Short Case for Final 2554

(1)

Short case

Tongy

(2)

Short describe

1. Cushing syndrome

2. Acromegaly

3. Graves’ disease

4. Postsurgical hypocalcemia

5. Short stature

6. DM

(3)

Cardio

• MS with AF with

PHT

• MR

• AS

• AR

• PS

• VSD

• ASD

• PDA

• Coarctation of Aorta

Takaysu

วันจันทร์ที่ 5 กันยายน 2011

(4)

ผู้ป่วยมาด้วยคอโต

จงตรวจร่างกาย

General appearance & BP First& Pulse

(5)

Hyperthyroidism

Eye

•Exopthalmos

From lateral view

•Lid Lag

•Retraction

• Proptosis

•Chemosis

•Corneal ulcer

•EOM

เปิดตาด้วย

Diffuse aloplacia, fine hair

(6)

Thyroid gland

• Surgical scar

• Bruit *

• Size estimation

• Consistency&tender

• Nodule

• Lymph node

(7)

Thyroid Examination

คลํา Thyroid Gland โดยคลําทีละข้าง

เช่นถ้าต้องการตรวจข้างซ้าย ให้ใช้นิ้ว

หัวแม่มือของมือซ้าย กดไปที่ Thyroid

Cartilage และดันไปด้านตรงข้าม

คลํา Thyroid Gland โดยใช้มือ

อีกข้าง โดยอาจให้ผู้ป่วยกลืน

น้ําลายเพื่อดูว่าก้อนขยับตามการ

กลืนหรือไม่

(8)

Hyperthyroidism

1.Tachycardia,AF

2. MPV

3. Gynecomstria

Neuro

Leg

• Pretibial myxedema

(Plaqe แข็ง กดไม่บุ๋ม)

(9)

Hyperthyroidism

Skin

• Vitiligo

• Moist&Warm

• Palmar erythema

• เล็บ

• Acopachy ( clubbing) เจ็บ

• Suggest autoimmune

• Onycholysis

• Plummer nail(นิ้วนาง)

• Tremor

(10)

Hyperthyroidism

Skin

• Vitiligo

• Moist&Warm

• Palmar erythema

• เล็บ

• Acopachy ( clubbing) เจ็บ

• Suggest autoimmune

• Onycholysis

(11)

Hyperthyroidism

Skin

• Vitiligo

• Moist&Warm

• Palmar erythema

• เล็บ

• Acopachy ( clubbing) เจ็บ

• Suggest autoimmune

• Onycholysis

• Plummer nail(นิ้วนาง)

• Tremor

(12)

Special Test

(13)

Hypothyroids

• PR

• BP

• General appearance

1. 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

(14)

CUSHINGS

(15)

1.Moon face

2.Pletora

3.Cataract

4.Acne

5.Hirsutism

6.Tenagiectasia

7.Oral tush,Hyperpigmentation

1.AN

2.Buffalo hump

3.Supraclavicular fat pad

1.VF

2.Moods

(16)

1 Proximal Myopathy

1.Truncal obesity

2.Board violaceous cutaneous Striae

3.Bimanual palapation

Thin skin

Easy bruising (s)

Palmar crease

(17)

Turner

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

(18)

(19)

HEENT "8"

(20)

HEENT "8"

1.Low set ear

2.Low posterior hair line

3.Fish like mouth

4.High arch palate

5.Micronathia

6.Hearing with OM

7.Posterior web neck

8.Thyroids??

(21)

(22)

(23)

Chest =2

CVS

(24)

Chest =2

Abdomen

CVS

(25)

Chest =2

EXT=6

Abdomen

CVS

(26)

Chest =2

1.BP 4 extremities

2.Cubitus valgus,Genu

3.Short of 4,5 metacarpal bone

4.Madelung deformities

5.Nail dysplasia

6.Lymphedema

EXT=6

Abdomen

CVS

(27)

No Secondary Sex

characteristic***

1.No Breast Development

2.No Axillary hair

3.No Pubic hair

4.Infertility(Amennorhea)

Work up

1.FSH/LH (increase)

2.Estradiol(Decrease)

3.Chromosome study(45/XO)

(28)

Acromegaly

(29)

(30)

1. Cutis veracities gyrata

2. Frontal brossing

3. Prominent supraorbital ridge

4. Coarse face

5. Big nose

6. Thick lip

7. Malocclusion

8. Teeth separation (ฟันล่าง)

9. Macroglossia

10. Deep and hollow sound*****

11. Prognatism*****

(31)

1. Cutis veracities gyrata

2. Frontal brossing

3. Prominent supraorbital ridge

4. Coarse face

5. Big nose

6. Thick lip

7. Malocclusion

8. Teeth separation (ฟันล่าง)

9. Macroglossia

10. Deep and hollow sound*****

11. Prognatism*****

12. VF(The last): Bitemporal hemianopia

1.Thyroid enlargement

2.Skin tag

3.AN

(32)

(33)

Cardiomegaly

Galactorrhea

(34)

Cardiomegaly

Galactorrhea

Proximal

myopathy

(35)

