大三下临床诊断学复件七年制

MucocutaneousHemorrhageThe

SecondAffiliatedHospitalofDalianMedicalUniversityVIP2Department

孙芸Etiology

ProblemsofVesselWallHereditaryhemorrhagictelangiectasia、Vasculitis、infectionsPlateletDisordersQuantitativeplateletdefects(Autoimmunethrombocytopenicpurpura,Heparin-inducedthrombocytopenia,Hypersplenism)Qualitativeplateletdefects(ThromboticthrombocytopenicPurpura,Bonemarrowfailure,Disseminatedintravascularcoagulation)CoagulationDisordersCongenital:Hemophilia、Hypofibrinogenemia、CoagulationfactordeficiencyAcquired:Liverdisease,Uremia，VitaminKdeficiencyEtiologyClinicalOccurrencePetechia:round、lessthan2mmPurpura:3-5mm、donotelevatetheskinormucosaEcchymosis:Alargerspot、morethan5mmHematoma:ElevatingtheskinormucosaEpistaxis(Nosebleed)Localcauses:lacerations,Rhinitis

Generalizedcauses:Congenitalhereditary

telangiectasia、Infectiousviralrhinitis、Coagulopathies、CirrhosisClinicalOccurrenceClinicalOccurrenceBleedinggumsLocalcauses:Infectiouspyorrheaalveolaris,Traumatictoothbrushing,LacerationsSystemiccauses:Vascularandblooddyscrasia,Thrombocytopenia,HemophiliaLumbodorsalgiaEtiologyTraumaInflammationDegenerativeJointDiseaseCongenitalDeformityofSpine

MetabolicBoneDiseaseTumorClinicalOccurrence1.VertebralDiseasesSpinalfracture、SlippeddiskHyperosteogeny、TuberculousspondylitisPurulentspondylitis、tumorClinicalOccurrence2.ParavertebralDiseases3.RadiculopathySpinalcordcompressionSubarachnoidhemorrhageClinicalOccurrence4.VisceralDiseasesUrologicdiseasesCavitaspelvicdisease5.DigestiveSystemDiseases6.RespiratoryDiseasesArthralgiaEtiology1.Trauma：AcuteInjury(Dislocationofjoint、Fractures)ChronicityInjury(Hyperostosis、Capsularthickening)2.Bacterial

Infection3.AllergicReactionandAutoimmunity(RheumatoidArthritis、SystemicLupusErythematosus)Etiology4.DegenerativeJointDisease5.MetabolicBoneDisease(VitaminDDeficiencyOsteopathy、Gout、DiabeticOsteopathy、Thyroiddiseases)6.ArticularTumor(Osteochondroma、a)ClinicalOccurrence1.TraumaticArthralgia(AfterTrauma、thenArthralgia、ArticularSwelling、ArticularDysfunction）2.PyogenicArthritis(itantSymptoms：Hyperpyrexia、Chilly、RedswellingandCalorofLocalJoint)3.TuberculousArthritis(itantSymptoms：LowGradeFever、Acratia、NightSweat、Magersucht）4.RheumaticArthritis(ErraticArthralgia,panywithMyocarditisandChorea)5.RheumatoidArthritis(Spindle-shapedswellingoftheproximatefingerjoin，

panywithMorningStiffnessandArticularMalformation)6.Gout(itantSymptoms：IncreasingofBloodUricAcid、

RedswellingandCalorofLocalJoint）ClinicalOccurrenceSpineandExtremities

PHYSICALEXAMINATIONOFTHESPINECurvesMotionsTendernessandPercussionpainPhysiologicalcurvatureofspineLateralviewofthefourspinecurvesExaminationofthespinalcurves

Kyphosis（gibbus）

LordosisScoliosisSpinalPathologicalDisorders

Thoracic

Kyphosis（gibbus）①Rickets②Tuberculosis③AnkylosingSpondylitis④VertebraeDegeneration⑤Traumaticspinalfracture

LumbarLordosis

AdvancedpregnancyGenerousascitesHip-jointtuberculosisEtiologicalfactor

Scoliosis1.Posturescoliosis（Changepositioncandisappear)

2.

