Cristina HOTOLEANU MEDICAL SEMIOLOGY AND INTERNAL MEDICINE iia itura NAPOCA STAR (Cui Napoca, 2011ehnmnoc a eu ee Aastra Preface “the aim of he book ato present he approach to TR patent: dca examaton, nud try evant physical exammaten, ard the main (arislemenary mvesigatons tat will con ot ioe oneal dogross, Sct a et Tie Sook le ended pmacy for the frlgn ‘Taber of te Faulty of Meione Desreres CP Bibel Najonles Remini >) HOTOLEANU, cristina ‘Biblioge “ ee ceeeee ee){nating do men mae neat esnosch than ging heath oro, owes (Cicer) STRUCTURE: | ANAMINESIS AND GENERAL PHYSICAL EXAM, COBIECTIVES OF THE CHAPTER: ‘To understaehe correct approach one patent ‘Tobe alata apply he sien of cca examination ‘Tobe alae aply he pncipes ane te tens oe ‘ory tg "Tobe abla ta perorm acomplte genara physical exam ‘spproch ote patent. gner! pencils nd ‘etnone 2. isto taking princes ans ens 4 genoa pysia rarinaton- steps man Famelogea! change Spearman ats Somattpsmapius ‘Penton: posture of te paint ‘heurage eearinaon| ‘Saves, eos, nse, mut ‘Son, harem oa, heron. Tevons ot shn Subevineous tes: edema, callers “Seuaon mutton sats mp re ndoaea sytem exrinaton ‘Muscuoskletl syst rearatoanc exam ‘measure: ypotermia ci,4. Approach tothe patent ‘Senerai principles and dofintions Ig dette ec examinaon to estab the dagose 8nd thus the cone! ery rim nen naar’ fet gi to cause no har) the Brncpeconsigred tobe an xo of ha nese a ‘The spproach he pant ives caters ‘st taking (anarmesi, leno he patent or eaves ine patents uncanreey Bevel phys examination ‘pectic Sraminaon othe stars ‘occa lerrelaton shoud be made a the end of eso Soom pon ‘Whe pabelcicl tga pen ae serpent erarinatons shoul be adered i tonh ng? Catboaton and to aad inomaton era san Saapet (toraticaenete dame, tam sever, core Fig. th approach oho pation root may be represent by 8 “The dagnosstnca tora ‘sdsesse ranfesatons Socom ot oe hu eyname press Cammean o erert seats 02), 29, plour! syndrome is cially manfsted wit dyson, ier eee Steere seems SareesCia mantestsions 7 e_|2 Jd => => ce 2 th reatonsipbemean syndomesease ‘The sical mantesatons of @ sid rio catoganen, symplom: pa. piptations San: jundiea, adore bath (ae he gonra agresantis tobe considered syretom) dysonea aa a 4. the corct approach othe patient and the agnosis grin lvl several sos: raed psa exam, cmpleeriny 2. Gomplrantry exams shoud be pertared based Spon to sce! dagnoaitauppestion ‘3. Gino! mantestatone of a patil conden {represented by symptoms andlor se 4 Goren aooses may be manfste wi ie same Syncroma. 2. History taking (anarmnesis) History tain aprons valuable pat of cia exarinaton represents the iormation gaferes by doctor by asking precise questons 19 the pollen r flavenomebedy he Frows, the potent. (hleroararinese in tie case) Good ‘conmuncsion side ot the door afaw nol ony a clear ‘nuoaion ofthe spans blag he eecvo imolement ti pet In ar eae, by sang ge ‘hare aro several papas of moses communication ‘acta ttenng empathy *averdanco to judge” te behav of the pation. Nonverbal communication plays so an important oe ple sltuae, showing concer secu he pao station Te lvays °ascg Semmunicatoninshes 2 wee te pers oars por aes (rom Ura a ometanera te ra atone) as shown mth Bena Pan's perspective Intonation Experience Dosts's Pepective 9. the aes of conmunati During intervening the i. ‘elonagat"eWhd He patois meat! orenanber he Speak ls witha norma to Avaid compteatad media en, f Suminatc te dsauzeoy "DO" Put simple ect questions Anamnesis ince te foto 2 reasons th a eet c 9 pooner © Bhysooial data (women) wins tps Suman, Se, rescence sono ho hoepalprosentng tthe 0 ©. past mecca history 4 fom istry hats, soca isons Carentan history 1. goer dats: 11m ratrance of a ‘pws seers teen ae ae pepntarce ‘2 Chldnodcongents sesses, Inactone contagious dscess) Adulthood, cory. aeroscerss and [Sterne manifestation af coronary istry snare (CAD), porehory aro {Soeac9 (PAD) sot rogers Hultinsan-citere syns) avery rare gona Fret ceracteza by he promatrey soaurence oo Sepects 2 opna, ‘The couree of castes ls nvenced by aga: hs, cilren and edory present more eavre couse of oeases ae 2 ‘reared ender ocometcaons; he ate val pros {mump) occuring at teenagers may aut ert and ffamhy, whereasin chen tor no such onsequcnce. 1.2. he rotvance Sf gander Excel he sexapeclnss (ting th oproductne sero lana forma, especive rotate aor he inn ex. pepondorance of vor! Gases! ‘Hise or pumanal, CAD (i renopause women ae Under entogen protection: hough, he proserce of ‘Eabees relive sbohee + Femol itl stenoi, nary none 113. rsevanen of residnce "‘Seoaranic area maybe assoisted wit an reasd i or some aaeaees, 0 * Baka nephropathy eth urchoit ear 8 feng poops hing tne, Siva pan ang the tora of he Dans Ro, + Mala an infocus dsase cased by Plasmon wicestead in topical and utter econ + Inpon Westen European counts, deat eso Sartovascule patogycccura dota ot pre ‘an n Wieser Euepe 2 the reasons ofthe admission othe hospital These represen! he main model compan of he patent [mplons and son ht should be orden ascot ehnw Impviance and the system of which bay ean 2 ute, paltatons, chest sin, vomit, ftove, dyspnea ‘These mantestatonschousbe eters aloes * shes, cysones, platoon (cxsovasoulr ‘meters oMiing, nausea (geste manson) * aio (genera. non spectc mansectaes) ‘Noi 9 mat not transcrpon of he patents sory. Avoid to ersldeo asa teaon of te samision tor ate Peso evessay fr sme specie reasons ty Io fnd tthe eae, 8 1 stone eolectincuang pons ae shoes ine ‘era conpaton ae dese) is step of anannaats sans jst an srumerton ane dows not. suppose any destpon ofthe omptane’ [ PRBS pater Wy you presente ocr? _ What wt ou condor ob te nan pblens)p Escala er abr conginns masse 2 allies seas associated fSgecavahremnia data ora aoa mal impora Bese Snare stoi acete bo ate suena ‘rato? ee Ter cot cher Seite ve Se ares ot cont the events a Chrondiogical order, starting a olansicre eae ceca ee oy ning win the momo of the aémssion 1 te cacauences nn Fence ns a nn io es Ba —f—e ni otters pare curent INS NON the ema gents eRe, irpetneersn 2 STE crm B=e lagosis end te prescbed te eaten was cerry foweg 2 Ralcton oh symptoms 8 aulomodeston th couse of he sca Sineovoran ome 2 the otro of here symptoms 4 hecsplanaton frie ant Saetion to Ue hesptacurent sito pe gee ° inoasedtasiysovety of th sytos (ea. chet pan at rat n patent ‘fort angi inte pst) © aonplaton (¢9: ae vetie fare du a sudion meena the Dood presse vee) © sie cs of ho nro ergy fg tomes ooning ans arisen) © eracwsten c's prevous canton Bereds of exceroton eh Cons CF ‘ntesied wes cough ssc Sete one fe est conmon symone: se be desc aeng peeaal 2 radon Sharer (germ, cs £ lonsty (mid, mocue 2 geri anion cos 1, pistes mareatons SQCRATES orl coud b hb in menrchg te ston oft ps Sata ecator cy sce, he a ty sovere) carr Sragaton nea & Sacre are soercele wi xn ESeons tat are asso ‘eg: atable angina: ing factors ‘locaton chest pain —prcara! 