a l e xa mi n a t i o n o f s e v e r a l o f t h e c r a n i a l n e r v e s i s c o n t a i n e d i n t h e d i s c u s s i o n o f t h e h e a d a n d n e ch a ipn e r .7 C k t

Olfactory Nerv e (Cranial Nerv e I)


T h e o l f a c t o r y mu c o s a l i n i n g t h e u p p e r t h i r d o f t h e n a s a l s e p t u m a n d t h e s u p e r i o r nasal concha contains the receptors and ganglion cells. T heir fibers converge into a b o u t 2 0 b r a n c h e s t h a t p i e r c e t h e c r i b r i f o r m p l a t e o f t h e e t h mo i d b o n e a n d consolidate to form the olfactory tract. P. 8 0 0

Te s ting S m e ll.

Ensure the patency of the nasal passages. Have the patient close her eyes; test e a c h n o s t r i l s e p a r a t e l y w h i l e t h e o t h e r i s o c c l u d e d . As k t h e p a t i e n t t o i d e n t i f y f a mi l o d o r s , s u c h a s c o f f e e , c l o v e s , a n d p e p p e r mi n t . N o xi o u s s u b s t a n c e s , s u c h a s a mmo n i a o r a l c o h o l , s h o u l d n o t b e u s e d b e c a u s e t h e y a l s o s t i mu l a t e r e c e p t o r s o f t h t r i g e mi n a l n e r v e a n d g i v e a f a l s e - p o s i t i v e r e s p o n s e .
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Optic Nerv e (Cranial Nerv e II)


T h e e xa mi n a t i o n a n d s t r u c t u r e o f t h e o p t i c n e r v e , c h i a s m, a n d t r a c t i s d i s c u s s e d i n C h a p t e r ,7o n p a g e s 2 1 3 a n d 2 5 9 f f .

Te s ting the R e tina.


Use suitable tests for vision, depending on the patient's acuity and ability to c o o p e r a t e ( p a g e 2 1 9 ) . E xa mi n e t h e f u n d i w i t h t h e o p h t h a l mo s c o p e ( p a g e 2 1 7 ) . Te s t t h e v i s u a l f i e l d s b y t h e c o n f r o n t a t i o n me t h o d ( p a g e 2 1 3 ) ; p e r i me t r y i s r e q u i r e d i f mo r e a c c u r a t e a n d d e t a i l e d i n f o r ma t i o n i s n e e d e d .

Oculomotor Nerv e (Cranial Nerv e III)


T h i s i s t h e mo t o r n e r v e t o f i v e e xt r i n s i c e y e mu s c l e s : t h e l e v a t o r p a l p e b r a e s u p e r i o r i s , me d i a l r e c t u s , s u p e r i o r r e c t u s , i n f e r i o r r e c t u s , a n d i n f e r i o r o b l i q u e . It s n u c l e u s l i e s i n t h e p o s t e r i o r mi d b r a i n , s u b d i v i d e d i n t o a p a r t f o r e a c h mu s c l e . Af t e r e me r g e n c e f r o m t h e b r a i n , t h e n e r v e p r o c e e d s b e t w e e n t h e s u p e r i o r c e r e b e l l a r a n d posterior cerebral arteries, then lateral and forward past the posterior clinoid process, and then along the lateral wall of the cavernous sinus, to enter the orbit through the superior orbital fissure.

Te s ting for Oc ulom otor P ar alys is .


S e e C h a p t e r ,7p a g e s 2 1 2 2 1 4 a n d 2 6 6 .

Trochlear Nerv e (Cranial Nerv e IV)

C N - IV i n n e r v a t e s t h e s u p e r i o r o b l i q u e mu s c l e . T h e t r o c h l e a r n u c l e u s a l s o l i e s i n t h e p o s t e r i o r mi d b r a i n , i n f e r i o r t o t h e t h i r d n e r v e n u c l e u s . It f o l l o w s a c i r c u i t o u s c o u r s e around the superior cerebellar and cerebral peduncles to pierce the free border of t h e t e n t o r i u m c e r e b e l l i n e a r t h e p o s t e r i o r c l i n o i d p r o c e s s . It p r o c e e d s f o r w a r d i n t h e lateral wall of the cavernous sinus and passes through the superior orbital fissure t e n t e r t h e s u b s t a n c e o f t h e s u p e r i o r o b l i q u e mu s c l e .

Te s ting for Tr oc hle ar P ar alys is .


S e e C h a p t e r ,7p a g e 2 1 2 .

Trigeminal Nerv e (Cranial Nerv e V)

CN-V is the largest cranial nerve; its sensory root supplies the superficial and deep s t r u c t u r e s o f t h e f a c e a n d t h e d e e p s t r u c t u r e s o f t h e h e a d a n d i t s mo t o r r o o t i n n e r v a t e s t h e mu s c l e s o f ma s t i c a t i o n . It s n u c l e u s h a s a p o n t i n e l o c u s a n d a n o t h e r p o r t i o n d e s c e n d s t h r o u g h t h e p o n s a n d me d u l l a t o t h e s u b s t a n t i a g e l a t i n o s a . Af t e r l e a v i n g t h e p o n s t h e n e r v e e n t e r s t h e t r i g e mi n a l g a n g l i o n , l y i n g a t t h e p e t r o u s a p e x o f t h e t e mp o r a l b o n e . T h e f i r s t t r i g e mi n a l d i v i s i o n , o r o p h t h a l mi c b r a n c h ( C N - V1 ) , e me r g e s f r o m t h e t r i g e mi n a l g a n g l i o n , g i v i n g f i b e r s t o t h e c o r n e a , c i l i a r y b o d y, conjunctiva, nasal cavity and sinuses, and skin of the eyebrows, forehead, and nos T h e s e c o n d d i v i s i o n , o r ma xi l l a r y b r a n c h P. 8 0 1 ( C N - V2 ) , s u p p l i e s s e n s o r y f i b e r s t o t h e s k i n o f t h e s i d e o f t h e n o s e , t h e u p p e r a n d l o w e r e y e l i d s , t h e p a l a t e , a n d ma xi l l a r y g u ms . T h e t h i r d d i v i s i o n , o r ma n d i b u l a r
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b r a n c h ( C N - V3 ) , i s mi xe d . It s s e n s o r y f i b e r s s u p p l y t h e t e mp o r a l r e g i o n , t h e a u r i c u l l o w e r l i p , l o w e r f a c e , mu c o s a o f a n t e r i o r t w o - t h i r d s o f t h e t o n g u e , ma n d i b u l a r g u ms , a n d t e e t h . T h e mo t o r r o o t o f C N - V3 i n n e r v a t e s t h e mu s c l e s o f ma s t i c a t i o n : ma s s e t e r t e mp o r a l i s , a n d i n t e r n a l a n d e xt e r n a l p t e r y g o i d .

Te s ting the Tr ige m inal N e r ve .

M o t o r D i vi s i o n : s p e c t f o r t r e mo r o f t h e j a w, i n v o l u n t a r y c h e w i n g mo v e me n t s , a n d In t r i s mu s ( s p a s m o f t h e ma s t i c a t o r y mu s c l e s ) . Te s t t h e p a i r e d t e mp o r a l a n d ma s s e t e r mu s c l e s b y p a l p a t i n g s y mme t r i c a l r e g i o n s w h i l e t h e p a t i e n t c l e n c h e s t h e t e e t h ; c o mp a r e mu s c l e t e n s i o n o n t h e t w o Fsi ig . e1 4(- 1)A d i s p a r i t y i n t e n s i o n o f t h e t w o d s ; mu s c l e s i n d i c a t e s p a r a l y s i s o n t h e w e a k s i d e i f a n d w h e n t h e t e e t h a r e a l i g n e d n a t u r a l l y o r a t o n g u e b l a d e i s i n s e r t e d t o c o r r e c t a ma l a l i g n me n t . T h e mo u t h c a n n o t b e c l o s e d t i g h t l y i n b i l a t e r a l p a r a l y s i s . If t h e r e i s ma l a l i g n me n t o f t h e i n c i s o r s w h e n t h e mo u t h i s o p e n e d , p a r a l y s i s o f t h e p t e r y g o i d mu s c l e o n t h e w e a k s i d e i s i n d i c a t e S e n s o r y D i vi s i o W:i t h t h e p a t i e n t ' s e y e s c l o s e d , t e s t t a c t i l e p e r c e p t i o n o f t h e f a c i a l n s k i n b y a s k i n g t h e p a t i e n t t o i n d i c a t e w h e n y o u t o u c h h i m w i t h a s h ri e d o f g a u ze ( F g. 1 4 - 1 B . Te s t p a i n s e n s i b i l i t y o f t h e s k i n a n d mu c o s a w i t h s t e r i l e p i n p r i c k s . W h e n p a i ) s e n s i b i l i t y i s l o s t , o n e c a n a l s o t e s t f o r t e mp e r a t u r e p e r c e p t i o n b y t o u c h i n g t h e p a t i e n t w i t h t e s t t u b e s o f w a r m a n d c o l d w a t e r. In e a c h t e s t , c o mp a r e s y mme t r i c a l p o i n t s ; ma p o u t a r e a s o f a b n o r ma l s e n s a t i o n i n d e t a i l . T h e j a w j e r k t e s t s b o t h t h e mo t o r a n d s e n s o r y c o mp o n e n t s o f t h e t r i g e mi n a l n e r v e . Te s t t h e c o r n e a l r e f l e x b y having the patient look upward while you gently touch the cornea (not the sclera) w i t h a s ma l l s h r e d o f s t e r i l e g a u ze ; t h i s n o r ma l l y i n d u c e s b l i n k i n g . T h e c o r n e a l r e f l e i s a b i l a t e r a l r e f l e x t e s t i n g t h e f i f t h a n d s e v e n t h c r a n i a l n e r v e s o n t h e s i d e s t i mu l a t a n d t h e s e v e n t h c o n s e n s u a l l y. W i t h a n a f f e r e n t ( C N - V) l e s i o n , t h e r e s p o n s e f r o m b o t h s i d e s w i l l b e d e p r e s s e d . W i t h a n i p s i l a t e r a l e f f e r e n t ( C N - VII) l e s i o n , t h e d i r e c t reflex is lost, but the consensual is preserved.

Abducens Nerv e (Cranial VI)

T h e a b d u c e n s i s t h e mo t o r n e r v e t o t h e l a t e r a l r e c t u s . It s n u c l e u s l i e s b e n e a t h t h e facial colliculus. T he nerve runs below the posterior clinoid process, through the cavernous sinus and the superior orbital fissure, to enter the substance of the later r e c t u s mu s c l e .

Te s ting for Abduc e ns P ar alys is .


S e e C h a p t e r ,7p a g e 2 1 2 .

Facial Nerv e (Cranial Nerv e VII)

T h e f a c i a l n e r v e c o n t a i n s mo t o r, a u t o n o mi c , a n d s e n s o r y f i b e r s . It s u p p l i e s mo t o r f i b e r s t o t h e mu s c l e s o f t h e s c a l p , f a c e , a n d a u r i c u l a a s w e l l a s t o t h e b u c c i n a t o r, p l a t y s ma , s t a p e d i u s , s t y l o h y o i d e u s , a n d t h e p o s t e r i o r b e l l y o f t h e d i g a s t r i c u s . Au t o n o mi c mo t o r f i b e r s r u n t h r o u g h t h e c h o r d a t y mp a n i n e r v e , a b r a n c h o f C N - VII, t o c a u s e v a s o d i l a t a t i o n a n d s e c r e t i o n i n t h e s u b ma xi l l a r y a n d s u b l i n g u a l s a l i v a r y glands. Sensory fibers furnish the organs of taste on the anterior two-thirds of the t o n g u e a n d s e n s a t i o n t o t h e e a r c a n a l a n d b e h i n d t h e e a r. P. 8 0 2
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F i g . 1 4 - 1 Te s t i n g S o m e C r a n i a l N e r ve s . A . M o t o r D i vi s i o n o f t h e F i f t h ( T r i g e m i n a l ) N e r ve : S e e t e xt . B . S e n s o r y D i vi s i o n o f t h e F i f t h ( T r i g e m i n a l ) : The t hr ee br anc hes of t he s ens or y t r i gemi nal ar e opht hal mi c , max i l l ar y, and mandi bul ar, as i ndi c at ed by t he. C . eas t o r D i vi s i o n o f t h e S e ve n t h ar M o ( F a c i a l ) When t he pat i ent opens t he mout h t o s how c l enc hed t eet h, onl y t he : unpar al y zed s i de of t he f ac e r et r ac t s ; t he c heek mus c l es f or m c r eas es on t he nor mal s i de; t he ey el i d f i s s ur es ar e i nc r eas ed. The par al y zed s i de r emai ns s moot h wi t h ey el i d openM o t o r D i vi s i o n o f t h e N i n t h ( G l o s s o p h a r y n g e a l ) . D. a n d Te n t h ( Va g u s ) N e r ve s : t he pat i ent opens t he mout h and s ay s ah, When t he uv ul a dev i at es t owar d t he s t r ong s i de. Upon s wal l owi ng, t he l ar y nx nor mal l y el ev at es , as i ndi c at ed by t he mot i on of t he t hy r oi d c ar t i l age i n t he nec k ( Adam' s appl e) ; i t does not r i s e i n bi l at er al E . Tale s i c c e s s o r y . par h y A s ( E l e ve n t h N e r ve ) : pat i ent i s as k ed t o r ot at e t he head t owar d t he mi dl i ne The agai ns t t he r es i s t anc e of t he ex ami ner ' s hand whi l e t he ot her hand pal pat es t he t ens i on i n t he s t er noc l ei domas t oi d mus c l e. The t r apezi us c an l i k ewi s e be t es t ed f or par al y s i s T h e Tw e l f t h ( H y p o g l o s s a l ) NThe pr ot r udi ng . F. e r ve : t ongue dev i at es t o t he par al y zed s i de; mus c l e at r ophy may al s o be pr es ent .

Te s ting the Fac ial N e r ve .


M o t o r :In s p e c t t h e f a c e i n r e p o s e f o r e v i d e n c e o f f l a c c i d p a r a l y s i s . H a v e t h e p a t i e n t p e r f o r m t h e s e s e v e n mo t i o n s t o d e mo n s t r a t e a s y mme t r y i n d i c a t i n g u n i l a t e r a l p a r a l y s i s a n d t o d e t e r mi n e w h e t h e r t h e c a u s e i s a l o w e r mo t o r n e u r o n ( L M N ) o r a n u p p e r mo t o r n e u r o n ( U M N ) l e s i o n . B e c a u s e t h e L M N s o f t h e l i d s a n d f o r e h e a d a r e innervated bilaterally from the UMNs, UMN lesions do not affect the upper lid or forehead. (a) Face in repose: shallow nasolabial folds in both UMN and LMN; palpebral fissure widened in LMN. (b) Elevation P. 8 0 3 of an eyebrow and wrinkling of the forehead is absent in LMN, but present in UMN.
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(c) Frowning: lowering of the eyebrow is absent in LMN, present in UMN. (d) Tight closing of an eye is absent in LMN, with an associated upturning of the unclosed ey ( Bel l phenomenonT h e l i d s c l o s e n o r ma l l y i n U M N . W h e n t h e e y e s a r e t i g h t l y ). closed, weakness of one upper lid can be detected by forcing the lids open with the t h u mb . ( e ) S h o w i n g t e e t h : t h e l i p s d o n o t r e t r a c t f u l l y i n e i t h e r U M Ni g .r L M N ( s e e F o 1 4 - 1 C . ( f ) W h i s t l i n g a n d p u f f i n g c h e e k s a r e a b s e n t o r d i mi n i s h e d i n b o t h U M N a n d ) L M N . ( g ) A n a t u r a l s mi l e : t h e l i p s a n d c o r n e r s o f t h e mo u t h d o n o t f u l l y e l e v a t e w i t h L M N l e s i o n s . T h e p a r a l y s i s o f t h e mo u t h i s o v e r c o me b y mo t i o n s r e s p o n d i n g t o e mo t i o n , s o a s y mme t r i c a l s mi l e ma y o c c u r i n U M N e ns e ars e . Ta s t eTe s t S di so y ( ): w i t h s u g a r, v i n e g a r ( d i l u t e a c e t i c a c i d ) , q u i n i n e , a n d t a b l e s a l t . W r i t e t h e w o r d s s w e e t , s o u r, b i t t e r, a n d s a l t y o n a p i e c e o f p a p e r s o t h e p a t i e n t c a n p o i n t o u t h e r s e n s a t i o n s . H o l d t h e p r o t r u d e d t o n g u e i n g a u ze a n d t o u c h s u c c e s s i v e l y o n e s i d e o f the anterior two-thirds of the lingual dorsum with the test substance on an applicato a f t e r t h e p a t i e n t h a s r e s p o n d e d , a p p l y a s u b s t a n c e t o t h e o t h e r s i d e . R e me mb e r, sweet receptors are located on the tip of the tongue. Have the patient rinse the tongue well with water between tests.

Acoustic Nerv e (Cranial Nerv e VIII)

T he eighth nerve is a relatively short trunk consisting of the cochlear and vestibula s e n s o r y n e r v e s . T h e y a r e mo r p h o l o g i c a l l y a n d f u n c t i o n a l l y d i s t i n c t . B e g i n n i n g i n different nuclei, the two sets of fibers join a single trunk entering the internal a u d i t o r y me a t u s . T h e c o c h l e a r n e r v e s u p p l i e s t h e o r g a n o f C o r t i , w h i l e t h e v e s t i b u l a n e r v e f u r n i s h e s s e n s o r y e n d i n g s f o r t h e s e mi c i r c u l a r d u c t s .

Te s ting the Ac ous tic N e r ve .


C o c h l e a r P o r t i o n : e t e s t s f o r h e a r i n g a r e d e s c r iC h a pitn r 7 n p a g e s 2 0 9 Th bed e o 2 1 0 .Ve s t i b u l a r P o r t i oN o t e s p o n t a n e o u s n y s t a g mu s ; u s e t h e l a b y r i n t h i n e t e s t s n: d e s c r i b e d iC h a p t e r 7 n p a g e s 2 1 0 2 11 . n o

Glossopharyngeal Nerv e (Cranial Nerv e IX)

C N - IX c o n t a i n s s e n s o r y, mo t o r, a n d a u t o n o mi c f i b e r s . It s u p p l i e s t h e s e n s o r y o r g a n s f o r p a i n , t o u c h , a n d t e mp e r a t u r e i n t h e mu c o s a o f t h e p h a r y n x, f a u c e s , a n d p a l a t i n e tonsil; in addition, it is the nerve of taste for the posterior third of the tongue. S o ma t i c mo t o r f i b e r s t r a v e l t h r o u g h b o t h t h e g l o s s o p h a r y n g e a l a n d v a g u s t o i n n e r v a t e t h e mu s c l e s o f t h e p h a r y n x. T h e n e r v e t r u n k e me r g e s f r o m t h e me d u l l a a n p a s s e s t h r o u g h t h e j u g u l a r f o r a me n o f t h e s k u l l w i t h t h e v a g u s a n d a c c e s s o r y n e r v e s . It f o l l o w s t h e i n t e r n a l c a r o t i d a r t e r y a n d c u r v e s u n d e r t h e s t y l o i d p r o c e s s , t h e n g o e s f o r w a r d t o t h e p h a r y n x.

Te s ting the Glos s ophar ynge al N e r ve .


T his is tested with the vagus nerve.

Vagus Nerv e (Cranial Nerv e X)


M o s t e xt e n s i v e o f t h e c r a n i a l n e r v e s , t h e v a g u s c a r r i e s mo t o r, s e n s o r y, a n d a u t o n o mi c f i b e r s t o t h e n e c k , t h o r a x, a n d a b d o me n . It e xi t s t h e s k u l l i n t h e j u g u l a r f o s s a . It s c e r v i c a l b r a n c h e s a r e t h e p h a r y n g e a l , s u p e r i o r P. 8 0 4
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laryngeal, recurrent laryngeal, and superior cardiac nerves. T he thoracic branches are the inferior cardiac, anterior and posterior bronchials, and esophageal nerves. t h e a b d o me n , i t s ma j o r b r a n c h e s a r e t h e g a s t r i c a n d h e p a t i c n e r v e s a n d t h e c e l i a c a n d s u p e r i o r me s e n t e r i c g a n g l i a .

Te s ting of the Glos s ophar ynge al and Vagus N e r ve s .

P h a r y n x:W h i l e i n s p e c t i n g t h e p h a r y n x, h a v e t h e p a t i e n t o p e n h i s mo u t h a n d s a y a h , n o t i n g e l e v a t i o n o f t h e u v u l a . Ab s e n c e o f e l e v a t i o n i n d i c a t e s b i l a t e r a l p a r a l y s w h i l e u n i l a t e r a l e l e v a t i o n d e v i a t e s t h e u v u l a t o w a r d t h e s t r oF i g . s 1d e 1(D e e n i 4 - )s . N o t e w h e t h e r t h e f a u c i a l p i l l a r s c o n v e r g e e q u a l l y. Te s t t h e g a g r e f l e x b y t o u c h i n g t h b a c k o f t h e t o n g u e w i t h a t o n g u e b l a d e . Te s t t h e p h a r y n g e a l mu c o s a f o r a r e a s o f a n e s t h e s i a b y t o u c h i n g w i t h a n a p pLi a r y o r. Wa t c h t h e l a r y n g e a l c o n t o u r s i n l c a t n x: t h e n e c k t o a s c e r t a i n i f t h e y r i s e w i t h s w a l l o wi g .g 1(4 -e1)D Te s t f u r t h e r b y F n s e. h a v i n g t h e p a t i e n t s w a l l o w s o me w a t e r ; p a r a l y s i s ma y c a u s e c o u g h i n g o r r e f l u x i n t o t h e p o s t e r i o r n o s e . H o a r s e n e s s ma y i n d i c a t e u n i l a t e r a l v o c a l c o r d p a r a l y s i s , w h i l e d y s p n e a a n d i n s p i r a t o r y s t r i d o r a r e a s s o c i a t e d w i t h b i l a t e r a l i n v o l v e me n t . M a k e a n i n d i r e c t e xa mi n a t i o n o f t h e v o c a l c o r d s , a s d e s c rab ee r i n n p a g e 2 2 5 . Ch i pt d 7 o

Accessory Nerv e (Cranial Nerv e XI)

T h e a c c e s s o r y n e r v e ( f o r me r l y t h e s p i n a l a c c e s s o r y ) i s t h e mo t o r n e r v e t o t h e t r a p e zi u s a n d s t e r n o c l e i d o ma s t o i d . It a r i s e s i n t h e me d u l l a a n d t h e u p p e r c e r v i c a l c o r d a n d p a s s e s u p w a r d t h r o u g h t h e f o r a me n ma g n u m a n d e me r g e s f r o m t h e s k u l l t h r o u g h t h e j u g u l a r f o r a me n . It r u n s b a c k w a r d n e a r t h e i n t e r n a l j u g u l a r v e i n a n d descends before branching. One branch enters the upper part of the s t e r n o c l e i d o ma s t o i d , a n d t h e o t h e r e n t e r s t h e p o s t e r i o r t r i a n g l e o f t h e n e c k t o s u p p t h e u p p e r p o r t i o n o f t h e t r a p e zi u s .

Te s ting of the Ac c e s s or y N e r ve .

P a l p a t e t h e u p p e r b o r d e r s o f t h e t r a p e zi i w h i l e t h e p a t i e n t r a i s e s h i s s h o u l d e r s against the resistance of your hands. Look for scapular winging as the patient l e a n s a g a i n s t a w a l l w i t h p a l ms a n d a r ms e xt e n d e d . Te s t t h e s t e r n o c l e i d o ma s t o i d b y h a v i n g t h e p a t i e n t t u r n h i s h e a d t o o n e s i d e a n d a t t e mp t t o b r i n g h i s c h i n b a c k t o t h mi d l i n e a g a i n s t t h e r e s i s t a n c e o f y o u r h a n g . ( 1 4 - 1)E N o t e t h e s t r e n g t h o f Fi d see . r o t a t i o n a n d t h e p r o mi n e n c e o f t h e t e n s e d mu s c l e s i n t h e n e c k .

Hypoglossal Nerv e (Cranial Nerv e XII)

T h e h y p o g l o s s a l i s t h e mo t o r n e r v e t o t h e t o n g u e . It a r i s e s i n t h e me d u l l a , p a s s e s t h r o u g h t h e h y p o g l o s s a l c a n a l b e s i d e t h e f o r a me n ma g n u m, c o u r s e s d o w n w a r d w i t h t h e i n t e r n a l c a r o t i d a r t e r y, j u g u l a r v e i n , a n d v a g u s n e r v e , t h e n c u r v e s f o r w a r d b e h i n t h e ma n d i b l e t o t h e r o o t o f t h e t o n g u e .

Te s ting of the H ypoglos s al N e r ve .

W h e n t h e t o n g u e p r o t r u d e s , l o o k f o r t r e mo r s , a t r o p h y o f o n e l a t e r a l mu s c l e ma s s , a n d f a s c i c u l a t i o n s . W h e n o n e s i d e i s p a r a l y ze d , t h e t o n g u e d e v i a t e s t o w a r d t h e w e a s i d e ( s e e i g . 1 4 - 1)F O c c a s i o n a l l y, d e v i a t i o n o f t h e t o n g u e r e s u l t s f r o m a n u p p e r F . mo t o r n e u r o n l e s i o n . Te s t mu s c l e s t r e n g t h b y h a v i n g t h e p a t i e n t p u s h t h e t o n g u e against the cheek while your hand resists from the outside.
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P. 8 0 5 Te s t l i n g u a l s p e e c h b y h a v i n g t h e p a t i e n t r e p e a t L a , L a , L a (Cih a p ta lrs ; s e e l ngu e 7, p a g e 2 2 6 f o r K , L , M t e s t ) .

M otor Examination
M o t o r s y s t e m f u n c t i o n r e q u i r e s a n o r ma l a n d i n t a c t s k e l e t o n , n o r ma l mu s c l e ma s s a n d f u n c t i o n a n d n o r ma l f u n c t i o n o f t h e p y r a mi d a l a n d e xt r a p y r a mi d a l mo t o r n e r v e s y s t e ms . J o i n t mo t i o n mu s t b e t e s t e d t o a s s e s s mu s c l e mo v e me n t s , s o o r t h o p e d i c , r h e u ma t o l o g i c , a n d n e u r o l o g i c e xa mi n a t i o n s o v e r l a p a n d a r e i n t e r d e p e n d e n t .

Inspecting for Muscle Atrophy


W h e n e v e r p o s s i b l e , c o mp a r e t h e ma s s e s o f s y mme t r i c a l mu s c l e s a t t h e s a me l e v e l . W h e n b i l a t e r a l a t r o p h y i s s u s p e c t e d , t h e e xa mi n e r mu s t e v a l u a t e t h e f i n d i n g s f r o m k n o w l e d g e o f n o r ma l a n a t o my a n d t h e i n d i v i d u a l v a r i a t i o n s e n c o u n t e r e d i n e xp e r i e n c e w i t h ma n y p e r s o n s .

Testing Muscle Tone

T h e p a t i e n t i s a s k e d t o r e l a x w h i l e mu s c l e t o n e i s a s s e s s e d b y r e s i s t a n c e t o p a s s i v j o i n t mo t i o n t h r o u g h a n o r ma l r a n g e . T h e e xa mi n e r mu s t l e a r n t h e f e e l o f n o r ma l r e s i s t a n c e w i t h w h i c h t o c o mp a r e t h e p a t i e n t ' s f i n d i n g s . R e l a xa t i o n i s d i f f i c u l t f o r s o me p a t i e n t s , s o l e a r n t o t e s t t o n e w h e n t h e p a t i e n t ' s a t t e n t i o n i s d i v e r t e d . G e n t l y r o c k i n g o r l i f t i n g a l i mb f r o m t h e b e d a n d w a t c h i n g i t f a l l d i s c l o s e s i t s t o n e . W h e n t h p a t i e n t s i t s o n t h e e d g e o f t h e e xa mi n i n g t a b l e , t h e f r e e d o m w i t h w h i c h t h e l e g s swing indicates their tone.

Testing Muscle Strength

F i r s t , h a v e t h e p a t i e n t a c t i v e l y mo v e t h e Fmu.s 1 l4e)2 W h e n mo t i o n i s i g c - .( a c c o mp l i s h e d , h a v e t h e p a t i e n t c o n t r a c t t h e mu s c l e o r mo v e a g a i n s t y o u r r e s i s t a n c e w h i l e p a l p a t i n g t h e c o n t r a c t i n g mu s c l e . If t h e P. 8 0 6 p a t i e n t c a n n o t mo v e a l i mb i n t h e u s u a l ma n n e r, l a y t h e e xt r e mi t y o n t h e t a b l e o r b e a n d h a v e t h e p a t i e n t mo v e i t i n a d i r e c t i o n u n a f f e c t e d b y g r a v i t y. An a r b i t r a r y s c a l e u s e d f o r g r a d i n g mu s c l e s t r e n g t h .

F i g . 1 4 - 2 Te s t i n g M u s c l e S t r .eThe hpat i ent i s r equi r ed t o ac t agai ns t t he ngt r es i s t anc e of t he ex ami ner .


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Grading of Muscle Stre ngth (Ox ford Scale ) G r a d e 0 N o mu s c l e mo v e me n t G r a d e 1 A t r a c e o f mu s c l e mo v e me n t w i t h o u t j o i n t mo t i o n G r a d e 2 B o d y p a r t mo v e s w i t h g r a v i t y e l i mi n a t e d G r a d e 3 B o d y p a r t mo v e s a g a i n s t g r a v i t y b u t n o t r e s i s t a n c e G r a d e 4 B o d y p a r t mo v e s a g a i n s t g r a v i t y a n d s o me r e s i s t a n c e G r a d e 5 N o r ma l

M u s c l e s t r e n g t h i n t h e l o w e r e xt r e mi t i e s n o r ma l l y e xc e e d s u p p e r a r m s t r e n g t h i n t h e e xa mi n e r, s o mi l d d e g r e e s o f w e a k n e s s a r e e a s i l y mi s s e d w i t h r e s i s t e d mo t i o n . To t e s t l o w e r e xt r e mi t y s t r e n g t h , t h e f o l l o w i n g t e s t s a r e u s e f u l : ( a ) O b s e r v e t h e p a t i e n t a r i s e a f t e r s i t t i n g o n t h e f l o o r. U s e o f b o t h a r ms t o a s s i s t r i s i n g a n d r a i s i n g t h e buttocks, first by working the hands on the floor toward the feet and then up the leg i n d i c a t e s p r o xi ma l mu s c l e w e a kGower(s s i gn ( b ) H a v e t h e p a t i e n t h o p o n b o t h ness ). f e e t , t h e n o n e a c h f o o t i n d e p e n d e n t l y. N o r ma l l y, t h e h e e l w i l l n o t s t r i k e t h e g r o u n d . Having the patient hop on a piece of paper will accentuate the sound of the heel s t r i k e ( c r e a t i n g a g a l l o p r h y t h m) , i n d i c a t i n g g a s t r o c n e mi u s a n d s o l e u s mu s c l e weakness.

EXAM INATION OF REFLEXES

T h e s t r e t c h r e f l e x i s a s i mp l e r e f l e x a r c o f a mu s c l e c e l l , a s e n s o r y, a n d a mo t o r n e u r o n . T h e a f f e r e n t l i mb i s t h e s e n s o r y n e u r o n w h o s e c e l l b o d y i s i n t h e d o r s a l r o o g a n g l i o n , s e n s o r y d e n d r i t e i n t h e mu s c l e a n d w h o s e a xo n p e n e t r a t e s t h e g r a y ma t t e o f t h e c o r d . T h e d e n d r i t e i n n e r v a t e s t h e mu s c l e s p i n d l e , a s p e c i a l i ze d r e c e p t o r o r g a w i t h i n t h e mu s c l e . S t r e t c h i n g t h e mu s c l e e v o k e s a n a f f e r e n t i mp u l s e t h r o u g h t h e d o r s a l r o o t g a n g l i o n t o t h e c o r d ' s g r a y ma t t e r, w h e r e i t s y n a p s e s w i t h t h e a xo n a n d t h e d e n d r i t e o f t h e L M N i n t h e a n t e r i o r h o r n . T h e e f f e r e n t l i mb o f t h e a r c c o n s i s t s o t h e L M N , t h e mu s c l e s y n a p s e , a n d t h e mu s c l e f i b e r s o f t h e mo t o r u n i t .

M o s t r e f l e x a r c s a r e mo r e c o mp l e x b u t a r e e xt e n s i o n s o f t h e b a s i c t w o - n e u r o n u n i t (F i g . 1 4 -)3 T h e a f f e r e n t a n d e f f e r e n t n e u r o n s ma y b e s e p a r a t e d b y i n t e r v e n i n g . c o n n e c t o r n e u r o n s a t t h e s a me s p i n a l l e v e l o r a t w i d e l y d i f f e r e n t l e v e l s , s o a f f e r e n t a n d e f f e r e n t i mp u l s e s t r a v e l u p a n d d o w n t h e c o r d f o r c o n s i d e r a b l e d i s t a n c e s . T h e i n t e g r i t y o f t h e r e f l e x a r c i s b r o k e n b y ma l f u n c t i o n o f a n y o f i t s e l e me n t s : r e c e p t o r o r g a n , s e n s o r y n e r v e , d o r s a l r o o t g a n g l i o n , s p i n a l g r a y ma t t e r, a n t e r i o r s p i n a l r o o t , mo t o r n e r v e , mo t o r e n d p l a t e , o r e f f e c t o r o r g a n . T h e p h y s i c a l s i g n o f a n i n t e r r u p t e d r e f l e x a r c i s a d i mi n i s h e d o r a b s e n t r e f l e x. W h e n a d e s c e n d i n g mo t o r p a t h w a y ( t h e p y r a mi d a l t r a c t ) i n t h e c o r d i s i n j u r e d a t a l e v e l h i g h e r t h a n t h e r e f l e x a r c , n o r ma l i n h i b i t i o n f r o m h i g h e r c e n t e r s i s l o s t , p r o d u c i n g a h y p e r a c t i v e r e f l e x. P. 8 0 7

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F i g . 1 4 - 3 C o m p o n e n t s o f a S p i n a l R e f .l e x A r c

In f e r e n c e s a r e ma d e f r o m a s s e s s me n t o f r e f l e x a r c s a t k n o w n l e v e l s o f t h e b r a i n s t e m a n d s p i n a l c o r d . A n o r ma l r e f l e x ( a ) a t t e s t s t h e i n t e g r i t y o f e v e r y e l e me n t i n t h e r e f l a r c a n d ( b ) i n d i c a t e s t h e p r o p e r f u n c t i o n i n g o f t h e d e s c e n d i n g mo t o r t r a c t s . A d i mi n i s h e d o r a b s e n t r e f l e x i n d i c a t e s ma l f u n c t i o n o f o n e o r mo r e c o mp o n e n t s o f t h e a r c o r a b s e n c e o f f a c i l i t a t o r y i n f l u e n c e s f r o m a b o v e . A l e s i o n ma y b e l o c a l i ze d f r o m the known levels of the reflex centers. In t h e r o u t i n e e xa mi n a t i o n , t h e c l i n i c i a n u s u a l l y t e s t s a f e w r e f l e x a r c s , r e p r e s e n t a t i v e o f v a r i o u s l e v e l s i n t h e c o r d a n d b r a i n s t e m. W h e n a n a b n o r ma l i t y i s e n c o u n t e r e d , i t s l e s i o n ma y b e p i n p o i n t e d b y t e s t i n g s p e c i f i c r e f l e x a r c s .

Brainstem Reflexes
M a n y o f t h e s e a r e t e s t e d i n t h e r o u t i n e e xa mi n a t i o n o f t h e c r a n i a l n e r v e s . T h e findings are valuable only when the level of the reflex center is known. T he cranial n e r v e i n n e r v a t i o n o f t h e a f f e r e n t a n d e f f e r e n t l i mb s a r e s h o w n i n p a r e n t h e s e s .

D ir e c t P upillar y R e ac tion to Light.


T h e i r i s c o n s t r i c t s w h e n b r i g h t l i g h t i s s h o n e u p o n t h e r e t i n a ( a f f e r e n t C N - II; e f f e r e i p s i l a t e r a l C N - III) .

C ons e ns ual P upillar y R e ac tion to Light.


S t i mu l a t i o n o f o n e r e t i n a w i t h l i g h t c a u s e s c o n t r a l a t e r a l c o n s t r i c t i o n o f t h e p u p i l a s w e l l a s a h o mo l a t e r a l r e s p o n s e ( a f f e r e n t C N - II; e f f e r e n t c o n t r a l a t e r a l C N - III) .

C ilios pinal R e fle x .


Pinching the skin of the back of the neck causes pupillary dilatation (afferent c e r v i c a l s o ma t i c n e r v e s ; e f f e r e n t - c e r v i c a l s y mp a t h e t i c c h a i n ) .

C or ne al R e fle x . J aw R e fle x .

To u c h i n g t h e c o r n e a c a u s e s b l i n k i n g o f t h e e y e l i d s ( a f f e r e n t C N - V; e f f e r e n t C N - VII) .

W h e n t h e mo u t h i s p a r t i a l l y o p e n e d a n d t h e mu s c l e s r e l a xe d , t a p p i n g t h e c h i n c a u s e s t h e j a w t o c l o s e . T h e r e f l e x c e n t e r i s i n t h e mi d - p o n s ( a f f e r e n t C N - V; e f f e r e n
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C N - V) .

Gag R e fle x .
G a g g i n g o c c u r s w h e n t h e p h a r y n x i s s t r o k e d . T h e r e f l e x c e n t e r i s i n t h e me d u l l a ( a f f e r e n t C N - IX, - X; e f f e r e n t C N - IX, - X) . P. 8 0 8

The Muscle Stretch Reflexes

T h e s e mu s c l e s t r e t c h r e f l e xe s a r e mi s n a me d d e e p t e n d o n r e f l e xe s ( D T R s ) . T h e y a r e e l i c i t e d b y a s u d d e n t a p o n t h e t e n d o n , w h i c h s t r e t c h e s t h e mu s c l e .

Ge ne r al P r inc iple s for E lic iting M us c le S tr e tc h R e fle x e s .


T h e l i mb s h o u l d b e r e l a xe d . Id e n t i f y t h e t e n d o n o f i n s e r t i o n o f t h e mu s c l e t o b e t e s t e d . S t r e t c h t h e mu s c l e s l i g h t l y b y l i mb p o s i t i o n i n g o r t h u mb p r e s s u r e o n t h e t e n d o n . S t r i k e a b r i s k b l o w o n t h e t e n d o n w i t h t h e f i n g e r o r r e f l e x h a mme r. If n o r e f l e x i s p r e s e n t , r e i n f o r c e me n t c a n b e u s e d . T h i s i s a c c o mp l i s h e d b y h a v i n g t h e patient concentrate on a voluntary act such as pulling on interlocked fingers or clenching the fists.

T h e r e i s c o n s i d e r a b l e v a r i a b i l i t y i n n o r ma l r e f l e xe s , f r o m a b s e n t t o b r i s k . S i g n i f i c a n a s y mme t r y b e t w e e n r i g h t a n d l e f t a t t h e s a me l e v e l i s a b n o r ma l . C l o n u s , t h e s u s t a i n e d r e p e t i t i v e ma i n t e n a n c e o f t h e r e f l e x a r c w i t h t o n i c s t r e t c h o f t h e mu s c l e i s a l w a y s a b n o r ma l . A f o u r - p o i n t s c a l e , d e n o t e d b y n u mb e r s o r p l u s e s , i s c o mmo n l y used to grade the reflex response.

0, 0

No response

1, +

Detectable, but weak

2, ++

Easily detectable

3, +++

B r i s k w i t h a t mo s t a f e w b e a t s o f c l o n u s

4, ++++

Sustained clonus

R e fle x C e nte r at C 5 to T1 : P e c tor alis R e fle x (M e dial and Late r al Ante r ior Thor ac ic N e r ve s ).
H a v e t h e p a t i e n t e l e v a t e t h e a r m a b o u t 1 0 d e g r e e s i n 9 0 d e g r e e s F ifg a b d u c t i o n ( o .
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1 4 - 4 A. P l a c e t h e f i n g e r s o f y o u r l e f t h a n d o n t h e p a t i e n t ' s s h o u l d e r w i t h y o u r t h u mb ) e xt e n d e d d o w n w a r d t o p r e s s f i r ml y o n t h e t e n d o n o f t h e p e c t o r a l i s ma j o r. W i t h t h e r u b b e r h a mme r, s t r i k e y o u r t h u mb a b l o w d i r e c t e d s l i g h t l y u p w a r d t o w a r d t h e p a t i e n t ' s a xi l l a . T h e mu s c l e c o n t r a c t i o n c a n b e s e e n o r f e l t .

R e fle x C e nte r at C 5 to C 6 : B ic e ps R e fle x (M us c uloc utane ous N e r ve ).

P l a c e t h e e l b o w a t 9 0 d e g r e e s o f f l e xi o n w i t h t h e a r m s l i g h t l y p r o n a t e d . G r a s p t h e e l b o w w i t h y o u r l e f t h a n d s o t h a t t h e f i n g e r s a r e b e h i n d a n d y o u r t h u mb p r e s s e s t h e b i c e p s b r a c h i i t e n d o n ( si e e 1 4 - 4)B S t r i k e a s e r i e s o f b l o w s o n y o u r t h u mb w i t h F g. . t h e r u b b e r h a mme r, v a r y i n g y o u r t h u mb p r e s s u r e w i t h e a c h b l o w u n t i l t h e mo s t s a t i s f a c t o r y r e s p o n s e i s o b t a i n e d . T h e n o r ma l r e f l e x i s e l b o w f l e xi o n .

R e fle x C e nte r at C 5 to C 6 : B r ac hior adialis R e fle x (R adial N e r ve ).

H o l d t h e p a t i e n t ' s w r i s t w i t h y o u r l e f t h a n d w i t h t h e f o r e a r m r e l a xe d i n p r o n a t i o n ( s e F i g . 1 4 - 4)C W i t h a v e r t i c a l s t r o k e , t a p t h e f o r e a r m d i r e c t l y, j u s t a b o v e t h e r a d i a l . s t y l o i d p r o c e s s . T h e n o r ma l r e s p o n s e i s e l b o w f l e xi o n a n d s u p i n a t i o n o f t h e f o r e a r m

R e fle x C e nte r at C 6 to C 7 : P r onator R e fle x (M e dian N e r ve ).

H o l d t h e p a t i e n t ' s h a n d v e r t i c a l l y s o t h e w r i s t i s s u s pF in d e1 4 - 4)e eF r o m e g. d (sD . t h e me d i a l s i d e , s t r i k e t h e d i s t a l e n d o f t h e r a d i u s d i r e c t l y w i t h a h o r i zo n t a l b l o w. T n o r ma l r e s p o n s e i s p r o n a t i o n o f t h e f o r e a r m. An a l t e r n a t e me t h o d i s t o s t r i k e t h e d i s t a l e n d o f t h e u l n a d i r e c t l y w i t h a b l o w me d i a d . P. 8 0 9

F i g . 1 4 - 4 D e e p R e f l e xe s I . A . P e c t o r a l i s R e f l e x. B . B i c e p s B r a c h i i R e f l e x. C . B r a c h i o r a d i a l i s R e f l e x. D . P r o n a t o r R e f l e x. E . T r i c e p s B r aTher e e f l e x: chii R ar e t wo al t er nat i v e pos i t i ons : Hol d t he pat i ent ' s ar m at 90 degr ees abduc t i on,
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al l owi ng t he r el ax ed f or ear m t o dangl e wi t h t he el bow at f l ex i on, or hav e t he pat i ent f ol d t he ar ms and gr as p t he f or ear ms wi t h t he hands ( r ei nf or c ement c an be obt ai ned by hav i ng t he pat i ent t i ght en t he gr as p on t he ar ms ) .

R e fle x C e nte r at C 7 to C 8 : Tr ic e ps R e fle x (R adial N e r ve ).

H o l d t h e p a t i e n t ' s a r m a t 9 0 d e g r e e s a b d u c t i o n a n d e l e v a t i o n , a l l o w i n g t h e r e l a xe d f o r e a r m t o d a n g l e w i t h t h e e l b o w a t 9 0 d e g r e e s f l e xi o n 4s 4)E Ta p t h e Fig. 1 ( - ee . t r i c e p s b r a c h i i t e n d o n j u s t a b o v e t h e o l e c r a n o n p r o c e s s . T h e n o r ma l r e s p o n s e i s e l b o w e xt e n s i o n . Al t e r n a t i v e l y, h a v e t h e p a t i e n t f l e x b o t h e l b o w s , b r i n g i n g t h e a r ms p a r a l l e l a c r o s s t h e c h e s t F is e e1 4 - 4)E H a v e e a c h h a n d g r a s p t h e o t h e r f o r e a r m. ( g. . R e i n f o r c e me n t c a n b e o b t a i n e d b y h a v i n g t h e p a t i e n t g r a s p h a r d e r a n d e xt e n d i n g t h e l b o w s l i g h t l y.

R e fle x C e nte r at T8 to T9 : U ppe r Abdom inal M us c le R e fle x .


Ta p t h e mu s c l e s d i r e c t l y n e a r t h e i r i n s e r t i o n s o n t h e c o s t a l ma r g i n s a n d xi p h o i d p r o c e s s F(i g . 1 4 - 5)A .

R e fle x C e nte r at T9 to T1 0 : M iddle Abdom inal M us c le R e fle x .

S t i mu l a t e t h e mu s c l e s o f t h e mi d - a b d o me n b y t a p p i n g a n o v e r l a i d f i n g e r o r d o u b l e d t o n g u e b l a d e s ( sF ie . 1 4 - 5)B eg . P. 8 1 0

F i g . 1 4 - 5 A b d o m i n a l M u s c l e R e f l e xe s . A . U p p e r A b d o mhe :abdomi nal Tap t e n mus c l es di r ec t l y wi t h t he r ef l ex hammer, near t hei r at t ac hment s t o t he c os t al mar gi n B . M i d - A b d o m e n : ac e y our f i nger or a doubl e- t ongue bl ade on t he . Pl mus c l es and t ap t he pl ex i met er o w e r A b d o m e Tap t he l ower abdomi nal . C. L n: mus c l es di r ec t l y at t hei r at t ac hment s near t he s y mphy s i s pubi s .

R e fle x C e nte r at T11 to T1 2 : Lowe r Abdom inal M us c le s .


Ta p t h e mu s c l e i n s e r t i o n s d i r e c t l y, n e a r t h e s y mp h y s i sFpg .b i1s4 - 5)e e iu (sC .

R e fle x C e nte r at L2 to L4 : Quadr ic e ps R e fle x (Fe m or al


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N e r ve ).

S e v e r a l me t h o d s a r e a v a i l a b l e . In e a c h , a n o r ma l r e s p o n s e i s e xt e n s i o n o f t h e k n e e a n d c o n t r a c t i o n o f t h e q u a d r i c e p s f e mo r i s c a n b e Lp a l s aDe d .g l i n g i(g . 1 4 eg p t an F 6 A) : G r a s p t h e l o w e r t h i g h w i t h y o u r l e f t h a n d P. 8 11 w h i l e y o u r r i g h t d e l i v e r s a h a mme r t a p o n t h e p a t e l l a r t e n d o n , j u s t b e l o w t h e p a t e l l a S i t t i n g , F e e t o n t h e F l o o g .( 1 4 - 6)B T h e p a t i e n t s i t s o n a c h a i r o r l o w b e d . Fi r : H a v e t h e p a t i e n t ' s t o e s c u r l e d i n p l a n t a r f l e xi o n a n d k n e e s l i g h t l y e xt e n d e d f r o m a r i g h t a n g l e b y mo v i n g t h e f o o t f o r w a r d o n t h e f l o o r. Ta p t h e p a t e l l a r t e n d o n d i r e c t l y. L y i n g S u p i n e ( T h r e e M e t h oM s ) hod 1 i t h y o u r h a n d u n d e r t h e p o p l i t e a l d et : W f o s s a , l i f t t h e p a t i e n t ' s k n e e f r o m t h e t a b l e . Ta p t h e p a t e l l a r t e n d oF i g .i r e c t l y ( s e e n d 1 4 - 6 C . M et hod 2 r a s p t h e p a t i e n t ' s f o o t , f l e xi n g t h e h i p a n d k n e e , a n d r o t a t e t h e ) G k n e e o u t w a r d a n d d o r s i f l e x t h e f o o t . Ta p t h e p a t e l l a r t e n d o n F i ig .e c t4 y ( s e e d r 1 l6 D) . M et hod 3 i t h t h e k n e e e xt e n d e d a n d t h e l i mb l y i n g o n t h e t a b l e , p u s h t h e W patellar tendon distad with your index finger on the insertion of the quadriceps t e n d o n . Ta p d o w n w a r d o n t h e i n d e x f i n g ei r .( s e e 6)E T h e mu s c l e c o n t r a c t i o n F g 14- . p u l l s t h e p a t e l l a p r o xi ma l l y.

