Semiology Flashcards
Nonarticular structures
include supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin
Painful on ACTIVE range of motion
Focal tenderness in regions adjacent to articular structures
Have physical exam findings remote from joint capsule
Rare to have swelling, crepitus, instability, deformity
Articular structures
synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule and juxtaarticular bone
Deep or diffuse pain Pain on active and passive movement Limited range of motion on active and passive movement Swelling Crepitation Instability Locking Deformity
Osteoarthritis
Most common MSK condition
Crepitus with active motion: crunchy
Risk factors:
- age
- obesity
- female gender
- joint injury
- genetics
*Knee, hip, wrist (carpometacarpal squaring), hand carpometacarpal, DIP, PIP *(no synovitis, erythema, warmth), only RA involves the MCP), spine, shoulder (NFL touchdown sign is positive
Chronic pain, loss of function
-Morning stiffness < 30 min
Diagnose with history and physical
Xray: insensitive test, absence of findings does not rule out disease
- -asymmetric joint space narrowing*
- spur formation
- cortical bone thickening
- subchondral cysts
ACR criteria:
-cold effusion
Pes Anserine Bursitis
Pain just below knee at ateromedial aspect of tibia that occurs when exercising or climbing
Meniscal injury
Pain usually occurs acutely and is associated with trauma
Buckling and locking of knee
Tenderness over joint line
McMurray: clicking felt when knee compressed and rotated during varus and valgus; point knee towards shoulders while flexing
Trochanteric bursitis
Pain and tenderness over greater trochanter
Pain can radiate down thigh in some cases
Should do Xray to insure no other contributions
Biceps tendonitis
results from impingement or instability
Pain aggravated by lifting, pulling or repetitive overhead movements
Tenderness on palpation of biceps tendon with arm slightly externally rotated
Adhesive capsulitis
ROM limited on active and passive motion
Usually painless
Present with patient with chronic shoulder problems, seen in Parkinson’s patients
Physically cannot raise arm
-should be able to get arm to T7-T8
Rotator Cuff Tendonitis
Pain is worsened activity and night
Most common shoulder pain: 29%
Usually no history of trauma
Should not have weakness (if weakness = tear)
Carpal Tunnel Syndrome
Nocturnal aching wrist
- pain with squaring of the palm
- bilateral hand numbness and tingling: *helps with shaking it out
- worse at night
- numbness along middle finger*
Risk:
- female
- obesity
- pregnancy
Tinel's = taping test Phalen's = funny; 1 min; fingers pointed down, wrists facing each other
DeQuervain’s Tenosynovitis
Exercise related involving extensive wrist and thumb action
-gripping/grasping like carry small children
Tenderness at anatomic snuff box
Finkelsteins maneuver to aid diagnosis
Women 30-50 yo
Rheumatoid arthritis
Need to check RF, anti-ccp, Xrays (periarticular osteopenia, erosion, symmetric joint space narrowing)
- Involves the MCP and PIP joints bilaterally*
- Symmetric polyarthritis with prolonged morning stiffness*
30% have normal labs
Psoriatic arthritis
*Dactylitis: finger like a sausage
Pencil in cup deformity on Xray*
Nail pitting is specific
Can precede skin findings by up to 10 years
Spondyloarthropathies
refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself
Acral lentiginous melanoma
with nail bed involvement the nail plate may have dark brown discoloration (due to melanin).
Beau’s lines
transverse grooved (e.g. depressed) lines parallel to lunula occurring after serious medical illness, post-surgical and/or severe infections.
Clubbing
produced by soft tissue growth at the nail bed and identified by noting a greater anterior-posterior distance at the nail bed as compared to the same distance at the distal interphalangeal joint (also creates a nail-finger angle >180 degrees).
typically occurs in response to thoracic disease, including cyanotic congenital heart disease, cystic fibrosis, pulmonary fibrosis, lung cancer, and severe hepatic cirrhosis (with hepato-pulmonary syndrome). Although reported in severe COPD, other pathology (e.g. lung cancer) must be excluded before accepting COPD as the sole cause.
