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
• • Hippocrates described cephalohematoma,
hydrocephalus, diarrhea, strophulus, asthma and varicella
• • Soranus of Ephesus (c. AD 100) described the test for
maternal milk quality appreciation (if the milk drop sticks
to the nail, it has sufficient fats, if does not stick – has not
fats)
• • Galen (c. AD 200) described otitis, pneumonia, prolapse
of intestin, rickets.
• • Avicenna, (c. AD 990) – tetanos, convulsions, meningitis,
omphalitis.
• • Avenzoor (c. 1150) performed tracheotomy.
• • Hieronymus in 1583 has writen the book De Morbus
Pusiorum
History of pediatrics
• In IX century - Rhazes (Muhammad ibn
Zakarīya Rāzi - Persia) has described the
child’s diseases (is considering the father of
pediatrics).
• 1530 Thomas Phaer, Book of the child.
• 1852 first hospital in London The Hospital
for Sick Children, Great Ormond
• Abraham Jacobi, - the founder of pediatrics
in USA .
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 pediatrics
• Thomas Sydenham (1624–1689), Hippocrate of
England, described scarlet fever, rubella,
epilepsy, rickets, fever, scorbutus, chorea which
is known as St. Vitus Dance.
History of pediatrics
• Edward Jenner (1749–1823) has vaccinated first
time a 8 years boy against smallpox.
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 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.
Pediatrics
• Pediatrics has as study object the
growing, development and pathology of
the child from the birth until 18 years age.
Pediatrics - subspecialities:
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preventive pediatrics;
social pediatrics;
neonatology (new-born - 0-28 days);
infantile psychiatry;
cardiology;
pediatric pneumology;
nutritional and metabolism diseases;
oncology;
surgery, orthopedy and pediatric traumatology.
Preventive pediatrics
• includes all measures destined to maintain the health
and to prevent the appearance of disease in children.
• It is dividing in :
Primary prophylaxis – avoidance of healthy
individual taking ill (vaccination, water chlorining)
Secondary prophylaxis– recognition and elimination
of disease precursors and the addressing to population
with increased risk for certain affection. Includes also
the diseases complications prevention.
Tertiary prophylaxis– has the goal the improving or
stopping of still established disease complications,
avoiding the evolution to invalidity or decease.
Primary prophylaxis
• includes 2 types of measures:
A) measure applied to collectivity
B) measure applied individually
Measure applied to collectivity
• A) it is realizing through a series of public health
programs which differ from country to country in
function of its development degree.
Some programs of public health with central value
are not still universally adopted.
Applied measures: - accidents prevention– is
difficult and can’t be performed through public
education.
Prevention of intoxications (detergents, alcohol,
mushrooms etc.)
prevention of suicides and murders
prophylaxis of pregnancy in adolescents
prevention of drugs using.
Pediatrics – in Republic of Moldova
creation of abilities for physical and
neuropsychical health state assessment in
children and adolescents
• care and alimentation of healthy and sick
child
• organization and carrying out of
prophylactic, sanitaro-antiepidemical and
medical measures at home and in
preschool and school institutions
Pediatrics – in Republic of Moldova
• Correct diagnosis of acute and chronic
diseases on the base of anamnesis, clinical
and paraclinical examination, conformable
to WHO diseases classification
• appreciation of investigations and treatment
volume after national standards of RM
• According to emergency care to children at
stages home - FDC - hospital
• assimilating of correct dispensary control of
healthy and sick children.
Goal of discipline:
Study of child’s physiologic and
pathologic changes, knowledge of child’s
diseases evolution, diagnosis, treatment
and prophylaxis, development of clinical
reasoning and medical synthesis –
defining elements in the training of each
physician.
Objectives of forming:
• To appreciate the state of physical and
neuropsychical development, to determine
the groups 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 prescribing and interpretation
of laboratory investigations and paraclinical
examination in dependence of basic
pathology and national standards;
• To possess the general medical manoeuvres
in diverse pathologies of the child;
Objectives of forming:
• Enteral and parenteral alimentation;
• gastric washing, performing of evacuator and
medicamentous enemas, urinary bladder
catheterization;
• Determining of pulse, arterial pressure, respiration
rate;
• Interpretation of radiologic, ultrasonographic, ECG
data, general laboratory, microbiologic, biochemical,
immunologic investigations;
• To determine the tactics of 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
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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
• It constitutes the period to extrauterine life
adaptation, in which a series of characteristic
phenomena have place, for example: physiologic
icterus, physiologic weight loss, genital crise etc.