F i g . 1 4 - 6 K n e e J e r k ( A l t e r n a t i ve P o s i t i o n s ) . A . W i t h t h e P a t i e n t ' s L e g s Dangling. B. Sitting. C. With the Patient Supine, Method 1. D. With the P a t i e n t S u p i n e , M e t h o d 2 . E . W i t h t h e P a t i e n t S u p i n e a n d K n e e E xt e n d e d , M e t h o d .3

R e fle x C e nte r at L2 to L4 : Adduc tor R e fle x (Obtur ator N e r ve ).


W i t h t h e p a t i e n t s u p i n e , p l a c e t h e l o w e r l i mb i n s l i g h tFag .d 1 4 t i7)A D i r e c t l y i b u c - o.n ( t a p t h e a d d u c t o r ma g n u s t e n d o n j u s t p r o xi ma l t o i t s i n s e r t i o n o n t h e me d i a l e p i c o n d y l e o f t h e f e mu r. N o r ma l l y, t h e t h i g h a d d u c t s . If t h e q u a d r i c e p s r e f l e x i s a b s e n t a n d t h e a d d u c t o r r e f l e x i s p r e s e n t , t h i s i n d i c a t e s a l e s i o n o f t h e f e mo r a l nerve.

R e fle x C e nte r at L4 to S 2 : H am s tr ing R e fle x (S c iatic N e r ve ).


H a v e t h e p a t i e n t s u p i n e w i t h h i p s a n d k n e e s f l e xe d a t a b o u t 9 0 d e g r e e s a n d t h e
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thighs rotated slightly outward. Place your left hand under the popliteal fossa so th i n d e x f i n g e r c o mp r e s s e s t h e me d i a l h a ms t r i n g t e n d o n ( a b u n d l e o f t e n d o n s f r o m s e mi t e n d i n o s u s , s e mi me mb r a n o s u s , g r a c i l i s , s a r t oF i u s )1 ( s e)e Ta p y o u r r g. 4-7B . f i n g e r. T h e n o r ma l r e s p o n s e i s f l e xi o n o f t h e k n e e a n d c o n t r a c t i o n o f t h e me d i a l ma s s o f h a ms t r i n g mu s c l e s . Te s t t h e l a t e r a l h a ms t r i n g s i n a s i mi l a r ma n n e r : w i t h y o finger P. 8 1 2 c o mp r e s s t h e l a t e r a l h a ms t r i n g t e n d o n j u s t p r o xi ma l t o t h e f i b u l a r h e a d a n d t a p y o u f i n g e r. T h e n o r ma l r e s p o n s e i s c o n t r a c t i o n o f t h e l a t e r a l h a ms t r i n g ma s s ( b i c e p s f e mo r i s ) a n d f l e xi o n o f t h e k n e e .

F i g . 1 4 - 7 D e e p R e f l e xe s I I . A . A d d u c t o r M a g n u s R e f l e x. B . H a m s t r i n g R e f l e x. C . A c h i l l e s R e f l e x ( T h r e e W a y s ) dangl i ng, k neel i ng, and s.upi ne Leg :

R e fle x C e nte r at L5 to S 2 : Ac hille s R e fle x (Tibial N e r ve ).

T h e n o r ma l r e s p o n s e i s c o n t r a c t i o n o f t h e g a s t r o c n e mi u s a n d p l a n t a r f l e xi o n o f t h e f o o t .L e g s D a n g l i n g ( sF ie . 1 4 - 7)C W i t h y o u r l e f t h a n d , g r a s p t h e p a t i e n t ' s f o o t e g : a n d p u l l i t i n t o d o r s i f l e xi o n t o f i n d t h e d e g r e e Ac h i l l e s s t r e t c h t h a t p r o d u c e s t h e o p t i ma l r e s p o n s e . Ta p t h e t e n d o n dKrn e elly.n g ( s eF i g . 1 4 - 7)C H a v e t h e i ect i e : p a t i e n t k n e e l w i t h t h e f e e t h a n g i n g o v e r t h e e d g e o f a c h a i r, t a b l e , o r b e d . W i t h y o u l e f t h a n d d o r s i f l e xi n g t h e f o o t , t a p t h e t e n d o n d i r e c t l y. As s e s s b o t h t h e c o n t r a c t i o n a n d r e l a xa t i o n o f t h e mu s c l e ; d e l a y e d r e l a xa t i o n ( h u n g - u p r e f l e x) i s c h a r a c t e r i s t i c o h y p o t h y r o i d i s m. p i n e ( s eF i g . 1 4 - 7)C P a r t i a l l y f l e x t h e p a t i e n t ' s h i p a n d k n e e Su e : w h i l e r o t a t i n g t h e k n e e o u t w a r d a s f a r a s c o mf o r t p e r mi t s . W i t h y o u r l e f t h a n d , g r a s t h e f o o t a n d p u l l i t i n t o d o r s i f l e xi o n , t h e n t a p t h e Ac h i l l e s t e n d o n d i r e c t l y.

The Superficial (Skin) Reflexes

T h e s e r e f l e x a r c s h a v e r e c e p t o r o r g a n s i n t h e s k i n r a t h e r t h a n i n mu s c l e f i b e r s . T h e a d e q u a t e s t i mu l u s i s s t r o k i n g , s c r a t c h i n g , o r t o u c h i n g . If t h e r e i s n o r e s p o n s e , a p a i n f u l s t i mu l u s s h o u l d b e t r i e d . T h e s u p e r f i c i a l r e f l e xe s a r e l o s t i n d i s e a s e o f t h e p y r a mi d a l t r a c t .

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R e fle x C e nte r at T5 to T8 : U ppe r Abdom inal S k in R e fle x .


H a v e t h e p a t i e n t s u p i n e a n d r e l a xe d , w i t h t h e a r ms a t t h e s i d e s a n d k n e e s s l i g h t l y f l e xe d . U s e a f r e s h ( p r e v i o u s l y u n u s e d ) p i n t o s t r o k e t h e s k i n o v e r t h e l o w e r t h o r a c c a g e f r o m t h e mi d a xi l l a r y l i n e t o w a r d t h e Fmi d l 1n e 8)A Wa t c h f o r i p s i l a t e r a l i g . i 4 - (. c o n t r a c t i o n o f t h e mu s c l e s i n t h e e p i g a s t r i c a b d o mi n a l w a l l . W h e n t h e mu s c l e c o n t r a c t i o n s c a n n o t b e s e e n , o b s e r v e f o r u mb i l i c a l d e v i a t i o n t o w a r d t h e s t i mu l a t e d s i d e . In v e r y o b e s e p e r s o n s , r e t r a c t t h e u mb i l i c u s t o w a r d t h e o p p o s i t e s i d e t o f e e l i p u l l t o w a r d t h e s i d e o f s t i mu l a t i o n .

R e fle x C e nte r at T9 to T11 : M id-Abdom inal S k in R e fle x .


M a k e s i mi l a r s t r o k e s f r o m t h e f l a n k t o w a r d t h e mi d l i n e a t t h e u mb i l i c a l l e v e l .

R e fle x C e nte r at T11 to T1 2 : Lowe r Abdom inal S k in R e fle x .


M a k e s i mi l a r s t r o k e s f r o m t h e i l i a c c r e s t s t o w a r d t h e mi d l i n e o f t h e h y p o g a s t r i u m.

R e fle x C e nte r at L1 to L2 : C r e m as te r ic R e fle x .


In ma l e s , s t r o k e t h e i n n e r a s p e c t o f t h e t h i g h f r o m t h e i n g u i n a l c r e a sg . d o w n ( s e e Fi e 1 4 - 8 B . N o r ma l l y, t h i s c a u s e s c o n t r a c t i o n o f t h e c r e ma s t e r w i t h p r o mp t e l e v a t i o n o f ) the testis on the ipsilateral side. A slow and irregular rise of the testis results from mu s c u l a r c o n t r a c t i o n i n t h e d a r t o s t u n i c a n d i s n o t t h e r e f l e x r e s p o n s e .

R e fle x C e nte r at L4 to S 2 : P lantar R e fle x .

G r a s p t h e p a t i e n t ' s a n k l e w i t h y o u r l e f t h a n d . W i t h a b l u n t p o i n t a n d mo d e r a t e p r e s s u r e , s t r o k e t h e s o l e n el a r er s b o r d e r, f r o m t h e h e e l t o w a r d t h e b a l l , w h e r e at i t al t h e c o u r s e s h o u l d c u r v e me d i a l t o f o l l o w t h e b a s e s o f t hF i g .o e s -(8)D e o r e t 14 se F . t h e b l u n t p o i n t , u s e a w o o d e n - t i p a p p l i c a t o r, t h e e n d o f a P. 8 1 3 s p l i t w o o d e n t o n g u e b l a d e , o r t h e d u l l h a n d l e e n d o n a r e f l e x h a mme r. If n o r e s p o n s i s o b s e r v e d , a p i n s h o u l d b e u s e d a s t h i s i s a n o c i c e p t i v e r e f l e x. N o r ma l l y, t h i s p r o d u c e s p l a n t a r f l e xi o n o f t h e t o e s a n d , o f t e n , t h e e n t i r e f o o t r e s p o n d s w i t h p l a n t a r f l e xi o n . T h e p r e s e n c e o f a n e xt e n s o r p l a n t a r r e s p o n sBabi ns kli e d a e is cal s i gn i t s h o u l d b e n o t e d a s p r e s e n t o r a b s e n t . In d i s e a s e o f t h e p y r a mi d a l t r a c t , t h i s ; r e f l e x r e s u l t s , w i t h s o me o r a l l o f f o u r c o mp o n e n t s : d o r s i f l e xi o n o f t h e g r e a t t o e , f a n n i n g o f a l l t o e s , d o r s i f l e xi o n o f t h e a n k l e , a n d f l e xi o n o f t h e k n e e a n d t h i g h .

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F i g . 1 4 - 8 S k i n R e f l e xe s a n d P y r a m i d a l T r a c t S i g n s . A . A b d o m i n a l S k i n R e f l e xe s . B . C r e m a s t e r i c R e f l e x. C . A n k l e Wi oh uhe pat i ent s upi ne, l i f t Cl t n t s: t he k nee i n s l i ght f l ex i on wi t h t he mus c l es r el ax ed. Gr as p t he f oot and j er k i t i nt o dor s i f l ex i on, t hen hol d i t under s l i ght t ens i on i n t hat di r ec t i on. I n a pos i t i v e r es pons e, t he f oot r eac t s wi t h a number of c y c l es of al t er nat i ng dor s i f l ex i on and pl ant ar f l ex i on. The mot i on may di e i n a f ew c y c l es ( uns us t ai ned c l onus ) , or i t may per s i s t as l ong as t he t ens i on i s hel d ( s us t ai. nedBcal b i n s k i D. onus ) Sign .

R e fle x C e nte r at S 1 to S 2 : S upe r fic ial Anal R e fle x .


S t r o k e t h e s k i n o r mu c o s a o f t h e p e r i a n a l r e g i o n . N o r ma l l y, t h e a n a l s p h i n c t e r s contract.

POSTURE, BALANCE, AND COORDINATION: THE CEREBELLAR EXAM

P r e c i s e v o l u n t a r y mo v e me n t r e q u i r e s g r a d e d c o n t r a c t i o n o f t h e a g o n i s t , o r p r i me mo v e r, w i t h a c o r r e s p o n d i n g g r a d e d r e l a xa t i o n o f t h e a n t a g o n i s t a b o u t e a c h j o i n t . O t h e r mu s c l e s a c t t o f i x t h e j o i n t w i t h p r o p e r t e n s i o n . T h e t o t a l i n t e g r a t i o n o f t h e s e mo v e me n t s , c a l l c oor di nat i on s ed , i P. 8 1 4 p a r t i a l l y me d i a t e d t h r o u g h e f f e r e n t a n d a f f e r e n t t r a c t s o f t h e c e r e b e l l u m. T h e vestibular apparatus and the cerebral cortex also participate. Maintenance of postu a n d b a l a n c e r e q u i r e s s e n s o r y i n p u t f r o m t h e j o i n t s , mu s c l e s , t e n d o n s , a n d v e s t i b u l a s y s t e m, a n d c o o r d i n a t e d mo t o r o u t p u t s me d i a t e d b y t h e c e r e b r a l c o r t e x a n d b a s a l ganglia.

Testing Station (Equilibratory Coordination)

As k t h e p a t i e n t t o s t a n d c o mf o r t a b l y w i t h t h e h a n d s a t t h e s i d e s . O b s e r v e t h e p o s i t i o n o f t h e f e e t . N o r ma l l y, t h e f e e t w i l l b e j u s t a f e w c e n t i me t e r s a p a r t a n d t h e k n e e s o p p o s e d . A w i d e s t a n c e s u g g e s t s a n a c c o mmo d a t i o n t o i n s t a b i l i t y o f s t a n c e . N e xt h a v e t h e p a t i e n t p u t t h e f e e t t o g e t h e r a n d o b s e r v e f o r s t a b i l i t y. N o t e s w a y i n g o
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t h e t r u n k o r e l e v a t i o n o f t h e a r ms t o ma i n t a i n b a l a n c e . N o w h a v e t h e p a t i e n t c l o s e her eyes while again observing for loss of balance. Be ready to support her should s h e l o s e h e r b a l a n c e a n d r e a s s u r e h e r y o u w i l l p r o t e c t h e r. F a l l i n g d u r i n g t h e t e s t i t h e R o m b e r g s i g n s h e r e ma i n s s t a b l e , t e l l h e r y o u a r e g o i n g t o t a p h e r g e n t l y t o . If a s s e s s h e r s t a b i l i t y. G e n t l y p u s h h e r l a t e r a l l y o n e a c h u p p e r a r m, f o r w a r d o n t h e u p p e r b a c k a n d , l a s t , b a c k w a r d o n t h e c h e s t . W i t h n o r ma l p r o p r i o c e p t i o n , v e s t i b u l a r me c h a n i s m, c e r e b e l l u m a n d mo t o r p a t h w a y s s h e w i l l r e ma i n s t a b l e t h r o u g h o u t . H a v e h e r o p e n h e r e y e s , a n d , a f t e r f a i r w a r n i n g , p u s h mo r e f i r ml y o n h e r c h e s t t o c h e c k f ma xi ma l s t a b i l i t y.

Testing of Diadochokinesia

N o r ma l c o o r d i n a t i o n i n c l u d e s t h e a b i l i t y t o a r r e s t o n e mo t o r i mp u l s e a n d s u b s t i t u t e i t s o p p o s i t e . L o s s o f t h i s a dylstdi adoc hok i nes i a c h a r a c t e r i s t i c o f c e r e b e l l a r bi i y ( ) s d i s e a s e . M a n y s i mp l e t e s t s ma y b e e mp l o y e d t o t e s t f o r d y s d i a d o c h o k i n e s i s . A l t e r n a t i n g M o ve m e nFsg(. 1 4 - 9)A ( a ) H a v e t h e p a t i e n t h o l d h i s f o r e a r ms ti : v e r t i c a l l y a n d a l t e r n a t e p r o n a t i o n a n d s u p i n a t i o n i n r a p i d s u c c e s s i o n . In c e r e b e l l a r d i s e a s e , t h e mo v e me n t s o v e r s h o o t , u n d e r s h o o t , o r a r e i r r e g u l a r a n d i n a c c u r a t e ; t h e mo t i o n s ma y b e s l o w e d o r i n c o mp l e t e i n d i s e a s e o f t h e p y r a mi d a l t r a c t . ( b ) H a v e t h e patient rapidly tap his fingers on the table, or close and open the fists. (c) Holding t h e a r ms a t 9 0 d e g r e e s e l e v a t i o n a n d 0 d e g r e e s a b d u c t i o n ma y s h o w t h e a f f e c t e d a r m d e v i a t i n g i n a b d u c t i o n . ewar t - Hol mes Rebound Si gn. 1 4 - 9)A W h i l e St ( d ) (F i g : t h e p a t i e n t c l e n c h e s h i s f i s t , w i t h e l b o w f l e xe d a n d f o r e a r m p r o n a t e d , g r a s p h i s f i s t f r o m a b o v e a n d p u l l s t r o n g l y a t t e mp t i n g t o e xt e n d h i s e l b o w a g a i n s t h i s r e s i s t a n c e ; s u d d e n l y r e l e a s e y o u r g r i p a n d o b s e r v e f o r r a p i d c o n t r o l o f r e b o u n d . T h e e xa mi n e r mu s t g u a r d a g a i n s t i n j u r y t o t h e p a t i e n t . W i t h c e r e b e l l a r d i s e a s e t h e f o r e a r m ma y r e b o u n d i n s e v e r a l c y c l e s o f e xt e n s i o n f l e xi o n , o r t h e p a t i e n t ma y s t r i k e h i ms e l f i f not guarded.

Testing for Dyssynergia and Dysmetria

F i n g e r - t o - N o s e Te s t i:t h t h e p a t i e n t ' s e y e s o p e n , h a v e t h e p a t i e n t f u l l y e xt e n d h i s W elbow and, in a wide arc, rapidly bring the tip of the index finger to the tip of his n o s e ( s e e i g . 1 4 - 9)B In c e r e b e l l a r d i s e a s e , t h i s a c t i o n i s a t t e n d e d b y a n a c t i o n F . t r e mo r. W h e n t h e ma n e u v e r i s p e r f o r me d w i t h t h e e y e s c l o s e d , t h e s e n s e o f p o s i t i o n in the shoulder and P. 8 1 5 e l b o w i s t e s t e d . In a v a r i a n t o f t h i s ma n e u v e r, h a v e t h e p a t i e n t ma k e w i d e a r c s w i t h b o t h a r ms t o a p p r o xi ma t e t h e t i p s o f h i s i n d e x f i n g e r s i n Hre e lt- to f - h ih i n f o n o S m. Te s t : W i t h t h e p a t i e n t s u p i n e a n d t h e l o w e r l i mb s r e s t i n g i n e xt e n s i o n , a s k t h e patient to raise one heel and place it on the opposite knee, then slide the heel dow t h e s h i n ( s e ei g . 1 4 - 9)C T h e mo v i n g f o o t s h o u l d b e d o r s i f l e xe d , a n d t h e mo t i o n F . s h o u l d b e p e r f o r me d s l o w l y a n d a c c u r a t e l y. In c e r e b e l l a r d i s e a s e , t h e a r c o f t h e h e e to the knee is jerky and wavering, the knee is frequently overshot, and the slide d o w n t h e s h i n i s a c c o mp a n i e d b y a n a c t i o n t r e mo r. W i t h t h e e y e s c l o s e d , t h e mo t i o n a r e i n a c c u r a t e i n p o s t e r i o r s p i n a l c o l u mn d i s e a s e . F r e q u e n t l y, t h e h e e l s l i d e s o f f t h s h i n , b u t a c t i o n t r e mo r i s a b s e n t .

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F i g . 1 4 - 9 Te s t f o r C e r e b e l l a r D i.sSee e ex t f or f ul l des c r i pt iA . Te s t s eas t . ons f o r D i a d o c h o k i n e sThe abi l i t y t o per f or m al t er nat i ng mov ement s may be ia: t es t ed by hav i ng t he pat i ent hol d t he f or ear ms v er t i c al l y ; t hen as k t he pat i ent t o qui c k l y al t er nat e pr onat i on and s upi nat i on i n t he v er t i c al pos i t i on. Anot her met hod i s t he St ewar t - Hol mes r ebound t es t , i n whi c h t he pat i ent i s r eques t ed t o f l ex t he bi c eps br ac hi i mus c l e by pul l i ng agai ns t t he wr i s t hel d by t he ex ami ner. Whi l e at f ul l s t r engt h, t he ex ami ner s uddenl y r el eas es t he wr i s t and obs er v es f or c ont r ol of t he r eboundn g e r - t o - N o s e Te s t . C . H e e l - t o - K n e e . B. Fi Te s t s . D . H o o ve r S i g n o f H y s t e r is :di s t i ngui s hes hy s t er i c al par al y s i s of Thi a t he l ower l i mb f r om par al y s i s wi t h an or gani c c aus e. Tak e a pos i t i on at t he f oot of t he s upi ne pat i ent . Cr adl e eac h of t he pat i ent ' s heel s i n one of y our pal ms and r es t y our hands on t he t abl e. Hav e t he pat i ent at t empt t o r ai s e t he af f ec t ed l i mb. I n or gani c di s eas e, t he as s oc i at ed mov ement c aus es t he unaf f ec t ed heel t o pr es s downwar d; i n hy s t er i a, t he as s oc i at ed mov ement i s abs ent .

Testing Skilled Acts

To i n s p e c t h a n d w r i t i n g , a s k t h e p a t i e n t t o w r i t e s e n t e n c e s o n p a p e r. Te s t t h e patient's skill at buttoning and unbuttoning a coat or shirt. Let the P. 8 1 6 p a t i e n t p i c k u p p i n s o r t h r e a d a n e e d l e . Te s t t h e p a t i e n t ' s s k i l l a t c u t t i n g f i g u r e s o u of paper with scissors.

Testing the Vestibular Apparatus


P a s t p o i n t i n g a n d o t h e r t e s t s a r e d e s cCih a p t en 7 n p a g e 2 11 . r bed i r o

The Gait

T h e g a i t i s i n f l u e n c e d b y t h e r a t e , r h y t h m, a n d t h e c h a r a c t e r o f t h e mo v e me n t s e mp l o y e d i n w a l k i n g . In a s s e s s i n g t h e n e u r o l o g i c c o n t r i b u t i o n t o g a i t , p a i n f u l a n d r e s t r i c t i v e c o n d i t i o n s o f t h e j o i n t s , mu s c l e s , a n d o t h e r s t r u c t u r e s mu s t b e e xc l u d e d . O b s e r v e t h e p a t i e n t ' s u s u a l g a i t i n a w e l l - l i g h t e d h a l l w a y. N o t e t h e p o s t u r e o f t h e h e a d , n e c k a n d t r u n k , s w i n g o f e a c h a r m, l e g s w i n g , w i d t h o f s t a n c e , s i ze o f s t e p s a n d c l e a r a n c e o f t h e t o e f r o m t h e f l o o r. B e s u r e t o o b s e r v e a l l t h r e e p h a s e s o f g a i t : touch down, which should occur with the lateral heel; stance, which should be
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c e n t e r e d ; a n d p u s h - o f f w h i c h s h o u l d c o me o f f t h e g r e a t t o e . F o o t s t r i k e s a r e n o r ma l l y i n a n e a r l y s t r a i g h t l i n e . Al s o o b s e r v e t h e t u r n f o r l o s s o f b a l a n c e o r mu l t i p s ma l l s t e p s t o g e t t u r n e d a r o u n d . N e xt , h a v e t h e p a t i e n t w a l k a w a y f r o m y o u o n t h e toes, observing from behind, turn and walk toward you on the heels observing from t h e f r o n t ; n o t e h o w f a r t h e h e e l s a n d t o e s , r e s p e c t i v e l y, a r e h e l d o f f t h e g r o u n d . E xa mi n e t h e w e a r o n t h e p a t i e n t ' s s h o e s ; a b n o r ma l w e a r p a t t e r n i s a g o o d c l u e t o disorders of the foot and gait.

SENSORY EXAM INATION


A c o mp l e t e a s s e s s me n t o f s e n s o r y f u n c t i o n s i s n o t ma d e i n t h e r o u t i n e p h y s i c a l e xa mi n a t i o n , w i t h t h e e xc e p t i o n o f p a t i e n t s w i t h d i a b e t e s . B u t a h i s t o r y o f l o c a l i ze d p a i n , n u mb n e s s , o r t i n g l i n g , o r t h e f i n d i n g o f mo t o r d e f i c i t s , c a l l s f o r a d e t a i l e d s e n s o r y e xa mi n a t i o n . T h e p r e r e q u i s i t e s f o r s e n s o r y a s s e s s me n t a r e ( a ) d e t a i l e d k n o w l e d g e o f s e g me n t a l a n d p e r i p h e r a l n e r v e d i s t r i b u t i o n i n t h e s k i n b y r e f e r e n c e t o s u cg s c h a r-t s a s Fi h . 14 1 0 a n d1 4 - 11 ( b ) a l u c i d s e n s o r i u m a n d a d e q u a t e a t t e n t i o n o n t h e p a r t o f t h e p a t i e n t , to secure cooperation, and (c) a graphic record of the distribution of sensory defici T h e d i a g r a m ma y b e u s e d f o r i mme d i a t e c o mp a r i s o n o n r e t e s t i n g , b e c a u s e s e v e r a l e xa mi n a t i o n s f o r s e n s a t i o n s h o u l d a l w a y s b e p e r f o r me d . D i s p a r i t i e s i n t w o e xa mi n a t i o n s ma y p o i n t t o d e c e p t i o n b y t h e p a t i e n t , s o y o u s h o u l d c o n f u s e t h e p a t i e n t b y v a r y i n g t h e o r d e r.

T h e d e t a i l e d e xa mi n a t i o n o f t h e c r a n i a l n e r v e s i n c l u d e s t e s t i n g o f t h e s p e c i a l s e n s e a n d t h e c u t a n e o u s s e n s i b i l i t y o f t h e h e a d . F o r t h e r e ma i n d e r o f t h e b o d y, t h e distribution of sensibility for cutaneous pain, touch, pressure, position, and vibratio should be evaluated. When a deficit in the pain sense is encountered, the sensibilit f o r t e mp e r a t u r e s h o u l d a l s o b e t e s t e d . W h e n a n a r e a o f a l t e r e d c u t a n e o u s s e n s i b i l i t i s f o u n d , t h e b o r d e r s s h o u l d b e ma r k e d w i t h a s k i n p e n c i l , a n d a d i a g r a m s h o u l d b e ma d e i n t h e p a t i e n t ' s r e c o r d . P. 8 1 7

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F i g . 1 4 - 1 0 C u t a n e o u s S e n s a t i o n i n t h e A n t e r i o r A s p e c t o.f t h e B o d y

P. 8 1 8

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F i g . 1 4 - 11 C u t a n e o u s S e n s a t i o n i n t h e P o s t e r i o r A s p e c t o f t h e B o d y .

P. 8 1 9

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F i g . 1 4 - 1 2 S e n s o r y Te s t i n g a n d O t h e r P h e nSeee nex t f or des c r i pt i ons . om t a . A . Te s t i n g S h a r p - D u l l w i t h a S a f e t y P i n . B . Te s t i n g P o s i t i o n S e n s e i n t h e To e s . C . Te s t i n g Vi b r a t o r y S e n s e . D . Te s t i n g Tw o - P o i n t D i s c r i m i n a t i o n . E . Te s t i n g f o r D e r m a t o g r a p h i s m : e t he s k i n wi t h a bl unt obj ec t ; t he nor mal St r ok r es pons e i s a pal e l i ne al ong t he pat h of s t i mul at i on, t he whi t e l i ne. The abnor mal r es pons es ar e a r ed l i ne i n whi c h t he ar ea bec omes br i ght r ed and t hen ex t ends wi t h r ed mot t l i ng, and, wi t h mor e ex agger at ed r es pons e, t he l i ne dev el ops a wheal t hat bec omes r ai s ed, edemat ous., F. T r o p he c and pal i P l a n t a r U l c e r i n Ta b e s D o r s a l i s .

Basic Sensory Modalities


Te s ting P ain and Touc h S e ns e .

S u p e r f i c i a l P a i n ( S h a r p - D H lal v : t h e p a t i e n t c l o s e h i s e y e s a n d a s k , W h a t d o u )e you feel? Use the point and the dull guard end of a sterile open safety pin as a s t i mu l u sF(i g . 1 4 - 1 2 A H o l d i t l i g h t l y b e t w e e n y o u r t h u mb a n d i n d e x f i n g e r s o t h a t ). t h e p i n s l i d e s s l i g h t l y w i t h e a c h a p p l i c a t i o n . If t h e r e i s d o u b t a b o u t t h e r e s p o n s e , m s h a r p a n d d u l l s t i mu l i f r o m t h e p o i n t a n d h e a d o f t h e p i n . C o mp a r e s i d e - t o - s i d e w i t h t h e s a me d e g r e e o f p r e s s u r e a n d a s k , Is i t t h e s a me ; i t i s mo r e o b j e c t i v e i f t h e p a t i e n t r e p o r t s d i f f e r e n c e s t h a n i f y o u s u g g e s t t h e m. In ma p p i n g d e f i c i t b o r d e r s , s l o w l y s t i mu l a t e t h e s k i n f r o m n o n s e n s i t i v e t o s e n s i t i v e s k i n , h a v i n g t h e p a t i e n t i n d i c a t e w h e r e t h e s e n s a t i o n c h a n g e s . S e n s i b i l i t y t o p a i n ma y b e n o r ma l , r e d u c e d ( hy pal ges i) a a b s e n tanal ges i)a o r i n c r e a s ehy ( al ges)i .aD e e p P a i nTe s t f o r , ( , d per : d e e p o r p r o t o p a t h i c p a i n b y p r e s s u r e o n t h e n e r v e t r u n k s , a n d t e n d o n s . F o r e xa mp l e i n t h eAbadi e s i gno r t a b e s d o r s a l i s , t h e n o r ma l p r e s s u r e t e n d e r n e s s o f t h e Ac h i l l e s f tendon is lost.

Te s ting Te m pe r atur e S e ns e .

W h e n p a i n s e n s e i s i mp a i r e d , t e s t f o r t e mp e r a t u r e s e n s i b i l i t y b e c a u s e t h e p a t h w a y s are closely associated. Have the patient close the eyes. Use glass tubes of hot and cold water P. 8 2 0 o r t e s t f o r c o l d p e r c e p t i o n w i t h a c o l d t u n i n g f o r k a n d w a r m p e r c e p t i o n b y e xh a l i n g
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t h e s k i n t h r o u g h y o u r w i d e s p r e a d l i p s . As k t h e p a t i e n t t o d i s t i n g u i s h b e t w e e n w a r m and cold.

Te s ting Tac tile S e ns e .


W i t h t h e p a t i e n t ' s e y e s c l o s e d , c o mp a r e s e n s a t i o n r i g h t t o l e f t b y s t r o k i n g t h e s k i n w i t h a s h r e d o f s t e r i l e g a u ze a n d h a v i n g t h e p a t i e n t i n d i c a t e w h e n a n d w h e r e y o u t o u c h h i m. If y o u s u s p e c t t h a t h e i s u s i n g h i s e y e s , ma k e s h a m t e s t s n e a r b u t w i t h o t o u c h i n g t h e s k i n . G r a d e t h e r e s u l t s a s anes t het i c , hy pes t het in d n o r ma l , , ac hy per es t het. i c

Te s ting P r opr ioc e ption: P os ition S e ns e .

With the patient's eyes closed, grasp a finger on the sides (avoid grasping on the to a n d b o t t o m o r t o u c h i n g a d j a c e n t f i n g e r s b e c a u s e t h a t p r o v i d e s t o u c h c u e s ) . E xt e n d o r f l e x t h e f i n g e r a t o n e j o i n t a n d a s k t h e p a t i e n t t o s t a t e i t s Fp g .s i1 i4 -n ( s e e io t o 1 2 B) . S i mi l a r l y, t e s t t h e s e n s e o f p o s i t i o n i n t h e d i s t a l j o i n t o f t h e p a t i e n t ' s g r e a t t o e N o r ma l y o u n g p a t i e n t s d i s c r i mi n a t e 1 2 d e g r e e s o f mo v e me n t i n t h e i r d i s t a l f i n g e r j o i n t s a n d 3 5 d e g r e e s o f t h e g r e a t t o e . Te s t p o s i t i o n s e n s e i n t h e l e g o r a r m w i t h t h e e y e s c l o s e d . P l a c e o n e l i mb i n a p o s i t i o n a n d a s k t h e p a t i e n t t o p l a c e i t s c o u n t e r p a r t i n a s y mme t r i c a l p o s i t i o n .

Vibr ator y S e ns e : P alle s the s ia.

P l a c e t h e h a n d l e o f a v i b r a t i n g 1 2 8 - H z t u n i n g f o r k o v e r b o n y p r o mi n e n c e s , s u c h a s the styloid processes of the radii, the subcutaneous aspects of the tibiae, the ma l l e o l i o f t h e a n k l e s , o r t h e i n t e r p h a l a n g e a l j o i n t o f t h e g r e a t t o e , a n d t i me h o w l o n g t h e p a t i e n t f e e l s t h e v i b r a t i o n g(.s e e - 1 2)C C o mp a r e s y mme t r i c a l p o i n t s . Fi 14 . When the patient indicates that the vibration of the fork has ceased, place the h a n d l e o n y o u r o w n w r i s t t o d e t e c t a n y p e r s i s t e n c e o f v i b r a t i o n . Yo u n g p a t i e n t s f e e l vibration for about 15 seconds in the great toe and 25 seconds in the distal joint of t h e f i n g e r, w h e r e a s 7 0 - y e a r - o l d s f e e l i t f o r 1 0 a n d 1 5 s e c o n d s , r e s p e c t i v e l y. M a k e sham tests by setting the fork in vibration and unobtrusively stopping it with your finger before applying the handle to the patient.

P r e s s ur e S e ns e .

S t a n d a r d i ze d mo n o f i l a me n t s a r e a v a i l a b l e t o p r e c i s e l y c h e c k f o r p r o t e c t i v e p r e s s u r e s e n s a t i o n . An e s t h e s i a t o a 1 0 - g mo n o f i l a me n t i s a s e n s i t i v e t e s t f o r l o s s o f p r o t e c t i s e n s a t i o n t o p r e s s u r e i n j u r y. Al l d i a b e t i c s s h o u l d b e t e s t e d a t l e a s t o n c e a y e a r w i t h t h i s t e c h n i q uC a[p u t o G M , C a v a n a g h P R , U l b r e c h t J S , e t a l . As s e s s me n t a n d e ma n a g e me n t o f f o o t d i s e a s e i n p a t i e n t s w i t h d i a b e t e s . M ed 9 9 4 ; 3 3 1 : 8 5 4 N Engl J 1 8 6 0 . Te s t t h e p a t i e n t ' s a b i l i t y t o d i s c r i mi n a t e b e t w e e n o b j e c t s o f d i f f e r e n t w e i g h t s b ] p l a c i n g t h e m i n t h e p a t i e n t ' s p a l ms . Te s t t h e a b i l i t y t o d i s t i n g u i s h b e t w e e n p r e s s u r e f r o m t h e h e a d o f a p i n a n d t h e t i p o f y o u r f i n g e r. P r e s s o v e r t h e j o i n t s a n d subcutaneous aspects of bones for perception of pressure.

Testing Higher Integrativ e Functions


S te r e ognos is .
S i mp l e s e n s o r y p e r c e p t i o n s h o u l d h a v e b e e n p r e v i o u s l y d e mo n s t r a t e d a s n o r ma l .
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Te s t t h e p a t i e n t ' s a b i l i t y t o d i s t i n g u i s h f o r ms b y p l a c i n g o b j e c t s i n t h e p a t i e n t ' s h a n while the patient's eyes are P. 8 2 1 c l o s e d . U s e c o i n s , p e n c i l s , g l a s s , w o o d , me t a l , c l o t h , a n d o t h e r f a mi l i a r a r t i c l e s .

F i g . 1 4 - 1 3 E xc l u s i o n Te s t f o r M a j o r N e r ve I n j u r y i n t h e U p p e r L i m b . Sens at i on i s i nt ac t i n t he pal mar t i ps of t he i ndex and l i t t l e f i nger s ; ex t ens i on of t he di gi t s of t he hand i s uni mpai r ed .

Two-P oint D is c r im ination.

Te s t t h e a b i l i t y t o d i s t i n g u i s h t h e s e p a r a t i o n o f t w o s i mu l t a n e o u s s t e r i l e p i n p r i c k s ( s e eF i g . 1 4 - 1 2)D B y s e p a r a t i n g t w o p i n p o i n t s a t v a r i o u s d i s t a n c e s , f i n d t h e . d i s t a n c e a t w h i c h t h e p a t i e n t p e r c e i v e s t h e m a s t w o p o i n t s r a t h e r t h a n a s o n e . Te s t a n d c o mp a r e s y mme t r i c r e g i o n s . T h e n o r ma l d i s t a n c e v a r i e s i n d i f f e r e n t p a r t s o f t h e b o d y, f r o m 1 mm o n t h e t o n g u e , t o 2 8 mm o n t h e f i n g e r t i p , 4 0 mm o n t h e c h e s t a n d f o r e a r m, a n d 7 5 mm o n t h e u p p e r t h i g h a n d u p p e r a r m.

P e r c e ption of Figur e s on the S k in (Gr aphe s the s ia).

Te l l t h e p a t i e n t w h e t h e r y o u w i l l w r i t e n u me r a l s o r l e t t e r s r i g h t - s i d e u p . T h e n , w i t the patient's eyes closed, use a blunt point to trace a figure 1 cm high on the distal p a d o f t h e i n d e x f i n g e r. T h e f i g u r e s s h o u l d b e a t l e a s t 2 c m h i g h o n o t h e r b o d y p a r t As k t h e p a t i e n t t o i d e n t i f y t h e m.

TESTING SPECIFIC PERIPHERAL NERVES


Exclusion Test for Major Nerv e Injury in the Upper Limb
N o r ma l s e n s i b i l i t y t o a s t e r i l e p i n p r i c k i n t h e t i p s o f t h e i n d e x a n d l i t t l e f i n g e r s e xc l u d e s ma j o r i n j u r y t o t h e me d i a n a n d u l n a r n e r v e s . N o r ma l a b i l i t y t o e xt e n d t h e t h u mb a n d f i n g e r s e xc l u d e s i n j u r y o f t h e r a d iF ilg n e r4 -e) 3 a . 1 v 1 .(

Te s ting the M e dian N e r ve .


M o t o r F u n c t i o n : hs ner Tes tF (g . 1 4 - 1 4 .A H a v e t h e p a t i e n t c l a s p t h e h a n d s Oc i ) f i r ml y t o g e t h e r ; t h e i n d e x f i n g e r c a n n o t f l e x w h e n t h e i n n e r v a t i o n o f t h e f l e xo r d i g i t o r u m s u b l i mi s h a s b e e n i n j u r e d a n y w h e r e b e l o w t h e a n t e cFlb i t aon o s s a . u ex i l f of t he Thumb i(g . 1 4 - 1 4)B H o l d t h e p a t i e n t ' s f i r s t me t a c a r p o p h a l a n g e a l j o i n t w i t h F .
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y o u r t h u mb a n d i n d e x f i n g e r s s o t h a t t h e me t a c a r p a l b o n e i s e xt e n d e d a n d a s k t h e p a t i e n t t o b e n d t h e i n t e r p h a l a n g e a l j o i n t ; f a i l u r e i n d i c a t e s p a r a l y s i s o f t h e f l e xo r p o l l i c i s l o n g u s , i n n e r v a t e d b y t h e v o l a r i n t e r o s s e u s t h a t b r a n c h e s f r o m t h e me d i a n n e r v e i n t h e mi d d l e t h i r d o f t h e f o r e a r m. i on of Thumb s t t h e a c t i o n o f t h e Abduc t . Te abductor pollicis P. 8 2 2 b r e v i s , i n n e r v a t e d e xc l u s i v e l y b y t h e me d i a n n e r v e , t o d i s t i n g u i s h i t f r o m l o w - l e v e l p a r a l y s i s o f t h e u l n a r n e r v e . ( a enber g Or i ent al Pr ay er Pos(Ftiig . 1 4 - 1 4)C War t ) i on . H a v e t h e p a t i e n t e xt e n d a n d a d d u c t t h e f o u r f i n g e r s o f e a c h h a n d , w i t h t h u mb s e xt e n d e d , t h e n r a i s e t h e t w o h a n d s i n f r o n t o f t h e f a c e s o t h e y a r e s i d e b y s i d e i n t s a me p l a n e , w i t h t h u mb s a n d i n d e x f i n g e r s t o u c h i n g t i p t o t i p . P a r a l y s i s o f t h e a b d u c t o r p o l l i c i s b r e v i s p r e v e n t s f u l l r a n g e o f t h u mb a b d u c t i o n , s o t h u mb s d o n o t coincide when index fingers touch. (b) Pen- Touc hi ng Tes ti g . 1 4 - 1 4)D H a v e t h e (F . patient rest the supinated hand on the table holding the patient's fingers flat. Hold p e n o r p e n c i l h o r i zo n t a l a b o v e t h e t h u mb a n d a s k t h e p a t i e n t t o r a i s e h i s t h u mb t o touch the object in a plane of 90 degrees with the table. T his tests the patient's a b i l i t y t o a b d u c t t h e t h u mb . o r y F u n c t i oPhal en t esi ts p e r f o r me d b y h a v i n g Sens n: t h e p a t i e n t p r e s s t h e b a c k s o f t h e h a n d s t o g e t h e r w i t h t h e w r i s t s f l e xe d a t 9 0 d e g r e e s f o r a mi n u t e . N u mb n e s s a n d t i n g l i n g o f t h e t h u mb , i n d e x, mi d d l e , a n d h a l f o t h e r i n g f i n g e r i n d i c a t e c o mp r e s s i o n o f t h e me d i a n n e r v e , a s i n t h e c a r p a l t u n n e l s y n d r o meF(i g . 1 4 - 1 4 E T h eTi nel s i gnp a g e 7 3 5 ) i s o f t e n u s e f u l . W h e n t h e n e r v e ). ( l e s i o n i s i n t h e w r i s t , t h e s e n s o r y l o s s o n t h e p a l ma r s u r f a c e i s r e s t r i c t e d t o t h e d i s two-thirds of the radial digits.

F i g . 1 4 - 1 4 M e d i a n N e r ve P a r a lSee st ex t f or des c r i pt i onsO c h s n e r . ysi . A. Te s t :The pat i ent c annot f l ex t he i ndex f i nger on t he par al Bzedhs im b . y . T u de F l e xi o n Te s The pat i ent c annot f l ex t he di s t al j oi nt of t he .t humb t: .C W a r t e n b e r g O r i e n t a l P r a y e r S i g n : y s i s pr ev ent s ex t ens i on of t he t humb Par al s o i t s t i p c annot r eac h i t s. mat ee n - To u c h i n g TeThe t humb c annot D. P st: abduc t t o t ouc h t he obj ec t when t he medi an ner v e i s E . Tal e zede a o f . par h y A r A n e s t h e s i aThi s i nc l udes t he r adi al t hr ee di gi t s of t he pal mar as pec t and : f ol ds ov er t he t i ps t o t he dor s al as pec t wher e i t c ov er s t he di s t al phal anges of t he s ame di gi t s ( bl ue) .
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Te s ting the U lnar N e r ve .

Motor Function: eakness in adduction of the fingers results from paralysis of the W i n t e r o s s e u s p a l ma r i s . T h i s i s P. 8 2 3 d e mo n s t r a t e d b y p u l l i n g a s h e e t o f p a p e r f r o m b e t w e e n t h e p a t i e n t ' s e xt e n d e d a n d a d d u c t e d f i n g e r s t o a s s e s s t h e p r e s s u r e e xe r t e d b y t h e s i d e s oF i tgh e1 f4i - g e r s ( f . n 15A . Paralysis of the adductor pollicis can be tested by asking the patient to grip ) e a c h e n d o f a f o l d e d p a p e r b e t w e e n t h u mb s o n t o p a n d i n d e x f i n g e r s u n d e r n e a t h . H a v e t h e p a t i e n t p u l l t h e h a n d s a p a r t w h i l e g r i p p i n g t h e p a p e r. T h e t h u mb w i t h a n i n a d e q u a t e a d d u c t o r b e c o me s f l e xe d a t i t s i n t e r p h a l a n g e a l j o i n t f r o m i n v o l u n t a r y a c t i o n o f t h e f l e xo r p o l l i c i s l o n g u s , i n n e r v a t e d b y t h e me d ga n1 n e1 v)e In Fi i . 4- r5B ( . l e s i o n s a t o r b e l o w t h e e l b o w, t e s t f o r p a r a l y s i s o f t h e f l e xo r c a r p i u l n a r i s b y h a v i n g the patient's supinated hand lie on the table. Hold all digits but the little finger flat a g a i n s t t h e t a b l e . H a v e t h e p a t i e n t a b d u c t t h e l i t t l e f i n g e r ma xi ma l l y ; i f t h e r e i s n o p a r a l y s i s , t h e t e n s e d t e n d o n ma y b e s e e n o r p a l p a t e d a t i gh e 4 -r1 s)tC( F t . 1w i5 . S e n s o r y F u n c t i oAn a r e a o f a n e s t h e s i a c o v e r s t h e u l n a r d i g i t s a n d t h e n: c o r r e s p o n d i n g r e g i o n o f t h e p a l m. A s i mi l a r d i s t r i b u t i o n o c c u r s o n t h e d o r s a l a s p e c t e xc e p t w h e n t h e n e r v e l e s i o n i s a t t h e w r i s t s o t h e a r e a i s c o n s t r i c t e d t o t h e d i s t a l h a l f o f t h e l i t t l e f i nF ie r. (1 4 - 1 5)D g g .

F i g . 1 4 - 1 5 U l n a r N e r ve P a r a lSees t ex t f or des c r i pt i onsP a p e r - P u l l i n g . ysi . A. Te s t :Thi s t es t s t he adduc t or s of t he f i nger s by hav i ng t he pat i ent hol d a pi ec e of paper bet ween t wo adduc t ed f i nger s ; t he ex ami ner pul l s t he paper t o t es t t he s t r engt h of c ompr es s i on ex er t ed by t he adducdoru c t o r P o l l i c i s . B. A t d s Te s t :I n ul nar par al y s i s , t he t humb c annot ex er t enough pr es s ur e i n adduc t i on, s o i t f l ex es i nv ol unt ar i l y f r om ac t i on of t he f l ex or pol. lCc i s l s t o f i . Te ongus F l e xo r C a r p i U l n a rThe pat i ent at t empt s t o f l ex t he f r ee f i nger, but t he is: par al y zed t endon i n t he wr i s t does not .t enseea o f A n e s t h e sThe ul nar . D Ar ia: 1. 5 di gi t s on bot h as pec t s of t he hand ( bl ue) .

