TALLER DE SIMULACIÓNSEMIOLOGÍA MÉDICA

INFORMACIÓN GENERAL๏ Tutores:

- Dr. Claudio Maclean - Dr. Javier Webar

๏ Sesiones: - Lunes/Jueves/Viernes 14:00–16:30 hrs. - Dos semanas (6–7 sesiones)

๏ Asistencia 100%

J.WEBAR.V@GMAIL.COM

OBJETIVOS๏ Semiología

๏ Semiotecnia - “De forma ordenada y sistematizada.” - Descripción de hallazgos del examen físico.

๏ Síndromes clínicos

CONTENIDOS

EXAMEN GENERAL CARDIOVASCULAR

RESPIRATORIO ABDOMINAL

NEUROLÓGICO OTROS*

* CUELLO, MAMAS, EXTREMIDADES INFERIORES.

EVALUACIÓN๏ Evaluación Formativa

- Desempeño en actividades de simulación - Actitud y diligencia

๏ Calificación = Aprobado v/s Reprobado - Un alumno reprobado no puede aprobar la asignatura de

Semiología Médica.

๏ Evaluación tipo ECOE–MINICEX - Última sesión de simulación

EXAMEN FÍSICO GENERALSIMULACIÓN EN SEMIOLOGÍA

CONSTITUCIÓN

ESTADO NUTRICIONAL

IMC kg / m2

Normal

Desnutrición

Sobrepeso

Obesidad

PIELLESIONES ELEMENTALES

MÁCULADiscoloración circunscrita y plana.

PÁPULALesión sólida y solevantada < 0.5 cm de diámetro.

PLACALesión sólida y solevantada > 0.5 cm de diámetro

(usualmente confluencia de varias pápulas).

NÓDULOLesión sólida, circunscrita y elevada > 0.5 cm de diámetro

(un nódulo > 2 cm se llama tumor)

VESÍCULAColección circunscrita de líquido libre < 0.5 cm

(si es > 0.5 cm se conoce como Bula)

PÚSTULAColección circunscrita de leucocitos y líquido libre de tamaño variable

UÑASALTERACIONES

VARIANTES NORMALES

ONICOMICOSIS

CO

INO

LIQ

UIA

HIPOCRATISMO DIGITAL

SISTEMA

LINFÁTICO

INFLAMATORIA

blanda múltiples

móvil no adherida

sensible < 1 mes

AD

ENO

PAT

ÍAS

TUMORAL

pétrea única/asimétrica

inmóvil adherida

indolora > 3 meses

hepatoesplenomegalia / palidez / síntomas B*

¿ ?

¿ ?* Fiebre, pérdida de peso, sudoración nocturna.

DESHIDRATACIÓN

SIGNOS DE DESHIDRATACIÓN

Signo SEN ESP

Sequedad axilar 50 82Sequedad de mucosas 85 58Hundimiento ocular 62 82Confusión 57 73Relleno capilar > 2 cm 11 89Taquicardia postural (≥ 30 lpm) 97 98Hipotensión ortostática 9-27% 94Taquicardia supina 12 96Hipotensión supina 33 97

¿ ?

Signo SEN ESP

Sequedad axilar 50 82Sequedad de mucosas 85 58Hundimiento ocular 62 82Confusión 57 73Relleno capilar > 2 cm 11 89

Taquicardia postural 97 98

Hipotensión ortostática 9-27% 94Taquicardia supina 12 96Hipotensión supina 33 97

Aumento de FC ≥ 30 lpm después de 1 minuto de bipedestación.

FOVEA (+) FOVEA (–)

• Edema Localizado - Dilatación venosa - Obstrucción venosa - Inflamación

!• Edema Generalizado

- Renal - Cardiaco - Cirrótico

• Linfedema - Traumático - Quirúrgico - Postrombótico - Tumoral

!• Mixedema

CARDIOVASCULARSIMULACIÓN EN SEMIOLOGÍA

Pulso Arterial

4r

SOPL

OS

CA

RD

IAC

OS

RESPIRATORIOSIMULACIÓN EN SEMIOLOGÍA

CONDENSACIÓN OBSTRUCCIÓN

O. PLEURALNEUMOTÓRAX

SÍNDROMES RESPIRATORIOS

CONDENSACIÓN

!V. VOCALES aumentadas

!SONORIDAD

matidez !