Koilonychia
(aka spooning of nail) - the nail curves upward away from nail bed (concave instead of the normal convex appearance). This is a classic finding in iron deficiency anemia/malnutrition.
Lindsay’s nails
also termed half-and-half nails, the proximal portion of the nail is pale/whitish while the distal 20-60% of the nail is brown, pink or reddish.
- Associated with renal failure and hyperkalemia (abnormal heart rhythms, peaked T waves with QRS widening*
- administer calcium
Mees’ lines
transverse white band parallel to the lunula.
Originally described with arsenic intoxication, may also be seen with thallium as well as after acute medical conditions such as lymphoma and malaria.
Most common etiology is following cancer chemotherapy (a poison of sorts) and arsenic poisoning
Muehrcke’s lines
two or more paired transverse white bands associated with severe hypoalbuminemia (usually < 2.2 g/dL).
Nail pitting
small depressions in nail that are present in up to 50% of patients with psoriasis (usually more severe cases).
Onycholysis
irregular separation of the nail plate from the hyponychium. Can be traumatic in origin, but also seen in psoriasis and hyperthyroidism/Graves’s
Periungual fibroma
(aka Koenen tumor) - flesh-colored papule of nail folds (toes > hands) seen in ~50% of patients with tuberous sclerosis (see below under skin).
Quitter’s nail
heavy cigarette smoking leads to orange-brown discoloring of the nails and fingers holding the cigarette. A normal proximal nail with distal discoloration indicates smoking cessation - chronicity of abstinence can be estimated by understanding that nail growth is 0.8 - 1.0 mm per week.
Splinter hemorrhages
small brown or red streaks perpendicular to the lunula, and often involving the distal nail. These are most commonly traumatic in origin, but classically a consequence of microembolism from infectious endocarditis. They are also reported in scleroderma and trichinosis.
Terry’s nails
proximal paleness of nail with only 1-2 mm of preserved pink distal border (appears dark).
-originally described with liver cirrhosis, TB, heart failure, but can also be seen in other severe medical conditions (e.g. heart failure, poorly controlled diabetes, hepatitis).
Arachnodactyly (aka spider fingers)
long fingers that are associated with Marfan syndrome. The wrist circumference is less than the distance encompassed by the subject’s 5th finger and thumb.
Bouchard’s node
bony protuberance of proximal IP joint without findings of inflammation - this is a finding in osteoarthritis.
Boutonniere deformity
produced by extension at the distal IP joint and flexion at the proximal IP joint - a finding in severe, chronic rheumatoid arthritis.
Dupuytren’s contractures
shortening of the finger flexors in the palm, may be idiopathic in origin but also associated with alcohol abuse and alcoholic cirrhosis
Heberden’s node
bony protuberance of distal IP joint without findings of inflammation - this is a finding in osteoarthritis.
Janeway lesion
painless red macular lesion of palms/soles produced by embolism, usually due to infectious endocarditis
Joint hypermobility
ability to dorsiflex 5th finger > 90 degrees with forearm flat and/or passive apposition of the thumb to the flexor aspect of forearm; these findings suggest classic Ehlers-Danlos syndrome
Large, fleshy hands
consider acromegaly if rings no longer fit
Mechanic’s hands
thickened, cracked and dirty-appearing palmar skin mimicking those of a manual laborer suggests the anti-synthetase syndrome variant of dermatomyositis.
consider lung disease, internal cancer, or autoimmune
Subtype of dermatomyositis
Osler node
originally described in subacute bacterial endocarditis, these are painful red raised lesions of the ventral surface of fingers/toes caused by immune complex deposition
Pallor
Nail beds and palms is associated with severe anemia (hemoglobin < 7.0 g/dL)
however, the conjunctivas are a better site for assessment
Swan neck deformity
produced by extension at the proximal IP joint and flexion at the distal IP joint - a finding in severe, chronic rheumatoid arthritis
Actinic keratosis
pre-malignant lesion typically seen over sun-exposed areas.
Tips of ears, face, back of hands, pre-cancerous
Basal cell carcinoma
- low grade cancer* with typical appearance: papule with translucent and “umbilicated” border, central ulceration and telangiectasia
- Pearl colored papula*
Dermatomyositis
♣ Gottron’s papules/sign - red, often scaly papules over the MCPs and PIPs - the term Gottron’s sign is applied to similar finding of the fingers, elbows and knees.