Mov ements of Specific Muscles and Nerv es


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It i s f r e q u e n t l y d e s i r a b l e t o i d e n t i f y t h e mu s c l e s a n d n e r v e s i n v o l v e d i n a d e f i c i t o f b o d i l y mo v e me n t . T h e f o l l o w i n g i s a c o mp i l a t i o n o f t h e p r i n c i p a l mu s c l e mo v e me n t s , t h e i r c a u s a t i v e mu s c l e s , a n d t h e i r i n n e r v a t i o n ( i n p a r e n t h e s e s ) . O u r s u r v e y s t a r t s w i t h c r a n i a l n e r v e s a n d p r o c e e d s d i s t a l l y i d e n t i f y i n g mo v e me n t s s e r v e d b y c e r v i c a l , t h o r a c i c , l u mb a r, a n d P. 8 2 4 s a c r a l r o o t s s e q u e n t i a l l y. T h e r e a d e r c a n u s e t h e l i s t i n s e v e r a l w a y s : a n a b n o r ma l mo v e me n t c a n b e t r a c e d t o t h e p e r i p h e r a l n e r v e a n d s p i n a l r o o t s ; a b n o r ma l mo v e me n t s c a n b e p r e d i c t e d f o r e a c h p e r i p h e r a l n e r v e o r s p i n a l s e g me n t . E y e b r o w , e l e v a t i oF r o n t a l i s ( C N - VII f r o m i n f e r i o r p o n s ) . . n Ey e brow, de pre ssion dow nw ard and inw ard, w rinkling of the fore he ad . C o r r u g a t o r ( C N - VII f r o m i n f e r i o r p o n s ) . U p p e r e y e l i d , e l e v a t i. oL e v a t o r p a l p e b r a e s u p e r i o r i s ( C N - III f r o m u p p e r ns mi d b r a i n ) . E y e l i d s , c l o s i n g , w r i n k l i n g o f f o r e h e a d , c o m p r e s s i o n o f l .a c r i m a l s a c O r b i c u l a r i s o c u l i ( C N - VII f r o m i n f e r i o r p o n s ) . *E y e b a l l , e l e v a t i o n a n d a d d u. cSiu p e r i o r r e c t u s ( C N - III f r o m u p p e r mi d b r a i n ) . t on *E y e b a l l , e l e v a t i o n a n d o u t w a r d r o tIntf ie r no r o b l i q u e ( C N - III f r o m u p p e r . a oi mi d b r a i n ) . *E y e b a l l , d e p r e s s i o n a n d r o t a t i o n d o w n w a r d a n.dIn ne r ia rrd r e c t u s ( C N - III if w o f r o m u p p e r mi d b r a i n ) . *E y e b a l l , d e p r e s s i o n a n d r o t a t i o n d o w n w a r d a n d. o u tpw airo r o b l i q u e ( C N Su er d IV f r o m mi d b r a i n ) o r p r i ma r y d o w n w a r d r o t a t i o n , s e c o n d a r y i n w a r d ( i n t o r s i o n ) rotation, and tertiary weak outward rotation. *E y e b a l l , a d d u c t i oM e d i a l r e c t u s ( C N - III f r o m u p p e r mi d b r a i n ) . . n *E y e b a l l , a b d u c t i oL a t e r a l r e c t u s ( C N - VI f r o m i n f e r i o r p o n s ) . . n P u p i l , c o n s t r i c t .i o ni l i a r y ( C N - III a n d p a r a s y mp a t h e t i c f r o m u p p e r mi d b r a i n ) . C L i p s , r e t r a c t i.oZ y g o ma t i c ( C N - VII f r o m i n f e r i o r p o n s ) . n L i p s , p r o t r u s i.oO r b i c u l a r i s o r i s ( C N - VII f r o m i n f e r i o r p o n s ) . n M o u t h , o p e n i n g y l o h y o i d ( C N - V f r o m p o n s ) , d i g a s t r i c u s ( C N - VII f r o m p o n s ) . . M M a n d i b l e , e l e v a t i o n a n d r e t r a c t ia sn e t e r a n d t e mp o r a l i s ( C N - V f r o m mi d . M os pons). M a n d i b l e , e l e v a t i o n a n d p r o t r.uP ti e rn g o i d ( C N - V f r o m mi d - p o n s ) . s o y P h a r y n x , p a l a t i n e e l e v a t i o n a n d p h a r y n g e a l c o n s te v c t ioo nv e l i p a l a t i n i . L ri a r a n d p h a r y n g e a l c o n s t r i c t o r ( C N - IX a n d X f r o m me d u l l a ) . To n g u e , d e p r e s s i o n a n d p r o t r.u Gie n i o g l o s s u s ( C N - XII f r o m me d u l l a ) . s on N e c k , r o t a t i o n o f t h e h e at d r n o c l e i d o ma s t o i d a n d t r a p e zi u s ( C N - XI f r o m me d u l l a . S e and upper cervical cord). Ne ck, fle x ion ectus capitis anterior (C1 to C3). . R
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N e c k , e x t e n s i o n , a n d r o t a t i o n o f t h.e Sh ee n i u s c a p i t i s e t c e r v i c i s ( C 1 t o C 4 ) . pl ad

*O p h t h a l m o l o g i c I n t e r p r e t a t i o n o f M u s c l e A h ei otn ms ma r k e d w i t h . T ct i e a s t e r i s k s c o n s t i t u t e t h e a c t i o n s o f t h e o c u l o r o t a t o r y mu s c l e s , a s a s s i g n e d b y t h e a n a t o mi s t s a n d s o me n e u r o l o g i s t s . S h a r p l y d i v e r g e n t i n t e r p r e t a t i o n s a r e f u r n i s h e d b t h e o p h t h a l mo l o g i s t s o n t h e b a s i s o f c l i n i c a l f i n d i n g s . T h e d i r e c t i o n o f mo v e me n t o f the eyes is a result of the actions of synergists and antagonists producing six c a r d i n a l p o s i t i o n s o f g a ze , c o r r e s p o n d i n g t o t h e s i x e xt r a o c u l a r mu s c l e s . P a r a l y s i s a s i n g l e mu s c l e r e s u l t s i n t h e i n a b i l i t y o f t h e e y e t o a t t a i n i t s c a r d i n a l p o s i t i o n , w h i i n f o u r o f t h e s i x mu s c l e s , d o e s n o t c o r r e s p o n d t o t h e p r e d i c t i o n o f t h e a n a t o mi s t s . P. 8 2 5 N e c k , l a t e r a l b e n d. i n g c t u s c a p i t i s l a t e r a l i s ( C 1 t o C 4 a n d s u b o c c i p i t a l n e r v e ) . Re S p i n e , f l e x i o n e c t u s a b d o mi n i s ( T 8 t o T 1 2 ) . . R S p i n e , e x t e n s i.oT h o r a c i c a n d l u mb a r i n t e r c o s t a l s ( t h o r a c i c n e r v e s f r o m T 2 t o L 1 ) . n S p i n e , e x t e n s i o n a n d r o t a tS o n s p i n a l i s ( t h o r a c i c n e r v e s f r o m T 2 t o T 1 2 ) . . i e mi S p i n e , e x t e n s i o n a n d l a t e r a l b e nQ un g r a t u s l u mb o r u m ( l u mb a r p l e xu s f r o m . di ad T 10 to L2). R i b s , e l e v a t i o n a n d d e p r e s s ic a l e n i a n d i n t e r c o s t a l ( c e r v i c a l a n d t h o r a c i c . S on nerves from C4 to T 12). R i b s , e l e v a t i .o n e r r a t u s p o s t e r i o r s u p e r i o r ( f r o m T 1 t o T 4 ) . S D i a p h r a g m , e l e v a t i o n a n d d e p r e sT ho nd i a p h r a g ma t i c mu s c l e s ( p h r e n i c n e r v e . si e f r o m C 3 t o C 5 ) . R e me mb e r d i a p h r a g ma t i c i n n e r v a t i o n b y t h e p h r e n i c n e r v e w i t h t h e r h y me , C 3 , 4 , a n d 5 t o k e e p t h e ma n a l i v e . S c a p u l a , r o t a t i o n a n d e x t e n s i o n o. f U p p e r t r a p e zi u s ( C N - XI f r o m C 3 t o C 4 ) . ne ck S c a p u l a , r e t r a c t i o n w i t h s h o u l d e r e l e v a t id l n a n d l o w e r t r a p e zi u s ( C N - XI . Mid o e from C3 to C4). S c a p u l a , e l e v a t i o n a n d r e t r a cRih on o i d s ( d o r s a l s c a p u l a r n e r v e f r o m C 5 ) . . t o mb Arm , e le v ation upraspinatus (suprascapular nerve from C5 to C6), upper . S t r a p e zi u s ( C N - XI f r o m C 3 t o C 4 ) . A r m , e l e v a t i o n a n d r o t a t Do nt o i d ( a xi l l a r y n e r v e f r o m C 5 t o C 6 ) . . i el A r m , d e p r e s s i o n a n d a d d u c tMod d l e p e c t o r a l i s ma j o r ( a n t e r i o r t h o r a c i c n e r v e . iin from C5 to T 1). A r m , d e p r e s s i o n a n d m e d i a l r o.t a tuo n c a p u l a r i s ( s u b s c a p u l a r n e r v e f r o m C 5 S i bs t o C 7 ) , t e r e s ma j o r ( t h o r a c o d o r s a l n e r v e s f r o m C 5 t o C 7 ) . A r m , d e p r e s s i o n a n d l a t e r a l r o.t a t i oa s p i n a t u s ( s u p r a s c a p u l a r n e r v e f r o m C 5 In f r n to C6). E l b o w , f l e x i o n i c e p s b r a c h i i , b r a c h i a l i s ( mu s c u l o c u t a n e o u s n e r v e f r o m C 5 t o C 6 ) . . B E l b o w , e x t e n s i.oT r i c e p s b r a c h i i ( r a d i a l n e r v e f r o m C 7 t o T 1 ) . n E l b o w , s u p i n a t i. oB i c e p s b r a c h i i ( mu s c u l o c u t a n e o u s n e r v e f r o m C 5 t o C 6 ) , n brachioradialis (radial nerve from C5 to C6). E l b o w , s u p i n a t i o n a n d e l b o w f l. eB ri a c h i o r a d i a l i s ( r a d i a l n e r v e f r o m C 5 t o C 6 ) . x on
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E l b o w , s u p i n a t i o n a n d e l b o w f l. eB ri a c h i o r a d i a l i s ( r a d i a l n e r v e f r o m C 5 t o C 6 ) . x on E l b o w , p r o n a t i.oP r o n a t o r t e r e s ( me d i a n n e r v e f r o m C 6 t o C 7 ) . n W r i s t , e x t e n s i o n a n d a d d u.c t i xtn n s o r c a r p i u l n a r i s ( r a d i a l n e r v e f r o m C 7 t o Eo e C8). W r i s t , e x t e n s i o n a n d a b d u c t i o n o.f E xtn d s o r c a r p i r a d i a l i s l o n g u s ( r a d i a l ha en nerve from C6 to C7). W r i s t , e x t e n s i o n o f t h e h a n de n s o r d i g i t o r u m c o mmu n i s ( r a d i a l n e r v e f r o m C 7 . E xt to C8). W r i s t , f l e x i o n a n d a b d u c tFoe xo r c a r p i r a d i a l i s ( me d i a n n e r v e f r o m C 7 t o C 8 ) . . il n W r i s t , f l e x i o n a n d a d d u c tFoe xo r c a r p i u l n a r i s ( u l n a r n e r v e f r o m C 7 t o C 8 ) . . il n T h u m b , a d d u c t i o n a n d o p p o s i Ad d u c t o r p o l l i c i s l o n g u s ( u l n a r n e r v e C 8 t o T 1 ) . . tion P. 8 2 6 T h u m b , a b d u c t i o n a n d e x t e n s i od u c t o r p o l l i c i s l o n g u s a n d b r e v i s ( me d i a n a n d . Ab n radial and [posterior interosseous nerves] from C7 to C8). T h u m b , e x t e n s i o n o f d i s t a l p h.aEa ne n s o r p o l l i c i s l o n g u s ( r a d i a l n e r v e f r o m C 7 l xt x to C8). T h u m b , e x t e n s i o n o f p r o x i m a l p h aE a n x s o r p o l l i c i s b r e v i s ( r a d i a l n e r v e f r o m . l xt e n C7 to C8). T h u m b , f l e x i o n o f d i s t a l p h .a lF l n x r p o l l i c i s l o n g u s ( me d i a n n e r v e f r o m C 7 t o a e xo T 1). T h u m b , f l e x i o n o f p r o x i m a l p h.aFae xo r p o l l i c i s l o n g u s a n d b r e v i s ( me d i a n l l nx nerve from C7 to T 1). T h u m b , f l e x i o n a n d o p p o s.i tOo n o n e n s p o l l i c i s ( me d i a n n e r v e f r o m C 8 t o T 1 ) . i pp F i n g e r s , f l e x i o n a n d a d d u c t i o n o f l i t t l .e O i n g e r n s d i g i t i mi n i mi ( u l n a r fppone nerve from C8 to T 1). F i n g e r s , a d d u c t i o n o f f o u r f i .n g e rma r i n t e r o s s e i ( u l n a r n e r v e f r o m C 8 t o T 1 ) . Pal s F i n g e r s , a b d u c t i o n o f f o u r f i .n g e r s a l i n t e r o s s e i ( u l n a r n e r v e f r o m C 8 t o T 1 ) . Do F i n g e r s , e x t e n s i o n o f h a nxt e n s o r d i g i t o r u m c o mmu n i s ( r a d i a l n e r v e f r o m C 7 t o . E d C8). F i n g e r s , f l e x i o n o f h. aP a l ma r i n t e r o s s e i ( i n t e r o s s e o u s n e r v e s f r o m C 7 t o T 1 ) , nd l u mb r i c a l e s ( u l n a r a n d me d i a n n e r v e s f r o m C 7 t o T 1 ) . F i n g e r s , e x t e n s i o n o f i n t e r p h a l a n g e a.l In t ien t s s e i p a l ma r i s a n d l u mb r i c a l e s jo ros ( i n t e r o s s e o u s n e r v e ; me d i a n a n d u l n a r n e r v e s f r o m C 7 t o T 1 ) . F i n g e r s , f l e x i o n o f t h e d i s t a l p h a.l a n e xo r d i g i t o r u m p r o f u n d u s ( me d i a n a n d Fl ge s ulnar nerves from C7 to T 1). F i n g e r s , f l e x i o n o f m i d d l e p h a l.a n g e s r d i g i t o r u m s u b l i mi s ( me d i a n n e r v e F l e xo from C7 to T 1). A b d o m e n , c o m p r e s s i o n w i t h f l e x i o n o. f R r u nu s a b d o mi n i s ( l o w e r t h o r a c i c tect k nerves from T 6 to L1).
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A b d o m e n , f l e x i o n o f a b d o m i n a l w a l l o b l iO b l eq y u s a b d o mi n i s e xt e r n u s . qu i lu (lower thoracic nerves from T 6 to L1). H i p , f l e x i o n i a c u s ( f e mo r a l n e r v e ) , p s o a s ( L 2 t o L 3 ) , s a r t o r i u s ( f e mo r a l n e r v e f r o m . Il L2 to L3). H i p , e x t e n s i o n l u t e u s ma xi mu s ( i n f e r i o r g l u t e a l n e r v e f r o m L 4 o r S 2 ) , a d d u c t o r . G ma g n u s ( s c i a t i c n e r v e a n d o b t u r a t o r n e r v e f r o m L 5 t o S 2 ) . H i p , a b d u c t i o n l u t e u s me d i u s ( s u p e r i o r g l u t e a l n e r v e f r o m L 4 t o S 1 ) , g l u t e u s . G ma xi mu s ( i n f e r i o r g l u t e a l n e r v e f r o m L 4 t o S 2 ) . H i p , a d d u c t i o n d u c t o r ma g n u s ( s c i a t i c a n d o b t u r a t o r n e r v e s f r o m L 5 t o S 2 ) . . Ad H i p , o u t w a r d r o t a t. i o nu t e u s ma xi mu s ( i n f e r i o r g l u t e a l n e r v e f r o m L 4 t o S 2 ) , Gl obturator internus (branches from S1 to S3). H i p , i n w a r d r o t a t.i o n o a s ( b r a n c h e s f r o m L 2 t o L 3 ) . Ps K n e e , f l e x i o n i c e p s f e mo r i s , s e mi t e n d i n o s u s , s e mi me mb r a n o s u s , g a s t r o c n e mi u s . B (all through sciatic nerve from L5 to S2). K n e e , e x t e n s i .o n u a d r i c e p s f e mo r i s ( f e mo r a l n e r v e f r o m L 2 t o L 4 ) . Q A n k l e , p l a n t a r f l e x i o n s t r o c n e mi u s ( t i b i a l n e r v e f r o m L 5 t o S 2 ) . . Ga A n k l e , d o r s i f l e x .i o n t e r i o r t i b i a l ( d e e p p e r o n e a l n e r v e f r o m L 4 t o S 1 ) . An A n k l e , i n v e r s i.oP o s t e r i o r t i b i a l ( t i b i a l n e r v e f r o m L 5 t o S 1 ) . n P. 8 2 7

TABLE 141 M ini-M ental State Examination


Or i ent at i on Poi nt s

_ _ _ _ _ W h a t i s t h e ( t i me ) ( d a t e ) ( d a y ) ( mo n t h ) ( y e a r ) ?

(5)

_ _ _ _ _ W h e r e a r e w e ( s t a t e ) ( c o u n t y ) ( c i t y ) ( h o s p i t a l ) ( w a r d )( 5 ) ?

Regi s t r at i on

_ _ _ _ _ N a me t h r e e o b j e c t s a n d a s k t h e p a t i e n t t o r e p e a t t h e m3 u n t i l ( ) a l l t h r e e a r e l e a r n e d . R e c o r d t h e n u mb e r o f t r i a l s .

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At t ent i on and Cal c ul at i on

_ _ _ _ _ As k t h e p a t i e n t t o s u b t r a c t s e r i a l 7 s f o r f i v e t i me s .

(5)

Rec al l

_ _ _ _ _ As k t h e p a t i e n t t o r e c a l l t h e t h r e e o b j e c t s n a me d a b o v 3 ) ( e.

Language

_ _ _ _ _Nami ng P e n c i l a n d w a t c h . :

(2)

_ _ _ _ _Repet i t i on N o i f s , a n d s , o r b u t s . :

(1)

_ _ _ _ _Thr ee- s t age c ommand k e p a p e r i n y o u r r i g h t h a n d , f o l (d3 ) : Ta i t i n h a l f , a n d p u t i t o n t h e f l o o r.

_ _ _ _ _Readi ng O b e y i n s t r u c t i o n g i v e n i n w r i t i n g : C l o s e y o u r ( 1 ) : eyes.

_ _ _ _ _Wr i t i ng W r i t e a s e n t e n c e . :

_ _ _ _ _ C o p y i n g : C o n s t r u c t a p a i r o f i n t e r s e c t i n g p e n t a g o n s (a1 )d n a s k t h e p a t i e n t t o c o p y t h e m.

S O U R C E : C r u m R M , An t h o n y J C , B a s s e t t S S , F o l s t e i n M F. P o p u l a t i o n - b a s e d n o r ms f o r t h e M i n i - M e n t a l S t a t e E xa mi n a t i o n b y a g e a n d e d u c a t i o n a l l e v e l . J AM A 1 9 9 3 ; 2 6 9 : 2 3 8 6 2 3 9 1 .

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A n k l e , e v e r s i .o n e r o n e u s l o n g u s ( s u p e r f i c i a l p e r o n e a l n e r v e f r o m L 4 t o S 1 ) . P G r e a t t o e , d o r s i f l e x i E xt e n s o r h a l l u c i s l o n g u s a n d b r e v i s ( s u p e r f i c i a l p e r o n e a l . on nerve from L4 to S1).

M ENTAL STATUS SCREENING EXAM INATION

D u r i n g t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n , t h e a l e r t p h y s i c i a n f o r ms a n i mp r e s s i o o f t h e p a t i e n t ' s me n t a l s t a t u s . W e a r e i n d e b t e d t o F o l s t e i n a n d c o l l e a g u e s f o r d e v i s i n g a n d v a l i d a t i n g t h e M i n i - M e n t a l S t a t e E xa m ( Me 1 4 -),1 a n e f f i c i e n t Ta b l M S E , i n v e n t o r y o f c o g n i t i v e f u n c toos t e i n M F, F o l s t e i n S E , M c H u g h P R . M i n i - me n t a l Filn [ s t a t e A p r a c t i c a l me t h o d f o r g r a d i n g t h e c o g n i t i v e s t a t e o f p a t i e n t s f o r t h e c l i n i c i a n J Ps y c hi at r Res9 7 5 ; 1 2 : 1 8 9 1] 9 8 c o r e s o f l e s s t h a n 2 0 ma y i n d i c a t e d e me n t i a , 1 . S d e l i r i u m, s c h i zo p h r e n i a , o r a f f e c t i v e d i s o r d e r. T he Mini-Cog is a validated screening test that uses the registration and recall q u e s t i o n s f r o m t h e M i n i - M e n t a l S t a t e E xa mi n a t i o n a n d t h e c l o c k d r a w i n g e xe r c i s e . T h e l a t t e r i s p e r f o r me d b y d r a w i n g a c i r c l e a n d P. 8 2 8 p l a c i n g t h e n u me r a l 1 2 i n i t s p r o p e r c l o c k p o s i t i o n . T h e n a s k t h e p a t i e n t t o f i l l i n t h e r e ma i n i n g n u me r a l s f o l l o w e d b y i n d i c a t i n g a p a r t i c u l a r t i me s u c h a s 4 : 3 5 [S c a n l a n J , B o r s o n S . T h e M i n i - C o g : R e c e i v e r o p e r a t i n g c h a r a c t e r i s t i c s w i t h e xp e r t a n d n a i v e r a t e r s . J Ger i at r Ps y c hi at r y 1 ; 1 6 : 2 1 6 2] 2 2 r r o r s i n e i t h e r t a s k I nt 200 . E i n d i c a t e t h e n e e d f o r d e t a i l e d e v a l u a t i o n o f c o g n i t i v e f u nh a ipo n r ( s)e e C ct te 15 .

Neurologic Sym ptom s General Symptoms


He a d a c h e : S e e p a g e 8 0 5.f f

M emor y Loss: P a t i e n t s o f t e n c o mp l a i n o f f o r g e t f u l n e s s , e s p e c i a l l y o f p e o p l e ' s n a me s . P a r a d o xi c a l l y, i t i s r a r e l y t h e p a t i e n t w h o i s c o n c e r n e d a b o u t me mo r y l o s s w h o h a s s e r i o u s p r o b l e m. C h a n g e s i n b e h a v i o r, f a i l u r e t o c o mp l e t e e xp e c t e d t a s k s , d i f f i c u l t y w i t h i n s t r u me n t a l a c t i v i t i e s o f d a i l y l i v i n g , e s p e c i a l l y ma n a g i n g f i n a n c e s , a r e mo r e l i k e l y t o b e c l u e s t o s i g n i f i c a n t i mp a i r me n t s i n me mo r y a n d c o g n i t i o n . Al w a y s f o r ma l s c r e e n f o r c o g n i t i v e i mp a i r me n t i f t h e r e i s a n y c o n c e r n .

Cranial Nerve Symptoms


Visual Loss: S e e C h a p t e r ,7p a g e 2 3 2 . Ab s e n t o r Ab n o r m a l Ta s t e a n d S m e l l : Ag e u s i a , D y s g e u s i a , An o s m i a : S e e C h a p t e r ,7p a g e 2 3 2 . Ri n g i n g i n t h e E a r s : T i n n i t u s : S e e C h a p t e r ,7p a g e 2 3 0 . He a r i n g L o s s :
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S e e C h a p t e r ,7p a g e 3 2 2 .

Ve r t i g o : S e e C h a p t e r ,7p a g e 3 2 2 . Double Vision: Diplopia: S e e C h a p t e r ,7p a g e 2 3 1 . Difficulty Swallowing: Dysphagia: S e e C h a p t e r ,7p a g e s 2 3 3 a n d 3 2 7 , C n d p t e r ,8p a g e s 5 3 3 a n d 5 6 3 5 6 4 . aha
P. 8 2 9

Difficulty Speaking: Dysar thr ia: S e e C h a p t e r ,7p a g e 3 3 0 f f a n d p a g e 8 7 5 . D i f f i c u l t y S p e a k i n g : Ap h a s i a : S e e p a g e 8 7.5 Pain in the Face: S e e C h a p t e r ,7p a g e 2 2 9 . As y m m e t r i c a l F a c e o r S m i l e : S e e p a g e 8 3,2 F a c i a l N e r v e S i g n s . Ho a r s e n e s s : S e e C h a p t e r ,7p a g e 3 0 4 . Ne c k a n d S h o u l d e r We a k n e s s : S e e C h a p t e r 1 3p a g e s 7 1 6 f f a n d 7 4 6 f f . ,

M otor Symptoms
We a k n e s s : S e e p a g e 8 3.3P a t h o p h y s i o l o g W:e a k n e s s ma y a r i s e f r o m l e s i o n s i n t h e b r a i n , y s p i n a l c o r d , p e r i p h e r a l n e r v e s , mo t o r e n d p l a t e , o r mu s c l e , e i t h e r p r i ma r y o r a s a r e s u l t o f g e n e r a l i ze d me t a b o l i c a b n o r. ma lei aik n e s s i s a c o mmo n c o mp l a i n t t h a t W t es r e q u i r e s a c o mp l e t e e v a l u a t i o n . A c a r e f u l h i s t o r y i s r e q u i r e d t o i d e n t i f y t h e s p e c i f i c a c t i v i t i e s t h a t a r e i mp a i r e d . D i f f i c u l t y w i t h r i s i n g f r o m a c h a i r o r c l i mb i n g s t a i r s s u g g e s t s p r o xi ma l mu s c l e w e a k n e s s , w h e r e a s d i f f i c u l t y w r i t i n g , o p e n i n g j a r s a n d doors, and catching the toes while walking suggest distal weakness. Global w e a k n e s s c a n b e s e e n w i t h g e n e r a l i ze d mu s c l e d i s e a s e s , my a s t h e n i a g r a v i s , a n d p o l y n e u r o p a t h i e s ( e . g . G u i l l a i n - B a r r s y n d r o me ) . D u r i n g p h y s i c a l e xa mi n a t i o n , o b s e r v e f o r f a s c i c u l a t i o n s , a s s e s s mu s c l e ma s s , t o n e , a n d s t r e n g t h , a n d e v a l u a t e t h e r e f l e xe s . H y s t e r i c a l w e a k n e s s i s n o t r a r e a n d ma l i n g e r i n g i s p e r h a p s mo r e c o mmo n ; t h e s e d i a g n o s e s c a n o n l y b e ma d e a f t e r o r g a n i c d i s e a s e i s e xc l u d e d b y a thorough evaluation, including laboratory tests. Ac u t e E p i s o d i c We a k n e s s : C a t a p l e x y : E p i s o d i c l o s s o f mo t o r a n d p o s t u r a l c o n t r o l i s p r e c i p i t a t e d b y l a u g h t e r o r s t r o n g e mo t i o n s . T h e r e i s mo me n t a r y l o s s o f v o l u n t a r y mo t o r p o w e r i n c l u d i n g s p e e c h ,
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w i t h o u t l o s s o f c o n s c i o u s n e s s o r p o s t u r a l t o n e . C a t a p l e xy i s s e e n i n p a t i e n t s w i t h n a r c o l e p s y. P. 8 3 0

M uscle Pain: M yalgia: S e e a l s o h a p t e r 1 3p a g e 7 1 0 . T h i s i s a c o mmo n , b u t n o n s p e c i f i c f i n d i n g . C , G e n e r a l i ze d my a l g i a s , e s p e c i a l l y i n t h e b a c k a n d p r o xi ma l l i mb mu s c l e s f r e q u e n t l y a c c o mp a n y f e b r i l e i l l n e s s o f a n y c a u s e . S e v e r e my a l g i a s a r e c o mmo n i n s e v e r a l i n f e c t i o u s d i s e a s e s ( e . g . , Ly me d i s e a s e , t r i c h i n o s i s , a n d d e n g u e ) ; o t h e r e l e me n t s o t h e h i s t o r y a r e o f mo r e u s e t h a n t h e p r e s e n c e o f my a l g i a i n ma k i n g t h e s p e c i f i c d i a g n o s i s . D r u g s ( e . g . , s t a t i n s ) a l s o c a u s e my a l g i a s s o a c o mp l e t e me d i c a t i o n a n d h e r b a l t h e r a p y h i s t o r y i s ma n d a t o r y. In p e r s o n s o l d e r t h a n 5 0 y e a r s o f a g e , a b r u p t o n s e t o f my a l g i a s i n t h e p r o xi ma l mu s c l e s ( s h o u l d e r s > p e l v i c g i r d l e ) s u g g e s t s p o l y my a l g i a r h e u ma t i c a .

M uscle Stiffness: P a t h o p h y s i o l o g O:v e r u s e o f s k e l e t a l mu s c l e i n d u c e s a d a ma g e r e p a i r c y c l e t h a t y i s f e l t b y t h e p a t i e n t a s p a i n a n d s t iUfn d e rs s e l e a d s t o mu s c l e a t r o p h y, w h i c h . f nes u ma y b e a c c o mp a n i e d b y s t i f f n e s s . T h e u n c o n d i t i o n e d p a t i e n t o f t e n c o mp l a i n s o f s o r e , s t i f f mu s c l e s 1 2 d a y s f o l l o w i n g u n a c c u s t o me d e xe r c i s e ( w e e k e n d a t h l e t e s y n d r o me ) . E xa mi n a t i o n s h o w s n o a b n o r ma l i t i e s o t h e r t h a n t e n d e r n e s s a n d o c c a s i o n a l l y mi l d s p a s m i n t h e a f f e c t e d mu s c l e s . P a t i e n t s w i t h i n h e r i t e d d i s o r d e r s o mu s c l e me t a b o l i s m o r e l e c t r o l y t e d i s o r d e r s c a n d e v e l o p s e v e r e my o n e c r o s i s w i t h e xe r c i s eD D X: Ab r u p t o n s e t o f p r o xi ma l mu s c l e s s t i f f n e s s i n a p e r s o n o l d e r t h a n 5 0 . y e a r s o f a g e w i t h o u t a c l e a r - c u t p r e c i p i t a t i n g e v e n t s u g g e s t s p o l y my a l g i a r h e u ma t i c a . G e n e r a l i ze d c r a mp s w i t h t e t a n y a r e s e e n w i t h h y p o c a l c e mi a . Tw i t c h e s a n d T i c s : S e e p a g e 8 4.2 I r r e s i s t i b l e L e g M o v e m e n t s : Re s t l e s s L e g s S y n d r o m e : S e e p a g e 8 7.8 M uscle Spasm: Cr amps, Dystonias: S e e p a g e 8 7.3

Reflex Symptoms
M uscle Spasm: Spasticity: S e e p a g e 8 3.4

Posture, Balance, and Coordination Symptoms


Loss of Balance: Falling: S e e p a g e 8 5.0 D i f f i c u l t y Wa l k i n g : S e e p a g e 8 4.0 Ve r t i g o :
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S e e C h a p t e r ,7p a g e 3 2 2 .

Shaking: Tr emor s: S e e p a g e 8 4.1


P. 8 3 1

Sensory Symptoms

Al t e r e d S e n s a t i o n : T i n g l i n g a n d Nu m b n e s s , P a r e s t h e s i a s : P a t h o p h y s i o l o g T : n g l i n g a n d n u mb n e s s o f a b o d y p a r t i n d i c a t e i mp a i r me n t o f t h e yi n o r ma l p r e s s u r e , p a i n , a n d / o r t o u c h s e n s o r y Tu n c tp o nt e r n o f t h e s y mp t o ms . f he iat g i v e s a g o o d i n d i c a t i o n o f t h e a n a t o mi c l e v e l o f t h e n e r v e i n j u r y : s y mp t o ms o n o n e s i d e o f t h e e n t i r e b o d y i n d i c a t e a p r o b l e m i n t h e t h a l a mu s o r c o r t e x; l o s s o n o n e s i d o f t h e b o d y b e l o w a s p e c i f i c l e v e l s u g g e s t s s p i n a l c o r d i n j u r y ; s y mp t o ms i n a p e r i p h e r a l n e r v e d i s t r i b u t i o n i mp l i e s i n j u r y t o t h a t n e r v e ; a n d s y mme t r i c a l d i s t a l p a r e s t h e s i a ( s t o c k i n g - g l o v e d i s t r i b u t i o n ) s u g g e s t s a g e n e r a l i ze d s e n s o r y ( w i t h o r w i t h o u t mo t o r ) n e u r o p a t h y. Te s t f o r t h e s p e c i f i c mo d a l i t i e s o f s e n s a t i o n a r e r e q u i r e d P a i n w i t h No n - p a i n f u l S t i m u l i : Al l o d y n i a : S e e p a g e 8 4.4 Al t e r e d S e n s a t i o n : P a i n : S e e p a g e 8 4.4

Neurologic Signs Cranial Nerve Signs

B e c a u s e t h e s i g n s o f c r a n i a l n e r v e d y s f u n c t i o n c a n b e mi mi c k e d b y n o n - n e u r o l o g i c e n d - o r g a n d i s e a s e , t h e s e s i g n s a r e d i s c u sh a p t e n ,7The Head and Nec k C sed i r Ex ami nat i onS i g n s o f c r a n i a l n e r v e d y s f u n c t i o n a r e t h e a b s e n c e o f n o r ma l f u n c t i o n s . a s d e mo n s t r a t e d b y t h e p h y s i c a l e xa m. O n c e e n d - o r g a n d i s e a s e i s e xc l u d e d , t h e challenge is to decide whether the lesion is central (brain) or peripheral (nerve). T h f o l l o w i n g i s a b r i e f l i s t o f s o me s p e c i f i c c r a n i a l n e r v e s i g n s .

O l f a c t o r y Ne r v e ( C N- I ) : An o s m i a : S e e C h a p t e r ,7p a g e 2 8 1 . O p t i c Ne r v e S i g n s : V i s u a l F i e l d C u t s : S e e C h a p t e r ,7p a g e 2 5 8 .
P. 8 3 2

O c u l o m o t o r ( C N- I I I ) P a r a l y s i s : S e e Ey e M ov ement Si gnsa g e 2 5 2 , n o r ma l i t i e s o f G,a p a g e 2 5 3 , a n d l , p Ab ze Pupi Si gns p a g e 2 6 6F i(g . 1 4 - 1) 6 U n i l a t e r a l c o mp l e t e p a r a l y s i s i s u s u a l l y c a u s e d b y , . d i r e c t p r e s s u r e f r o m t u mo r, a n e u r y s m, o r h e r n i a t i n g b r a i n . L e s s c o mmo n a r e c a v e r n o u s s i n u s t h r o mb o s i s a n d g r a n u l o ma t o u s p r o c e s s a t t h e b a s e o f t h e b r a i n , f o e xa mp l e , t u b e r c u l o u s me n i n g i t i s a n d To l o s a - H u n t s y n d r o me . P u p i l l a r y - s p a r i n g o c u l o mo t o r n e r v e p a l s y ma y b e a c o mp l i c a t i o n o f d i a b e t e s me l l i t u s .

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F i g . 1 4 - 1 6 T h e C a r d i n a l P o s i t i o n s o fEac h eof t he s i x pos i t i ons i s t he . Gaz r es ul t of s y ner gi s t s and ant agoni s t s ac t i ng wi t h a s pec i f i c mus c l e. Par al y s i s of t he s pec i f i c mus c l e pr ev ent s t he ey e f r om at t ai ni ng t he c ar di nal pos i t i on f or t he mus c l e .

T r o c h l e a r Ne r v e ( C N- I V ) P a r a l y s i s : S e e Ey e M ov ement Si gnsa g e 2 5 2 , a n d , p Abnor mal i t i es of Gaze g e 2 5 3 ( s e e , pa F i g . 1 4 - 1 6 C N - IV ma y b e i n v o l v e d w i t h C N - III a n d C N - VI i n t h e c a v e r n o u s s i n u s . ). T r i g e m i n a l Ne r v e ( C N- V ) S i g n s : T h e c o r n e a l r e f l e x ma y b e a b s e n t a n d t h e j a w c l o s u r e w e a k a n d / o r a s y mme t r i c . Ir r i t a t i v e l e s i o n s o f t h e mo t o r r o o t ma y c a u s e s p a s m o r t r i s mu s . Ir r i t a t i o n o f t h e s e n s o r y r o o t r e s u l t s i n t i c d o u l o u r e u x. Ab d u c e n s Ne r v e ( C N- V I ) S i g n s : S e e Ey e M ov ement Si gnsa g e 2 5 2 , a n d , p Abnor mal i t i es of Gaze g e 2 5 3 ( s e e , pa F i g . 1 4 - 1 6 D i a b e t i c mo n o n e u r o p a t h y i s a l s o c o mmo n . C N - VI ma y b e i n v o l v e d w i t h ). C N - III a n d C N - IV i n t h e c a v e r n o u s s i n u s .
P. 8 3 3

F a c i a l Ne r v e ( C N- V I I ) S i g n s : Ir r i t a t i o n o f t h e c o r n e a at i t i)s a n d c o n j u n c t i v a e (at oc onj unc t i v i t i s s i c c ay k er ( k er ) ma o c c u r a s a r e s u l t o f i n a d e q u a t e l i d c l o s i n g . W e a k n e s s ma y b e ma n i f e s t b y p o c k e t i n g o f f o o d i n t h e c h e e k s a n d d i f f i c u l t y w i t h e f f i c i e n t ma s t i al ts o n . ,m l o n i c Fac c a i pas c c o n t r a c t i o n s o f t h e f a c i a l mu s c l e s , ma y o c c u r b e c a u s e o f d e n e r v a t i o n . T h e c a u s e o f peripheral palsies of the facial nerve is usually unknown. T hey occasionally occur i s a r c o i d o s i s , t u mo r s o f t h e t e mp o r a l b o n e a n d c e r e b e l l o p o n t i n e a n g l e , p o l i o my e l i t i s , n e o p l a s ms , i n f e c t i o u s p o l y n e u r i t i s ( G u i l l a i n - B a r r s y n d r o me ) , Ly me d i s e a s e , AID S , a n d s y p h i l i s . T h e f a c e i s e xp r e s s i o n l e s s , t h e ma s k - l i k e f a c i e s , i n P a r k i n s o n d i s e a s e In t h eRams ay - Hunt s y ndr ome r p e s zo s t e r v i r u s i n f e c t s t h e g e n i c u l a t e g a n g l i o n o f , he t h e s e n s o r y b r a n c h o f t h e f a c i a l n e r v e t o p r o d u c e a f a c i a l p a l s y, l o s s o f t a s t e o n t h e a n t e r i o r t w o - t h i r d s o f t h e t o n g u e , a n d p a i n a n d v e s i c l e s i n t h e e xt e r n a l a u d i t o r y c a n a l o n t h e s a me s i d e . H e r p e t i c l e s i o n s i n t h e e a r c a n a l i s t h e c l u e t o d i a g n o s i s . Id i o p a t h i c f a c i a l n e r v e p a r a l y s i sl i pal s. y Bel s Au d i t o r y Ne r v e ( C N- V I I I ) S i g n s : Ab n o r m a l He a r i n g a n d / o r B a l a n c e : S e e p a g e s 4 5 a n d2 4 6, r e s p e c t i v e l y. 2
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G l o s s o p h a r y n g e a l Ne r v e ( C N- I X ) a n d Va g u s Ne r v e ( C N- X ) S i g n s : Patients will have difficulty with articulation and the pharyngeal phase of swallowin E xa m s h o w s p o o r a n d / o r a s y mme t r i c e l e v a t i o n o f t h e s o f t p a l a t e a n d u v u l a . Ac c e s s o r y Ne r v e ( C N- X I ) S i g n s : We a k n e s s o f t h e S t e r n o c l e i d o m a s t o i d and Tr apezius M uscles: Patients will have weakness of head rotation and shoulder shrug. Hy p o g l o s s a l Ne r v e ( C N- X I I ) S i g n s : To n g u e D e v i a t i o n a n d At r o p h y : S e e p a g e s 9 7 2 9 .8 2

M otor Signs
M o s t a b n o r ma l mo v e me n t s o f mu s c l e a r e r e s p o n s e s o f n o r ma l c o n t r a c t i l e t i s s u e t o a b n o r ma l n e r v o u s s t i mu l i , s o t h e y a r e p r o p e r l y i n c l u d e d i n t h e n e u r o l o g i c e xa mi n a t i o n . T h e s i g n s a r e f r e q u e n t l y e n c o u n t e r e d i n a n a p p r a i s a l o f t h e mu s c u l o s k e l e t a l s y s t e m b y a n a t o mi c r e g i o n s . P. 8 3 4

We a k n e s s : M u s c l e P a r a l y s i s , P a r e s i s , a n d P a l s y : Par al y s i ss d e f i n e d a s c o mp l e t e l o s s a n d i sa s d i mi n u t i o n o f mu s c l e p o w e r i par es f r o m a b n o r ma l i t i e s o f t h e u p p e r mo t o r n e u r o n ( U M N ) , l o w e r mo t o r n e u r o n ( L M N ) , p e r i p h e r a l n e r v e o r mu s c l e f iPal rssy.i s a n o n s p e c i f i c d e s c r i p t i v e t e r m t h a t be i n d i c a t e s p a r a l y s i s a n d / o r p a r e s i s . In c r e a s e d t o n e a n d u n i n h i b i t e d r e f l e xe s ( s pas t i c i t yo c c u r w i t h U M N l e s i o n s , w h e r e a s L M N a n d p e r i p h e r a l n e r v e l e s i o n s ) r e s u l t i n f l a c c i d p a r a l y s i s a n d mu s c l e a t r o p h y. P r i ma r y d i s e a s e o f mu s c l e i s a s s o c i a t e d w i t h f l a c c i d p a r a l y s i s a n d v a r i a b l e c h a n g e s i n mu s c l e b u l k . It i s e s s e n t i a to take a careful history to assess the onset of paralysis: acute, subacute, or chronic. M US C L E PARALY S I S C L I NI C AL O C C URRE NC E : Congeni t al o r p h y r i a , mu s c u l a r d y s t r o p h y, f a mi l i a l p e r i o d i c p a r a l y s i s , p a r a my o t o n i a p c o n g e n i t a , c e r e b r a l p a l s y ; r i ne y p e r t h y r o i d i sIm; opat hi c o n i n f l a mma t o r y Endoc h di n my o p a t h i e s ; l ammat or y / I mmune i l l a i n - B a r r s y n d r o me , my a s t h e n i a g r a v i s , I nf Gu p o l y my o s i t i s , d e r ma t o my o s i t i s , mu l t i p l e s c l e r o s i s , I v aec tu lous o l i o my e l i t i s ; nf s c i i t i p ; s M et abol i c / Toxece c t r o l y t e d i s t u r b a n c e s ( h i g h o r l o w p o t a s s i u m, ma g n e s i u m, il c a l c i u m) , d r u g s ( mu s c l e r e l a xa n t s , a n e s t h e t i c s , a mi n o g l y c o s i d e s - r a r e l y ) , h e a v y me t a p o i s o n i n g , h y p e r t h y r o i d my o p a t h y, b e r i b e r i , a n e mi a , p e r n i c i o u s a n e mi a , a my l o i d o s i s M ec hani c al / Tr aumaa i n a n d s p i n a l c o r d t r a u ma , e p i d u r a l h e ma t o ma , p e r i p h e r a l br n e r v e t r a u ma ; Neopl as t i c p i d u r a l me t a s t a sNeur ol ogi c o l y n e u r o p a t h y, e es; p t r a n s v e r s e my e l i tPs ;y c hos oc i al y s t e r i a , ma l i n g e r iVas c ul ars t r o k e , s p i n a l c o r d is h ng; infarction, subdural and epidural bleeding, vasculitis.

M u s c l e At r o p h y : P a t h o p h y s i o l o g S : v e r e mu s c l e a t r o p h y o c c u r s w i t h L M N a n d p e r i p h e r a l n e r v e ye i n j u r y a s a r e s u l t o f l o s s o f t h e t r o p h i c e f f e c t o f mo t o r n e r v e s o n mu s c l e f i b e r s ; mu c l e s s a t r o p h y o c c u r s w i t h U M N l .e s i o o p h y o n l y b e c o me s a p p a r e n t a f t e r w e e k s At r n s t o mo n t h s f o l l o w i n g t h e n e r v e Fas c y. ul at i ons e eFas c i c ul at i ons l o w ) a r e injur i c (s be s e e n w i t h L M N l e s i o n s , b u t a r e a b s e n t w i t h U M N l e s i o n s . G e n e r a l i ze d w e a k n e s s a n d


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a t r o p h y a c c o mp a n i e d b y f a s c i c u l a t i o n s , o f t e n mo s t e v i d e n t i n t h e t o n g u e a n d s ma l l mu s c l e s o f t h e h a n d s , a l o n g w i t h u p p e r mo t o r n e u r o n s i g n s , s u g g e s t p r i ma r y mo t o r n e u r o n d i s e a s e , f o r e xa mp l e , a my o t r o p h i c l a t e r a l s c l e r o s i s . S e g me n t a l d i s e a s e i s c h a r a c t e r i s t i c o f p o l i o my e l i t i s a n d d i s e a s e s o f t h e s p i n a l c o r d a n d n e r v e p l e xu s e s .

Hy p o t o n i a : D e c r e a s e d r e s t i n g mu s c l e t o n e o c c u r s w i t h l o w e r mo t o r n e u r o n i n j u r y, s u c h a s p o l i o my e l i t i s , a r o o t s y n d r o me , a n d p e r i p h e r a l n e u r o p a t h y. It i s a l s o e n c o u n t e r e d i n cerebellar and other central lesions. Hy p e r t o n i a : E xt r a p y r a mi d a l l e s i o n s , s u c h a s p a r k i n s o n i s m, p r o d u c e i n c r e a s e d r e s t i n g mu s c l e tone. C o g w h e e l Ri g i d i t y : O n p a s s i v e mo t i o n o f a l i mb , t h e e xa mi n e r f e e l s mu s c u l a r r e s i s t a n c e a s a s e r i e s o f s t e p w i s e r e l a xa t i o n a r r e s t c y c l e s , r a t h e r t h a n a s mo o t h g i v i n g w a y. T h i s p h e n o me n o n i s a n e xp r e s s i o n o f t h e i n c r e a s e d mu s c l e t o n e i n P a r k i n s o n d i s e a s e . It disappears during sleep. Spasticity: P a t h o p h y s i o l o g In: u p p e r mo t o r n e u r o n p a r a l y s i s , t o n e o f t h e s t r e t c h e d mu s c l e s i s y i n c r e a s e d , a n d u n i n h i b i t e d s t r e t c h r e f l e xe s p r o d u c e c o n t i n u o u s c l o n i c c o n t r a c t i o n ( s p a s t i c i t.y ) h e n a l i mb i s mo v e d a g a i n s t s p a s t i c mu s c l e s , t h e r e s i s t a n c e ma y W s u d d e n l y c e a s e , g i v i n g as p- k ni f e f f e c t . L o n g , c o n t i n u e d s p a s t i c i t y r e s u l t s i n cl a mu s c l e f i b r o s i s a n d s h o r t e n i n g , k n o w n ra s t ur e c ont ac .
P. 8 3 5

M yoclonus: A s i n g l e , s u d d e n j e r k , o r a s h o r t s e r i e s , o c c u r r i n g i n s l o w o r r a p i d s u c c e s s i o n , ma y b e s o p o w e r f u l a s t o t h r o w t h e p a t i e n t t o t h e f l o o r. U n l i k e t r e mo r, my o c l o n u s ma y n o d i s a p p e a r w i t h s l e e p a n d i s f r e q u e n t a t s l e e p o n s e t . It i s a c o mmo n c o mp l i c a t i o n o f c h r o n i c me p e r i d i n e u s e a n d o t h e r me t a b o l i c e n c e p h a l o p a t h i e s . M yotonia: T h e mu s c l e s c o n t i n u e i n c o n t r a c t i o n a f t e r a v o l u n t a r y o r r e f l e x a c t h a s c e a s e d . R e c o v e r y f r o m c o n t r a c t i o n i n d u c e d b y t a p p i n g t h e mu s c l e b e l l y w i t h a r e f l e x h a mme i s p r o l o n g e d . Af t e r s h a k i n g h a n d s , t h e f i n g e r s r e l u c t a n t l y r e l a x. W h e n t h e f i n g e r s a r f l e xe d o n t h e s u p i n a t e d p a l m, a t t e mp t e d e xt e n s i o n i s s l o w a n d d i f f i c u l t . T h e mo v e me n t i s t y p i c a l o f my o t o n i a c o n g e n i t a a n d my o t o n i c d y s t r o p h y.

