Subject: IM/PD Topic: Physical Examination: Approach to Patient with Dermatologic Diseases Lecturer: Dr.

Castillo Date of Lecture: July 15, 2011 Transcriptionist: all for love! Ha! Pages: 9
General Instructional Objectives: y To know how to approach a patient with skin disorder (Dermatology is a visual specialty and accurate 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 science y a dermatologist has to be observant and visually literate y there s a pattern of recognition and hence, able to give a diagnosis by just looking at the lesions y difference lies in the fact that there is some lesions that occur in a particular disease y disadvantage is that some tend to overlook 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 it s a visual science. I. To know how to describe the skin lesions just like in any PE must remember the use of 4 maneuvers: A. Inspection o The most common maneuver used in dermatology 1. 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 condition o Pls note the following:  <1 cm is a macule [their standard]  < 2 cm is a macule [Harrison] y secondary o modification of a primary lesion, arising from a primary lesion, etc. 2. Note the shape or configuration of individual lesion o oval, round, etc. 3. Note the arrangement of multiple lesion: y Grouped: i. Herpetiform ii. Linear o Seen in contact dermatitis iii. serpiginous o snake-like y Disseminated o scattered, discrete, diffuse 4. Note the size (Note: Doc mentioned that Harrison s will use a reference of 2 cm to distinguish between patch and plaques) 5. Note the color o Red, black, brown 6. Note the surface: y Smooth y Interdigitated o Rough surface o Finger-like projections o eg, wart

SY 2011-2012

7. Note the distribution y Extent of involvement: i. isolated, localized o present in only one part o eg, feet, hands, head, etc. ii. generalized o all over body o associated with systemic condition o May be due to hypersensitivity from a food ingested or drug o Also seen in viral diseases  ex. Measles, Varicella, infantile childhood diseases y Symmetry: o Is it unilateral or 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 moist o ex. neck areas, axilla, inguinal o eg, intercrural between digits o this is seen in fungal infection ii. exposed areas o 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 contact o phototoxic  Some drugs result to this characteristic pattern after exposure to the sun  ex. Gout and HPN o Photocontact dermatitis  Same manifestation after exposure to the sun and this is due to soap or lotion(especially whitening lotions) iii. dermatomes B. Palpation: y note the consistency 1. Soft: y lip-like consistency 2. Doughy: y nose-like consistency y caritilaginous 3. Hard: y forehead-like consistency C. Percussion y Rarely used y Very tedious D. Auscultation: y bruit in hemangioma o sound of the blood rushing in and out of the vessels II. Know how to correlate the findings with: A. HPI in the standard format 1. Epidemiology: y Age y Sex y Race

B.

C. D.

E.

2. Duration: y Since when? y Acute- Less than 6 weeks y Chronic- more than 6 weeks y Recurrent ( pabalik-balik ) o ex. atopic dermatitis hikasabalat 3. Evolution: y Varicella(chicken pox) will have following pattern: macule vesicle on erythematous base pustule crusted y Take note of the site and manner of spread 4. Symptoms y Referable to skin i. Pruritis o Common complain ii. Pain o Due to bacterial infection (ex. Furuncle, abscess) iii. Paresthesia iv. Anesthetic: o hypopigmentation patch that is anesthetic- r/o Hansen s Disease  note that Hansen s disease affects the peripheral nerves y Constitutional i. Generalized macula-papular rash o r/o viral exanthems, measles, or drug reaction o usually start from face going down o Note that in viral infection, the rash usually disappears within 2-3 days, when it reaches the foot, the fever should disappear o Some patient deviates from the regular evolution of symptoms due to other reasons such as reactions to drugs ii. Fever iii. Cough Past History y 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 using or excessive use of gloves leading to fungal infection Review of Systems Family History/Social History 1. r/o genetic diseases 2. Occupational hazards 3. STD s Laboratory and Special Examinations 1. Dermatopathology: usually a skin biopsy is done y Light microscopy: i. Site ii. Process iii. cell types y Immunofluorescence: for autoimmune diseases y Special techniques: stains, transmission, electron microscopy, etc. 2. Microbiologic examination of skin material: scales, crusts, exudates, or tissue y Direct microscopic examination of skin i. For yeast and fungus: 10% KOH preparation o Scrape the edge/border of the lesion  This is usually the active site of fungal proliferation (tineacorporis) o lyses keratin for better viewing of dermatophytes o Tineaversicolor: should see spaghetti and meatballs  Recall: causative agent: Malassezia furfur o Candida: spores only are viewed