♣ Heliotrope rash - violet discoloration of upper eyelids
♣ Shawl sign - widespread, flat, reddened area over upper back, shoulders and posterior neck
♣ V sign - similar to shawl sign, except that reddened skin conforms to a V-neck sweater pattern of the anterior chest
Internal malignancies
Gottron’s papules
red, often scaly papules over the MCPs and PIPs - the term ________ sign is applied to similar finding of the fingers, elbows and knees.
Heliotrope rash
violet discoloration of upper eyelids
Shawl sign
widespread, flat, reddened area over upper back, shoulders and posterior neck
Dermatomyositis
V sign
similar to shawl sign, except that reddened skin conforms to a V-neck sweater pattern of the anterior chest
Dermatomyositis
Hyperextensibility
defined as ability to stretch the skin >4 cm at forearm or neck before feeling resistance; this is a finding in Ehlers-Danlos syndrome
Hyperpigmentation
must consider the patient’s background race/ethnicity and sun exposure.
diffuse ____________ may be seen with primary adrenal failure (aka Addison’s disease), hemochromatosis and hyperthyroidism
Livedo reticularis
mottled/reticulated, red-blue lacy skin discoloration with central pallor associated with small vessel vascular processes including vasculitis
- *-anti-phospholipid syndrome
- cholesterol embolism syndrome**
Malar rash
one of the diagnostic criteria for systemic lupus erythematosus (and the genesis of the term lupus: Latin for wolf)
Melanoma
malignant tumor of melanocytes with multiple manifestations (e.g. lentiginous, nodular).
occur on skin without striking sun exposure (e.g. vulva) and remember ocular site.
Depth determines prognosis
-most malignant skin cancer
Neurofibromas
non-tender, soft, fleshy, sessile or pedunculated skin tumors - if present in great number should consider Von Recklinghausen’s disease and seek café-au-lait macules and axillary freckles (aka Crowe sign)
Axillary freckling with Lisch nodules = 100% specific
Psoriasis
common disease (1-2% of population) most commonly manifested as red plaques with silvery scales of the extensor surfaces of arms and legs, as well as trunk and scalp. Other types include guttate, pustular, inverse and erythrodermic
Squamous cell carcinoma
often occur on sun-exposed skin (70%) and also associated with chronic scarring and inflammation, these usually begin as a nodule that often grows into a fungating lesion.
Develops from actinic keratosis
Thin skin with visible small vessels
a finding in Ehlers-Danlos syndrome type 4, a condition associated with arterial rupture (e.g. aortic dissection)
Tuberous sclerosis
characteristic skin findings include hypopigmented, often elliptical macules (aka ash-leaf spots), flesh-colored or red papules of central face that may mimic acne vulgaris (angiofibromas - previously adenoma sebaceum), periungual fibromas and Shagreen patch (flesh-colored, orange-peel-like connective tissue plaque, usually located on the lower back)
patients usually have epilepsy, cognitive and neuropsychiatric disorders, an increased risk of cancer, a distinctive renal lesion (angiomyolipoma) and a risk of developing cystic lung disease (confirm with TSC gene test).
Vitiligo
focal loss of melanin usually due to autoimmune condition; consider other autoimmune conditions
Consider hashimotos thyroiditis
Xanthomas
(tuberous, eruptive and tendon) - nodular, papular and tumorous lesions
-collection of cholesterol and found in hyperlipidemia (familial variants)
Early atherosclerosis
Blastomycosis
skin is the 2nd most common organ involved; the lesions may appear verrucous, ulcerate and closely mimic squamous cell cancer
Only present for weeks to months
Ecthyma gangrenosum
hemorrhagic vesicles or pustules that evolve into necrotic ulcers, these are a manifestation of infectious vasculitis due to Pseudomonas aeruginosa bacteremia.
Erythema chronicum migrans
painless, rounded, slowly expanding red lesions with central clearing (may be target-like) at site of tick bite in early Lyme disease.