Te t a n y : P a t h o p h y s i o l o g T : e t h r e s h o l d f o r mu s c u l a r e xc i t a b i l i t y i s l o w e r e d s u c h t h a t yh i n v o l u n t a r y s u s t a i n e d c o n t r a c t i o n s o c c u r, e i t h e r p a i n l e s s o r p a i n f u l . An y c a u s e o f a l o w i o n i ze d s e r u m c a l c i u m c a n r e s u l t i n t e t a n y, i n c l u d i n g h y p o p a r a t h y r o i d i s m, a c u t e h y p e r v e n t i l a t i o n , a n d h y p o ma g n e sT h e a o n t r a c t i n g mu s c l e s f e e l r i g i d a n d . e mi c u n y i e l d i n g . S p a s m ma y b e p r e c e d e d b y n u mb n e s s a n d t i n g l i n g i n t h e l i p s a n d l i mb s . C o n t r a c t i o n s o f t h e h a n d s a n d f e e t a r e t e r me d c o lar popedal s pas m c lectively . In c a r p a l s p a s m, t h e w r i s t i s f l e xe d a n d f l e xi o n a t t h e me t a c a r p o p h a l a n g e a l j o i n t s i s c o mb i n e d w i t h e xt e n s i o n o f t h e i n t e r p h a l a n g e a l j o i n t s . T h e h y p e r e xt e n d e d f i n g e r s


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a r e a l s o a d d u c t e d t o f o r m a c o n e a n d t h e t h u mb i s f l e xe d o n t h e p a l m. T h i s p r e s e n t a d i a g n o s t i c p o s t u r e c a l l e d o b s t e t r i c i a n ' s h a n d . In l a t e n t t e t a n y, c a r p a l s p a s m ma y b i n d u c e d b y o c c l u d i n g t h e b r a c h i a l a r t e r y f o r 3 mi n u t e s w i t h a n i n f l a t e d s p h y g mo ma n o me t e r c u f f ; t e t a n y i n d u c e d b y t h i s ma n e u v e r iTr ousls eauh e s cal ed t s i gn Ta p p i n g t h e f a c i a l n e r v e a g a i n s t t h e b o n e j u s t a n t e r i o r t o t h e e a r p r o d u c e s . i p s i l a t e r a l c o n t r a c t i o n o f f a c i a l mu s c l e s ; t h i s t ek s i gn i s u n i f o r ml y p r e s e n t Chv os i s . It i n l a t e n t t e t a n y, b u t s o me c o n t r a c t i o n o c c u r s i n s o me n o r ma l p e r s o n s .

Fasciculations: P a t h o p h y s i o l o g D:a ma g e t o t h e n e r v e s u p p l y i n g a mu s c l e r e s u l t s i n s p o n t a n e o u s y mo t o r u n i t f i r i n g t h a t i s v i s i b l e a s a t w i t c h i n g o f mu s c l a r sie e wsi t c h e s a r e . Co e f b t r o f t e n c a u s e d b y e xp o s u r e t o c o l d , f a t i g u e , o r o t h e r c o n d i t i o n s , a n d a r e n o t s e r i o u s . F a s c i c u l a t i o n s mu s t b e c a r e f u l l y s o u g h t w h e n t h e mu s c l e i s r e l a xe d b e c a u s e t h e y a r e n o t p o w e r f u l e n o u g h t o mo v e a j o i n t o r a p a r t . In t h e p r e s e n c e o f mu s c l e a t r o p h o r w e a k n e s s , t h e i r p r e s e n c e i s a t t r i b u t a b l e t o p r o g r e s s i v e d e n e r v a t i o n o f t h e mu s c l Fi br i l l at i onsr e t w i t c h e s o f i n d i v i d u a l mu s c l e f i b e r s ; t h e y a r e i n v i s i b l e , b u t c a n b e a d e mo n s t r a t e d b y e l e c t r o my o g r a p h y.

Reflex Signs
Abnormal Reflexes in Pyramidal Tract Disease
Alte r e d N or m al R e fle x e s .

A l e s i o n o f t h e p y r a mi d a l t r a c t a l mo s t i n v a r i a b l y c a u s e s c o mp l e t e s u p p r e s s i o n o f t h e n o r ma l s u p e r f i c i a l r e f l e xe s c a u d a l t o t h e l e v e l o f t h e l e s i o n . O n t h e c o n t r a r y, t h e mu s c l e s t r e t c h r e f l e xe s a r e h y p e r a c t i v e e xc e p t d u r i n g t h e a c u t e s t a g e o f d a ma g e , a in spinal shock, when they are absent. P. 8 3 6

I n c r e a s e d Re f l e x e s : C l o n u s , S p a s t i c i t y : P a t h o p h y s i o l o g N:o r ma l l y c e n t r a l i n h i b i t i o n o f t h e s p i n a l c o r d l i mi t s t h e s t r e t c h y r e f l e x t o a s i n g l e b e a t . L o s s o f i n h i b i t i o n a l l o w s t h e r e f l e x t o b e c o me s e l f p e r p e t u a t i n g . S p a s t i c i t y o c c u r s w i t h c o mp l e t e l o s s o f c o r t i c a l i n h i b i t i o n , l e a d i n g t o s u s t a i n e d c o n t r a c t i o n s o f o p p o s i n g mu s c l e g r o u p s , t h e f l e xo r s d o mi n a t i n g i n t h e a r ms , a n d t h e e xt e n s o r s i n t h e b a c k a n d hl y p e r a c t i v e r e f l e x ma y p r o d u c e . A egs c l o n u s , a r h y t h mi c c o n t r a c t i o n o f mu s c l e s i n i t i a t e d b y s t r e t c h i n g . C l o n u s ma y b e u n s u s t a i n e d , l a s t i n g f o r o n l y a f e w j e r k s d e s p i t e c o n t i n u e d s t r e t c h i n g , o r i t ma y b e s u s t a i n e d ( mo r e t h a n s e v e n b e a t s ) , p e r s i s t i n g a s l o n g a s s t r e t c h i n g i s a p p l i e d . ANK L E C L O NUS ( G AS T RO C NE M I US C L O NUS ) : W i t h t h e p a t i e n t ' s k n e e f l e xe d , g r a s p t h e f o o t a n d b r i s k l y d o r s i f l e x i t . R h y t h mi c c o n t r a c t i o n s o f t h e g a s t r o c n e mi u s a n d s o l e u s c a u s e t h e f o o t t o a l t e r n a t e b e t w e e n d o r s i f l e xi o n a n d p l a n t a r f l e xi o n i ( s e1 4 - 8)C F g. e . PAT E L L AR C L O NUS ( Q UAD RI C E P S C L O NUS ) : W i t h t h e p a t i e n t s u p i n e a n d t h e r e l a xe d l o w e r l i mb e xt e n d e d , g r a s p t h e p a t e l l a a n d p u s h i t q u i c k l y d i s t a l . T h e p a t e l l a w i l l j e r k u p a n d d o w n f r o m t h e r h y t h mi c c o n t r a c t i o n s o f t h e q u a d r i c e p s f e mo r i s . WRI S T C L O NUS ( F I NG E R F L E X O R C L O NUS ) :
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G r a s p t h e p a t i e n t ' s f i n g e r s a n d f o r c i b l y h y p e r e xt e n d t h e w r i s t . T h e w r i s t w i l l a l t e r n a r h y t h mi c a l l y b e t w e e n f l e xi o n a n d e xt e n s i o n . P. 8 3 7

Babinski Sign: P e r f o r m t h e t e s t f o r t h e p l a n t a r r e f l e x, p a g e 8 1 2 . Al t e r n a t e me t h o d s o f e l i c i t i n g B a b i n s k i r e f l e x h a v e b e e n d e s c r i b e d a s e p o n y mi c s i g n s . In t h e s i ,gn Oppenhei m g r e a t t o e d o r s i f l e xi o n i s e l i c i t e d w i t h p r e s s u r e a p p l i e d b y t h e t h u mb a n d i n d e x f i n g e or knuckles to the anterior tibia. T he pressure stroke should begin at the upper two t h i r d s o f t h e b o n e a n d b e c o n t i n u e d t o t h e Chaddoc k s i gn h e s t i mu l u s i s a a n k l e . In , t s c r a t c h w i t h a d u l l p o i n t . T h e p a t h o f s t i mu l a t i o n s h o u l d c u r v e a r o u n d t h e l a t e r a l ma l l e o l u s o f t h e a n k l e , t h e n a l o n g t h e l a t e r a l a s p e c t o f t h e d o r s u m o f t h e f o o t . T h e n o r ma l r e s p o n s e i s p l a n t a r f l e xi o n o f t h e t o e s a n d f o o t . T h e c o mp l e t e B a b i n s k i s i g n i s ( a ) d o r s i f l e xi o n o f t h e g r e a t t o e , ( b ) f a n n i n g o f a l l t o e s , ( c ) d o r s i f l e xi o n o f t h e a n k l e , a n d ( d ) f l e xi o n a n d w i t h d r a w a l o f t h e k n e e a n d h i p . Al l o f t h e s e s i g n s a r e p a t h o l o g i c r e s p o n s e s t o n o xi o u s s t i mu l i i n o r s p r e a d i n g t o t h e S 1 d e r ma t o me . P a r t i a r e s p o n s e s i n c l u d e o n l y d o r s i f l e xi o n o f t h e g r e a t t o e , f a i l u r e o f t h e s ma l l t o e s t o a b d u c t o r f a n , a n d f a n n i n g o f s ma l l t o e s w i t h o u t g r e a t t o e d o r s i f l e xi o n . C o mp l e t e a n p a r t i a l r e s p o n s e s a r e a l l i n d i c a t i v e o f d i f f e r e n t d e g r e e s o f p y r a mi d a l d i s e a s e , s o t h details of response should be accurately recorded. Ho f f m a n n S i g n : F i n g e r F l e x o r Re f l e x : T h i s i s a l s o c a l l e d t h e f i n g e r f l e xo r r e f l e x a n d h a s t h e s a me s i g n i f i c a n c e a s o t h e r mu s c l e s t r e t c h r e f l e xe s . H o l d t h e p a t i e n t ' s p r o n a t e d h a n d i n y o u r h a n d , w i t h f i n g e r s e xt e n d e d a n d r e l a xe d . S u p p o r t t h e p a t i e n t ' s e xt e n d e d mi d d l e f i n g e r b y y o u r r i g h t i n d e x f i n g e r h e l d t r a n s v e r s e l y u n d e r t h e d i s t a l i n t e r p h a l a n g e a lFjio i.n 1 4 -r e a s e ( g t c 1 7 B) . W i t h y o u r t h u mb , p r e s s t h e p a t i e n t ' s f i n g e r n a i l t o f l e x t h e t e r mi n a l d i g i t . T h e a b n o r ma l r e f l e x i s f l e xi o n a n d a d d u c t i o n o f t h e t h u mb . T h e o t h e r f i n g e r s ma y a l s o f l e x. W h e n t h e r e f l e x i s p r e s e n t b i l a t e r a l l y, i t ma y b e a n o r ma l v a r i a n t .

F i g . 1 4 - 1 7 S o m e P a t h o l o g i c R e .f lSee s ex t f or des c r i pt i onsG r a s p e xe t . A. R e f l e x:I n l es i ons of t he pr emot or c or t ex , t he pat i ent may be unabl e t o r el eas e her gr as.pB . H o f f m a n n S i gIn : py r ami dal t r ac t di s eas e, t he pat i ent ' s t humb n may f l ex and adduc t as y mmet r. i Cal M a y e r R e f l eHav e t he pat i ent c. ly x: pr es ent her r el ax ed s upi nat ed hand t o y ou. Fi r ml y f l ex t he r i ng f i nger at t he met ac ar pophal angeal j oi nt . The nor mal r es pons e i s adduc t i on and f l ex i on of t he t humb. Abs enc e of t hi s oc c ur s i n py r ami dal t r ac t di s eas e .
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Primitiv e Reflexes (Release Signs)


Al l o f t h e s e s i g n s ma y i n d i c a t e d i f f u s e c e r e b r a l d i s e a s e , b u t a r e s o me t i me s p r e s e n t i n n o r ma l i n d i v i d u a l s .

Gr as p R e fle x :

P l a c e y o u r i n d e x a n d mi d d l e f i n g e r s b e t w e e n t h e p a t i e n t ' s t h u mb a n d i n d e x f i n g e r, l a y i n g t h e m a c r o s s t h e p a t i e n t ' s p a l m. G e n t l y p u l l t h e m a c r o s s t h e p a l m w i t h a s t r o k i n g mo t i o n . G r a s p i n g w i t h t h e t h u mb a n d i n d e x f i n g e r i s a p o s i t i v e r e s p o n s e ( s e Fig. 14-17A When the grasp reflex is present, the patient cannot release the fingers ). a t w i l l . T h i s i s a n o r ma l r e s p o n s e i n i n f a n t s . L a t e r i n l i f e , l e s i o n s o f t h e p r e mo t o r c o r t e x ma y u n c o v e r t h e r e f l e x a s a p a t h o l o g i c f i n d i n g .

P alm om e ntal (R adovic i S ign):


S c r a t c h i n g o r p r i c k i n g o f t h e t h e n a r e mi n e n c e c a u s e s i p s i l a t e r a l c o n t r a c t i o n o f t h e mu s c l e s o f t h e c h i n . T h i s o c c u r s i n d i f f u s e c e r e b r a l d i s e a s e .

S nout/ S uc k R e fle x e s :
S c r a t c h i n g o r g e n t l e p e r c u s s i o n o f t h e u p p e r l i p ma y i n d u c e a p u c k e r i n g o r s u c k i n g mo v e me n t .

Spinal Automatisms
P. 8 3 8

S p i n a l a u t o ma t i s ms o c c u r w h e n t h e c e n t r a l i n h i b i t i o n s o f r e f l e xe s a r e l o s t i n s e v e r e disease of the spinal cord or brain.

S pinal R e fle x R e ac tions :

In e xt e n s i v e l e s i o n s o f t h e c o r d o r mi d b r a i n , p a i n f u l s t i mu l a t i o n o f a l i mb ma y p r o d u c e i p s i l a t e r a l f l e xi o n o f b o t h u p p e r a n d l o w e r e xt r e mi t i e s , c a l l e d i p s i l a t e r a l ma f l e xi o n r e f l e x, s p i n a l w i t h d r a w a l , o r s h o r t e n i n g r e f l e x.

M a s s Re f l e x : A t r a n s v e r s e l e s i o n o f t h e c o r d ma y p r o d u c e f l e xi o n f o l l o w e d b y e xt e n s i o n o f t h e l i mb s b e l o w t h e l e v e l o f l e s i o n . In c o mp l e t e t r a n s e c t i o n , o n l y f l e xi o n o c c u r s , a c c o mp a n i e d b y c o n t r a c t i o n s o f t h e a b d o mi n a l w a l l , i n c o n t i n e n c e o f u r i n e a n d f e c e s a n d a u t o n o mi c r e s p o n s e s , s u c h a s s w e a t i n g , f l u s h i n g , a n d p i l o mo t o r a c t i v i t y. T h i s c o mp l e x i s t e r me d s r ef l exIn v o l u n t a r y u r i n a t i o n ma y b e s t i mu l a t e d b y s t r o k i n g mas . t h e s k i n o f t h e t h i g h s a n d a b d o me n , a n a u t o ma t i c b l a d d e r. P r i a p i s m a n d s e mi n a l e j a c u l a t i o n ma y b e i n d u c e d b y s i mi l a r me c h a n i s ms . In t h e c r o s s e d e xt e n s o r r e f l e x, f l e xi o n o f o n e l i mb ma y b e a s s o c i a t e d w i t h e xt e n s i o n o f i t s c o u n t e r p a r t . In s o me c a s e s , t h e e xt e n s o r t h r u s t r e a c t i o n i s e n c o u n t e r e d : p r e s s u r e o n t h e s o l e c a u s e s e xt e n s i o n o f t h e l e g . W h e n t h e l e g i s p l a c e d i n f l e xi o n , s c r a t c h i n g o n t h e s k i n o f t h e t h i g h i n d u c e s e xt e n s i o n o f t h e l e g . P a i n f u l s t i mu l a t i o n o f t h e a r m o r c h e s t ma y r e s u i n a b d u c t i o n a n d o u t w a r d r o t a t i o n o f t h e s h o u l d e r.
P. 8 3 9

Signs of M eningeal Ir r itation:


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Ir r i t a t i o n o f t h e me n i n g e s b y me n i n g i t i s , s u b a r a c h n o i d h e mo r r h a g e , d r u g s , a n d i n c r e a s e d i n t r a c r a n i a l p r e s s u r e c a u s e a b n o r ma l c o n t r a c t i o n o f v a r i o u s mu s c l e g r o u p s , w h i c h a r e i d e n t i f i e d o n p h y s i c a l e xa mi n a t i o n .

NUC HAL RI G I D I T Y: T h e p a t i e n t c a n n o t p l a c e t h e c h i n o n t h e c h e s t . P a s s i v e f l e xi o n o f t h e n e c k i s l i mi t e b y i n v o l u n t a r y mu s c l e s p a s m, w h i l e p a s s i v e e xt e n s i o n a n d r o t a t i o n a r e n o r ma l . K E RNI G S I G N: W i t h t h e p a t i e n t s u p i n e , p a s s i v e l y f l e x t h e h i p t o 9 0 d e g r e e s w h i l e t h e k n e e i s f l e xe a t a b o u t 9 0 d e g r e e sg ( 1 4 - 1 8 A W i t h t h e h i p k e p t i n f l e xi o n , a t t e mp t s t o e xt e n d Fi . ). t h e k n e e p r o d u c e p a i n i n t h e h a ms t r i n g s a n d r e s i s t a n c e t o f u r t h e r e xt e n s i o n . T h i s i s a r e l i a b l e s i g n o f me n i n g e a l i r r i t a t i o n , w h i c h ma y o c c u r w i t h me n i n g i t i s , h e r n i a t e d d i s k , o r t u mo r s o f t h e c a u d a e q u i n a .

F i g . 1 4 - 1 8 Tw o S i g n s o f M e n i n g e a l I r r i t a t i o n . A . K e rWi gh S i g n : n i t t he pat i ent s upi ne, f l ex t he hi p and k nee, eac h t o about 90 degr ees . Wi t h t he hi p i mmobi l e, at t empt t o ex t end t he k nee. I n meni ngeal i r r i t at i on, t hi s at t empt i s r es i s t ed and c aus es pai n i n t he hams t r i ng. mus crl u d z i n s k i S i g n :ac e B . B es Pl t he pat i ent s upi ne and hol d t he t hor ax down on t he bed. At t empt t o f l ex t he nec k . Wi t h meni ngeal i r r i t at i on t hi s c aus es i nv ol unt ar y f l ex i on of t he hi ps .

B RUD ZI NS K I S I G N: W i t h t h e p a t i e n t s u p i n e a n d t h e l i mb s e xt e n d e d , p a s s i v e l y f l e x t h e n e c k . F l e xi o n o f t h e h i p s , a s i g n o f me n i n g e a l i r r i t a t i o n , i s a p o s i t i v e B r u d zi n si k i. s i 4 -n ( s e e F g 1g 1 8 B) .

S P I NAL RI G I D I T Y: M o v e me n t s o f t h e s p i n e a r e l i mi t e d b y s p a s ms o f t h e e r e c t o r s p i n a e . In e xt r e me c a s e s , t h e s p i n a l mu s c l e s a r e i n t e t a n i c c o n t r a c t i o n , p r o d u c i n g r i g i d h y p e r e xt e n s i o n of the entire spine with the head forced backward and the trunk thrust forward. T he c o n d i t i o n i s t e r me d s t hot onos opi .

Paradoxical Reflexes
I nve r s ion of the B r ac hior adialis R e fle x :
T h i s o c c u r s w h e n t h e h e a d o f t h e r a d i u s i s t a p p e d a n d t h e r e i s f l e xi o n o f t h e f i n g e r w i t h n o e l b o w f l e xi o n a n d f o r e a r m s u p i n a t i o n . It i n d i c a t e s a l e s i o n o f t h e C 5 n e r v e
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r o o t c o u p l e d w i t h s p i n a l c o r d d a ma g e a t t h a t l e v e l , u s u a l l y b e c a u s e o f c e r v i c a l spondylosis.

P ar adox ic al Tr ic e ps R e fle x :

W i t h l e s i o n s a t C 7 t o C 8 , t h e e l b o w ma y n o t e xt e n d ; i n s t e a d , f l e xi o n ma y o c c u r f r o m t h e h i g h e r i n n e r v a t i o n o f t h e f o r e a r m f lpar adox i c al r ef .l ex e xo r s , a

Posture, Balance, and Coordination Signs: Cerebellar Signs

T h e p e r f e c t e xe c u t i o n o f s k i l l e d eupr ax i ;a l o s s o f p r e v i o u s a b i l i t y i n acts is p e r f o r ma n c e apr ax i .a T h i s r e f l e c t s a b r a i n d i s t u r b a n c e i n c o n v e r t i n g a n i d e a i n t o a is s k i l l e d a c t . M a i n t e n a n c e o f p o s t u r a l e q u i l i b r i u m a t r e s t a n d w i t h mo v e me n t r e q u i r e s t h e p r o p e r f u n c t i o n o f p r o p r i o c e p t i v e me c h a n i s ms , t h e v e s t i b u l a r a p p a r a t u s , a n d t h e c e r e b e l l u m. L o s s o f c o o r d i n a t i o n i n ma i n t a i n i n g p r o p e r p o s t. uT e e sp a t i e n t at ax i a r h i w h o i s i n c o o r d i n a t e l y i n g d o ws t ata c at ax;i af t h e c o n d i t i o n i s o n l y e v i d e n t o n n h is i s t a n d i n g o r mo v i n g , kti net i c at ax i a i is .

Dysdiadochokinesis: L o s s o f t h e a b i l i t y t o a r r e s t o n e mo t o r i mp u l s e a n d s u b s t i t u t e i t s o p p o s i t e , dy s di adoc hok i nes i a c h a r a c t e r i s t i c o f c e r e b e l l a r d i s e a s e . , s


P. 8 4 0

Dyssyner gia and Dysmetr ia: F a i l u r e t o p r o p e r l y c o o r d i n a t e t h e c o n t r a c t i o n o f s y n e r g i s t i c mu s c l e d u r i n g a mo v e me n t idy s s y ner gi aIn a b i l i t y t o c o n t r o l t h e d i s t a n c e , p o w e r a n d s p e e d o f a s . mo v e me n t idy s met r i.aF i n g e r - t o - N o s e Te s t :c e r e b e l l a r d i s e a s e , t h i s a c t i o n i s s In a t t e n d e d b y a n a c t i o n t r e mo r. W h e n t h e ma n e u v e r i s p e r f o r me d w i t h t h e e y e s c l o s e d t h e s e n s e o f p o s i t i o n i n t h e s h o u l d e r a n d e l b o w H s e e-s to -d . h i n Te s t : ie tl t e S In cerebellar disease, the arc of the heel to the knee is jerky and wavering, the knee i f r e q u e n t l y o v e r s h o t , a n d t h e s l i d e d o w n t h e s h i n i s a c c o mp a n i e d b y a n a c t i o n t r e mo In p o s t e r i o r c o l u mn d i s e a s e , t h e h e e l ma y h a v e d i f f i c u l t y f i n d i n g t h e k n e e , a n d t h e r i d e d o w n t h e s h i n w e a v e s f r o m s i d e t o s i d e , o r t h e h e e l ma y f a l l o f f a l t o g e t h e r.

Wi d e S t a n c e : At a xi a f r o m p r o p r i o c e p t i v e , v e s t i b u l a r, o r c e r e b e l l a r d i s e a s e i s l e s s w h e n t h e p a t i e n stands on a broad base, the feet widely apart. Instability of Station: Vi s u a l C o m p e n s a t i o ne r e b e l l a r a t a xi a i s n o t a me l i o r a t e d b y v i s u a l o r i e n t a t i o n , C: w h i l e t h e a t a xi a f r o m p o s t e r i o r c o l u mn d i s e a s e i n v o l v e s d i s o r d e r e d p r o p r i o c e p t i o n a n d o n l y a p p e a r s o r i s w o r s e n e d w h e n t h e e y e s a r e c l o s eg s i gn Romber d ( ) . D i r e c t i o n o f F a l l i n g :d i s e a s e o f t h e l a t e r a l c e r e b e l l a r l o b e s , f a l l i n g i s t o w a r d t h e In a f f e c t e d s i d e . L e s i o n s o f t h e c e r e b e l l a r mi d l i n e o r v e r mi s ma y c a u s e f a l l i n g i n d i s c r i mi n a t e l y, d e p e n d i n g e n t i r e l y o n t h e i n i t i a l s t a n c e o f t h e p a t i e n t .
P. 8 4 1

G a i t At a x i a : P a t h o p h y s i o l o g G:a i t i s a c o mp l e x a c t i v i t y r e q u i r i n g n o r ma l s e n s o r y i n p u t f r o m t h e y f e e t , s p i n a l c o r d , a n d v e s t i b u l a r s y s t e m, a n d n o r ma l mo t o r a n d c e r e b e l l a r f u n c t i o n .
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Imp a i r me n t s i n a n y o f t h e s e s y s t e ms l e a d s t o c h a r a c t e r i s t i c c h a n .g e s i n t h e g a i t Careful inspection of gait can greatly aid identification of the site of the lesion.

G AI T ATAX I A: C E RE B E L L AR D I S E AS E : T h e a t a xi a p r o d u c e s a s t a g g e r i n g , w a v e r i n g , a n d l u r c h i n g w a l k t h a t i s n o t v i s u a l l y c o mp e n s a t e d . W i t h a l e s i o n i n t h e mi d - c e r e b e l l u m, mo v e me n t s a r e i n a l l d i r e c t i o n s . When a cerebellar lobe is involved, staggering and falling are toward the affected s i d e . T h e a t a xi a i s s o me w h a t s t e a d i e d b y s t a n d i n g o r w a l k i n g o n a w i d e b a s e ; t h a t i s , w i t h t h e l e g s f a r a p a r t . At a xi a s e c o n d a r y t o v e s t i b u l a r d i s e a s e ma y a p p e a r s i mi l a

G AI T ATAX I A: P O S T E RI O R C O L UM N D I S E AS E : In t a b e s d o r s a l i s , t h e p o s t e r i o r c o l u mn o f t h e c o r d i s a f f e c t e d , s o p r o p r i o c e p t i v e i mp u l s e s a r e d e f e c t i v e . T h e a t a xi a i s mu c h g r e a t e r w i t h t h e e y e s c l o s e d . T h e f e e t a r e l i f t e d t o o h i g h , a n d f r e q u e n t l y t h e y a r e s e t d o w n w i t h e xc e s s i v e f o r c e . T h e p a t i e n t f i xe s h i s e y e s w h e r e h e i s w a l k i n g t o c o mp e n s a t e f o r l o s s o f p r o p r i o c e p t i o n . At a xi a c a u s e d b y p e r i p h e r a l n e r v e s e n s o r y l o s s ma y l o o k s i mi l a r.

G AI T ATAX I A: D E M E NT I A: At a xi a o f g a i t i n p a t i e n t s w i t h o u t d e me n t i a p r e d i c t s a s i g n i f i c a n t l y i n c r e a s e d r i s k f o t h e d e v e l o p me n t o f n o n - Al zh e i me r d e me n t i a d u r i n g a f o l l o w - u p o f o v e r 6 y e a r s [Ve r g h e s e J , L i p t o n R B , H a l l C B , e t a l . Ab n o r ma l i t y o f g a i t a s a p r e d i c t o r o f n o n Al zh e i me r ' s d e me n t i aEngl J M ed 0 0 2 ; 3 4 7 : 1 7 6 1 1 7.6 8 N . 2 ] G AI T ATAX I A: S T E P PAG E G AI T, F O O T D RO P : W h e n t h e d o r s i f l e xo r s o f t h e f o o t a r e p a r a l y ze d , t h e f o o t s l a p s d o w n o n t o t h e f l o o r. To c o mp e n s a t e f o r t h e t o e d r o p , t h e p a t i e n t mu s t r a i s e t h e t h i g h e xc e s s i v e l y, a s i f walking upstairs. Unilateral toe drop usually results from injury of the peroneal n e r v e . B i l a t e r a l p a r a l y s i s ma y o c c u r f r o m p o l y n e u r o p a t h i e s , p o l i o my e l i t i s , l e s i o n s o t h e c a u d a e q u i n a , o r p e r o n e a l a t r o p h y i n C h a r c o t - M a r i e - To o t h d i s e a s e . P E RO NE AL M US C UL AR AT RO P HY: C HARC O T - M ARI E - T O O T H D I S E AS E : T h i s i s a h e r e d i t a r y d i s e a s e o f u n k n o w n c a u s e . P r e s e n t i n g s y mp t o ms a r e f o o t d r o p , p a i n , w e a k n e s s , n u mb n e s s a n d p a r e s t h e s i a s o f t h e l o w e r l e g s . T h e s y n d r o me i s s l o w l y p r o g r e s s i v e w i t h c l a w f o o t a n d f o o t d r o p , f r o m w e a k p e r o n e i , t i b i a l i s a n t e r i o r, a n d e xt e n s o r l o n g u s d i g i t o r u m. M u s c l e s t r e t c h r e f l e xe s a r e a b s e n t a n d t h e r e i s c u t a n e o u s h y p e s t h e s i a a n d t h e s l a p p i n g g a i t . T h e f o r e a r m ma y b e a f f e c t e d . G AI T ATAX I A: HE M I P L E G I C G AI T: T h e p a t i e n t w a l k s w i t h t h e a f f e c t e d l o w e r l i mb e xt e n d e d a t t h e h i p , k n e e , a n d a n k l e a n d t h e f o o t i n v e r t e d . T h e t h i g h ma y s w i n g i n a l(a ti ec a l a r c t i on) t h e c r r umduc o r p a t i e n t ma y p u s h t h e i n v e r t e d f o o t a l o n g t h e f l o o r. G AI T ATAX I A: S PAS T I C G AI T, S C I S S O RS G AI T: In p a r a p a r e s i s w i t h a d d u c t o r s p a s m, t h e k n e e s a r e p u l l e d t o g e t h e r s o t h e b o d y mu s s w a y l a t e r a l l y a w a y f r o m t h e s t e p p i n g l i mb t o a l l o w i t t o c l e a r t h e f l o o r. T h e f e e t ma o v e r s t e p e a c h o t h e r l a t e r a l l y, a l t e r n a t e l y c r o s s i n g a c r o s s t h e l i n e o f t r a v e l w i t h e a c step. G AI T ATAX I A: F E S T I NAT I NG G AI T, PARK I NS O NI AN G AI T: T h e t r u n k a n d n e c k a r e r i g i d a n d f l e xe d . T h e a r m s w i n g i s d i mi n i s h e d o r l o s t u n i l a t e r a l l y o r b i l a t e r a l l y. T h e s t e p s a r e s h o r t a n d s h u f f l i n g a n d b e c o me f a s t e r i n a n a t t e mp t t o a v o i d f a l l i n g f o r w a r d ( c h a s i n g t h e c e n t e rf es t gnat iion: T u r n s a r e o f i r a v t) y . slow and in-block, without evident turning of the head on the trunk or the trunk on
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the pelvis.

G AI T ATAX I A: M AG NE T I C G AI T: T he stance is wide and the steps are short and shuffling. T he feet are not lifted fro t h e f l o o r, a s i f h e l d d o w n b y ma g n e t s . T h i s i n d i c a t e s d i f f u s e c e r e b r a l d i s e a s e . G AI T ATAX I A: C L O WNI S H G AI T, HUNT I NG T O N C HO RE A: Wa l k i n g i s a t t e n d e d b y g r o t e s q u e mo v e me n t s c a u s e d b y t h e i n t e r p o s i t i o n o f p u r p o s e l e s s i n v o l u n t a r y c h o r e a o n g a i t mo v e me n t s . G AI T ATAX I A: WAD D L I NG G AI T, M US C UL AR D Y S T RO P HY: T he patient walks with a broad base. T he thighs are thrown forward by twisting the p e l v i s t o c o mp e n s a t e f o r t h e w e a k q u a d r i c e p s mu s c l e s . A s i mi l a r g a i t i s e mp l o y e d b those with bilateral dislocations of the hips.
P. 8 4 2

Tr emor s: P a t h o p h y s i o l o g C:o a r s e , p o o r l y c o o r d i n a t e d , c o n t r a c t i o n s o f o p p o s i n g mu s c l e y g r o u p s a r e u n a b l e t o ma i n t a i n s t a b l e p o s t u r e a n d s o p r o d u c e o s c i l l a t i n g mo v e me n t s a t o n e o r mo r e j o.i nT s e a mp l i t u d e ma y b e e i t h e r f i n e o r c o a r s e , a n d t h e r a t e e i t h e r th r a p i d o r s l o w. M o v e me n t s ma y b e r h y t h mi c o r i r r e g u l a r. Al l t r e mo r s d i s a p p e a r d u r i n g s l e e p . E xa mi n e t h e a f f e c t e d p a r t a t r e s t w i t h t h e mu s c l e s r e l a xe d , w i t h ma i n t e n a n c e o f p o s t u r e a g a i n s t g r a v i t y a n d w i t h mo v e me n t . E S S E NT I AL T RE M O R: P a t h o p h y s i o l o g T : i s i s a n a c c e n t u a t i o n o f t h e n o r ma l f i n e mo t o r mo v e me n t s yh ma d e t o ma i n t a i n p o s t u r e . It i s a c c e n t u a t e d w i t h i n c r e a s e d a d r e n e r g i c s t i mu l a t i o n o mu s c l e a n d ma y b e a f a mi l i a l Alrlapte r s o n s h a v e t h i s t y p e o f t r e mo r, b u t i t i s . t i u s u a l l y a t a n a mp l i t u d e b e l o w t h e l i mi t o f v i s i b l e d e t e c t i o n . It i s a c c e n t u a t e d w i t h a n xi e t y a n d i s c h a r a c t e r i s t i c o f h y p e r t h y r o i d i s m a n d a l c o h o l w i t h d r a w a l . T h e t r e mo r i s r a p i d a n d f i n e . It i s a b s e n t i s r e p o s e a n d a c c e n t u a t e d b y t r y i n g t o ma i n t a i n a p o s t u r eL[o u i s E D . E s s e n t i a l t r eN Engl J M ed 0 0 1 ; 3 4 5 : 8 8 7 8 9 1 mo r. 2 ]. PARK I NS O N T RE M O R: P a t h o p h y s i o l o g T : i s i s a r e s u l t o f d a ma g e t o t h e e xt r a p y r a mi d a l mo t o r s y s t e m o f yh t h e s u b s t a n t i a n i g r a i n P a r k i n s o n d iT e a ste e mo r i s p r e s e n t a t r e s t a n d . she r d i mi n i s h e d o r a b s e n t w i t h mo v e me n t . It i s s l o w a n d c o a r s e a n d o f t e n d e s c r i b e d a s p i l l - r o l l i n g f r o m t h e c h a r a c t e r i s t i c mo v e me n t s o f t h e f i n g e r s a n d w r i s t . P a r k i n s o n t r e mo r i s u s u a l l y a s y mme t r i c a t U nts e t J[. T r e mo r : H o w t o d e t e r mi n e i f t h e ot i R p a t i e n t h a s P a r k i n s o n ' s d i s e a s eat r i c s 9 9 8 ; 5 3 : 3 0 ]3 6 Ger i . 1 . C E RE B E L L AR T RE M O R: P a t h o p h y s i o l o g P : o r c e r e b e l l a r c o o r d i n a t i o n o f mu s c l e c o n t r a c t i o n a s s o c i a t e d yo w i t h mo v e me n t l e a d s t o l i mb o s c i l l a t i o n , o f t e n a c c e n t u a t e d w i t h a t t e mp t s a t f i n e c o n t r o l Ac t i o n o r i n t e n t i o n t r e mo r o c c u r s i n mu l t i p l e s c l e r o s i s a n d c e r e b e l l a r d i s e a s e . i n w h i c h v o l u n t a r y mo v e me n t s i n i t i a t e a n d s u s t a i n a s l o w o s c i l l a t i o n o f w i d e a mp l i t u d e . T ics: N o r ma l mo v e me n t s o f mu s c l e g r o u p s , s u c h a s g r i ma c i n g , w i n k i n g , o r s h o u l d e r s h r u g g i n g , a r e r e p e a t e d a t i n a p p r o p r i a t e t i me s . T h e r e a c t i o n i s s t e r e o t y p e d f o r t h e i n d i v i d u a l . T i c s ma y b e a c q u i r e d b e h a v i o r a l h a b i t s o r a s i g n o f o r g a n i c d i s e a s e , f o r
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e xa mp l e , To u r e t t e s y n d r o me . T h e y ma y b e a b o l i s h e d b y d i v e r t i n g t h e p a t i e n t ' s a t t e n t i o n a n d t h e y d i s a p p e a r d u r i n gJ s ln ke p i[c J . To u r e t t e ' s s y n d rN me . a e ov o Engl J M ed 2 0 0 1 ; 3 4 5 : 11 8 4 11.9 2 ] P. 8 4 3

Dyskinesia: D y s k i n e s i a s a r e c o mp l e x a b n o r ma l i t i e s o f mu s c l e mo v e me n t . T h e y a r e c e n t r a l l y me d i a t e d . S e v e r a l c h a r a c t e r i s t i c p a t t e r n s a r e r e c o g n i ze d :

C HO RE I F O RM M O V E M E NT S : R a p i d , p u r p o s e l e s s , j e r k y, a s y n c h r o n o u s mo v e me n t s i n v o l v e v a r i o u s p a r t s o f t h e b o d y. Al t h o u g h s o me a r e s p o n t a n e o u s , ma n y a r e i n i t i a t e d a n d a l l a r e a c c e n t u a t e d b v o l u n t a r y a c t s , a s i n e xt e n d i n g t h e a r ms o r w a l k i n g . T h e y c o mmo n l y o c c u r i n b o t h S y d e n h a m a n d H u n t i n g t o n c h o r e a ; i n t h e l a t t e r, t h e mo v e me n t s a r e c o a r s e r a n d mo r b i za r r e . T h e y d i s a p p e a r w i t h s l e e p . AT HE T O I D M O V E M E NT S : In c o n t r a s t t o c h o r e i f o r m mo v e me n t s , t h e s e a r e s l o w e r a n d w r i t h i n g , r e s e mb l i n g t h e a c t i o n s o f a w o r m o r s n a k e . T h e d i s t a l p a r t s o f t h e l i mb a r e mo r e a c t i v e t h a n t h e p r o xi ma l . G r i ma c e s a r e mo r e d e l i b e r a t e t h a n i n c h o r e a . T h e g r o t e s q u e a t h e t o i d h a n i s p r o d u c e d b y f l e xi o n o f s o me d i g i t s w i t h o t h e r s e xt e n d e d . T h e y d i s a p p e a r w i t h s l e e p . T h e me c h a n i s m i s n o t u n d e r s t o o d , b u t t h e mo v e me n t s a r e f r e q u e n t l y associated with diseases of the basal ganglia and levodopa therapy of Parkinson disease. HE M I B AL L I S M US : One side of the body is affected by sustained, violent, involuntary flinging mo v e me n t s o f t h e l i mb s . T h e s e r e s u l t f r o m a l e s i o n i n t h e c o n t r a l a t e r a l s u b t h a l a mi c nucleus of Luys, usually secondary to stroke. T hey disappear with sleep.

E p i s o d i c L o s s o f E x t e n s o r To n e : As t e r i x i s ( L i v e r F l a p ) : As k t h e p a t i e n t t o e l e v a t e h i s o r h e r a r ms t o 9 0 d e g r e e s i n 0 d e g r e e a b d u c t i o n , w i t h f i n g e r s a n d w r i s t s e xt e n d e d a n d f i n g e r s s p r e a d . T h e r e i s s u d d e n r e l a xa t i o n o f t o n e followed by restoration at the wrists and interphalangeal joints. T his occurs becaus e xt e n s o r t o n e i s l o s t a n d r e g a i n e d , r e s e mb l i n g a f l a p p i n g mo t i o n . T h e f i n g e r s d e v i a l a t e r a l l y a n d e xh i b i t a f i n e t r e mo r. W h e n t h e l e g o f t h e s u p i n e p a t i e n t i s e l e v a t e d a n t h e f o o t d o r s i f l e xe d , a s i mi l a r f l a p o c c u r s a t t h e a n k l e . An a l t e r n a t e t e s t f o r a n o b t u n d e d p a t i e n t i s t o i n d u c e t h e p a t i e n t t o s q u e e ze t w o o f t h e e xa mi n e r ' s f i n g e r s ; a s t e r i xi s i s f e l t a s a n a l t e r n a t e l y c l e n c h i n g a n d u n c l e n c h i n g g r i p . As t e r i xi s o c c u r s i n a n y f o r m o f me t a b o l i c e n c e p h a l o p a t h y i n c l u d i n g l i v e r f a i l u r e , u r e mi a , a n d hypercapnia as a consequence of respiratory failure. M uscle Cr amps: Dystonias: S e e p a g e 8 7.3

As s o c i a t e d M o v e m e n t s : S y n k i n e s i a : As s o c i a t e d mo v e me n t s , o r s y n k i n e s i a s , a r e i n v o l u n t a r y mo t o r p a t t e r n s , mo r e c o mp l e t h a n r e f l e xe s , t h a t n o r ma l l y a c c o mp a n y v o l u n t a r y a c t s , s u c h a s s w i n g i n g t h e a r ms w h i l e w a l k i n g , f a c i a l mo v e me n t s o f e xp r e s s i o n , a n d mo t i o n s a c c o mp a n y i n g c o u g h i n g a n d y a w n i n g . F r e q u e n t l y, t h e s e a r e l o s t i n d i s e a s e o f t h e p y r a mi d a l t r a c t o r t h e b a s
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g a n g l i a ; f o r e xa mp l e , t h e p a t i e n t w i t h p a r k i n s o n i s m w a l k s w i t h o u t s w i n g i n g t h e a r ms An e a r l y s i g n o f c o r t i c o s p i n a l t r a c t d a ma g e ma y b e l o s s o f s y n k i n e t i c mo v e me n t s . K n o w l e d g e o f n o r ma l a n d a b n o r ma l p a t t e r n s o f s y n k i n e s i s c a n a s s i s t i n t h e identification of the patient with factitious neurologic illness. T he detailed testing o s y n k i n e s i s i s b e y o n d t h e s c o p e o f t h i s t e xt . T h e r e a d e r s h o u l d c o n s u l t t e xt b o o k s o f neurologic diagnosis.

Sensory Signs

L o s s o f n o r ma l s e n s a t i o n c a n r e s u l t f r o m i n j u r y t o e i t h e r t h e p e r i p h e r a l o r c e n t r a l n e r v o u s s y s t e m. T h e d i s t r i b u t i o n o f t h e s e n s o r y l o s s , t h e mo d a l i t i e s i n v o l v e d a n d t h p r e s e n c e o r a b s e n c e o f mo t o r i n v o l v e me n t a r e u s e f u l i n d i s t i n g u i s h i n g p e r i p h e r a l n e r v e f r o m p l e xu s , r o o t , a n d c e n t r a l i n j u r y. P. 8 4 4

Ab n o r m a l P a i n S e n s a t i o n : Changes in pain sensation can result from injury to any portion of the pain pathway ( p e r i p h e r a l n e r v e , s p i n a l c o r d , o r b r a i n ) . S e n s i b i l i t y t o p a i n ma y b e n o r ma l , r e d u c e d ( hy pal ges i) a a b s e n tanal ges i)a o r i n c r e a s ehy ( al ges)i .a , ( , d per AL L O D Y NI A: P a t h o p h y s i o l o gAl:l o d y n i a i n d i c a t e s d a ma g e t o t h e s e n s o r y p a t h w a y s , u s u a l l y i n y t h e d o r s a l r o o t o r s p i n a l c o r d ; i t i s n o t a s i g n o f p e r i p h e r a. l Al eody nin j u r y n l rve i a ( al l o = d i f f e r i n g f r o m n o r mani a= p a i n ) i s t h e p e r c e p t i o n o f p a i n w i t h s t i mu l i t h a t dy l ; a r e n o r ma l l y n o t p a i n f u l s u c h a s l i g h t t o u c h o r v i b r a t i o n . P a t i e n t s c o mp l a i n o f p a i n with the touch of clothing or bedding and with weight bearing on the feet. Lightly touch and stroke the skin over the suspected area and apply a tuning fork to look fo a l l o d y n i a . U s e a mi l d l y u n c o mf o r t a b l e s t i mu l u s l i k e t h e s h a r p e n d o f a b r o k e n t o n g u d e p r e s s o r t o e l i c i t h y p e r e s t h e s i a . Al l o d y n i a i s f o u n d i n p o s t h e r p e t i c n e u r a l g i a , d i a b e t i c r a d i c u l o p a t h i e s , a n d c o mp l e x r e g i o n a l p a i n s y n d r o me a n d o t h e r c h r o n i c p a i s y n d r o me s . Hy s t e r i c a l An e s t h e s i a : H y s t e r i a ma y b e r e v e a l e d i n o u t l i n i n g t h e b o r d e r s o f a n a r e a o f a n e s t h e s i a b y s t i mu l a t i n g f r o m t h e c e n t e r t o t h e b o r d e r i n a zi g za g g i n g l i n e , w h i c h s e e ms t o confuse the patient and results in disparities between successive tests.

L o s s o f P a i n a n d Te m p e r a t u r e S e n s e s : P a t h o p h y s i o l o g P : i n a n d t e mp e r a t u r e f i b e r s c r o s s n e a r t h e i r e n t r y i n t o t h e c o r d . ya D i s r u p t i o n o f t h e c r o s s i n g f i b e r s l e a d s t o l o s s o f t h e s e mo d a l i t i e s w i t h p r e s e r v a t i o n o f o t h e r r e g i o n a l s e n s a tAs n t h e p a t i e n t t o d i s t i n g u i s h b e t w e e n h o t a n d c o l d . . iok Te mp e r a t u r e a n d p a i n d i s c r i mi n a t i o n i s l o s t i n s y r i n g o my e l i a w h i l e t a c t i l e s e n s e i s retained.

Ta c t i l e E x t i n c t i o n Te s t : In p a r i e t a l l o b e d i s e a s e , t h e p a t i e n t ma y p e r c e i v e t o u c h a c c u r a t e l y w h e n t h e s t i mu l a t i o n i s a p p l i e d t o t h e r i g h t a n d l e f t c o n s e c u t i v e l y ; i f t h e p o i n t s a r e s t i mu l a t e d s i mu l t a n e o u s l y, t h e p a t i e n t n o l o n g e r p e r c exv engui r hes h e a f f e c t e d s i d e . ei ti s, o s , t Loss of Position and Vibr ation Sense: P a t h o p h y s i o l o g P : s i t i o n a n d v i b r a t i o n s e n s e a r e c a r r i e d i n t h e p o s t e r i o r c o l u mn s yo


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o f t h e s p i n a l c .o rD a ma g e t o t h e p o s t e r i o r c o l u mn s r e s u l t s i n i mp a i r e d d p r o p r i o c e p t i o n l e a d i n g t o a b n o r ma l i t i e s i n s t a n c e a n d g a i t . P o s t e r i o r c o l u mn d i s e a s e s i n c l u d e v i t a mi2 dB f i c i e n c y a n d t a b e s d o r s a l i s . 1n e

L o s s o f I n t e g r a t i v e F u n c t i o n : As t e r e o g n o s i s : In a b i l i t y t o r e c o g n i ze f a mi l i a r o b j e c t s b y t o u c h i s a s t e r e o g n o s i s . As s u mi n g t h e p r i ma r y s e n s o r y mo d a l i t i e s a r e i n t a c t , i t i s a s i g n o f c o r t i c a l d i s e a s e , a n i n a b i l i t y t o i n t e g r a t e t h e mu l t i p l e i n p u t s .
P. 8 4 5

Autonomic Nervous System Signs


Temperature Regulation:

S e e C h a p t e r ,4p a g e 5 9 . S o me i n s t a n c e s o f h y p e r t h e r mi a o c c u r f r o m l e s i o n s o f t h e h y p o t h a l a mu s o r h i g h c e r v i c a l c o r d . H y p o t h e r mi a i s e n c o u n t e r e d i n i n s u l i n s h o c k a n my xe d e ma , a l t h o u g h t h e r o l e o f t h e a u t o n o mi c s i n t h e l a t t e r c o n d i t i o n i s d o u b t f u l .

