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Pediatrics as discipline. Department of pediatrics. Pediatrics. Pediatrics is a Greek term , which proceeds from two words : παῖς  ( pais  = child) ἰατρός  ( iatros  = doctor ). History of pediatrics.

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pediatrics as discipline

Pediatrics as discipline

Department of pediatrics

pediatrics
Pediatrics
  • Pediatrics is aGreek term , whichproceedsfrom two words:
  • παῖς (pais = child)
  • ἰατρός (iatros = doctor )
history of pediatrics
History ofpediatrics
  • • Hippocrates described cephalohematoma, hydrocephalus, diarrhea, strophulus, asthmaand varicella
  • • Soranus of Ephesus (c. AD 100)described the test for maternalmilk quality appreciation (if the milk drop sticksto the nail, it has sufficientfats, if does not stick – has not fats)
  • • Galen (c. AD 200) described otitis, pneumonia, prolapseof intestin, rickets.
  • • Avicenna, (c. AD 990) – tetanos, convulsions, meningitis, omphalitis.
  • • Avenzoor (c. 1150)performed tracheotomy.
  • • Hieronymusin 1583 has writen the bookDe Morbus Pusiorum
history of pediatrics1
History of pediatrics
  • In IX century -   Rhazes (Muhammad ibn Zakarīya Rāzi - Persia)has described thechild’s diseases (is considering the father ofpediatrics).
  •  1530 ThomasPhaer,  Book of the child.
  • 1852 first hospital in London The Hospital for Sick Children, Great Ormond
  • Abraham Jacobi, - the founder ofpediatricsinUSA .
history of pediatrics2
History of pediatrics
  • Hôpital des Enfants Malades (French = Hospital for Sick Children), in Paris , june, 1802
  • Charité (hospital founded in1710) in Berlin has opened a separately pavilion for children in 1830
  • Saint Petersburg  - 1834
  • Vienna and  Breslau (Wrocław) - 1837.
history of pediatrics3
History of pediatrics
  • Thomas Sydenham (1624–1689), Hippocrate ofEngland, described scarlet fever, rubella, epilepsy, rickets, fever, scorbutus, chorea whichis known as St. Vitus Dance.
history of pediatrics4
History of pediatrics
  • Edward Jenner (1749–1823) hasvaccinated first time a 8 years boyagainstsmallpox.
history of pediatrics5
History of pediatrics
  • Prof. Mihail Manicatide, born at Giurgiu in 1867, is considered the founder of rumanian scientific school of pediatrics.
  • He is the author of two treatises of infant medicine for students, appeared in many editions.
  • Dr. Alfred D. Rusescu, born in 1895 at Bucharest, organized pediatrics and superior medicine studies on modern basis, being the mentor of great professors which developed the pediatrics until our times.
history of pediatrics6
History of pediatrics
  • Faculty of Medicine from Yassy opened its courses at 1 december 1879, but the chair of infantile Clinic appears la 1897.
  • The chair had as basis the Gregorian Institute founded in 1852, and the clinical base functioned in the infantile section of Epitropia “Holy Spiridon" from Yassy.
pediatrics1
Pediatrics
  • Pediatricshasas study object the growing, developmentand pathology of the childfrom the birth until 18 years age.
pediatrics subspecialit ies
Pediatrics - subspecialities:
  • preventive pediatrics;
  • social pediatrics;
  • neonatology (new-born - 0-28 days);
  • infantile psychiatry;
  • cardiology;
  • pediatricpneumology;
  • nutritional and metabolism diseases;
  • oncology;
  • surgery, orthopedyand pediatrictraumatology.
p reventiv e pediatrics
Preventive pediatrics
  • includesall measures destinedto maintain the healthand to preventthe appearance of disease in children.
  • It is dividing in :Primary prophylaxis – avoidance ofhealthyindividual taking ill (vaccination, water chlorining)Secondary prophylaxis– recognitionand elimination of disease precursors and the addressing to populationwith increased risk for certain affection. Includes also the diseases complications prevention.Tertiary prophylaxis– has the goal theimprovingorstopping of stillestablished disease complications, avoiding the evolution to invalidity or decease.
primary prophylaxis
Primary prophylaxis
  •   includes 2 types of measures:A) measureapplied tocollectivity

B) measureapplied individually

measure applied to collectivity
Measure applied to collectivity
  • A) it is realizing through a series of public healthprogramswhich differ from country to country in functionof its development degree.Some programs of public health with central valueare not still universally adopted.Applied measures: - accidents prevention– is difficultand can’t beperformedthrough public education.Prevention of intoxications (detergents, alcohol, mushrooms etc.)prevention ofsuicidesandmurdersprophylaxis of pregnancyin adolescentsprevention of drugs using.
pediatrics in republic of moldova
Pediatrics – in Republic of Moldova

creation ofabilitiesforphysical and neuropsychical health state assessmentin children and adolescents

