general - curs 5 - semiologia tegumentelor mucoaselor si fanerelor
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SEMIOLOGIA TEGUMENTELOR, MUCOASELOR SI FANERELORSEMIOLOGIA TEGUMENTELOR, MUCOASELOR SI FANERELORSimptomul cutanat principal – Pruritul- traduce iritatia subliminara a terminatiilor nervoase (fibrele amielinice C) de catre stimuli variati-poate fi generalizat si localizat
Pruritul generalizat – cauze:• modificari de temperatura si de mediu ambiant, agenti fizici si chimici• afectiuni interne – sindroame colestatice, DZ, limfoame maligne, mielom multiplu, leucoza limfatica cronica, IRC, carcinomul gastric si pulmonar• afectiuni endocrine – hipo- si hipertiroidia, hiperfoliculinismul• afectiuni dermatologice – prurigo, urticaria, eczeme, lichen plan• alergii medicamentoase si de contact (detergenti)
Pruritul localizat:• genital – diabet, carente vitaminice, sideropenie, neoplasm uterin, factori neurogeni• nazal – astm, parazitoze, uremie, hiperfoliculinism, morfinomanie• auricular – diabet, micoze• scalp – alcoolism, menstruatie• trunchi si extremitati – hepatita, ciroza, insuficienta renala, sarcina, pediculoza, poliglobulie
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Examenul obiectiv al tegumentelor, mucoaselor si fanerelor
- netezime - grosime- consistenta - elasticitate- temperatura - culoare
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Modificarile de culoare ale pieliiModificarile de culoare ale pielii
1. Paloarea1. Paloarea
- este principalul semn al anemiei la nivelul tegumentelor si mucoaselor - este principalul semn al anemiei la nivelul tegumentelor si mucoaselor (conjunctivala, bucala, labiala, linguala)(conjunctivala, bucala, labiala, linguala)
- are diferite nuante, in functie de etiologia anemiei:- are diferite nuante, in functie de etiologia anemiei:• paloarea paloarea marcatamarcata (alba ca varul) (alba ca varul)• paloarea cu nuanta paloarea cu nuanta galbuie ca cearagalbuie ca ceara• paloarea cu nuanta paloarea cu nuanta cenusiecenusie• paloarea cu nuanta paloarea cu nuanta galben-paigalben-pai• paloarea si paloarea si icter scleralicter scleral• paloarea paloarea galben-murdargalben-murdar• paloarea paloarea “cafea cu lapte”“cafea cu lapte”• paloarea prin vasoconstrictie (↑ catecolaminelor plasmatice)paloarea prin vasoconstrictie (↑ catecolaminelor plasmatice)• paloarea prin infiltrarea tegumentelorpaloarea prin infiltrarea tegumentelor• paloarea prin hipodezvoltarea capilarelor dermicepaloarea prin hipodezvoltarea capilarelor dermice
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Paloarea
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2. Icterul
- este determinat de cresterea valorilor bilirubinei serice (V.N = 0,3-1 mg% sau 10mg‰)- la valori de 20 mg‰: subicter conjunctival- valori > 30 mg‰: icter tegumentar
Tipuri semiologice de icter• icter flavinic• icter rubinic• icter verdinic• icter melas (negru)
Clasificarea etiologica a icterelor• ictere hemolitice• ictere hepatocelulare• ictere mecanice
Diagnostic diferential• ingestia de atebrina• carotinoza
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Icterul
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3. Cianoza- trebuie diferentiata de pseudocianoza din crisiaza, argiroza, melanoza arsenicalase descriu cianoza hemoglobinica (↑ Hb reduse) si cianoza hemiglobinica (derivati anormali de hemoglobina)
Cianoza hemoglobinica (cianoza propriu-zisa)
* cianoza generalizata - prin tulburari in circulatia pulmonara - consecutiv unui sunt dreapta-stanga intracardiac - cianoza periferica de staza
* cianoza localizata - acrocianoza - livedo reticularis (aspect de cutis marmorata) - livedo racemosa - aspect reticular la nivelul peretelui abdominal - phlegmatia coerulea dolens
Cianoza hemiglobinica
* prin exces de methemoglobina (methemoglobinemie): - idiopatica (caracter familial)deficit de reductaza eritrocitara - methemoglobinemia idiopatica paroxistica nefamiliala - methemoglobinemie toxica
* prin exces de sulfhemoglobina (cianoza enterogena autotoxica)
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Sindrom Raynaud
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livedo reticularis
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cianoza periferica