0a riaton 30 upper Ib one cub! ido, Tos tre ca start prossre, const ‘preauce by physical ator otved by rst tegyeene adminseaton tons minutos ‘oeeacted ([cyesionterpaioe 7) 2 5 6 ith aly, possible epatons, dyeone8 what ate you conganng oTand wen ‘athe yu cone ben? Have you esoytere ban cecoendadt Nove youtlowed neoraaty? ‘iat hs happened te? Have yeu noes compaton ora sie tos orne wear? | 7 Wij have you decid 0 vist th doctor 2 3 coanore a wane Get ext 00" Vat present agnosia ps ue ce sreaoiie n:nat Bumetocses” 15Coa ibnpat wero? ‘Al remarcat o compl sauun eect ‘ver al vate? (eco at deci 8 rezetat scum a 4 parsnal hitry ‘he rlevane of preona physiologic hist “nis nce data about ‘+ enstua el (age of menarche, inert Stren is ene od ape + se foe eortracoptive or hanrene Teplacoment erapy + prograncy (number 3 proprances and chisron, abortions. premature cid, ‘newborn weg, saenens Gur argc) The menstrual Ge ropresons th hormone changes included im 3 pasos fcr, ovata lien osany ee ‘elease of an egg. " Host oye octr ewan 2.25 dye wih 240 day of ‘itunaton of pout 3040 rie el ek rain cll eae. The eda ge of ‘Anveaty ache caus oct n precodow puberty (a unos? an 8). Conta prococaue posiy snes spans! end mene te cary matrei” of yeas slutar-oonaal "ms, wheres’ pososes favoepuneny Senodctooiindepenient aaa ‘he mac resides inde tongs: ‘+ Amenorrhea: ious °" Brary never menstted: absence of Iaraaten bya 16 youn he peste ot ‘are pubertal eveoant ot by og 1 pans Inthe absence of nomal publ devcbyiant 6 econ (monarctapreseat tan no pris or Sag elnsneaie mone more cron sess sy aranoroa and eran soe oe Seldicon oe mypoalieptanpovean arenas aac by cay over + Pymereral and pv pan thal asates oe gh and ary: are common nine absence pal > Seay ae ue an underiing pataey ‘rcometioae re Prana) Monona sroesive esta! Seeang more fan 10 Nip tare tandmic D8) « iazrone booing at regrow, betwee nara Morera aoa nalemions ay Sur ene Bona, clapton Sore was en 9 ea: oa secs ein i eg aon Ta eS ee, ee ats ne aaa eres by_ these J scenes are lnfuenctd of tron Several tera, grane, Sega changor Thus, cits ot ahseiegs“montasistone of eae bowel syne, {Bee Meade, severe noun reaction, hypoayeorie Sees enacts promere or dng pee. Eesha pee ogant erases: ae merepas stoger an ie some cxovercuar aks man athe ‘ere aoe moun thee is v0 svesal aresment sta he poi 2 greens syarome (NS) WHE. yo {enna gee fresonce cf ertonel ord phys sme mg tts. pse at fe mens fj (sua "0 dys $e Si foson tat eter wih some septsthe manitestatons ini ~ Tension, ably, dysphoria (unhappiness) tho mest ‘smmon ad spec er PMS + notapeciie manfestatens ray insomnia, ebgue + physical ymplns basing, aia pan nto, tenderness nthe breasts, cyt ache, npn mace ps, headache (ral convacptive ss or hormane replacement therapy may ‘epresont ik actors er wonous tomnooemocne ‘ariovascar events (sole, Rea atch). 82 Ropettvesportansous abortions may occur in pains with {trombophiie, ctagenosis fupus), cabot: th et are comosomalabnarnaites othe eranyeiens Pregnancy and partum ar aesooatd wt an ieeased fk fr wecaus vomboembolsm and’ may" etacosee ae 08. Deets may tur chan Ianfostatone of cra: Bost parry, (thou a preessing Bran cane). i resent 0 letvstenny cancion Tp her symotonsictide route, vomtng, nessa se ite HELLP sycrma:dbdorara pan, Warfare pts, posstie temporary Bindnase Fisk acts or pre-eclampsia and ec Imps nel: young age of be motber, pressing vaccuar pethooyy, Hromieoes i {especialy antshecpraipie snare 18 Sires a first time? How ch i Jo goae a norma amount of bleed? soaerirmensene? ee bag mer soreness ee ee cea “Catiimp dreazs otrle? . ae cote SST CEES Sb te ovance of pat mecca! Nistoy “Tee iterations betnnen past media etary sant songs va acne exis of epg 9: opr wth aes 5; nocortacse roc ast oscar nus rn cancion ed. ho nt odious descr (9, contagious seas dung hishood)retical eosses {seat intrenons ected Toe chante medieal documents at conti he di ‘montored by pen, Ne trons ree Sh sr rete eee Se anwar | _ ama het | erate bot ah aat? “Alster veun eauatisn? ‘Al ute levee chug? (ind au dpa acest? 8. the relvance of amily tory Fan ilo i movant tom 2 pains of view he geet the exposure fo he sae agertpatos The Iory "ester reson rtiacoral vans Being the vest of reeactors baker So) ‘ous ee frvtormenal facors (eg: cownaly ones ices Iypstancn, ens Grnkeriiam oes?” ily Hl of premature eoorayaey deans (or cher arovacul ven reresri a eardonercisr tak a ‘Several acess oresant an autora! orinant nha both pron re hetrocyesu, eho reach sanse"o! bg wes. 8 25K Chines at Soe 20 trina alle, ad» 25% chance of being ozyous for he 1 9258 a for te corral, af to dren wl seron ronosan SPOTS ulbsomal dominant condiions: actondropasia, Gecsjonese rerocn, poyachy, Mars synone, eer oceavewaranenf bot paris Or scape, auch oar cen hana 25% cance ot SA et che clven i eras a fren tercomeun reese the abe ee ee dona: ne a he olen wi exes te VR, Teawaree core Cyc oss, phnyhstonura eset aicon ot an nhertes ioe, fy stony Mi eetps etn fra et oe generations, cksing 263) Signe and coneanganiy. ‘Bin ntnooge apent(o. fetane tino, ‘ers of he fami ae exposed to the gecaais) (Gestion ae you pares fe a ee hoy prema dah o¢corgovascul ver 0 "hfoerdararon, sok) belo age oF 40- eats oy dese atin nour oi (Temsaipor cent SDA id. 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Gach ou Wu cave aos OnIES | eowsul? veeura ont reeled. ult mart promalus eau vorcnencodiovencl (art mocarGe oc Sove) nant do vara 40 do an? sworn ante dve,sulerh de nama bor?___) ea Wray ad, a was he ceee 9: sec nd occupational Noy, habs, dg histo nec 8 MOT ay show aspect rato the prosening Tete re several leans hat shoud be mentone bv 4g constons © etary rstitons (tin yaneain practi, © Belreas (6 fa mess, high conconratag Sacots dot) © Aa UnhEDY det astood type, night mena ning eps sna ia ye esi tetoe pe 2 mane eee Paso oF acommended ‘Some cccupatone preaspos a ‘ tone Precspos0 In dueases- as shown in abe 2 “Tebl : laonshp betwoen sme ocupations- issaces: neo tmanteaiatone (Cecupsion—owsase Ponto Franetatons Tipjard wore Nisateora, Sever years frrkarsn ssbectosarbeness lear Davy aavars ——Tynphoeyae—Witin Tweak Famers lung Win sovert (eotine alerle hove hese) Divers Decompression tmmednteiang sickness po sever dave patna Vario ils Band More han 3 rents | (ung atomatve medina teres, 8 Stet © lenges st madeatons © possible accion o dug eg. benzodiazepines, oid © eamplanenconcotanes Cet isdn’ by the aministaon of the ‘padeaton as presebed by doctor Concrcance mater tom showing the ‘aed decsien between decor an ao scoring patents wins + Trav “ns may prectsposeo several tessos (agrees fares}, Ae ravel may merece th of mide or ‘Searor.Pelongod mmnooiaaton dung Wave reciposes to waroue hromboarest a+ Sroking: [HEPA shut be asked hfe ever mote: yea: ‘Simoni calculate he pack oar ofa eas here Number of cigarette x numberof years areeatay ‘Smoking i ssoiaed with an inressed sk or Iaignacis ape ung cane, pop ler, farcovascule diseases canny ater disses, prghera) ler dscsse, sok), COPD, abacreamshens coon ater =) COPD, tobacco ambieps comets [Simran ident aso the passive sok Car ar pe smokey oer Sig Present ova ora! tty mparsvely to gaan smokers xcaph von farcnoma of he orl caviy rym and oop + Sons history, ‘The pot slid be stad abou severe aspects: eres a regular partner a te oment ‘Using of cancion meh ‘A emia tamed dese theory sce inert ou neano tenon Asana east ui at cou be fun Small glass of winolone half pint One shoe of pr Neate tat ry once {eile coneuncton of 4 gf pure ennai (Soe fa SE eet tonaaeneceee 4 vm enki: dtd by 2 manne of inking at ‘hured physica andl moral Roath damage « Neahol depensance:coratarzd by he longs '> rong dete to arrk accel Scty cooling sng 5 Sloandnranad dose are needed choo {he ponous loc othe one sos {ifn omer when sting sapped ‘anesatone Pouce women swesig, ans, {Bebyard, posble sours, auton. Th Ieneaaone ae loved by sah ngenton “pre are sev souing too ele atl robes (CAGE FAST col abune ances ity SS: acho. Sst ceran, cota atopy, Womike's cuppa caer Gen womens sebelar prprral copay + pepo revopty 1 Grete mypecaon 1 ete detrcion , 5 Sno (de oe bre marow sppressin ‘opulent shoue be ake atte ant an po ink semana fring (oxpcialy binge arkng sha mem dein) + Uso of ti age: Tho aie st eompleatons induced by i