Perspiration:
L o c a l i ze d a r e a s o f s w e a t i n g ma y o c c u r i n s y r i n g o my e l i a , p e r i p h e r a l n e r v e i n j u r y, o r n e u r o p a t h y. An h i d r o s i s i s a c o mp o n e n t o f H o r n e r s y n d r o me a n d a u t o n o mi c i n s u f f i c i e n c y ( s e v e r e c o mb i n e d d e g e n e r a t i o n ) .

Tr ophic Distur bances: P a t h o p h y s i o l o gL o s s o f i n n e r v a t i o n l e a d s t o f u n c t i o n a l d e f i c i e n c i e s o f t h e s w e a t y: a n d o i l g l a n d s o f t h e . sC ion i n e d w i t h d e c r e a s e d s e n s a t i o n , t h e s k i n i s mo r e k mb v u l n e r a b l e t o i n j u r y a n d i n f e c t i o n . T h e s k i n b e c o me s s h i n y, s mo o t h , t h i n , a n d d r y. P a i n l e s s u l c e r s ma y d e v e l o p o v e r b o n y p r o mi n e n c e s o f t h e f e e t i n p e r i p h e r a l n e u r o p a t h y f r o m d i a b e t e s o r t a b e s d o r s a l i s , a n d s y r i n g oF i ge l 1a -(1 2 F my . i 4 s e .e ) C h a r c o t j o i n tC h(a p t e r 1 3p a g e 7 9 9 ) a r e a n e u r o p a t h i c a r t h r o p a t h y c a u s e d b y l o s s s , o f p r o p r i o c e p t i o n a n d p r o t e c t i v e s e n s a t i o n r e q u i r e d t o ma i n t a i n j o i n t a l i g n me n t . P i l o m o t o r Re a c t i o n s : S c r a t c h i n g t h e mi d a xi l l a r y s k i n p r o d u c e s p i l o mo t o r e r e c t i o n ( g o o s e f l e s h ) . T h e n o r ma r e s p o n s e i s a b o l i s h e d b e l o w t h e l e v e l o f a t r a n s v e r s e c o r d l e s i o n . An e xa g g e r a t e d r e a c t i o n ma y o c c u r o n t h e a f f e c t e d s i d e i n h e mi p l e g i a . B l o o d P r e s s u r e Re g u l a t i o n : S e e C h a p t e r ,4p a g e 8 6 . O r t h o s t a t i c h y p o t e n s i o n w i t h o u t t a c h y c a r d i a i s c o mmo n w i t h a u t o n o mi c n e r v o u s s y s t e m d i s e a s e s . Bladder /Bowel Function: P a t i e n t s w i t h a u t o n o mi c n e r v o u s s y s t e m d i s e a s e s o f t e n l o s e c o n t r o l o f b l a d d e r a n d bowel function producing incontinence and/or urinary and fecal retention.

Some Peripheral Nerve Signs


P. 8 4 6 P. 8 4 7 P. 8 4 8
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Sciatica: S e e C h a p t e r 1 3p a g e 7 9 0 . , Ac q u i r e d C a l c a n e o v a l g u s : T i b i a l Ne r v e P a l s y ( A S c i a t i c C o m p o n e n t ) : T h e t i b i a l n e r v e i s t h e mo t o r n e r v e t o t h e g a s t r o c n e mi u s g r o u p a n d i n t r i n s i c mu s c l e in the sole of the foot; it is sensory to the skin of the sole. Paralysis of the tibial n e r v e c a u s e s a c a l c a n e o v a l g u s d e f o r mi t y b y t h e u n o p p o s e d a c t i o n o f t h e d o r s i f l e xo r s a n d e v e r t o r s o f t h e i fg . o1 4 - 1 9 A P l a n t a r f l e xi o n a n d i n v e r s i o n o f F o t ( ). the foot are weak and the ankle jerk is absent. T he sole is anesthetic, thus vulnerable to trophic ulcers.

F i g . 1 4 - 1 9 N e r ve L e s i o n s o f t h e L o w e r L i m b . A . T i b i a l N e r veThe r a l y s i s : Pa f oot as s umes t he pos t ur e of c al c aneov al gus f r om par al y s i s of t he pl ant ar f l ex or s . The s ol e of t he f oot i s anes t het i B . ( blo m m o n P e r o n e a l N e r ve . c C ue) P a r a l y s i sThe f oot as s umes t he pos i t i on of equi nov ar us ; i t c annot be : dor s i f l ex eda f oot dr op. The dor s um of t he f oot , and f r equent l y t he l at er al as pec t of t he l eg, ar e anes t het i c Cbl F e m o r a l N e r ve P a r a l yThe: k nee . ( . ue) sis c annot be ex t ended when s i t t i ng. The r egi on of anes t hes i a c ov er s t he maj or por t i on of t he ant er i or t hi gh and medi al as pec t . of. tE xclleg i o n Te s t D he u s f o r M a j o r N e r ve I n j u r y i n L o w e r Sens at i on i s i nt ac t i n t he web bet ween Limb: t he gr eat t oe and s ec ond t oe; ex t ens i on ( dor s i f l ex i on) of t he gr eat t oe i s nor mal l y per f or med .

Ac q u i r e d E q u i n o v a r u s : C o m m o n P e r o n e a l Ne r v e P a l s y ( A S c i a t i c Component): T h e c o mmo n p e r o n e a l n e r v e i s t h e mo t o r n e r v e t o t h e mu s c l e s o f t h e a n t e r i o r a n d l a t e r a l c o mp a r t me n t s o f t h e l e g a n d t h e s h o r t e xt e n s o r s o f t h e t o e s ; i t i s s e n s o r y t o the dorsum of the foot and ankle. Peroneal paralysis causes an equinovarus d e f o r mi t y w i t h i n a b i l i t y t o d o r s i f l e x t h e f o o t a n d t o e s a f oF i tg .d r1o p 1 9 B e o 4- (se ). An a r e a o f a n e s t h e s i a c o v e r s t h e d o r s u m o f t h e f o o t a n d s o me t i me s e xt e n d s u p t h e l a t e r a l s i d e o f t h e l e g . T h e n e r v e ma y b e r o l l e d u n d e r t h e f i n g e r s w h e r e i t w i n d s a r o u n d t h e f i b u l a r h e a d ; t h i s ma n e u v e r e l i c i t s e xt r e me t e n d e r n e s s w h e n n e u r i t i s i s
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present while there is little tenderness in tabes. Pressure injury to the nerve at the f i b u l a r h e a d ma y o c c u r i n c o ma a n d f r o m c o n s t r i c t i n g c a s t s .

Complete Par alysis of the Foot: Combined T ibial and Common Per oneal Palsy (Complete Sciatic Par alysis): Al l mu s c l e s b e l o w t h e k n e e a r e p a r a l y ze d . An a r e a o f a n e s t h e s i a e xt e n d s o v e r t h e sole and dorsum of the foot and up the lateral aspect of the leg. L a c k o f K n e e E x t e n s i o n : F e m o r a l Ne r v e P a l s y : T h e f e mo r a l n e r v e i s t h e mo t o r n e r v e f o r t h e q u a d r i c e p s f e mo r i s . W h e n t h e n e r v e i s i n j u r e d , p a t i e n t s c a n n o t w a l k a n d s t a n d i n g i s u n s t a b l e . E xt e n s i o n o f t h e k n e e i s i mp o s s i b l e ( s e eg . 1 4 - 1 9)C An e s t h e s i a i s w i d e s p r e a d o v e r t h e a n t e r o me d i a l Fi . a s p e c t o f t h e t h i g h , k n e e , l e g , a n d t h e me d i a l a s p e c t o f t h e f o o t .

S h o u l d e r We a k n e s s : D o r s a l S c a p u l a r Ne r v e P a r a l y s i s : T h e n e r v e s u p p l i e s t h e r h o mb o i d s t h a t e l e v a t e a n d r e t r a c t t h e s c a p u l a . T h e s e mu s c l e s a s c e n d o b l i q u e l y f r o m t h e me d i a l b o r d e r o f t h e s c a p u l a t o t h e s p i n o u s p r o c e s s e s o f t h e u p p e r t h o r a c i c v e r t e b r a e . Al t h o u g h c o v e r e d b y t h e t r a p e zi u s , t h e y ma y b e p a l p a t e d t h r o u g h t h i s s u p e r f i c i a l mu s c l e w h e n t h e s h o u l d e r s a r e d r a w n b a c k w a r d ; c o mp a r i s o n o f t h e t w o s i d e s ma y d i s c l o s e u n i l a t e r a l p a l s y. S h o u l d e r We a k n e s s : S u p r a s c a p u l a r Ne r v e P a r a l y s i s : T he nerve supplies the supraspinatus and the infraspinatus. Paralysis prevents (a) scratching of the back of the head, (b) turning a doorknob with the arm outstretched a n d ( c ) c o mp l e t i n g a l i n e o f w r i t i n g w i t h o u t mo v i n g t h e p a p e r t o t h e l e f t ( w h e n t h e p a t i e n t i s r i g h t - h a n d e d ) . At r o p h y o f t h e s e mu s c l e s ma y b e p a l p a t e d a s d e p r e s s i o n s above and below the scapular spine.

S h o u l d e r We a k n e s s : L o n g T h o r a c i c Ne r v e P a r a l y s i s : T h e n e r v e s u p p l i e s t h e s e r r a t u s a n t e r i o r t h a t h o l d s t h e s c a p u l a t o t h e t h o r a x. P a r a l y s i s p r o d u c e s a w i n g e d s c a p u lF i g .s e e - 4 1 A a g e 7 5 1 ) w h e n t h e p a t i e n t a ( 13 , p pushes the hand forward against a wall. We a k Ab d u c t i o n o f t h e Ar m : Ax i l l a r y Ne r v e P a r a l y s i s : T h i s ma y b e c a u s e d b y n e u r i t i s , f r a c t u r e o f t h e h u me r a l n e c k , d i s l o c a t i o n o f t h e s h o u l d e r, o r o c c a s i o n a l l y b y s c a p u l a r f r a c t u r e . T h e d e l t o i d i s p a r a l y ze d a n d a t r o p h i e d . E l e v a t i o n o f t h e a r m i n 9 0 d e g r e e s o f a b d u c t i o n i s i mp o s s i b l e . A p a t c h o f sensory loss on the lateral aspect of the shoulder is often found.

We a k Ad d u c t i o n a n d D e p r e s s i o n o f t h e Ar m : An t e r i o r T h o r a c i c Ne r v e Par alysis: T h i s n e r v e s u p p l i e s t h e p e c t o r a l i s ma j o r a n d mi n o r. In s p e c t i o n d i s c l o s e s p a r a l y s i s w h e n t h e p a t i e n t p r e s s e s t h e h a n d d o w n o nFtih e 1 4p 2(0 B g. hi - ). We a k Ad d u c t i o n a n d D e p r e s s i o n o f t h e Ar m : T h o r a c o d o r s a l Ne r v e Par alysis: T h e l a t i s s i mu s d o r s i i s s u p p l i e d b y t h i s n e r v e . To d e mo n s t r a t e p a l s y, g r a s p t h e p o s t e r i o r a xi l l a r y f o l d o f mu s c l e , j u s t b e l o w t h e s c a p u l a r a n g l e , a n d h a v e t h e p a t i e n c o u g h ; t h e n o r ma l mu s c l e t e n s e s i (gs. e1 4 - 2 0)C F e .

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F i g . 1 4 - 2 0 N e r ve L e s i o n s o f t h e U p p e r T r u n k . A . H o r n e r S y n d r otm e : I nj ur y o t he s uper i or c er v i c al s y mpat het i c gangl i on on one s i de c aus es i ps i l at er al pt os i s of t he ey el i d, mi os i s , and anhi dr os i s ofBt.he afr a le s i s o f t h e . P ac y P e c t o r a l i s M a j o r M u s cnj ur y t o t he ant er i or t hor ac i c ner v e c aus es par al y s i s I le: of t he pec t or al i s maj or and mi nor mus c l es . When t he pat i ent i s as k ed t o pr es s t he hands down on t he hi ps , t he nor mal pec t or al i s mus c l e i s t ens ed but t he par al y zed one i s .not P a r a l y s i s o f t h e L a t i s s i m u s D o r s i M u s c l e : C. The ex ami ner gr as ps t he l at i s s i mus mus c l es i n hi s hands and as k s t he pat i ent t o c ough. A par al y zed mus c l e does not t ens e wi t h . c oughi ng

F l a i l Ar m : E r b - D u c h e n n e P a r a l y s i s : L o w e r mo t o r n e u r o n p a r a l y s i s o f t h e b r a c h i a l p l e xu s ma y o c c u r f r o m f o r c e f u l depression of the shoulder during birth or a blow on the shoulder later in life. T he a r m h a n g s l i mp l y w i t h t h e f i n g e r s f l e xe d a n d t u r n e d p o s t e r i o r l y, aFfi lg . i l a r m ( s e e a 1 3 - 4 1 B p a g e 7 5 1 ) . W i t h p a r t i a l r e c o v e r y, mo t i o n s o f t h e e l b o w a n d h a n d ma y b e , r e g a i n e d . T h e b i c e p s r e f l e x i s l o s t a n d t h e r e i s mu s c l e w a s t i n g . We a k E l b o w F l e x i o n : M u s c u l o c u t a n e o u s Ne r v e P a r a l y s i s : T he biceps brachii and brachialis are supplied by this nerve. Paralysis can usually b e d e mo n s t r a t e d b y i n s p e c t i o n o f t h e a r m w h e n t h e e l b o w i s f l e xe d a g a i n s t r e s i s t a n c e . A s ma l l a r e a o f a n e s t h e s i a o c c u r s o n t h e v o l a r s u r f a c e o f t h e f o r e a r m.

P. 8 4 9 I n c o m p l e t e E x t e n s i o n o f Wr i s t a n d F i n g e r s : Ra d i a l Ne r v e P a r a l y s i s : P a t h o p h y s i o l o g In: i t s s p i r a l c o u r s e a r o u n d t h e h u me r u s , t h i s n e r v e i s e xp o s e d t o y i n j u r y f r o m f r a c t u r e o f t h e s h a f t . T h e r a d i a l n e r v e i s o f t e n c o mp r e s s e d d u r i n g i t s c o u r s e a r o u n d t h e s p i r a l g r o o v e o f t h e h u me r u s ( S a t u r d a y . n i g h o rp a l s y ) Mot t d e f i c i t s d e p e n d u p o n t h e l e v e l o f i n j u r y. In j u r y i n t h e a xi l l a c a u s e s p a r a l y s i s o f t h e t r i c e p s b r a c h i i , a n c o n e u s , b r a c h i o r a d i a l i s , a n d e xt e n s o r c a r p i r a d i a l i s l o n g u s . A l e s i o n a t t h e l e v e l o f t h e u p p e r t h i r d o f t h e h u me r u s s p a r e s t h e t r i c e p s w h i l e d a ma g b e t w e e n t h e h u me r a l u p p e r t h i r d a n d 5 c m a b o v e t h e e l b o w a l s o s p a r e s t h e b r a c h i o r a d i a l i s . In n e r v a t i o n o f t h e w r i s t e xt e n s o r s ma y b e i n j u r e d a t a l o w e r l e v e l . An y l e s i o n i n v o l v i n g t h e e xt e n s o r c a r p i r a d i a l i s l o n g u s p r e v e n t s f i xa t i o n a t t h e w r i s t i n g r a s p i n g , p r o d u c i n g a w r i s t - d go p 4 - 2 1 A P a r a l y s i s o f t h e e xt e n s o r d i g i t o r u m Fi r . 1 ( ). c o mmu n i s p r e v e n t s e xt e n s i o n o f t h e w r i s t a n d f i n g e r s w i t h t h u mb a n d f i n g e r d r o p . W h e n t h e d e e p b r a n c h o f t h e r a d i a l n e r v e i s i n j u r e d , r a d i a l d e v i a t i o n o f t h e w r i s t ma o c c u r w i t h o u t w r i s t - d r o p . S e n s o r y l o s s o n t h e d o r s u m o f t h e h a n d e xt e n d s f r o m t h e


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r a d i a l b o r d e r t o t h e d o r s u m o f t h e f i f t h me t a c a r p a l ; t h e d o r s u m o f t h e t h u mb i s i n v o l v e dF(i g . 1 4 - 2 1 B T h e d i s t r i b u t i o n o f a n e s t h e s i a i s q u i t e i r r e g u l a r, b u t i t u s u a l l y ). i n c l u d e s d o r s u m o f t h u mb t o f i r s t p h a l a n x a n d w e b .

F i g . 1 4 - 2 1 R a d i a l N e r ve P a r a lThe sex t ens or s of t he wr i s t ar e par al y zed, . ysi s o t he hand dr oops when i t i s pl ac ed at t he end of t he t abl e wi t h no s uppor t ; t hi s s i gn i s c al l ed wr i s t - dr op. The r egi on of anes t hes i a i nc l udes t he dor s al as pec t of t he r adi al t hr ee di gi t s ( bl ue .s hadi ng)

I n c o m p l e t e F l e x i o n o f T h u m b a n d F i n g e r s : M e d i a n Ne r v e P a r a l y s i s : T h e n e r v e i s e xp o s e d t o t r a u ma i n t h e a n t e c u b i t a l f o s s a . It s u p p l i e s t h e f l e xo r s o f t h w r i s t s , d i g i t s , a n d p r o n a t o r s o f t h e f o r e a r m: p r o n a t o r t e r e s , p r o n a t o r q u a d r a t u s , f l e xo r c a r p i r a d i a l i s , f l e xo r d i g i t o r u m s u b l i mi s , f l e xo r d i g i t o r u m p r o f u n d u s ( e xc e p t t h f o u r t h a n d f i f t h d i g i t s ) , f l e xo r p o l l i c i s b r e v i s , f l e xo r p o l l i c i s l o n g u s , o p p o n e n s p o l l i c l u mb r i c a l , a b d u c t o r p o l l i c i s l o n g u s , a n d b r e v i s . Al l t h e s e mu s c l e s a r e i n n e r v a t e d b e l o w t h e e l b o w. T h e mo s t c o mmo n s i t e o f me d i a n n e r v e e n t r a p me n t i s a t t h e c a r p a t u n n e l ( s eCar pal Tunnel Sy ndr ome a p t e r 1 3p a g e 7 3 5 ) . e , Ch ,


P. 8 5 0

Ad d u c t o r We a k n e s s o f F i n g e r s : Ul n a r Ne r v e P a r a l y s i s : T h e u l n a r n e r v e i s mo s t v u l n e r a b l e n e a r t h e e l b o w w h e r e i t c u r v e s p o s t e r i o r l y a r o u n d t h e me d i a l e p i c o n d y l e . T h e c h i e f mo t o r d i s a b i l i t y f r o m p a l s y i s l o s s o f t h e f i n e r i n t r i n s i c mo t i o n s o f t h e h a n d , a s ma y b e i n f e r r e d f r o m a l i s t o f i n n e r v a t e d mu s c l e s : a d d u c t o r p o l l i c i s , f l e xo r c a r p i u l n a r i s , i n t e r o s s e u s p a l ma r i s a n d d o r s a l i s , f l e xo r p o l l i c i s b r e v i s , o p p o n e n s d i g i t i mi n i mi , f l e xo r d i g i t o r u m p r o f u n d u s ( i n p a r t ) . W i t h i n j u r y t o t h e n e r v e , i n s p e c t i o n w i l l s h o w a n a b d u c t i o n d e f o r mi t y o f t h e l i t t l e f i n g e r f r o m p a r a l y s i s o f t h e i n t e r o s s e i , i n t e r o s s e o u s mu s c l e a t r o p h y, a n d p a r t i a l c l a w h a n d f r o m f l e xi o n d e f o r mi t y o f t h e mi d d l e a n d d i s t a l i n t e r p h a l a n g e a l j o i n t s o f t h ring and little fingers. Clawhand: Klumpke Par alysis: A l o w e r mo t o r n e u r o n l e s i o n a t t h e b r a c h i a l p l e xu s o r u l n a r n e r v e p r o d u c e s p a r a l y s i o f t h e i n t r i n s i c h a n d mu s c l e s r e s u l t s i n t h e c l a wF ia n d1 ( s e e, Dp a g e 7 2 5 ) . h g. 3-28 S e n s a t i o n o n t h e u l n a r a s p e c t o f t h e a r m, f o r e a r m, a n d h a n d ma y b e l o s t .

Neurologic Syndrom es
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Falling

Loss of Balance and Falls: F a l l s a r e a c o mmo n p r o b l e m, e s p e c i a l l y o v e r a g e 7 5 . M a n y p a t i e n t s w i l l n o t v o l u n t e e r t h i s i n f o r ma t i o n u n l e s s s p e c i f i c a l l y a s k e d . M a i n t e n a n c e o f n o r ma l b a l a n c e r e q u i r e s t h e c o mp l e x i n t e r a c t i o n o f ma n y p a r t s o f t h e n e r v o u s s y s t e m: p r o p r i o c e p t i v s e n s o r y n e r v e s a n d t r a c t s , v e s t i b u l a r s y s t e m, mo t o r t r a c t s a n d n e r v e s , mu s c l e s , c e r e b e l l u m, a n d b a s a l g a n g l i a . Ab n o r ma l i t i e s i n a n y o f t h e s e s t r u c t u r e s c a n p r o d u c e f a l l s . W h e n p r o p r i o c e p t i v e f u n c t i o n i s i mp a i r e d , p a t i e n t s c o mp e n s a t e w i t h t h e i r e y e s t o l o c a t e t h e ms e l v e s i n s p a c e ; v i s u a l i mp a i r me n t ( i n c l u d i n g u s e o f b i - a n d t r i f o c a l l e n s e s ) a r e a f r e q u e n t c o n t r i b u t o r t o f a l l s . S k e l e t a l a b n o r ma l i t i e s , e s p e c i a l l y o f t h e j o i n t s , a r e a c o mmo n p r e c i p i t a n t . D e c r e a s e d me n t a t i o n a n d r e a c t i o n t i me s b e c a u s e o f d r u g s ( e . g . , b e n zo d i a ze p i n e s , a n t i c h o l i n e r g i c s ) o r a g i n g f r e q u e n t l y c o n t r i b u t e t o r i s k o f f a l l i n g . A c o mp l e t e n e u r o l o g i c e xa mi n a t i o n i s r e q u i r e d t o i d e n t i f y a l l t h e c o n t r i b u t i n g a b n o r ma l i t i e s . P r e v e n t i o n o f f a l l s i s a ma j o r f o c u s o f t h e g e r i a t r i c a s s e s s me n t i[b b i t t s G M . P a t i e n t s w h o f a l l : H o w t o p r e d i c t a n d p r e v e n t i n j u r i e s . T Ger i at r i c s 9 9 6 ; 5 1 : 2 4 2 8 ,; 3 1u d e n s k i S , R i g l e r S K . C l i n i c a l o v e r v i e w o f 1 St i n s t a b i l i t y i n t h e e l d Cl li y. Ger i at r M ed 9 6 ; 1 2 : 6 7 9 6; 8 8i n e t t i M E , In o u y e S K , er n 19 T G i l l T M , D o u c e t t e J T. S h a r e d r i s k f a c t o r s f o r f a l l s , i n c o n t i n e n c e , a n d f u n c t i o n a l d e p e n d e n c e : U n i f y i n g t h e a p p r o a c h t o g e r i a t r i c s y n d r o me 9 . ; 2 7 3 : 1 3 4 8 J AM A 1 9 s 5 1 3 5 3. ]

Headache
P. 8 5 1

He a d a c h e : P a t h o p h y s i o l o g T : e h e a d c o n t a i n s ma n y p a i n - s e n s i t i v e s t r u c t u r e s . M e c h a n i s ms yh o f h e a d a c h e i n c l u d e i n f l a mma t i o n , i n f e c t i o n , a r t e r i a l d i l a t i o n , h e mo r r h a g e , c h a n g e s o f p r e s s u r e w i t h i n c l o s e d s p a c e s , e xp a n d i n g ma s s l e s i o n s p r o d u c i n g t r a c t i o n o r c o mp r e s s i o n o f s t r u c t u r e s , t r a u ma , t i s s u e i s c h e mi a , a n d t i s s u e d e s t r u c t i o n . T h e c o mmo n e xt r a c r a n i a l c a u s e o f h e a d a c h e i s s u s t a i n e d c o n t r a c t i o n o f t h e mu s c l e s o f t h e h e a d , n e c k , a n d s h o u.l d ee a d a c h e r e f e r s t o p a i n p e r c e i v e d mo r e t h a n H rs mo me n t a r i l y i n t h e c r a n i a l v a u l t , t h e o r b i t s , a n d t h e n a p e o f t h e n e c k ; p a i n e l s e w h e i n t h e f a c e i s n o t i n c l u d e d . An u r g e n t i n t e n s i v e s e a r c h f o r s e r i o u s p a t h o l o g y i s r e q u i r e d i f y o u r p a t i e n t d e s c r i b e s a s e v e r e h e a d a c h e u n l i k e a n y e xp e r i e n c e d i n t h e p a s t S t e i n e r T J , F o n t e b a s s o M . H e a dBMh e . 0 0 2 ; 3 2 5 : 8 8 1 8 8 6 e e a l s o [ ac J 2 ]. S p a g e s 3 1 3 1 7 . 6 HE AD AC HE C L I NI C AL O C C URRE NC E : Congeni t al r t e r i o v e n o u s ma l f o r ma t i o n s , h y d r o c eEndocs ;i ne a phalu r p h e o c h r o mo c y t o ma ; opat hi cd i o p a t h i c i n t r a c r a n i a l h y p e r t e n s i o n ; I di i I nf l ammat or y / I mmune n t c e l l a r t e r i t i s , s a r c o i dnfs i s t; i ous n i n g i t i s gia I o ec me ( b a c t e r i a l , v i r a l , my c o b a c t e r i a l , f u n g a l , d r u g s ) , e n c e p h a l i t i s ( v i r a l , e . g . , h e r p e s s i mp l e x, H IV, W e s t N i l e f e v e r, e a s t e r n a n d w e s t e r n e q u i n e e n c e p h a l i t i s , S t . L o u i s encephalitis, California encephalitis, LaCrosse encephalitis, and dengue), rickettsia i n f e c t i o n s , s i n u s i t i s , o t i t i s , ma s t o i d i t i s , n o n - C N S v i r a l i n f e c t i o n s ( e . g . , i n f l u e n za , c y t o me g a l o v i r u s , v a r i c e l l a ) , p a r a s i t e s ( e . g . , ma l a r i a , n e u r o c y s t i c e r c o s i s ) , p r o t o zo a ( e . g . , t o xo p l a s mo s M et abol i c / Toxac a l g e s i c r e b o u n d h e a d a c h e , h y p o xi a , is); in h y p e r c a p n i a , h y p o g l y c e mi a , a l c o h o l a n d i l l i c i t d r u g w i t h d r a w a l , c a r b o n mo n o xi d e
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p o i s o n i n g , c a f f e i n e a b s t i n e nec hani c al / Tr auma c e l e r a t e d a n d ma l i g n a n t M ce; ac h y p e r t e n s i o n , t r a u ma , h e a d t r a u ma , c o n c u s s i o n , mu s c u l a r t e n s i o n , t e mp o r o ma n d i b u l a r j o i n t d i s e a s e , i n c r e a s e d i n t r a c r a n i a l p r e s s u r e , g l a u c o ma , d e c r e a s e d i n t r a c r a n i a l p r e s s u r e ( C S F l e a k ) ; t i c r i ma r y a n d me t a s t a t i c b r a i n Neopl as p t u mo r s , t u mo r s i n t h e s i n u s e s , p i t u i t a r y Neur ol s ; c g r a i n e , c l u s t e r t u mo r ogi mi h e a d a c h e , p a r o xy s ma l h e mi c r a n i a , t r i g e mi n a l n e u r a l g i a , o c c i p i t a l n e u r a l g i a ; Ps y c hos oc i al t r e s s Vas c ul armi g r a i n e , i n t r a c r a n i a l a n e u r y s m, h e mo r r h a g e s ; ( i n t r a c e r e b r a l , s u b d u r a l , e p i d u r a l , a n d s u b a r a c h n o i d ) , v e n o u s s i n u s t h r o mb o s i s , stoke, cerebral vasculitis.

H i s t o r y :In q u i r e c a r e f u l l y f o r t h e a t t r i b u t e s o f p a i n (PrQ RocT ) :i v e and P ov S at Pal l i at i v e Fac t or s u ma , me d i c a t i o n s , s u b s t a n c e a b u s e , p o s i t i o n o f t h e h e a d a n d tra b o d y, c o u g h i n g , s t r a i n i n g , e mo t i o n a l t e n s i o n , r e l i e f w i t h ma s s a g e , a n d r e s o l u t i o n w i s l e e p ;Qual i t yw h e t h e r b u r n i n g , a c h i n g , d e e p o r s u p e r f i c i a l , l a n c i n a t i n g , t h r o b b i n g , o r continuous; Regi on I nv ol v ed a n i a l , f a c i a l , o r b i t a l , u n i l a t e r a l , bSevt er iat ly; s e cr ila er u t h e 1 1 0 s c a l e ; aTi d ngw h e n h e a d a c h e s b e g a n , f r e q u e n c y, t i me o f d a y, n mi d u r a t i o n , p a t t e r n o f i n t e n s i t y. In q u i r e a b o u t f a mi l y me mb e r s w i t h a h e a d a c h e h i s t o r y Id e n t i f y a s s o c i a t e d s y mp t o ms , f o r e xa mp l e , f e v e r, s t i f f n e c k , n a u s e a a n d v o mi t i n g , constipation or diarrhea, diuresis, rhinorrhea, visual disturbances (e.g., photophobi s c o t o ma t a , t e a r i n g , d i p l o p i a ) , c e r e b r a l s y mp t o ms ( e . g . , c o n f u s i o n , s l u r r e d s p e e c h , a u r a , p a r e s t h e s i a s , a n e s t h e s i a s , mo t o r p a r a l y s i s , v e r t i g o , mo o d , a n d s l e e p d i s t u r b a n c e sP .h y s i c a l E x a m : s p e c t t h e s k i n a n d s c a l p f o r b u l g e s a n d a r e a s o f ) In e r y t h e ma . W i t h d e e p p r e s s u r e p a l p a t e a n d p e r c u s s t h e b o n e s o f t h e c r a n i u m a n d f a c e f o r t e n d e r n e s s a n d i r r e g u l a r i t i e s o f c o n t o u r. P a l p a t e t h e n e c k mu s c l e s a n d t h e u p p e r b o r d e r s o f t h e t r a p e zi i f o r u n u s u a l t e n d e r n e s s . P a l p a t e t h e c a r o t i d a n d t e mp o r a l a r t e r i e s f o r p u l s a t i o n s a n d t e n d e r n e s s . E xa mi n e t h e e y e s f o r p u p i l l a r y irregularities, P. 8 5 2 c o n j u n c t i v a l i n j e c t i o n o r a b n o r ma l e xt r a o c u l a r mo t i o n ; u s e t h e c o n f r o n t a t i o n t e s t ( p a g e 2 1 3 ) t o d e t e c t g r o s s d e f e c t s i n t h e v i s u a l f i e l d s . E xa mi n e t h e f u n d u s f o r c h o k e d d i s k s a n d r e t i n a l h e mo r r h a g e s . Au s c u l t a t e t h e c r a n i u m f o r b r u i t s . P e r f o r m a t h o r o u g h n e u r o l o g i c e xa mi n a t i o n w i t h s p e c i a l a t t e n t i o n t o t h e c r a n i a l n e r v e s a n d t h e d e e p t e n d o n r e f l e xe s .

M u s c u l a r C o n t r a c t i o n He a d a c h e : Te n s i o n - Ty p e He a d a c h e : P a t h o p h y s i o l o g S : s t a i n e d c o n t r a c t i o n o f t h e n e c k , h e a d , a n d s h o u l d e r mu s c l e s yu c a u s e s f a t i g u e a n d p a i h r o n i c i n t e r mi t t e n t h e a d a c h e s o c c u r i n t h e o c c i p u t a n d . Cn t e mp o r a l r e g i o n s , o f t e n w i t h t e n d e r n e s s i n t h e n e c k a n d t r a p e zi i . U s u a l l y t h e p a i n h a s r e c u r r e d i r r e g u l a r l y f o r ma n y y e a r s , w i t h o u t p e r i o d i c i t y. T h e s e n s a t i o n i s d e s c r i b e d a s mi l d o r mo d e r a t e d i s c o mf o r t , v i s e - l i k e , a h e a v y f e e l i n g , a s e n s e o f p r e s s u r e , a t i g h t b a n d , c r a mp i n g , a c h i n g , o r s o r e n e s s ; i t i s s t e a d y r a t h e r t h a n t h r o b b i n g . T h e p a i n i s n o t a u g me n t e d b y c o u g h i n g , s t r a i n i n g a t s t o o l , o r s h a k i n g t h e h e a d . It u s u a l l y b e g i n s i n t h e o c c i p u t a n d e xt e n d s u p w a r d t o t h e t e mp o r a l r e g i o n s a n d d o w n t h e n a p e o f t h e n e c k t o t h e s h o u l d e r s . It ma y l a s t f o r a f e w h o u r s , w i t h i n t e n s i f i c a t i o n n e a r t h e d a y ' s e n d ; o r i t ma y p e r s i s t f o r ma n y d a y s , w a xi n g a n d w a n i n g t h r o u g h o u t . T h e o n s e t o f a n e p i s o d e i s o f t e n r e l a t e d t o e mo t i o n a l t e n s i o n o r t o o c c u p a t i o n a l a c t i v i t y. T h e p a i n i s r e l i e v e d b y e xt e r n a l s u p p o r t o f t h e h e a d , t h e a p p l i c a t i o n o f h o t p a c k s o r ma s s a g e t o t h e n e c k a n d mi l d Phy sl igce s i c s . a n a al


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Si gns Te n d e r n e s s ma y b e f o u n d i n t h e u p p e r b o r d e r o f t h e t r a p e zi i o r t h e i n t r i n s i c . n e c k mu s c l e s .D X: T h e s y mp t o ms a n d s i g n s a r e c h a r a c t e r i s t i c . Te n s i o n - t y p e D headaches are the only type not intensified by coughing or straining at stool; they a r e a l s o t h e o n l y t y p e a me l i o r a t e d b y s h a k i n g t h e h e a d . It c o mmo n t o h a v e f e a t u r e s o f b o t h t e n s i o n t y p e a n d mi g r a i n e h e a d a c h e .
P. 8 5 3 P. 8 5 4

M igr aine: P a t h o p h y s i o l o g T : e e xa c t p a t h o g e n e s i s o f mi g r a i n e i s u n c e r t a i n , b u t g e n e t i c yh f a c t o r s a r e i mp o r t a n t . S o me p a t t e r n s h a v e a d e f i n e d g e n e t i c b a s i s , f o r e xa mp l e , 5 0 % o f p a t i e n t s w i t h f a mi l i a l h e mi p l e g i c mi g r a i n e h a v e a n i d e n t i f i e d g e n e t i c a b n o r ma l i t y. Spreading cortical neurologic depression is characteristic, perhaps initiated in the t r i g e mi n a l p r o j e c t i o n s y s t e m o f t h e b r a i n s t e m. Va s c u l a r c o n s t r i c t i o n a n d d i l a t i o n o c c u r i n ma n y, b u t n o t a l l p a t i e n t s ; c o n s t r i c t i o n c a n r a r e l y l e a d t o i s c h e mi c c e r e b r a e v e n t s . R e l e a s e o f s u b s t a n c e P a n d n e u r o g e n i c i n f l a mma t i o n ma y p l a y a r o l e . S e r o t o n i n , d o p a mi n e , a n d n o r a d r e n a l i n e a r e a l l i mp o r t a n t i n t h e mi g r a i n o u s p r o c e s s a n d t h e i r r e c e p t o r b l o c k e r s a r e u s e d i n t.r e a timei n t h e r i t a b l e d i s o r d e r w i t h Th s s p e r i o d i c u n i l a t e r a l h e a d a c h e f r e q u e n t l y p r e c e d e d bc l as s ac rmi gr ai)ne y an i u a ( . G e n e r a l i ze d t h r o b b i n g h e a d a c h e a s s o c i a t e d w i t h n a u s e a , l i g h t a n d s o u n d s e n s i t i v i t y i s e v e n mo r e c o mmo n . T h e p r e v a l e n c e o f mi g r a i n e i s e s t i ma t e d t o b e 2 5 % ( mo r e c o mmo n i n w o me n t h a n i n me n ) i n t h e U n i t e d S t a t e s . P a t i e n t s w i t h mi g r a i n e h a v e a n i n c r e a s e d i n c i d e n c e o f R a y n a u d p h e n o me n o n . O n s e t i s u s u a l l y i n a d o l e s c e n c e , b u t ma y o c c u r a t a n y a g e ; ma n y h a v e e xp e r i e n c e d mo t i o n s i c k n e s s i n c h i l d h o o d . T h e a t t a c k s o c c u r f r o m a f e w t i me s a y e a r t o s e v e r a l t i me s p e r w e e k . P e r i o d s o f f r e q u e n h e a d a c h e a t t a c k s ma y b e s e p a r a t e d b y p e r i o d s o f n o n e o r f e w a t t a c k s . O f t e n , mi g r a i n e i s c o i n c i d e n t w i t h s o me p h a s e o f t h e me n s t r u a l c y c l e . T h e c l i n i c a l p a t t e r n v a r i e s s o mu c h a mo n g i n d i v i d u a l s t h a t e a c h i n d i v i d u a l mu s t b e c o n s i d e r e d s e p a r a t e l y. P e r s o n s w i t h r e c u r r e n t s i c k o r s i n u s h e a d a c h e s , w i t h o u t d e f i n i t e d o c u me n t a t i o n o f i n f e c t i o n , mo s t l i k e l y h a v e G og rd s n e P J , L i p t o n R B , mi a a i b y [ F e r r a r i M D . M i g r a i n e C u r r e n t u n d e r s t a n d i n g a n d tN eEngl n t .M ed r a t me J 2 0 0 2 ; 3 4 6 : 2 5 7 2; 7 0a d y R , D o d i c k D W. D i a g n o s i s a n d t r e a t me n t o f M ayro i n e . C mi g a Cl i n Pr oc 0 0 2 ; 7 7 : 2 5 5 2 6 1 2 ]. M I G RAI NE WI T H AURA: C L AS S I C M I G RAI NE : T h e p a r o xy s m o f c l a s s i c mi g r a i n e h a s f o u r T h e s e s .d r o m e : a t t a c k i s pha Pro An o f t e n t r i g g e r e d b y a p e r i o d o f a n xi e t y, t e n s i o n , o r s l u g g i s h n e s s . O t h e r t r i g g e r s i n c l u d e b r i g h t l i g h t s , l o u d n o i s e , s t r o n g o d o r s , s k i p p e d me a l s , v a r i o u s f o o d s a n d beverages, and changes in sleep patterns. A day or so before the attack, the patien ma y f e e l d e p r e s s e d o r f e e l a s e n s e o f u n u s u a l w e l l - b e i n g ; o c c a s i o n a l l y, h u n g e r i s n o t e d .T h e A u r a : i g r a i n o u s p h e n o me n a a r e t y p i c a l l y u n i l a t e r a l , b u t a r e M o c c a s i o n a l l y b i l a t e r a l ; t h e s i d e ma y v a r y i n d i f f e r e n t a t t a c k s . P a t i e n t s t e n d t o r e p e a t h e i r d i s t i n c t i v e a u r a i n s u c c e s s i v e a t ts uals .Di s t ur banc es :c i nt i l l at i ng Vi a c k As s c ot oma u s u a l l y i n v o l v i n g b o t h e y e s , p r e s e n t s a s f l a s h i n g l i g h t s ; s o me t i me s t h e r e , a r e b l a c k a n d w h i t e w a v y l i n e s , l i k e t h e s h i mme r i n g ma d e b y h e a t w a v e s r i s i n g f r o m p a v e me n tFor t i f i c at i on s pecma y b e e xh i b i t e d , w i t h zi g za g c o l o r e d p a t t e r n s w i t h . tra d a r k c e n t e r s mo v i n g a c r o s s t h e v i s u a l f i e l d . D i s t i n c t p a t t e r n s o f t h e a u r a a r e a s s o c i a t e d w i t h mi g r a i n e v a r i a n t s y n d r o me s ( s iece M i gr ai ne Var i antls w ) . Cl as be o
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Ot her Neur ol ogi c Ev ent e : r o l o g i c s y mp t o ms o c c u r r i n g d u r i n g t h e a u r a d e f i n e N su s p e c i a l mi g r a i n e s y n d r o me s d i s c u s s e dTb e l o w. a d a c h e : h e a t t a c k ma y b e g i n he He T a n y t i me o f t h e d a y o r n i g h t ; t h e h e a d a c h e i s f r e q u e n t l y p r e s e n t o n a w a k e n i n g . S o m p a t i e n t s h a v e a t y p i c a l a u r a w i t h o u t s u c c e e d i n g h e a d a c h e . U s u a l l y, a s t h e a u r a d i mi n i s h e s , u n i l a t e r a l h e a d a c h e a p p e a r s o n t h e s i d e o p p o s i t e t o u n i l a t e r a l v i s u a l o r s o ma t o s e n s o r y s y mp t o ms d u r i n g t h e a u r a . T h e p a i n ma y s t a r t a b o v e o n e o r b i t a n d s p r e a d o v e r t h e e n t i r e s i d e o f t h e h e a d t o t h e o c c i p u t a n d n e c k , o r i t ma y b e g i n i n t h e b a c k o f t h e h e a d a n d mo v e f o r w a r d . R a r e l y, t h e s i t e o f p a i n i s b e l o w t h e e y e , i n f r o n t o f t h e e a r, b e h i n d t h e ma n d i b u l a r a n g l e , i n t h e n a p e o f t h e n e c k , o r i n t h e shoulders. T he pain spreads and intensifies to a severe throbbing, boring, aching h e a d a c h e o v e r a b o u t a n h o u r. C o n s t a n t n o n t h r o b b i n g p a i n o c c u r s i n 5 0 % o f p a t i e n t s . T h e p a i n i s o f t e n a u g me n t e d i n t h e r e c l i n i n g p o s i t i o n , l e s s e n e d w h e n s i t t i n or standing. Shaking the head, coughing, or straining at stool intensifies the pain. Al t h o u g h t h e p a i n ma y b e s e v e r e , i t u s u a l l y d o e s n o t d i s r u p t s l e e p ; i n f a c t , t h e h e a d a c h e i s u s u a l l y l e s s e n e d b y l y i n g i n a d a r k , q u i e t r o o m. N a u s e a a n d , l e s s c o mmo n l y, v o mi t i n g o f t e n a c c o mp a n y t h e h e a d a c h e . P h o t o p h o b i a , p h o n o p h o b i a , a n d a n n o y a n c e f r o m o d ohy per os mi) aa r e c o mmo n d u r i n g t h e h e a d Phy e . c al rs ( ach si Si gns Dur i ng HeadacT h e p a t i e n t ma y a p p e a r n o r ma l o r b e i n c a p a c i t a t e d w i t h he: c o l d l i mb s a n d p a l e s k i n . T h e d u r a t i o n o f t h e p a r o xy s m i s u s u a l l y f r o m 2 t o 6 h o u r s a n d i s r e l i e v e d b y s l e e p . R e c o ve r y : h e n a n a t t a c k t e r mi n a t e s w i t h s l e e p , t h e The W p a t i e n t a w a k e n s w i t h o u t h e a d a c h e a n d e xp e r i e n c e s a s e n s e o f b u o y a n c y a n d w e l l b e i n g .D D X: T h e d i a g n o s i s i s e a s y i n a l o n g - e s t a b l i s h e d c a s e w i t h r e l a t i v e l y t y p i c a l s y mp t o ms . W h e n t h e o n s e t i s r e c e n t a n d t h e s y mp t o ms u n u s u a l , o t h e r i n t r a c r a n i a l d i s o r d e r s mu s t b e e xc l u d e d . O p h t h a l mo p l e g i c mi g r a i n e c a n s i mu l a t e a l e a k i n g a n e u r y s m i n t h e c i r c l e o f W i l l i s . Al t h o u g h h e mi p l e g i a c a n b e a mi g r a i n o u s p h e n o me n o n , mo r e s e r i o u s c a u s e s s h o u l d b e s o u g h t .

C l a s s i c M i g r a i n e Va r i a n t s : T h e s e v a r i a n t f o r ms o f c l a s s i c mi g r a i n e a r e d i s t i n g u i s h e d b y t h e p a r t i c u l a r p a t t e r n o the aura. Ophthalmic M igr aine: T h e s c o t o ma t a ma y b e s u c c e e d e d b y mo me n t a r y banops i s s , t h e e n t i r e l i n d n e ,a i n f i e l d , o r i n t h e l o w e r o r u p p e r q u a d r a n t s ; o r t h e p a t t e r n ma y b e b i t e mp o r a l o r h o mo n y mo u s h e mi a n o p s i a . Ophthalmoplegic M igr aine: T r a n s i e n t u n i l a t e r a l p a r a l y s i s o f C N - III ( o c u l o mo t o r ) p r o d u c e s l a t e r a l d e v i a t i o n a n d ptosis. T his occurs in young girls.

Dysphagic M igr aine: U n i l a t e r a l p a r e s t h e s i a s o r a n e s t h e s i a s ma y o c c u r i n t h e f a c e , t h e a r m, o r t h e f o o t . W h e n t h e r i g h t s i d e i s i n v o l v e d , e xp r e s s i v e d y s p h a s i a a n d h o mo n y mo u s h e mi a n o p s i ma y b e p r e s e n t . B a s i l a r Ar t e r y M i g r a i n e : T h e s c o t o ma t a a n d a n e s t h e s i a s o f t h e f a c e a n d l i mb s a r e b i l a t e r a l , a n d v e r t i g o o r c r a n i a l n e r v e p a l s i e s ma y b e p r e s e n t f r o m b r a i n s t e m n u c l e a r i s c h e mi a . T h e t r a n s i t i o f r o m a u r a t o h e a d a c h e ma y b e a c c o mp a n i e d b y mo me n t a r y l o s s o f c o n s c i o u s n e s s o r light sleep. He m i p l e g i c M i g r a i n e :


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T h i s i s s p e c t a c u l a r b u t r a r e . T h e p a r a l y s i s i s mo s t l i k e l y t o o c c u r i n mi g r a i n o u s p a t i e n t s e xp e r i e n c i n g p a r e s t h e s i a s . T h e r i g h t s i d e i s mo r e o f t e n i n v o l v e d . T h e p a t i e n t c o mp l a i n s o f n u mb n e s s o r w o o d e n n e s s o f t h e a f f e c t e d l i mb s . Al t h o u g h w e a k n e s s ma y b e t h e c o mp l a i n t , i t ma y o n l y b e ma n i f e s t b y e xa g g e r a t i o n o f t h e d e e t e n d o n r e f l e xe s a n d B a b i n s k i s i g n . T h e p a r a l y s i s l a s t s f o r 1 0 4 0 mi n u t e s , b u t ma y p e r s i s t f o r 2 3 d a y s ; u s u a l l y t h e r e a r e n o p e r ma n e n t s e q u e l a e . M a n y n e u r o l o g i s t s a r e r e l u c t a n t t o ma k e t h i s d i a g n o s i s w i t h o u t e xc l u d i n g mo r e s e r i o u s a n d i r r e v e r s i b l e d i s o r d e r s . T h e d i a g n o s i s i s s t r o n g l y s u p p o r t e d b y a f a mi l y h i s t o r y o f h e mi p l e g i c mi g r a i n e .