  • careand alimentation of healthy and sick child
  • organizationandcarrying outof prophylactic, sanitaro-antiepidemicaland medical measuresat home and in preschool and school institutions
pediatrics in republic of moldova1
Pediatrics – in Republic of Moldova
  • Correct diagnosis of acute and chronic diseases on the base of anamnesis, clinicalandparaclinical examination, conformable to WHO diseases classification
  • appreciationofinvestigationsand treatment volume after national standards of RM
  • According toemergency care to childrenatstageshome - FDC - hospital
  • assimilatingof correct dispensary control ofhealthy and sick children.
goal of discipline
Goal of discipline: 

Studyof child’s physiologic and pathologic changes, knowledge of child’s diseases evolution, diagnosis, treatmentandprophylaxis, development ofclinical reasoning and medical synthesis – defining elementsin the training of eachphysician.

objectives of forming
Objectives of forming:
  • To appreciate the state of physical and neuropsychical development, to determine thegroups of health and risk in children;
  • To perform the collection of anamnesis and objective clinical examination of children, interpretation of collected data;
  • To argue the prescribingandinterpretation of laboratory investigations and paraclinical examinationin dependence of basic pathology and national standards;
  • To possess the general medical manoeuvres in diverse pathologies of the child;
objectives of forming1
Objectives of forming:
  • Enteralandparenteral alimentation;
  • gastric washing, performingof evacuator and medicamentous enemas, urinary bladder catheterization;
  • Determining of pulse, arterial pressure, respiration rate;
  • Interpretation ofradiologic, ultrasonographic, ECG data, general laboratory, microbiologic,biochemical, immunologic investigations;
  • To determine the tacticsof medical conduct in the cases of emergencies: shock, coma, acute respiratory and cardiac failure, crisis of bronchial asthma, accidental poisonings, traumas, insect bites, sinking.
childhood periods
Childhood periods
  • There are evidencing the following periods:
  • · new-born period (4 weeks);
  • · suckling period (until 1 year);
  • · period of milk teeth (from 1 until 6-7 yrs);
  • · period of big childhood (from 8 until 11 yrs);
  • · period of sexual maturation (12-17 yrs).
period of new born
Period of new-born
  • It constitutesthe period to extrauterine life adaptation, inwhicha series of characteristic phenomena have place, for example: physiologic icterus, physiologic weight loss, genital crise etc.
  • Durationof new-born period is considered untilthe age of 30 days (so-the first month of life).
period of suckling
Period of suckling
  • This period, which lasts from 1 month until 1 year, ischaracterizedby very active growing.
  • The period of suckling has the most rapid period of growing, not spread in another periods. In this period, also, thepsychomotory developmentof suckling is in permanent progress, especially due to continuous development of nervous system.
period of infant little child
Period of infant (little child)
  • After 1 year age, the child isnot still considered suckling baby, he walks alone, speaks, becomes active. The growing in height and weight is less accentuated.
  • This period includes the age between 1 and 3 yrs.Inthis period the surrounding conditions organization is very important.
  • Correct infant follow-up, good conduced education workcontributesto assimilationof first hygienic skillsand of elementary education rules.
preschool period
Preschool period
  • It occurs between 3 and 7 yrs, the age in which the child’s mind intensively developsdue tomore complex developmentof central nervous system.
  • Assimilation of knowledge about surrounding world increases continuously, in report with development of attention, spirit ofobservation, memory.
  • The child becomes more independent, due tocontinuous development of thesefunctions.
school period
School period
  • The growing rhythm is more lent at this period beginning (incomparisonto preschool age), for to its endto accelerate, at the same timewith pubertyappearance.
  • Gradually, the exterior aspect of pupilgets near to that of adult. Due to central nervous system maturation, the pupilhas more complex psychic activity, which allowsto assimilate variousandample knowledge.
slide28
SEMEIOLOGY

semeion – sign

logos – science, speech

Semeiologyis the fundamental basisofdiagnosis which can beestablishedon the basis of anamnestic datawhichorientates, of clinical datawhichsubstantiateand oflaboratory data which confirm it.

