Block 1 Flashcards
flat cells in the stratum corneum, which have lost nuclei, and lamellated lipids
corneocytes
corium
dermis
where the epidermal appendages, including nails, hair and glands, originate.
dermis
Three important aspects in skin history to seek out
- symptoms attributed to the skin lesion
- chronology of appearance, change, and disappearance of the lesions
- conditions of exposure, injury, or medication that may have induced or altered the disease
In the physical exam of the skin, three categories of observation should be made in sequence:
- anatomic distribution of the lesion 2. configuration of groups of lesions 3. the morphology of the individual lesions
Cardinal Features of skin lesions
Type Shape
Major Characteristics of skin lesions
Color Surface Consistency
First manifestations of the development of the disease
Primary Skin Eruptions
Develop from primary eruptions through transformation, inflammation, regression or healing
Secondary Skin Eruptions
Macule Patch Plaque Papule Nodule Vesicle Bullae Pustule Wheal
Primary Eruptions
Scale Crust Erosion Abrasion Crack Ulcer Scar Atrophy Lichenification
Secondary Eruptions
transitory or persistent change in skin coloration with no change in surface structure or consistency.
Macule
flat lesion greater than 1 cm in diameter
Patch
slightly raised lesion greater than 1 cm in diameter
Plaque
Solid elevations on the skin, up to 1 cm in size
Papule
solid elevations larger than one centimeter
Nodule
transient edema in the corium of light hue and lasting for only a few hours
Wheal
single chambered or multi chambered cavity filled with fluid up to 1 cm in size
Vesicle
fluid filled cavity greater than one centimeter in size
Bullae
eruption which contains a pus-filled cavity visible to the naked eye
Pustule
chronic rubbing leads to thickening of the skin with accentuation of the skin creases
Lichenification
independently scaling particles of corneal cells associated in groups
Scale
deposits which consist of dehydrated secretion, blood or necrotic tissue
Crust
sharply delimited, reddened weeping area from which serous secretion and punctiform hemorrhages are discharged
Excoriations
sharply delimited, reddened area due to a surface loss of epidermal tissue, which does not open a capillary. Heals without scarring
Erosion
fissural tear in the skin, occasionally bleeds
Crack
defect of a previously damaged skin extending to the epidermis or deeper, with poor tendency to heal and healing with scar formation
Ulcer
inferior replacement of a loss of substance with connective tissue
Scar
thinning and transparency of the epidermis or dermis or both
Atrophy
diascopy
press a transparent, firm object such as a glass slide against a lesion
If the lesion blanches or loses its erythematous color, this suggests that the erythema is due to ?
capillary dilation
If the lesion does not blanch or lose its red color, this suggests that the erythema is due to ?
extravasation of blood (this can result from vasculitis or destruction of the vessel wall).
the hard keratin cover of the dorsal portion of the distal phalanx
nail plate
The nail plate is generated by the ________ at the proximal portion of the nail bed
nail matrix
As the nail grows, the distal part of the matrix produces the deeper or superficial layers of the nail plate?
deeper while the proximal portion makes the superficial layers.
The nail is bound proximally by the ?and distally by the distal nail fold (defined by the separation created by the anterior ligament between the distal nail bed and the nail plate;
eponychium (the skin just proximal to the cuticle)
The nail is bound laterally by the?
nail folds
The nail is bound distally by the?
distal nail fold (defined by the separation created by the anterior ligament between the distal nail bed and the nail plate;
3 different layers of the nail:
The nail plate (the nail). The nail bed (ventral matrix, sterile matrix). The eponychium (cuticle).
This is the keratinized structure, which grows throughout life
nail plate (the nail)
This is the vascular bed that is responsible for nail growth and support. It lies protected between the lunula (the “half moon” seen through the nail) and the hyponychium (the posterior part of the nail bed epithelium)
nail bed (ventral matrix, sterile matrix)
The epidermal layer between the proximal nail fold and the dorsal aspect of the nail plate.
eponychium (cuticle).
Fingernails grow ?
2 -3 mm a month or 0.1 – 0.15 mm a day
Toenails grow ?
1 mm a month
Growth rate
(about 6 months from cuticle to free edge)
Loss of normal Lovibond angle Increase in nail fold density Pulmonary and CVs diseases GI Hyperthyroidism <1%
Clubbing
Spoon shaped concave nails, normal in children resolves with aging
Koilonychia
Cause of Koilonychia?
Fe deficiency, diabetes mellitus, protein def, exposure to petroleum based solvents, SLE and Raynaud’s disease
Transverse depression across the nail plate
Beau’s lines
Occurs when growth at the nail root (matrix) is interrupted by trauma OR any severe acute illness e.g. heart attack, measles, pneumonia, or fever.
Beau’s lines
These lines emerge from under the nail folds weeks later, and allow us to estimate when the patient was sick.
Beau’s lines
Probable underlying disease when Beau’s lines are present?
Severe infection, MI, hypotension, shock, hypocalcemia, surgery
Punctate depressions in the nail plate caused by defective layering of the nail plate
Nail Pitting
Usually associated with psoriasis, affecting 10 to 50 % of patients
Nail Pitting
Causes of Nail Pitting?
Also caused by systemic diseases, including Reiter’s syndrome and other CTDs, sarcoidosis, pemphigus, alopecia areata, lichen planus and incontinentia pigmenti. Any localized dermatitis (atopic or chemical dermatitis) that disrupts orderly growth in proximal nail fold also can cause pitting.