• Duration of new-born period is considered until
the age of 30 days (so- the first month of life).
Period of suckling
• This period, which lasts from 1 month until 1
year, is characterized by very active growing.
• The period of suckling has the most rapid
period of growing, not spread in another
periods. In this period, also, the psychomotory
development of suckling is in permanent
progress, especially due to continuous
development of nervous system.
Examination of suckling
Period of infant (little child)
• After 1 year age, the child is not 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. In
this period the surrounding conditions organization
is very important.
• Correct infant follow-up, good conduced education
work contributes to assimilation of first hygienic
skills and of elementary education rules.
Preschool period
• It occurs between 3 and 7 yrs, the age in which
the child’s mind intensively develops due to
more complex development of central nervous
system.
• Assimilation of knowledge about surrounding
world increases continuously, in report with
development of attention, spirit of observation,
memory.
• The child becomes more independent, due to
continuous development of these functions.
School period
• The growing rhythm is more lent at this period
beginning (in comparison to preschool age), for
to its end to accelerate, at the same time with
puberty appearance.
• Gradually, the exterior aspect of pupil gets near
to that of adult. Due to central nervous system
maturation, the pupil has more complex psychic
activity, which allows to assimilate various and
ample knowledge.
• SEMEIOLOGY
semeion – sign
logos – science, speech
Semeiology is the fundamental basis of diagnosis which
can be established on the basis of anamnestic data which
orientates, of clinical data which substantiate and of
laboratory data which confirm it.
• Semeiology – interpretation of different diseases signs
having the goal to establish more correctly and more
rapidly the diagnosis.
• Semeiology uses symptoms, signs, syndromes and also
paraclinical investigations which must be aimed for
diagnosis confirmation.
• Symptoms – have subjective character, being related
by patient, are variable in different cases, after
perception mode and not always are objective (fever,
headache, insomnia, astenia, hiccups, dyspnea etc.)
• Signs – objective manifestations produced by disease,
observed by patient and completed by physician
through proper feelings(e.g. murmur, rale, dullness
etc.)
• Syndrome–group of symptoms and signs which
expresses a pathologic state, which have a common
physiopathologic mechanism; allow by their sum the
orientation to certain diagnosis; for elucidating or
confirmation the complementary investigations as
possible aimed are performing. Conclusion resulted
from signs and symptoms analysis and confirmation
by analyses guide us to the diagnosis which could be
also a syndrome.
• The health – is defined by WHO as „ a state of complete
physical, mental and social good and not consists only from
disease or inflammation absence”
• The disease is defined in different mode but after Rumanian
medical dictionary represents: „ deviation from health state due
to some internal medium modifications or external medium
agents action” or „ is a deviation or turning off from normal with
undesirable consequences on personal comfort and social
activity”.
• Acute disease – a short duration episode at the end of which the
patient takes again his normal activity.
• Chronic disease– a long duration disease which generates
permanent, partial or total incapacity, there is an organic or
functional alteration which obligates the patient to modify his
normal life mode and which persists more long time.
Teguments
• At birth, the epidermis is very thin and the
smallest irritation produces lesions which very
easily are infecting.
• New-born has the skin covered by protector fat
layer (named vernix caseosa), after removal of
which the fine 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.
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, thorax and after
all on abdomen (in the age around 45 days).
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
reserve and of diverse organs supporting.
• In healthy child, the teguments palpation gives
a special sensation of resistance to pressing.
Teguments of suckling baby
• In healthy breast fed suckling they are whitepink, 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 baby
• are elastic, skin fold returns immediately to
initial form;
• in dehydration states the fold returns slowly or is
persistent.
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
• Begin to develop in 2-3 months age and in 2 yrs
when the corresponding nervous centers are
maturating achieve their integral functional
activity.
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
• It is big in report to his corporal weight and decreases
with the age.
• Skin surface is calculating after Lassabliere formula:
• Skin s. =T 2x0,92
• Specific skin surface represents the report between
skin surface and corporal weight:
• Skin s. (in cm 2)/W(kg)
• in n.b. specific skin surface = 660 cm 2/kg body;
• in 1 year specific skin surface = 420 cm 2/kg body;
• in adult specific skin surface = 220 cm 2/kg body.
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
• 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
• 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.