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Modificari de pigmentare cutanata
Hiperpigmentarile cutanate
1. Hiperpigmentarile cutanate cu caracter difuz• melanodermia addisoniana (boala Addison)• hemocromatoza (diabetul bronzat sau ciroza pigmentara)• alte hiperpigmentari generalizate:
• acromegalie• tratament cu ACTH• denutritie, casexie• boli renale• boli hepatice• amenoreea primara• melanoza vagabonzilor• cauze medicamentoase si toxice
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Hiperpigmentarile cutanate - Hiperpigmentarile cutanate cu caracter difuz
melanodermia addisoniana (boala Addison)
Hemocromatoza
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alte hiperpigmentari generalizate - acromegalie
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2. Hiperpigmentarile regionale
• masca gravidica (cloasma gravidica)• hipertiroidia (semnul Jellineck)• pelagra• porfiria• carente vitaminice si sindroame de malabsorbtie (melanoza Riehl)• cancerul de prostata tratat cu estrogeni (hiperpigmentarea areolelor mamare)• insuficienta circulatorie venoasa cronica (dermita ocra Favre-Chasse)• acantosis nigricans
acantosis nigricans
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3. Hiperpigmentarile circumscrise
• efelide (pistrui)• nevi pigmentari – nevii plani, lentigouri (alunite), nevi verucosi pigmentari, nevi pigmentari multipli (neurofibromatoza sau boala Recklinghausen)• scleroza tuberoasa (epiloia sau boala Bourneville) – macule hipopigmentate in “frunza de artar” si hiperpigmentate “café-au-lait”• sindromul Albright – pete pigmentare pe o jumatate de corp• nevul fuscoceruleu oftalmo-maxilar Ota• sindromul Peutz-Jeghers• lentiginoza periorificiala sau sindromul LEOPARD (L – lentigouri, E – tulburari de conducere pe ECG, O – ochi indepartati, P – stenoza arterei pulmonare, A – anomalii genitale, R – retard al cresterii, D – surditate) • melanomul malign
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nevi pigmentari multipli (neurofibromatoza sau boala Recklinghausen)
sindromul Peutz-Jeghers
nevi pigmentari
Hiperpigmentarile circumscrise
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Hipocromiile cutanate
1. Hipocromiile cutanate difuze• albinismul
2. Hipocromiile cutanate cu caracter regional• vitiligo (discromie cutanata) – poate fi asociat cu boala Basedow sau cu boala Addison, este un element al sindromului Harada• intoxicatia cu benzilhidrochinona (fotografi)
3.Depigmentarile circumscrise• pe teritoriul eruptiei zosteriene• in teritoriul unei cicatrici
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albinism
vitiligo
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Eritemul cutanat
Eritemele generalizate• eritemul rujeolic (morbiliform)• in intoxicatii medicamentoase si lues secundar• flush• rash – in boli contagioase• eritrodermia exfoliativa (“omul rosu” al lui Hallopeau)• eritemele figurate – inele, arc de cerc (eritemul Leiner)
Eritemele localizate• eritemul palmoplantar• eritemul pelagros• eritemul de menopauza• eritemul fiziologic
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Flush
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Hemoragiile cutanate
Petesiile si vibices
Echimozele – aspecte particulare:• “in ochelari” (fractura bazei craniului)• pe fata interna a bratului (fractura de cap humeral)• pe fata interna a coapsei (fractura de femur)
Hematomul
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Eruptiile cutanate
1. Papula • urticarie (leziune eritemopapulopruriginoasa)• dermografism (prin reflex de axon)• micoze cutanate (placarde eritematoase acoperite de
scuame)• pitiriazis versicolor• verucile (negii)
urticarie (leziune eritemopapulopruriginoasa)
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dermografism (prin reflex de axon)
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pitiriazis versicolor
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2. Cheratozele si cheratodermiile
aspect generalizat- ihtioza
aspect localizat- sediu palmo-plantar (tiloza)- hipercheratoza foliculara (“piele de gaina”)
cheratoza solara
ihtioza
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3. Telangiectaziile – aspecte particulare:
• in “desen de bancnota” (ciroza hepatica)• interscapulovertebrale (semnul Turban) – adenopatii mediastinale• la nivelul primelor vertebre toracice (semnul Francke) – tuberculoza
