2011-07-medicine-approach to patient with dermatologic diseases

8/6/2019 2011-07-Medicine-Approach to Patient With Dermatologic Diseases

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General Instructional Objectives:

y To know how to approach a patient with skin disorder (Dermatology is a visual specialty andaccurate descriptions are necessary for record keeping).

Specific Instructional Objectives:

y In medicine, the traditional approach is to take the history, before doing the PE, in dermatology,some prefer to reverse the order.

Dermatology

y Purely a visual sciencey a dermatologist has to be observant and visuallyliteratey theres a pattern of recognition and hence, able togive a diagnosis by just looking at the lesionsy difference lies in the fact that there is some lesions that occur in a particular diseasey disadvantage is that some tend tooverlook their lesion because the manifestation is subtle and will

only seek consult when their lesion/disease is already bad

Remember that the following is done after history taking but sometimes PE is done before history taking

since its a visual science.

I. To know how to describe the skin lesions just like in any PE must remember the use of4 maneuvers:A. Inspection

o The most common maneuver used in dermatology1. Type of skin lesion: (this was discussed in more details in PD derma and will not be

included in this transcription.Thank you!)y Primary

o directly from conditiono Pls note the following:


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7. Note the distributiony Extent of involvement:

i. isolated, localizedo present in onlyone parto eg, feet, hands, head, etc.

ii. generalizedo allover bodyo associated with systemic conditiono May be due to hypersensitivity from a food ingested or drugo Also seen in viral diseases

ex.Measles, Varicella, infantile childhood diseasesy Symmetry:

o Is it unilateralor bilateral?o eg, herpes zoster follows dermatomal pattern and is usually asymmetrical.

y Characteristic pattern:i. intertriginous

o flexural areas of body that are usually moisto ex. neck areas, axilla, inguinalo eg, intercrural between digitso this is seen in fungal infection

ii. exposed areaso lesions seen in the dorsal aspect of forearm but the ventral aspect is

clear; also seen on face and neck

o may be due to photo contacto phototoxic

Some drugs result to this characteristic pattern after exposureto the sun

ex.Gout and HPNo Photocontact dermatitis Same manifestation after exposure to the sun and this is due to

soap or lotion(especiallywhiteninglotions)

iii. dermatomesB. Palpation:

y note the consistency1. Soft:

y lip-like consistency2. Doughy:

y nose-like consistencyy caritilaginous

3.

Hard:y forehead-like consistency

C. Percussiony Rarely usedy Very tedious

D. Auscultation:y bruit in hemangioma

o sound of the blood rushing in and out of the vesselsII. Know how to correlate the findings with:

A. HPI in the standard format1. Epidemiology:

y Agey Sexy Race


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2. Duration:y Since when?y Acute- Less than 6 weeksy Chronic- more than 6 weeksy Recurrent (pabalik-balik)

oex. atopic dermatitis

hikasabalat3. Evolution:

y Varicella(chicken pox)will have following pattern: maculevesicle on erythematousbasepustulecrusted

y Take note of the site and manner of spread4. Symptoms

y Referable to skini. Pruritis

o Common complainii. Pain

o Due to bacterial infection (ex.Furuncle, abscess)iii. Paresthesiaiv. Anesthetic:

o hypopigmentation patch that is anesthetic- r/o Hansens Disease note that Hansens disease affects the peripheral nerves

y Constitutionali. Generalized macula-papular rash

o r/o viral exanthems, measles, or drug reactiono usually start from face going downo Note that in viral infection, the rash usually disappearswithin 2-3 days,

when it reaches the foot, the fever should disappear

o Some patient deviates from the regular evolution of symptoms due toother reasons such as reactions to drugs

ii. Feveriii. Cough

B. Past Historyy Did patient try new detergent, perfume, soap?y Is it occupation related?y Note the recurrence of hand dermatitis and eczema that may be due to the soap the

patient is usingor excessive use ofgloves leading to fungal infection

C. ReviewofSystemsD. Family History/Social History

1. r/ogenetic diseases2. Occupational hazards3. STDsE. Laboratory and Special Examinations1. Dermatopathology: usually a skin biopsy is done

y Light microscopy:i. Site

ii. Processiii. cell types

y Immunofluorescence: for autoimmune diseasesy Special techniques: stains, transmission, electron microscopy, etc.

