diagnostic topografic.ppt

7/22/2019 Diagnostic topografic.ppt

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Diagnostic topograficDr. Ioana Saulescu


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Scopul prezentarii

Conturarea unui dg.

diferential in functiede regiuneamusculo-scheletalaafectata.


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Suferintele osteo-articulare

Multiple afectiuni;

Afectare locala;

Boli sistemice.

Examenul clinic corect si complet

Cheia diagnosticului diferential


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Intrebati pacientul!

Anamneza detalii importante!

Durerea: cea mai frecv. cauza de prezentare,

Caracteristicile durerii:-mod de debut,-evolutie,-cdt. de aparitie,-redoare matinala.

Manifestari asociate, A.H.C.,

A.P.P.

Durerea de tip mecanic

Durerea de tip inflamator


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Examenul obiectiv

Aspect general: inclusiv modif. ale teg.,

Evaluarea struct. osteo-articulare

(inclusiv mobilitatea):-tumor,-rubror,-calor,-functio lesa?

Afectare simetrica sau asimetrica?


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De ce atat de important?

Examenul clinic corect restrange ariadg. diferential,

Uneori permite dg. pozitiv:


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Tipuri de sindroame articulare

Sufer. inflamatorie Sufer. degenerativa

Tip de distributie,

Modalitatea de debut si evolutie in timp,

Manifestari extraartic. asociate,

Asocierea sau nu cu durerea lombara joasa


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Tipuri de sindroame articulare

Nr. de articulatii: mono., oligo.( 2-4),poli.(5),

Debut: acut( in ore/zile), cronic (in sapt.,persista peste 3 luni),

Aditiv/migrator,

Persistent/recurent,

Simetric,asimetric.


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Monoartrita acuta

In ordinea frecventei: guta, posttraumatic,septica.

Alte cauze: distrofia simpatica reflexa,artrita reactiva, artrita psoriazica.

Antibioterapie pana la excludereacu certitudine a artritei septice.


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Monoartrita cronica

Infectioasa( micobacterii etc.),

Microcristale,

SSN, sarcoidoza,Tumori.

OBLIGATORIU biopsie sinoviala cuex. anatomopatologic si bacteriologic


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Poliartrite

De ob. cronice,

Acute: artrita reactiva, boala Still, f.rar poliartrita reumatoida.


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Nu uitati

Durereamsculoscheletala:

Articulara,

Periarticulara,

Neurogena,

Referata.


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Cauzele durerii de mana

Afect. articulara:*inflamatorie( PR, SpSN, LES, SclerozaSistemica, Microcristale ),*degenerativa,

*infectioase,*tumori,

Afect. periarticulara: tenosinovite, chist sinovial,

Durerea referata: col. cervicala, boli cardiace,

Sdr. umar-mana.


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Examinarea mainii

Inspectie:-modif. unghiale:*unghia psoriazica,*hemoragii subunghiale, telangiectazii( BMTC,

LES, Scleroza Sistemica, vasculite),-modif. tegumentare:*ingrosate, ceroase (Scleroza Sistemica,cheiroartropatia diabetica),

*ulceratii digitale(Scleroza Sistemica, vasculite),*placarde de psoriazis,*keratodermia blenoragica( Artrita reactiva),*mana de mecanic ( Dermatomiozita) etc.


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Examinarea mainii (2)

Inspectie:-noduli subcutani( P.R., tofi gutosi, artroza,calcif. subcutane),-sist. muscular:

*atrofia mm. interososi (P.R., Distrofia simpticareflexa),*atrofia eminentei tenare( sdr. tunel carpian),*retractia aponevrozei palmare( sdr. Dupuytren),

-modif. alinierii struct. osteo-articulare:*deviere si deformari ale degetelor( P.R., LES,Scleroza Sistemica, artroza)


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Prinderea articulara in principalele

suferinte ale mainii
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2


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Mana artrozica

Caract. mecanic,

Rizartroza,

Afecteaza artic. IFP si

IFD: nodulii Bouchard siHeberden,

Devierea falangelor indirectii diferite: degeteserpuitoare,

artroza eroziva,

artroza sec.hemocromatozei: MCF II,III.


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Mana reumatoida

Caract. inflamator, Afectare simetrica: RCC,

carp, MCF, IFP,

precoce sensibilitate la

presiunea stiloidei ulnare, deget fuziform ( IFP),

deviere ulnara/radiala,deformare in gat de lebada,

in butoniera, atrofia mm. interososi (

mana in spate de camila).