AUSCULTACIÓN crépitos, broncofonía,

soplo tubario*

!V. VOCALES

disminuidas !

SONORIDAD hipersonoridad

!AUSCULTACIÓN sibilancias y roncus

o silencio*

OBSTRUCCIÓN

!V. VOCALES

disminuidas !

SONORIDAD hipersonoridad

!AUSCULTACIÓN

MP disminuido

NEUMOTÓRAX

!V. VOCALES

disminuidas !

SONORIDAD matidez

!AUSCULTACIÓN

disminución MP

O. PLEURAL

* En derrames extensos, en el límite entre el derrame y el parénquima normal pueden haber hallazgos de condensación.

K2

THE NORMAL CXR • 5

Figure 2.3AP CXR (left image) and PA CXR (right image) of an adult male taken 1 day apart. Note the apparent difference in cardiac size and lung volumes and the loss of clarity in the apices.

Figure 2.4Annotated lateral CXR illustrating the anatomy.

Lateral• The better visualization of the mediastinal structures due to a high kV technique reduces the

necessity for routine lateral views.

• A lateral view provides clearer visualization of the area anterior to the mediastinum and posterior to the diaphragms and may help interpretation of an abnormality seen on a frontal view (Fig 2.4).

• If a low kV technique is used a lateral is necessary to image the areas behind the heart and hemi-diaphragms.

• Other pathology better appreciated on the lateral CXR is right middle lobe or lingularr collapse and/or consolidation, which may be missed on a frontal CXR due to the orientation of the X-ray beam (Fig 2.5).

10 • THE WHO MANUAL OF DIAGNOSTIC IMAGING

K2

Figure 2.12Left image shows mediastinal contours, the right image is a coronal reconstruction of the mediastinum from CT scanning; a- aortic outflow tract, b- right atrium, c- pulmonary artery outflow, d- left atrial appendage, e- left ventricle.

Figure 2.13The arrows mark the paraspinal lines representing the soft tissue that lies adjacent to the spine. On the right there is very little soft tissue and the line is very close ( 2 mm) from the spine. On the left the aorta courses down the anterior left aspect of the spine causing the paraspinal line to be further from the spine. The relevance of these lines is in the detection of paraspinal pathology such as tumours or spinal fracture causing haematoma. Bulging/widening of these lines suggests paraspinal pathology.

Mediastinal contour (Fig 2.12)

Paraspinal lines

10 • THE WHO MANUAL OF DIAGNOSTIC IMAGING

K2

Figure 2.12Left image shows mediastinal contours, the right image is a coronal reconstruction of the mediastinum from CT scanning; a- aortic outflow tract, b- right atrium, c- pulmonary artery outflow, d- left atrial appendage, e- left ventricle.

Figure 2.13The arrows mark the paraspinal lines representing the soft tissue that lies adjacent to the spine. On the right there is very little soft tissue and the line is very close ( 2 mm) from the spine. On the left the aorta courses down the anterior left aspect of the spine causing the paraspinal line to be further from the spine. The relevance of these lines is in the detection of paraspinal pathology such as tumours or spinal fracture causing haematoma. Bulging/widening of these lines suggests paraspinal pathology.

Mediastinal contour (Fig 2.12)

Paraspinal lines

K2

THE NORMAL CXR • 5

Figure 2.3AP CXR (left image) and PA CXR (right image) of an adult male taken 1 day apart. Note the apparent difference in cardiac size and lung volumes and the loss of clarity in the apices.

Figure 2.4Annotated lateral CXR illustrating the anatomy.