  • Semeiology – interpretation ofdifferent diseases signs having the goalto establish more correctly and more rapidly the diagnosis.
  • Semeiologyuses symptoms, signs, syndromesand also paraclinical investigationswhich must be aimed for diagnosis confirmation.
slide29
Symptoms – have subjective character, being relatedby patient, are variable in different cases, after perceptionmode and not alwaysare objective (fever, headache, insomnia, astenia, hiccups, dyspnea etc.)
  • Signs – objective manifestations produced by disease, observed by patient and completed by physician throughproper feelings(e.g. murmur, rale, dullness etc.)
  • Syndrome–group of symptomsandsignswhichexpressesa pathologic state, whichhave acommon physiopathologicmechanism; allowby their sum the orientation to certain diagnosis; forelucidatingorconfirmation the complementary investigations as possible aimed are performing. Conclusion resulted fromsigns and symptoms analysis andconfirmationbyanalysesguide us to the diagnosis which could be also a syndrome.
slide30
The health – is defined by WHO as „ a state of completephysical, mental and social good andnotconsistsonlyfromdisease or inflammation absence”
  • The diseaseis defined in different mode but afterRumanian medical dictionary represents: „ deviationfrom health state duetosome internal medium modifications orexternal medium agents action” or „ isadeviationor turning off from normal withundesirable consequences on personal comfort and social activity”.
  • Acute disease – ashort duration episodeat the end of which the patient takes again his normal activity.
  • Chronic disease– a long duration disease whichgenerates permanent, partialor total incapacity, there is an organic orfunctional alterationwhich obligates the patientto modify his normal life mode and which persistsmore long time.
tegument s
Teguments
  • At birth, the epidermisis very thin and the smallest irritation produceslesionswhich very easily are infecting.
  • New-born has the skin coveredby protector fat layer (named vernix caseosa), after removal of which thefine epidermis, by pink color, appears.
  • The skin has the protection role of organs which it covers, of body constant temperature maintaining; has, also, the respiration function, which in children is very important.
tegument s1
Teguments
  • Subcutaneous layer of fat is not completely formed at birth, and is developing gradually:
  • It appears first of all on face, after that on superior and inferior members, thoraxand after all on abdomen (in the age around 45 days).
skin fold
Skin fold
  • It has in suckling babies the thickness by 1,5-2 cm. This fat layer (cellular, subcutaneous tissue) has the role of protection, role in the thermoregulation mechanism, role of nutritive reserveandofdiverse organs supporting.
  • In healthy child, the teguments palpation givesa special sensation of resistance to pressing.
teguments of suckling baby
Teguments of suckling baby
  • In healthy breast fed suckling they are white-pink, velvet-like, in artificially fed they are more pale.
  • The thickening of epidermis horny layer and basal cells pigment appearance begin, the chromatoforming cells develop, the resistance to infections and physico-chemical agents increases.
  • Dermis is maturating, the dermal papillae are multiplying, the capillaries become longer.
teguments of suckling baby1
Teguments of suckling baby
  • are elastic, skin fold returns immediately to initial form;
  • in dehydration states the fold returns slowly or is persistent.
sebaceous glands
Sebaceous glands
  • good developed at birth, have sometimes an excess of secretion which determines the appearance of seborrheic dermatitis at the head skin level.
sweat glands
Sweat glands
  • Begin to develop in 2-3 months age and in 2 yrs when the corresponding nervous centers are maturating achieve their integral functional activity.
slide38
Hair
  • During growing they change the color.
  • During the puberty installation as part of secondary sexual characters the facial, axillar, anterior thoracic, pubian, on external part of members hair growing appear.
suckling skin surface
Suckling skin surface
  • It is bigin report to his corporal weight and decreases with the age.
  • Skin surfaceis calculating after Lassabliere formula:
  • Skin s. =T 2x0,92
  • Specific skin surface represents thereportbetweenskin surface and corporal weight:
  • Skin s. (in cm 2)/W(kg)
  • ­  in n.b. specific skin surface = 660 cm 2/kg body; 
  • ­  in 1 yearspecific skin surface = 420 cm 2/kg body; 
  • ­  in adult specific skin surface = 220 cm 2/kg body.
cellular subcutaneous tissue
Cellular subcutaneous tissue
  • Good represented in new-born on the face, continues to develop on superior, inferior members, thorax and still at 6 weeks on abdomen.
  • In malnutrition states its disappearance occurs in the inverse order of its appearance:
  • abdomen, thorax, inferior members, superior members, and at the end - on face (Bichat pads disappearanse).
clinical assessment of suckling nutrition state
Clinical assessment of suckling nutrition state
  • Measurement of thoracic (normal 1-1,5 cm) and abdominal (1,5-2 cm) skin fold thickness,
  • Presence of adductors folds on thigh internal part
  • presence of turgor (resistance which we feel at pressure taking between fingers the tissues on the external part of thigh;
  • in malnutrition – the disappearance of cellular subcutaneous tissue
  • turgor is diminished; sometimes is pasty in suckling babies excessively fed with floury products).
clinical assessment of suckling baby nutrition state
Clinical assessment of suckling baby nutrition state
  • More precise assessment of nutrition state is realizing calculating:
  • ponderal index(PI),
  • perimeter of medium arm (MAP),
  • Nutritional index (NI) and
  • body Mass Index - BMI.
slide43

EXAMENATION OF TEGUMENTS, MUCOSAE ANDDERIVATES

  • COLOR OF TEGUMENTS
      • Pallor:there ismore open color of tegumentsand mucosae andappears in the case of superficialcirculation reducing, in vasoconstrictionorappears more frequently in anemias.
  • - iron deficient anemia – waxy or chalk pallor
  • In hemolytic and megaloblastic anemia –yellowish, like to wheat straw.
  • In chronic leukemia and CRF – agrey-sallow color appears
  • In bacterial infectiousendocarditis – pallor isby milk coffee type
      • Redness :appearsthroughaccentuated vasodilatationor circulatory oxihemoglobin quantity increasing (polyglobulia)
  • After exposure to increased temperature or in febrile states, after physical effort, in neuro-vegetative dystonia,in carbon oxide intoxication, in primaryor secondary polyglobulias.
slide44

Cyanosis (kianos):there is a bluish – violet colorof skin and mucosaeand appears due to reduced hemoglobin increasingat the level of small vessels in certain areas.