Organicscoliosis

(Changepositioncannotdisappear）

SpinalMotion１.Normalmotion

FlexionExtensionLateralRatationBendingCervical35º-45º

35º-45º

45º

60º-80°Thoracic

30º

20º

20º

35ºLumbar75°-90°30°20°-35°30°Total128°125°73.5°115°

Examination

２.Limitationofmotion(cause）SofttissueinjuryHyperosteogenySlippeddiskSpinalfracture/dislocations

TendernessandPercussionPainTendernessDirectPercussionPainIndirectPercussionPain

ExaminationofTenderness

DirectPercussionPain

IndirectPercussionPainSpecialExaminationCervical：Spurlingsign（cervicalosteoarthritisandslippeddisk）Anteflexiocircumflexnecktest（degenerationofcervicalfacet）Jugularpressiontest（cervicalosteoarthritis

、sciatica)Circumflexnecktest

（vertebralarterytypeofcervicalosteoarthritis

）

LambarandSacral：

Rockingtest

（lumbosacraldisease)

Pick-uptest（lumbarspondylosis）

Laseguesign（<70°lumbarintervertebraldiscprotrusion

、sciatica）

Neckflexionsign（lumbarintervertebraldiscprotrusion）

Femoralnervestretchingtest（prone、upperlumbarintervertebraldiscprotrusion)

EXTREMITIESANDJOINTS

InspectionandPalpationForm、LocationandMovement

TheUpperLimbJointsLength、Shape、DeformitiesMuscularatrophy、Skin、VesselsShoulderjointElbowjointWristjointandHand

KoilonychiaIronDeficiencyAnemia

AcropachyDrumStick-shapedFingersLungcancerBronchiectasisLungabscessCongenitalheartdiseaseInfectiveendocarditisCirrhosisAcromegalyPituitarytumorAdenomaofanteriorpituitarygland

MyophagismClawhand（鸟形手）：Ulnarnerveinjury

RheumatoidarthritisSpindle-shaped

swellingoftheproximatefingerjoin

MusclediseaseperipheralneuropathydisuseatrophyMuscleAtrophyTheLowerLimbJointsgenuvarus

、valgus

Rickets（O-shapelegs）（X-shapelegs）

Talipesvarus、valguscongenitalmalformation、poliomyelitis

Varixoflowerextremity

Physicalwork、longStanding

Arthritis

FloatingPatellaTest

GoutAnchylosis、Hypertrophy、Deformity、Goutydeposition、Diabrosis。MentalStatusConsciousnessMemoryThinkingAffectionIntelligenceLanguageDisturbanceofConsciousness

Definition：

AscendingreticularactivatingsystemCerebralcortexLevelofconsciousnessdisorderContentofconsciousnessdisorderClassification：Levelofconsciousnessdisorder：somnolence、stupor、coma：light、middle、deepContentofconsciousnessdisorder：confusion、deliriumLevelofconsciousnessdisorderclassification

painarousalunconscioustendonreflexlightreflexvitalsignreaction

reactionspontaneousmovement

Somnolence＋＋＋＋＋稳定（明显）（呼唤）stupor

＋＋＋＋＋稳定

(迟钝)(大声呼唤)coma

light

＋－可有＋＋无变化

middle

重刺激可有－很少－迟钝轻度变化

deep

－－－－－显著变化ContentofconsciousnessdisorderConfusion

DeliriumNeurogenicExaminationNeurogenicExamination

SensoryexaminationNervousreflexexaminationAutonomicnerveexaminationCranialnervesexaminationMotionexaminationCranialnervesexamination

ⅠOlfactoryN

ⅡOpticN

ⅢOculomotorN

ⅣTrochlearN

ⅤTrigeminalN

ⅥAbducentN

ⅦFacialN

ⅧVestibulocochlearN

ⅨGlossopharyngealN

ⅩVagusN

ⅪAccessoryN

ⅫHypoglossalN1、OlfactoryNerve

AnatomicstructureTestingSmell

2、OpticNerve

Anatomicstructure

TestingtheOpticNerve:VisualAcuityVisualFieldsFundi3.OculomotorN、TrochlearN、AbducentNAnatomicstructureTestingMethod:RimaoculiandEyelidEyeball:OcularpositionOcularmovementNystagmus、DiplopiaPupil:Size3-4mm;Form、size(bilateral)Lightreflex(Direct、Indirect）

modationreflexandConvergencereflex4、Trigeminalnerves

Anatomicstructure

TestingMethod:

MotorFunction

SensoryFunction

Reflex:CornealReflexMandibularReflex5、Facialnerve

Anatomicstructure

TestingMethod:MotorfunctionGustation6、VestibulocochlearnerveAnatomicstructureTestingMethod:CochlearNerve:HearingTestsTuningforktest:RinneTest；WeberTestVestibularnerve

7、Glossopharyngeum、VagusNAnatomicstructureTestingMethod:MotorFunctionSensoryFunctionPharyngealReflex:PseudobulbarParalysisVerabulbarParalysis