Lateral• The better visualization of the mediastinal structures due to a high kV technique reduces the

necessity for routine lateral views.

• A lateral view provides clearer visualization of the area anterior to the mediastinum and posterior to the diaphragms and may help interpretation of an abnormality seen on a frontal view (Fig 2.4).

• If a low kV technique is used a lateral is necessary to image the areas behind the heart and hemi-diaphragms.

• Other pathology better appreciated on the lateral CXR is right middle lobe or lingularr collapse and/or consolidation, which may be missed on a frontal CXR due to the orientation of the X-ray beam (Fig 2.5).

ABDOMENSIMULACIÓN EN SEMIOLOGÍA

•  Enf.%Biliar%•  Hepa..s%•  Cólico%Renal%•  Diver.culi.s%

•  Apendici.s%•  Torsión%Ovárica%•  PIP%•  Emb.%Ectópico%

•  Cólico%Renal%•  Bazo%(Injuria)%•  Diver.culi.s%

•  Torsión%Ovárica%•  Diver.culi.s%•  PIP%•  Emb.%Ectópico%

•  Obstrucción%I.%•  Apendici.s%•  ADA%•  EII%•  Gastroenteri.s%

•  Pancrea..s%•  Enf.%Biliar%•  Úlcera%Pép.ca%•  IAM%

CHAPTER 6 Ascites

67

sion is performed along radial spokes from the subcostalmargin downward toward the pelvis. The percussion noteis initially dull but changes sharply to a loud note at theborder of increased pelvic density. In the absence of ascites,the border is approximately 4.5 cm above the pelvic crest(the pelvic baseline). In patients with ascites, free fluidraises the demarcating border clearly above the pelvicbaseline. When the patient is supine, this clear line ofdemarcation is obliterated because the free fluid gravitatesto the flanks.

Although most of the physical examination for ascitesshould focus on the abdomen, extra-abdominal signs may

provide evidence for conditions associated with ascites. Phys-ical findings that may be useful by their presence or absenceinclude evidence of liver disease (eg, jaundice, spider angio-mas) or heart disease (eg, cardiac gallop).

ACCURACY OF HISTORY AND SYMPTOMS FOR ASCITES We examined the effect of medical history items on the proba-bility of ascites in male veteran inpatients (Table 6-2).9 Medicalhistories, obtained by internal medicine house staff, were com-pared with reference standard abdominal ultrasonographicfindings. Positive histories of hepatitis or heart failure gener-ated likelihood ratios (LRs) of 3.2 and 2.0, respectively. How-ever, alcoholism (positive LR [LR+], 1.4) or a history ofcarcinoma (LR+, 0.91) had little effect on the odds of ascites.

Other questions about the patient’s present illness may beeven more useful. In this same study, the patient’s symptomsof increased abdominal girth, weight gain, or ankle edemagave LR+ values of 4.2, 3.2, and 2.8, respectively. The absenceof increased abdominal girth (negative LR [LR–], 0.17) orankle swelling (LR–, 0.10) decreased appreciably the diag-nostic likelihood of ascites. For example, in a patient with alow pretest probability of ascites (<20%), the absence ofrecent ankle edema decreases the probability of ascites to lessthan 2.5%. Clearly, the patient’s medical history and currentsymptoms are valuable for at least 2 reasons. First, certainitems may suggest the presence or absence of ascites. Second,in patients suspected of having ascites, a focused physicalexamination for ascites is needed. The clinical history distin-guishes patients with high and low probabilities for ascites.Ascites is unlikely when patients report no increase inabdominal girth, and ascites is very unlikely in male patientswho report no history of recent ankle swelling.

PRECISION OF THE SIGNS FOR ASCITES Six gastroenterologists examined 50 hospitalized alcoholicpatients for the presence or absence of ascites. Their overall

Figure 6-1 Percussion Techniques for Detecting Ascites

A R E A O FD U L L N E S S

Gas-filled smallintestine loops

Bulging flank

A R E A O FT Y M PA N Y

Supine position

Examiner progressively percusses the abdomen beginning at the umbilicus moving toward the flanks, listening for the transition from tympany to dullness.