rs misuse ‘3 nectens:hopats, HIV sbscassee ‘opthromeoonbotsn 5 Venue pos: omboplebis, iriver breoees may lend ore! end espatory ‘ah 2s[eens pen ———— [tetsu nae —T ere Sse HSU Wratisyourorotscon? ero dai ou wer? 828 you exposed Do you alee wih | Neyouretre? Bi tap ame | Poyeu ute some medcaons st a2torng fo pryatoans advice? ave you noticed ay sdf ofthe | cine Have you ntced sone cca Imanfestatore rate o> ave you oversee > cies apn pa endpaper starrer cea sone hy ‘at this moment? be | kos pater Have ou ore faa Sou rasta anes Ar Sinn oor era |" “calvay _ Yor ye cing [nin Su 2% ~ Hyes-how mary crates daly a or leet engur eau cu petonantiamsa? Cte peranane in le cere? Ee prose ave? Uo rai erat? Suet x Liza madeaments? Cantar prasoott «= Alramaret fects adveree se mecca «calor nuit tina? ramaront mantota nice ego do 3 tg po 2 it an? 1 Sint expuslo tunel pes? (aca neva | ira tuneaes) Paros sowal sta in cast ; 24h wth aeration of nea sop pk presont) he seventy of amas assess ui {hat indus fat o to oye et 21 Bono apr No ey oping 2 Eye openngnretponse to pain 3. Eye openng in spcuen 4 Eves opening sptancousy ) Bes wea rasponae 1° No verbal response 2. Incamretenie sounds, 3 apprnnaie words (msoesbe conversion) 5 Onan €) Best motor response 1" No motor espense 2 Extension pain (cecerebrate response) 9 Sasgow Cora Sea “ 4. Abnormal eon fo pin (Secorteat scons) 4. Reson pan 5 Lxmies to pan (Poros mvemens ones pont stro) 6 Gime some spe sp of hos errs om 1 pin 4,5 respective 6 Fs ee slog) aiows be Ganeealin cor Errees pans Hue 8-12 ponte Mier pont ‘coma may be du odorant causes. tology of oma could be foptinmin sing rnemetochneal orl tsa. eter tone "Eenderna ‘insta betes me Iygoatyeens) "Bonga decency, opiate "Urema,enal sores us compicaton (ete “Tinectons ‘Ppsyehatre, corny + Sepace-coipyng (mon, stoke ‘oaho conto tad by asso onsivaness te 2 a = vant eon hon 2, set.nted sso conscious winon niyo math posi ane an allowed by oan — ‘ean a eblgy s)ope cout be lsd roe Cele arene eo emis “epecal voc pes of eis, Sracyearda, ow fow datos (aovnene cedar aa eae, rac Catto costucon ete sonal, fperopne carlonyopsty Nareardc: oto Yasovagal rgponae 0 sa, eaten wi orhotast,stiator Seapine base ra sue eco) cone dee force dst resrnancne es » eran sino 2, et inet tne Seen a ieaiiingznene so my farioreiand + terested ae maybe a ino schzcpvena pene ‘epee of ether maniac eprosion wih norma ‘urtoing batvoonchrcrs ane Sopesia ~ "is manosad win races, esas ret ana diston Z ~ ec cad wn ns eo rd sap disurbonn changun apse” fatgue, lou stetoon aay gu ls Wats 3) oss sessrat king means connecting and ® a xoaig ex Tra Sardar may mie be tougtor ayof e, inwhch these are pogo) anc hase cea ‘Bam ought fom ig of eat and ough conen (elusone} ae acts n sensor " ‘The aleratn of tem contet ray elt il ~" Halechatons mean fase au ses or {acl sensation nthe bvance he Pa ‘one * “Wal halcinatons may scar in 1% sniepy hl wth ug "doy acl, gustatory halts ‘nay be unain opsopey sohaoven wceatinare sre omisore were scar son aaron narrator area oxo! , Paranoia: is dafinad as the sensation of being at trentened or perso Sheeston an compusions! apres erisent Prada prs, atonal a rinse far Seranstastens, making pete avl Batson mean ae bat based on reoect Inerenceasout etre rey ats tm Stones sensor and ognton feu of onto cotinine re near Bsonaion fo uo, plce ant person) conten snd Seton maar, wna seoda, spnocn tosstoed sk eonbacl ssa nsigees ve + Oetatn: coud be assessed acing the ay de, rth a yar, ware or ae ord # she Frows whe he tse « shurterm memone reefs t retin iormaton rer 9.5 mine he patent shoud recast of hes ‘hects aer 8 nuts ee Mes of aonememany: ments, drum. + Longer memony the part shuld eal events ofthe ‘vou oda, 2 ea 0 viz em ony may cone ingore + Cees for concert oem dium, i payors, exzophrona ss drt of conten and baught fom 38 wo trot parcepten alvcratons) behav: Bizare) anor ‘oiton (sty whorl|. SOMATOTYPE: HaBITUS ‘Accartng to Shaon tare ar 3 main somteype based u the predorinance of re germ ayers chamaryene dace toe tte ender, (gona tn) te masesenn meee hak ed blood esse) andthe ecodenn es ans nara Sytem a5) ‘Thee ot may erate win sore yk oa ~ Tandomorp: sprees slow Spy. Moasrorh te haréwating tig win eooaten wa nay sonorh conse oe len ans {eat tals win a pedapostan ends He Fg: eco, endo and mescrnorph ro smttypes (rom ah to on) “pine aap, abs mans x ote ormaton othe boay, some specie ysl eats associated wih sccepiany ta prj Sele ‘Severs sect pen abs cad ba api ‘vse aa sytedavosoa 4 09. Maran syrarome (inactive tissu dors 8 _harectie bya spec habits iahing some rrusouosxstl chang engender body with ésproporionst long + arathnadacty. ong Sages ipemobity athe ont Except specie hai, pants wth Marfan syparome may present earovaseuar ‘anges, one subuation, spontaneous preumotorae ‘stroma shot oral stature maybe uo to dire causs. shor statu may result n proporionate everest (ne tody appears normal proportioned, but aonermaly =m) fr espropotonate dvarhiem (one or more body parts are telat lage or sal in conpersen wo thoao of 8 read re. A proparinala dwarhism may be dus to the grow amore detieny, eo calle piulary wars ’ deproprtonate anarhsm appears In achonroplese: tte limbs sro aspoporioaly short coreares to funk (abdominal aoa), wit tho hood lrger Ban oral ands ‘ect asp! hotace An atroral a tatre dul be de othe excass of grat humo The coneaquenes of he excess of growth Romans spend upon te age whon acu ‘Gsantem aren) duo he propbera exces of ‘grown hormone sung in abreraialsature !cromagny edu te eens of gros Porne ‘aeute (ater epiphysea! plate core a puberty), ‘manocos win tne enargaret of the han, fot Spd facalfoaures (a progressive hereanng of Me fing and shoe ast) ss wel ae vacoregaPOSTURE: FOSmION OF THE PATIENT ‘ret ae several pinpas that shou be kop in mind hen staring th examination ofthe potion lhe an "eapect th privacy and op te patent coven Soprprate wapng 'stamnaon shouldbe dane in stnng poston, githa. spin, over specie potions sccm tho am ofeare ~ 2 ebecow= pate e zy ndti r ‘fang, Fe The ate of on he patent dng the ram may be ce ofthe 2 Act bt take ay positon © Fassivo:inmobie patio usely cue to @ severe ‘anaton (oma) ‘© ecu postlons—corlaod with &conton or oculrpoions of he patent are dus octet symptoms (oa. eeocae erty of Sanco ee cir ranges Garr ms end eee 5) postions spans! pain suggesting a posstie patbocoy anal ou" mahametan- th pation! isa onthe ifteted frearmas co a ‘cura in sete pancreatic fn Fig6.Loaring onal fou — amen oa ramet ee Nt ane )postons against dyspnea sere. soot oe bron a, iesas postions due to osteomuscuar changes; ~ Recipe head (heassod ech mescieong ~ sm. involuntary contraction fhe muses ‘ad stfoss wth hoes an pin fae {amoot and stile) ncn posal ane inmenigte ‘arpa spn (rousseau sign oF Muscles spasm (prenged conracton of ‘Sonica: hand: nt, 30 © the muscle ters duo ltopasrg is Fypoeslcomia ander hypomagnesemia a8) ‘ransidin anise pcbcion Sexy staan arc foal saan ras” ‘sardonicus (ig. 7), LFS Fig8, Troussenu sign ~ nga mrt even eanvacoe fe and as oe checmareare Siemens | Seaewecneae Eee timcer cas alta ciara, F107. point solder with tetanus (Chares Bel inthe Royel e0ple), age (over 40), sex (men rather than Coles tpn ap) = omen) family tty, psa: dabets ‘Seaham, rau, or seas, ~Toricol the hos ites wart at nck et peter ssa santo fn sea Bhar, Gil syne scton snr ugealemoval ot adenade Isang sacra ofthe ce crv ts) aayeate ge ‘ray be concent eo a) 2 *Fp. Dupuyron'scontactre IM. NEUROLOGICAL EXAMINATION i Pl nmin rest al ct Cras nes Sensory yon Reto ‘Anamesisn pouvocldardor rel sigan apace aston: mening, nl eh on sar ‘tense emus arty ed {laton predisposes ot, pepe Sonn encores cho! cre eee Sons crebvescle “ Habits, socal ston stroking, alcoho! the man mers neue: s)Hesaashe * Uniatr! headache preceded by fasting igh and assciled win plone ly to bea mgraine wien sa ' Pan oer ane ape dung minutes of hows, fra using of to forehead Is custr ada + Opal adeshe essocatd wth mock shes sugest are spondocs + Algearaseg headache associa wi \Sowsnaes andor voting cova be dot {orelsd veal pressure + Apersstont unisterl nessaene ove {omperl saa aseedtated with bing of elon suggests tompora arate by Dazaness ‘erige nhs stuston hee fa sense ‘of moion (ee surounigs, fhe hows). Ustad cascada wih oor ‘manfestators, such 25 nave, Sweatg, headache, wise ‘Peripheral vestuliesions; Usual wtout datas and nk 9 Drugs: ea.minoghyeosies, Sssocatd wih deatnes nts © Conta cours maybe essocted ‘wt dopa, tana © Maniore dasa fe manestad in nodes of ergo, us and ropes cestness. 