EXAMENATION OF TEGUMENTS, MUCOSAE AND
DERIVATES
• COLOR OF TEGUMENTS
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Pallor : there is more open color of teguments and mucosae and appears in the
case of superficial circulation reducing, in vasoconstriction or appears 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 – a grey-sallow color appears
In bacterial infectious endocarditis – pallor is by milk coffee type
Redness :appears through accentuated vasodilatation or 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 primary or secondary
polyglobulias.
 Cyanosis (kianos) :there is a bluish – violet color of skin and mucosae and
appears due to reduced hemoglobin increasing at 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:
- volume of 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) it is
better seen on palms or conjunctival mucosa
-association with other pigments in the same time, for ex. with jaundice
-concentration of Hemoglobin in blood, appearing more rapidly in
polyglobulia than 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
-methemoglobinemia and sulphhemoglobinemia (intoxication with nitrites,
nitrotoluene, benzene etc)
-argiria – deposition of silver salts in teguments, giving a bluish-grey
colouring
In the cyanosis appearance the absolute level of redused Hemoglobin has importance.
La anemics, especially at values ↓5 g. /100 ml blood the cyanosis can’t be
distinguished.
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CENTRAL CYANOSIS: is due to insufficient saturation of arterial blood with
oxygen, which leads to reduced Hemoglobin absolute level increasing in arterial
blood over limit value of 5 g/100 ml. This cyanosis is generalized and involves
both teguments and mucosae, the temperature being not decreased; there is socalled warm cyanosis
Causes of central type cyanosis:
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Respiratory causes:
-affections which reduce the circulation bed: massive pneumonias, bronchopneumonias,
miliar TBC, extended pulmonary fibroses, massive pleuresies, pneumothorax,
fibrothorax, kypho-scoliotic thorax, etc.
- Affections which produce the respiratory pathways obstruction: laryngo-tracheal
diseases, tumors which compress respiratory pathways, bronchial asthma, chronic
broncho - pulmonal obstructive diseases, etc.
2. Cardiac causes:
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left cardiac failure, mitro-aortic valvulopathies, cardiomyopathies, disorders of
rhythm and conductibility.
congenital complexe cardiopathies which can be installing at birth, persisting all life
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– blue disease
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Potent ductus arteriosus
arterio-venous fistulas of great and middle vessels, with veno-arterial shunt after
aneurismas or on small vessels, in hereditary telangiectasia.
3. Mixt causes: cardiac and respiratory. The chronic cor pulmonale in which the right
heart failure consecutively some broncho - pulmonal affection appearing, is
typically.
 PERIPHERAL CYANOSIS:is determined by vasoconstriction followed by blood
circulation speed slowing in a peripheral area, which leads to increased oxygen
extraction by tissues from arterial blood.
- Generalized cyanosis: appears after exposure to cold or in congestive cardiac failure,
when the cutaneous compensatory vasoconstriction is associated. It is more
pronounced on the limbs which are cold and in the right and congestive cardiac
failure the edemas can appear.
-Localized cyanosis– appears in venous or arterial trunks obstructions and is strictly
localized at corresponding area. If the obstacle is in superior vena cava the cyanosis
of cephalic extremity, of superior members, of neck and of thorax superior part
appears(cyanosis in pelerine with or without edema).
Disorders of pigmentation:
-Hypomelanoses
are characterized by melanic pigment decreasing or absence. The
albinism characterized by absence of pigment in skin, hair and eyes and vitiligo
characterized by light color with hyperpigmented contour spots appearance take part
from this group.
-Hypermelanoses appear through numeric increasing of melanic cells and their
overloading with pigment and are due to hormonal causes: chronic insufficiency of
suprarenal glands (Addison disease), hyperthyroidism (Basedow disease).
Ephelides- small brown – redish spots on cheeks, shoulders, back, dorsal part of
hands appear through pigmentation of skin under the form of freckles and have
familial and constitutional character.
-Icterus is the yellow colouring of the skin, mucosae and scleres determined by their
impregnation with bilirubin when it has increased values in blood (over normal
value by1mg at 100 ml of blood).
Teguments in children
Hyperpigmentation
Hyperpigmentation
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 :a small, round prominence on skin, with the diameter under 0,5 cm,
palpable; appears in scarlet fever, urticaria
 Nodule is a dermic or hypodermic formation by varied dimensions, palpable, which
appears in xantomatosis, lipomatosis, erythema nodosa.
 Vesicle is a raised above the surrounding skin plane, under 1cm diameter, fluidfilled lesion which appears in varicella, herpes Zoster.