M I G RAI NE WI T HO UT AURA: C O M M O N M I G RAI NE : T h e o n s e t i s s l o w e r t h a n c l a s s i c mi g r a i n e a n d t h e d u r a t i o n i s o f t e n l o n g e r, 4 7 2 h o u r s . It ma y p e r s i s t t h r o u g h s l e e p . T h e h e a d a c h e i s u n i l a t e r a l o r b i l a t e r a l . In o t h e r e s p e c t s , c o mmo n a n d c l a s s i c mi g r a i n e a r e s i mi l a r.

P. 8 5 5 C l u s t e r He a d a c h e : Hi s t a m i n e He a d a c h e , Hi s t a m i n e C e p h a l g i a : P a t h o p h y s i o l o gT : e h e a d a c h e i s p r o d u c e d b y d i l a t a t i o n o f b r a n c h e s o f t h e yh i n t e r n a l c a r o t i d a r t e r y, e s p e c i a l l y t h o s e s u p p l y i n g t h e me n i n g e s i n n e r v a t e d b y t h e t r i g e mi n a l n e r v e . Al t h o u g h t h e s y n d r o me c a n b e s i mu l a t e d b y t h e i n j e c t i o n o f h i s t a mi n e i n t o t h e i n t e r n a l c a r o t i d a r t e r y, t h e r e i s n o c o n c l u s i v e e v i d e n c e t h a t h i s t a mi n e p l a y s a r o l e i n t h e n a t u r a l .d iT h irsd es f i v e t o s i x t i me s mo r e c o mmo n so i r i n me n ; o n s e t i s t y p i c a l l y i n t h e t h i r d t o f o u r t h d e c a d e s o f l i f e . A f a mi l y h i s t o r y o f mi g r a i n e o r c l u s t e r h e a d a c h e s i s n o t u n c o mmo n . C l u s t e r h e a d a c h e a r e mo s t c o mmo n l y e p i s o d i c ( o c c u r r i n g s e v e r a l t i me s a d a y o r w e e k f o r s e v e r a l w e e k s , w i t h l o n g i n t e r mi s s i o n s b e t w e e n e p i s o d e s ) , b u t ma y b e c h r o n i c ( h e a d a c h e s p e r s i s t i n g f o mo r e t h a n a y e a r w i t h o u t i n t e r mi s s i o n ) . T h e h e a d a c h e b e g i n s w i t h o u t a u r a a n d l a s t s 1 5 1 2 0 mi n u t e s ( a v e r a g e 4 0 mi n u t e s ) . It i s u n i l a t e r a l , s e v e r e , b o r i n g , a n d t h r o b b i n g It r e c u r s c o n s i s t e n t l y o n t h e s a me s i d e . It i s u s u a l l y ma xi ma l j u s t i n f e r i o r t o t h e me d i a l c a n t h u s o f t h e o r b i t , b u t ma y o c c u r i n t h e t e mp l e o r i n t h e s i d e o f t h e f a c e , a n d i t ma y s p r e a d t o t h e n e c k a n d s h o u l d e r. F l u s h i n g , e d e ma a n d s w e a t i n g o f t h e s k i n , l a c r i ma t i o n , c o n j u n c t i v a l i n j e c t i o n , n a s a l c o n g e s t i o n , r h i n o r r h e a , p a r t i a l H o r n e s y n d r o me , a n d t e mp o r a l a r t e r y d i l a t a t i o n ma y o c c u r o n t h e aDf D c t e d s i d e . f e X: P a r o xy s ma l h e mi c r a n i a i s b r i e f e r a n d mo r e c o mmo n i n w o me n ; i n R a e d e r s y n d r o me , the pain is identical in quality but is persistent without discreet attacks.

P a r o x y s m a l He m i c r a n i a : T h e c a u s e i s u n k n o w n ; w o me n a r e mo r e c o mmo n l y a f f e c t e d t h a n me n . It i s mo r e often chronic than episodic. T he headache is indistinguishable from cluster headache, but the pattern is distinct. Headaches are short, lasting on average 15 mi n u t e s , mo r e f r e q u e n t , u p t o 4 0 t i me s p e r d a y, a n d u n i f o r ml y a b o l i s h e d b y i n d o me t h a c i n .
P. 8 5 6 C h r o n i c D a i l y He a d a c h e : T r a n s f o r m e d M i g r a i n e , Re b o u n d He a d a c h e : P a t h o p h y s i o l o g R:e g u l a r d a i l y u s e o f mi l d a n d / o r o p i a t e a n a l g e s i c s l e a d s t o y r e b o u n d h e a d a c h e s w h e n t h e p a t i e n t g o e s w i t h o u t t h e me d i c a t i o n f o r a f e w h o u r s . O f t e n t h e s e a r e p a t i e n t s w i t h a h i s t o r y o f t e n s i o n - t y p e o r mi g r a i n e h e a d a c h e w h o h a v e d e v e l o p e d d a i l y p e r s i s t e n t h e a d a c h e r e l i e v e d o n l y t e mp o r a r i l y b y me d i c a t i o n .
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history of regular daily use of prescription or over-the-counter analgesics and the absence of aura, neurologic findings, or other causes of headache are the keys to d i a g n o s i s . O v e r u s e o f c a f f e i n e i n mi g r a i n e u r s w i l l a l s o p r e c i p i t a t e c h r o n i c d a i l y, r e b o u n d h e a d a c h e s . T h e t r e a t me n t i s c o mp l e t e a b s t i n e n c e f r o m a n a l g e s i c s f o r 2 w e e k s . M i g r a i n e u r s s h o u l d n o t u s e a n a l g e s i c s mo r e t h a n 2 d a y s a w e e k . If t h i s proves inadequate, prophylactic therapy should be instituted.

I c e C r e a m He a d a c h e : S e e C h a p t e r ,7p a g e 3 1 7 . Hy p e r t e n s i v e He a d a c h e : P a t h o p h y s i o l o g T : e e v i d e n c e p o i n t s t o s e g me n t a l d i l a t a t i o n o f b r a n c h e s o f t h e yh e xt e r n a l c a r o t i d a r t e r y. D i g i t a l c o mp r e s s i o n a b o l i s h e s t h e h e a d a c h e w h e n a p p l i e d t o t h e e xt e r n a l c a r o t i d , f r o n t a l , s u p r a o r b i t a l , p o s t a u r i c u l a r, o r o c.c iIn i t a l a r t e r i e s p p a t i e n t s w i t h mi l d h y p e r t e n s i o n , t h e i n c i d e n c e a n d t y p e s o f h e a d a c h e a r e n o d i f f e r e n t t h a n i n n o r mo t e n s i v e p e r s o n s . H e a d a c h e o c c u r s i n h a l f t h e p a t i e n t s w i t h a c c e l e r a t e d h y p e r t e n s i o n w i t h o u t e n c e p h a l o p a t h y. T h e d i a s t o l i c p r e s s u r e mu s t e xc e e d 1 2 0 mmH g t o c a u s e h e a d a c h e . T h e h e a d a c h e s a r e o f t e n o c c i p i t a l , a l t h o u g h o t h e r r e g i o n s ma y b e i n v o l v e d . T h e y a r e n o t n e c e s s a r i l y u n i l a t e r a l a n d t h e r e i s n o aura. He a d a c h e f r o m F e v e r : S e e C h a p t e r ,4p a g e 6 1 . He a d a c h e : G i a n t C e l l Ar t e r i t i s , Te m p o r a l Ar t e r i t i s : S e e C h a p t e r ,8p a g e 4 7 1 . He a d a c h e : O c c i p i t a l Ne u r i t i s : S e e p a g e 3 1.7

P. 8 5 7 He a d a c h e : T r a c t i o n , D i s p l a c e m e n t , I n f l a m m a t i o n C a u s i n g I n t r a c r a n i a l He a d a c h e s : P a t h o p h y s i o l o gT : e p a i n - s e n s i t i v e i n t r a c r a n i a l s t r u c t u r e s a r e t h e d u r a a n d t h e yh a r t e r i e s a t t h e b a s e o f t h e b r a i n , t h e c e r e b r a l a r t e r i e s i n t h e s a me r e g i o n , t h e g r e a t v e n o u s s i n u s e s , a n d c e r t a i n n e r v e s ( C N - V, - IX, - X, a n d C 1 3 ) . T h e g r e a t e r p o r t i o n o t h e d u r a a n d c r a n i u m i s i n s e n s i t i v e . M e c h a n i s ms p r o d u c i n g h e a d a c h e s f r o m intracranial disorders include (a) traction on the superficial cerebral veins and v e n o u s s i n u s e s , ( b ) t r a c t i o n o n t h e mi d d l e me n i n g e a l a r t e r i e s , ( c ) t r a c t i o n o n t h e basilar arteries and their branches, (d) distention and dilatation of the intracranial a r t e r i e s , ( e ) i n f l a mma t i o n n e a r a n y p a i n - s e n s i t i v e r e g i o n , a n d ( f ) d i r e c t p r e s s u r e o r t r a c t i o n b y t u mo r s o n c r a n i a l a n d c e r v i c a l Tn e r v e s u l t i n g h e a d a c h e s ma y b e . he r t h r o b b i n g w h e n a r t e r i e s a r e i n v o l v e d ; o t h e r w i s e t h e p a i n i s s t e a d y. H e a d a c h e s a r e o f t e n i n t e n s i f i e d b y mo v e me n t s o f t h e h e a d , c e r t a i n p o s t u r e s , a n d r a p i d c h a n g e s i n cerebrospinal fluid pressure.

T RAC T I O N- D I S P L AC E M E NT: B RAI N T UM O R: P a t h o p h y s i o l o g B : n i g n a n d ma l i g n a n t i n t r a c r a n i a l n e o p l a s ms c o mp r e s s a n d p l a c e ye t r a c t i o n o n s u r r o u n d i n g s t r u .c tH ee s a c h e ma y b e t h e f i r s t s y mp t o m. It c a n b e ur ad i n t e r mi t t e n t o r c o n s t a n t . T h e p a i n ma y b e mi l d o r e xc r u c i a t i n g a n d o c c u r a n y w h e r e i t h e c r a n i u m. T h e h e a d a c h e s a r e n o t c h a r a c t e r i s t i c o f a n y d e f i n e d h e a d a c h e


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s y n d r o me . A s y mp t o m t h a t o c c u r s w i t h i n c r e a s e d i n t r a c r a n i pulp re s s u r e , al s e s y nc hr onous t i nni, t use n t i f i e s t h e h e a d a c h e a s c a u s e d b y r a i s e d i n t r a c r a n i a l id p r e s s u r eD D X: B r a i n t u mo r s h o u l d b e s u s p e c t e d w h e n e v e r t h e o n s e t i s r e c e n t , a . r e c e n t c h a n g e i n t h e c u s t o ma r y h e a d a c h e p a t t e r n h a s o c c u r r e d , o r a n a p p a r e n t mi g r a i n e a u r a p e r s i s t s a f t e r t h e h e a d a c h e s u b s i d e s .

T RAC T I O N- D I S P L AC E M E NT: B RAI N AB S C E S S : P a t h o p h y s i o l o gA :l o c a l i ze d r e g i o n i n t h e b r a i n p a r e n c h y ma b e c o me s i n f e c t e d a n d y e n c a p s u l a t e d , e n c l o s i n g l i q u e f i e d b r a i n a n d p u s . In f e c t i o n i s e i t h e r h e ma t o g e n o u s o f r o m l o c a l e xt e n s i o n mp t o ms a n d s i g n s o f b r a i n ma s s a p p e a r c o i n c i d e n t w i t h o r . Sy a f t e r i n f e c t i o n i n t h e e a r s , p a r a n a s a l s i n u s e s , l u n g s o r, r a r e l y, o s t e o my e l i t i s o r o t h e s o u r c e . W h e n t h e p r i ma r y i n f e c t i o n h a s n o t b e e n r e c o g n i ze d , t h e d i s t i n c t i o n f r o m b r a i n t u mo r ma y n o t b e e v i d e n t u n t i l i ma g i n g i s o b t a i n e d . L e s s t h a n h a l f t h e p a t i e n t w i t h b r a i n a b s c e s s e xh i b i t t h e c l a s s i c t r i a d o f f e v e r, h e a d a c h e , a n d f o c a l d e f i c i t . B RAI N AB S C E S S C L I NI C AL O C C URRE NC E : Di r ec t Ex t ens i ono m o t i t i s o r s i n u sHemat ogenousn e u mo n i a , e n d o c a r d i t i s fr itis; p ( e s p e c i a l lSt aphy l oc oc c us aur)euss t e o my e l i t i s , o t h e r b a c t e r e mi a s ( p a t i e n t s w i t h y , o cyanotic congenital heart disease and right-to-left shunts are particularly s u s c e p t i b l e ) , t o xo p l a s mo s i s i n H IV- i n f e c t e d Penetn at ; ng Tr aumat e r patie r tsi af n e u r o s u r g e r y, g u n s h o t w o u n d s , o p e n s k u l l f r a c t u r e s .

T RAC T I O N- D I S P L AC E M E NT: S UB D URAL HE M AT O M A: P a t h o p h y s i o l o g T : a u ma l e a d s t o t e a r i n g o f t h e s ma l l e r v e i n s b e t w e e n t h e yr f i xe d d u r a a n d t h e mo b i l e a r a c h n o i d a n d b r a i n , p r o d u c i n g l o w - p r e s s u r e b l e e d i n g a n d s l o w l y a c c u mu l a t i n g h e ma.t o ma t o ms a n d s i g n s o f e xp a n d i n g i n t r a c r a n i a l ma s s S y mp o c c u r s o me t i me f o l l o w i n g h e a d t r a u ma . Af t e r a s e v e r e h e a d i n j u r y, t h e i mme d i a t e a c c u mu l a t i o n o f b l o o d i n t h e s u b d u r a l s p a c e i s n o t u n e xp e c t e d a n d o f f e r s n o d i a g n o s t i c d i f f i c u l t y. H o w e v e r, mi n o r h e a d t r a u ma ma y b e f o l l o w e d b y a l a t e n t p e r i o o f d a y s , w e e k s , o r mo n t h s b e f o r e t h e o n s e t o f h e a d a c h e s o r o t h e r n e u r o l o g i c s y mp t o ms . T h e p r o g r e s s i o n , t i mi n g , a n d a t t r i b u t e s o f t h e p a i n a r e s i mi l a r t o t h o s e o a b r a i n t u mo r w i t h r e l a t i v e l y r a p i d e xp a n s i o n . O f t e n n o p h y s i c a l s i g n s a r e p r e s e n t i n i t i a l l y ; l a t e r, l o c a l i zi n g s i g n s o f a n e xp a n d i n g i n t r a c r a n i a l ma s s b e c o me e v i d e n t . D r o w s i n e s s , me n t a l c o n f u s i o n , o r c o ma ma y a p p e a r w i t h o u t h e a d a c h e o r o t h e r s i g n s e s p e c i a l l y w i t h b i l a t e r a l f r o n t a l s u b d u r a l s . T h e d i a g n o s i s i s c o n f i r me d b y C T o r M R I i ma g i n g .

T RAC T I O N- D I S P L AC E M E NT: I NT RAC E RE B RAL HE M O RRHAG E : P a t h o p h y s i o l o g T : e me c h a n i s m o f a r t e r i a l r u p t u r e i n h y p e r t e n s i o n i s yh unknown; bleeding is usually from deep striatal vessels. T he site is usually i n t r a c e r e b r a l ; r a r e l y i s i t s u b a r a c h n o i d . C e r e b r a l a my l o i d a n g i o p a t h y w e a k e n s v e s s e w a l l s ; i t i s a s s o c i a t e d w i t h i n t r a c e r e b r a l h e mo r r h a g e w i t h o u t p r e c e d i n g h y p e r t e n s i o . In a b o u t h a l f t h e p a t i e n t s , t h e o n s e t i s ma r k e d b y a s u d d e n , s e v e r e , g e n e r a l i ze d h e a d a c h e , f o l l o w e d b y r a p i d l y e v o l v i n g n e u r o l o g i c s i g n s . F r e q u e n t l y, t h e p a t i e n t v o mi t s ; o f t e n , t h e r e i s n u c h a l r i g i d i t y. S e i zu r e s a n d / o r c o ma ma y s u p e r v e n e . T h e s e q u e n c e o f e v e n t s a n d t h e n e u r o l o g i c ma n i f e s t a t i o n s v a r y w i t h t h e s i t e a n d v o l u me o f h e mo r r h a g Put amen: s e n s a t i o n o f i n t r a c r a n i a l d i s c o mf o r t i s f o l l o w e d i n 3 0 e. A mi n u t e s b y d y s p h a g i a , h e mi p l e g i a , a n d s o me t i me s a nThal amus :. esthesias H e mi p l e g i a a n d h e mi a n e s t h e s i a s w i t h d y s p h a s i a , h o mo n y mo u s h e mi a n o p s i a , a n d
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e xt r a o c u l a r p a r a l y s e s a r e c o mmo ebel l um: l o w l y d e v e l o p i n g , w i t h r e p e a t e d Cer n . S v o mi t i n g , o c c i p i t a l h e a d a c h e s , v e r t i g o , p a r a l y s i s o f c o n j u g a t e l a t e r a l g a ze , a n d o t h e o c u l a r d i s o r d e r s . :P r o mp t u n c o n s c i o u s n e s s a n d d e a t h w i t h i n a f e w h o u r s . Pons

I NT RAC E RE B RAL HE M O RRHAG E C L I NI C AL O C C URRE NC E : H y p e r t e n s i o n , a n e u r y s m ( t r a u ma t i c , i n f l a mma t o r y, s a c c u l a r o r my c o t i c ) , a n g i o ma s , c e r e b r a l a my l o i d a n g i o p a t h y, e r o s i o n f r o m n e o p l a s m, c o mp l i c a t i n g c e r e b r a l i n f a r c t i o ( e mb o l i s m, t h r o mb o s i s ) , h e mo r r h a g i c d i s o r d e r s , a n d c o a g u l a t i o n d e f e c t s .


P. 8 5 8

T RAC T I O N- D I S P L AC E M E NT: S UB ARAC HNO I D HE M O RRHAG E : P a t h o p h y s i o l o g S : b a r a c h n o i d h e mo r r h a g e u s u a l l y r e s u l t s f r o m r u p t u r e o f a yu saccular (berry) aneurysm of the circle of Willis. Often, rupture is preceded by l e a k a g e , i n c o n t r a s t t o t h e r u p t u r e o f a n a r t e r y f r o m h yN e wt e n ssi e tn .o f p r on o s e v e r e h e a d a c h e b e t w e e n a g e 1 4 a n d 5 0 s h o u l d s u g g e s t a r u p t u r e d a n e u r y s m; p r o mp t d i a g n o s i s a n d t h e r a p y ma y b e l i f e s a v i n g . C N - III s i g n s ma y b e s e e n a n d s h o u l d a l w a y s s u g g e s t a r u p t u r e d a n e u r y s m; s t i f f n e c k ma y b e p r e s e n t , b u t i t s a b s e n c e d o e s n o t e xc l u d e a r u p t u r e d a n e u r y s m. T h e p a t i e n t u s u a l l y r e p o r t s h a v i n g t h e w o r s t h e a d a c h e o f h i s l i f e . E xc r u c i a t i n g g e n e r a l i ze d h e a d a c h e ma y b e s u c c e e d e d b y n u c h a l r i g i d i t y, c o ma , a n d o f t e n d e a t h . T RAC T I O N- D I S P L AC E M E NT: L UM B AR P UNC T URE HE AD AC HE : P a t h o p h y s i o l o g C:S F i s l o s t t h r o u g h t h e p u n c t u r e h o l e i n t h e d u r a , d e c r e a s i n g t h e y C S F v o l u me . f e w h o u r s o r d a y s a f t e r a l u mb a r p u n c t u r e , t h e p a t i e n t d e v e l o p s a A constant or throbbing, usually bifrontal or suboccipital, deep headache. Moderate n e c k s t i f f n e s s ma y o c c u r. T h e p a i n i s i n t e n s i f i e d w h e n s t a n d i n g , s h a k i n g t h e h e a d , o r w i t h b i l a t e r a l j u g u l a r v e i n c o mp r e s s i o n . It i s l e s s e n e d b y t h e h o r i zo n t a l p o s t u r e a n d f l e xi o n o r e xt e n s i o n o f t h e n e c k . T RAC T I O N- D I S P L AC E M E NT: I D I O PAT HI C I NT RAC RANI AL HY P E RT E NS I O N:

S y mp t o ms r e s e mb l e t h o s e o f a b r a i n t u mo r. E l e v a t e d c e r e b r o s p i n a l f l u i d p r e s s u r e i s f o u n d , w i t h n o s t r u c t u r a l a b n o r ma l i t y. T h e t y p i c a l p a t i e n t i s a y o u n g o b e s e w o ma n w i t h r e c e n t r a p i d w e i g h t g a i n . F u n d u s c o p i c e xa m r e v e a l s p a p i l l e d e ma ; i f l o n g s t a n d i n g , t h e d i s k s ma y b e p a l e . T r a n s i e n t v i s u a l o b s e r v a t i o n s a r e c o mmo n . P r e v e n t i o n o f v i s u a l l o s s r e q u i r e s p r o mp t d i a g n o s i s a n d t h e r a p y. T h e h e a d a c h e i s mu c h l i k e c o mmo n mi g r a i n e e xc e p t t h a t i t i s o f t e n d a i l y. If p r e s e n t , p u l s e synchronous tinnitus identifies increased intracranial pressure.

I NF L AM M AT O RY: B AC T E RI AL M E NI NG I T I S : H e a d a c h e i s a p r o mi n e n t e a r l y s y mp t o m o f me n i n g i t i s . It i s g e n e r a l i ze d , t h r o b b i n g o r c o n s t a n t , a n d a c c o mp a n i e d b y f e v e r a n d s t i f f n e c k . B e c a u s e t h e me n i n g e s a r e i n f l a me d , t h e h e a d a c h e i s i n t e n s i f i e d b y s u d d e n mo v e me n t s o f t h e h e a d . T h e h e a d a c h e ma y b e a c c o mp a n i e d o r f o l l o w e d b y d r o w s i n e s s o r c o ma . S i g n s o f me n i n g e a l i r r i t a t i o n a r e n u c h a l r i g i d i t y a n d K e r n i g a n d B r u d zi n s k i s i g n s . Al t h o u g h ma n y f e b r i l e i l l n e s s e s a r e a c c o mp a n i e d b y s o me d e g r e e o f h e a d p a i n , t h e h e a d a c h e o f me n i n g i t i s i s e s p e c i a l l y s e v e r e . W h e n h e a d a c h e i s a s s o c i a t e d w i t h s t i f f n e c k , a l u mb a r p u n c t u r e i s i n d i c a t e id [ J , H a t a l a R , C o o k D J , W o n g J G . D o e s t h i s a d u l t At t a p a t i e n t h a v e a c u t e me n i n g i AM? 1 9 9 9 ; 2 8 2 : 1 7 5 1 8 1 J tis A ].


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P. 8 5 9

He a d a c h e P r e s e n t o n Aw a k e n i n g : H e a d a c h e s p r e s e n t o n a w a k e n i n g s h o u l d s u g g e s t mi g r a i n e , c a r b o n mo n o xi d e p o i s o n i n g , s l e e p a p n e a , a n d a n a l g e s i c r e b o u n d h e a d a c h e . Te n s i o n h e a d a c h e s a r e not present on first awakening. C ARB O N M O NO X I D E P O I S O NI NG : P a t h o p h y s i o l o g E : e s s i v e a mo u n t s o f c a r b o xy h e mo g l o b i n a r e f o r me d f r o m y xc i n h a l a t i o n o f c a r b o n mo n o xi d e g a s l e a d i n g t o d e c r e a s e d oT hgs n a t iu ln s xy i e r e s o t . f r o m i n h a l a t i o n o f p r o d u c t s o f c o mb u s t i o n i n p o o r l y v e n t i l a t e d s p a c e s , f o r e xa mp l e , c a r s w i t h ma l f u n c t i o n i n g e xh a u s t s y s t e ms , h o me s w i t h ma l f u n c t i o n i n g g a s f u r n a c e s , a n d b u r n i n g c h a r c o a l i n a n e n c l o s e d s p a c e . S y mp t o ms c o n s i s t o f h e a d a c h e , d i zzi n e s s , n a u s e a a n d v o mi t i n g , me n t a l c o n f u s i o n , a n d v i s u a l d i s t u r b a n c e s p r o g r e s s i n g t o o b t u n d a t i o n , c o ma a n d d e a t h . T h e k e y s i g n i s c h e r r y - r e d s k i n a n d mu c o s a a c c o mp a n i e d b y a b o u n d i n g p u l s e , h y p e r t e n s i o n , mu s c u l a r t w i t c h i n g , stertorous breathing, and dilated pupils. L o c a l i z e d He a d a c h e : P a r a n a s a l S i n u s i t i s : S e e p a g e 3 2.5

Seizures

Seizur es: P a t h o p h y s i o l o g S : i zu r e s a r e c a u s e d b y d i s o r d e r e d e l e c t r i c a l a c t i v i t y i n t h e b r a i n ye t h a t ma y b e f o c a l , f o c a l i n o n s e t w i t h g e n e r a l i za t i o n , o r g e n e r a l i ze d a t t h e o n s e t . S e i zu r e s a r e c l a s s i f i e d a s g e n e r a l i ze d o r p a r t i a l . P a r t i a l s e i zu r e s a r e d e f i n e d a s t h o s e w i t h a f o c a l o n s e t , r e g a r d l e s s o f w h e t h e r t h e y g e n e r a l i ze l a t e r i n t h e i r c o u r s e [C h a b o l l a D R . C h a r a c t e r i s t i c s o f t h e e p i M ay oeCl i n Pr oc 0 2 ; 7 7 : 9 8 1 9] 9 0 lepsi s. 20 . S E I ZURE S C L I NI C AL O C C URRE NC E : Congeni t al o n g e n i t a l b r a i n i n j Endoc r i ne y p o g l y c e mi I di opat hi cd i o p a t h i c c ury; h a; i e p i l e p s yI;nf l ammat or y / I mmunes c u l i t i s nf ec t i ous n i n g i t i s , e n c e p h a l i t i s , b r a i n va I; me a b s c e s s , n e u r o c y s t i c e r c o set abol i c / Toxfi e v e r, d r u g w i t h d r a w a l ( a l c o h o l , M is; c b a r b i t u r a t e s , b e n zo d i a ze p i n e s , a n t i c o n v u l s a n t me d i c a t i o n s ) , a mp h e t a mi n e s , c o c a i n e p h e n c y c l i d i n e , t h e o p h y l l i n e , h y p o g l y c e mi a , h y p o c a l c e mi a , u r e mi a , l i v e r f a i l u r e , h y p o xi a , p e n i c i l l i n s a n d o t h e r b e t a - l a cec hani c al / Tr auma a d t r a u ma ; M t a ms ; he Neopl as t i c r i ma r y o r me t a s t a t i c c a n c e r, i n s u lNeur ol ;ogi c p i l e p s y, p i n o ma e d e g e n e r a t i v e d i s e a s e s o f t h e PsN S hos oc i al r u g a b u s e , p h y s i c a l a b u s e ; C yc ; d Vas c ul ars t r o k e , v a s c u l i t i s , h e mo r r h a g e .
W h e n t h e p a t i e n t h a s a s e i zu r e t h e i mme d i a t e a p p r o a c h i s t o p r e v e n t i n j u r y a n d s u p p o r t c a r d i o r e s p i r a t o r y f u n c t i o n i f n e c e s s a r y. H o w e v e r, t h e p h y s i c i a n r a r e l y o b s e r v e s t h e e v e n t , s o a t h o r o u g h h i s t o r y a n d e xa mi n a t i o n a r e e s s e n t i a l t o i d e n t i f y t h e c a u s e a n d t o e xc l u d e o t h e r c a u s e s o f i mp a i r e d c o n s c i o u s n e s s . In a p a t i e n t t r e a t e d f o r s e i zu r e s , l o o k f o r c a u s e s o f r e l a p s e a n d e v a l u a t e a d e q u a c y o f t h e r a p y. F o r p a t i e n t s w i t h n e w o n s e t o f s e i zu r e s , s e e k t h e c a u s e , s u p p l e me n t i n g y o u r n e u r o l o g i c e xa mi n a t i o n w i t h a p p r o p r i a t e i ma g i n g a n d l a b o r a t o r y s t u d i e s . P. 8 6 0

Par tial Seizur es: P a t h o p h y s i o l o g P : r t i a l s e i zu r e s b e g i n w i t h i n a s p e c i f i c r e g i o n o f t h e b r a i n ya


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i d e n t i f i e d b y t h e i n i t i a l s y mp t o ms o f t h e s e i zu r e s . T h e y ma y r e ma i n l o c a l i ze d , s p r e a t o a l a r g e r b u t l i mi t e d a r e a o f t h e c o r t e x, o r p r o g r e s s t o a g e n e r a l i ze d s e i zu r e i n v o l v i n g b o t h c e r e b r a l h e mi s p h e rre sa l s e i zu r e s a r e c l a s s i f i e d a s s i mp l e i f t h e Pa ti . e v e n t i s l i mi t e d t o a s ma l l p o r t i o n o f o n e c o r t e x a n d c o n s c i o u s n e s s i s n o t a l t e r e d . C o mp l e x p a r t i a l s e i zu r e s i n v o l v e l a r g e r a r e a s o f t h e c o r t e x a n d c o n s c i o u s n e s s i s i mp a i r e d , a l t h o u g h n o t l o s t .

PART I AL S E I ZURE : PART I AL M O T O R, J AC K S O NI AN S E I ZURE : T h i s i s a n e p i s o d i c d i s o r d e r. An a t t a c k o f t e n b e g i n s w i t h t w i t c h i n g o f t h e mu s c l e s i n s i n g l e r e g i o n o f t h e b o d y. T h e t w i t c h e s b e c o me mo r e v i o l e n t w i t h i n c r e a s i n g a mp l i t u d e . T h e d i s t u r b a n c e s p r e a d s t o c o n t i g u o u s mu s c l e g r o u p s u n t i l t h e e n t i r e i p s i l a t e r a l s i d e ma y b e i n v o l v e d i n c l o n i c c o n t r a c t i o n s . T h e s e i zu r e ma y s t o p a t a n y s t a g e o f i t s s p r e a d , o r t h e c o n t r a l a t e r a l s i d e ma y b e a f f e c t e d t o p r o d u c e a g e n e r a l i ze d mo t o r s e i zu r e . C o n s c i o u s n e s s i s u s u a l l y r e t a i n e d e xc e p t w h e n t h e a t t a c i s g e n e r a l i ze d . U s u a l l y t h e s e i zu r e s a r e c a u s e d b y a f o c a l l e s i o n i n t h e mo t o r c o r t e s u p p l y i n g t h e mu s c l e s i n i t i a l l y i n v o l v e d i n t h e p r o g r e s s i o n . PART I AL S E I ZURE : PART I AL - C O M P L E X , P S Y C HO M O T O R: T h e s e a r e o f t e n a c c o mp a n i e d b y a n a u r a o f a n a b n o r ma l p s y c h i c e v e n t . T h e s e c a n b e o l f a c t o r y, v i s u a l , o r g u s t a t o r y d i s t u r b a n c e s , o r e v e n a p h e n o me n o n s u c h a s j v u . T h e a t t a c k ma y l a s t f r o m a f e w mi n u t e s t o a f e w h o u r s . S u d d e n b u t s u b t l e l o s s o higher levels of consciousness occurs in which the patient is unaware of what t r a n s p i r e s b u t r e t a i n s mo t o r f u n c t i o n s a n d a b i l i t y t o r e a c t i n a n a u t o ma t i c f a s h i o n . T h e p a t i e n t ma y r e s p o n d t o q u e s t i o n s , b u t t h e a n s w e r s d i s c l o s e l a c k o f u n d e r s t a n d i n g . T h i s ma y b e t h e o n l y o b j e c t i v e c l u e . R e p e t i t i v e a i ml e s s mo v e me n t s , w h i c h a r e o f t e n s t e r e o t y p e d , ma y b e r e p o r t e d . P a t i e n t s g e n e r a l l y d o n o t b e c o me v i o l e n t o r a s s a u l t i v e d u r i n g a n a t t a c k . O n l y o c c a s i o n a l l y a r e t h e r e t o n i c mu s c l e s p a s ms o f t h e l i mb s . Amn e s i a f o r t h e a t t a c k i s p a r t i a l o r c o mp l e t e . T h i s c o n d i t i o n s h o u l d p r o mp t a s e a r c h f o r a f o c a l l e s i o n i n t h e t e mp o r a l l o b e .

P. 8 6 1 S e c o n d a r y G e n e r a l i z e d S e i z u r e : To n i c - C l o n i c , M a j o r M o t o r , G r a n d M a l : P a t h o p h y s i o l o g M:o s t ma j o r mo t o r s e i zu r e s b e g i n f r o m a u n i l a t e r a l s ma l l f o c u s i n y o n e h e mi s p h e r e t h e n p r o g r e s s t o i n v o l v e t h e i p s i l a t e r a l h e mi s p h e r e a n d c r o s s t h e c o r p u s c a l l o s u m t o i n v o l v e t h e c o n t r a l a t e r a l h e mi s p h e r e , p r o d u c i n g a s e c o n d a r y g e n e r a l i ze d s e i zuTe .e r e ma y o r ma y n o t b e a w a r n i n g o r a u r a . S e v e r a l h o u r s o r rh d a y s b e f o r e t h e a t t a c k , p r o d r o ma t a ma y b e n o t e d , w i t h f e e l i n g s o f s t r a n g e n e s s , d r e a my s t a t e s , i n c r e a s e d i r r i t a b i l i t y, l e t h a r g y o r e u p h o r i a , r a v e n o u s a p p e t i t e , f e e l i n o f i mp e n d i n g d i s a s t e r, h e a d a c h e s , o r o t h e r s y mp t o ms . T h e a u r a i s a p a r t i a l s e i zu r e , a n d t h e p a t i e n t l e a r n s i t s s i g n i f i c a n c e . T h e p a t i e n t ma y e xp e r i e n c e v a g u e e p i g a s t r i c sensations such as nausea or hunger and palpitation, vertigo, or sensations in the h e a d . An y a u r a o r f o c a l s e i zu r e r e f l e c t s f o c a l b r a i n d i s e a s e . C o n s c i o u s n e s s i s l o s t s u d d e n l y a n d s i mu l t a n e o u s l y w i t h t h e e p i l e p t i c c r y f r o m s u d d e n e xp u l s i o n o f a i r t h r o u g h t h e g l o t t i s . T h e p a t i e n t i s h e l p l e s s a n d f a l l s , o f t e n i n c u r r i n g i n j u r i e s . To n i c s p a s m o f a l l mu s c l e s o c c u r s w h i c h ma y b e s o v i o l e n t a s t o f r a c t u r e b o n e s . B r e a t h i n c e a s e s f r o m s p a s m o f t h e t h o r a c i c mu s c l e s a n d c y a n o s i s ma y b e d e e p . S u d d e n l y, t h e t o n i c s t a t e s u b s i d e s , f o l l o w e d b y c l o n i c mo v e me n t s t h a t i n c r e a s e i n s t r e n g t h w i t r e p e t i t i o n t h e n c e a s e . F o a mi n g a t t h e mo u t h r e s u l t s f r o m f o r c e d e xp u l s i o n o f a i r a n d s a l i v a . C l o n i c mo v e me n t s o f t h e j a w s c a u s e b i t i n g o f t h e t o n g u e , c h e e k s a n d l i p s .
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F r e q u e n t l y, t h e r e i s i n v o l u n t a r y d e f e c a t i o n a n d u r i n a t i o n . U n c o n s c i o u s n e s s u s u a l l y l a s t s a f e w mi n u t e s , b u t ma y l a s t h o u r s . O n r e t u r n o f c o n s c i o u s n e s s p a t i e n t s a r e o f t e n c o n f u s e d a n d a mn e s t i c f o r t h e s e i zu r e a n d p r e c e d i n g e v e n t s a n d c o mp l a i n o f h e a d a c h e , s t i f f n e s s , a n d s o r e mu s c l e s . S e i zu r e s a r e f r e q u e n t l y f o l l o w e d b y a d e e p sleep.

Gener alized Seizur e: P a t h o p h y s i o l o g G:e n e r a l i ze d s e i zu r e s i n v o l v e t h e e n t i r e c e r e b r a l c o r t e x a t o n s e t y s o t h e y d o n o t h a v e a n aH irs t.o r y o b t a i n e d f r o m b y s t a n d e r s i s c r i t i c a l i n u a d e t e r mi n i n g w h e t h e r a s e i zu r e w a s g e n e r a l i ze d o r f o c a l a t o n s e t . G E NE RAL I ZE D S E I ZURE : AB S E NC E , P E T I T M AL : An e p i s o d e c o n s i s t s o f a s u d d e n t r a n s i t o r y d i mi n u t i o n o r l o s s o f c o n s c i o u s n e s s w i t h n o a b n o r ma l mu s c l e mo v e me n t s . T h e a t t a c k u s u a l l y l a s t s f r o m s e v e r a l t o 9 0 s e c o n d s , d u r i n g w h i c h t i me t h e p a t i e n t ' s e y e s a r e w i d e o p e n a n d s t a r i n g . F u l l c o n s c i o u s n e s s i s r a p i d l y a n d c o mp l e t e l y r e s t o r e d . In j u r i e s ma y r e s u l t f r o m t h e mo me n t a r y l a p s e , b u t n o t f r o m f a l l s b e c a u s e t h e r e i s n o l o s s o f p o s t u r a l t o n e . T h e p a t i e n t i s v a g u e l y a w a r e o f h a v i n g mi s s e d s o me t h i n g .

G E NE RAL I ZE D S E I ZURE : M AJ O R M O T O R, G RAND M AL : T h i s s e i zu r e i s i d e n t i c a l t o t h e s e c o n d a r y g e n e r a l i ze d s e i zu r e e xc e p t f o r t h e a b s e n c of an aura or any evidence of focal onset of the event. Consciousness is lost withou w a r n i n g a n d t h e p a t i e n t i s a mn e s t i c f o r t h e e v e n t .

Impaired Consciousness

D i s t u r b a n c e s o f c o n s c i o u s n e s s ma y b e c l a s s i f i e d p a r t i a l l y a c c o r d i n g t o d e g r e e . Let har gy s d r o w s i n e s s c a u s e d b y a c o n d i t i o n o t h e r t h a n n o r ma onfl us iponIn i c l s e e ., a t t e n t i o n i s d u l l e d , p e r c e p t i o n i s i mp a i r e d , me mo r y i s d e f e c t i v e , a n d t h e g e n e r a l a w a r e n e s s o f s u r r o u n d i n g s i s l i midel i.r iIn , c o n f u s i o n i s a c c o mp a n i e d b y t e d um h a l l u c i n a t i o n s . Al t h o u g h d e l i r i u m i s s o me t i me s a c c o mp a n i e d b y a g i t a t i o n a n d v i o l e n t e mo t i o n a l r e s p o n s e s , t h e p a t i e n t ma y b e q u i e t a n d w i tupor i w n . s o mn o l e n t St h d r a s a s t a t e d u r i n g w h i c h t h e p a t i e n t ma y b e mo me n t a r i l y a r o u s e d b y q u e s t i o n s o r p a i n f u l s t i mu l i Coma i s t h e d e e p e s t s t a t e o f u n c o n s c i o u s n e s s i n w h i c h t h e p a t i e n t i s . mo t i o n l e s s a n d u n r e s p o n s i v e t o s t i mu l i . A b r i e f l o s s o f c o n ss y o u s n ea n di s c i nc ope s s p r e s e n t s a d i f f e r e n t g r o u p o f d i a g n o s t i c p r o b l e ms f r o m t h o s e s u g g e s t e d b y c o ma .

Episodic Impaired Consciousness


P. 8 6 2

Na r c o l e p s y : P a t h o p h y s i o l o g T : i s d i s o r d e r i s i d i o p a t h i c o r o c c u r s s e c o n d a r y t o b r a i n i n j u r y. yh T h e r e i s i mp a i r e d a b i l i t y t o v o l u n t a r i l y ma i n t a i n w a k e f u l n e s s a s s o c i a t e d w i t h i mme d i a t e o n s e t o f R E M ( r a p i d e y e mo v e me n T)hs l ed ip .p a t h i c f o r m u s u a l l y t e ie o o c c u r s i n y o u n g a d u l t s a n d ma y b e a s s o c i a t e d w i t h s u d d e n l o s s o f mo t o r t o n e w i t h o u t l o s s o f c o n s c i o u s n e s s ( ex)y i n a b i l i t y t o mo v e u p o n a w a k e neep ( c at apl , sl ing par al y s i)s a n d v i s u a l o r a u d i t o r y h a l l u c i n a t i o n s a t s l ehy pnagogi(c , ep onset hal l uc i nat i ons r o n a w a k e n i n g pnopompi c hal l uc i nat)i.ons e p a t i e n t ) o hy ( Th e xp e r i e n c e s u n e xp e c t e d , i n a p p r o p r i a t e , a n d i r r e s i s t i b l e s h o r t s p e l l s o f s l e e p . T h e r e ma y b e s e v e r a l a t t a c k s p e r d a y o f b r i e f s o mn o l e n t p e r i o d s w i t h n o d e t e r i o r a t i o n o f
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me n t a t i o n . P. 8 6 3 P. 8 6 4

Syncope: P a t h o p h y s i o l o g S : n c o p e o c c u r s d u r i n g t r a n s i e n t d i mi n u t i o n o f t h e c e r e b r a l yy c i r c u l a t i o n o r c h a n g e s i n t h e c o mp o s i t i o n o f t h e b l o o d , a s i n h y p o g l y c e mi a o r h y p o c a p n e a . Imp a i r e d c i r c u l a t i o n o f t h e b r a i n ma y o c c u r f r o m i n e f f e c t i v e c a r d i a c a c t i o n ( my o c a r d i a l i n s u f f i c i e n c y o r d y s r h y t h mi a s ) , l o s s o f p e r i p h e r a l r e s i s t a n c e i n t h v a s c u l a r t r e e p r o d u c i n g h y p o t e n s i o n , o r f r o m v a s c u l a r r e f l e xe s . In t h e e r e c t p o s i t i o n c o n s c i o u s n e s s i s l o s t w h e n t h e me a n a r t e r i a l p r e s s u r e d e c l i n e s t o 2 0 3 0 mmH g o r w h e n t h e h e a r t s t o p s f o r 4 5 s e c o n d s . In t h e h o r i zo n t a l p o s i t i o n , mo r e e xt r e me c o n d i t i o n s c a n b e t o l e r aT e d . p a t i e n t ma y c o mp l a i n o f w e a k s p e l l s , l i g h t t he h e a d e d n e s s , o r b l a c k o u t s . A c a r e f u l h i s t o r y mu s t b e o b t a i n e d f r o m b o t h t h e p a t i e n t a n d w i t n e s s e s . T h e h i s t o r y a n d i n i t i a l p h y s i c a l e xa m a r e o f t h e g r e a t e s t u s e f u l n e s s i n e s t a b l i s h i n g a s p e c i f i c e t i o l o g y. E xt e n s i v e i n v e s t i g a t i o n s a r e u n l i k e l y b e u s e f u l , u n l e s s t h e h i s t o r y o r e xa m d i r e c t y o u t o a s p e c i f Kca p oa g nWs i s [ i di or o N. S y n c o p eN Engl J M ed 0 0 0 ; 3 4 3 : 1 8 5 6 1 8.6 T h e mo s t c o mmo n c a u s e o f s y n c o p e . 2 ] 2 i s t h e v a s o v a g a l , o r v a s o d e p r e s s o r, f a i n t . O t h e r c o n s i d e r a t i o n s a r e c a r d i a c d y s r h y t h mi a s ( Ad a ms - S t o k e s a t t a c k s e i t h e r t a c h y - o r b r a d y c a r d i a ) , s e i zu r e , a n a p h y l a xi s , a u t o n o mi c d y s f u n c t i o n w i t h o r t h o s t a t i c h y p o t e n s i o n , p u l mo n a r y e mb o l i s m, a o r t i c s t e n o s i s , a n d c e r e b r o v a s c u l a r d i s e a s e . S Y NC O P E : VAS O VAG AL S Y NC O P E , FAI NT I NG : P a t h o p h y s i o l o gS: d d e n v a s o d i l a t i o n l e a d s t o d e c r e a s e d c a r d i a c f i l l i n g a n d yu f o r c e f u l my o c a r d i a l c o n t r a c t i o n o n a n u n d e r f i l l e d v e n t r i c l e t r i g g e r s my o c a r d i a l r e c e p t o r s , w h i c h r e f l e xi v e l y c a u s e s t r o n g v a g a l o u t f l o w, l e a d i n g t o b r a d y c a r d i a , f u r t h e r h y p o t e n s i o n , a n d s y n c o p e . W i t h r e c u mb e n c y, t h e v e n o u s r e t u r n i mp r o v e s a n r e c o v e r y e n s u eT h e a t t a c k i s i n d u c e d i n h e a l t h y p e r s o n s b y f e a r, a n xi e t y, o r p a i n . A s. h o t e n v i r o n me n t f a c i l i t a t e s t h e o n s e t b y p r o d u c i n g v a s o d i l a t a t i o n . F a t i g u e , i l l n e s s , a l c o h o l c o n s u mp t i o n , o r h u n g e r i n c r e a s e s s u s c e p t i b i l i t y. T h e p a t i e n t c a n u s u a l l y s u p p l y a h i s t o r y o f t h e p r o d r o me t h a t i s d i a g n o s t i c . R e c o v e r y f o l l o w s a s s u mp t i o n o f t h e h o r i zo n t a l p o s i t i o n . T h e v a s o v a g a l ( n e u r o c a r d i o g e n i c ) a t t a c k h a s t h r e e s t a g e s . T h e p r o d r o me i s b r i e f a n d u s u a l l y b e g i n s i n t h e e r e c t p o s i t i o n . T h e p a t i e n t f e e l s l i g h t - h e a d e d a n d u n s t e a d y. Ya w n i n g , d i mmi n g o f v i s i o n ( a s a c o n s e q u e n c e o f t h e i n t r a o c u l a r p r e s s u r e c o l l a p s i n g a r t e r i o l e s ) , n a u s e a a n d v o mi t i n g , a n d s w e a t i n g a r e c o mmo n . T h e f a c e b e c o me s p a l e o r a s h e n g r a y. If t h e p a t i e n t r e c l i n e s p r o mp t l y t h e a t t a c k ma y b e a b o r t e d . T h e s y n c o p a l s t a g e c o n s i s t s o f mu s c l e w e a k n e s s a n d i mp a i r e d c o n s c i o u s n e s s . T h e p a t i e n t f a l l s t o t h e f l o o r e i t h e r s l o w l y o r a b r u p t l y, u s u a l l y a v o i d i n g i n j u r y. T h e p a t i e n t ma y b e me n t a l l y c o n f u s e d b u t s t i l l h e a r v o i c e s a n d d i ml y s e e t h e s u r r o u n d i n g s , o r, t h e r e i s c o mp l e t e u n c o n s c i o u s n e s s . U n c o n s c i o u s n e s s ma y l a s t f o r a f e w s e c o n d s t o a t mo s t a f e w mi n u t e s . U s u a l l y t h e mu s c l e s a r e u t t e r l y f l a c c i d a n d mo t i o n l e s s , a l t h o u g h s o me t i me s t h e r e a r e a f e w c l o n i c j e r k s o f a r ms a n d lce g s ul s i v e s y nc opeu t s e l d o m a f u l l t o n i c c l o n i c onv ( ) b convulsion. Urinary or fecal incontinence is rare. T he skin appears strikingly pale o c y a n o t i c a n d t h e p u l s e i s w e a k o r a b s e n t . B r a d y c a r d i a i s a c c o mp a n i e d b y a r t e r i a l h y p o t e n s i o n a n d e xt r e me l y s h a l l o w, q u i e t b r e a t h i n g . D u r i n g r e c o v e r y t h e p a t i e n t r e ma i n s w e a k , b u t i s a w a k e a n d l u c i d . In t h e h o r i zo n t a l p o s i t i o n , t h e f a c e g r a d u a l l y
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s u f f u s e s w i t h p i n k , t h e b l o o d p r e s s u r e r i s e s , t h e p u l s e b e c o me s p a l p a b l e a n d a c c e l e r a t e d , t h e b r e a t h i n g d e e p e n s a n d q u i c k e n s , t h e e y e l i d s ma y f l u t t e r. T h e p a t i e n t a w a k e n s w i t h i mme d i a t e a w a r e n e s s o f t h e s u r r o u n d i n g s a n d me mo r y f o r t h e p r o d r o me . T h e mu s c l e w e a k n e s s p e r s i s t s f o r s o me t i me , s o a t t e mp t s t o r i s e p r e ma t u r e l y ma y i n d u c e a n o t h e r a tea c o n[ AM , H a mmi l l S C , R e a F R , e t a l . F t nt k Va s o v a g a l s y n c o p e . I nt er n M ed0 0 0 ; 1 3 3 ; 7 1 4 7 2 5 Ann 2 ].