2. Microbiologic examination of skin material: scales, crusts, exudates, or tissuey Direct microscopic examination of skin

i. F

or yeast and fungus:10%

KOH preparationo Scrape the edge/border of the lesion

This is usually the active site of fungal proliferation (tineacorporis)o lyses keratin for better viewingof dermatophyteso Tineaversicolor: should see spaghetti and meatballs

Recall: causative agent:Malassezia furfuro Candida: spores only are viewed


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ii. For bacteria:o Lesions with pus

Recall: not all pus has bacteriao Grams stain

iii. For virus: Tzanck smearo because virus usually resides at base of vesicleo search for multinucleated cello only indicates that there is a viral infection and willNOT specify the type

of viral infection

iv. For spirochetes: dark field examinationv. For parasites: scabies mite from a burrow

y Culture:i. Bacterial

ii. Viraliii. Parasiticiv. Mycologic

3. Laboratory examinations of bloody Bacteriologic: culturey Serologic: ANA, STS, serologyy Hematologic: Hematocrit or hemoglobin, cells, differential smeary Chemistry: fasting blood sugar, blood urea nitrogen, creatinine, liver function, and

thyroid function tests

y Imaging (X-ray, CT scan, MRI, ultrasound)o rarely done

y Urinalysisy Stool examination (for occult blood, eg, in vasculitis syndromes; for ova and

parasites; for porphyrins)

y Woods lamp examinationi. Emits 300 nm oflight(UV) and usually shows fluorescence when put on a lesions

ii. Urine: pink orange fluorescence in porphyria cutaneatardaiii. Freckles- darken in woods lampiv. Erythrasma- coral red fluorescence; seen in inguinal region(intertriginous area);

causative agent: Corynebacterium

y Patch testingo Dealingwith contact dermatitiso Testing to different antigen to find out the cause of allergy

Fig 1.patch testing


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Fig 2.secondary lesions: Minimal silvery scales

on bilateral elbowspsoriasis

Fig 3: marked silvery scales along

hairlinepsoriasis

Fig, 4.Macule and Patch at the back

Fig 5.macules and patches, diffuse, found on

back, herald patch, Christmas tree

patternpityriasisrosea

Fig. 6. Papules on digitated surfaceVerruca

(Coalescent of this will form plaque)

Fig 7.papule, shiny and smooth surface,

umbilicatedMolloscumcontagiosum

Recall: umbilicated- crated like


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Fig 8.Grouped vesiclesVaricella Zoster

Fig. 9. Group vesicles-->Herpes simplex

Fig. 10. Bullous impetigo

Fig. 11 Vesicle

Fig. 12.Vesicles

Fig. 13.polycyclic lesion, dyskeratotic

nailonychomycosis and tineacorporis

Fig. 14.polycyclic lesion

granuloma annulare


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Fig, 15.tineaversicolor(an-an) caused byM.

furfur that lodge on the stratum corneum; it

gives out a metabolic acid that cause the

hypopigmentation. Pls note that in fair

complexion, it gives a hyperpigmented

appearance and in dark skinned it is seen as

hypopigmented

Fig. 16.tineaversicolor but note skin is

hyperpigmented (common in Caucasian skin

type, whereas ethnic skin types may result in

hypopigmented)

Fig. 17.Rubella, r/o drug reaction by relyingon

history.Note that drug reaction can occur alongwith the virus infection, acutelyor delayed.

Fig. 18.Scarlet fever

Fig. 19.Recent chicken pox, note the raindrop

on rose petalVaricella Zoster

Fig. 20. Varicella with crusting

Evolution: Erythema macule vesiclecrusting


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Fig. 21.Macule ofleprosy. Test for hyposthesia.

Fig. 22.macule ofleprosy

Fig. 23.angioedema.

Medical emergency as it

sometimes involves edema of the

airway.(above) and normal (below)

Fig. 24. Bulla


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Fig. 25.Vitiligo.Order KOH to r/o tinea. Note

hypopigmented areas.

Recall: vitiligo is an autoimmune disease

Fig. 26. Papule

Fig. 27.Leprosy

Fig. 28.this is a Flaccid (soft) bullasuperficial(Note that tense bullae deeper involvement)

Fig. 29 confluent patches

End of transcription

Nakakabaliwitranxsi Doc! Hahahaha!I tried my

best! Good luck batch mates!

Fear not for I am with you: be not dismayed,for I am your God: Iwill strengthen you, Iwill

help you, Iwill uphold you with My righteous

right hand. Isaiah 41:10

2011-07-medicine-approach to patient with dermatologic diseases

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