Upload File

the hands and the tongue lets look at the patient, not just the labs, images, ekgs, i.e. expanding...

  • Home
  • Documents
  • The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:
43
The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Upload: esmond-morris

Post on 29-Jan-2016

218 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

The Hands and the Tongue

Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Page 2: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

The Hands:

Examination of the hand can reveal several physical findings helpful for diagnosis

Start the exam with the Handshake:Moist and warm hands think….

nervousness, thyrotoxicosis look for tremor, eye signs

Inability to let go your hand think….MyotoniaLook for other signs of myotonic dystrophy:

hatchet face, cataracts, baldness, myopathic facies

Page 3: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Physical Examination:

Inspection

Palpation

Range of motion

Stability

Muscle and Tendon Function

Nerve Assessment

Vascular Assessment

Integument Assessment

Page 4: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Discoloration

Deformity

Muscular atrophy

Trophic changes (sweat pattern, hair growth)

Swelling

Wounds or scars

Also: compare to normal hand

Inspection: Look For….

Page 5: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Discoloration:

Redness: cellulitis

White: arterial blockage

Blue/purple: venous congestion

Patches of blue/purple: trauma

Black spots/lines: rule out melanoma

Other color producing processes:

fungi, viruses, psoriasis

Page 6: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:
Page 7: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Osteoarthritis:

Heberden’s nodes: DIP

Bouchard’s nodes: PIP

Page 8: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Rheumatoid Arthritis

Boutonniere deformity: flexion of PIP and extension of DIP

Swan neck deformity: extension of the PIP, flexion of DIP

Page 9: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Dupuytren’s Contractures:

Palmar or digital fibromatosis

Flexion contracture

Painless nodules near palmar crease

Male> Female

Epilepsy, diabetes, pulmonary dz, alcoholism

Page 10: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Mallet FingerHyperflexion injuryRuptured terminal extensor mechanism at DIPIncomplete extension of DIP joint or extensor lag

Treatment: stack splint

Page 11: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Muscle Atrophy:

Generalized: may indicate disuse

Specific muscle groups: suggest nerve pathology

Thenar atrophy: carpal tunnel syndrome Interossei atrophy: cubital tunnel or cervical spine

problem

Subcutaneous atrophy: often after local steroid injection

Page 12: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Range of Motion Assessment

Page 13: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Nerve AssessmentRadial: test dorsal thumb-index web space

Median: test palmar surface of index or thumb

Ulnar: test palmar aspect of little finger

Digital nerves: test each the radial and ulnar side of each fingertip on the palmar aspect

Page 14: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Proximal median nerve dysfunction

Thenar atrophy, inability to

flex 1st & 2nd fingers at PIP aka Pope’s Hand or Hand of Benediction

Ask patient to use both hands to make and “Okay” sign by forming a circle with thumb and index finger

Median nerve palsy may make

one hand produce a pinched circle

http://www.netterimages.com/images/vtn/000/000/007/7639-150x150.jpg
Page 15: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Ulnar nerve damagehypothenar atrophy and inability

to flex 4th & 5th digits at the PIP aka Claw Hand

Froment’s Sign: Ask patient to hold a piece of paper between thumb and index finger

If you can pull paper away (a positive Froment’s sign), it suggests that an ulnar palsy has weakened the thumbs strength of opposition

Page 16: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Special Tests: Finkelstein’s

Used to test for deQuervain’s tendonitisinflammation of the EPB and APL

tendons in the 1st extensor

compartment

Patient is asked to make a fist with the fingers overlying the thumb

Examiner then ulnarly deviates the wrist (gently)

Positive findings: pain along the 1st compartment

Page 17: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Special Tests: Tinel’s

A provocative test for carpal tunnel syndromeThe examiner percusses with two fingers directly over the distal palmar

crease in the midline

Positive test: patient reports paresthesias in the median distribution when the nerve is percussed

Page 18: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Special Tests: Phalen’sA provocative test for carpal tunnel syndrome

The patient’s wrist is held in maximum flexion for two minutes

Positive test: patient reports paresthesias in the median distribution

Page 19: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Special Tests: Allen’s

Tests ulnar and radial artery blood flowPatient makes a tight fist and examiner manually occludes both radial and ulnar artery

Examiner releases one of the vessels and examines for reperfusion in the long finger

Abnormal test: hand reperfusion > 5 seconds

Test is repeated for the other artery

Page 20: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Nail Abnormalities: Clues to Systemic DiseaseClubbing:

First described by Hippocrates in 5th century B.C

thickening of the soft tissue beneath the proximal nail plate that results in sponginess of the proximal plate and thickening in that area of the digit

Page 21: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Important causes of clubbing

