the hands and the tongue lets look at the patient, not just the labs, images, ekgs, i.e. expanding...
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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
Physical Examination:
Inspection
Palpation
Range of motion
Stability
Muscle and Tendon Function
Nerve Assessment
Vascular Assessment
Integument Assessment
Discoloration
Deformity
Muscular atrophy
Trophic changes (sweat pattern, hair growth)
Swelling
Wounds or scars
Also: compare to normal hand
Inspection: Look For….
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
Osteoarthritis:
Heberden’s nodes: DIP
Bouchard’s nodes: PIP
Rheumatoid Arthritis
Boutonniere deformity: flexion of PIP and extension of DIP
Swan neck deformity: extension of the PIP, flexion of DIP
Dupuytren’s Contractures:
Palmar or digital fibromatosis
Flexion contracture
Painless nodules near palmar crease
Male> Female
Epilepsy, diabetes, pulmonary dz, alcoholism
Mallet FingerHyperflexion injuryRuptured terminal extensor mechanism at DIPIncomplete extension of DIP joint or extensor lag
Treatment: stack splint
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
Range of Motion Assessment
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Physical Examination: Normal tongue
Abnormal Tongue 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”
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
Hairy Tongue:Best-known condition causing the tongue to appear hairy is Oral Hairy Leukoplakia
A black, hairy tongue consistent with aspergillus overgrowth
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
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
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”
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
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