45Physical exam: 1) Stance and git depen un vin, roprocepve,corconpn, etaoyrant Corebetar pathway owermcrneccnesand | pa renees | The naj to slancs may reveal ome patho feauces vad s + an tb patients tancing up tag wit eat ose onthar and aye pen cnyigo aang Siagen a corsola cot ares clog + Saying ching ore of stance wih dosed ys ahews ees sian ropocenne trator andiscnadered see pesine Romberg tn Noa gas ne resto oper untoning fhe ‘mscubseltel and ners sytem, Tha ar sovera pho pee of gat undying a specie doo (010) At an tty wie bn support and tho fat troun outward. mopgess Cetoboir crt eee ~ Antal ps avai pain on weight-bearing tution cae ah knee cr nice utes is charted by evry shor sane pass oh theinpred sce ~ Aora gatte os of ait t cary out uposefl movements nine absence see or sercory mpaimont Ie titan swings fra an coutwaréin a Grouse manner, oualy Soe ~ {Stor ge th legs ae ed together nd the {oss ana eet cagged one moving cul be Soon Inparaareis ~ Propulsive g i stoosed ga. wih gt esis andthe head and neck nt owas 46 may oe in Parson siase ~ Siopoge (ean “rop fois eto pel caumpy (hen corn Pe Fone feces (Waazang exaggerated Sting he weight fom Soe o sto, s nanfostatonof hp ghee jet gt is narod by tare IMovenets somatnae mig ats Vd abe 40, sever pataag yest ot 0 spas) ses . a (0) stoppage ‘Ltrmureaion ciastes may be dt doanoss, usm, oon per, smatonl Ser" sd ese “a apoat tol can be dared wo 3 ain agar, sree load aa dstubonoe of acto, ct ‘Eisorsef he tng, ip, re oracle sates: Mastona grove, Pakson dca ~ Djaphom ona para fve or ‘pducten due tly ptley, sch anna a+ Dysonaia occur when be ru eninantnomiphere w donaoes as | Heaton of underage exes oa, | ~helorguage areas are cls eta amin eral maser ti gta pate) q when ha etn es Broce’ area ero ona rein to proton ot ors rhe expassn of amapea oe | when Watch's are (supe poster ‘erat obe soe cs bg ‘ne alain ote eae spoken sngugo. a hn he eon vo eves adacent ions of {he pret be he uncer mean ess ~Thus ee ae 3 yoes of dyspnast + Exoostiv (ot oye dah asin of bree sea. chased oye ‘educon nine uma’ ot or atgaarang See ‘omsrenaon real * Recap (senor) Sasha ie ‘tetoheisontt ome oor compatenson, Spec fay be Rue + hte yap - 9 ombinaton of bot exprssive snd recone syephase ode by cage of Soin Gece ana Wors (the bain sens may rest nthe flowing Fetes 8 the ateation of comprehending writen Tenguogo, wn ead rao, ‘protlme iyadlton and sutacton (ayscacuta) lnpeiment fing ealed ayegresha, 43) te canal paves examination 1 Fist cana nave, the ofacory nerve not std tly thet procans of pahoogc martestations, such 9 nosia (asotsrnty each nose sno! be separatay aces using ($Strcs of cteent moe andthe examin of th nce, [Paning nasal vetbue shold te pero [ons could be bata! outa Stl anos is ue (euitoret cause, sah as pet rerio eet Rston, epour, bel kl ecu, onl Facute: congo uses the unistrl anor aos n hee Caura whoa ffcure and meningioma ofthe oiacory gore 2 The et fx he sacond canal nerve, the opti nerve, cad re visu sey, eu! es and fod. yin acuty could be decesteain abologe processes inva the lene, comes tds, pte ne. ‘A uaan ose ofan! boss mayo du: cot uses (ster! oop obo aun), alasal optic neve Flay. Aprogrocove onset suggest cataracts severe cbt ‘Sinonathy,blsieral ope newer corereseon), enbyop [retra camage}, Uninoralbnanase ray oscurin aia aay beveinoccusen,fomporal ser, migrane, Sua is Tse of vue foe presents ferent os * Concane cesease oft el (ural vor: may ‘ecurin gloom rena dzases, mgr {Lose of anal mscus) vision of cane scolomat ‘uso the comyetinnon one apt none, tox cavses {met sean tobacen a leno! ambyopa, untae \eouarlocone and amas of ote nove "Binal hemioopi u aBlaterl estore of the ”nrosed pte. _Bronpors horas mae win ost Sarnage othe fres fom a aval ae owns Ss they docuscte eh pty trou aopherygema, pra: org). ant. perro, acho or caine Sbusn in aae cares hore an eeaeed Spt othe movements he Putanach dese havo slow and foarse charactraed by the boat of te trum ower onde.‘ ‘Tomo redead by voli moverents and > Repping mor consist io felon ans ‘xin ofthe wits ke 3 bs wigs ‘cere port enceslopay, oma, ‘reopen fale > Garbett lesen wor occu usring en ‘sive movement nas abent trot + Fasceuaton: is dtd os raga ropes or tches under ‘he on ovryingmuscies Concur a ros, a pete sisters Gone ter ayaa xr) ans + yoann Fe aude shocktke contactons of @ scl or aroup of mctsnvolng a wht er. Thy may fedueto:ptycloge stations (hon fling sloop oF ‘Surisd by a sudden Pole), epsosy, te ain Gamage, deme + “etapa itu moverents: are de oe ‘damage of extapjramsal amas and ray be aostad {8 opens, chorea andlor alanis + Dytona characterized by an strerral and ‘rained posture, usualy rein the i ot + Cherea characterized by regu, ony and Sra movements, + atts scene by sow ad sustained ‘overeating he ital aro bes, + Groreoinetod movements mean samion ssbetas hse 2 types of mover prev memes a + Homasms: se eet high amplitude, fa. te maveront aay cy rr se ‘of the limbs. a Seow * Sure ay pete Secranerencenymemome, eeesiaeuaGeaeman cme si Inpractc we use tbe ire ane nl costes 1) «re doce wih he oe etn pur th Gehan ‘ove he potions te ota scan epoca Ao crus wih potent saree 9 hon, tei eng Soto oi te Fig: lens tat % ‘Tra tore esses nv the srl of passe 2) Tovements oft ot. “he acne of examination he flowing ort upp shot patente Nand ae spat the ow Fert wine rato oe oar, Peon ad reo ofthe wis bow snd ates n erent rotons eer ts ere enol orate For "Seis and hen the nee exo, Serre mainpeheogt spec het ray be reveled re he fone Seanad one hypotonia sates usualy slower meter neone ieson + is enovate wth mse wasting ypreon + coder iereolar cease ani tho exy Ghose o soe, + aninroages onetypartni) may be manifested ss "Spay. fined ma a wot pent ‘itis detect wn quck movements “eceue m upper mar neurene pathology inde aarocated wit fyperelon, Babine sign, pose onus. slate upper mons mere vu on fronton whereas ho og is iors evr on exo Rig a ousted resttancstroughout ne range movement nae eelcad wih sow movers ‘errs in Parknaorts acoso! cecerbed ‘Se tageanen soy. Ervepyrami stor uiotolat a charateaed by 2 noma "one al eet and shineeaaod fre ae sean movements so2) power Zhe mala rent assessed using he mociod Me Resoarch Coun scale ee Temerrcen Cru iSite. eee, 5: Noma! power See } ‘The meta def may be mantestd as: aresys (patil det) ‘ne examination nls sever leg (compee det), menoplegia (lag of sng ay arog (pei of oraha ofthe cy) parpess nae 698), eval saa ofa four) 4) Coorsnaton tes hat may real a Coretta cseass (0 te duge euch os phonon nol eat-in test patent rune tho he ‘demyetnaton U9 an own te oppo ‘in ereber esas he hes! obbieg al | ‘verte place, no mater te yes