 Bulla is a vesicle with purulent content which appears in acnea, variola, impetigo.
 Cyst is a soft, raised, encapsulated lesion filled with semisolid or liquid contents.
 Crusts have deposits of solidified exudates on tegument surface which appear in the
evolution of herpes, zone Zoster or as consequence of erosions, ulcerations or at the
level of cutaneous eczema.
 Cicatrix appears after skin plagues healing where the fibrous tissue is developing.
 Fissures are deep linear defects of the skin below its basal membrane level.
 Erosion is a superficial defect of the skin.
 Ulcer is a deep defect of the skin below its basal membrane level.
 Gangrena is a necrosis of tissue and underlying stratum which can suprainfect
becoming fetide.
 Scar is 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.
 Atrophy is 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 spots by small dimensions (< 1cm) by round or oval
form which appear on skin or mucosae.
 Ecchymoses :are hemorrhagic dermo-hypodermic spots more than 1cm.
 Telangiectasies:are small vessels dilatations on the skin or mucosae which appear in
hypovitaminoses B, cirrhosis.
Teguments in children
ecchymoses
ecchymoses
Teguments in children
Teguments in children
Impetigo
varicella
Teguments in children
Atopic dermatitis
Atopic dermatitis
Reticular livedo
Periarteritis nodosa
Periarteritis nodosa
Teguments in children
Fungic affection
Contact dermatitis
Teguments in children
Coxachie disease
Urticaria
Teguments in children
Scarlet fever
Roseola
Examination of hair:
 Hypotrichosis represents hair rarefying (hypothyroidism, Addison disease).
 Calvition is the hair loosing on determined area.
 Allopecia is the head hair loosing.
 Hypertrychosis is hair density increasing in cutaneous hairy areas.
 Hirsutism represents the hypertrychosis on more extended areas
 Qualitative modifications of hair include the fiber thickness, shining and hair pigmentation.
Examination of nails:
The form, thickness, friablity and their color are examining.
• Bulging – pathologic accentuation of nail convexity appears in the case of
hyppocratic fingers and is characterized by last phalange soft tissues hypertrophy
and aspect of the nail like to glass watch. This aspect appears in different bronchopulmonary diseases (neoplasma, bronchiectasis, pulmonary abscess, empiema,
interstitial fibrosis), cardiac diseases (congenital angio-cardiopathies, infectious
endocarditis, cardiac failure), digestive diseases (hepatic cirrhosis, intestinal
polyposis, ulcero-hemorrhagic rectocolitis), polyglobulias.
• Koilonychia is flattening and concavity of the nail plate with loss of normal contour,
producing a spoon-shaped nail. It is observed in iron deficient anemias, mixedema,
acromegaly.
Adipose and muscular system:
• Adipose tissue is assessed by general inspection and by
measurement of skin fold on abdomen or on arm,
appreciating in this way the patient’s nutrition state.
• Muscular system is examining by inspection and palpation,
establishing therefore the development and musculature
tonus: hypertrophy, hypotrophy, muscular hypertonia,
hypotonia or normal aspect.
Facies can offer important data about the presence of some respiratory diseases such as:
 vultuos facies– with red cheekbones , shining eyes, on febrile background, which
appears in lobar pneumonia (Jaccoud sign - hyperemia on the same part with
pneumonia).
 pale facies, so-called „venice facies” typical in 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, cheekbones and nose top – denotes a severe
pulmonary affection (bronchopneumonia, massive pneumonia, pulmonary
neoplasma,etc.) or chronic cor pulmonale.
 cyanotic-black, „blue-bloatter” facies appears in mediastinal syndrome
 „pink-puffer” facies typical for emphysematous patients
Examen of teguments and mucosae – reveal described facies modifications in which the
labial herpes characteristic in viral pneumonias or in lobar pneumonia is adding.
Don’t forget to examine the inferior members teguments.
Ostheo-articular system:
• Objective examination of bones:
• Fractures are characterized by abnormal mobility of one bone segment and bone
crepitation.
• Bone deformations appear as a result of abnormal growing and development of
bones, tumoral proliferation or endocrine (acromegaly) or metabolic (rickets,
osteomalacia, Paget disease) disorders.
• Obiective examination of articulations:
-Congestion – redish coloring of teguments around articulations appears in the
case of arthrites (articular inflammation).
-Tumefaction of periarticular tissues leads to articular deformation, spontaneous
pain at movement and limitation of articular mobility.
