Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2920_Библиотеки_им_академика_М_И_Перельмана

duces ataxia, but when it does, the ataxia is usually unilateral; bilateral ataxia suggests trau­matic hemorrhage. Associated signs and symp­toms include vomiting, headache, decreased LOC, irritability, and focal neurologic defects. If the cerebral hemispheres are also affected, focal or generalized seizures may occur.

of symptoms, a life-threatening neuropathy can produce sensory ataxia. Diphtheria can be ac­companied by fever, paresthesia, and paralysis of the limbs and possibly the respiratory muscles.

usually begins with a mild viral infection, fol­lowed by peripheral nerve involvement and, rarely, sensory ataxia. It may also cause ascend­ing paralysis and respiratory distress.

thiamine deficiency, Wernicke’s encephalopathy produces gait ataxia and, rarely, intention tremor or speech ataxia. With severe ataxia, the patient may be unable to stand or walk. Ataxia decreas­es with thiamine therapy. Associated signs and symptoms include nystagmus, diplopia, ocular palsies, confusion, tachycardia, exertional dysp­nea, and orthostatic hypotension.

In children, ataxia occurs in acute and chronic forms and results from congenital or acquired disease. Acute ataxia may stem from febrile in­fection, brain tumors, mumps, and other disor­ders. Chronic ataxia may stem from Gaucher’s disease, Refsum’s disease, and other inborn er­rors of metabolism.

When assessing a child for ataxia, consider his level of motor skills and emotional state. Your examination may be limited to observing the child in spontaneous activity and carefully questioning his parents about changes in his motor activity, such as increased unsteadiness or falling. If you suspect ataxia, refer the child for a neurologic evaluation to rule out a brain tumor.

Refer the child to special education services, rehabilitation centers, and support groups. Provide him with emotional support during the frequent medical evaluations required for athetosis.

An aura is a sensory or motor phenomenon, idea, or emotion that marks the initial stage of a seizure or the approach of a classic migraine

After eliciting a positive Babinski’s reflex, evalu­ate the patient for other neurologic signs. Evalu­ate muscle strength in each extremity by having the patient push or pull against your resistance. Passively flex and extend the extremity to assess muscle tone. Intermittent resistance to flexion and extension indicates spasticity, and a lack of resistance indicates flaccidity.

familial disorder that may produce bilateral Babinski’s reflex. Accompanying it are high­arched feet, hypoactive DTRs, hypotonia, ataxia, head tremor, weakness, and paresthesia.

ki’s reflex may occur as the result of primary corticospinal damage or secondary injury asso­ciated with increased intracranial pressure. Hy­peractive DTRs and spasticity commonly occur with Babinski’s reflex. The patient may also have weakness and incoordination. Other signs and symptoms vary with the type of head trau­ma and include headache, vomiting, behavior changes, altered vital signs, and decreased LOC with abnormal pupillary size and response to light.

The onset, location, and distribution of pain and its response to activity and rest provide im­portant clues about the cause. Pain may be acute or chronic and constant or intermittent. It may remain localized in the back or radiate along the spine or down one or both legs. Pain may be exacerbated by activity—usually, bend­ing, stooping, or lifting—and alleviated by rest, or it may be unaffected by either.

ISTORY AND PHYSICAL EXAMINATION

Next, perform a thorough physical examina­tion. Observe skin color, especially in the pa­tient’s legs, and palpate skin temperature. Pal­pate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Ob­serve the patient’s posture if pain doesn’t pro­hibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, back­ward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolum­bar spine for point tenderness. Then ask the pa­tient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles

Life-threatening dissection of an abdominal aortic aneurysm may initially cause low back pain or dull abdominal pain, but it usually pro­duces constant upper abdominal pain. A pulsat­ing abdominal mass may be palpated in the epi­gastrium; after rupture, though, it no longer pulsates. Aneurysm dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, mild to moderate ten­derness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) ap­pear if blood loss is significant.

spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also char­acteristic. This disorder can cause local tender­ness, fatigue, fever, anorexia, weight loss, and occasionally iritis.

pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or

sacral pain and severe cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It’s accompanied by constipation, abdominal tenderness, dysmenorrhea, and dys­pareunia.