Examiner rolls the patient to the lateral recumbent position and repeats percussion. The area of dullness shifts to the dependent side and the area of tympany shifts to the top.

A Percussion for flank dullness

B Percussion for shifting dullness

A R E A O FT Y M PA N Y

AREA OF

DULLN

ESS

Lateral recumbentposition

Figure 6-2 Testing for a Fluid Wave

Fluid impulse

Tap

CHAPTER 6 Ascites

67

sion is performed along radial spokes from the subcostalmargin downward toward the pelvis. The percussion noteis initially dull but changes sharply to a loud note at theborder of increased pelvic density. In the absence of ascites,the border is approximately 4.5 cm above the pelvic crest(the pelvic baseline). In patients with ascites, free fluidraises the demarcating border clearly above the pelvicbaseline. When the patient is supine, this clear line ofdemarcation is obliterated because the free fluid gravitatesto the flanks.

Although most of the physical examination for ascitesshould focus on the abdomen, extra-abdominal signs may

provide evidence for conditions associated with ascites. Phys-ical findings that may be useful by their presence or absenceinclude evidence of liver disease (eg, jaundice, spider angio-mas) or heart disease (eg, cardiac gallop).

ACCURACY OF HISTORY AND SYMPTOMS FOR ASCITES We examined the effect of medical history items on the proba-bility of ascites in male veteran inpatients (Table 6-2).9 Medicalhistories, obtained by internal medicine house staff, were com-pared with reference standard abdominal ultrasonographicfindings. Positive histories of hepatitis or heart failure gener-ated likelihood ratios (LRs) of 3.2 and 2.0, respectively. How-ever, alcoholism (positive LR [LR+], 1.4) or a history ofcarcinoma (LR+, 0.91) had little effect on the odds of ascites.

Other questions about the patient’s present illness may beeven more useful. In this same study, the patient’s symptomsof increased abdominal girth, weight gain, or ankle edemagave LR+ values of 4.2, 3.2, and 2.8, respectively. The absenceof increased abdominal girth (negative LR [LR–], 0.17) orankle swelling (LR–, 0.10) decreased appreciably the diag-nostic likelihood of ascites. For example, in a patient with alow pretest probability of ascites (<20%), the absence ofrecent ankle edema decreases the probability of ascites to lessthan 2.5%. Clearly, the patient’s medical history and currentsymptoms are valuable for at least 2 reasons. First, certainitems may suggest the presence or absence of ascites. Second,in patients suspected of having ascites, a focused physicalexamination for ascites is needed. The clinical history distin-guishes patients with high and low probabilities for ascites.Ascites is unlikely when patients report no increase inabdominal girth, and ascites is very unlikely in male patientswho report no history of recent ankle swelling.

PRECISION OF THE SIGNS FOR ASCITES Six gastroenterologists examined 50 hospitalized alcoholicpatients for the presence or absence of ascites. Their overall

Figure 6-1 Percussion Techniques for Detecting Ascites

A R E A O FD U L L N E S S

Gas-filled smallintestine loops

Bulging flank

A R E A O FT Y M PA N Y

Supine position

Examiner progressively percusses the abdomen beginning at the umbilicus moving toward the flanks, listening for the transition from tympany to dullness.

Examiner rolls the patient to the lateral recumbent position and repeats percussion. The area of dullness shifts to the dependent side and the area of tympany shifts to the top.

