7

Clinical Manifestation of Disease

Prepared by:malek ahmad

University of Malaya

Tremor

•Abolished on movement•Eg: parkinsonism

Resting tremor•Increase amplitude as reach target (dysmetria)•Eg: cerebellar damage (MS, stroke)Intentional

tremor

•Amplitude remains the same throughout movement (no dysmetria)

•Eg: essential tremor

Action tremor

•Present on maintained posture•Eg: benign essential tremor (AD, improve with alcohol), anxiety,

thyrotoxicosis, B-agonistPostural tremor

•Postural tremor developing after a delay of ~10sec•Eg: parkinsonRe-emergent

tremor

Rhythmic, oscillatory movement of body part (hands and legs)

Approach of patient with tremor

Sit up with arm supported by pillow (accentuated by count 100 backward)

Stretch out the arms with fingers seperated

Finger-nose test

Rest tremor

Postural tremor

Intentional trempr

Action tremorIn exam always think of

Parkinson’s disease

Cerebellar signs

•Slurred/ataxic/staccatoSpeech

•Nystagmus Eye movement

•Reduce Tone and power

•Finger-nose test/dysdiadochokinesia

Coordination

•Failed Romberg’s testyGaits

•Intentional tremorTremor

DANISH

Assessment of coordination

• Finger-nose test• Dysdiadochokinesia• Pronator driftUL• Heel-shin test

LL

Dupuytren contractureNodular thickening of CT over 4th and 5th finger

Local hypoxia, ischemia, increase XO xtvt, reduce O2, free radical, fibroblast proliferation, type III collagen, fibrosis

Alcohol Smoking

Heavy manual labour

Trauma

Palmar erythema

Liver dysfunction –

portal HPTPregnan

cy

Polycythemia

Thyrotoxicosis

Dermatoses- exzema/psori

asis RA

Finger clubbing CVS• Cyanotic heart disease• IE• Infected graft• Aneurysm• Atrial myxoma

RESPI• Bronchiectasis• CF• Cancer • Empyema• Fibrosing alveolitis• TB• Mesothelioma

GIT• GI lymphoma• IBD• Malabsorption;coeliac• Cirrhosis

Unilateral • UL artery aneurysm• Bronchial AV

malformation

Grade •Softening of nail bedGrade I•Obliteration of the angle of the nail bedGrade II

•Overlying skin to become tense, shiny and wet and increasing the curvature of the nail, resulting in parrot beak or drumstick appearanceGrade III•Swelling of the fingers in all dimensions associated pain and swelling of the wrist and radiographic evidence of subperiosteal new bone formationGrade IV

Occur due to interruption of

Face sympathetic supply

• At brainstem: demyelination, vascular disease• At cord: syringomyelia• At thoracic outlet: pancoast’s tumor

Sympathetic’s trip on internal carotid artery

• Into the skull: carotid aneurysm• Thence the orbit

Horner’s syndrome

•Ptosis P•Anhydrosis A •Myosis M•EnopthalmosE•Loss of ciliaspinal reflexLa

Pancoast’s syndrome

Invade sympathetic plexus

• Ipsilateral horner’s syndrome

Brachial plexus

• Arm pain

Recurrent laryngeal nerve

• Hoarse voice, bovine cough, due to vocal cord palsy

RA: 0-8 mmHg

LA: 1-10 mmHg

RV: 15-30 / 0-8 mmHg

LV: 100-140 / 5-12 mmHg

PA: 15-30 / 3-12 mmHg

AO: 100-140 / 60-80 mmHg

O2 saturation:LH (95%)RH (75%)