Short Case for Final 2554

Short caseTongy

วันจันทร์ท่ี 5 กันยายน 2011

Short describe

1.Cushing syndrome

2.Acromegaly

3.Graves’ disease

4.Postsurgical hypocalcemia

5.Short stature

6.DM


Cardio

• MS with AF with PHT

• MR

• AS

• AR

• PS

• VSD

• ASD

• PDA

• Coarctation of Aorta

Takaysu


ผู้ป่วยมาด้วยคอโตจงตรวจร่างกาย

General appearance & BP First& Pulse

Tachycardia,Bounding pulse,wide PP,Systolic hypertension


Hyperthyroidism

Eye Eye •Exopthalmos From lateral view •Lid Lag •Retraction

•Proptosis •Chemosis •Corneal ulcer •EOM เปิดตาด้วย

Diffuse aloplacia, fine hair


Thyroid gland

• Surgical scar

• Bruit *

• Size estimation

• Consistency&tender

• Nodule

• Lymph node


Thyroid Examinationคลํา Thyroid Gland โดยคลําทีละข้าง เช่นถ้าต้องการตรวจข้างซ้าย ให้ใช้นิ้วหัวแม่มือของมือซ้าย กดไปที่ Thyroid Cartilage และดันไปด้านตรงข้าม

คลํา Thyroid Gland โดยใช้มืออีกข้าง โดยอาจให้ผู้ป่วยกลืนน้ําลายเพื่อดูว่าก้อนขยับตามการกลืนหรือไม่


Hyperthyroidism

1.Tachycardia,AF2. MPV3. Gynecomstria

Neuro• Motor: Proximuscle weakness• Reflex: Hyperreflexia

Leg• Pretibial myxedema (Plaqe แข็ง กดไม่บุ๋ม)


Hyperthyroidism

Skin •Vitiligo•Moist&Warm•Palmar erythema

• เล็บ • Acopachy ( clubbing) เจ็บ • Suggest autoimmune • Onycholysis • Plummer nail(นิ้วนาง) • Tremor


Hyperthyroidism




Hyperthyroidism




Special Test

• Pemberton test


Hypothyroids

• PR

• BP

• General appearance1. Apathy

2. Puffy face

3. Coase hair

4. Loss of Latateral 1/3 of eye brown

5. Macroglossia

6. Husky voice

•Thyroids•Skin: Coarse,Yellow hand•Ext:edema•Motor•Slow relaxation,Myoedema


CUSHINGS• General appearance & BP First


1.Moon face2.Pletora3.Cataract4.Acne5.Hirsutism6.Tenagiectasia7.Oral tush,Hyperpigmentation

1.AN2.Buffalo hump3.Supraclavicular fat pad

1.VF2.Moods


1

Proximal Myopathy

1.Truncal obesity2.Board violaceous cutaneous Striae3.Bimanual palapation

Thin skinEasy bruising (s)Palmar crease

Kyphosis,compression


Turner

• General appearance & BP +Pulse(4)+First,ส่วนสูง??



HEENT "8"


HEENT "8"

1.Low set ear2.Low posterior hair line3.Fish like mouth 4.High arch palate5.Micronathia6.Hearing with OM7.Posterior web neck8.Thyroids??



Chest =2


Chest =2

CVS


Chest =2

Abdomen

CVS


Chest =2

EXT=6

Abdomen

CVS


Chest =2

1.BP 4 extremities2.Cubitus valgus,Genu3.Short of 4,5 metacarpal bone4.Madelung deformities 5.Nail dysplasia6.Lymphedema

EXT=6

Abdomen

CVS


No Secondary Sex characteristic***

1.No Breast Development2.No Axillary hair3.No Pubic hair4.Infertility(Amennorhea)

Work up

1.FSH/LH (increase)2.Estradiol(Decrease)3.Chromosome study(45/XO)


Acromegaly General appearance & BP First,ส่วนสูง??



1. Cutis veracities gyrata2. Frontal brossing3. Prominent supraorbital ridge4. Coarse face5. Big nose 6. Thick lip 7. Malocclusion8. Teeth separation (ฟันล่าง)9. Macroglossia10. Deep and hollow sound*****11. Prognatism*****12. VF(The last): Bitemporal hemianopia


1. Cutis veracities gyrata2. Frontal brossing3. Prominent supraorbital ridge4. Coarse face5. Big nose 6. Thick lip 7. Malocclusion8. Teeth separation (ฟันล่าง)9. Macroglossia10. Deep and hollow sound*****11. Prognatism*****12. VF(The last): Bitemporal hemianopia