Treat with antibiotics
Herpes zoster
manifestation of recurrent VZV (herpes) infection, begins with burning dysesthesias of involved dermatome followed in a few days by vesicular dermatomal rash that does not cross the midline. Over time the rash will crust and fade, but the neuropathic pain may persist for many weeks.
Lupus vulgaris
(aka tuberculous chancre) - due to primary bacillus inoculation (TB) in non-sensitized host, it usually involves the face and hands, often in the setting of previous local minor trauma. Begins as a nodule that ulcerates with induration.
Secondary syphilis
multiple presentations, rash often involves the palms and soles.
Bell’s palsy
an idiopathic disorder of the Facial nerve (CN 7) producing unilateral facial weakness including an inability to close the eye.
Bilateral ptosis
unusual finding that signals neuromuscular weakness - disorders to consider include myasthenia gravis, Miller-Fisher variant of Guillain-Barre syndrome and botulism.
Corneal reflex
using a cotton wisp the examiner’s hand approaches from lateral aspect (avoiding being seen) and lightly strokes the cornea over the sclera; this is predominantly a test of sensation via ophthalmic division of Trigeminal nerve (CN 5), but Facial nerve (CN 7) fibers involved in efferent limb of reflex.
Deep tendon reflexes
• test the peripheral nerve (e.g. lower motor neuron), motor unit and upper motor neuron input with 2+/4 being normal. Hyper-reflexive responses (≥3+/4) can be seen diffusely with hyperadrenergic states (e.g. hyperthyroidism, amphetamine use) and focally with upper motor neuron disease, as the latter exert an inhibitory effect on lower motor neurons. Hyporeflexia occurs with neuropathy, acute spinal disease, lower motor neuron damage/disease and neuromuscular junction disease such as myasthenia gravis (and poor technique).
o Clonus is the term given to repeated contraction after elicitation of the deep tendon reflex, indicating extreme hyper-reflexia (aka 4+/4) o Hypothyroidism (picture) is associated with a slow relaxation phase of the deep tendon reflex.
Clonus
term given to repeated contraction after elicitation of the deep tendon reflex, indicating extreme hyper-reflexia (aka 4+/4)
Hypothyroidism
associated with a slow relaxation phase of the deep tendon reflex.
o Coarse, dry hair and skin with loss of lateral eyebrows
o Moderate weight gain and myalgia
o Bradycardia
o Cold intolerance
o Constipation
o Deep tendon reflexes with slow relaxation phase (aka Woltman sign)
Cortical stroke
hemiplegia/paresis usually indicates a vascular etiology for the weakness.
80% caused by ischemia (most in the carotid artery distribution), produce weakness in a predictable pattern based on the arrangement of the cortical motor strip (see slideshow). Hand and face have large representation due to their multiple complicated actions; as such, there tends to be involvement of both with often relative sparing of the lower extremity.
usually involve sensory cortex, and often areas serving speech (deficit = aphasia).
Lacunar stroke
typically produce pure motor (or pure sensory) deficits.
Upper face involvement differentiates cortical stroke
Pathologically are infarcts of small penetrating arterioles that effect the radiation (or white matter projections) of the cortical neurons, and as such, a relatively small lesion can effect a larger distribution (e.g. upper and lower extremity) without sensory deficit or other indication of a cortical event.
Transient ischemic attack (TIA)
may involve different mechanisms: 1) Low flow states due to large artery occlusion; 2) Small emboli, which can be from large artery or heart (two most common sources); or 3) Lacunar from stenosis of a small penetrating vessel.
may involve the anterior circulation (carotid arteries) or the posterior circulation (vertebral and basilar arteries), and the symptoms will reflect such. By definition resolves within 24 hours and identifies a patient at high risk of stroke. It is essential that these patients be evaluated promptly.
Doll’s eyes
(aka oculocephalic reflex) - this is a test of brainstem, Vestibulocochlear nerve (CN 8) and semicircular canal function that should be performed in comatose patients only. Manually raise both eyelids and move the head side-to-side - the eyes should move in tandem; failure to do so implies damage to one or more of structures above.