  • True cyanosis: in conditions of reduced hemoglobin absolute quantity increasing. In capillaries (over 5 g /100 ml of blood). It appears more at extremities and depends from some factors:

- volumeof skin and mucous capillaries, thickness and transparence of cutaneo-mucous layer (best observed on ears lobes, cheek bones, lips and nail bed).

-skin pigmentation (in black race or other skin hyperpigmentations) itis better seen on palms or conjunctival mucosa

-associationwith other pigments in the same time, for ex. with jaundice

-concentration of Hemoglobin in blood, appearing more rapidly in polyglobuliathan in anemia

  • False cyanosis appears in:

-intoxication with carbon oxide (carboxyhemoglobinemia), which has a bluish color with carmine tint

-polycytemia vera, when the cyanosis has red-violet aspect

slide45

-methemoglobinemia and sulphhemoglobinemia (intoxication with nitrites, nitrotoluene, benzene etc)

-argiria – deposition of silver salts in teguments, giving abluish-grey colouring

In the cyanosis appearance the absolutelevel of redused Hemoglobin has importance. La anemics, especially at values ↓5 g. /100 ml bloodthe cyanosiscan’t be distinguished.

  • CENTRAL CYANOSIS: is due to insufficient saturation of arterial blood with oxygen, which leads to reduced Hemoglobin absolutelevel increasingin arterial blood over limit value of 5 g/100 ml. This cyanosis is generalized and involves both tegumentsand mucosae, the temperaturebeing not decreased;there is so-called warm cyanosis

Causes of centraltype cyanosis:

  • Respiratory causes:

-affectionswhich reducethe circulation bed: massive pneumonias, bronchopneumonias, miliarTBC, extended pulmonary fibroses, massivepleuresies, pneumothorax, fibrothorax, kypho-scoliotic thorax, etc.

- Affections which produce the respiratory pathways obstruction: laryngo-tracheal diseases, tumorswhich compress respiratory pathways, bronchial asthma, chronic broncho - pulmonal obstructive diseases, etc.

slide46

2. Cardiac causes:

  • left cardiac failure, mitro-aorticvalvulopathies, cardiomyopathies, disorders of rhythm and conductibility.
  • congenital complexe cardiopathieswhich canbe installing at birth, persisting all life – blue disease.
  • Potent ductus arteriosus
  • arterio-venous fistulasof great and middle vessels, with veno-arterial shunt after aneurismasor on small vessels, in hereditary telangiectasia.

3. Mixt causes: cardiac and respiratory. The chronic cor pulmonalein which the right heart failure consecutively some broncho - pulmonal affection appearing, is typically.

  • PERIPHERAL CYANOSIS:isdeterminedby vasoconstrictionfollowed byblood circulation speed slowing in a peripheral area, which leads to increased oxygen extraction by tissuesfrom arterial blood.

-Generalized cyanosis:appears after exposure to cold or in congestive cardiac failure, when the cutaneous compensatory vasoconstrictionis associated. It is more pronounced on the limbs which are cold and in the right and congestive cardiac failure the edemas can appear.

slide47

-Localized cyanosis– appearsin venous or arterial trunks obstructions and is strictly localized at corresponding area. If the obstacle is in superior vena cava thecyanosisof cephalic extremity, of superior members, of neck and of thorax superior part appears(cyanosisin pelerinewith or without edema).

Disorders of pigmentation:

-Hypomelanosesare characterized by melanic pigment decreasing or absence. The albinism characterized byabsence of pigment in skin, hairand eyes and vitiligo characterizedbylight color with hyperpigmented contour spotsappearance take part from this group.

-Hypermelanosesappearthrough numeric increasing of melanic cellsand their overloading with pigment and are due to hormonal causes: chronic insufficiencyof suprarenal glands (Addison disease), hyperthyroidism (Basedow disease). Ephelides- small brown – redish spots on cheeks, shoulders, back, dorsal part of hands appearthroughpigmentation of skin under the form of frecklesand have familial and constitutional character.