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Mana in spondilartropatii

seronegative

Artrita psoriazica

Afect. IFD,

Oligoartrita asim. /

Poliartritasimetrica,

Dactilita.

Artrita reactiva

Rar,

Dactilita,

Keratodermiablenoragica
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/400740074007photo3.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/400740074007photo3.jpg&template=izoom2


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Mana in artropatii cu microcristale

Condrocalcinoza

Varstnici, asociata cuartroza,

Monoartrita acutapumn,

Artropatie cronicape MCF, cel mai frecv.

II,III.

Guta

De obicei formacronica,

RCC, MCF, IFP, Tofi.


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Mana sclerodermica

Sclerodactilie,

Reducerea mobilit. artic.IF= mana in gheara,

Sdr. Raynaud,

Anomalii de pigmentare,telangiectazii,

Calcif. subcutane,ulceratii.


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LES

Artrita simetrica,neerozivaRCC, MCF,IFP,

Artropatia Jaccoud.

Artrite infectioase

Gonococice: afect. deob.1-2 artic., frecv. RCC,tenosinovite,

Bacteriene non-

gonococice:monoartic.,

Virale: ParvovirusulB19, rubeola, vir.

Hepatitice (mimeazaPR).
http://www.uhrad.com/msiarc/msi048b2.jpg


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Cotul

Afect. periarticulara: cea mai frecventa,*bursita olecraniana,*epicondilita laterala/mediala,

Afect. articulara:*P.R.,*Artrite Infectioase,*Guta,*Sp.SN,*Artroza(vibratii),*Tumori,

Durerea referata: de la col. cervicala,umar,mana, cardiaca


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Examenul obiectiv

*leziuni cutanate(psoriazis),*noduli subcutani(PR, Guta,

Scleroza sistemica,

Dermatomiozita),

*tumefactie in recesul

lat.=sinovita,

*tumefactie deasupra

olecranului= bursita,*durere la palparea

directa=epicondilita.


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Bursita olecraniana

Localizare superficiala,

Forma posttraumatica,

Inflamatorie aseptica:

PR, microcristale ,

Inflamatorie septica:eventual asociata cucelulita locala, m.a. la

imunodeprimati


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Epicondilitele

Afect. insertieiflexorului comun peepicondilul medial

Afect. insertieiextensorului comun peepicondilul lateral


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Umarul

Afectare periarticulara:*tendinita/ruptura mansetei rotatorilor,*tendinita bicipitala,*tendinita calcifianta,*bursita subacromiala

Afectare articulara:*artrita / artroza gleno-humerala,*capsulita adeziva

Durerea referata:

*col. cervicala,*lez. viscerale toracice,*lez. viscerale abdominale,*sdr. umar-mana.


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Examenul obiectiv

Durerea de umar folosita ptr. variate afectiuni

De evaluatcentura scapulo-humerala,

Col. vertebrala C-T

Mobilitatea activa si pasiva


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Examenul obiectiv(2)

Important de observat asimetriile,

Atrofia musculara: sufer. cr. a artic.gleno-humerale( PR),

Sinovita: vizibila cand lich. este in cantit.f. mare,

Evaluarea mobilitatii active si pasive.


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Centura scapulo-humerala

Atentie la Poli-Dermatomiozita,Polimialgie Reumatica,

Fibromialgie.


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Genunchiul

Afectarea articulara: inflamatorie (PR, SpSN, LES,Scleroza Sistemica, Microcristale), infectioasa,tumorala, degenerativa ( primara/secundara),

Afectare periarticulara:bursite( prepatelara,

anserina), chist Baker, tendinite,

Afectarea traumatica: ruptura de menisc, deligamente,

Durerea referata: coxartroza.


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Afectarea genunchiului

Sufer. artrozica,

Sufer. Infl.,

Microcristale.


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Piciorul

Afect. articulara:*boli inflamatorii ( PR, Sp SN, Guta),*boli degenerative ( Artroza),*infectioase,*modif. de statica ( halux valgus, degetul inciocan, picior plat, picior cavus), congenital,

Afect. periarticulara:*fasciite plantare ( SpSN),*bursite retrocalcaneene, retroachileene.

Durerea referata: col. lombara, genunchi,

Distrofia simpatica reflexa.