1.Thyroid enlargement2.Skin tag3.AN



CardiomegalyGalactorrhea



Proximal myopathy



HepatomegalySplenomegaly

Proximal myopathy



HepatomegalySplenomegaly

Proximal myopathy

1.Spade like finger2.เท้าหนา(Heel pad thickening)3.CTS4.Ring tigthening5.Oily skin6.Hyperhydrosis


Acromegaly

•GH producing pituitary tumor•Bronchial carcinoid•Small cell lung cancer


Marfan


• Skin • Small papule in neck, • Striae distensae • Soulder • Lumbar region

1. Frontal brossing2. Long narrow face

1. Blue sclera2. Ectopia lentis3. Myopia4. Iridodonesis

Palate • High arched palate • Crowding of teeth

Chest 1. Pectus excavatun2. Pneumothorax3. ICD scar

Hand1. Hypermobile of joint2. Arachnodactyly3. Thumb sign4. Wrist sign

Foot Flat feet(pes Panus)

Heart1. MVP2. AR3. Coarc

Spine1. Scoliosis 2. Kyphosis3. Dural ectasia

Hernia

Tall


Hypocalcemia


วิธีการ วัด BP SBP+20 2-5 minResult: Add of thumb+ Flex MCP,wist,Extension of IP (spreading of finger)

1. Brittle hair with Aloplacia2. Cataract3. Papilledema4. Chvostek sign5. Teeth hypoplasia6. Thyroids scar7. Bronchospasm8. Extremity :Dry puffy,Coarse skin,dermatitis9. Neuro: Parkinsonism10.HOA11.Mucocutaneous candidiasis

Troussaau sign


DM• Peripheral pulse: Dorsalis pedis,Post Tibail a.

• Sensation

• Proprioception

• ตรวจซอกนิ้วเท้า

• ตรวจฝ่าเท้า (ดูแผล)

• ตรวจ Skin(Dry skin)


Neurology

• Facial weakness

• Entrapment Neuropathy:CTS

• Tremor: Parkinson’s disease,ET

• Ptosis:CN III palsy

• Visual field defect: Occipital lobe lesion

• Generalized weakness


Facial Palsy

• CN VII(แยก Upper&Lower)• Motor: ยักค้ิว,หลับตา,ยิงฟัน,เป่าปาก

• Sensory:รับรส Anterior 2/3

• Reflex:Corneal reflex

• EOM

• CN V(Motor&Sensory)

• CN VIII(Hearing)

• Cerebellar function

• หู(Lesion,Retroauricular pain),Mastoids,Parotidวันจันทร์ท่ี 5 กันยายน 2011

DDx

1. Ramsay-Hunt syndrome

2. CP angle Tumor (7,8>5+ Cerebellar ข้างเดียวกัน)

3. Parotid gland tumor

4. Otitis media

5. Facial trauma


Bilateral Ddx

• MG

• GBS

• Basal arachnoiditis

• Muscular dystrophy

• MD,FSHMD,OPMD

• Bilat Bell


Carpal Tunnel syndrome

• Lumbricoides: First,Second

• Opponen pollicis

• Abductor pollicis brevis

• Flexure pollicis brevis

LOAFKey Muscle


Step

• ดู: Thenar atrophy,Sx scar

• Pinprick sensation

• Key muscle: Intrinsic&Extrinsic hand

• Tinel’s and Phalen test





Etiology

• DM/Ischemia

• RA

• Hypothyroids

• Acromegaly


PTOSIS



Ptosis

• ข้างเดียว หรือ สองข้าง ,Complete or incomplete

• Pupil

• EOM


MG1.Ptosis กี่ข้าง +Pupils2.Enhance ptosis3.EOM4.CN:Facial diplegia, Gag5.Tounge: Trifurrow tounge6.Nasal voice7.Jaw jerk8.นับเลข,พูดชื่อ9.Thyoird10.Neck muscle11.Motor12.DTR13.Fatigability :ให้คนไข้ยก แล้วจะ weakขึ้นลง



Radial nerve


Wasting Hand

• Cord: Syringomyelia,Central cord tumor

• Motor neoron: ALS

• Root: C pondylosis,Brachial plexus

• Nerve: Neuropathy=> Poly or Mono

• Muscle: Dysuse


Syringomyelia• Cervical: Upper thoracic

• Clinical

• Segmental sensory loss เสีย Pain,Tempเฉพาะระดับที ่cross ใน cord =>ชามแสบมร้อนมทิ่ม

• Dissociative sensory loss(Preserve propioception)

• โดนmotor neuron ระดับนั้นได=้> LMN hand atrophy,Decrease reflex

• Cord dilate=> Pressure UMN+BBK+Hyperreflexia,Bowel bladder เสีย แต่ Sacral sparing