-Icterusis the yellow colouring of the skin, mucosae and scleresdeterminedby theirimpregnation with bilirubin when it has increased values in blood (over normal value by1mg at 100 ml of blood).

tegument s in children
Tegumentsin children

Hyperpigmentation

Hyperpigmentation

slide49

CUTANEOUS LESIONS:

  • Macula: smooth spot, by pink or redish color, with small dimensions (under 1cm diameter) which not exceeds tegumentar plane and appears in erruptive infectious diseases such as measles, rubella, typhoid fever.
  • Papule:asmall, round prominenceon skin, with the diameter under 0,5 cm, palpable; appears in scarlet fever, urticaria
  • Noduleis a dermic or hypodermic formation byvaried dimensions, palpable, whichappears in xantomatosis, lipomatosis, erythema nodosa.
  • Vesicleis araised above the surrounding skin plane, under 1cmdiameter, fluid-filled lesion whichappearsin varicella, herpesZoster.
  • Bullais a vesiclewith purulent content whichappearsin acnea, variola, impetigo.
  • Cystis asoft, raised, encapsulated lesion filled with semisolid or liquid contents.
  • Crustshave depositsof solidified exudateson tegument surface which appear in the evolution of herpes, zone Zoster oras consequence of erosions, ulcerations oratthe level ofcutaneous eczema.
  • Cicatrixappearsafterskin plagues healing where the fibrous tissue is developing.
  • Fissuresaredeep linear defects of the skin below its basal membrane level.
  • Erosionis a superficial defect of the skin.
slide50

Ulceris a deep defect of the skin below its basal membrane level.

  • Gangrenais a necrosis of tissueand underlying stratum which can suprainfect becoming fetide.
  • Scaris a change in the skin secondary to some injury or inflammation. Sites may be erythematous, hypopigmented or hypertrophic depending on their age or character. Sites on hair-bearing areas may be characterized by destruction of hair follicles.
  • Atrophyis an acquired loss of substance. In the skin, this may appear as a depression with intact epidermis (i.e., loss of dermal or subcutaneous tissue) or as sites of shiny, delicate, wrinkled lesions (i.e., epidermal atrophy).

Vascular lesions at the skin level:

  • Petechiae: are hemorrhagic spotsby small dimensions (< 1cm) by round or oval form which appear on skin or mucosae.
  • Ecchymoses:are hemorrhagic dermo-hypodermic spots more than 1cm.
  • Telangiectasies:aresmall vessels dilatations on the skin or mucosae which appear in hypovitaminoses B, cirrhosis.
tegument s in children1
Tegumentsin children

ecchymoses

ecchymoses

tegument s in children3
Tegumentsin children

Impetigo

varicella

tegument s in children4
Tegumentsin children

Atopic dermatitis

Atopic dermatitis

reticular livedo
Reticular livedo

Periarteritisnodosa

Periarteritis nodosa

tegument s in children5
Tegumentsin children

Fungic affection

Contact dermatitis

tegument s in children6
Tegumentsin children

Coxachie disease

Urticaria

tegument s in children7
Tegumentsin children

Scarlet fever

Roseola

slide59

Examination ofhair:

  • Hypotrichosisrepresentshairrarefying (hypothyroidism, Addison disease).
  • Calvitionis the hair loosing on determined area.
  • Allopeciais the head hair loosing.
  • Hypertrychosisis hair density increasing in cutaneoushairy areas.
  • Hirsutismrepresents the hypertrychosison more extended areas
  • Qualitative modifications of hair include the fiber thickness, shiningandhair pigmentation.

Examination ofnails:

The form, thickness, friablityand their color are examining.

  • Bulging– pathologic accentuation ofnail convexity appearsin the case of hyppocratic fingersand is characterizedby last phalange soft tissueshypertrophy and aspect of the nail like to glass watch. This aspect appears in different broncho-pulmonary diseases (neoplasma, bronchiectasis, pulmonary abscess, empiema, interstitial fibrosis), cardiac diseases (congenital angio-cardiopathies, infectious endocarditis,cardiac failure), digestive diseases (hepatic cirrhosis, intestinalpolyposis, ulcero-hemorrhagicrectocolitis), polyglobulias.
  • Koilonychia is flattening and concavity of the nail plate with loss of normal contour, producing a spoon-shaped nail. It is observed iniron deficient anemias, mixedema, acromegaly.
slide60

Adiposeand muscular system:

  • Adiposetissue is assessed by general inspectionandbymeasurement of skin fold on abdomen or on arm, appreciating in this way the patient’s nutrition state.
  • Muscular system isexaminingby inspectionand palpation, establishingthereforethe developmentand musculature tonus: hypertrophy, hypotrophy, muscularhypertonia, hypotoniaor normalaspect.
slide61

Faciescan offer important data about thepresence ofsome respiratory diseasessuch as:

  • vultuos facies– withred cheekbones , shining eyes, on febrile background, which appears in lobar pneumonia (Jaccoud sign - hyperemiaon the same part with pneumonia).
  • pale facies, so-called „venice facies” typicalin the past for TBC or in advanced phases - pale-yellowish , hectic, hollow facies with sunken eyes, with dark rings but red cheekbones(„cemetery roses”).
  • Cyanotic facies – especially of lips, cheekbonesand nose top – denotes a severe pulmonary affection (bronchopneumonia, massive pneumonia, pulmonary neoplasma,etc.) or chronic cor pulmonale.
  • cyanotic-black, „blue-bloatter” facies appearsin mediastinal syndrome
  • „pink-puffer” facies typical for emphysematous patients

Examen of tegumentsand mucosae – revealdescribed facies modifications in which the labial herpes characteristic in viral pneumonias or in lobar pneumonia is adding.