S Y NC O P E : AK I NE T I C E P I L E P S Y: C o mmo n f e a t u r e s i n a k i n e t i c e p i l e p s y, b u t r a r e i n s y n c o p e , a r e l a c k o f p a l l o r, s u d d e o n s e t w i t h o u t p r o d r o me , i n j u r y f r o m f a l l i n g , t o n i c c o n v u l s i o n s w i t h u p t u r n e d e y e s , u r i n a r y o r f e c a l i n c o n t i n e n c e , a n d p o s t i c t a l me n t a l c o n f u s i o n w i t h h e a d a c h e a n d drowsiness. Most of these features occur occasionally with syncope. S Y NC O P E : O RT HO S TAT I C O R P O S T URAL S Y NC O P E : S e e C h a p t e r ,4p a g e 8 6P a t h o p h y s i o l o g N:o r ma l l y i n t h e e r e c t p o s i t i o n , p o o l i n g . y o f t h e b l o o d i n t h e l o w e r l i mb s i s p r e v e n t e d b y v a s o c o n s t r i c t i o n me d i a t e d t h r o u g h t h a u t o n o mi c n e r v o u s s y s t e m. W h e n t h e r e i s d e c r e a s e d i n t r a v a s c u l a r v o l u me o r t h e c o mp e n s a t o r y me c h a n i s m i s b l o c k e d , b l o o d i s p o o l e d i n t h e l e g s a n d a r t e r i a l h y p o t e n s i o n r e s u lDs s t i n c t i v e f e a t u r e s o f a u t o n o mi c i n s u f f i c i e n c y a r e n o r ma l h e a r t t i. r a t e , a n d a b s e n c e o f p a l l o r a n d s w e a t i n g . R e c o v e r y o c c u r s i n t h e h o r i zo n t a l p o s i t i o S Y NC O P E : HY S T E RI C AL S Y NC O P E : T h i s w a s t h e s w o o n o f y o u n g n i n e t e e n t h - c e n t u r y w o me n w i t h s t r o n g e mo t i o n s . It u s u a l l y o c c u r r e d i n t h e p r e s e n c e o f w i t n e s s e s . T h e f a l l w a s g r a c e f u l a n d h a r ml e s s . T h e s k i n c o l o r, h e a r t r a t e , a n d b l o o d p r e s s u r e w e r e a l l n o r ma l . E i t h e r t h e p a t i e n t l a mo t i o n l e s s o r ma d e u n i n h i b i t e d r e s i s t i n g mo v e me n t s . S Y NC O P E : AD AM S - S T O K E S S Y ND RO M E : P a t h o p h y s i o l o gT : e a t t a c k s o f u n c o n s c i o u s n e s s o c c u r w h e n c a r d i a c a s y s t o l e yh l a s t s mo r e t h a n 5 s e c o n d s i n t h e v e r t i c a l p o s i t i o n o r 1 0 s e c o n d s i n t h e h o r i zo n t a l . U s u a l l y, a s y s t o l e r e s u l t s d u r i n g t h e t r a n s i t i o n f r o m a p a r t i a l t o a c o mp l e t e h e a r t b l o o r f r o m t h e o n s e t o f p a r o xy s ma l t a c h y c a r d i a o r v e n t r i c u l a r fhb rni l lt a tei oh e a r t W ie h n. r h y t h m i s r e g u l a r a n d t h e r a t e l e s s t h a n 4 0 p e r mi n u t e , h e a r t b l o c k c a n b e distinguished from sinus bradycardia by the variation in intensity of the first heart s o u n d s . An E C G i s r e q u i r e d f o r c o n f i r ma t i o n . T h i s f o r m o f s y n c o p e o c c u r s i n a n y p o s i t i o n w i t h o u t a p r o d r o me . S Y NC O P E : S Y NC O P E WI T H VALV UL AR HE ART D I S E AS E : P a t h o p h y s i o l o g M:u s c u l a r v a s o d i l a t i o n w i t h e xe r c i s e i n p a t i e n t s w i t h a f i xe d y c a r d i a c o u t p u t l e a d s t o c e r e b r a l h y p o p e r f u s i o n a n dE s y ntc o p ema y i n d u c e xe r i n . t y p i c a l s y n c o p e i n a p a t i e n t w i t h a o r t i c s t e n o s i s o r, l e s s c o mmo n l y, a o r t i c r e g u r g i t a t i o n o r p u l mo n a r y h y p e r t e n s i o n . S Y NC O P E : C ARO T I D S I NUS S Y NC O P E : P a t h o p h y s i o l o g U:s u a l l y t h i s o c c u r s i n p a t i e n t s o l d e r t h a n a g e 6 0 y e a r s w i t h y h y p e r t e n s i o n o r o c c l u s i o n o f o n e c a r o t i d a r t e r y. R o t a t i o n o f t h e h e a d o r w e a r i n g a tight collar puts pressure on the carotid bulb, inducing syncope. T he vagal s t i mu l a t i o n ma y r e s u l t i n o n e o f t h r e e r e s p o n s e s : ( a ) s i n o a t r i a l b l o c k , ( b ) h y p o t e n s i w i t h o u t b r a d y c a r d i a , o r ( c ) s y n c o p e w i t h n o r ma l p u l s e r a t e a n d b l o o d p r e s s u r e . S y n c o p e r e l a t e d t o s p e c i f i c mo t i o n s o f t h e n e c k s u g g e s t c a r o t i d s i n u s s y n c o p e . C i r c u ms t a n t i a l p r o o f i s f u r n i s h e d w h e n a n a t t a c k i s r e p r o d u c e d b y ma s s a g i n g t h e c a r o t i d s i n u s . B e f o r e s t i mu l a t i o n i s a t t e mp t e d , d e t e r mi n e t h a t b o t h c a r o t i d a r t e r i e s
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a r e p u l s a t i n g a n d p a t e n t . T h e ma n e u v e r i s d a n g e r o u s w h e n o n e a r t e r y i s o c c l u d e d . B o t h c a r o t i d s s h o u l d n e v e r b e s t i mu l a t e d s i mu l t a n e o u s l y. C o n t i n u o u s E C G mo n i t o r i n g i s p e r f o r me d w h i l e t h e c a r o t i d s i n u s i s g e n t l ydo not atg e d ; ma s s o oc c l ude t he v es.s el c c l u s i o n d u r i n g t h e ma n e u v e r h a s p r o d u c e d c e r e b r a l i n f a r c t i o n O and death.

S Y NC O P E : HY P E RV E NT I L AT I O N: P a t h o p h y s i o l o g H:y p e r v e n t i l a t i o n r e s u l t s i n h y p o c a p n e a ; t h i s i n d u c e s d i mi n i s h e d y c e r e b r a l b l o o d f l o w.f o r e t h e a t t a c k , t h e p a t i e n t i s a n xi o u s o r e mo t i o n a l l y u p s e t . Be T he patient is not conscious of hyperventilation but feels tightness in the chest or s u f f o c a t i o n . T h e p r o d r o me i s u s u a l l y a t t e n d e d b y n u mb n e s s a n d t i n g l i n g o f a r ms a n f a c e , s o me t i me s c a r p o p e d a l s p a s ms o c c u r. L o s s o f c o n s c i o u s n e s s ma y b e p r o l o n g e d c o mp a r e d w i t h mo s t o t h e r t y p e s o f s y n c o p e . T h e s y mp t o ms a r e r e p r o d u c e d b y having the patient overventilate. Rebreathing into a paper bag will arrest the attack a n d d e mo n s t r a t e a me t h o d o f s e l f - t r e a t me n t . S Y NC O P E : C O UG H S Y NC O P E ( T US S I V E S Y NC O P E ) : S e v e r e p a r o xy s ms o f c o u g h i n g , l a u g h i n g , o r v o mi t i n g ma y i n d u c e a n a t t a c k o f s y n c o p e , u s u a l l y i n me n , r a r e l y i n w o me n . T h e h i s t o r y o f t h e o n s e t i s u s u a l l y d i a g n o s t i c . T h e me c h a n i s m i s d i s p u t e d : e i t h e r c o mp r e s s i o n o f t h e c e r e b r u m b y t r a n s mi s s i o n o f i n c r e a s e d i n t r a t h o r a c i c p r e s s u r e t o t h e c e r e b r o s p i n a l f l u i d o r r e d u c t i o n o f c a r d i a c o u t p u t b y t h e Va l s a l v a ma n e u v e r.

S Y NC O P E : M I C T URI T I O N S Y NC O P E : Particularly in a patient with peripheral vasodilatation from a warm bed, voiding of l a r g e v o l u me ma y c a u s e s y n c o p e . S i mi l a r l y, t h e r a p i d d e c o mp r e s s i o n o f a n o v e r f i l l e b l a d d e r b y c a t h e t e r i za t i o n o r t h e r e mo v a l o f l a r g e v o l u me s o f a s c i t i c f l u i d ma y a l s o cause syncope. S Y NC O P E : HY P O G LY C E M I C S Y NC O P E : T h e p r o d r o me ma y r e s e mb l e a v a s o v a g a l s p e l l b u t c o n f u s i o n i s p r o mi n e n t . T h e syncopal stage is frequently prolonged and loss of consciousness is usually i n c o mp l e t e . In s t e a d , t h e r e i s mu s c l e w e a k n e s s w i t h me n t a l c o n f u s i o n . T h e b l o o d s u g a r i s u s u a l l y b e l o w 3 0 mg / 1 0 0 mL ; t h e s y mp t o ms a r e r e l i e v e d b y t h e i n t r a v e n o u s a d mi n i s t r a t i o n o f g l u c o s e o r i n j e c t i o n o f g l u c a g o n .
P. 8 6 5

Coma
P. 8 6 6 P. 8 6 7 P. 8 6 8

Coma: P a t h o p h y s i o l o g C:o ma r e s u l t s f r o m s e r i o u s d i s r u p t i o n o f b r a i n f u n c t i o n t h a t y i mp a i r s t h e r e t i c u l a r a c t i v a t i n g s y s t e m s u c h t h a t c o n s c i o u sC e s s i iss l a s t . n o ma o s t a t e o f p r o l o n g e d u n c o n s c i o u s n e s s . T h e e xa mi n a t i o n r e q u i r e s a s p e c i a l a p p r o a c h b e c a u s e t h e p a t i e n t c a n n o t g i v e a h i s t o r y, a n d c o o p e r a t i o n i s a b s e n t . T h e me d i c a l s t u d e n t o r h o u s e o f f i c e r w h o i s f i r s t c o n f r o n t e d w i t h t h i s s i t u a t i o n ma y w e l l b e b a f f l a n d d i s c o n c e r t e d , b u t e xp e r i e n c e d e mo n s t r a t e s t h a t t h e c o r r e c t d i a g n o s i s w i l l b e r a p i d l y e s t a b l i s h e d i n mo s t c a s e s b y a s t r u c t u r e d c o mp l e t e p h y s i c a l a n d n e u r o l o g i c


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e xa mi n a t i o n a n d u s e o f r a d i o l o g i c a n d l a b o r a t o r y t e s t i n g . In f o r mu l a t i n g a d i a g n o s i s t w o a xi o ms s h o u l d b e f o l l o w e d . ( a ) F i n d i n g o n e c l u e t o t h e c a u s e o f c o ma d o e s n o t p r o v e t h e c a u s e . F o r i n s t a n c e , a c o ma t o s e p a t i e n t w i t h t h e o d o r o f a l c o h o l o n t h e b r e a t h ma y h a v e s u s t a i n e d a h e a d i n j u r y w h i l e i n t o xi c a t e d ; a p e r s o n i n j u r e d i n a n a u t o mo b i l e a c c i d e n t ma y h a v e h a d a n a n t e c e d e n t s t r o k e t h a t l e d t o t h e a c c i d e n t ; o r a n u n c o n s c i o u s p a t i e n t w i t h a f e w s e d a t i v e t a b l e t s a t t h e b e d s i d e ma y h a v e t a k e n t h e d r u g f o r s y mp t o ms o f me n i n g i t i s o r b r a i n t u mo r. ( b ) A c o mp l e t e n e u r o l o g i c e xa mi n a t i o n i s i n s u f f i c i e n t , t h e o t h e r s y s t e ms o f t h e b o d y mu s t a l s o b e a s s e s s e d : f i n d i n g a t r i a l f i b r i l l a t i o n r a i s e s t h e p o s s i b i l i t y o f c e r e b r a l e mb o l i s m; t h e r e t i n a e ma y c o n t a i n s i g n s o f d i a b e t e s ; d e mo n s t r a t i o n o f a c o n s o l i d a t e d l u n g s u g g e s t s l o b a r p n e u mo n i a o r p n e u mo c o c c a l me n i n g i t i s ; e xa mi n a t i o n o f t h e a b d o me n h a s d i s c o v e r e d a d i s t e n d e d b l a d d e r, l e a d i n g t o a d i a g n o s i s o f u r e mi a f r o m p r o s t a t i c o b s t r u c t i o n . T h d i f f e r e n t i a l d i a g n o s i s a n d ma n a g e me n t o f c o ma i s b e y o n d t h e s c o p e o f t h i s t e xt . T h r e a d e r s h o u l d c o n s u l t t e xt b o o k s o f me d i c i n e , n e u r o l o g y, a n d e me r g e n c y me d i c i n e .

HI S T O RY O F T HE C O M AT O S E PAT I E NT: In t e r v i e w t h e r e l a t i v e s , a c q u a i n t a n c e s , a t t e n d a n t s , o r p o l i c e o f f i c e r s w h o d i s c o v e r e t h e p a t i e nC. i r c u m s t a n c e s o f D i s c o ve ro w w a s t h e p a t i e n t f o u n d ? W e r e t h e r e t H y: any drugs or poisons nearby? Were the surroundings such as to suggest poisoning f r o m c a r b o n mo n o xi d e o r g a s o l i n e f u me s ? Wa s t h e r e e v i d e n c e o f t r a u ma ? W h a t w a s known about the patient's antecedent intake of food and fluids? Who prepared the f o o d ? W h a t w e r e t h e s y mp t o ms a n d a c t i o n s b e f o r e t h e o n s e t o f c o ma ? D i d t h e p a t i e n t h a v e p a i n , d i a r r h e a , o r v o miat sn gH i s t o r y : s t h e p a t i e n t k n o w n t o P it ? Wa h a v e e p i l e p s y, d i a b e t e s , h y p e r t e n s i o n , o r a l c o h o l o r d r u g a d d i c t i o n ? D i d t h e p a t i e n t h a v e s u i c i d a l t h o u g h t s ? Wa s t h e p a t i e n t e v e r h o s p i t a l i ze d i n a me n t a l i n s t i t u t i o n ? Wa s t h e p a t i e n t k n o w n t o b e t a k i n g me d i c i n e s ? H a d t h e r e e v e r b e e n o p e r a t i o n s f o r ma l i g n a n c y ? H a s t h i s h a p p e n e d b e f o r e ? As s e s s p a t e n c y o f t h e a i r w a y a n d t h e p r e s e n c e o f a d e q u a t e r e s p i r a t i o n s a n d p u l s e . Vi t a l S i g n sN o t e a n y a b n o r ma l i t G e n e r a l I n s p e c t i oN o t e p o s t u r e ; l o o k f o r : ies. n: t r e mo r s o r mu s c l e j e r k s ; i n s p e c t t h e r e s p i r a t o r y mo v e me n t s f o r b r a d y p n e a , t a c h y p n e a , K u s s ma u l b r e a t h i n g , C h e y n e - S t o k e s b r e aoh :L o o k f o r p a l l o r, Col t r ing. i c t e r u s , t h e c y a n o s i s o f me t h e mo g l o b i n e mi a , t h e c h e r r y - r e d c o l o r o f c a r b o n mo n o xi d e h e mo g l o bSn .a l p a n d S k u lL : o k f o r c o n t u s i o n s , l a c e r a t i o n s , g u n s h o t ic lo w o u n d s ; p a l p a t e f o r d e p r e s s e d s k u l l f r a c t u r e s a n d i n s p e c t t h e ma s t o i d f o r h e ma t o ma o f b a s i l a r s k u l l f r a c t Bat t l( e s i gnE y e s : In s p e c t f o r p e r i o r b i t a l b r u r s i ncg ( ure ). i ac oon s i gn o f b a s i l a r s k u l l f r a c t u r e . L i f t t h e e y e l i d s a n d l e t t h e m c l o s e ; l a g g i n g o f o n e l i d ) s u g g e s t s h e mi p l e g i a . T h e p a t i e n t w i t h h y s t e r i a r e s i s t s o p e n i n g b y c l o s i n g t h e l i d s t i g h t e r. In c o ma , t h e e y e s r e ma i n f i xe d o r o s c i l l a t e s l o w l y f r o m s i d e t o s i d e ; o s c i l l a t i o n i s l a c k i n g i n h y s t e r i a i n w h i c h t h e e y e s ma y w a n d e r b u t f i x mo me n t a r i l y. Conjugate deviation of the eyeballs is toward the affected side in destructive lesion of the frontal lobe, away from the affected side in irritative lesions. T he presence o e xt r a o c u l a r mu s c l e p a l s i e s a s s i s t s i n l o c a l i zi n g a n i n t r a c r a n i a l l e s i o n . Af t e r c o n f i r mi n g t h e a b s e n c e o f n e c k i n j u r y, o p e n t h e e y e l i d s a n d q u i c k l y t u r n t h e h e a d f r o m s i d e t o s i d e . T h e e y e s o f t h e c o ma t o s e p a t i e n t w i t h c e r e b r a l d a ma g e t u r n i n t h o p p o s i t e d i r e c t i o n i n a c o n j u g a t e mo v e me n t i f t h e b r a i n s t e m i s i n t a c t ( d o l l ' s e y e s ) . T h i s o c u l o c e p h a l i c r e f l e x i s l o s t w i t h l e s i o n s o f t h e p o n s o r mi d b r a i n . C a l o r i c s t u d i e i n w h i c h y o u t e s t a n o c u l o v e s t i b u l a r r e f l e x, p r o v i d e i n f o r ma t i o n o f s i mi l a r s i g n i f i c a n c e . T h e s e a r e p e r f o r me d b y i r r i g a t i n g t h e e a r c a n a l w i t h 3 0 5 0 mL o f i c e
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w a t e r a n d n o t i n g t h a t , w i t h c e r e b r a l d y s f u n c t i o n a n d a n i n t a c t b r a i n s t e m, a t o n i c conjugate deviation of the eyes toward the cold ear lasts for 30120 seconds. B i l a t e r a l , w i d e l y d i l a t e d p u p i l s o c c u r i n p r o f o u n d p o s t t r a u ma t i c s h o c k , ma s s i v e c e r e b r a l h e mo r r h a g e , e n c e p h a l i t i s , p o i s o n i n g w i t h a t r o p i n e - l i k e d r u g s , a n d t h e e n d s t a g e s o f b r a i n t u mo r. B i l a t e r a l p i n p o i n t p u p i l s s u g g e s t o p i a t e p o i s o n i n g o r a p o n t i n h e mo r r h a g e . A u n i l a t e r a l u n r e a c t i v e p u p i l i n d i c a t e s a r a p i d l y e xp a n d i n g l e s i o n o n t h i p s i l a t e r a l s i d e , a s i n s u b d u r a l o r mi d d l e me n i n g e a l e p i d u r a l h e mo r r h a g e o r b r a i n t u mo r. E xa mi n e t h e o c u l a r f u n d i f o r t h e e xu d a t e s a n d h e mo r r h a g e s o f d i a b e t e s a n d n e p h r i t i s , a n d t h e c h o k e d d i s k s o f i n c r e a s e d i n t r a c r a n i a la p r e s s uue .c l e s : F cial M r s As y mme t r y o f t h e f a c e ma y i n d i c a t e h e mi p l e g i a . T h e mo u t h d r o o p s o n t h e a f f e c t e d s i d e ; t h e c h e e k p u f f s o u t w i t h e a c h e xp i r a t i o n . P a i n f u l p r e s s u r e o n t h e s u p r a o r b i t a l n o t c h c a u s e s t h e mo u t h t o g r i ma c e i n a n a s y mme t r i c p a t t e r n t o r e v e a l t h e w e a k s i d e O r a l C a vi t yE xa mi n e t h e t o n g u e f o r l a c e r a t i o n s f r o m b i t i n g d u r i n g a s e i zu r e . L o o k : f o r a d i p h t h e r i t i c me mb r a n e , o t h e r s i g n s o f p h a r y n g i t i s , o r u l c e r a t i o n o r d i s c o l o r a t i o f r o m p o i s o n s .r e a t h :S me l l t h e b r e a t h f o r a c e t o n e , a mmo n i a , a l c o h o l o r i t s B s u c c e s s o r a l d e h y d e s , p a r a l d e h y d e , a n d o t h e rao s : L o o k f o r p u s , s p i n a l f l u i d , E r dors. o r b l o o d e me r g i n g f r o m t h e e xt e r n a l a c o u s t i c me a t u s o r b l o o d b e h i n d t h e d r u m f r o m b a s i l a r s k u l l f r a c t u re c k : Te s t f o r n u c h a l r i g i d i t y, K e r n i g s i g n , a n d B r u d zi n s k i s i g n , N e. l o o k i n g f o r e v i d e n c e o f me n i n g e a l i r rCth e iso nP e r c u s s a n d a u s c u l t a t e t h e i at t: . c h e s t f o r p n e u mo t h o r a x, c o n s o l i d a t i o n , w h e e zi n g , o r c re a r t a t i o n .u l t a t e H e p i :Au s c f o r r h y t h m, r a t e , a n d s t r e n g t h o f t h e h e a r t s o u n d s a n d a n y a b n o r ma l s o u n d s . A b d o m e n : s c u l t a t e f o r b r u i t s a n d p a l p a t e f o r ma s s e s o r r i g i d i t y s u g g e s t i n g Au p e r i t o n i t i s o r f l u i idm b s :Te s t e a c h l i mb s u c c e s s i v e l y f o r f l a c c i d i t y b y l i f t i n g i t a n d L . l e t t i n g i t f a l l t o t h e b e d . If a n y mu s c l e t o n e i s r e t a i n e d , a d i f f e r e n c e i n t h e t w o s i d e i n d i c a t e s a h e mi p l e g i a . T h e r e f l e xe s o n t h e p a r a l y ze d s i d e a r e a b s e n t d u r i n g t h e s t a g e o f s p i n a l s h o c k , b u t i n d e e p c o ma , a l l r e f l e xe s a r e l o s t . In d e e p c o ma , t h e B a b i n s k i r e f l e x i s p r e s e n t b i l a t e r a l l y, s o i t c a n n o t b e e mp l o y e d t o l o c a l i ze a l e s i o n . s o me r e f l e xe s a r e r e t a i n e d , a d i f f e r e n c e i n t h e t w o s i d e s i s e ng n i r iyc a n t . S si so f E xa m i n a t i o nIn s e mi - c o ma , o n l y t h e r e s p o n s e s t o p a i n f u l s t i mu l i c a n b e e v a l u a t e d . : T he patient will show defensive reactions when pricked in sensitive areas, but no r e s p o n s e i s f o r t h c o mi n g w h e n a n a l g e s i c r e g i o n s a r e s t i mu l a t e d . If t h e s t i mu l a t e d r e g i o n i s s e n s i t i v e b u t p a r a l y ze d , a d e f e n s e o r w i t h d r a w a l mo v e me n t ma y o c c u r o n t h e o p p o s i t e s i d e ; t h e f a c i a l e xp r e s s i o n w i l l i n d i c a t e p a i n . D e e p p r e s s u r e s e n s e s h o u l d b e t e s t e d b y c o mp r e s s i o n o f t h e Ac h i l l e s t e n d o n , t h e t e s t i s , a n d t h e supraorbital notch. C l a s s i f y t h e s e r i o u s n e s s o f c e r e b r a l d y s f u n c t i o n b y u s i n g t h e G l a s g o w C o ma S c a l e (Ta b l e 1 4 -) 2i n w h i c h mi l d i s 1 3 t h r o u g h 1 5 , mo d e r a t e i s 9 t h r o u g h 1 2 , a n d s e v e r e i s 3 t h r o u g h 8 p o i n t s . P a t i e n t s w i t h s c o r e s l e s s t h a n 8 a r e i n c o ma .

TABLE 142 Glasgow Coma Scale


Response Score

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Ey es Open

_____

Spontaneous

_____

To s p e e c h

_____

To p a i n

_____

Ab s e n t

Ver bal

_____

Converses/oriented

_____

Converses/disoriented

_____

In a p p r o p r i a t e

_____

In c o mp r e h e n s i b l e

_____

Ab s e n t

M ot or

_____

Obeys

_____

L o c a l i ze s p a i n

5
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W i t h d r a w s ( f l e xi o n )

_____

D e c o r t i c a t e ( f l e xi o n ) r i g i d i t y

_____

D e c e r e b r a t e ( e xt e n s i o n ) r i g i d i t y 2

_____

Ab s e n t

D I F F E RE NT I AL D I AG NO S I S O F C O M A: T h e mu l t i p l e e t i o l o g i e s o f c o ma c a n b e c o n v e n i e n t l y d i v i d e d i n t o t h r e e c a t e g o r i e s , w h i c h ma y b e s u g g e s t e d b y f i n d i n g s f r o m t h e h i s t o r y a n d p h y s i c a l e xa mi n a t i o n . M E TAB O L I C E NC E P HAL O PAT HY: P a t h o p h y s i o l o g M:e t a b o l i c d e r a n g e me n t s o r t o xi n e xp o s u r e i mp a i r s b r a i n f u n c t i o n y a n d l e a d s t o c o mao ma o c c u r s w i t h n o r ma l p u p i l l a r y r e s p o n s e s , n o r ma l b r a i n s t e m C. r e f l e xe s a n d n o f o c a l n e u r o l o g i c d e f i c i t s . As t e r i xi s , my o c l o n u s , a n d C h e y n e - S t o k e s r e s p i r a t i o n c o - o c c u r. N o n e u r o i ma g i n g i s n e e d e d . T r e a t me n t i s c o r r e c t i o n o f t h e me t a b o l i c d i s t u r b a n c e . D e ler i u m p a g e 8 9 0 . Se i , M E TAB O L I C E NC E P HAL O PAT HY C L I NI C AL O C C URRE NC E : H y p o g l y c e mi a , h y p o xi a , h y p e r c a r b i a , h y p o n a t r e mi a , i n t o xi c a t i o n s ( e . g . , a l c o h o l , b e n zo d i a ze p i n e s , b a r b i t u r a t e s , o p i a t e s ) , s e v e r e h y p o t h y r o i d i s m, a n d ma n y o t h e r s .

T RANS T E NT O RI AL HE RNI AT I O N: P a t h o p h y s i o l o gAn e xp a n d i n g ma s s i n a s u p r a t e n t o r i a l c o mp a r t me n t mo v e s t i s s u e y: t o a n o t h e r c o mp a r t me n tp i c a l l y, t h e u n c u s o f t h e t e mp o r a l l o b e c o mp r e s s e s t h e Ty . t h i r d n e r v e a n d t h e n t h e mi d b r a i n i n i t i a l l y p r o d u c i n g f o c a l d e f i c i t s . P r o g r e s s i o n f r o m t h e f o c a l d e f i c i t s t o c o ma a n d d e a t h c a n b e r a p i d .

C L I NI C AL O C C URRE NC E : B r a i n t u mo r ( p r i ma r y o r me t a s t a t i c ) , b l e e d i n g ( i n t r a c e r e b r a l , s u b d u r a l , e p i d u r a l ) , c e r e b r a l e d e ma a s s o c i a t e d w i t h i n f a r c t i o n ( a r t e r i a l o r v e n o u s ) , a b s c e s s , e n c e p h a l i t i o r ma s s i v e l i v e r n e c r o s i s . B RAI NS T E M I NJ URY: P a t h o p h y s i o l o g D:i r e c t d a ma g e o c c u r s t o t h e b r a i n s t e m r e t i c u l a r a c t i v a t i n g s y s t e m y that runs from the upper pons to the lower diencephalon and is responsible for ma i n t a i n i n g c o n s c i o u s n e s s . o n s e t i s u s u a l l y a b r u p t , e i t h e r f o l l o w i n g t r a u ma o r T he a c u t e s e v e r e h e a d a c h e . E me r g e n t n e u r o i ma g i n g i s r e q u i r e d . C L I NI C AL O C C URRE NC E : T r a u ma a n d s p o n t a n e o u s h e mo r r h a g e a r e t h e mo s t c o mmo n e t i o l o g i e s .

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dgdiagnexam

Cerebrovascular Syndromes
P. 8 6 9

T r a n s i e n t I s c h e m i c At t a c k ( T I A) : P a t h o p h y s i o l o g T : r e s u l t s f r o m a f a i l u r e o f p e r f u s i o n d u e t o h e mo d y n a mi c y IA c a u s e s o r mi c r o e mb o l i s m. L e s s c o mmo n c a u s e s a r e i n s i t u a r t e r i a l t h r o mb o s i s , a r t e r i a l d i s s e c t i o n a n d v e n o u s s i n u s t h r o mb o s i s . T h e s y mp t o ms r e f l e c t t h e a r e a o f i s c h e mi aT IA i s , b y d e f i n i t i o n , t h e a c u t e o n s e t o f a f o c a l n e u r o l o g i c d e f i c i t i n a . specific vascular distribution with full recovery within 24 hours of onset. Events u s u a l l y l a s t 5 2 0 mi n u t e s . T h e d i f f e r e n t i a l d i a g n o s i s o f T IA i n c l u d e s c o n v u l s i o n s , s y n c o p e , mi g r a i n e , f o c a l c e r e b r a l ma s s e s , s u c h a s s u b d u r a l h e ma t o ma s , c a r d i a c diseases, and labyrinthine disorders. Diplopia, syncope, transient confusion, and p a r a p a r e s i s a r e u n c o mmo n s y mp t o ms o f T IA. N e u r o l o g i c s i g n s a r e u s u a l l y a b s e n t b e t w e e n a t t a c k s . T h e c o r r e c t d i a g n o s i s a n d p r o mp t e v a l u a t i o n o f T IA a r e i mp o r t a n t b e c a u s e i t i s a n i n d i c a t i o n o f i mp e n d i n g s e r i o u s c e r e b r a l i n f a r c t i o n ; u p t o 2 5 % o f p a t i e n t s w i t h a n e w T IA w i l l h a v e a s t r o k e w i t h i nJ 2 4 n so u r s S C . T r a n s i e n t oh h ton [ i s c h e mi c a t t a cN . Engl J M ed 0 0 2 ; 3 4 7 : 1 6 8 7 1 6.9 2 k 2 ] T RANS I E NT I S C HE M I C AT TAC K ( T I A) : C ARO T I D ART E RY T I A: S y mp t o ms a n d s i g n s a r e r e l a t e d t o t h e i p s i l a t e r a l c e r e b r a l h e mi s p h e r e a n d / o r r e t i n a F i n d i n g s i n c l u d e c o n t r a l a t e r a l w e a k n e s s , c l u ms i n e s s , n u mb n e s s o f t h e h a n d , h a n d a n d f a c e , o r e n t i r e h a l f o f t h e b o d y, d y s a r t h r i a , a p h a s i a , a n d i p s i l a t e r a l a ma u r o s i s f u g a x w i t h mo n o c u l a r v i s u a l l o s s ( w h i c h c a n b e c o mp l e t e b l i n d n e s s s e c t o r v i s u a l l o s s ) , u s u a l l y d e s c r i b e d a s a s h a d e c o mi n g d o w n . C a r o t i d b r u i t s o r r e t i n a l e mb o l i ma y b e f o u n d . AM AURO S I S F UG AX : P a t h o p h y s i o l o g C:h o l e s t e r o l e mb o l i f r o m r u p t u r e d a t h e r o s c l e r o t i c p l a q u e s i n t h e y c o mmo n o r i n t e r n a l c a r o t i d a r t e r y t r a n s i e n t l y o c c l u d e f l o w t o t h e T e t i rne l a r t e r y. rhe a i s s u d d e n o n s e t o f mo n o c u l a r b l i n d n e s s , o f t e n d e s c r i b e d a s a s h a d e b e i n g p u l l e d d o w n , w h i c h l a s t s a f e w mi n u t e s a n d r e s o l v e s s p o n t a n e o u s l y. It i s a t r a n s i e n t i s c h e mi c a t t a c k ( T IA) o f t h e i p s i l a t e r a l c a r o t i d c i r c u l a t i o n a n d c a r r i e s a 2 5 % r i s k o f s t r o k e i n t h e n e xt 4 8 h o u r s . T RANS I E NT I S C HE M I C AT TAC K ( T I A) : V E RT E B RO B AS I L AR ART E RY T I A: S y mp t o ms a n d s i g n s a r e r e l a t e d t o t h e p o s t e r i o r c i r c u l a t i o n a n d ma y a f f e c t v i s i o n a n d c r a n i a l n e r v e f u n c t i o n . F r e q u e n t c o mp l a i n t s a r e c o mb i n a t i o n s o f b i n o c u l a r v i s u a d i s t u r b a n c e o r l o s s , v e r t i g o , d y s a r t h r i a , a t a xi a , u n i l a t e r a l o r b i l a t e r a l w e a k n e s s o r n u mb n e s s a n d d r o p a t t a c k s ( s u d d e n l o s s o f p o s t u r a l t o n e a n d c o l l a p s e w i t h o u t l o s s of consciousness).

He m i p a r e s i s ( He m i p l e g i a ) : S t r o k e : P a t h o p h y s i o l o gP: r e s i s o f e i t h e r t h e r i g h t o r l e f t s i d e o f t h e b o d y i n d i c a t e s ya c o n t r a l a t e r a l d i s e a s e o f t h e b r a i n o r i p s i l a t e r a l h i g h s p i n a l d i s e a s e . T h e mo s t c o mmo n c a u s e i s v a s c u l a r o c c l u s i o n o f t h e mi d d l e c e r eC r a l s a r oe rs n e s s i s b o n c i t u y. n o t i mp a i r e d a n d t h e p a t i e n t i s s o me t i me s u n a w a r e o f t h e d e f i c i t . If t h e v i s u a l p a t h w a y s a r e a f f e c t e d , a h o mo n y mo u s h e mi a n o p s i a w i l l b e f o u n d . W i t h mi d d l e c e r e b r a l o c c l u s i o n s , t h e a r m i s mo r e s e v e r e l y a f f e c t e d t h a n t h e l e g ; w i t h a n t e r i o r c e r e b r a l a r t e r y s t r o k e , t h e l e g i s mo r e a f f e c t e d t h a n t h e a r m. C e r e b r a l v e n o u s s i n u s t h r o mb o s i s p r e s e n t s w i t h s y mp t o ms a n d s i g n s o f c e r e b r a l v a s c u l a r d i s e a s e w i t h l e s s
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dgdiagnexam

discrete evidence of focal lesions.

He m i p a r e s i s : C o n v e r s i o n Re a c t i o n : In p a t i e n t s w i t h c o mp l a i n t s o f u n i l a t e r a l w e a k n e s s o r p a r a l y s i s o f t h e l e g s b u t c o n f u s i n g f i n d i n g s , t r y t o e l i c i t t h er s i gnw h i c h d e p e n d s o n t h e a b s e n c e o f a Hoov e , n o r ma l a s s o c i a t e d mo v e meyn t (i nes i) a P l a c e t h e p a t i e n t s u p i n e , s t a n d a t t h e s nk . f o o t o f t h e t a b l e , a n d p l a c e a p a l m u n d e r e a c h h e e l . As k t h e p a t i e n t t o r a i s e t h e a f f e c t e d l i mb ( sF ie . 1 4 - 9)D N o r ma l l y, t h e u n a f f e c t e d l i mb w i l l p r e s s d o w n w a r d i n eg . t h e e f f o r t t o r a i s e t h e a f f e c t e d l i mb . In n e i t h e r o r g a n i c d i s e a s e n o r h y s t e r i a w i l l t h e l e g b e n o r ma l l y r a i s e d , b u t i n o r g a n i c d i s e a s e , t h e a s s o c i a t e d mo v e me n t o f p r e s s i n g d o w n w i t h t h e u n a f f e c t e d h e e l w i l l s t i l l b e p r e s e n t . It i s a b s e n t i n c o n v e r s i o n r e a c t i o n . T h e s i g n i s h e l p f u l o n l y w h e n t h e p a t i e n t h a s , o r c l a i ms t o h a v e , p a r a l y s i s o f o n e l e g . P a r a p l e g i a mu s t b e e xc l u d e d .


P. 8 7 0

Caver nous Sinus T hr ombosis: P a t h o p h y s i o l o g T : r o mb o s i s w i t h o c c l u s i o n o f t h e c a v e r n o u s s i n u s r e s u l t s yh f r o m b a c t e r i a l i n f e c t i o n o f t h e u p p e r l i p , t o o t h s o c k e t , e y e st ,i eo rt s ap re . s e n t Pa n f c e w i t h p a i n i n t h e e y e a n d f o r e h e a d , c h i l l s , f e v e r, a n d i mp a i r e d v i s i o n . P h y s i c a l f i n d i n g s i n c l u d e c h e mo s i s , e d e ma o f t h e e y e l i d s , e xo p h t h a l mo s , h y p e r e mi a , p a p i l l e d e ma , o r b i t a l t e n d e r n e s s , a n d c r a n i a l n e r v e p a l s i e s o f C N - III, - IV, a n d - VI. P r o g r e s s i o n l e a d s t o l e p t o me n i n g i t i s , b l i n d n e s s , i n t r a c e r e b r a l a b s c e s s , s e p t i c e mi a , and death.

Other M otor and Sensory Syndromes

T r i g e m i n a l Ne u r a l g i a : T i c D o u l o u r e u x : T h e c a u s e i s u n k n o w n . P a r o xy s ms o f e xc r u c i a t i n g p a i n o c c u r i n t h e d i s t r i b u t i o n o f a b r a n c h o f t h e f i f t h c r a n i a l n e r v e , o f t e n t r i g g e r e d b y c o l d a i r o n t h e f a c e , s n e e zi n g , s h a v i n g , c h e w i n g , o r o t h e r mo v e me n t s . M u s c l e s p a s ms , f l u s h i n g o f t h e f a c e , l a c r i ma t i o n , a n d s a l i v a t i o n , ma y o c c u r d u r i n g a n a t t a c k .

Par apar esis: P a t h o p h y s i o l o g L o s s o f mo t o r p o w e r t o b o t h l e g s i n d i c a t e s a t r a n s v e r s e y: l e s i o n o f t h e s p i n a l c o r d . T h e l e v e l i s d e t e r mi n e d b y t h e s e n sF rre q fui e n ti n g s . o y nd c a u s e s o f p a r a p a r e s i s a r e t r a u ma a n d t r a n s v e r s e my e l i t i s , w h i c h ma y f o l l o w s e v e r a l d i f f e r e n t t y p e s o f v i r a l i n f e c t i o n . E xt r i n s i c c o r d c o mp r e s s i o n b y h e r n i a t e d d i s k o r e p i d u r a l a b c e s s o r n e o p l a s m a r e l e s s c o mmo n b u t p o t e n t i a l l y t r e a t a b l e .

Quadr ipar esis: P a t h o p h y s i o l o g P : r e s i s o r p a r a l y s i s o f a l l l i mb s w i t h o u t c h a n g e s i n ya c o n s c i o u s n e s s i n d i c a t e s i mp a i r me n t o f t h e d e s c e n d i n g c o r t i c o s p i n a l ( p y r a mi d a l ) t r a c t s .T h e mo s t c o mmo n c a u s e i s t r a u ma t i c i n j u r y t o t h e c e r v i c a l s p i n e ; i n t h i s c a s e t h e b u l b a r mu s c l e s a r e s p a r e d . L e s s c o mmo n , b u t n o t r a r e , c a u s e s , u s u a l l y w i t h s o me b u l b a r i n v o l v e me n t , a r e mu l t i p l e s c l e r o s i s , p r i ma r y mo t o r s y s t e m d i s e a s e ( e . g a my o t r o p h i c l a t e r a l s c l e r o s i s ) , a n d b o t u l i s m. O n s e t o f n o n t r a u ma t i c g e n e r a l i ze d weakness or paralysis over a few hours or days suggests an electrolyte disturbance ( mo s t c o mmo n l y s e v e r e h y p o k a l e mi a ) . In t h e h o s p i t a l , o t h e r c a u s e s t o b e c o n s i d e r e are inadvertently high spinal anesthesia, paralytic drugs, and the polyneuropathy o
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dgdiagnexam

severe illness. P. 8 7 1

M ultiple Scler osis: P a t h o p h y s i o l o g M:u l t i f o c a l d e my e l i n i za t i o n o c c u r s i n t h e n e r v o u s s y s t e m y p r e s u me d t o b e me d i a t e d b y a u t o i mmu n e me c h ah e so n s.e t i s u s u a l l y f a i r l y T n i ms a b r u p t o v e r h o u r s t o a f e w d a y s , w i t h r e mi s s i o n s o c c u r r i n g o v e r w e e k s , i f a t a l l . Ac u t e o p t i c n e u r i t i s w i t h t r a n s i e n t v i s u a l l o s s i s a c o mmo n p r e s e n t i n g s y mp t o m. O t h e r s y mp t o ms i n c l u d e i n c o o r d i n a t i o n , p a r e s t h e s i a s , w e a k n e s s a n d l o s s o f s p h i n c t e r c o n t r o l . T h e s i g n s d e p e n d u p o n t h e l o c a t i o n o f t h e d e my e l i n a t i n g l e s i o n ( s a t a xi a , d y s a r t h r i a , i n t e n t i o n t r e mo r, o c u l a r p a l s i e s , v i s u a l l o s s , h y p e r a c t i v e d e e p r e f l e xe s , d i mi n i s h e d a b d o mi n a l r e f l e xe s , a n d t r o p h i c c h a n g e sChar k iot . T h e in sc n t r i ad o f s i g n s i s i n t e n t i o n t r e mo r, n y s t a g mu s , a n d s c a n n i n g s p e e c h . T h e d i s e a s e ma y b e p r o g r e s s i v e f r o m o n s e t w i t h i n e xo r a b l e l o s s o f f u n c t i o n , o r r e l a p s i n g - r e mi t t i n g w i t h c o mp l e t e r e s o l u t i o n o f t h e s y mp t o ms a n d s i g n s b e t w e e n r e l a p s e s . M a n y p a t i e n t s w i t h i n i t i a l l y r e l a p s i n g r e mi t t i n g d i s e a s e w i l l p r o g r e s s t o c h r o n i c p r o g r e s s i d i s e a s e w i t h i n c o mp l e t e r e mi s s i o n s o f e a c h C o mp s te n A, C o l e s A. M u l t i p l e relaps o [ s c l e r o s i sLanc et2 0 0 2 ; 1 2 2 1 1 2]3 1 . .

Am y o t r o p h i c L a t e r a l S c l e r o s i s : P a t h o p h y s i o l o g D:e g e n e r a t i o n o f u p p e r a n d l o w e r mo t o r n e u r o n s l e a d s t o y p r o g r e s s i v e w e a k n e s s a n d mu s c l e w a s tend i.s e a s e b e g i n s g r a d u a l l y, p r o c e e d s Th i g p r o g r e s s i v e l y, a n d e n d s f a t a l l y i n 2 t o 3 y e a r s . M u s c l e a c h e s a n d c r a mp s a r e a c c o mp a n i e d b y w e a k n e s s o f d i s t a l u p p e r l i mb s , s p r e a d i n g t o t h e l o w e r e xt r e mi t i e s ; d y s a r t h r i a , d y s p h a g i a , a n d d r o o l i n g i n d i c a t e b u l b a r i n v o l v e me n t . M u s c l e f a s c i c u l a t i o a n d a t r o p h y a r e s e e n , e s p e c i a l l y i n u p p e r l i mb s . F a s c i c u l a t i o n s ma y b e e v i d e n t i n t h e t o n g u e . H y p e r r e f l e xi a a n d s p a s t i c i t y o f l o w e r l i mb s i n d i c a t e u p p e r mo t o r n e u r o n i n v o l v e me nR o w l a n d L P, S h n e i d e r N A. Amy o t r o p h i c l a t e r a l s c lEngl i J . M ed t [ N eros s 2 0 0 1 ; 3 4 4 : 1 6 8 8 1 7.0 0 ] Poliomyelitis: P a t h o p h y s i o l o g In:f e c t i o n o f t h e s p i n a l c o r d b y p o l i o my e l i t i s v i r u s t y p e s I, II, o r III y l e a d s t o d e s t r u c t i o n o f l o w e r mo t o r n e u rloo s t i l l o c c u r s o u t s i d e t h e W e s t e r n . Po i n s H e mi s p h e r e , d e s p i t e e f f o r t s t o e r a d i c a t e i t t h r o u g h v a c c i n a t i o n . F e v e r, h e a d a c h e , s o r e t h r o a t , s t i f f n e c k , a n d p a i n i n t h e b a c k a n d l i mb s i s f o l l o w e d b y i n a b i l i t y t o mo o n e o r mo r e mu s c l e g r o u p s . S i g n s a r e v a r y i n g d e e p r e f l e xe s , w e a k n e s s , f a s c i c u l a t i o n s , h y p e r e s t h e s i a , p a r e s t h e s i a s , a n d l y mp h a d e n o p a t h y. K e r n i g a n d B r u d zi n s k i s i g n s ma y b e p r e s e n t . H e a l i n g ma y l e a d t o c o mp l e t e r e t u r n o f f u n c t i o n o r b e f o l l o w e d b y mu s c u l a r a t r o p h y. B u l b a r i n v o l v e me n t l e a d s t o w e a k n e s s o f t h e p h a r y n g e a l mu s c l e s a n d d i a p h r a g m. M a n y y e a r s a f t e r r e c o v e r y, i n s i d i o u s w e a k n e s s ma y r e c u r i n t h e a f f e c t e d mu s c l ets , i o s y ndr ome pos pol .
P. 8 7 2

Syr ingomyelia and Chiar i M alfor mations: P a t h o p h y s i o l o g T : e r e i s c a v i t a r y e xp a n s i o n w i t h i n t h e c e r v i c a l s p i n a l c o r d t h a t yh d a ma g e s t h e c e n t r a l l y c r o s s i n g s e n s o r y t r a c t s a n d t h e p y r a mi d a l t r a c t s . S y r i n g o my e l i a y(r i nx t o b e c o me h o l l omy el i a ma r r o w ) i s o f u n k n o w n c a u s e . s w; S y r i n g o my e l i a i s f r e q u e n t l y a s s o c i a t e d w i t h h i n d b r a i n ma l f o r ma t i o n s h e r n i a t i o n o f t h e c e r e b e l l a r t o n s i l s t h r o u g h t h e f o r a me n ma g n u m ( C h i a r i t y p e 1 ) . P a t i e n t s p r e s e n t


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w i t h d e c r e a s e d p a i n a n d t e mp e r a t u r e s e n s a t i o n i n t h e a r ms a n d s h o u l d e r s , l o w e r mo t o r n e u r o n w e a k n e s s i n t h e a r ms a n d u p p e r mo t o r n e u r o n w e a k n e s s w i t h s p a s t i c i t y i n t h e l e g s . C h i a r i t y p e 2 ma l f o r ma t i o n ( i n c o mp l e t e c l o s u r e o f t h e s p i n a l c a n a l ) i s a l w a y s a c c o mp a n i e d b y my e l o me n i n g o c e l e .