• Horner syndrome(C8-T1)

• Charcot joint at Shoulder/Elbowจาก sensory


Motor neuron Dz• PLS: UMN lateral colum เสีย,Spatic paralysis,Muscle ปกติ

• ALS:

• UMN( Spastic c Hyper reflexia+

• LMN(Muscle atrophy)

• Spinobulba muscular atrophy

• Kenerdy syndrome

• Bulba atrophy+Limb atrophy


C Spondylosis• กด Cord,Root Common C6-C8

• อาการ:

• ปวดต้นคอ

• Limit movement

• Lhermitte sign +ve (Flex neckแล้ว มี Electrical sense ลงไป Limb)


Saturday night palsy

Wrist drop

Sensory: Loss at dorsum of Thumb & Index finger

Motor: BrachioradialisExtensor carpi radialis brevis/LongusSupinatorExtensor Digitorum communisExtensor Digiti MinimiExtensor pollicis Longus/BrevisAbductor pollicis longus

Spare:Tricep brachii


Ulnar


ผู้ป่วยมาด้วยมือลีบ จงแสดงการตรวจร่างกาย


• General appearance

• Unilateral

• Deformities

• Atrophy fasciculation: ลิ้น,มือ

• Scar,Fracture

• Motor

• Reflex

• Sensory

• คลํา Nerve,Spine


Motor• Tone

• Power

• หนีบกระดาษ

• Formet sign

• Key muscle

• Flexor carpi ulnaris

• Flexor digitiminmi

• Flexor di pro 3,4

• Opponen di


Foot Drop

• Weakness of tibialis anterior ( common peroneal nerve, L4-5 root, corticospinal tract)

• Common perneal nerve-->peroneal muscles (foot eversion)

• L4-5 root --> tibialis posterior (foot inversion)



Foot drop• Obsevation

• Unilateral/Bilateral

• Foot deformities/Scar

• Scars or bruises: esp. at the head of the fibular

• Muscle atrophy/Fasciculation

• General appearance:thin

• Have a pateint walk/GaitGait :High stepping gait (comon peroneal n.)

• Motor examination

• Sensory examination


Pattern Recognition• Weakness of dorsiflexion and eversion--> common

peroneal nerve ตรวจหา weakness of EHL, normal reflex, typical sensory loss อาจมี scar at fibular head

• Weakness of dorsiflexion, normal eversion,sensory loss at first web space--> deep peroneal nerve

• Weakness of dorsiflexion and inversion--> L4-5 root or plexus lesion ตรวจหา weakness of hip abduction and sensory loss at L4-5 dermatome, reflex มักปกติ


Common Peroneal nerve

Foot drop

Sensory:As Figure

Motor

1.Extensor hallucis lungus/Brevis2.Extensor digitorum longus/Brevis3.TA4.Peroneous longus/Brevis



Tremor

Resting Essential Cerebellar

PD Hyperthyroids


PDดู หัวสั่น คางสั่น,Masked face,Decrease eye blinking,Resting tremor,

Pill roling,drooling, hand posture

ลุกเดิน

Tremor ActionReemerging tremor

Rigidity Cogwheel rigidity,Tone( Spastic,Hyper or Hypotone

Bradykinesia Finger tapping,Rapid alternated movement1.Stooped posture2.Difficult to initiating3.Short step4.Freezing gate5.Festinating gait6.Loss of arm swing7.En block turning8.Tandem9.Rhomberg10.Pull test


PDนั่ง

พูด: Monotone

เขียน:Micrographia

EOM

Cerebellar signs

Motor,DTR,Sensation


Gait Ataxia

นั่ง Trucal ataxia

เดิน Wide base gaitRhomberg sign(sensory ataxia=posterior column )Tandem gait

CN

Cerebellar

Nystagmus(KF ring,Retinitis pigmentosa)Scanning speech

Finger to nose test,intention tremorDiadokokinesiaLimb ataxia and over shootCheck and reboundRebound phenomenon of Gordon and HolmesHeel to shin test


Gait Ataxia

Frontal lobe sign1.Palmomental reflex2.Glabella3.Grasp

Motor

DTR

Proproception


Blurr vision

• VA: 14 นิ้ว Snellen chart,อ่านบนลงล่าง

• VF

• EOM

• Pupilary light reflex:• Direct Light Reflex• Consentual Light Reflex• Swinging light

• Accomodation

• Fundoscope


AIR

• SSc

• RA

• SpA

• Chronic trophaceous Gout

• Dermatomyositis


SSc

1.RV heaving,2.P2,3.Rub,4.Arrhythmia

1.Loss of wrinkle and facial expression2.Loss of 1/3 of eye brown3.Salt and Peper appearance4.Bird beak nose5.Fish mouth6.Telangiectasia

