Inspection

A glance at a patient can sometimes be enough to assess his health and diagnose the disease, e.g. anaphylactic shock, an attack of asthma, skin le­sions such as erythema, urticaria, or local angioneurotic oedema (usually localized on the face), and suggest the allergic nature of the affection. Changes in the skin become more pronounced in grave cases: vesicles and even necrotic lesions develop on the skin and mucosa.

The posture of the patient, e.g. a marked kyphosis of the chest in com­bination with lumbar lordosis and limited mobility of the spine (the trunk of the patient is fixed in the inclined "position of a beggar") suggests ankylosing spondyloarthritis (Bekhterev's disease). Affections of the spine, joints, acute inflammation of muscles (myositis) limit the patient's mobili­ty and sometimes immobilize him completely. The gait of the patient is quite informative for diagnosis. The paralytic gait of a patient with hemiplegia is characterized by the dragging limb. Paretic gait is characterized by slow movements of the patients and shuffling. It occurs in contracture of the extremities, paresis of the spinal origin. Unilateral affec­tion of joints of the lower extremities makes the patient spare the affected limb (limping on account of pain). It should be remembered that the hip joint is commonly affected in tuberculosis (tuberculous coxitis) usually in children; at later stages of the disease, ankylosis develops, the growth of the affected extremity is delayed, and the muscles become atrophied. Acute gonitis in adults can be of gonorrhoeal nature. Deranged innervation of muscles (paralysis, paresis of various nature), congenital myopathy (a group of diseases that are the subject of detailed discussion in the course on nervous diseases) are also important for the gait of a patient. Patients with grave disorders of muscular innervation are completely immobilized.

Marked deformation of small joints of the hand and foot is characteristic for rheumatoid arthritis. Disfigured terminal phalanges of the fingers with sclerotically changed skin on them (with necrosis in grave cases), or specific stretching folds round the mouth, especially in young women, suggest systemic scleroderma (collagen group of diseases). Cramped muscles (usually flexor muscles) are sometimes revealed on in­spection of the patient (development of contracture).

Erythema of the face skin, butterfly distribution of eruptions on the forehead (also mostly in young women) suggest a grave systemic di­sease of the connective tissue—systemic lupus erythematosus. Focal sclerotic changes on the skin of variable size are characteristic of local scleroderma.

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Special Part

Chapter 11. Diseases of Bones, Muscles, Connective Tissue.

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PALPATION ; .

When examining the skin by palpation, the physician can reveal in­creased dryness, e.g. in systemic scleroderma, indurative oedema, and (at later stages of the disease) atrophy of the skin and focal calcinosis of soft tissues, mainly of the fingers and around major joints. Consolidation of muscles may occur in systemic scleroderma and dermatomyositis. The muscles are also consolidated and become tender in ordinary myositis. In the presence of Raynaud's syndrome, palpation confirms abnormally low temperature of the skin of the extremities, especially of the terminal phalanges of the fingers.

Palpation of the joints reveals hyperthermia and oedema of the skin around them (in acute affections), tenderness and deformities of the joints. A thorough palpation can show whether only the joint or the surrounding soft tissues are also involved. In some cases, palpation can reveal that, despite tenderness of the joints and pain in them during movements, the joints are not affected by pathology.

Palpation is also used to study passive mobility of various joints; limited activity of joints can be due to pain in arthritis or arthrosis, and also in ankylosis (i.e. in articular immobility). In the presence of in­complete ankylosis, the movement may first be unobstructed, but then sud­denly discontinue as if hindered by some insurmountable barrier. Special diagnostic techniques are sometimes used. In cases suspected for coxitis (inflammation of the hip joint), overextension of the stretched leg should be tried. The patient lies in the prone position. The movement of the af­fected leg is limited in coxitis due to developing pain and reflex muscular contracture. Flexion and rotation in the affected joint should be tried with the patient lying on his back. In order to measure accurately the angle be­tween two articulating bones through which an affected leg can move, a special instrument, known as a goniometer, is used. It should be remembered that the joint function can also be limited by cicatricial shrinkage of muscles or tendons due to past myositis, inflammation of ten­dons or their sheaths, or wounds. Inspection of the skin of the extremities, palpation of the muscles and tendons can reveal the cause of limited ar­ticulation. Palpation of the joint can reveal fluctuation in the presence of acute inflammation with ample transudate in the joint, or in the presence of purulent exudate.

By giving passive movements to all joints one after another and by palpating the muscles, it is possilbe to determine their tension. Contractile muscular tension, which depends on dysfunction of the lower motor neuron, and plastic tension which shows the condition of the internal medium of myofibrillae, are distinguished. Muscular hypotension and

hypertension are possible. Hypotonic muscles are flaccid to the touch, the belly of long muscles is not pronounced, passive movements are possible in the full extent, and sometimes even in a greater extent than of normal mus­cle. The joints are loose. When the muscle is passively stretched, the ex­aminer does not feel any muscular resistance. Muscular hypotension occurs mostly in affections of the peripheral nerves and prolonged muscular inac­tivity (e.g. when the patient keeps his bed for a long period for some grave disease). Muscular hypertension arises as a result of increased reflex muscular tension in the presence of affected pyramidal tracts; the muscles are firm and difficult to stretch passively; muscular resistance increases with the speed and abruptness of passive movements.

In order to obtain a complete impression of the muscular condition, the force of muscles should be assessed. Two methods are used for the pur­pose. The patient may actively resist the physician's attempt to flex or ex­tend his extremity (static force), or, on the contrary, the patient tries to overcome the resistance of the physician's hand (dynamic force). There are special instruments, dynamometers, and dynamographs which determine the muscular power of various groups of muscles.