-Articular pain – sensibility is found at articulations palpation and at active or
passive movements effectuated by patient.
-Articular deformations are observing at attent inspection, having significance in
arthrites or în arthroses (degenerative articular processes with chronic character).
-Articular mobility is evidencing at
active or passive movements of
articulations, articular diseases determining the reducing or disappearance of one
articulation mobility both from pains cause, and from articular ankylosis or
semiankylosis cause
Locomotor system
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Locomotor system has three major components :
- bones
- articulations
- muscles and their nerves.
Skeleton and its functions
• gives the form and support to the body
• represents the storage of easy mobilizing
calcium (97%)
• Some elements of skeleton protect the body
from external and internal forces.
• The bones offer the attaching surfaces for
muscles and represents the movement levers.
• The dynamic agent of locomotion is represented
by skeletal muscle.
The major symptoms of locomotor
system affection
• · pain
• · functional incapability
Pain
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biting
smarting
burning
spearing
excruciating
pulsative
It can be continuous or intermittent, progressive
or alternant in evolution, localized or diffuse,
expressed or dull, superficial or profound.
Spatial characteristics
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! Number of affected articulations:
• monoarthritis (infectious arthritis);
• oligoarthritis (reactive arthritis = ReA);
• polyarthritis (rheumatoid polyarthritis = RPA);
! symmetry (RPA)/asymmetry (ReA);
! articular/periarticular feeling;
! distal irradiation: syndromes of nervous compression
(syndrome of tunnel/compartment);
! referred pain: for example, the affection of hip can
generate the pain in knees (especially in children).
Temporal characteristics
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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
persists in 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
• Often is accentuated in morning
• it is ameliorating after periods of articulation repose
if the articulation is used (RPA, SA);
• it can intensify if the articulation is overworked or
even only at moderated movements (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
• recent history of pharyngitis/angina (throat pain),
• Followed after 10-14 days by articular pains #
suspicion of AAR;
• • tbc, syphilis, hemophilia (hemarthrosis), renal
colics (uric lithiasis associated to gout),
cutaneous streptococcal, staphylococcal
infections
Other signs/symptoms
Other signs/symptoms: local: objective articular
(signs of inflammation: swelling, local warmth,
redness at palpation, spontaneous pain and
functional impotence) or periarticular
modifications;
• general/systemic # system disease:
• general: fever, astenia, loss of appetite;
• Multiorganic affection: cardiac, pulmonary, digestive,
renal.
Articular examination
• Enlargement in volume of articulation, liquid
accumulation, pain, flat contour of articulation,
bulging of sinovial sack bottom, with/without signs
of inflammation
(redness, warmth).
• At palpation fluctuation, pain. The knees: rotulian
shock, wave sign.
• Differential diagnostic: inflammation of periarticular
tissue, deformation of articulation through repeated
• traumatisms can be differentiated using echography
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
• Can be congenital (conjunctive tissue anomalies:
• Ehlers-Danlos syndrome) or acquired (ruptures of
• ligaments, muscular hypotonia in neuropathies.
Mobility decreasing
• Mobility examination must be performed with
attention in the case of traumatism, hemophilia.
• Identifying of affected articulations is carried out
in function of difficult performing movements:
combing, putting on shoes, buttoning.
Partial mobility decreasing
• Reversible
• • acute = (impossibility of
• Active or passive articulation mobilization): traumatisms,
inflammations,
• Inclusively by infectious case
• • chronic = stiffness: movement limitation often due to
• Inflammatory, reversible, intra- and periarticular processes.
• Can vary in function of day moment.
• Improvement as the articulation is used; accentuation after
• A period of articulation rest, especially in morning.
• Irreversible = semiankylosis:
• Movements limitation often after irreversible, intra- and
periarticular fibrosing processes, deformant cicatrix of articular
capsula: modifications are not by inflammatory type, but destructive
and cicatrizing, irreversible;
Mobility loosing
• Reversible = articular block: temporary fixing of
articulation in certain position and which can’t be
reducing actively or passively; can be antalgic, due to
muscular contracture, mechanical irritation due to
some intraarticular free body (fragment of cartilage, for
example broken meniscus), functional due to
sinovial inflammation (rarely until block, de regulă
remains at the level of stiffness);
• Irreversible = ankylosis: anatomic or therapeutic
irreversible process; after tbc arthritis, SA
Articular cracking
• friction of articular rugged cartilages surfaces.