A Percussion for flank dullness

B Percussion for shifting dullness

A R E A O FT Y M PA N Y

AREA OF

DULLN

ESS

Lateral recumbentposition

Figure 6-2 Testing for a Fluid Wave

Fluid impulse

Tap

CHAPTER 46 Splenomegaly

607

costal margin (Figure 46-2). In a normal examination, a fullstomach can result in initial percussion dullness, but as per-cussion continues along the perpendicular line tympany thenbecomes present because of the overlying lung. Splenomeg-aly is diagnosed when the dullness is present more than 8 cmabove the costal margin.8,9

2. Percussion by Castell MethodThe patient is placed in the supine position. Percussion iscarried out in the lowest intercostal space in the left anterioraxillary line in both expiration and full inspiration (Figure46-3). In a normal examination result, the percussion noteremains resonant throughout this maneuver. Splenomegalyis diagnosed when the percussion note is dull or becomesdull on full inspiration.10

3. Percussion of Traube Space The patient is supine, with the left arm slightly abducted foraccess to the entire Traube space (after its description byLudwig Traube, who ascribed its disappearance to pleuraleffusion, not an enlarged spleen),11 defined by the sixth ribsuperiorly, the midaxillary line laterally, and the left costalmargin inferiorly (Figure 46-3). With the patient breathingnormally, this triangle is percussed across 1 or more levelsfrom its medial to lateral margins. Normal percussion yieldsa resonant or tympanitic note. Splenomegaly is diagnosedwhen the percussion note is dull.12

Palpation Although many methods for palpation of the spleen havebeen reported in clinical texts and journals, only 3 have hadtheir precision or accuracy documented in the clinical litera-ture and will be described herein. Relaxation of the abdomi-nal wall is a prerequisite for successful palpation and can beassisted by both the examiner (friendly, gentle, and warmhands) and the patient (flexed, supported knees).

Two-Handed Palpation With Patient in Right Lateral Decubitus With the patient in the right lateral decubitus position, theexaminer's left hand is slipped from front to back around theleft lower thorax, gently lifting the left lowermost rib cageanteriorly and medially. The tips of the fingers of the exam-iner's right hand are pressed gently just beneath the left costalmargin, and the patient is asked to take a long, deep breath asthe palpation of a descending spleen is sought. If none is felt,the procedure is repeated, lowering the right hand 2 cmtoward the umbilicus each cycle, until the examiner is confi-dent that a massive spleen has not been missed. (Someauthorities suggest starting palpation over the lower abdo-men and moving up toward the costal margin.) The sameprocedure can be carried out with the patient supine.

One-Handed Palpation With Patient Supine This method is identical to the former one, except that nocounterpressure is applied by the left hand to the rib cage.With the patient supine, the tips of the fingers of the exam-iner's right hand are pressed gently just beneath the left costalmargin, and the patient is asked to take a long, deep breath asthe palpation of a descending spleen is sought. If none is felt,

Figure 46-2 Nixon Method to Detect SplenomegalyNixon method of percussion requires that the patient be placed in the right lateral decubitus position. Percussion is started at the midpoint of the left costal margin and proceeds perpendicularly. Splenomegaly is diagnosed when the dullness is present more than 8 cm above the costal margin.

Figure 46-3 Percussion in Traube Space and at Castell Spot to Detect SplenomegalyTraube space is defined by the sixth rib superiorly, the left anterior axillary line laterally, and the costal margin inferiorly. Castell spot is located at the junction of the lowest intercostal space and the left anterior axillary line.

Left costalmargin

Midaxillary line

8 cm

Right lateral decubitus positionExaminer begins percussion at midpoint of left costal margin in a perpendicular direction towards the midaxillary line.

Positive indication: dullness is present more than 8 cm above the costal margin.

Spleen

Enlarged spleen

Left costalmargin

Diaphragm(expiration)

Anterioraxillary line

Castell spot

Supine position

Rib 6

Traubespace

Diaphragm(inspiration)

Positionduringexpiration

Positionduringinspiration

Positionduringexpiration

Using Castell’s method, the examiner percusses at the level of Castell’s spot in both expiration and full inspiration.

Positive indication: percussion is dull or becomes dull on full inspiration.

Using Traube’s space, the examiner percusses across the space at one or more levels from medial to lateral margins while patient breathes normally.

Positive indication: percussion is dull.

Splenomegaly

Normal

Positionduringinspiration