Frontal release signs
Reflect primitive reflexes in patients with diffuse frontal lobe pathology (e.g. Alzheimer’s dementia)
- palmomental reflex: stroking the thenar area of the hand causes a reflex contraction ipsilaterally of the orbicularis oris and mentalis muscles
- suck reflex: sucking movements by the lips when they are stroked or touched
- snout: puckering or protrusion of the lips with percussion
- grasp reflex: the examiners hand is placed softly into patient’s palm during distraction - stroking of the patient’s palm produces a grasp by the patient that persists with movement
Cerebellar ataxia
*wide-based, unsteady, *lateral veering (e.g. multiple sclerosis, tumor of cerebellum)
Sensory ataxia
Loss of proprioception*, such that the patient substitutes visual and nociceptive clues in an attempt to maintain stability. This produces the “stamp and stick” gait (cannot orient body in space, stomp feet on the ground)
Causes include B12 deficiency, tabes dorsalis and other causes of posterior column disease.
Festinating gait
shuffling steps with rigidity; lower body appears to be chasing upper body - this is the classic gait of Parkinson’s disease.
Equine gait (or steppage gait)
*inability to dorsiflex foot *(e.g. trauma to peroneal nerve, Charcot-Marie-Tooth disease)
Plantar reflex
nociceptive (aka painful) reflex commonly elicited by firmly stroking the plantar surface of the foot from posterior to anterior. The normal response is flexion of the toes. Extension (aka Babinski reflex) is normal in the newborn, but is otherwise pathologic, indicating a problem with upper motor neurons. Common etiologies include cortical stroke, spinal cord disease from B12 deficiency, and occasionally from drug-induced encephalopathy.
o Triple flexion is the ultimate Babinski reflex with extension and fanning of the toes, dorsiflexion at the ankle, and flexion at the knee and hip
Triple flexion
ultimate Babinski reflex with extension and fanning of the toes, dorsiflexion at the ankle, and flexion at the knee and hip.
Pronator drift
*Test of subtle upper motor neuron disease (e.g. suspect cortical stroke with borderline weakness). *
The patient is instructed to hold arms out, palms upward and then close eyes. Patients with unilateral weakness have the effected limb drop with simultaneous pronation. Other diagnoses that may be suggested including, 1) malingering - the involved limb drops without pronation and 2) posterior column disease - the involved limb may “search” for the other limb, such as by moving superiorly.
Romberg test
tests posterior column function (e.g. position sense), initially used as a test of tabes dorsalis (tertiary syphilis). The patient is instructed to stand with feet together, and after stable to close eyes. Healthy persons can usually stand this way with eyes closed for 60 seconds
Action (or postural) tremor
becomes evident with action and includes hyperadrenergic (e.g. cocaine use, hyperthyroidism), physiologic, alcohol withdrawal and essential tremor.
Resting tremor
occurs in posture of repose and suppressed with activity; classic “pill-rolling” tremor of Parkinson’s disease (usually disappears with activity and complete relaxation).
Intention tremor
appears with action and worsens as goal is reached; cause relates to cerebellar disease.
Abducens palsy
presents as an inability to abduct the involved eye. This nerve has a relatively long course in the subarachnoid space and cavernous sinus, and as such, may be involved by meningeal processes (e.g. infectious meningitis), diseases associated with neuropathy (e.g. diabetes mellitus), cavernous sinus diseases (e.g. carotid artery aneurysm, rhinocerebral mucormycosis) and diseases that cause increased intracranial pressure (e.g. brain tumor).
Arcus senilis
white corneal ring associated with hyperlipidemia in patients < 40 years of age (normal finding in older patients).
Argyll Robertson pupil
caused by damage to the Edinger-Westphal nucleus, this was originally described in neurosyphilis. The pupils are small and do not react to light but do constrict (if closely examined) to the accommodation maneuver.
Blue sclera
although rarely reported in other entities, this finding strongly suggests osteogenesis imperfecta, a disease associated with recurrent bone fracture, short stature, scoliosis, hearing loss and skin laxity.
Cotton wool spot
white retinal lesion reflecting a micro-infarct, this can be seen in many diseases including diabetes and hypertension.