Cardiomegaly

Galactorrhea

Hepatomegaly

Splenomegaly

Proximal

myopathy

(36)

Cardiomegaly

Galactorrhea

Hepatomegaly

Splenomegaly

Proximal

myopathy

1.Spade like finger

2.เท้าหนา(Heel pad thickening)

3.CTS

(37)

Acromegaly

• GH producing pituitary tumor

• Bronchial carcinoid

• Small cell lung cancer

(38)

(39)

• Skin

• Small papule in neck,

• Striae distensae

• Soulder

• Lumbar region

1. Frontal brossing

2. Long narrow face

1. Blue sclera

2. Ectopia lentis

3. Myopia

4. Iridodonesis

Palate

• High arched palate

• Crowding of teeth

Chest

1. Pectus excavatun

2. Pneumothorax

3. ICD scar

Hand

1. Hypermobile of joint

2. Arachnodactyly

3. Thumb sign

4. Wrist sign

Foot

Flat feet(pes Panus)

Heart

1. MVP

2. AR

3. Coarc

Spine

1. Scoliosis

2. Kyphosis

3. Dural ectasia

Hernia

Tall

(40)

(41)

วิธีการ

วัด

BP

SBP+20

2-5 min

Result:

Add of thumb+ Flex MCP,wist,

Extension of IP (spreading of finger)

1. Brittle hair with Aloplacia

2. Cataract

3. Papilledema

4. Chvostek sign

5. Teeth hypoplasia

6. Thyroids scar

7. Bronchospasm

8. Extremity :Dry puffy,Coarse skin,dermatitis

9. Neuro: Parkinsonism

10.HOA

11.Mucocutaneous candidiasis

Troussaau sign

(42)

DM

• Peripheral pulse: Dorsalis pedis,Post Tibail a.

• Sensation

• Proprioception

• ตรวจซอกนิ้วเท้า

• ตรวจฝ่าเท้า (ดูแผล)

• ตรวจ Skin(Dry skin)

(43)

Neurology

• Facial weakness

• Entrapment Neuropathy:CTS

• Tremor: Parkinson’s disease,ET

• Ptosis:CN III palsy

• Visual field defect: Occipital lobe lesion

• Generalized weakness

(44)

Facial Palsy

• CN VII(แยก Upper&Lower)

• Motor: ยักคิ้ว,หลับตา,ยิงฟัน,เป่าปาก

• Sensory:รับรส Anterior 2/3

• Reflex:Corneal reflex

• EOM

• CN V(Motor&Sensory)

• CN VIII(Hearing)

•

(45)

DDx

1. Ramsay-Hunt syndrome

2. CP angle Tumor

(7,8>5+ Cerebellar ข้างเดียวกัน)

3. Parotid gland tumor

4. Otitis media

5. Facial trauma

(46)

Bilateral Ddx

• MG

• GBS

• Basal arachnoiditis

• Muscular dystrophy

• MD,FSHMD,OPMD

•

(47)

Carpal Tunnel syndrome

• Lumbricoides:

First,Second

• Opponen pollicis

• Abductor pollicis brevis

• Flexure pollicis brevis

LOAF

Key Muscle

(48)

Step

• ดู: Thenar atrophy,Sx scar

• Pinprick sensation

• Key muscle: Intrinsic&Extrinsic hand

(49)

(50)

(51)

(52)

Etiology

• DM/Ischemia

• RA

• Hypothyroids

(53)

PTOSIS

(54)

(55)

Ptosis

• ข้างเดียว หรือ สองข้าง ,Complete or incomplete

• Pupil

• EOM

(56)

MG

1.Ptosis กี่ข้าง +Pupils

2.Enhance ptosis

3.EOM

4.CN:

Facial diplegia, Gag

5.Tounge:

Trifurrow tounge

6.Nasal voice

7.Jaw jerk

8.นับเลข,พูดชื่อ

9.Thyoird

10.Neck muscle

11.Motor

12.DTR

13.Fatigability :

ให้คนไข้ยก แล้วจะ weakขึ้นลง

(57)

(58)

(59)

Wasting Hand

• Cord:

Syringomyelia,Central cord tumor

• Motor neoron:

ALS

• Root:

C pondylosis,Brachial plexus

• Nerve: Neuropathy=>

Poly or Mono

• Muscle:

Dysuse

(60)

Syringomyelia

• Cervical: Upper thoracic

• Clinical

• Segmental sensory loss

เสีย Pain,Tempเฉพาะระดับที่ cross ใน cord =>ชาม

แสบมร้อนมทิ่ม

• Dissociative sensory loss

(Preserve propioception)

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

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

Sacral sparing

(61)

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

(62)

C Spondylosis

• กด Cord,Root Common C6-C8

• อาการ:

• ปวดต้นคอ

• Limit movement

• Lhermitte sign +ve (Flex neckแล้ว มี Electrical

sense ลงไป Limb)

(63)

Saturday night palsy

Wrist

drop

Sensory:

Loss at dorsum of Thumb & Index finger

Motor:

Brachioradialis

Extensor carpi radialis brevis/Longus

Supinator

Extensor Digitorum communis

Extensor Digiti Minimi

Extensor pollicis Longus/Brevis

Abductor pollicis longus

Spare:Tricep brachii

(64)

(65)

ผู้ป่วยมาด้วยมือลีบ จงแสดง

การตรวจร่างกาย

(66)

• General appearance

• Unilateral

• Deformities

• _{Atrophy fasciculation: ลิ้น,มือ}

• Scar,Fracture

• Motor

• Reflex

• Sensory

(67)

Motor

• Tone

• Power

• หนีบกระดาษ

• Formet sign

• Key muscle

• Flexor carpi ulnaris

• Flexor digitiminmi

• Flexor di pro 3,4

• Opponen di

(68)

Foot Drop

• Weakness of tibialis anterior ( common

peroneal nerve, L4-5 root, corticospinal tract)

• Common perneal nerve-->peroneal muscles

(foot eversion)

(69)

(70)

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.)

(71)

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

(72)

Common Peroneal nerve

Foot drop

Sensory:As Figure

Motor

1.Extensor hallucis lungus/Brevis

2.Extensor digitorum longus/Brevis

3.TA

(73)

(74)

Tremor

Resting

Essential

Cerebellar

(75)

PD

ดู

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

Pill roling,drooling, hand posture

ลุกเดิน

Tremor

Action

_{Reemerging tremor}

Rigidity

Cogwheel rigidity,Tone( Spastic,Hyper or Hypotone

Bradykinesia

Finger tapping,Rapid alternated movement

1.Stooped posture

2.Difficult to initiating

3.Short step

4.Freezing gate

5.Festinating gait

6.Loss of arm swing

7.En block turning

8.Tandem

9.Rhomberg

10.Pull test

(76)

PD

นั่ง

พูด: Monotone

เขียน:Micrographia

EOM

Cerebellar signs

Motor,DTR,Sensation

(77)

Gait Ataxia

นั่ง

Trucal ataxia

เดิน

Wide base gait

Rhomberg sign(sensory ataxia=posterior column )

Tandem gait

CN

Cerebellar

Nystagmus(KF ring,Retinitis pigmentosa)

Scanning speech

Finger to nose test,intention tremor

Diadokokinesia

Limb ataxia and over shoot

Check and rebound

Rebound phenomenon of Gordon and Holmes

Heel to shin test

(78)

Gait Ataxia

Frontal lobe sign

1.Palmomental reflex

_2.Glabella

3.Grasp

Motor

DTR

(79)

Blurr vision

• VA: 14 นิ้ว Snellen chart,อ่านบนลงล่าง

• VF

• EOM

• Pupilary light reflex:

• Direct Light Reflex

• Consentual Light Reflex

• Swinging light

• Accomodation

• Fundoscope

(80)

AIR

• SSc

• RA

• SpA

• Chronic trophaceous Gout

(81)

SSc

1.RV heaving,

2.P2,

3.Rub,

4.Arrhythmia

1.Loss of wrinkle and facial expression

2.Loss of 1/3 of eye brown

3.Salt and Peper appearance

4.Bird beak nose

5.Fish mouth

6.Telangiectasia

1.Calcinosis cutis

2.Tendon friction rub

3.Digital pitting scar

4.Loss of digital fat pad

5.Acrolysis

6.Capillary nail fold

7.Raynaud

8.Sclerodactyly c flexor deformities

9.CTS

1.Motor power

2.Joint

3.Flexion contracture

Chest &Abdomen

• Skin thickening and

Telnagiectasis

• ฟัง=>Crep,Bowel sound

(82)

RA

1.Episcleritis,Scleritis/Scleromalacia (Perforan)

2.Dry eye

3.lacrimal gland enlargement

4.Parotid gland enlargement

5.C spine tenderness: Flex/Extend

1.Dry tounge

2.Dental carries

3.Hoarseness (Cricroarythnoiditis)

Lung:ILD,Pleural effusion

Heart:Rub,AR

Abdomen: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 defomities

Feet: Cock up toe/Hammer toe

(83)

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

(84)

Skin

• Scalp:

• Heliotrope

• V sign,Shawl sign

• Pokiloderma vasculare atrophican

• Calcinosis cutis and soft tisuue calcification

• Mechanic hand

(85)

AS

• ดู+expose+ ถอดรองเท้า

• เคาะดูว่าเจ็บที่ใด C-->L

• Spine mobility

• SI joint

• ตรวจตา

• Heart+ Peripheral pulse

• Peripheral joint

(86)

ดู+ expose+ ถอดรองเท้า

• Stoop posture

• Neck flexion deformity

• Loss of L lordosis

(87)

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

(88)

SI joint

• SI palpation

• Direct compression

• Provocative test

• Pelvic compression test

• Open book

(89)

Miscellaneous

• Advice

• สอนพ่นยา

• ฉีด Insulin

(90)

• 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

(91)

Dyslipid

• กินให้ครบ

• หลีกเลี่ยงอาการ Cholesterol สูง

• งดทอด, If ทอด ถั่วเหลือง,ข้าวโพด,ดอกทานตะวัน