piled o open movements are worsening wth lo tengo tate ption has ouch the examin wnt oe Stoo Igor acoe eth ata och hahor rose wis be ines oer cael ease be pabonntnne dae eyaetna) Tees ne tsp st he patent hasta ate sol he ok ‘quickly on the examiner's hand vote se = atthe upper rb lve snr ets to ternategucty roraton and supnion othe hand on he cou of Bierman ‘in corbala ease the movements Slow and cated dyesacocnotnels “se movements are fected a0 ‘xapytomisl sod pyrama s)he sonsry sya ese ona erp oh {mnporstu)poprorepion Seep srueraatons covering fre an ts) and Feroepon (vscar sensi serves by autenonic neous Ser + Pain (pinch) est a pins apple in ech sematoe, oh land ight se coparately, ond te pater asked fone Sharp (normal response) or dul (abort STomperaute osing” oes tive fed wth ht 40-45 oreo) and eo (5-10 deyoes) wat. Aborce of abit 0 fon heats amost aways assctod wh nail fos 2. ‘iaugh ase tsi ar et performed oun, thoy may BO (en spectestuatos, ag sngomyela ration test erating tuning fork pce on ne ofthe ‘tat irpsiangn| jot otha pant he rea espn is Ue eving of vraton. + popiepin tat asp the dtl pain of he ite Sogor brine patet ram he ados and move i up and coun and sok ‘he patents heine detects ne movers ‘The porishoral nenee examination ay rove hwracevate aspect a oson eats oa spec8¢ motor And Sensory oss Pereralneropaty may be manesie a: polnetzopaty (Gharaceriea bya sensory oss nove" andor woking. Batam) ané meneneuropaty ‘Carpal urna syrerome Il mantestea wih poaesthesieEE: andor pin nth hae, acing up, hear mele waa rior pin nth nae, radia ane, he abduction of the ler oes: hi cata sr rd shows rare dor aon ie sng ty na ma 2185 tho upper a ewer auaani I Sodomet otal spent conan abe saoming es tba umbsos mown tray an te mie ToWNg lateral nc up or own depending eyretowes Pte ets eresat he rafex conacton of 8 Pe er genes isc, mediate by a Monasynepke ‘Thon eoratg ofa sansry and cia neurone {fe roaponea ste musce coud Be meses es es ess sng on on ere © Gimiened (9) bearer amano afecing es _— : oo psec eget ants with Fay een maybe du to en voper rotor neurone mse. bay eared obser responce may oot toner mot one [osns, myopativs and yest. ie mupyetcambned sil cord and ot “Te sts of te main fess nce the olownae: The tof ron of a knee whe hearers tog ine nrapattarondon tne ate a xen whi tr hammer sing Ailes tancon "cope 0 brisk convacon ofthe ips mace with ‘nettean otter the Fen cpa the fren entonon due tote ts ‘entation conta lis rofex ne tow Nexon wie sking = Neuroiogic examination volves the analysis of gait and Slance speech, cranial nerves, motor ne sensory and relexos. tor nervous system, of ato figars olhe fe facie could bo found in amner tans wile DE Bo found in sver! ioasos, euch as i charade ora ne a pur ne sti ont x atone oye passe ele elagran cts ouohcr ie eat et ech Sor Giaeisoercamric ony mes este maniotason mn caneer The face's characters ctannnenonorare vss a mc utente eas Soa ere oe meat Sencar were ca trate Seoser See EST ein conte © Tho enlarge ofthe nse, © athsteng oft sk Pm om . 6© Prosminent cheektones © thefohens pager © Teeth gepnna © Mocrogoea Adan face (na face”) {hicron wit von nasal away obstruction (ach _Scenictis) resont eeu canstaniy open, wan re ‘ara ane longue postion, aig ached past and deal Sroming. Down sunam (isomy 2) is characterized by mental ‘eardatn, fea! changes and ther spec changes 1o"Mersephaly and anormal shape eho hss stoned nose 8 proud orgie © Gpwardalantng eyes © epraial ot (rounded edo kn athe mar ‘emer ofthe eyes) ‘The one anges nude singe cease of he pain and ‘en: ear, esvantoatinlabsornates, eased ok of ‘ome fom af sane (aon) Mzalema i caused by yeduced o absent fnctona tyros SRE ginny haan) oo acne Sulton ‘normal hyd gland, such hypothalame opty escsses {eoondary hypothyr, olen associated wah ote). The ‘ace presents specte changes >. White fa mon ace 9. Hereoghe sgn absence of hain he elena paket Pe eyebrow (72) ‘nas cincal manfestatons of mpzsera ine: coma in Saver con dry nd 038 sk, peti nan-ping edema (ue ‘omucopotyactancs intra) hypothermia, badyeara, @ Fig12. Hezoane sin " cer ater ploned expose thigh Tavs of cucocoricois, ue oendonenous canes [esdtencaical soos) or exagnous caus orapy wih fpfizan). The patents presen "eon moon foal Blea the anges nce supraavesar pase, Bula Fano (ecu istibton ot a ovr Ps cone sea) tuna bccn best, rs supi sae ovr fe sbcoren snd cormony. nyperenson, Sabetes mela, ‘Simic sto ecredoma) a connect ss dade, cherscurody spec can he cs oy 2 irony, epesnoncs an le icon be rey) 2 Spree rose 2 terest erat mou) Deca snares one cin a ioror citi, acingto The hereny Colage Rheumatology: - iertafon se snatching, pan niente orcs ins are ome Strip nono otk ice sto 2 Blan (be shove citron ined the «fae) © Distt ping scars or ales of ubtanc fom tne fngor paw pulmonary foo ~ a honeycomb ‘The pation may lo revert muerte manftatons (ons pan, musce wosness peste marfecaone (tered mayo he eater Ye), Rayoacd ‘enomonon (he scseaon oF phases arco xgoeue Bel cme, woes are 3 ome of eerader, ccd fo he mmanieststons “~ 1 Sodom en coup de ste” out of sword: is eracorzed by deep lson staan ow se of toe {and cron by tw cota eneus syste invlenant ime steraarma a cle meypea anaes he hands, ‘ams an face poets commonly presen’ plmonary hizeerson {EREST rms dined by to presse of pleat charges clos, Rayna syne esto ‘yametiy, sclredsay. oeangeciana, Fg 13: sceroderma faces ‘Sistemi ips enbvomatosss (SLE ian autoimmune disease wi systorcnvelvement anda sped faces: coraterzed by the presence of te Etta rash (an eunton cv te sen nds) o fe ‘pe rites citar SLE sagnose require tha pasance of Tie osoing manfostatons a anytime curing te patents, Malar roah Tontcloor Tits leone Thera corer neiroioge deter Therataege ceocers immunaoge cleorder *Antnclarantooay ‘Deematomyei in Sopa inarmtory myopathy wih ‘racer sen changes cous be a paraneoplastic Imantesiaion. Th most common Sn esas ashe iowa changos onto toe: ‘+ hallovope rs, 8 poral violaceous “usxyertnematos rash, at sometras oud ba ust a mia dscalraon slong th fyeld margin + rales cutaneous sgn 1 Gatun popes: sight elevated voiaceous apulos over boy prominenee (pareulany the metacerponatangea! ones, posal Irternatangea! jr the ea Ircanalangeal irs}, te eo, kre teat + pokiodema (langiocas9, ‘nyperpigmesiatonsvolaeeous anthems on the tenor saree + Catena of he sin or muses in about 0% ‘of chien and teenagers + Catena cts Is mates by frm, yolowis s"oles, fen over boy prominence 3 Secondary ifcion may Scar, ;Muscussholta manfesntons muse eeforness ota ematical rac ease sean once {ho ams are more affects tan the fons ar see espacaly othe anal anit he hands, vey hei *Pulmenaryinvlverent:¢canenly eprosenod torae a Wy epreserid by atlnts win diaeles mati present redness over the cheta, aed beast alate, (Gents faces coud be fund in chron congestive cardac faluro andi manfests win syanoss a pumiah cee ‘co shiny eyes put ovate Mica ia characterized by rosy cheeks wi a lush in {ue f datatin ofthe male calla culo ea no 8868 with pulnonaty hypertension duoto mite Himocmic fae is esoctted wth sever conten, euch at erly ae sro, ones apron be ‘he forehead is clammy, ee Palette rosn a ohana ace, wah “@xophtalmus, eyelid retraction, jd lag. ae Seats corrieey meme ikea emo iitciace chactorsnd by ton ossng ane pata gat esas haracazed by an energie of he font ‘4 part areas wth an nested vascuany ane ts oe 6 Joris th avscutaton of tha kul: ates present hort sll and frm othe ower mb. aaa epee, snise-sapnd ros ans tt and i ee Bore ver P ‘sIngpection of: ocular alignment, eyelids, the lacrimal icnnarnen ra ar ee