Ta b e s D o r s a l i s : Ne u r o s y p h i l i s o f t h e S p i n a l C o r d : P a t h o p h y s i o l o g C:h r o n i c i n f e c t i o n w i teponema pal l i dum d u c e s y Tr h pro d e g e n e r a t i o n o f t h e s p i n a l c o r d p o s t e r i o r c o l u mn s , d o r s a l r o o t s , a n d d o r s a l r o o t g a n g l i a . y mp t o ms i n c l u d e l i g h t n i n g - l i k e p a i n s i n t h e t r u n k a n d l o w e r l i mb s , S p a r e s t h e s i a s , u r i n a r y i n c o n t i n e n c e , a n d i mp o t e n c e . T h e r e i s l o s s o f p o s i t i o n s e n s e , a t a xi c w i d e - b a s e d g a i t , f o o t - d r o p , a n d l o s s o f r e f l e xe s . L o s s o f p o s i t i o n s e n s e l e a d s t o j o i n t d e s t r u c t i o n w i t h C h a r c o t d e f oTabete s . c r i s i s a b d o mi n a l p a i n a n d r mi t i i c v o mi t i n g w i t h a r e l a xe d a b d o mi n a l w a l l . G e n e r a l P a r e s i s : Ne u r o s y p h i l i s o f t h e B r a i n : P a t h o p h y s i o l o g B : a i n i n f e c t i o n w i t eponema pal l i dum d u c e s a t e r t i a r y yr Tr h pro s y p h i l i s s y n d r o me o f d e g e n e r a t i v e b r a i n d i h e af sn d i n g c a n b e r e c a l l e d u s i n g T s i e. t h e p n e u mo n i c PAR E S IS : p e r s o n a l i t y, a f f e c t , l o s s o f r e f l e xe s , e y e f i n d i n g s ( Ar g y l l R o b i n s o n p u p i l ) , s e n s o r y c h a n g e s , i n t e l l e c t u a l d e t dementiio n pr ec)oxa n d eriorat a ( , s p e e c h c h a n g e s . O t h e r s i g n s o f t e r t i a r y s y p h i l i s ma y b e p r e s e n t , s u c h a s a o r t i t i s w i t h a o r t i c i n s u f f i c i e n c y a n d g u mma f o r ma t i o n .

He m i s e c t i o n o f t h e S p i n a l C o r d : B r o w n S e q u a r d S y n d r o m e : P a t h o p h y s i o l o g H:e mi s e c t i o n o f t h e c o r d d a ma g e s t h e i p s i l a t e r a l d e s c e n d i n g y mo t o r p a t h w a y s a n d a s c e n d i n g p r o p r i o c e p t i v e p a t h w a y s ( c r o s s i n t h e b r a i n s t e m) , a n d t h e c o n t r a l a t e r a l s e n s o r y p a t h w a y s f o r p a i n a n d t e mp e r a t u r e ( c r o s s a t t h e i r s p i n a l r o o t l e v e lP ) .t i e n t s h a v e mo t o r p a r a l y s i s w i t h s p a s t i c i t y a n d l o s s o f sa p r o p r i o c e p t i o n o n t h e s i d e o f t h e l e s i o n a n d a b s e n t p a i n a n d t e mp e r a t u r e s e n s a t i o n o n t h e o p p o s i t e s i d e , b e l o w t h e l e v e l o f t h e i n j u r y.

Botulism: P a t h o p h y s i o l o g N:e u r o t o xi n s p r o d u c e d bos t r i di um bot ul i numy b e i n g e s t e d y Cl y ma o r a b s o r b e d f r o m c o n t a mi n a t e d w o uy mp t. o ms o n s e t i s o v e r h o u r s w i t h v a r i a b l e S nds c o mb i n a t i o n s o f w e a k n e s s , h e a d a c h e , d i zzi n e s s , d y s p h a g i a , a b d o mi n a l p a i n , n a u s e a a n d v o mi t i n g , d i a r r h e a , a n d d i p l o p i a . P h y s i c a l f i n d i n g s i n c l u d e f i xe d a n d d i l a t e d p u p i l s , n y s t a g mu s , p t o s i s , i r r e g u l a r r e s p i r a t i o n , s w o l l e n t o n g u e , h y p o r e f l e xi a , a n d i n c o o r d i n a t i o n . Imp r o p e r l y c a n n e d f o o d s p r e p a r e d i n t h e h o me a r e t h e mo s t c o mmo n cause.
P. 8 7 3

M yasthenia Gr avis: P a t h o p h y s i o l o gAn a u t o a n t i b o d y b i n d s t o t h e a c e t y l c h o l i n e r e c e p t o r a t t h e y: n e u r o mu s c u l a r j u n c t i o n b l o c k i n g n e u r o mu s c u l a r t r a n s mi s s i o n , e s p e c i a l l y w i t h r e p e t i t i v e e xc i t a t iAfn .e c t e d i n d i v i d u a l s c o mp l a i n o f i n c r e a s e d f a t i g a b i l i t y, t r a n s i e n t o f mu s c l e w e a k n e s s , d i p l o p i a , p t o s i s , e a s y f a t i g u e w i t h c h e w i n g a n d t a l k i n g , r e g u r g i t a t i o n , a n d d y s p h a g i a . D u r i n g a n a t t a c k t h e r e ma y b e l a c k o f f a c i a l e xp r e s s i o n , a b n o r ma l s p e e c h o r a p h o n i a , d i s c o n j u g a t e g a ze . In e xt r e me c a s e s , t h e p a t i e n t s o me t i me s c a n n o t l i f t h i s h e a d f r o m t h e p i l l o w w i t h o u t h a n d s u p p o r t . T h e r e i a n a s s o c i a t i o n w i t h t h y mo ma .


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Te t a n u s : Te t a n u s i s c a u s e d b y t h e t o xi nos tf r i di um t et ani t i n g o n my o n e u r a l j u n c t i o n s . A Cl o ac s i n g l e mu s c l e o r ma n y g r o u p s b e c o me r i g i d w i t h s u s t a i n e d t o n i c s p a s m. T h e ma s s e t e r i s f r e q u e n t l y i n v o l v e d e a r l y, h e n c e t h e t e rtmi s o c k j.aL o ( d n o i s e s , r l mus w u ) b r i g h t l i g h t s , o r p a i n i n d u c e s u p e r i mp o s e d v i o l e n t g e n e r a l i ze d s p a s ms . T h e c o n d i t i o s h o u l d n o t b e c o n f u s e d w i t h t e t a n y, w h i c h i t r e s e mb l e s o n l y i n n a me .

Ra b i e s : P a t h o p h y s i o l o g In:f e c t i o n b y a n e u r o t r o p i c v i r u s i s t r a n s mi t t e d b y t h e b i t e o f y i n f e c t e d ma mma lO n s e t i s ma r k e d b y l o c a l d y s t h e s i a r a d i a t i n g f r o m t h e s i t e o f s. e n t r y, ma l a i s e , n a u s e a , a n d s o r e t h r o a t . L a t e r, r e s t l e s s n e s s a n d h a l l u c i n a t i o n s o c c u T h e r e i s h y p e r e s t h e s i a o f t h e w o u n d a n d l a t e r, d y s a r t h r i a , d y s p h a g i a f o r f l u i d s , c o n v u l s i o n s , d e l i r i u m, a n d o p i s t h o t o n o s s t i mu l a t e d b y l i g h t s o r n o i s e s . B r e a t h i n g b e c o me s s h a l l o w a n d i r r e g u l a r w i t h h o a r s e n e s s o r a p h o n i a . T h e s t r e t c h r e f l e xe s a r e h y p e r a c t i v e a n d t h e r e i s n u c h a l r i g i d i t y, B a b i n s k i s i g n f o l l o w e d b y f l a c c i d p a r a l y s i s , a n d d e a t h . A h i g h i n d e x o f s u s p i c i o n i s r e q u i r e d t o ma k e t h e d i a g n o s i s a n d t o p r o t e c contacts to body fluids. Many patients diagnosed in the United States do not have a i d e n t i f i e d s o u r c e o f i n f e c t i o n ; b a t s a r e t h e mo s t c o mmo n s o u r c e w h e n o n e i s identified.

Dystonias: D y s t o n i a s a r e a b n o r ma l l y p r o l o n g e d t o n i c c o n t r a c t i o n s o f a mu s c l e o r mu s c l e g r o u p D y s t o n i a s a r e o f t e n a s s o c i a t e d w i t h c e r t a i n a c t i v i t i e s a n d c a n b e c o me d i s a b l i n g . T h p a t i e n t w i l l r e f e r t o t h e m a s a c r a mp . E xa mp l e s a r e w r i t e r ' s c r a mp , t o r t i c o l l i s , a n d d y s t o n i a s a s s o c i a t e d w i t h p l a y i n g mu s i c a l i n s t r u me n t s . Ac u t e D e m y e l i n a t i n g P o l y n e u r o p a t h y : G u i l l a i n - B a r r S y n d r o m e : P a t h o p h y s i o l o g T : i s i s a n i mmu n e - me d i a t e d d e my e l i n a t i n g d i s o r d e r o c c u r r i n g 1 yh 3 w e e k s a f t e r v i r a l i n f e c t i o n , l obac t er j ej uni s t r o e n t e r i t i s , o r, r a r e l y, a f t e r Campy ga s u r g e r y o r w i t h ma l i g n a n t l y mp h o mae i s u s u a l l y r a p i d l y p r o g r e s s i v e a s c e n d i n g T her . mo t o r w e a k n e s s w i t h p a i n i n b a c k a n d l i mb s , h e a d a c h e , a n d d i s t a l n u mb n e s s a n d t i n g l i n g . N a u s e a a n d v o mi t i n g c a n o c c u r. T h e r e i s a s c e n d i n g f l a c c i d p a r a l y s i s w i t h d i mi n i s h e d d e e p a n d s u p e r f i c i a l r e f l e xe s . C r a n i a l n e r v e i n v o l v e me n t c a u s e s d y s p h a s i a , d y s p h a g i a a n d d y s a r t h r i a . W i t h c h e s t w a l l i n v o l v e me n t , r e s p i r a t o r y f a i l u supervenes.


P. 8 7 4 P. 8 7 5

P e r i p h e r a l Ne u r o p a t h y : P a t h o p h y s i o l o gP: r i p h e r a l n e r v e d y s f u n c t i o n i n t h e a b s e n c e o f c e n t r a l n e r v o u s ye s y s t e m d i s e a s e i s c o mmo n . D i f f u s e l e s i o n s a r e c l a s s i f i e d a s a xo n a l i f t h e n e r v e c e l l a xo n i s p r i ma r i l y i n v o l v e d , o r d e my e l i n a t i n g i f t h e l e s i o n i s i n t h e my e l i n c o a t i n g o f t h e n e r v e . S i n g l e n e r v e t r u n k l e s i o n s ma y b e t r a u ma t i c , i s c h e mi c , o r i n f l a mma t o r y. P a t i e n t s p r e s e n t w i t h c o mp l a i n t s o f n u mb n e s s , b u r n i n g , u n s t e a d i n e s s ( o f t e n d e s c r i b e d a s d i zzi n e s s ) , f a l l i n g , o r w e a k n e s s . P h y s i c a l e xa m ma y s h o w s e n s o r y i mp a i r me n t ( p r e s s u r e , v i b r a t i o n , p o s i t i o n , p a i n a n d t e mp e r a t u r e o r s i mp l e t o u c h d e p e n d i n g o n t h e s i ze o f n e r v e s i n v o l v e d ) , mu s c l e w e a k n e s s a n d a t r o p h y w i t h f a s c i c u l a t i o n s , a n d / o r d i mi n i s h e d r e f l e xe s . R e l e a s e s i g n s a r e n o t p r e s e n t a n d p l a n t a


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r e s p o n s e i s f l e xo r i f p r e s e n t . D i f f u s e s y mme t r i c a l n e u r o p a t h i e s a r e u s u a l l y s e n s o r y a t o n s e t a n d l a t e r i n v o l v e mo t o r n e r v e s ; t h e y a r e p r i ma r i l y d i s t a l a n d p r o g r e s s p r o xi ma l l y a f f e c t i n g t h e f e e t b e f o r e t h e h a n d s . Is o l a t e d n o n t r a u ma t i c i n v o l v e me n t o f a l l c o mp o n e n t s o f a s i n g l e n e r v e i smononeur i t i s mul t i pl u s u a l l y r e s u l t i n g called , ex f r o m a n i n f l a mma t o r y l e s i o n c a u s i n g i s c h e mi a ; r e c o v e r y i s c o mmo n a n d c o mp l e t e [H u g h e s R AC . P e r i p h e r a l n e u r o p a t h y. 0 0 2 ; 3 2 4 : 4 6 6 4 6 9 n c e l e t AN . An BM J 2 ; Po a l g o r i t h m f o r t h e e v a l u a t i o n o f p e r i p h e r a l n eAm p a t h y. u r o Fam Phy s i c i an 1 9 9 8 ; 5 7 : 7 5 5 7]6 4 .

P E RI P HE RAL NE URO PAT HY C L I NI C AL O C C URRE NC E : Congeni t al h a r c o t - M a r i e - To o t h d i s e a s e , p o r p h y r i a , f a mi l i a l n Endoca t h y ; C e u r o p r i ne d i a b e t e sI;di opat hi c U p o l y n e u r o p a t h y, i d i o p a t h i c p o l y n e u r o pec t i y ; IC I nf a t h ous l e p r o s y, r a b i e s ( e a r l y a t i n o c u l a t i o n s i t e ) , p o s t h e r p e t i c n e u r a l g i a ; I nf l ammat or y / I mmuneu t e a n d c h r o n i c i n f l a mma t o r y p o l y n e u r o p a t h y, v a s c u l i t i s , ac s y s t e mi c l u p u s e r y t h e ma t o s u s , a my l o i d o s i s , c e l i a c d i s e a s e ;al / Tr auma M ec hani c c o n t u s i o n a n d l a c e r a t i o n , r e p e t i t i v e u s e , v i b r a t i o n ( e . g . , j a c k h a mme r s , p n e u ma t i c d r i l l s ) , c o l d i n j u r y ( c h i l b l a i n s a n d f r o s t b i t e ) , e l e c tM c aabol uc / Tox i c r i et l i n j i r y ; a my l o i d o s i s , p o r p h y r i a , d i a b e t e s , p o i s o n i n g ( a r s e n i c , o t h e r h e a v y me t a l s , p y r i d o xi n e ) , d r u g s ( e . g . , v i n c r i s t i n e ) , n u t r i t i o n a l d e f i c i e n c y2 (a n tda mi n s B 1 v i B) ; 6 Neopl as t i c a r a n e o p l a s t i c s y n d r o me s , me t a s t a t i c i n v a s i o n o f n c hoss ; i al p Ps y e r v e oc s u b s t a n c e a b u s e p r o d u c i n g u n c o n s c i o u s n e s s w i t h p r e s s u r e - i n d u c e d i s c h e mi a ; Vas c ul arv a s c u l i t i s .

P E RI P HE RAL NE URO PAT HY: D I AB E T E S : P a t h o p h y s i o l o g D:i a b e t e s t y p e s 1 a n d 2 a r e a s s o c i a t e d w i t h p e r i p h e r a l n e r v e y i n j u r y w i t h a l a t e n c y o f a b o u t 1 5 y e a r s f r o m o n s e t f o r t y p e 1 . D a ma g e i s t h o u g h t t o b e me t a b o l i c i n mo s t f o r ms , a n d i s c h e mi c i n t h e a c u t e r e v e rS eb le r a o r ms . si v e fl f o r ms o f d i a b e t i c n e u r o p a t h y a r e r e c oD ins zeld .s e n s o r i m o t o r n e u r o p as h y g ita it mo s t c o mmo n , p r e s e n t i n g a s n u mb n e s s o r b u r n i n g p a i n i n t h e f e e t a n d p r o g r e s s i n g p r o xi ma l l y w i t h l o s s o f p r o t e c t i v e s e n s a t i o n , t r o p h i c s k i n c h a n g e s , p r e s s u r e - i n d u c e d i s c h e mi c u l c e r a t i o n , a n d i n f e c t i o n l e a d i n g t o a mp u t a t i o n , i f p r e v e n t i v e me a s u r e s a r e n o t t a k e n . L i mb s a t r i s k a r e i n s e n s i t i v e t o a 1 0 - g mo n o f iSa mejn t M , s H u n t l mi e a t e t [ D L , E d e l ma n D , e t a l . C l i n i c a l e xa mi n a t i o n f o r t h e d e t e c t i o n o f p r o t e c t i v e s e n s a t i o n i n t h e f e e t o f d i a b e t i c p a t i e n t s . In t e r n a t i o n a l C o o p e r a t i v e G r o u p f o r C l i n i c a l E xa mi n a t i o n R e s e a rJ h . c Gen I nt er n M ed 9 9 ; 1 4 : 4 1 8 4] 2 4 s e v e r e f o r ms , 19 . In mu s c l e w a s t i n g a n d C h a r c o t j o i n t s A u tco n o m i c n e u r o p a tfh e q u e n t l y o c u r. ry i n v o l v e s t h e s t o ma c h w i t h g a s t r o p a r e s i s a n d d e l a y e d g a s t r i c e mp t y i n g w h i c h ma y ma k e c o n t r o l o f b l o o d s u g a r s v e r y d i f f i c u l t . S u d o mo t o r i n j u r y c o n t r i b u t e s t o s k i n f r a g i l i t y a n d u l c e r a t i o n . Imp o t e n c e i s c o mmo n a n d c o l o n a n d b l a d d e r d y s f u n c t i o n n o r a r e . T h e s e n s o r i mo t o r a n d a u t o n o mi c n e u r o p a t h i e s a r e d e l a y e d o r p r e v e n t e d b y t i g h t c o n t r o l o f b l o o d g l u c o s e .e t i c a m y o t r o p h y o r p o l y r a d i c u l oi p aa n y Diab s th a c u t e , p a i n f u l , i n f l a mma t o r y o r i s c h e mi c i n j u r y t o o n e o r mo r e s p i n a l r o o t s . P a t i e n t s p r e s e n t w i t h s e v e r e b a c k , c h e s t , a b d o mi n a l o r p r o xi ma l l e g p a i n , a n d p r o g r e s s i v e w e a k n e s s , a n d ma y h a v e b o w e l a n d b l a d d e r d y s f u n c t i o n . It i s u s u a l l y a c u t e i n o n s e t a n d a s y mme t r i c . R e c o v e r y i s e xp e c t e d o v e r mo n t h s i n mo s t p e oc rl a n iIs lo l a t e d p e. a n e r ve p a l s i e s s p e c i a l l y C N - III, - IV, a n d - VI a r e n o t u n c o mmo n a n d o f t e n mi s t a k e n , e f o r mu c h mo r e s e r i o u s i n t r a c r a n i a l p a t h o l o g y. T h e p u p i l i s s p a r e d i n C N - III l e s i o n s . D i a b e t i c a my o t r o p h y a n d c r a n i a l n e r v e l e s i o n s a r e n o t c l e a r l y r e l a t e d t o t h e d u r a t i o of diabetes or degree of blood sugar control.
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M e d i a n Ne u r o p a t h y : C a r p a l Tu n n e l S y n d r o m e : P a t h o p h y s i o l o g T : e me d i a n n e r v e i s c o mp r e s s e d i n t h e c a r p a l t u n n e l u n d e r t h e yh f l e xo r r e t i n a c u l u m o f t h e w r i s t b y f i b r o s i s o f t h e t e n d o n s h e a t h s , t r a u ma , a r t h r i t i s , o s o f t - t i s s u e s w e l l i n g .mp t o ms i n c l u d e n u mb n e s s a n d t i n g l i n g o f t h e h a n d i n a Sy variable distribution, often the entire volar surface of the hand. Signs include d e c r e a s e d s e n s a t i o n o n t h e v o l a r s u r f a c e o f t h e t h u mb , i n d e x, mi d d l e a n d r a d i a l h a l o f t h e r i n g f i n g e r. W i t h a d v a n c e d d i s e a s e t h e r e i s a t r o p h y o f t h e t h e n a r e mi n e n c e a n d w e a k n e s s o f t h u mb a b d u c t i o n a n d o p p o s i t i o n . O n e xa mi n a t i o n , i n c r e a s e d p a r e s t h e s i a a n d p a i n ma y b e e l i c i t e d w i t h f l e xi o n o f w r i s t s ( P h a l e n s i g n ) , o r t a p p i n g t h e me d i a n n e r v e i n t h e c a r p a l t u n n e l ( T i n e l s i g n ) . C L I NI C AL O C C URRE NC E : C a u s e s i n c l u d e r e p e t i t i v e u s e i n j u r y, d i a b e t e s me l l i t u s , mu l t i p l e my e l o ma , a my l o i d o s i s , a c o n g e n i t a l l y s ma l l c a r p a l t u n n e l , a n d r h e u ma t o i d a r t h r i t i s .

Disorders of Language and Speech


D i s o r d e r s o f S p e e c h : D y s a r t h r i a , D y s p h o n i a , At a x i a , a n d Ap r a x i a : Al t e r a t i o n s o f s p e e c h ma y b e c o n s i d e r e d i n s e v e r a l c a t e g o r i e s . ART I C UL AT I O N: D Y S ART HRI A: Ar t i c u l a t i o n i s t h e p r o d u c t i o n o f s o u n d s a n d t h e i r c o mb i n a t i o n s i n t o s y l l a b l e s . D i s o r d e r s o f t h e b r a i n p r ody s ar t hr i a;p e c i f i c d y s a r t h r i a s a r e i d e n t i f i e d b y t h e duce s t y p e s o f s o u n d s w h i c h a r e i mp r o p e r l y f o r meh a ps e r ,7p a g e 2 2 6 Dy s l al i a s C d (t e ). i i mp a i r e d a r t i c u l a t i o n f r o m n o n - n e u r o l o g i c s t r u c t u r a l d e f e c t s o r h e a r i n g l o s s . V O I C E : D Y S P HO NI A: T h i s c o n c e r n s p h o n a t i o n , r e s o n a t i o n , p i t c h , q u a l i t y, aDy s v o l u mes t h e n d phoni a . i d i s t u r b a n c e i n p i t c h , q u a l i t y, a n d v o l u me . al i ta n dhy ponas al i trye f e r t o Hy per nas y nasal resonance. RHY T HM : ATAX I A: T h i s d e a l s w i t h t h e t i mi n g a n d s e q u e n c e o f s y l l a b l e s . Ir r e g u l a r, s l o w s p e e c h w i t h p a u s e s a n d b u r s t s o f s o u n d s i s s c anni ng s peec h d i n d i c a t e s a c e r e b e l l a r called an d i s o r d e r, f o r e xa mp l e , mu l t i p l e s c l e r o s i s . F a l t e r i n g o r i n t e r r u p t i o n s i n s p e e c h a r e t e r me ds t ut t er i ng;h i s i s f r e q u e n t l y i n h e r i t e d o r ma y b e a d e v e l o p me n t a l d i s o r d e r. t S O UND S E L E C T I O N: AP RAX I A: T his is the inability to properly and consistently program a correct sequence of sounds, especially consonants. Have the patient repeat the word artillery five t i me s ; e a c h s o u n d i s f o r me d c o r r e c t l y, b u t t h e y a r e mi s p l a c e d a n d n o t w o a t t e mp t s ma y b e a l i k e . T h e p r o b l e m i s e v i d e n t w i t h w r i t i n g a s w e l l a s s p e e c h .
P. 8 7 6

D i s o r d e r s o f L a n g u a g e : Ap h a s i a s : L a n g u a g e i s t h e s y mb o l i c r e p r e s e n t a t i o n a n d i n t e r p r e t a t i o n o f me a n i n g i n v o i c e s o u n d s a n d w r i t t e n s y mb o lmbol i zat i on It i s a f a r mo r e c o mp l e x a c t i v i t y t h a n sy s ( ). s p e e c h , r e q u i r i n g e xt e n s i v e c e n t r a l i n t e r c o n n e c t i v i t y. L a n g u a g e i s e v a l u a t e d d u r i n g h i s t o r y - t a k i n g a n d w i t h t h e M i n i - M e n t a l S t a t e E xa m ( M M S E ) . S i x d o ma i n s a r e a s s e s s e d : ( a ) s p e e c h e xp r e s s i o n , b o t h s p o n t a n e o u s a n d a u t o ma t i c s e q u e n c e s ( e . g . , s i n g i n g , n u r s e r y r h y me s , a n d c u r s i n g ) ; ( b ) n a mi n g ; ( c ) s p e e c h c o mp r e h e n s i o n ; ( d )
300 / 305

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r e p e t i t i o n ; ( e ) r e a d i n g ; a n d ( f ) w ratmag i [o AR . Ap h a sNa . D i in s i Engl J M ed 1992;326: 531539 ].

AP HAS I AS : P a t h o p h y s i o l o g L a n g u a g e i s i n s t a n t i a t e d i n t h e d o mi n a n t h e mi s p h e r e , w h i c h i s y: t h e l e f t h e mi s p h e r e i n > 9 9 % o f r i g h t - a n d l e f t - h a n d e d p e o p l e . D a ma g e t o s p e c i f i c l a n g u a g e - p r o c e s s i n g a r e a s p r o d u c e s d i s t i n c t a p h a s iq u i .r e d i n a b i l i t y t o u s e An c a s l a n g u a g e c o r r e c t l y i s t e raphas i aa n d i n d i c a t e s a c q u i r e d d i s e a s e o f t h e b r a i n . me d C o n g e n i t a l o r d e v e l o p me n t a l d i s o r d e r s o f l a n g u a g e dyrs phas eas a e calli d . B RO C A AP HAS I A: P a t h o p h y s i o l o g T : e r e i s d a ma g e t o t h e B r o c a a r e a o f t h e l e f t f r o nh e l l o b e . yh T ta speech is nonfluent, often leaving out pronouns, prepositions, and the like; reading a n d w r i t i n g a r e a l s o a f f e c t e d . P a t i e n t s a r e a w a r e o f t h e i r d i f f i c u l t y a n d b e c o me f r u s t r a t e d . T h e y a p p e a r t o k n o w w h a t t h e y w a n t t o s a y. S p e e c h c o mp r e h e n s i o n i s r e l a t i v e l y s p a r e d f o r s i mp l e c o mmu n i c a t i o n . WE RNI C K E AP HAS I A: S p e e c h i s f l u e n t b u t w o r d s a r e j u mb l e d a n d s u b s t i t u t e d , o b s c u r i n g a l l me a n i n g ( par aphas i) a W r i t i n g i s s i mi l a r l y a f f e c t e d . R e a d i n g a n d v e r b a l c o mp r e h e n s i o n a r e . p o o r. T h e p a t i e n t i s u n a w a r e o f t h e i r d e f i c i t a n d ma y b e c o me a n g r y w h e n n o t understood. G L O B AL AP HAS I A: T h i s i s a c o mb i n a t i o n o f B r o c a a n d W e r n i c k e a p h a s i a . O T HE R AP HAS I AS : S e e n e u r o l o g y t e xt s f o r d i s c u s s i o n o f c o n d u c t i o n , a n o mi c , t r a n s c o r t i c a l , a n d subcortical aphasias. D i s o r d e r s o f L a n g u a g e : Al e x i a a n d Ag r a p h i a : Al ex i ai s t h e i n a b i l i t y t o r e a d .l ex i a s a n i mp a i r me n t o f r e a d i n g aAgriaphi a Dy s i b i l t y. is the inability to write.

Syndromes of Impaired M entation


Delir ium: S e e C h a p t e r 1 5p a g e 8 9 0 f o r t h e f u l l d i s c u s s i o n o f d e l i r i u m. ,
P. 8 7 7

He p a t i c E n c e p h a l o p a t h y : P a t h o p h y s i o l o gS: v e r e h e p a t o c e l l u l a r d y s f u n c t i o n a n d / o r p o r t a l h y p e r t e n s i o n ye w i t h p o r t a l - s y s t e mi c s h u n t i n g a l l o w s a c c u mu l a t i o n o f t o xi c me t a b o l i t e s l e a d i n g t o c e r e b r a l d y s f u n c t i o n .i s p r e s e n t s f o u r f e a t u r e s o n l y t h e l a s t t w o a r e d i s t i n c t i v e : Th ( a ) a l t e r e d me n t a l s t a t e v a r y i n g f r o m s l i g h t l o s s o f me mo r y t o c o n f u s i o n , s l u r r e d s p e e c h , s e d a t i o n , a n d c o ma ; ( b ) a s t e r i xi s , a l s o p r e s e n t i n c e r e b r o v a s c u l a r d i s e a s e , u r e mi a , a n d s e v e r e p u l mo n a r y i n s u f f i c i e n c y ; ( c ) s i g n s o f a b n o r ma l l i v e r f u n c t i o n s u c a s j a u n d i c e , p a l ma r e r y t h e ma , s p i d e r a n g i o ma t a , h e p a t o me g a l y, a n d a s c i t e s ; a n d ( d f e t o r h e p a t i c u s , s me l l i n g s o me t h i n g l i k e o l d w i n e , a c e t o n e , o r n e w - mo w n h a y ; i f p r e s e n t , i t i s d i s t i n c t i v e o f h e p a t i c c o ma . We r n i c k e - K o r s a k o f f S y n d r o m e :
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dgdiagnexam

P a t h o p h y s i o l o g T : i a mi n e d e f i c i e n c y i s c o mmo n i n a l c o h o l i s m a n d s y mp t o ms ma y yh o c c u r w h e n a d mi n i s t r a t i o n o f g l u c o s e c a u s e s a c u t e t h i a mi n e d e f i c i e n c y ( W e r n i c k e e n c e p h a l o p a t h y ) l e a d i n g t o c h r o n i c b r a i n i n j u r y ( K o r s a k o f fW e rnn i r o me ) . sy d cke s y n d r o me p r e s e n t s w i t h c o n f u s i o n , n y s t a g mu s , a t a xi a , o p h t h a l mo p l e g i a , i mp a i r e d me mo r y, a n d d e c r e a s e d a t t e n t i o n . It i s e s s e n t i a l t o r e c o g n i ze a n d t r e a t t h e p a t i e n t i mme d i a t e l y w i t h p a r e n t e r a l t h i a mi n e . K o r s a k o f f s y n d r o me i s a n i r r e v e r s i b l e c h r o n i c e n c e p h a l o p a t h y w i t h a n t e g r a d e a n d r e t r o g r a d e a mn e s i a a n d c o n f a b u l a t i o n . P. 8 7 8

Dementia: D e me n t i a i s a d e c l i n e i n c o g n i t i v e f u n c t i o n s u f f i c i e n t t o i mp a i r f u n c t i o n . It i n c l u d e s me mo r y l o s s ( r e c e n t mo r e t h a n r e mo t e ; i . e . , l o s s o f o r i e n t a t i o n ) a n d a t l e a s t o n e o f t h e f o l l o w i n g : a p h a s i a , a p r a xi a , a g n o s i a , o r a b n o r ma l e xe c u t i v e f u n c t i o n . It i s c h r o n and usually progressive, although the rate of progression is quite variable. P e r s o n a l i t y c h a n g e s a n d l o s s o f n o r ma l s o c i a l i n h i b i t i o n s a r e l a t e f i n d i n g s i n mo s t c a s e s . D e me n t i a i s e a s i l y mi s s e d e a r l y i n i t s c o u r s e i f n o t s p e c i f i c a l l y s o u g h t i n patients at risk. T here are no early physical findings, the release signs being late ma n i f e s t a t i o n s o f a d v a n c e d d i s e a s e . S c r e e n i n g w i t h t h e M i n i - M e n t a l S t a t e E xa m ( M M S E ) a n d c l o c k d r a w i n g t a s k a r e u s e f u l . M e d i c a l i l l n e s s c a n p r e s e n t a s d e me n t i a s o i t i s e s s e n t i a l t o e xc l u d e r e v e r s i b l e me d i c a l c o n d i t i o n s s u c h a s h y p o t h y r o i d i s m, o t h e r e n d o c r i n o p a t h i e s , me d i c a t i o n s i d e e f f e c t s , a n1 2vd t a mii n n c y. T h e r e d iefic e B a r e ma n y c a u s e s o f d e me n t i a , b u t Al zh e i me r d i s e a s e i s moK a rc a w i s h n [ s t l o mmo J H T, C l a r k C M . D i a g n o s t i c e v a l u a t i o n o f e l d e r l y p a t i e n t s w i t h mi l d me mo r y p r o b l e ms Ann I nt er n M ed0 0 3 ; 1 3 8 : 4 11 4 1 9 2 ]. D E M E NT I A C L I NI C AL O C C URRE NC E : Congeni t al a mi l i a l Al zh e i me r d i s e a s e , a d r e n o l e u k o d y s t r o p h y, H u n t i n g t o n d i s e a s e , F l i p o p o l y s a c c h a r i d o s e s , W i l s o n d i s e a s e , mi t o c h o n d r i a l d i s e a s e , p o r p h y r i a , D o w n s y n d r o me ( t r i s o my 2 1 ) ; r i ne y p o t h y r o i d i s m, Ad d i s o n d i s e a s e , C u s h i n g Endoc h s y n d r o me , h y p e r - a n d h y p o p a r a t h y r odi opat hi Al zh e i me r d i s e a s e , P i c k I i d i s m; c d i s e a s e , L e w y b o d y d i s e a s e , p r o g r e s s i v e s u p r a n u c l e a r p a l s y, f r o n t o t e mp o r a l d e me n t i a sI;nf l ammat or y / I mmunes c u l i t i s , s u b a c u t e s c l e r o s i n g p a n e n c e p h a l i t i s , va s a r c o i d o s i s nf ec t i ous IV i n f e c t i o n , s y p h i l i s , p r i o n d i s e a s e ( C r e u t zf e l d t - J a c o b I; H disease [CJD], bovine spongiform encephalopathy [vCJD], others), progressive mu l t i f o c a l l e u k o e n c e p h a l o p a t h y ( p a p o v a v i r u s ) , W h i p p l e d i s e a s e , p o s t e n c e p h a l i t i s ; M et abol i c / Toxc c r o n i c a l c o h o l i s m, v i t a mi ,n t B i a mi n e , a n d n i c o t i n i c a c i d ih 12 h d e f i c i e n c y, u r e mi a , l i v e r f a i l u r e , a l u mi n u m t o xi c i t y ( d i a l y s i s d e me n t i a ) , p o s t a n o xi a , d r u g i n t o xi c a t i o nec hani c al / Tr auma u t e a n d c h r o n i c h e a d t r a u ma , n o r ma l M; ac p r e s s u r e h y d r o c e p h a l u s , c h r o n i c s u b d u r a l h eNeoplma ;t i c a r a n e o p l a s t i c ma t o as p l i mb i c e n c e p h a l i t i s , b r a i n t u mo r s , a n d me t a s t a t Neur olcogi; c o n c o n v u l s i v e ic can er n s e i zu r e s , P a r k i n s o n d i s ePs y c hos oc i al e p r e s s i o n ( p s e u d o d e me n t i a ) , ase; d s c h i zo p h r e n i Vas c ul arv a s c u l a r d e me n t i a s ( mu l t i i n f a r c t , B i n s w a n g e r d i s e a s e ) . a;

AL ZHE I M E R D I S E AS E : P a t h o p h y s i o l o g N:e u r o f i b r i l l a t o r y t a n g l e s a n d p l a q u e s w i t h e xt r a c e l l u l a r d e p o s i t i o n y o f a my l o i d p r e c u r s o r p r o t e i n a c c u mu l a t e i n t h e b r a i n . T h e c a u s e i s p a r t l y g e n e t i c a n p o s s i b l y p a r t l y e n v i r o n me S tl a lw l y p r o g r e s s i v e d e me n t i a u s u a l l y b e g i n s i n t h e . n o s e v e n t h o r e i g h t h d e c a d e o f l i f e ; i t ma y o c c u r a t y o u n g e r a g e s , e s p e c i a l l y i n t h e h e r e d i t a r y s y n d r o me s . T h e i d e n t i c a l s y n d r o me o c c u r s u n i f o r ml y i n p a t i e n t s w i t h
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dgdiagnexam

t r i s o my 2 1 ( D o w n s y n d r o me ) a t a n e a r l i e r a g e , u s u a l l y i n t h e f o u r t h d e c a d e o f l i f e . T h e me n t a l d e t e r i o r a t i o n b e g i n s i n s i d i o u s l y w i t h me mo r y l o s s , d e p r e s s i o n , a n xi e t y, s u s p i c i o n , a n d l a t e r a mn e s i a , a g n o s i a , a p h a s i a , s h u f f l i n g g a i t , a n d r i g i d i t y. T h e d i a g n o s i s i s c l i n i c a l , a f t e r e xc l u d i n g t r e a t a b l e f o r ms o f d e me n t i a . Ima g i n g r e v e a l s d i f f u s e a t r o p h y o f t h e c e r e b r a l c o r t e x w i t h s y mme t r i c a l e n l a r g e me n t o f t h e l a t e r a l a n t h i r d v e n t r i c l e sD X: If s e v e r e p s y c h i a t r i c s y mp t o ms a r e p r e s e n t ( e . g . , D. h a l l u c i n a t i o n s , p s y c h o s i s ) , c o n s i d e r L e w y b o d y d i s e a s e . If t h e d e me n t i a i s r a p i d l y p r o g r e s s i v e , c o n s i d e r C r e u t zf e l d t - J a c o b d i s e a s e ( C J D ) o r v a r i a n t C J D ( v C J D , b o v i n spongiform encephalopathy).

Psychosis: S e e C h a p t e r 1 5p a g e 8 9 6 . ,

Other Syndromes
L e g D i s c o m f o r t Re l i e v e d b y Wa l k i n g : Re s t l e s s L e g s S y n d r o m e ( E k b o m Syndr ome): T h e p a t i e n t c o mp l a i n s o f l e g d i s c o mf o r t a t r e s t , o f t e n p r i o r t o s l e e p . T h e s e n s a t i o n ma y b e a c h i n g , d r a w i n g , p u l l i n g , p r i c k l i n g , r e s t l e s s n e s s , f o r mi c a t i o n , o r c o mp l e t e l y n o n d e s c r i p t . Al w a y s b i l a t e r a l , t h e s e n s a t i o n s a r e r e l i e v e d b y w a l k i n g o r ma s s a g e . T here are no pertinent physical findings. T he cause is unknown, but has been r e p o r t e d w i t h i r o n a n d f o l a t e d e f i c i e n c y a n d u r e mi a . F a mi l i a l f o r ms o c c u r. M a n y p a t i e n t s a l s o h a v e p e r i o d i c l i mb mo v e me n t s o f s l e e p . M o s t p a t i e n t s o b t a i n s o me r e l i e f w i t h d o p a mi n e a g o n i s trs e[y C J . R e s t l e s s l e g s s y n dNo me . J M ed Ea l r Engl 2 0 0 3 ; 3 4 8 : 2 1 0 3 2 1.0 9 ]
P. 8 7 9

Ho r n e r S y n d r o m e : A l e s i o n o f t h e c e r v i c a l s y mp a t h e t i c c h a i n p r o d u c e s t h e f o l l o w i n g s i g n s o n t h e i p s i l a t e r a l s i d e : ( a ) p a r t i a l p t o s i s o f t h e u p p e r e y e l i d a n d s o me e l e v a t i o n o f t h e l o w l i d ( i n v e r s e p t o s i s ) , ( b ) c o n s t r i c t i o n o f t h e p u p i l , mi o s i s , a c c o mp a n i e d b y p u p i l d i l a t i o n o r d e l a y a f t e r a l i g h t r e f l e x, a n d ( c ) a b s e n c e o f s w e a t i n g o n t h e f o r e h e a d a f a c e o f t h e a f f e c t e d s i d e F is e e1 4 - 2 0 A a g e 8 4 8 ) . If d a ma g e t o t h e s y mp a t h e t i c s ( g. , p o c c u r s e a r l y i n l i f e , p i g me n t a t i o n o f t h e i r i s ma y b e a f f e c t e d ; f o r e xa mp l e , t h e a f f e c t e d i r i s ma y r e ma i n b l u e w h e n t h e o t h e r c h a n g e s t o b r o w n i f t h e p a t i e n t i s b r o w n - e y e d . H o r n e r s y n d r o me o c c u r s w i t h i p s i l a t e r a l me d i a s t i n a l t u mo r a n d h a s b e e n r e p o r t e d w i t h s p o n t a n e o u s p n e u mo t h o r a x a n d b r a i n s t e m s t r o k e . C o m p l e x Re g i o n a l P a i n S y n d r o m e ( C RP S ) : Re f l e x S y m p a t h e t i c D y s t r o p h y, C a u s a l g i a : S e e C h a p t e r ,4p a g e 9 7 . Re p e a t e d B e l l P a l s y : M e l k e r s s o n S y n d r o m e : T his is a triad of scrotal tongue (lingua plicata) with repeated attacks of Bell palsy a n d p a i n l e s s , n o n p i t t i n g , f a c i a l e d e ma . T h e c a u s e i s u n k n o w n .
P. 8 8 0

Death: D e a t h i s a n o b v i o u s f a c t o f l i f e . M o s t a d u l t s c a n ma k e a r e a s o n a b l y a c c u r a t e
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dgdiagnexam

d i a g n o s i s o f d e a t h , b u t o c c a s i o n a l c a s e s p r o v e t o o c o mp l i c a t e d f o r t h e l a y p e r s o n s ' a b i l i t i e s . O n e o f t h e h o r r o r s t o r i e s i n me d i c a l h i s t o r y i s a p r o b a b l y a p o c r y p h a l e p i s o d e i n t h e l i f e o f Ve s a l i u s . In 1 5 6 4 , d u r i n g t h e h e i g h t o f h i s E u r o p e a n f a me a s a a n a t o mi s t , h e w a s a p p o i n t e d p h y s i c i a n t o P h i l i p II o f S p a i n . H e i s s a i d t o h a v e c o n d u c t e d a n a u t o p s y i n M a d r i d o n a y o u n g n o b l e ma n w h o h a d b e e n h i s p a t i e n t . Ac c o r d i n g t o t h e c u s t o m o f t h e t i me , t h i s w a s c a r r i e d o u t b e f o r e a l a r g e c r o w d o f c i t i ze n s . W h e n t h e t h o r a x o f t h e b o d y w a s o p e n e d , t h e h e a r t w a s s e e n t o b e b e a t i n g a n d t h e a n a t o mi s t w a s c o mp e l l e d t o l e a v e S p a i n h a s t i l y. S u c h e xp e r i e n c e s h a v e ma d e i t n e c e s s a r y t o h a v e a p h y s i c i a n o r o t h e r t r a i n e d p e r s o n p r o n o u n c e t h e d e a t h of a patient.

B i o l o g i c a l d e a t h i s t h e c e s s a t i o n o f f u n c t i o n o f a l l b o d i l y t i s s u e s . In t h e p r o c e s s o f dying, tissues and organ functions deteriorate at varying rates, so a precise end p o i n t i s d i f f i c u l t t o d e f i n e . F o r o r d i n a r y p u r p o s e s , i t i s c o n c l u s i v e t o r e c o g n i ze t h e i r r e v e r s i b l e c e s s a t i o n o f c i r c u l a t o r y, r e s p i r a t o r y, b r a i n , o r b r a i n s t e m f u n c t i o n s . T h i s partially assessed by unconsciousness and absence of the vital signs (cardiac a c t i v i t y, r e s p i r a t i o n s , a n d ma i n t a i n e d b o d y t e mp e r a t u r e ) , b u t t h e s e i n d i c a t o r s h a v e p r o v e d i n a d e q u a t e i n v i c t i ms o f c o l d w a t e r d r o w n i n g , f o r e xa mp l e , w h e n u n c o n s c i o u s n e s s , a p n e a , a n d i mp e r c e p t i b l e h e a r t b e a t a r e s t i l l c o mp a t i b l e w i t h r e s u s c i t a t i o n a n d f u l l r e c o v e r y. D i f f e r e n t c r i t e r i a a r e a l s o r e q u i r e d f o r p a t i e n t s r e c e i v i n g me c h a n i c a l r e s p i r a t i o n a n d c a r d i a c p a c i n g .

D E AT H E X AM I NAT I O N ( F O R M O S T PAT I E NT S ) : E xa mi n e f o r e v i d e n c e o f h e a r t c o n t r a c t i o n b y p a l p a t i n g f o r p u l s a t i o n s i n t h e c a r o t i d a r t e r i e s a n d a u s c u l t a t i n g t h e p r e c o r d i u m f o r h e a r t s o u n d s . An E C G w i l l d e t e r mi n e i f c a r d i a c e l e c t r i c a l a c t i v i t y i s p r e s e n t i n t h e a b s e n c e o f me c h a n i c a l c o n t r a c t i o n . Search for respiratory activity by placing the diaphragm of your stethoscope over th p a t i e n t ' s mo u t h w h i l e l i s t e n i n g f o r b r e a t h s o u n d s . Al s o , h o l d a c o l d mi r r o r a t t h e n o s t r i l s a n d mo u t h t o d e t e c t a d e p o s i t o f w a t e r v a p o r. N e u r o l o g i c f u n c t i o n i s assessed by several tests: call to the patient to test responsiveness; retract the e y e l i d s t o o b s e r v e t h e p u p i l l a r y r e a c t i o n t o l i g h t ( f i xe d d i l a t e d p u p i l s a r e s e e n w i t h d e a t h a n d s o me d r u g i n t o xi c a t i o n s ) ; r o t a t e t h e h e a d f r o m s i d e t o s i d e w i t h t h e l i d s r e t r a c t e d t o o b s e r v e w h e t h e r t h e e y e s r e ma i n f i xe d i n t h e i r o r b i t s o r mo v e i n c o n j u g a t e ( d o l l ' s e y e s ) , i n d i c a t i n g a n i n t a c t b r a i n s t e m; p e r f o r m i c e w a t e r c a l o r i c s t i mu l a t i o n i f t h e r e a r e n o e y e mo v e me n t s ; p r e s s t h e s t e r n u m a n d s q u e e ze t h e Ac h i l l e s t e n d o n s t o l o o k f o r a r e s p o n s e t o d e e p p a i n ; l i f t a n d l e t f a l l t h e l i mb s t o t e f o r mu s c l e t o n e ; c h e c k f o r g a g a n d c o r n e a l W i fj lde xe s [ F M . T h e d i a g n o s i s o f re ick E b r a i n d e a t h . Engl J M ed 0 0 1 ; 3 4 4 : 1 2 1 5 1 2.2 1 N 2 ] S UP P L E M E NTARY D E AT H E X AM I NAT I O N ( E S P E C I AL LY F O R NE ARD RO WNI NG AND PAT I E NT S WI T H M E C HANI C AL V E NT I L AT O RS AND PAC E M AK E RS ) : Vi c t i ms o f c o l d w a t e r i mme r s i o n d r o w n i n g e xp e r i e n c e r a p i d t o t a l b o d y c o o l i n g ( s e v e r e h y p o t h e r mi a ) a n d ma y me e t a l l t h e p r e c e d i n g c r i t e r i a o f d e a t h y e t s t i l l b e c a p a b l e o f r e s u s c i t a t i o n w i t h e xc e l l e n t n e u r o l o g i c f u n c t i o n a f t e r i mme r s i o n o f u p t o h o u r. A r e a s o n a b l e p r a c t i c a l g u i d e l i n e i s t h a t s u c h p a t i e n t s a r e n o t d e a d u n t i l t h e y are warm and dead. Other patients needing special consideration are those s u s t a i n e d b y me c h a n i c a l v e n t i l a t i o n a n d p a c e ma k e r s w h o f a i l t o me e t t h e c a r d i a c a n d r e s p i r a t o r y c r i t e r i a f o r d e a t h , b u t w h o ma y b e d e a d b y i r r e v e r s i b l e l o s s o f b r a i n function. T he clinician should always seek consultation from a neurologist in these
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c o mp l i c a t e d , a t y p i c a l c l i n i c a l s i t u a t i o n s .

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