Diabetic retinopathy
Microaneurysms and intraretinal microhemorrhages (aka dot and blot changes - see slideshow), cotton wool spots, flame hemorrhages, and vessel proliferation
Only secondary papilledema.
Hollenhorst crystal
a small bright lesion in a small retinal artery indicating cholesterol embolization and atherosclerosis.
Holmes-Adie syndrome
part of a systemic neurologic syndrome manifested as an irregular dilated pupil that has a delayed constriction to light.
Initially unilateral, this frequently progresses to involve both eyes and can be associated with a lack of deep tendon reflexes (areflexia).
involves denervation
Hypertensive retinopathy
Microvascular effects.
Papilledema in conjunction with the other findings denotes grade IV.
Internuclear ophthalmoplegia (INO)
this disorder is produced by damage to the medial longitudinal fasciculus running in the brainstem - this is not a cranial nerve palsy!
The exam finding is the inability to adduct the involved side - it may be unilateral or bilateral - there may be nystagmus of abducting eye.
Multiple sclerosis is the most common cause, but brainstem stroke and rarer pathology can potentially produce this finding.
Unilateral: stroke
Bilateral: MS or other demyelinating diseases
Marcus Gunn pupil
(afferent pupillary abnormality) - the involved eye does not react to light directly but does constrict to light directed to the opposite eye (consensual response) - see slideshow.
Oculomotor palsy
1) a downward and laterally deviated eye, 2) unilateral ptosis and 3) dilated pupil (mydriasis).
The parasympathic fibers mediating pupillary constriction tend to run on the outside of the nerve, and the fibers innervating extraocular muscles in the nerve core.
can occur with nerve core infarction (spares pupillary function) or early in the course of external compression (only a “blown” pupil)
Down and out palsy
eye deviated laterally and inferiorly (down and out) - may also have dilated pupil and ptosis. Causes include uncal herniation (greatest fear), diabetes, infarct
Papilledema
blurring of the optic disc margins produced by increased pressure transmitted through the optic nerve. As such, any disorder leading to increased intracranial pressure (ICP) may produce this: hypertensive crisis (aka malignant hypertension), brain tumor or abscess, meningitis
Retinal vein occlusion can produce findings without increased ICP.
Roth spot
representing hemorrhage within a cotton wool spot, this finding was initially described in infective endocarditis, but also can be seen in systemic lupus, diabetes and leukemia (and others).
Xanthelasma
yellowish subcutaneous lipid collection adjacent to medial canthus of eye that is indicative of hyperlipidemia/collection of cholesterol.
Consider athlerosclerosis with high risk of progression if Hollenhorst crstal is found
Aphthous ulceration
painful lesion of unknown etiology, often triggered by minor trauma. They are shallow and white-centered with erythematous border.
Behcet’s disease is a multisystem disorder with diffuse mucosal _________________, systemic vasculitis and CNS involvement.
Coating
caused by accumulation of dead cells and microbial colonization (often correlated with illness, poor oral intake and lack of oral hygiene). Other diagnoses to consider include candidiasis (aka thrush) - often with burning pain, leukoplakia (see below) and secondary syphilis (aka condyloma lata).
Epiglottitis
- classically caused by H. influenza infection in childhood, this is a medical emergency*.
- Look for thumb sign on Xray*
The patient will have a sore throat, difficult phonation, dysphagia, odynophagia, dyspnea and drooling. Exam reveals a red, enlarged epiglottis. Get immediate surgical consultation and do not swab the area - you may precipitate acute airway occlusion!
Epistaxis
(nosebleed) - the nasal mucosa is very vascular and subject to frequent local trauma and inflammation, explaining the frequency of its occurrence.
divided into anterior and posterior sites: anterior bleeding presents at the nares in the upright person, while posterior bleeding drains through the pharynx where it may be “coughed” up.
Most cases will be benign in origin, but as with any clinical bleeding, the patient should be queried about possible bleeding diathesis (e.g. cirrhosis, anticoagulant medication, blood dyscrasia). Recurrent bleeding may also be a clue to more serious local pathology (e.g. tumor, vasculitis).