pulmonara apicala• cu caracter dendritic, la baza hemitoracelui (ghirlanda Sahli)
telangectazii
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4. Hemangioamele- nevii rubini- stelutele vasculare sau angioamele arahneiforme (“spider nevi”)- angioamele plane (* in teritoriul trigemenului - sindromul Sturge-Weber )
sindromul Sturge-Weber
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5. Angioamele cavernoase
6. Tuberculii
7. Nodulii• noduli dermo-hipodermici (eritem nodos)• nodulii Ossler• nodulii Meynet• guta – tofi gutosi• poliarterita nodoasa – noduli subcutanati
noduli dermo-hipodermici (eritem nodos)
noduli Osler
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Guta – tofi gutosi
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Tumorile cutanate
Tumorile cutanate benigne• cisticercoza• cancere (pulmonar, mamar, renal, gastric, uterin) – metastaze cutanate• hipercolesterolemie – xantelasma, xantoame eruptive• chistul epidermoid (sebaceu)• cheloidul• dermatofibromul (fibromul in pastila)• fibromul moale
chistul epidermoid (sebaceu) cheloidul
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cancer mamar
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Tumorile cutanate maligne• carcinomul bazocelular• carcinomul spinocelular
carconom bazo celular
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Pierderi de substanta cutanata
• Ulceratiile – ulcerul perforant plantar, ulcerele arteriale, ulcerele venoase
• Eroziunea• Exulceratia• Cicatricea ulcerele venoase
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ulcer diabeticulcer neuropatic (spina bifida)
ulcer post traumatic (paraplegie)
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Cicatricea
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Atrofiile cutanate• Vergeturile• Sclerozele cutanate, sclerodermia liniara
Vergeturile
scleroderma
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Modificarile secretiei sudorale
Anhidroza • Localizata – pe jumatate de fata (sindromul Claude Bernard-Horner)• Generalizata – in atrofiile cutanate, sindromul Christ-Siemens
sindromul Claude Bernard-Horner
stanga – normal dreapta - patologic
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Hiperhidroza (hiperdiaforeza)
Localizata• palmo-plantar (distonie neuro-vegetativa)• extremitatile superioare (sindromul Raynaud)• hemicraniu (migrena)• teritoriul auriculo-temporal (sindromul Frey)• la cap si fata, in timpul meselor (diabetici)
Generalizata• septicemii, supuratii pulmonare cronice, tbc pulmonara cavitara• coma hipoglicemica, socul cardiogen, colapsul
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Semiologia unghiilor
1. Modificari de forma si grosime• onicogrifoza• onicoosteodisplazia• unghiile hipocratice (* hipocratismul digital) – osteoartropatia hipertrofianta pneumica Pierre-Marie-Bamberger• pahionichia• onicoliza, onicomadeza• santurile Reil si Bean• platonichia, coilonichia, aspectul de “frunza vesteda”
unghii hipocratice
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onicoliza
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coilonichia
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2. Modificari de culoare• leuconichia• culoare albastra• culoare brun-neagra• unghia pe jumatate alba, lipsita de lunula• liniile Muehrcke• lunule albastre (boala Wilson)• culoare galbena (sindromul Milroy)• culoare rosie-violacee• hemoragii liniare (“in aschie”)
leuconichia
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hemoragii liniare (“in aschie”)
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Semiologia parului
Hipertricoza• hipertricoza distrofica posterioara (“coada de faun”)• hipertricoza pavilionului urechii si conductului auditiv extern• hipertricozele dobandite
Hirsutismul (virilismul pilar)
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Hipotricoza •sindroame genetice ( Turner, Klinefelter)•boala Addison•semnul Chwostek (ciroza hepatica decompensata)
Alopecia•calvitia•alopeciile difuze•alopeciile areolare (“in luminisuri”)
Albirea precoce
Perii cancerosi – sindrom paraneoplazic
calvitia
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alopecie difuza
alopeciile areolare (“in luminisuri”)