rene See See ee, ements Bee se ede rete gor ono aie Seer Sane seomnames Sees : aceteeemeete aes Eonar! shoscnucmens, eae. @Ste try sts Soccer te Ss one © coMnea changes: 2 oy 1 ent deeona oct SSupncr waco ea © gma dt eye of he iis on ote Saran a ablation of eon " SESpE Seema ios: treme nd and Dasceacatncanerg Soames, ay a a, sees ges Ssbnincar ie D)e exaicaon ot ar cast ns: nape raninaten wy urcope sind hearing teste orisha Se, “lore cannon ar uso engeia Sausos iota rot, ete nce _protuding ears) “yoicen © St eh eat owt aos ove hk © tess, suing pie dn eter «tala utes by eae: sheet es © eischarge ftom the ear (tormea} could ben Papa, uc dent oad 7 ‘pation ot pana maybe paitlimnfecton trauma Pia raga ray revel tanernss not ofthe {inporrandbiar ots may rove ordomos, ‘Sepa: nor detneton _etiaton wih surecope alow a inepacton of be crn salary masks ipa membrane, run Sho oer sno cures snowing lst ude whore vice test (he examina td te patent, wh te mouth about 18 et te fetonts car and than a 60 es the pit can hear spores we at let tance he hewng = ‘ermal Weber and Rina ests oreovay coscrbed a rewooge san)” «he nose examinaton consi io th folwnas: pares, Indung mnsoapy ay reves nasal (aares and nace Sacro Nasal fers nce: “thynopima he noses 0, eiarged. Tuiboun Wis dete acaol abu sited nasal sou ‘leaned nso: do to acomenay early eal), nacs polyooes scare ofthe spt esting 8 sl daformiy ype, tronic Steg of cose Nasal Sachago coud unisiaro lata: according tothe pl ay be: wary, purulent (rt), ih loo ealed ‘Rial dort: aime, nectonMyportention, coaguopaty, sreccaglent eran). alpaton of fe nesal bones, facil swexing (reas of “bri asco, cance one mnslory aru). “Tne enalyo ote serae of aml sein ets for ‘factory nerve: he palo may prose "Sno, bypoemi fe abence, respectively ‘a eocreaoud aenae of sr Suet: veuma, inocton of upper esprtoy ba orgies °© Casoamia: asoama: an unpleasant srl ds oc Infocton othe urea resatery tac om THe exaMnarion oF Fa AMINATION OF THE SKIN, NALS aN Vit. en Tho main changes oft an Sarge fakin opt ; ky ey as encnet kn depends upon he onremogon,reeng ‘areaobin samen ard mein, 7D, ona pe tnd hppa PA ies, * Pall due to decreased xyhemogibin ve enor Sina a white Sin wane post _ among, don doen Alanon wn are amare re a= = Aaa menos | decane a + Stuatenssosoceted wih eae ee, sate slot it srry 70 = Loves palo, dv genamio-n peierlatory sesso "PAD): paler fhe ated um + Ryne aane a mone a8 Passe at exposure of hands faid plo ccoure inthe test stage ars {Slowed ty cyano sa hon, bores. sss duet 2 ain caies: excess tation ot + Fenris yarls endo high vel of nyomogienl Siete pehpebute) nay bofouna vans oF permanent trast redness cours pyoge shuaton’exeoso, exposure 0 + chon mand inoxcaton —chery thst + Ales (due Histamine easing) {etn esther at exposure Sin) 1 Garena tumors perenopavsal women — ptooes ofan Pareto osnacs may be seen “"unetes- uso casas (aces) + Se sone rns etn hee ut mer face) «= Povey te verroducton of ed ‘ood cela veto pimay process tne one mato fojvernema vera) ot Soconaay to erepaetnprodcon- op. aaptaton hgh att) “Te redness of tha ps, aspecal ofthe hyphen and ooremnences, oaied Wer pars and osu Crone er daases, ata abuse, eonnecive sie Sitorers, meumatod atts or coud be dopaths «+ Cyonossis data by inereases love! of reduces ‘omoglbin nthe bd (esollnis) vet 59 100rs (oormal values 259/100n). nyanoa is manifested wth bus col ofthe kn adr ‘mucous membranes. Icanbe een ptecontseie wae xem, ‘Them are mai ype of anos Thera ar 3 main pes of eyanosis: conta, peripheral and set assay be graze (no! common) ‘Senerazod ceria cyanosis ie du array Ir. satwra, benoit, COPD, poopie ung at igh aes oa sr astine People lvng lig suse a ‘ in mationapebineonia sutheredobisea, "ghtto te inracadas urs (Ekenmergers edocs mye of yas al mcs bath on ane oe ek ner rosa dame a cars reares andten eyanca, SP PeR= a han ‘Localized canta cyanols may occu in ase ua, eoharal cuanoss it may be also genera abl ay be also generalized ans enesiee pripherl jaro deo an ners {xan fe oxygen a the perbhoriesues eso of Secor a sowna dow fe od fon ti le Gs gh cada fale, cosittave porcaria een ‘guration or may occur shor exposure Ged + ldo ceo by 2 ahwah or oth sn and ‘eran nts ners a e ad ben's ial coves ta brn = vou a bn vl of at unc fhe ey's oe oh st m8 fat becare selon when bn 08) arenes sean According to etiology, there are 3 types of jaundice: 7 n pretends to an increased hemos, shin sresnonioe ro echrecleen by ems uncoated BR Inde sour aed sabres obi, troninnn be ure, ecto re We nase it fe atraion eamgaton ie sd coniaineg conga an cones ponhenibe teanve|nunaee dw trenstcon of FeSRege ais nthe lay yt glstoes ore seats crab it caoe a be eae Sees, olay suena cull esters). Mie chancery ness conte’ BRN ite sou den ond ple toe. Oo he menmantarsore me tng ) sopspuner ences reir oases eho eeateeimetom Se cecanmmetcasey teens fe nttawunr ater gee haearataaietiamrtcsienson (oenselcorsonyion ctea). + Hypepigmonttn ist rest ofinceased malin in and maybe geneaize resized. 204d otoundnsvera ivoses, sue 2 "Alsoen ase (croalrafcincy- due Screws oct) ‘iprperentton roves atte begining he ‘feat ucoe, sen comes, nope, 3, teas et ueclyoetypeigmenisie’ and en tcomes dfiaertmay be assoc wih ge snag. + Horocomatoss veto kon ovo st Geponton on ison xgane such a8 hort, Ie, a+ Depige sa noe act Seer see settee Simao, "ee ecreencrenaras ris Smee iSucees ameter gers ieee tse eth arnmars yon SRS ert aet ih Siemens = Gagtann tasters eee, aoe onieaat ‘cocu in women wh neressod eel of? Se eg ese Srreeuliase ear Pete Sosa eee ene stag Sa tener Ma am stro oronrou sear crc oem Eicken sransnersae. Raisimacone ere ‘A BAish topo produced by suphacmogiebin, | sentra nlaton s characteristic or. *7* Powoning “i amass pon Scena tn er ” vision voubls, stags + vile: areca ees tte Somes and rand be oro tre arom sn arin ‘s comment assoc : ‘tanmune sed ommeony ore Seoaaos na skins ssesse ching» esate of Sac fh hang, bli for several 8 yet Fe am geremeenyncno (tleanes (ea ere Danos syndrome} mn te aomnmns ranean tt Bae eieeiaiactmac eee FE ve oe eve an rons sow) PO tra te tn returns qui othe norms (Reecasoa tea Feels be ca ob asese case feds a anny pn an SOM Pi stare teats, Soha peeren aoe oe ret rt ne Tes et ae Fe rom ote Sh Bocce set 1%dary lesions oor a a complication of primary sons oe Sch ni al orig seal: resus ase of tran dn othe © Node a rd 8 are" papul,>1 ‘deequamaton fn catered ne donc ie en psoriasis: man eons ae ed 0 agus sna wie se cous forennte a mixture of ies serum, pus OF Sod ane epttal debs soon gd Seated sting oh kin, ees — Lenenieatin palpate ickening oe {cermaograshisn °° Stok he sin © Burrow Baron a sty eva in ual ove the nos, ows "inthe skin Sound sage fos ~ Bean mehr ren of nts (cerns) = Eien is. continuo he skin, os of ‘pera substane=, ere eon ascontnaty of he skin 2 ‘renecrbad capresso wt the 8s of (pusernal and dermal subtance (3.15) 1 abot mal pecans {betortng lee) F9.6.plague the lover bin erysotas " Fg 15: uw, est. Fopne changes ale lower %% nv {oat te sinc dark wi 9 Smid” spe + Wl gangrene: de to chemi ans Ineroosod kof epticera + Gas gangrene: proauced by Costu petingae, tet may sna the muscle throug a wound an nen spreads, roautngintexoma end shack Hentai sions Bscng no the akin is ales parr he aon dos nl appear on pressure ron svochng he sk, “Spa rain ome oho towing Senile purpure: esate ado and i sul oeated ‘ovr te dorsal fae ofthe hands a forearm + Hlanach Schoniin purpura a fom of vous, ‘heals bythe folowing re lovated eins, alae purpura ove th lamer ~ Widuo%oiefetane, mune causes This eanatan aft he nay, ents and atolrtstinal