Don’t forget to examine the inferiormembers teguments.

slide62

Ostheo-articular system:

  • Objectiveexamination of bones:
  • Fracturesarecharacterizedby abnormal mobilityof one bone segment and bone crepitation.
  • Bone deformations appearas a result of abnormal growing and development of bones, tumoral proliferationor endocrine (acromegaly) or metabolic (rickets, osteomalacia, Paget disease) disorders.
  • Obiective examinationof articulations:

-Congestion – redish coloring of tegumentsaround articulations appears in the case of arthrites (articular inflammation).

-Tumefaction of periarticular tissues leads to articular deformation, spontaneous painat movement and limitation of articular mobility.

-Articular pain – sensibilityisfoundat articulations palpation and at active or passive movements effectuated by patient.

-Articular deformationsare observing at attent inspection, having significance in arthritesor în arthroses (degenerative articularprocesseswith chroniccharacter).

-Articular mobility isevidencingat active or passive movements ofarticulations, articular diseases determining thereducingor disappearance ofonearticulation mobilityboth from pains cause, and from articular ankylosisor semiankylosiscause

l ocomotor system
Locomotor system
  • Locomotor system has three major components :
  • - bones
  • - articulations
  • - muscles and their nerves.
skeleton and its functions
Skeleton and its functions
  • gives the form and support to the body
  • represents thestorage ofeasy mobilizing calcium (97%)
  • Some elementsofskeletonprotect thebodyfromexternal and internal forces.
  • The bones offer the attaching surfaces for musclesand represents the movement levers.
  • The dynamic agent of locomotion isrepresentedby skeletal muscle.
the m ajor symptoms of locomotor system affection
The major symptomsof locomotor system affection
  • · pain
  • · functional incapability
slide66
Pain
  • biting
  • smarting
  • burning
  • spearing
  • excruciating
  • pulsative
  • It can be continuous or intermittent, progressiveor alternant in evolution, localized or diffuse, expressedor dull, superficial or profound.
spatial characteristics
Spatial characteristics
  • ! Number of affected articulations:
  • • monoarthritis (infectious arthritis);
  • • oligoarthritis (reactive arthritis = ReA);
  • • polyarthritis (rheumatoidpolyarthritis = RPA);
  • ! symmetry (RPA)/asymmetry (ReA);
  • ! articular/periarticular feeling;
  • ! distal irradiation: syndromesof nervous compression
  • (syndromeof tunnel/compartment);
  • ! referred pain: for example, the affection of hip can
  • generatethe pain in knees (especially in children).
t emporal characteristics
Temporal characteristics
  • Duration of arthralgies:
  • if occurs long time: continuous, recurrent,
  • periods of activity and periods of complete remission
  • if occurs many years # to exclude an acute infectious or
  • malignant process.
  • chronic infection (fungic, tuberculosis) can
  • persist a lot of years
  • persistsin one articulation or passes from one
  • articulation to another: migratory polyarthritis(one articulation affection # improvement # other articulation
  • affection): leukemia, gonococcic arthritis,
  • sarcoidosis, juvenile rheumatoid arthritis;
  • time: day moment when the pain begins to intensify;
inflammatory pain
Inflammatory pain
  • Often is accentuated in morning
  • itis ameliorating after periods of articulation repose if the articulation is used (RPA, SA);
  • it can intensify if the articulation is overworkedorevenonlyat moderatedmovements (also as in arthrosis);
  • When the pain is severe, the patient can wake up
  • PAR (and tendency) can produce early awake, especially when the patient stands on affected
  • member;
  • Sudden pain onset in one articulation
antecedents
Antecedents
  • recent history ofpharyngitis/angina (throat pain),
  • Followed after 10-14 days by articular pains # suspicion of AAR;
  • • tbc, syphilis, hemophilia (hemarthrosis), renal colics (uric lithiasis associated togout), cutaneousstreptococcal, staphylococcal infections
other signs symptoms
Other signs/symptoms

Other signs/symptoms: local: objective articular (signs of inflammation: swelling, local warmth, redness at palpation, spontaneous pain andfunctional impotence) orperiarticular modifications;

  • general/systemic # system disease:
  • general: fever, astenia, loss of appetite;
  • Multiorganicaffection: cardiac, pulmonary, digestive, renal.
a rticular examination
Articular examination
  • Enlargement in volumeof articulation, liquid accumulation, pain, flatcontour ofarticulation, bulgingof sinovial sack bottom, with/withoutsignsof inflammation

(redness, warmth).