1.Calcinosis cutis2.Tendon friction rub3.Digital pitting scar4.Loss of digital fat pad5.Acrolysis6.Capillary nail fold7.Raynaud8.Sclerodactyly c flexor deformities9.CTS

1.Motor power2.Joint3.Flexion contracture

Chest &Abdomen• Skin thickening and Telnagiectasis• ฟัง=>Crep,Bowel sound


RA1.Episcleritis,Scleritis/Scleromalacia (Perforan)2.Dry eye 3.lacrimal gland enlargement4.Parotid gland enlargement5.C spine tenderness: Flex/Extend

1.Dry tounge2.Dental carries3.Hoarseness (Cricroarythnoiditis)

Lung:ILD,Pleural effusionHeart:Rub,ARAbdomen:Splenomegaly

Fusiform swelling, Tenderness,Warm erythema at MCP,PIP,Wrist,elbow,Shoulder,Knee,Ankle Hand" Boutonniere/Swan's neck/ulnar deviation/Paino key signs/Z defomitiesFeet: Cock up toe/Hammer toeRupture extensor tendon

CTSSubcutaneous nodule(Scalp,ศอก,เข่า,มือ,เท้า)Baker cystSKIN: LCV,Ulcer


DM• V/S: Low grade fever

• GA:Head & SCalp,Hand and nail,Trunk(Upper chest &Trunk)

• SKin=>เยอะ

• CVS

• RS: ILD,PHT,

• Joint: Arthalgia or arthritis

• Neuro sign: Proximal muscle weakness,Neck muscle weakness

• Nail fold:Periungual telangiectasia

• Raynaud phenomenon

• Mechanic hand


Skin• Scalp:

• Heliotrope

• V sign,Shawl sign

• Pokiloderma vasculare atrophican

• Calcinosis cutis and soft tisuue calcification

• Mechanic hand

• Gotton sign&Pauple


AS

• ดู+expose+ ถอดรองเท้า• เคาะดูว่าเจ็บที่ใด C-->L

• Spine mobility

• SI joint

• ตรวจตา• Heart+ Peripheral pulse

• Peripheral joint


ดู+ expose+ ถอดรองเท้า

• Stoop posture

• Neck flexion deformity

• Loss of L lordosis

• Increase T kyphosis


Spine mobility

C spine:

• Flexion

• Extension

• Lateral

• Rotation

• Occiput to wall

• Tragus to wall(<10cm)

T spine

• Chest expansion

L spine

• Finger to floor

• Lateral bending

• Modifield Schober’s test


SI joint

• SI palpation

• Direct compression

• Provocative test

• Pelvic compression test

• Open book

• Closed book

• Patrick'S test(sign of 4)

• Gaenslen test' s test(sign of 4)วันจันทร์ท่ี 5 กันยายน 2011

Miscellaneous

• Advice

• สอนพ่นยา

• ฉีด Insulin


• GA• Short stature• Bronze skin• Edema

• HEENT• Frontal brossing• Pale and jaundice• Flattening of nasal bone• Maxiilary marrow hyperplasia • Chostek sign• Protussion of upper teeth

• Heart• RV heaving• Loud P2+Pericardial rub

Short case(Thalasemia with secondary hemochromatosis )

• Abdomen• Sx scar• Hepatolenomegaly

• Chronic liver signs• Hypogonad• Ext

•Chronic ulcer•Arthropathy•Fracture

• Neuro sign


Dyslipid• กินให้ครบ

• หลีกเลี่ยงอาการ Cholesterol สูง

• งดทอด, If ทอด ถั่วเหลือง,ข้าวโพด,ดอกทานตะวัน

• ควรกิน FIber สูง

• No smoking

• Excercise

Steinberger ST-2FPA


GA• Jaundice• BMI

HEENT• Pale and jaundice• KF ring • Fetor hepaticus

Heart• JVP• RV heaving• Loud P2+Pericardial rub•TR murmur

Cirrhosis

Chest: Gynecomastria Abdomen

• Distention•Superficail vein dilatation•Bruit•Liver &Spleen•HJR•fluid trill•Shifting dullness

Ext•Clubbing of finger•Leukonychiae•Dupuytren contracture•Pitting Edema of Leg

Neuro sign

Testicular atrophyAxillary hair lossPubic hair lossSkin

•Spider nevi•Palmar erythema•Bruit•Scartch mark•Tattoo•Xanthelasma•AN( NASH)


Documents

Short Case for Final 2554