ret (ocreneed ek of Femorsage) + soca rpresent elue hemorag sans of 1-9 samt + etyroses are dosper harnanhage lesions, vohing ‘Some an hype, dus usualy o rare + Tosangectas repebanis te citation ote sma ‘vestls, due SE" congenital eauses, klgpeTronaunay “drome veins teangiociss) ~ Stgued atvatens. ig inner cose sider ov locatad ever the wer pat! ha body Wober Rendu Ose syatems san heros ease[atest win arteovenovs mat 95 er, Cowal shin Talons ivan he bran, V2. Mal and nals Hat andra The ye and ie amon ora OBST! Sete, vic nd gents cers! MY YOY Wl accor fo ‘Tre main pablo poco te Monee means not 8 tows: hypovrerens he hans, (seas shin rep ese oe cag Tho ae sexe oese Sadan Mls loser may och 90ltenon scaring voto, oe ro i Innenuaton ofthe hair folicies: gree", ms aan ~ PRIMES eee o be an enn GRE Mh a non-ancrogenc eres MR sysorcdon roles mecinesap nese ered sre petologe changes of he nis may suggest an underhing 6 Feng tae (Hppecrat roms drums nae): ra ra yon nseane convey of a al ie tte co Engar a ste to wy stage Ire be ecogsed ung the Schr es when ie dt forges a ho oppose tga ar aposed the roa fps teacpace between nalbocs dapper: 17 ‘gn osu, fi ststencousbe cand aren eee" erator teases: COPD, ung cance rere [ung desases, os, ubereloes ung absoas, «+ Caraae deoaes:cynote congenital seas, ‘Sttscue endocarsis 1+ Baeatve dapnsssctvone intarvratoyssesres (Goutn score, Ueeratve cats), oes, especaly frivaybiary ees ‘iin deensok ponysomepetostoss,paimepantar Kerminsera ‘er conctions: eronegaly, pregnancy. Fig.17: ebbing tngarsi nd ofthe ie donee pressure at stnon ofthe rized by the persis 18). es. a be chavactnrized by ¥ eee Oo.) ng edema cheese 2 mal elegede sy be as cn avian Seat 8 rrroan general isauas and cai fe eat ius ota crite mente ser nga orton cis wes ec mat noe an, Te ay ro Te cnc et ores ar ey eto in ona aty c “Sean ao bo eaeg, igieecaasaaaii dota "he ese cot 2 oat iy 1 tra e ecerale ean en coop 3 ‘ racine vena oes) se tn ot ae Ova ioe tea real ay yn oF tara oy ert ch tae ae eno incre eraser owjoaprca ata fone tt cy ‘ontasn ee oun’ nea nat a etry eau805, orice hb ra ae cienybi: ube ound n EN chen pana Seman ri seer eag leah hc st rm shows tie norte oa og daa ot aon ee tr rn et tes ete 0 ay ' Re eee 8 @ral hypertension (reesse hysostatpressurein nator) ene portant cavity (asco) ante lower Seen ssn nt comyrsse te rece ven 1 Endocine edeme ereP eine cui be found nce endoaine Ipesaes such a ee err charac by probbal non-iting esara Nn 1 Mperldostoroncm, fst ous be inno anor, bata inate prman ( actonltyperniaga} ean snineoasod ‘osu reaeorpon by woneys and il Pryor pana a ese co Secrtary to an ovractviy of te rnin angina ayer fuss Wh 8 oereased renal od Ho") 4 Premenste!anarone:smanste wih ame (ens "Shor symptom) duet ormanal changes. inpragney caravan compression ray esd 0 edori ot thotowertints. Locatzed edema i uote: vnous and mph cause, = or a oe lone © ea te aon ° idsteronm vcd a ena re Fane nee tig ctl ee yt eahing edema ocr Over roe or ec eee At the aa region (mn bestest od amet ana th yates pega Seay tot ansseous eu, In glmensongory rer es manifested way neat, Such A enous oa ero sompression by ena eg tue) ander inte ‘tomo, ome ato nd as (2p. romeue VT) enuses a venous ve (CSimprcnce fun nvarccs vas). Kvo}e8 rrr tne owe mb homer te upper HMB may Paso aeces «ore cpals edema: s ut lain lmphate vse, meheunee of bstructon, flares or congenial cerees Ris sorte. ronpiing edema as may bo a tecad ae earns, wir a cremate eiorgemank (rt acted nb 1.1) ©) Hepat edema di: Mypoaburinema a 80 synthesis of Protas ne vt grad eas 8s 4WiU2. Cotter eetaton acura fpr ort obi {Rosina lo an increased pressure above ine eek see ‘rseauive atin and ananars* SHE A ‘The aes obetucton an ce tee obetucton and consecive caters craton 6 Gesctcang ote ibs, hypecencon he upper its, nd tothe meartan of te ductus artriosus. is characterized he ie ve wer evens ‘evenovscostuebon may aes cava veins, portal vin. «Super cova von cistron leas othe dlaaton of the vt orf an ue’ on ha or ‘Soe ows om up doun assis wih edema {an anon ofthe upper prt ote body (1.20), 20 sir cova ven ton in aon fons ¥ ‘of the thorax + Inferior cava vein abstuction eas to Simla aspects Thelin lower part te body tba bed Bows rm «poral hypotension leads to esophageal anastomoses ‘oye ec festa) eal estore, yemamode, araunbical anastomoses caput rota (ig.2)occurs when tha inakeexcsees he energy sed I's ra payenetogeal factors as we 25 = hypahyros. Cutings Pao, rede synaromeproongos uke some es Fpicocoricts). ‘The ditrbuton ofthe tis more important than he Presta The abdominal coset ing 9 a aoe appaareoe, wih await rato geste than OB 3nd. nmaes ie naroited witha nore prognosis (erie grodorearestrban offline lower pa of Brody a peor tapos sopect "ine wast iat req the corect measurement of to crcforanes a tn wet ate mapa betwaen the tasmrgn ond fe liae rest and of rips, ate wisest oan the blocks, rato more ban 1.0 or rhen and 0.08 fe famen asso th nereacedcardavascuy 3k {Shoay i 2 mar heath grobien, ofan assoc wit actos mest ype 2 chem hes esas cyslipicomi, Stenson cant, veron enoxosoian. = ‘Sepnapes folucaseate, FePradanataton ol tet could be cain, manestes wth tpomes, wo ereuecrbed solr wit sk Mnatoee, une expec ove he funk sProgestve wodyetopiy: snorted By @ ‘dminohed subeanenss Uso the a8, rack fimo and dia part ofthe logs and an excess ‘dsroutan onto loner part ol he urk nthe ‘ens esveiated wih ates elt end WIV ‘Meco receiving anova therapy A posta dno cold be ound in Cushing Edom th fata ated pecemarty canta leoong re fal men fac” (rounded pear {Gee) ural num and tn ina uo toasts Fig2t clara creation ove the abdomen de son te et porta Vis. Nutone! statis ind rate en weit lao Homes, ts cons Haceein meee 210288 of intra-abdominal fat wich san imporiant ee ‘gk facto. : WoightiHeight (kai) of devi smonogtan. A Se Le ere Underioht < 185 gin) Nowa jasae3 Oversee 25-298 Obese 30300 (See enna deo eu) Mor obesiy 340 88 »Severe unerwsigh (BM <18 5) cals cachexia, ual ue ‘Gree ooliatg dena mh a alan YY ur noes Lymph nodes may bo palpable a soma peop espe the slbmandbur, vila ard guia greups Ine oe, toy are ‘noble wih sz usaly lees hans ci camoter hs fereiiony. taut sin we palpating ‘Adenopay (te elargrrent oe meh nodes) is common (tate facion and malgrances, ‘Tre examination ees hing (ave ‘Rieger! to mph mas ane pte ho fobatons petomas one ashe vane gers fora (dard cimumvoy obec ase asset years eres he desion ofthe followings: ve “ Sonstney Sromiyxcnto en op tases ‘Saree sora in “pants pscton 2) hotocaton ‘The ai supra rph nodes groups ae located a: carve, ‘lary, eptochiear, guna and pote area, Tha fe? ‘rouge are otominod win he patting, whores the est 2 ‘ube wih ne pao yng down. “ne eval nodes a pabated tm bend the yore submandbulr. pearl, tonsa: supraciavesiar and Geep ena lands be er rangle fe eck ro he fe ‘ttn pant Be seater agi, up bach of he neck ad the poster aural an nepal {Selo roses ontario se petri, 90 joa noes: sng the tut to palate he patents rade aces: pataton just below the inguaigament and in ofthe ephanaus vt nose: Taqar bt hands ppt fossa with he re SZenopthy maybe manested wih dent grades of ‘pe conssteny: Tedgins ante thy re rubbary in uberculosis they may ited and in atari thy fal ogay A toy inca coud ve duo elation. ' ELIE toh codes are neti Fnabon tate tsp tinct o'sniuontne a maenaney Petes associated wth ral or bactel irecon A caval mmahacenopathy mey be duct acu Fronacoowe, ar mclon oa repr vet recon Titers cove eeazee on iwmpadnoraty Aymonasentsy Myresendo’ adenopathy occu i: ancr, tuberculosis, IV ‘changes of the shn-may occur a