FEVER, HYPERTHERMIA AND HYPOTHERMIA

Physical Examination of the Skin

The diagnosis and treatment of dermatologic disease rests on the physicians ability to recognize the basic and sequential lesions of the skin

Skin lesions: visible and accessible Advantage: since it is accessible, an intervention such as a biopsy can be performed easily

Disadvantage: There are thousands of skin diseases that for some (especially first-timers) would look the same (thus, one must be keen enough to distinguish) Physicians: must learn to read skin for clues to underlying systemic disease

** sometimes a history is no longer needed in order to make a diagnosis

Detailed Examination of the Integumentary System

Skin

Hair

Nails

Mucous membranes

Major Characteristics of Skin Lesions1. Color ( a factor of 4 pigmentsa. Melanin (brownish hue)

b. Oxyhemoglobin (reddish/erythematous hue)

c. Deoxyhemoglobin (bluish hue)

d. Carotene (yellowish hue)2. Consistency and feel of lesion(via palpation) Soft, doughy, firm, hard, infiltrated, dry, moist, mobile, tender

Abnormalities in Skin ColorBrownish Discoloration Caf au lait spots (increased melanin production) Neurofibrimatosis/von Recklinghausens Disease, von Hippel Lindau disease, McCune-Albright syndrome Addisons disease (deposition of melanin in the mucous membrane) Can be found in normal people

Bronze, Dark or Grayish Black Discoloration Hemochromatosis

Iron deposition in pancreas e.g., DM

Yellow Skin Discoloration /Jaundice

Inc serum bilirubin

RBC hemolysis ( yellowish skin and sclera (most prominent discoloration) Anemia

Yellow tinge sallow appearance

Best seen in areas where stratum corneum is thinnest (nails, lips, mucous membrane & palpebral conjunctiva)Hypopigmentation - Vitiligo

Acquired /autoimmune loss of melanin pigment Related to other autoimmune diseases such as Hashimotos Thyroiditis, hyperthyroidism, DM, pernicious anemia

Chalk-white discolorationErythema (Redness)

Increased cutaneous flow

Most commonly a component of inflammation

E.g., Drug eruption, viral exanthema (with fever, malaise, joint pains, lymphadenopathy)

To distinguish obtain drug intake history (2-4 weeks)

Drugs that may cause Discoloration Clofazimin (Leprosy drug) Dark brown Main lesion discoloration Quinacrine (antimalarial) Yellow

Amiodarone (antihypertensive, antiarrhythmic) Bluish Minocycline (for severe acne) Bluish Turgor Rapid assessment of tissue hydration

Lift a fold of skin and note ease with which it is moved (mobility) & speed with which it returns to place (turgor) Faster return means better hydration for the patient

Increase in turgor if it remains elevated Hair Facial, axillary & pubic hairs dependent on presence of sex hormones, thus, affected by sex & age of patient

If with excessive hair, suggestive of endocrine disease Alopecia areata - baldingNails May provide a clue to certain systemic disease

Psoriasis vulgaris (oil spots, onycholysis, loosening of nail, crumbling of nail, little pits on nails) Renal disease Half & half nails (proximal white & distal pink/brown)

Hemochromatosis

Spoon nails (koilonychia)

Due to faulty iron metabolism

Pulmonary, cardiac, hepatic & GIT disease

Clubbing (more common in cardiac diseases)Four Cardinal FeaturesType of Lesion Primary or Secondary

E.g., macule, papule, nodule, vesicleShape and Arrangement of Lesions Provide Clues to the DiagnosisLinear

Phytodermatitis- plant dermatitis Allergic reaction to plant particles usually seen in exposed areas of gardeners/housewivesIris/Target bulls eye or iris lesions Erythema on periphery and central portion (papule or vesicle) of discoloration violet or purple color Steven Johnsons Syndrome

Pathognomonic of erythema multiforme

Herpetiform Herpes simplex virus

Annular / Ring like

Fungal infections

Tinea capitis/ tinea corporisArciform arc-like

Polycyclic different shapes (seen in granuloma annulare - HIV) Grouped lesions xanthomas (cholesterol deposits that can be yellowish or reddish)

Round

Oval

Vesicles in a band on dermatome/ zosteriform Herpes zoster

Only one side of body

50-70%- found in trunk

Multiple coalescing vesicles; erythematous lesion

Umbilicated looks like an umbilicus (presence of indentation in the middle part

Distribution

Extent of involvement circumscribed, regional, generalized, universal (*generalized entire body) What percent of the body surface is involved? (entire palm is roughly 1%)

Pattern symmetry, exposed areas, sites of pressure, intertriginous areas * pressure urticaria

* intertriginous fungal/candidal infections ( axillary, intramammary, inguinal areas Characteristic location

Flexural e.g., childhood atopic dermatitis

Extensors

Intertriginous areas

Glabrous areas without hair

Palms and soles (e.g., scabies)

Dermatomal

Trunks

Lower extremities

Exposed areasBasic/Primary Skin Lesions- Most of the time, patient does not have basic lesion anymore due to late consultationMacule

Circumscribed, flat lesion

Differs in color

Size < 1 cm

Any shape Sometimes with fine scaling:

Maculosquamous Hyperpigmented Ephelides/freckles

Tinea vesicolor freckles, flat moles, tattoos, port-wine stains, and the rashes of rickettsial infections, rubella, measles, and some allergic drug eruptions

Patch

Circumscribed, flat lesion

Size > 1cm

Any shape

Fine scaling Is a large macule (coalescence of many macules) E.g., vitiligo

Papule

Small (1cm

May be formed by confluence of papules

Lichenification: due to rubbing (kalyo?) Psoriasis vulgaris and granuloma annulareNodule