Frank’s sign
(aka diagonal earlobe crease) - has been associated with coronary artery disease (CAD) and peripheral vascular disease, the associated relative risk for this sign is debated, although bilateral, deep creases may convey a higher risk.
Gingival hyperplasia
the most common cause is chronic use of phenytoin (Dilantin®, seizure medication). Other drugs to be considered include calcium channel blockers and cyclosporine. Leukemic infiltration (due to acute myelogenous leukemia) may mimic this condition.
Atrophic Glossitis
an abnormality of the tongue resulting in inflammation (often painful), there are multiple causes (often benign disorders). Chronic glossitis with atrophy may be a clue to a more widespread nutritional disorder (e.g. vitamin and mineral deficiency). Look for other signs of nutritional deficiency (e.g. angular cheilitis, anemia, peripheral neuropathy, dermatitis).
Smooth tongue due to loss of papillae
Tongue may be painful or painless
Gorlin sign
the ability to touch the nose with tongue occurs in ~50% of subjects with Ehlers-Danlos syndrome, but < 10% of normal subjects can perform this feat
Hoarseness
encompassed change in voice character or strength and implies pathology of the vocal cords. This may be due to focal damage/neoplasm or nerve damage.
Persisting beyond (3) weeks demands evaluation, including in most cases direct laryngoscopic examination.
Kaposi sarcoma
immunocompromised patients (esp. AIDS) may develop this neoplasm related to Human Herpes Virus 8 infection. It appears as raised or flat purple-red lesions anywhere on the oral mucosa (e.g. gingiva, tongue, palate).
Koplik’s spot
white lesion on a red base found on the buccal mucosa and lips in measles.
Lead lines
actually a series of grey-black dots observed 1 mm from the free margin of the gum.
- heavy metal toxicity, including lead, bismuth, mercury, gold, silver, thallium and copper
- not seen where teeth are absent.
Leukoplakia
these are pre-malignant lesions associated with tobacco use. Hairy __________ is a lesion generally found on the lateral aspect of the tongue in immunocompromised patients, esp. HIV/AIDS. This lesion reflects Epstein-Barr Virus induced epithelial hyperplasia. Unlike oral ____________ this is not pre-malignant. Discovering hairy ____________ in a patient should suggest HIV testing if status unknown.
Oral:
White plaques anywhere on the oral mucosa
A response to chronic irritation, a pre-malignant lesion
Should be biopsied
Hairy:
Corrugated white lesion seen on the lateral aspect of the tongue
Reflects EBV-induced epithelial hyperplasia
Suspect HIV/AIDS
Lemierre’s syndrome
(aka septic jugular vein thrombophlebitis) - usually begins as pharyngitis due to *Fusobacterium necrophorum infection that invades tissue and spreads to the carotid sheath, producing the septic thrombosis of the jugular vein (resides in sheath).
Patients present with fever, neck stiffness and dysphagia*. Important exam findings are tenderness over jaw angle and sternocleidomastoid muscle. The infected thrombus may embolize to lung producing mass lesions that may cavitate (aka septic pulmonary embolism).
Ludwig’s angina
(aka submandibular space infection) - begins as an infection of mandibular teeth with extension into submandibular space. Expanding infection of this space elevates the floor of the mouth and tongue leading to airway compromise.
Macroglossia
(aka large tongue) - most commonly due to trauma or inflammation from caustic ingestions or allergic reactions (e.g. angioedema); however, can also be a finding in hypothyroidism, acromegaly and amyloidosis.
Nasal pruritis
(aka Wartenburg symptom) - intense and unrelieved __________ has been associated with brain tumor, esp. with involvement of the floor of the 4th ventricle.
Nasal septal perforation and saddle nose deformity
processes that destroy the nasal cartilages produce these findings, including intranasal cocaine abuse, Granulomatosis with polyangiitis (formerly Wegener’s granulomatosis), congenital syphilis, sarcoidosis and relapsing polychondritis (red ear). The saddle nose deformity is a depression over the nasal bridge caused by collapse of the underlying cartilage.
Parotitis
these glands may be inflamed and tender in multiple conditions including viral infections (e.g. mumps), inflammatory conditions (e.g. sarcoidosis, systemic lupus erythematosus), and many others.