8、Accessorynerve：

SternocleidomastoidmuscleTrapeziusmuscle

9、HypoglossalNerve：

UpperMotorNeuronLesion

LowerMotorNeuronLesionMotorExamination◆Musclebulk（Nutrition）◆Muscletone◆Musclestrength◆Coordinationofmovement◆Involuntarymovement◆GaitMuscleBulkAmyotrophy(Lowermotorneuronlesion、myopathyanddisuseatrophy）Pseudohypertrophy（Myopathy）MuscleTone

Hypotonia：

LowerMotorNeuronDiseaseCerebellumDiseasesPosteriorFuniculusofSpinalCordDiseases

Hypertonia：

Clasp-knifeRigidity－PyramidalLesionEadPipeRigidity－Extrapyramidal

LesionCogwheelRigidity－Tremor

Testing

MuscleStrength

GradingofMuscleStrengthGrade０

NomusclemovementGrade

ⅠAtraceofmusclemovementwithoutjointmotionGradeⅡ

BodypartmoveswithgravityeliminatedGradeⅢ

BodypartmovesagainstgravitybutnotresistanceGradeⅣBodypartmovesagainstgravityandsomeresistanceGradeⅤNormal（OxfordScale）ClassificationofParalysis(Pattern)MonoplegiaHemiparalysisCrossedHemiparalysisParaplegiaCerebralcortexlesionInternalcapsulelesionBrain

stemdisorderMyeleterosisLevelCompletenesspleteness（Paresis）

Character

UppermotorneuronLowermotorneuronParalysisParalysis

（StiffParalysis）（SoftParalysis）DistributionWholeLmbsMuscleGroup

（Monoplegia、Hemiplegia、Paraplegia）Muscletonus↑（Clasp-knife）↓

SpasticparalysisFlaccidparalysisTendonreflex↑

↓OR_Pathologicalreflex+_Amyotrophy_+Myofasciculiquiver_+Coordinationofmovement

Cerebellum、Vestibulum、Deepsensation、normalmyodynamiacoordinationFinger-to-noseTest0.5cm

Cerebellum

(identical）DeepsensationHeel–to-kneeTest

Cerebellum（Unsteadiness）Deepsensation（Couldn'tfind）DiadochokinesiaRombergsigne：Cerebellum、SensibilityInvoluntarymovementChoreaticmovementAthetosisTremorInactivity（ExtrapyramidalSystem）Intention（Cerebellum）GaitAbnormalSpasticHemipoegicGait（AcuteCerebrovascularDisease）SpasticParaplegiaGait（ScissorsGaitCongenitalSpasticParaplegia

）AtaxiaGait（DrunkenGaitTabesDorsalis）FestinatingGait（Parkinsonism）SteppageGait（PeronealParalysis）SwayingGait（ProgressiveMuscularDystrophy）Specialsense：SmellVisionTasteHearingSensoryexaminationGeneralsensation：Superficialsensation：Algesia、TemperatureSense

—LateralSpinothalamicTractThigmesthesia

—AnteriorSpinothalamicTractPosteriorFuniculusDeepsensation：

KinestheticSenseTopesthesiaPallesthesia

—PosteriorFuniculusCombinedsensation：

LocalizationTwoPointDiscriminationGraphesthesiaSenseStereognosis—Cortex

NervousReflexExaminationReflexArc：ReceptorAfferentNeuronsContactNeuronsEfferentNeuronsEffector

ReflexExamineDeepReflexShallowReflexPathologicalReflexMeningealIrritationsign

1.DeepReflex（TendonReflex）●BicepsReflex（C5-6）●TricepsReflex（C6-7）●RadiofilmRefle（C5-6）●KneeReflex（L2-4）●AnkleReflex

（S1-2）●HoffmannSign(C7－T1）●RossolimoSign(C7－T1）●Clonus（AnklePatella）GradingofDeepReflexStrength0：Areflexia1+：Hyporeflexia2+：Normalreflex3+：ReinforcementofreflexNormalorPathologicalreflex4+：Hyperreflexia、Clonus，

PathologicalReflexTestingDeepReflexofUpperExtremityTestingDeepReflexofLowerExtremity

HoffmannSigneRossolimoSigneAnkleclonus（TendonReflexAccentuation）Patellarclonus

WeakenordisappearofDeepRefex●LowerMotorNeuronParalysis●MuscleDisease（PeriodicParalysis、MyastheniaGravis）●NervousShock●DeepComa、DeepSleep、DeepAnesthesia、GenerousSedative●SomeHealthy

ReinforcingofDe