stagiu 1-semiologia aparatului locomotor
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reumatologie iasiTRANSCRIPT
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SEMIOLOGIA APARATULUI LOCOMOTOR STAGIU 1
Asist. Univ. dr. Luana Macovei
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simptome
l osteo-articulare: durere, redoare articular, tumefiere articular, impoten funcional;
l musculare: scderea forei musculare, l musculare: scderea forei musculare, mialgii;
l neurologice: durere, parestezii, deficit motor;
l nespecifice;l specifice;
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Durerea
l sediul dureriil caracterul durerii l durata durerii l durata durerii l debutul durerii l evoluia durerii l factori precipitai i/sau agravani ai durerii l factori care amelioreaz durerea l alte particulariti ale durerii
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Sediul durerii
l Articularl Periarticularl Periarticularl Entezelorl Ososl Muscularl Generalizat/difuzl Viscerall Nerv
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Sediul durerii articulare
l articula ii periferice(membre superioare i (membre superioare i inferioare)
l axial (artic. SI, discovertebrale i IAP);
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Durerea articular periferic
l numrul de articulaii interesate 1. o articulaie-monoarticular, 2. ntre 2-4 articulaii-oligoarticular, 3. > 5 articulaii-poliarticular
l tipul de articulaii interesate si distributia afectarii:
- articulaii mici, medii, mari simetric / asimetric
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Tipul de articula ii interesate n diferite boli
simetric asimetric
articula ii mici MCF, IFP, MTF PR, LESIFD ApsIFP, IFD poliartroz
IFP, IFD artrit reactivIFP sarcoidoz, gutC-MC I - rizartrozIFP, IFD poliartroz
MCF2,3- hemocromatozC-MC I - rizartroz
articula ii medii RC, TT, coate - PR, LES,sarcoidoz
RC, TT, coate- artritapsoriazic, artrita reactiv,gut, RAA
articula ii mari umeri, CF, genunchi PR, CF, genunchi - artroza primitiv
CF, genunchi ONA, artrozsecundar, sinovitvilonodular, spondilartrite
RAA
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Caracterul durerii articulare
l caracterul durerii articulare: 1. mecanic: durerea care se
exacerbeaz la micare i se amelioreaz cu repausul;
ArtrozaDiscopatiiamelioreaz cu repausul;
2. inflamator: durerea care se exacerbeaz n repaus i se amelioreaz cu micarea;
3. permanent sau mixt: durerea este prezent att n repaus ct i la mi care, uneori cu accentuare n repaus (nocturn) - n afec iuni de tip inflamator sau n timpului mi crii - n afec iuni de tip degenerativ;
PR, LES, SD, gut, artrita infecioas, spondilartrite, etc.
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Caracterul durerii articulare periferice
1. aditiv: durere la o nou articula ie nainte ca afectarea celei precedente s fie ameliorat;
PR, artrita psoriazic, artrita reactiv, LES, artroza
s fie ameliorat;
2. intermitent/episodica: durere articular separat de intervale libere, asimptomatice;
3. migrator: durere la o noua articula ie dupa ameliorarea celei precedente.
gut, pseudogut, sarcoidoz, b. Lyme, FMF
hidartroza intermitent,
RAA, artrita viral (VHB)artrita gonococica, LES
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Durata durerii articulare
l sub 6 sptmni = durere acut: rubor, calor, tumor, functio lesa = artrita acut (n artrita lesa = artrita acut (n artrita infec ioas, gut, pseudogut, etc.)
l peste 6 sptmni = durere cronic: tumefiere, redoarei/sau impoten funcional = artrita cronic (PR, LES, spondilartrite, artroza, ONA, etc).
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Redoarea articular
l reprezint senzaia de nepenire articular ce apare dup o perioad de imobilizare.
l durat 30 min: afeciuni de tip inflamator (PR, LES, spondilartrite, etc)
l durata 15 min: afeciuni de tip degenerativ (artroz).
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Tumefierea articular:
l Artrit: epanamentul articular mrete global articulaia i este nsoit de limitarea mobilitiiactive/pasive; active/pasive;
l afeciuni inflamatorii periarticulare (bursit/tenosinovit): tumefierea este relativ bine localizat i nu afecteaz mobilitatea articular pasiv;
l tumefierea de prti moi non-articular (celulita/tromboflebita): tumefierea depeste limitele articulare i asociaz semne clinice specifice;
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Durerea articular axial/vertebrala
l sediul: sacrat, lombo-sacrat, lombar, dorsal, cervical
l caracterul: mecanic / inflamator / permanent-mixt
l iradierea 1. sistematizat (respectarea unui dermatom) - n caz de conflict disco-radicular;
!!! pe fa a posterioar coapsa pna la nivelul spa iului popliteu, alternant sciatica n bascul/ durere fesiera alternanta n spondilartrite;
2. nesistematizat (fr respectarea unui dermatom).