Palpable, solid, round/oval lesion

Deeper than papule

Depth (not diameter) distinguishes it from papule

Hard, soft, movable, fixed, etc Neurofibromatosis

nevi, warts, lichen planus, insect bites, seborrheic and actinicWheal

Hives/uticaria

Evanescent flat/ rounded papule or plaque, pink (evanescent meaning can travel from one location to another within 24 hours) Epidermis- unaffected

Borders unstable

Allergic response

dermographism when there is scratching ( an elevated lesion will occur at the site due to histamines effect on the skin Warm

Skin asthma, ectopic dermatitisVesicle

0.5 - 0.5 1cm, contains fluid Burns, insect bites (for allergic patients); pemphigus vulgaris (autoimmune disease, needs high dose of corticosteroids)Pustule

Hallmark of infection Circumscribed raised lesion with purulent exudates

Pus

Leukocytes, cellular debris

Furuncle (deep necrotizing folliculitis) Deep necrotizing folliculitis

Carbuncle

Coalescing furuncles*folliculitis ( furuncle ( carbuncle * increase incidence of folliculitis during the summer ( heat aggravates Staph infections

Secondary LesionsCrust

Results when serum, blood or purulent exudates dries on the skin surface

Characteristic of injury & pyogenic infections

Yellow dried serum

Green/ yellow green purulent exudates

Brown/ dark red- blood

Honey-colored impetigo

Fissure

Linear cleavages or cracks in the skin

Painful Anal; angles of mouth, heelsExcoriation

Superficial excavations of epidermis

May be linear or punctuate

Result from scratching Atopic dermatitis (childhood 2-7 years old)Lichenification

Thickening of the skin as a consequence of persistent, prolonged, vigorous rubbing

Accentuation of normal skin markings

Hyperpigmentation

Induration E.g., Lichen Simplex ChronicusErosion

Moist circumscribed lesion resulting from loss of epidermis

Rupture of vesicles and bullae

Do not scar unless infectedAtrophy

Diminution or thinning of the skin Scleroderma autoimmune

Stria GravidumUlcer

Hole or defect that remains after an area of epidermis and part of dermis is destroyed

Dermis heals with scarring Venous ulcer medial mallelous; presents with varocities in upper legs Decubitus ulcers in prolonged immobility/bedrestScar

Fibrous tissue replacement

Consequence of healing at site of prior ulcer or wound

Hypertrophic or atrophic Hypertrophy remain in the area

Keloid claw-like spread to adjacent areas

Atrophic depression

Scales

Abnormal shedding or accumulation of epidermis in perceptible flakes Psoriasis

Keratotic plug upper arm and thigh Pityriasiform branny

Psoriasiform micaceous

Icthyosiform fish scales

Keratotic horny masses

Follicular keratotic plugs

Clinical TestsDimple Sign Dermatofibroma Apply pressure ( feels like a button/depression [(+) test]Nikolskys sign

Sheetlike removal of epidermis by gentle traction

positive when slight rubbing of the skin results in exfoliation of the skin's outermost layer and gravitation of fluid towards the opposite side

if intradermal (+); if subdermal (-) Pemphigus vulgaris/ TEN

Dariers sign

Development of urticarial wheel in uticaria pigmentosa Stroking of skin ( development of urticariaAuspitz sign

Pinpoint bleeding after removal of scale in psoriasisAdditional Slides: (Puro pictures to e, kaso di nya binigay ppt..)

Leprosy tuberculoid only one lesion Chicken pox vesicle ( umbilicated ( ulcerated

Foot, Hand , Mouth Disease- viral lesion

Herald Patch

Tinea capitis dirty looking scalp

General P.E.

Indicated by clinical presentation and differential diagnosis

Pay particular attention to vital signs, lymphadenopathy, hepatomegaly, splenomegaly

Summary

Dermatological diagnosis is based primarily on visual inspection

Use magnifying glass, oblique lighting and woods lamp

Palpation, diascopy, scratching of lesions

Provides further clues

Combine PE with clues from the history to come up with diagnosis

Approach to Dermatologic Patient There are hundreds of cutaneous disease

A disease entity may have different clinical appearances

Skin diseases are dynamic and may evolve in morphology

Obtain a brief history from the patient

NOTE:

Duration when did it start?

Rate of onset how did it start?

how have lesions changed?

Location where did it start?

how did it spread?

Brief History Previous episodes has something similar occurred before?

Family history

Allergies, medical history

Occupation,, hobbies, travel, exposure

Previous treatments

Review of systems

Determine the extent of the eruption by having the patient disrobe completely under good lighting

Determine the primary lesion

Determine the nature of the secondary lesion

Determine the distribution of the lesion

Formulate a differential diagnosis

Special Procedure Skin Biopsy

Punch biopsy disposable

2-10mm diameter

Punch thru layers, making sure to include all up to fat area

Apply local anesthetic

Gram stain

Crusts, scales, exudates

Potassium hydroxide examination

For yeast and fungi

10% KOH causes separation of epidermal cells, allows visualization of hyphae/spores Tinea versicolor spaghetti and meatballs appearance Tzanck smear

Vesicular and bullous lesions

Direct smear of the floor of lesion to look for giant multinucleated cells

Woods light examination

Filtered UV light

Urine-porphyria

Hair and skin changes in pigmentation, fluorescence

Patch tests

Document sensitivity to a substance or antigens Diascopy

Differentiates vasculitis(blanching absent) from erythema (blanching present)References:

Lecture and Notes from Dr. Medel

Ultimate Mafia Trans

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