  • At palpation fluctuation, pain. The knees: rotulian shock, wave sign.
  • Differential diagnostic: inflammation of periarticular tissue, deformation of articulationthrough repeated
  • traumatisms can be differentiated using echography
member deformation
Member deformation

vicious positions due to bones, articular, periarticular changes: knees (varus, valgus), hip (varus, valgus), foot (plate, hollow, equine), halux valgus, vertebral column (scoliosis, kyphosis, lordosis)

Articular deformations: nodules Heberden, Bouchard, neuropathic articulation (Charcot)

mobility increasing
Mobility increasing
  • Can be congenital (conjunctive tissue anomalies:
  • Ehlers-Danlos syndrome) or acquired (ruptures of
  • ligaments, muscular hypotonia in neuropathies.
mobility decreasing
Mobility decreasing
  • Mobility examination must be performed withattention in the case of traumatism, hemophilia.
  • Identifyingof affected articulations is carried out in function of difficult performing movements: combing, putting on shoes, buttoning.
partial mobility decreasing
Partial mobility decreasing
  • Reversible
  • • acute = (impossibilityof
  • Active or passive articulation mobilization): traumatisms, inflammations,
  • Inclusively by infectious case
  • • chronic = stiffness: movement limitation often due to
  • Inflammatory,reversible, intra- andperiarticular processes.
  • Can vary in function of day moment.
  • Improvementas the articulation is used; accentuationafter
  • A period of articulation rest, especially in morning.
  • Irreversible = semiankylosis:
  • Movements limitation often after irreversible, intra- andperiarticularfibrosing processes, deformant cicatrix of articularcapsula: modificationsare not by inflammatory type, but destructive and cicatrizing, irreversible;
mobility loosing
Mobility loosing
  • Reversible = articular block: temporary fixing of

articulation in certain position andwhichcan’t be

reducingactively or passively; can be antalgic, due to muscular contracture, mechanical irritation due to some intraarticular free body (fragment ofcartilage, forexamplebroken meniscus), functionaldue to sinovial inflammation (rarely until block, de regulă remains at the level of stiffness);

  • Irreversible = ankylosis: anatomic ortherapeutic

irreversible process; after tbc arthritis, SA

a rticular cracking
Articular cracking
  • friction ofarticularruggedcartilages surfaces.
  • Not confound withphysiologic cracks (sliding ofligaments/tendonsover bone surfaces).
  • Other causes: shoulder luxation, shifting of biceps tendon from bicipital groove, lesions of meniscus (knee), dysfunction of temporomandibular articulation.
laboratory examinations
Laboratory examinations
  • General
  • inflammatory: inflammatory syndrome (ESR, fibrinogen, α2-globulins, C-reactive protein)
  • noninfectious/systemic:
  • systemic lupus erythematosus : complement, lupic cells,
  • circulant immune complexes, specific antibodies;
  • Rheumatoidpolyarthritis: rheumatoidfactor;
  • acute polyarticular rheumatism: ASLO;
  • infectious/local: leucocytosis, leucocytary formula
  • (neutrophilia) > SLE (leucopenia)
  • degenerative: notmodified
special articular liquid examination
Special: articular liquid examination
  • Articular puncture.
  • Normal aspect.
  • Viscosity increaseswith hialuronic acid concentration
  • Or with leucocytes count.
  • Macroscopic aspect:
  • • transparent, viscous, not coagulable, cells < 10/µL
  • degenerativeartropathies ;
  • • turbid # inflammatory process (many cells ormany fibrin);
special articular liquid examination1
Special:articular liquid examination
  • Cellularity:
  • • <200/µL normal
  • • 200-2.000/µL not inflammatory
  • • 2.000-20.000(75.000)/µL inflammatory
  • • >20.000/µL septic (infectiousarthrites)
  • ~30 000/µL specific infectious arthritis(tbc): turbid oreven purulent liquid,lymphocytes predominate
  • >100.000/µL nonspecific infectious arthritis: yellow-
  • Greenish liquid, turbid (purulent), neutrophils predominate; in culture the germ is identifying.
general principles of examination
General principles of examination
  • asymmetry: nodules, atrophy, tumoral masses, deformations.
  • signs of inflammation: swelling, local warmth (using the
  • back part of palm for to compare one part with
  • another), redness, sensibility to palpation.
  • palpation: zones of sensibility orbone discontinuity.
  • Articular cracking – the articular cartilages surface

is rugged.

  • amplitudeof articular movements (inflammed articulations can be painful and must be moved with

kindness).

  • Isolated (individual muscles) and integrated (muscular groups) muscular functionand gait refer to neurologic examination.
  • Assessment ofneck, superior and inferior members musculature force.
functional impotence
Functional impotence
  • Causes are multiple:
  • interruptionof osseous continuity or of musculo-tendinous formations which executethe movement,
  • blockage,
  • stiffnessor articular ankyloses,
  • antalgic reaction as a consequence of traumatism orsomepainful affection,
  • Lesions of rahidian nervesor
  • lesions of central nervous system etc.
muscular pain m y algia
Muscular pain (myalgia)
  • In inferior member at gait- peripheralischemia (pain of ischemic musculature).
  • Associated with weakness-suspicionof primary

muscular affection.