Unilateral swelling, tenderness, and fever
-a condition caused by an impacted calculus usually seen in chronically ill patients (Staph. aureus is the usual causative organism). Painless parotid and lacrimal gland enlargement is a finding in alcoholism.
Pharyngeal exudate
Although Streptococcus pyogenes (group A, β-hemolytic) is the best known pathogen, fusobacterium, EBV, gonorrhea, and other pathogens are considerations. Most cases occur in children, where the child presents with abrupt fever, sore throat, headache, and difficulty swallowing.
Exam findings include the classic triad of objective fever, _______________, and tender anterior cervical adenopathy.
Untreated there is a risk of rheumatic fever.
Pharyngeal pseudomembrane
typically caused by Corynebacterium diphtheria infection, this disease can be confused with more common causes of pharyngitis.
This complication can be life threatening as it may obstruct the airway.
CM:
Fever, sore throat, weakness and odynophagia
Grayish membrane formation is very specific (but less sensitive)
Complications include myocarditis, neuritis and death due to airway obstruction
Other findings include cervical adenopathy (bull’s neck), fever, weakness, heart failure, neuropathy and malodorous breath. Throat culture should identify the pathogen.
Rhinorrhea
(aka “runny nose”) - may be part of acute rhinitis occurring in the context of viral infection, or be non-infectious in origin (i.e. allergic rhinitis).
CSF _______ is a rare and serious condition to consider in the setting of prior facial/skull injury or surgery - this reflects a fistula between the nose and subarachnoid space, and as such places the patient at risk for bacterial meningitis.
Tooth tenderness
use a tongue blade to assess
-dental caries could be present
also a useful finding if tooth abscess is suspected, such as in a diabetic with unexplained ketoacidosis. Maxillary teeth may also be tender when maxillary sinusitis is present.
Acute sinusitis:
A complication of sinus ostia obstruction (e.g. nasal polyp)
Symptoms: facial and maxillary tooth pain; sinus congestion
Exam: facial and maxillary tooth tenderness; abnormal transillumination
Complications: periorbital cellulitis, meningitis, subdural empyema, cranial sinus thrombosis
Tragus sign
tenderness with depression of _________ *suggests otitis externa *(as will pulling on the involved pinna), usually a bacterial infection of the epidermis of the ear canal. These signs are not present with otitis media (differential feature).
Pulling on ear elicits pain = otits externa
Vertigo
the feeling of unsteadiness with motion, most often rotary in nature. The patient may fall down or have great difficulty remaining upright during the symptom. Associated symptoms may include nausea, pallor, and sweating.
dysfunction of the vestibular system is present. This includes the inner ear structures, CN VIII, and the brainstem.
drug and alcohol use should be assessed.
Gout
caused by uric acid crystal deposition in joint, this disease usually begins acutely with intense pain and inflammatory joint finding. 90% of patients have great toe involvement. Rarely occurs in premenopausal women.
Pes anserine bursitis
produces pain with exercise and/or stair climbing inferior to knee at antero-medial aspect of tibia; tenderness to percussion over bursa is clinically confirmatory
McMurray test
palpable clicking with knee compression and rotation during varus and valgus stress; positive test indicates meniscal injury (acute onset of pain, often with trauma, buckling or locking sensation)
Drawer sign
knee flexed to 90 degrees and examiner pulls lower leg anteriorly; ability to move leg > 1 cm is consistent with anterior cruciate ligament tear
Drop arm test
the patient raises arm to 90 degrees of abduction and lower it slowly. A suddenly dropped arm is considered positive and suggestive of a rotator cuff tear.
Adhesive capsulitis
Reduced passive and active range of motion (ROM), usually painless
Positive Touchdown Sign is expected: inability to fully raise effected arm
Bicipital tendonitis
pain aggravated by lifting, pulling or overhead movements; confirmatory test is palpation tenderness over bicipital tendon
Phalen’s test
Carpal Tunnel Syndrome test
compression of wrists together (flexed) for 60 seconds produces pain/paresthesia in median nerve distribution (positive test)