Lungs:LUNG CANCER

clubbing is in general an ominous sign for this“beware of the yellow clubbed digit”

Yellow from nicotine, and clubbed from cancerPUS in the lung

bronchiectasis as in CFLung abscess and empyema

FIBROSIS but has to be considerable fibrosis to do this

COPD IS NOT A CAUSE OF CLUBBING even though some textbooks say so–if it were clubbing would be a pretty useless sign, and many VA patients would have clubbing, but they don’t

Page 22: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Important causes of clubbing

Heart Causes:R to L shunts, Endocarditis, Pericarditis, atrioventricular malformations

There are other causes of clubbing, outside the heart and lungs

Inflammatory bowel disease, cirrhosis, congenital heart disease, fistulas

Page 23: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Pseudoclubbing:distinguished from clubbing by the preservation of the nail-fold angle and bony erosion of the terminal phalanges on radiography

changes in fingers are the result of soft-tissue collapse owing to severe bone erosions of the terminal phalanges

Page 24: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Pitting:

caused by defective layering of the

superficial nail plate by the proximal nail matrixany localized dermatitis (e.g., atopic or chemical dermatitis) that disrupts orderly growth in that area also can cause pitting

Psoriasis, Reiter’s syndrome, incontinentia pigmenti, alopecia areata

usually is associated with psoriasis affecting 10 to 50 percent of patients with that disorder

Page 25: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Paronychia: Inflammation of the nail folds–red, swollen, often tender

Frequent immersion in water a risk factor for chronic paronychia

If an abscess has formed, the recommended treatment is to drain the abscess by doing an I&D

Page 26: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Herpetic Whitlow:

Occupational hazard for respiratory therapists and housestaff who work around oral secretions

HSV-1 is the cause in ~ 60% of casesHSV-2 cause in the remaining 40%

• Diagnosis usually is clinical• Definitive diagnostic testing includes:

Tzanck test, viral cultures, serum antibody titers, fluorescent antibody testing, or DNA hybridization

Self-limited diseaseTreatment often is directed toward symptomatic reliefUse antibiotic treatment only in cases complicated by bacterial superinfection

Page 27: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Acral lentiginous melanoma

Accounts for about 2-3% of all melanomas

most common type of malignant melanoma among Asians and dark-skinned individuals, with a particular predilection for the soles of the feet

The involvement of the proximal nail fold (Hutchinson’s sign) is considered

a clue to the diagnosis

Page 28: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Koilonychia:

represented by transverse and longitudinal concavity of the nail -resulting in a “spoon-shaped” nail

Iron deficiency anemia, hemochromatosis, Raynaud’s disease, SLE, trauma, nail-patella syndrome

Page 29: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Yellow nail:

Associated with:Lymphedema, pleural effusion, immunodeficiency, bronchiectasis, sinusitis, rheumatoid arthritis, nephrotic syndrome, thyroiditis, tuberculosis, Raynaud’s disease

yellow nail syndrome:Triad of yellow slow-growing nails, lymphedema, and pleural effusions

Page 30: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Splinter hemorrhage

longitudinal thin lines, red or brown in color, that occur beneath the nail plate

Subacute bacterial endocarditis, SLE, rheumatoid arthritis, antiphospholipid syndrome, peptic ulcer disease, malignancies, oral contraceptive use, pregnancy, psoriasis, trauma

Page 31: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Tongue

The tongue manifests the features of many systemic illnesses and is a natural site for oral pathology

On physical examination, there are several characteristics that should be noted

ColorTextureSize

Page 32: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Physical Examination: Normal tongue

Dorsal surface Pinkish-red color

Rough-appearing texture on the dorsal surface due to the presence of papillae

three varieties with different sizes

Ventral Surfacesimilarly be pinkish-red

some vasculature may be visible

Tongue should fit comfortably in the mouth with the tip against the lower incisors

Page 33: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Physical Examination: Normal tongue

Examination of the tongue should occur in the following steps:

Have the pt touch the tip of the tongue to the roof of their mouth and inspect the ventral surface

Have the pt protrude the tongue straight out and inspect for deviation, color, texture, and masses

With gloved hands, hold the tongue with gauze in one hand while palpating the tongue between the thumb and index finger of the other, noting masses and areas of tenderness

Page 34: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Physical Examination: Normal tongue

Page 35: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Abnormal Tongue Findings:

Page 36: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Smooth Tongue:

Most common cause is the use of dentures

Can also be a late sign of iron, folate, Vit B12 deficiency

Glossitis may also cause the tongue to appear smooth

Among women, low-estrogen states may cause a “menopausal glossitis”

Page 37: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Discolored Tongue:

Due to a variety of conditions

Micronutrient deficiencies is perhaps the best-known of these

B12 deficiency-> causing a sore, beefy-red tongue

Pellagra-> causing a black tongue

Geographic tongue:Benign condition in which discolored, painless patches of the tongue appear and then reappear, often in a different distribution

Page 38: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Hairy Tongue:Best-known condition causing the tongue to appear hairy is Oral Hairy Leukoplakia

A black, hairy tongue consistent with aspergillus overgrowth

Page 39: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Ulcers: Many different causesInspecting ulcers, it is important to note:

size, number, color, distribution, and whether or not they cause the patient any discomfort

Of particular concern is a single erythematous, often painful ulcer that does not heal

May indicate that the patient has lingual or oral cancerparticularly if the patient uses tobacco and/or alcohol

Patient history and risk factors are important to note in these cases

Page 40: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Aphthous ulcers:Painful form of ulcer that is

most frequently encountered Minor aphthous ulcers:

usually 2-8mm in size, spontaneously heal w/in 14 days

Major aphthous ulcers:>1cm in size and may scar when they heal

Herpetiform ulcers:pin-point size, often multiple, and may coalesce to form a larger ulcer

These ulcers may result in odynophagia when they occur toward the posterior surface of the oropharynx

Page 41: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Microglossia: May result from pseudobulbar palsy, the result of damage

to the upper motor neurons of the corticobulbar tracts that innervate the tongue

This results in a small, stiff tongue

There may be an apparent microglossia resulting from ankyloglossia, a congenitally short lingual frenulum commonly called a “tongue tie”

Page 42: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Macroglossia:

Exam should include palpation of the sublingual glands, will be displaced in true macroglossia

Macroglossia maybe congenitally present in acromegaly New-onset macroglossia in an adult is essentially

pathognomonic for amyloidosis and should be treated as such until proven otherwise

Page 43: The Hands and the Tongue Lets look at the patient, not just the Labs, images, EKGs, i.e. Expanding our physical exam skills and findings:

Fasciculation:

Indicative of lower motor neuron injuryMay present with dysarthria or dysphagia

Amyotrophic lateral sclerosis is of particular concern with new-onset of these

Can cause atrophy of tongue


Bite your tongue! Slip of the tongue Tongue tied0e2adbce82be14fd6bcb-5584cc5742c63ca82c29a0709ec0b026.r46.… · Cat got your tongue? Silver Tongued Bite your tongue! Slip of the

Performing 12 Lead EKGs Emergency Department Union Hospital

Tajweed Rules Of The - isact.org.au · The Tongue Parts The tongue’s root Deepest part of the tongue Middle of the tongue Tip of the tongue Head of the tongue Edge of the tongue

May 2012 NNA EKGs 1892-1897

Mastering The Tongue

MAC 5000 Ruhe-EKG-Analysesystem - Frank's …frankshospitalworkshop.com/equipment/documents/ecg/user...Vektor-EKGs ..... 5-2 Aufzeichnen eines signalgemittelten EKGs (Option)

The Mingling Tongue

Understanding EKGs Pgs 11-15

The Tongue of Fire.qxp:The Tongue of Fire - MacMatequintapress.macmate.me/PDF_Books/The_Tongue_of_Fire.pdf · The Tongue of Fire.qxp:The Tongue of Fire 5 12 2008 01:53 Page 6. proof

Performing 12 Lead EKGs

James the tongue

Heart Failure Brochure - Reading 12 Lead EKGs

Interpretation of Abnormal EKGs - 360training.com · Interpretation of Abnormal EKGs ... This image is an abnormal EKG tracing. Apply each step by asking the questions and calculating

The human tongue

Reading EKGs for Beginners

The Lying Tongue

Lab This Week: EKGs and Blood Pressure

Chap 8 reading ekgs

Tongue Diagnosis Webinar - Bradley McEwen 21.07.15 · PDF fileExamination of the tongue • In tongue diagnosis, observation of the surface of the tongue is mainly focused on the:

Understanding EKGs Pgs 1-10

The Tongue Sep.pdf

Arrythmias and EKGs 1

Guarding the tongue

12 Lead EKGs

“The Mother Tongue“ and Mother Tongue-based Multi Lingual Education

EKGs in pre-operative management for OSH transfers

INTRODUCTION TO EKGs STUDY GUIDE

The tongue

PART 2 – EKGs 1886-1891

AMReport EKGs 1.16.12

EKGs - Students

May 2007 EKGs of the Month

Taming The Tongue

Mother Tongue Other Tongue - SCILT > Home · Mother Tongue Other Tongue ... my poem rhyme in Russian and I like the way it sounds in my own ... Father tongue now English My ‘tongue’

PART 1 -- EKGs 1880-1885