For bacteria: o Lesions with pus  Recall: not all pus has bacteria o Gram s stain iii. For virus: Tzanck smear o because virus usually resides at base of vesicle o search for multinucleated cell o only indicates that there is a viral infection and will NOT specify the type of viral infection iv. For spirochetes: dark field examination v. For parasites: scabies mite from a burrow y Culture: i. Bacterial ii. Viral iii. Parasitic iv. Mycologic 3. Laboratory examinations of blood y Bacteriologic: culture y Serologic: ANA, STS, serology y Hematologic: Hematocrit or hemoglobin, cells, differential smear y 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 Urinalysis y Stool examination (for occult blood, eg, in vasculitis syndromes; for ova and parasites; for porphyrins) y Wood s lamp examination i. Emits 300 nm of light(UV) and usually shows fluorescence when put on a lesions ii. Urine: pink orange fluorescence in porphyria cutaneatarda iii. Freckles- darken in wood s lamp iv. Erythrasma- coral red fluorescence; seen in inguinal region(intertriginous area); causative agent: Corynebacterium y Patch testing o Dealing with contact dermatitis o Testing to different antigen to find out the cause of allergy

ii.

Fig 1.patch testing

Fig 2.secondary lesions: Minimal silvery scales on bilateral elbows psoriasis

Fig 5.macules and patches, diffuse, found on back, herald patch, Christmas tree pattern pityriasisrosea

Fig 3: marked silvery scales along hairline psoriasis

Fig. 6. Papules on digitated surface Verruca (Coalescent of this will form plaque)

Fig, 4. Macule and Patch at the back

Fig 7.papule, shiny and smooth surface, umbilicated Molloscumcontagiosum Recall: umbilicated- crated like

Fig. 12.Vesicles Fig 8. Grouped vesicles Varicella Zoster

Fig. 9. Group vesicles-->Herpes simplex

Fig. 13.polycyclic lesion, dyskeratotic nail onychomycosis and tineacorporis

Fig. 10. Bullous impetigo

Fig. 14.polycyclic lesion granuloma annulare

Fig. 11 Vesicle

Fig, 15.tineaversicolor( an-an ) caused by M. 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. 18. Scarlet fever

Fig. 19. Recent chicken pox, note the raindrop on rose petal Varicella Zoster

Fig. 16.tineaversicolor but note skin is hyperpigmented (common in Caucasian skin type, whereas ethnic skin types may result in hypopigmented)

Fig. 20. Varicella with crusting Evolution: Erythema macule vesicle crusting

Fig. 17.Rubella, r/o drug reaction by relying on history. Note that drug reaction can occur along with the virus infection, acutely or delayed.

Fig. 21. Macule of leprosy. Test for hyposthesia.

Fig. 23.angioedema. Medical emergency as it sometimes involves edema of the airway.(above) and normal (below)

Fig. 22.macule of leprosy

Fig. 24. Bulla

Fig. 27. Leprosy

Fig. 28.this is a Flaccid (soft) bulla superficial (Note that tense bullae deeper involvement) Fig. 25.Vitiligo.Order KOH to r/o tinea. Note hypopigmented areas. Recall: vitiligo is an autoimmune disease

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: I will strengthen you, I will help you, I will uphold you with My righteous right hand. Isaiah 41:10

Fig. 26. Papule