eamatory processes Adeoopathy may be localized or goneraizes Cenaraltadndonoshy cer lactone: Epstein Ba ures (andi fver or Burtsymanoms},cjtomepaeurss, HIV, ys pm as ya P faignancies: uke, heron 1 Syatme dienes: sysiome lupus ertherstoss, osarcsidoss ‘egestas mayo unin interes ang sry Subeulanoous tasue assessment includes the analysl of: ruttion status, edema, cofatral relation, mph nodes Vil. THE ENDOCRINE SySTEM ‘Ararnesis and ganar! ysl exam may veal sovera) pamotogle apes Fine man ayintoms incu: changes in body woah ans ‘ppate, bowel nat. pgneriton, sweating, gaaciornoea (Gabeloge beast preducien by bth sons), peep, aja, recess, ss ofl, mersbuaton ecules. F Chango in eppato ard woe ‘an inreasad appa wih wait os charactorans hypereyodion or canted betes mets ‘nineased appoe wih weight ga ous m Cushing's ‘Syndrome, hypotelami ooasos ‘oss of eppatte wih wage less occurs in arora inealoney,enronla nes ans eae. ‘oss ofappetie wth weigh gan canbe fund in hroatyrsii + changes in tows habit Diora sasselte wt hypertyroism ae arora Insfioney, wile consipason may occ" n hyphen and heresies + changes othe skin ae hie Increased saestng oes: hypehyoism, precciromoctoma,hypogvenrs. Dry sn cous be found hypothyraien, Fusing of te face asd neck ovine te carcinoid rome (gto ees of voc paple om uno.) typewienaton acu gona stnaihaccea” agente irronaton mayb und fypephitaton Muigo maybe xoosatee min saarl nce desos (taser dese, Aso dona) toss oft wal ard pac hr ees mpcgonaen or adrenal insufficiency. cote “his maybe found i: rypoyrisism, Aan’ ease + Poiana: occ uevtyndaetes mai, ‘bots nb primary slp neo paenopaicor Iypatalame isco or das), pesaeema, bcos) 2 yat real cosas. Polya means an reresse volume of une (more than 3 Ser Poi fd yon hasnt Wt an ‘tengo ewer ft ay aa revel scan amped fo encore + “Tnyodectay can load hypotyrom anor Fypeparatyoisam ub + "Hypatension may 9 de oerdocene diseases: heoehamacyoma, Cui syndrome ami istry: nay tow reser i ase, dleoctes meta mati enn aclacs (MEN) apome (ar an tot crn gp Sanceac arr ys cuca: herbed, ‘pheochromocytoma. ig THYROID GLAND ‘The noma hyo gand maybe palpate n about 5% of feraos nd 25% of males. A gote means onotgemant of tho mys gan Braman of yi equces Inepecton ote nace rom ne et oon: *‘oa tyro swerg while he pant swans heya roves upwards on svaling ‘ins ei enges ott nec: 2 tyrldetomy ar (at ‘peace ot he noc), cited vars oer the waper pao {Pe rns eso wih tein fe extemal ‘Rudteven: may suggest he oodteral extension of [EE qoier dnote fhe sea may oveurin suppurative tyrone papi bein the gaint, te examiner aces he hands “an taltat of te pote neck ne 2 index gor ouhing en Panes the yrs white pasont swallows The goWe PURSES series scaring tothe: si, shape, consistency, tarvemaes, med eeadon wih be claptrag ofthe sthoscone or 8 potsble hyo bat ‘Te gotr shuld be desebed scorn Testes iny oy van ho bsonceof the lower border ‘ay saggosta revostemal oxension ote go 1 Soape ane sure 21S pores reroute symmetrical inte eter sages Sirlet ney bacore nodular Te sua Is sus son Dee disease, wheres ts fonda nuns or SiShnoslor goto, Nodkos shoud be aso ceserbed acrorsns Dies cen, teaderaes, abit. frm adenopathy the gotersuogcts a yl eacar joa Tat gost are mobil, moving upwards wih swalowea, The (iets disuruly edt sureunanasruchzes mcase of ‘cloner ora very ge got. S} Consistency, 2 sat Sostance is noma. Simple gtr suum. ttoross avery hats conettency suggests hyraid cane The ‘Shr plea ery hor asimot's tyros. A rao ede cold bed eae, caation 8 & fat fri. ‘hrencomess 2htaestenceess occurs in hyo, wheres caizes 8 Iepdomoss may sugget he taecng into a eye pity ort nomenon May ecu" nhypryoam ands oa gh bao ow that maybe esocted wth a palpi tl " Ager maybe esata win unl, hyphyricm pean rae ism hypahyriiomor Rtas git cous be duet tireldis Rasninan Gooace + ane dfcnay (pe sok) = rage um, serocone ean Sol tyne may represent fear adenoma, Simple ot hrohage i acolo shade, inalorancy (reo pray seme, reno). typerylanmans nena set fy ‘inane Cina matesacone nus sgn of oympatote thera (eer acycad, sveng) sea noaar Moer of asrenorje antsy sae ‘haciendo eine ce whae cessing ropes srs yo Simaiig hormone Teepe one sae a fy cir cos Chr aces ren x afea, Rathi mpey stacey irae Sten noon mor ae Giessen er enone pte snxiely pan mis caee wih auopaby — shin {Rhee man nyengomte on opie {tabes dorsalis). " oe + fain very mre in conpainent sone tome i nec ogee tres clan oe wlss msboayero {at ccs ater mys spotareray os anes it ory pooner Steng estos onttparss) Trp psn tt orci card oe dt ane psouogut: roca an oie ont of severe ar esoosed wit ease a ovsang of ‘ecient gout realy neste ak ‘attroparges one step att aes rn et deals vara dy sn nis mowing ta et ante vr apa of oye cou nau rer stan ant pen or days cle pinsrome ‘reunion 102 ris sds by arta setae wih swoing of he [Bit tay be manfosied as acute or evans rm and cous sone et (monorits}:cue to infctens (opie sts- usualy wt staphylococel gonocnecl ttlogy or ue to usreians, rau, hemes, Serra sponsjontte cena) mt ssovera ont pohyartnis:n infections, raumais stats, seronogabvesponcvoarbits, gu, prousegod, comactve issue dcoas. nets present aferant manosations according tthe Saering caus: sh eumati arte bare es symmettcl Invovenest fhe proxi ntarhaangea etecarpophalangeal and wit ps bows, kes, {area ana metatrsopalongeal ois inoninlosing spore here 8 usualy 20 aymeetrl aris te seat jo, pro, Fipe knees and shots sin porate ati the aris ives sia he Stal mierpalangeal ons, sacri ars ‘sual asaoated wih pearl infamaion (cacy) sin Retr syndrome the artemis sacotiac rts spt, ip, kre sin ostacart pan i ceo, progrssve,afoctng oops aged 40 Bone pin characterized as penetrating, deep ands ‘werent ah A ocala pa suggests trou, cvone ‘ntesion (staomyai) avacculrrectos. A amuse pan ‘ney oon oxtomaiada ana Papas cave. In foc {he pan's sharp. stabg, aggravated by movements sel pain (myalgia) desoted usualy ao a doen pn sometimes poor eeland, Nataly eggravatod by we of ‘he musa Paral musi aes nay be pat wheres {sal rupture mayne relatvaly pao, Pan ay be {esoeiaed win uid wees such a pohmyost, The 103Ian causes of maga incl: fection (a, bacteria Parasite) rauna (weratoma, habaomjay),armainy Eenators (symyaigin heures, ml, ‘Samateyis, omporal amar), ar (en, conan). ‘nor pes of Bala ne: he refers pin fam a dterent ste sand rade pai, e.g: pain producos by urbane Poigy mayo fn the og ) silos ‘Sites dln 2 a stjectvesaneaton of esetance to ‘Stnss i uot diferent causes, such a: nanan on ‘ote ana tennis cow scatietancents Sra frets symoatate dystosty (enberopaios) The patie othe sfiness may suggest he uraryng cave: fess cccuing ean te ming an lasing at Toast 1 Pou suggest anitarematoy atte suites esutng ata rst ane ning enya minutos on moverent suggests mectanca caus, ©) Aled clogs funeion ‘Woskress may be due jnt ara murce cscs, Dorper’ naa lasone Prowna’ wooknoas Suggests a pivary musce asese (cermatomyests,paiymyets) ora secondary, Iryepthy fo lea ase sare thyrotoncoee) Dist wosknes commonly ue lo nero causes (porpteral neuropathy of tars or vtamin Y2 Alteeney) comectve taue danrsers,prenea ‘muses srophy (Ohret Mare Toot sssace 9 ‘armen horas neworuseuaraceace mansetad ‘win woasnassand'oss af tureton of te dat musoa) tos 4 An ntermiton wens that worsens uring acy (hamctaraee myarhena gr ‘Nproprenave and gereaized weakness may be due ‘amotnaurone Seen, staal manifestations (eas by goerl Diva exam Essen rcnaractorst in domatemostis (ee ah tos ry en, sce yes changes: o ii anyon seria, o wip iar nae, © tidosonesimnartan ‘come ©. 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