  • Spontaneous muscular pain - systemic inflammatory states: generalized myalgias;
  • infections:
  • • viral (acute febrile diseases)
  • • bacterial: streptococcus, staphylococcus, gonococcus,
  • secondaryor tertiarlues;
  • muscularphlegmon: swelling, pain, sometimes supuration;
  • overloading (after intense effortsfor which the
  • respective individual has not training)
m uscular hypotony
Muscularhypotony
  • syndromeofneuro-muscular pathology;
  • pyramidal syndromein acute stage;
  • lesionsof posterior rootsand posterior cords (tabes);
  • cerebellum affection syndrome;
  • periodic familial paralysis.
muscular hypertony
Muscular hypertony
  • antalgic contracture (of spinal musclesin acute lumbago
  • or in lumboischiasis, of abdominal musculaturein
  • peritonitis, neck stiffness in meningeal syndrome);
  • neurologic lesions.
  • • spasticityor pyramidal contracturein
  • pyramidal syndrome:
  • In the trial offlexion/extensionof member, there is a big resistance, then, this resistance being surpassed, the movementis easy realizing (like to pocket knife closing).
  • • rigidity or extrapyramidal contracture (contractureissurpassed gradually withsensationof toothed wheal orled tube)
muscular atrophy
Muscular atrophy
  • Amyotrophy-flatteningof normal muscular relief, oftensubstituted by depressions, the bone relief having contrast prominence.
  • Causes:
  • • inactivity (immobilizationin gyps or after some
  • Osteoarticular lesion: ankylosis).
  • • myogene (protopathic) by primarily muscular cause
  • primitivemyopathies: progressive muscular dystrophies (PMD).
  • Initially more genetically different subtypes were described.
  • predominant localization of amyotrophies:
  • pelvifemoral (Duchenne, Becker), pelviscapular,
  • pelviscapulofacial (congenital PMD, myotonic PMD), facioscapulohumeral, oculopharingeal, distal.
bone pain
Bone pain
  • Profound, piercing, dullor intense.
  • In rest with nocturnal accentuation # the patient
  • can’t sleep: acute infections: acute ostheomyelitis (AOM);
  • ● permanentwith progressive accentuation or in very intense during short time accesses (malignant bone tumors); connected with movement:
  • ● fractures – sharp pain, precededby traumatism;
  • ● sometimes in chronic infections: chronic ostheomyelitis (COM), TBC.
  • Infectious causes:
  • Non-specific (AOM, COM);
  • • AOM – intense sensibility to touching; is intensifying as the infection
  • persists), inflammatory edema (hard), redness, increased local temperature, functional impotence: does not move respective member due to pain
  • the movement amplifies the pain). Nocturnal aggravation, due to congestion.
  • • chronic ostheomyelitis (COM).
bone deformations
Bone deformations
  • Ostheoporosis, ostheomalacia, rickets,Paget disease, syphilis
  • tertiary syphilis: ostheoperiostitisandgome ostheomyelitis
  • = ostheoperiostitisaffecting long and flat bones, withevolutionto necrosis andulceration # the formations contain necrosis material by gum consistence (gome), which are opening on the skin surface # ulcerations.
  • congenital tardive syphilis: In children from mothers with syphilis (especially recent, active, in the first year of infection) - intrauterine, transplacentar infection. Manifestations equivalent to tertiary
  • syphilis: plastic ostheoperiostitis (tibia inyataghan)
  • and gomous ostheomyelitis (nose in the form ofsaddle or opera glasses).
formations in bones
Formations in bones
  • Traumatic causes: callus after fracture, vicious callus:
  • discrepancy, angling, torsionof both bone fragments, nervous, vascular compressions.
  • Infectious causes:
  • ● AOM: signs of inflammation:
  • Very painful swelling, erythema, local warmth; sometimes local regional adenopathy
  • ● COM;
  • Tumoral causes:
  • ● benign bone tumors, bone cysts: well delimited, painless, adhere to bone, not adhere to superficial planes, no ulcer, when are very voluminous.
  • ● malignant bone tumors: infiltrative formation, adherence to profound plane, but in soft parts; variable consistence, sometimes ulcerations; parchment-like crepitation(like to egg shell breaking); local circulation isincreased (tissular turn-over more accelerated as in normal bone), withincreased local temperature and evident venous network; sarcomas givemetastasis especially on sanguine pathway # usually there is not adenopathy;
  • ● multiple bone tumors: multiple myeloma (at the level of calotte) adherent to profound plane,
  • mobile relatively to teguments, hard orpseudofluctuant (can be confound with sebaceous cysts).
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