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debutul durerii articulare
l brusc, acut: gut, artrita infecioas, posttraumatic, lombosciaticaposttraumatic, lombosciatica
l insidios: PR, LES, artroz,ONA etc.;
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evoluia durerii articulare
l acut: artrita infecioas, gut;
l cronic: artroz, PR, spondilartrite;
l intermitent: gut, pseudogut;
l migrator: RAA, sarcoidoz-form acut, artrita viral, artrita gonococic, boala Lyme;
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factori precipitai i/sau agravani ai durerii articulare
l efortul fizic, frigul, umezeala, ortostatismul prelungit n afeciuni de tip prelungit n afeciuni de tip degenerativ/mecanic
l repausul n afeciuni de tip inflamator;
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factori care amelioreaz durerea articular
l repausul, AINS n afeciuni de tip degenerativ
l mi carea, AINS i CS n afeciuni de tip inflamator;
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Durerea periarticular
l origine n structurile anatomice din jurul articula iei (tendon, articula iei (tendon, bursa, ligament, capsul);
l are caracter mecanic l este accentuat de
mi carea activ i rezistiv n timp ce mi carea pasiv nu o influen eaz
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Durerea articulara vs periarticulara
ARTICULARA PERIARTICULARA
DURERE
TUMEFIERE
MOBILITATEA
profunda, difuza localizata
rar
activa dureroasa in anumite planuri/rezistiva
accentueaza
frecvent
activa+pasiva limitata dureroasa toate planurile
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Durerea de la nivelul entezelor
l durere la locul de inserie pe os al ligamentelor, ligamentelor, tendoanelor, capsulei articulare - n spondilartrite, dislipidemii
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Durerea osoasa
l are caracter continuu, l are caracter continuu, nocturn, profund, difuz, fr legtur cu mi carea;
l este localizat frecvent la nivelul coloanei vertebrale, pelvisului i segmentelor proximale ;
neo primitive/secundare, osteoporoz, osteomalacie;
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Durerea generalizata
afecteaz diferite pr i ale corpului difuz, imprecis cu sau fr focalizare articular fibromialgie, sdr miofascial
Tender point
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Durerea referata
l durerea cu ritm necaracteristic sim it la distan de originea anatomic; originea anatomic;
l cel mai frecvent are origine visceral (pancreas, stomac, vezica biliar, cord, rinichi, etc.).
l examenul ariei respective este normal (palparea i mobilitatea ariei dureroase nu influen eaz durerea).
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Impotena funcional
n funcie de tipul de afectare articular se remarc mai multe tipuri de impoten funcional:mai multe tipuri de impoten funcional:
l deficitul de mers: gonartroz, coxartroz, lombosciatic;
l deficitul de prehensiune: PR; SDl deficitul de ortostaiune: lumbago, coxartroza
avansat; l deficitul funcional al coloanei vertebrale.
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Durerea muscular
l mialgia (proximal, distal, generalizat) - simptom nespecific, de nsoire.
l scderea forei musculare proximal i/sau distal: miopatii inflamatorii (PM,DM, MI), metabolice , iatrogene (corticosteroizi, statine, fibra i, colchicin,
hidroxicloroquin), secundare unor afeciuni neurologice (lombosciatic,
scleroza multipl) sau afeciuni articulare avansate (degenerative sau inflamatorii);
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Simptome neurologice
l durerea neurogen- compresiunea sau iritarea unei rdcini nervoase (n
sciatic) sau nerv periferic (n sindromul de canal compresiunea sau iritarea unei rdcini nervoase (n sciatic) sau nerv periferic (n sindromul de canal carpian sau ulnar);
- caracter radicular, plexal, nevritic, polinevritic, medular, cu caracteristici semiologice specifice;
l tulburri de sensibilitate: parestezii, disestezii, etc.; l deficit motor: parez, paralizie de tip periferic (flasc)
sau central (spastic).
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Simptome nespecifice
- inapetena, - subfebrilitate/febr, - scdere ponderal, - fatigabilitate, etc.
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Simptome specifice
1. leziuni cutanate (fotosensibilitate, eritem, noduli, ulceraii, etc.)2. manifestri digestive: diaree, rectoragie (colita ulcerativ, boala
Crohn); disfagie distal (sclerodermie sistemic) sau proximal Crohn); disfagie distal (sclerodermie sistemic) sau proximal (polimiozit),
3. manifestri neurologice: parestezii distale sistematizate (sindrom radicular sau mononevrit) sau nesistematizate (polinevrit),
4. manifestri ale glandelor exocrine: xerostomie, xeroftalmie (sindrom Sjogren).
5. manifestri pleuro-pulmonare: toracodinie, tuse, dispnee (PR, LES, PM, SA),
6. manifestri cardio-vasculare: palpitaii, durere anginoas, fenomen Raynaud, etc.
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DURERE ARTICULARA ?
Cauza non-articulara Traumatism/Fractur Fibromialgie Polimialgia reumatica Bursita Tendinita
6 saptamani?
Acuta
Nu Da
Nu
Da Tendinita
Cronica
Caracter inflamator?1. Redoare matinala?2. Tumefiere articulara?3. Simptome specifice?4. VSH / CRP crescut?
ARTRITA ACUT Infectioasa Guta Pseudoguta sdr Reiter
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Caracter inflamator?
ARTRITA CRONICA DE CAUZAINFLAMATORIE
ARTRITA CRONICA DE CAUZANEINFLAMATORIE
Numar articulatii interesateIFD, I C-MC, soldsau genunchi interesate?
DaNu
nu 1-4 >5da
mono/oligoartrita cronica inflamatorie infectioasa artrita psoriazica sdr Reiter AIJ
OsteonecrozaArtrita Charcot ARTROZA
Poliartrita cronica
inflamatorie
nu 1-4 >5da
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Artrita cronica inflamatorie asimetrica
IFP, MCF sau MTF
Poliartrita cronica inflamatorie
Simetrica?
DaNu
asimetrica artrita psoriazica sdr Reiter
LESSclerodermiePolimiozita
Poliartrita reumatoida
IFP, MCF sau MTFInteresate ?
Nu Yes
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