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Examenul obiectiv

Inspectie:-modif. unghiale:*unghia psoriazica, hipercheratoza, onicoliza,*hipocratism,*hemoragii subunghiale, telangiectazii( BMTC,

LES, Scleroza Sistemica, vasculite),-modif. tegumentare:*ulceratii digitale(Scleroza Sistemica, vasculite),*durioane,

*lez. eritematodescuamative (guta)*placarde de psoriazis,*keratodermia blenoragica( Artrita reactuiva).


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Examenul obiectiv(2)

Inspectie:-noduli subcutani( P.R., tofi gutosi, artroza,calcif. subcutane),

-sist. muscular:*atrofia mm. interososi (P.R., Distrofia simpticareflexa),-modif. alinierii struct. osteo-articulare:

*deviere si deformari ale degetelor( P.R., artroza,tulburari de statica).


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Piciorul in Poliartrita Reumatoida si

Artrita Psoriazica

PRArtic. MTF,IFP,

subtalara, glezne,Deget in ciocan

Durioane

APDactilita, asimetric,

Modif. unghiale,

IFD, MTF
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/373037303730photo12.jpg&template=izoom2


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Artrita reactiva

Afect. Monoartic./oligoartic. asimetrica,

Frecvent gleznele,

Dactlita,

Entezita: fasciita plantara,tendinita achileana,

Keratodermablenorrhagicum,

Eritem nodos: Yersinia.


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Guta

Atacul acut:monoartic., pe MTFhaluce,

Mai rar: dorsul

piciorului, glezna,

Adesea aspectpseudoflegmonos,

Lasa teg. descuamate,

Formele cronice: tofi.


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Soldul

Afect. Articulara:

*inflamatorie( PR, SpSN),*infectioasa,*degenerative (coxartroza),*tumori,

Afect. periarticulara:*osul periartic.(osteonecroza aseptica, infectii,boala Paget, congenital, tumori),*tes. moi( bursite, tendinite, capsulite,microcristale),

De tip referat:*col. lombara,*afect. vasculare,*afect. abdomino-pelvine.


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Examen fizic

Durerela nivel inghinal, antero-lat. coapsa, iradierein genunchi, mecanic/inflamator,

Inspectie:*scurtareamb. inferior,

*atrofia mm. gluteali de partea afectata,*contracturivicioase prin pozitii antalgiceprelungite:--in flexie: ridicarea pelvisului pe parteacontralaterala,

--in abductie ( boli infl.): ridicarea pelvisului departea afectata,*modif. ale mersului.


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Examen fizic(2)

Palpare:

*dureroasa:

-fata lat.( bursite trohanteriene),

-inghinal intern( tendinita adductorilor),

Mobilitate:

*testul Patrick,

*testul Trendelenburg.


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Afectarea soldului

Sufer. artrozica,

Sufer. Infl.,

Microcristale.


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Coloana vertebrala

Caracterul durerii,

Redoarea matinala,

Fact. declansatori, Conditii de ameliorare,

Durata simptomelor.


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Evaluarea clinica

Evaluata initial ca un intreg, ulterior pesegmente,

Curburi, tulb. de statica, asimetrii,

Durere la palpare si percutie, Contracturi musculare,

Mobilitate: flexie laterala, ant.,extensie,

rotatie.


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Coloana cervicala

Sufer. degenerativa: durere localizata/radiculalgie, sdr. Barre-Lieou.

Cauza inflamatorie:

*Spondilita Anchilozanta ( bolnavul carenu vede soarele),*PR ( subluxatia atlanto-axiala),

Infectioase,

Tumori.


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Coloana toracala

Spondiloza dorsala: de ob. secundara tulb.de statica, bolii Scheurman,

Hiperostoza idiopatica difuza,

Osteoporoza, osteomalacie, Spondilartropatii seronegative,

Infectii,

Boala Paget, Tumori.


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Coloana lombara

Spondiloza lombara, lumbago acut, sdr.trofostatic,

Hiperostoza idiopatica difuza,

Osteoporoza, osteomalacie, Spondilartropatii seronegative,

Infectii,

Boala Paget, Tumori.


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Articulatia sacro-iliaca

SpSN,

Septica TBC,

Boala Paget,

Neo,

Iliita condensanta,

Guta, PR ( f.rar).


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Privire generala

diagnostic topografic.ppt

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