• Not confound with physiologic cracks (sliding of
ligaments/tendons over bone surfaces).
• Other causes: shoulder luxation, shifting of
biceps tendon from bicipital groove, lesions of
meniscus (knee), dysfunction of
temporomandibular articulation.
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;
• Rheumatoid polyarthritis: rheumatoid factor;
• acute polyarticular rheumatism: ASLO;
• infectious/local: leucocytosis, leucocytary formula
• (neutrophilia) > SLE (leucopenia)
• degenerative: not modified
Special: articular liquid examination
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Articular puncture.
Normal aspect.
Viscosity increases with hialuronic acid concentration
Or with leucocytes count.
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Macroscopic aspect:
• transparent, viscous, not coagulable, cells < 10/µL
degenerative artropathies ;
• turbid # inflammatory process (many cells or many
fibrin);
Special: articular liquid examination
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Cellularity:
• <200/µL normal
• 200-2.000/µL not inflammatory
• 2.000-20.000(75.000)/µL inflammatory
• >20.000/µL septic (infectious arthrites)
~30 000/µL specific infectious arthritis(tbc):
turbid or even 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
• 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 or bone discontinuity.
• Articular cracking – the articular cartilages surface
is rugged.
• amplitude of articular movements (inflammed
articulations can be painful and must be moved with
kindness).
• Isolated (individual muscles) and integrated (muscular
groups) muscular function and gait refer to neurologic
examination.
• Assessment of neck, superior and inferior members
musculature force.
Functional impotence
• Causes are multiple:
• interruption of osseous continuity or of musculotendinous formations which execute the
movement,
• blockage,
• stiffness or articular ankyloses,
• antalgic reaction as a consequence of
traumatism or some painful affection,
• Lesions of rahidian nerves or
• lesions of central nervous system etc.
Muscular pain (myalgia)
• In inferior member at gait- peripheral ischemia (pain
of ischemic musculature).
• Associated with weakness- suspicion of primary
muscular affection.
• Spontaneous muscular pain - systemic
inflammatory states: generalized myalgias;
• infections:
• • viral (acute febrile diseases)
• • bacterial: streptococcus, staphylococcus, gonococcus,
• secondary or tertiar lues;
• muscular phlegmon: swelling, pain, sometimes
supuration;
• overloading (after intense efforts for which the
• respective individual has not training)
Muscular hypotony
• syndrome of neuro-muscular pathology;
• pyramidal syndrome in acute stage;
• lesions of posterior roots and posterior cords
(tabes);
• cerebellum affection syndrome;
• periodic familial paralysis.
Muscular hypertony
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antalgic contracture (of spinal muscles in acute lumbago
or in lumboischiasis, of abdominal musculature in
peritonitis, neck stiffness in meningeal syndrome);
neurologic lesions.
• spasticity or pyramidal contracture in
pyramidal syndrome:
In the trial of flexion/extension of member, there is a big
resistance, then, this resistance being surpassed, the
movement is easy realizing (like to pocket knife closing).
• • rigidity or extrapyramidal contracture (contracture is
surpassed gradually with sensation of toothed wheal or
led tube)
Muscular atrophy
• Amyotrophy - flattening of normal muscular relief,
often substituted by depressions, the bone relief
having contrast prominence.
• Causes:
• • inactivity (immobilization in gyps or after some
• Osteoarticular lesion: ankylosis).
• • myogene (protopathic) by primarily muscular cause
• primitive myopathies: 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
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Profound, piercing, dull or intense.
In rest with nocturnal accentuation # the patient
can’t sleep: acute infections: acute ostheomyelitis (AOM);
● permanent with progressive accentuation or in very intense during short
time accesses (malignant bone tumors); connected with movement:
● fractures – sharp pain, preceded by 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
• Ostheoporosis, ostheomalacia, rickets, Paget disease,
syphilis
• tertiary syphilis: ostheoperiostitis and gome
ostheomyelitis
• = ostheoperiostitis affecting long and flat bones, with
evolution to necrosis and ulceration # 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 in yataghan)
• and gomous ostheomyelitis (nose in the form of
saddle or opera glasses).
Formations in bones
• Traumatic causes: callus after fracture, vicious callus:
• discrepancy, angling, torsion of 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 is
increased (tissular turn-over more accelerated as in normal bone), with
increased local temperature and evident venous network; sarcomas give
metastasis 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 or pseudofluctuant (can be confound
with sebaceous cysts).