Presence of longitudinal striations or ridges, can be due to advanced age or: Rheumatoid arthritis; Peripheral vascular disease; Lichen planus; and Darier’s disease (striations are red/white
Onychorrhexis
Central ridging in Onychorrhexis can be due to ?
protein, folic or Fe deficiency
Median Nail Dystrophy
Central Nail Canal
Causes of Central Nail Canal?
Severe arterial disease (Heller’s fir tree deformity) – peripheral vascular artery disease Severe malnutrition and repetitive trauma
Longitudinal hemorrhagic streaks involving the nail bed.
Splinter hemorrhage
Causes of Splinter hemorrhage?
Trauma (most common), Derm disease (psoriasis), Idiopathic, and Systemic disease (subacute bacterial endocarditis )
If multiple nails are involved simultaneously in splinter hemorrhage and they occur near the lunula think of?
systemic disease.
If one or a few nails are involved in splinter hemorrhage and they occur near the end of the nail plate think of ?
trauma
Red lunula
Cardiovascular disease, collagen vascular disease or hematologic malignancy
Pale blue lunula suggests ?
diabetes mellitus
Proximal portion is white (edema and anemia) and distal portion is red, pink or brown
Lindsay’s half & half nails
Lindsay’s half & half nails could be a sign of?
Renal or liver disease
Clinical: Proximal white nail with narrow distal pink or brown band (0.5 to 3mm)
Terry’s nails
The nail looks opaque and white, but the nail tip has a dark pink to brown band.
Terry’s nails
Causes of Terry’s nails
cirrhosis, CHF, DM, cancer, hyperthyroidism, malnutrition, ageing
Confined to the nail bed. Will disappear when distal digit is squeezed.
Muehrcke’s Lines
Clinical: Double white transverse lines affecting numerous nails.
Muehrcke’s Lines
Causes of Muehrcke’s Lines ?
Chemotherapy and Hypoalbuminemia secondary to nephrotic syndrome, liver disease, or glomerulonephritis.
Transverse type of true leukonychia caused by systemic disease.
Mee’s lines
Clinical: Single or multiple transverse lines that involve multiple nails.
Mee’s lines
The pigment is in the nail plate.
Mee’s lines
Causes of Mee’s lines
Arsenic poisoning, Hodgkin’s disease, CHF, leprosy, malaria, chemotherapy, carbon monoxide poisoning, other systemic insults
Red brown discoloration of the nail bed
oil spot sign, salmon patch
Very common in Psoriasis
oil spot sign, salmon patch
Distal separation of nail plate from nail bed
Onycholysis
Causes of Onycholysis
Thyrotoxicosis, psoriasis, trauma, contact dermatitis, tetracycline, eczema, fungal or bacterial infections
Longitudinal Pigmented Bands (LPB)
Melanonychia
Pigmented band appearing in the distal matrix and extending to the tip of the nail.
Melanonychia
Be suspicious if: Develops in a single digit in adult life especially in 6th decade or later Develops abruptly in previously normal nail Becomes suddenly darker or wider
Melanonychia
the number of hairs on the head
120,000–150,000
number of hairs/cm2
250
the total surface area of a head of hair 20 cm long
6 m2
rate of growth of hair
1 cm/month
strands of hair we naturally lose each day
100 – 120
weight a single hair can withstand
100 gms
not greasy or dry, not permed or colored, holds style well, looks healthy
Normal
limp, looks flat lacks volume, soon gets greasy after shampoo
Fine/Greasy hair
looks dull, feels dry and rough, tangles easily, treated chemically, dry and frizzy, may have split ends
Dry
Alternating light and dark bands The light bands are areas on the shaft with vacuoles May be autosomal dominant
Pili annulati
Beaded appearance due to periodic narrowing of the hair shaft Autosomal dominant Fragile hair and dystrophic alopecia
Monilethrix
Bamboo hair
Trichorrhexis invaginata
Netherton’s syndrome, autosomal recessive
Trichorrhexis invaginata
Regularly spaced nodules along the shaft caused by intermittent fractures with invagination of the distal hair into the proximal portion
Trichorrhexis invaginata
Hair is twisted along the long axis Maybe congenital or acquired
Pili torti
Results from a disturbance of the follicle from a scarring inflammatory process, mechanical stress or cicatricial alopecia
Pili torti
Brittle hair shaft with breaks at varying lengths
Pili torti
Present in Menke’s, Bjornstad, Crandall syndromes
Pili torti
Abnormal fragility
Trichorrhexis nodosa
Congenital – Menke’s syndrome, Trichodystrophy, arginosuccinic aciduria
Trichorrhexis nodosa
May be accompanied by mental retardation, motor defect, ichthyosis, seizure disorders, growth abnormalities
Trichorrhexis nodosa
Acquired – excessive hair styling
Trichorrhexis nodosa
Split ends
Trichoptilosis
Most common complaint about hair
Hair loss
Most common hair problems
Telogen effluvium Male Pattern Baldness Female Pattern Baldness Trichotillomania Alopecia areata
Skilled interviewing techniques
The skin accounts for how many percent of the adult body weight?
6% (Dr. Montero)
16% (Bates)
Thin avascular keratinized, epithelium
Epidermis
Outer Layer of epidermis
stratum corneum (dead keratinized cells)
Inner Layer of the epidermis
stratum basale
(malphigian layer);site
where melanin and keratin are formed
Stratum spinosum
Migration from inner to outer layer is about?
1 month
dense layer of interconnecting collagen and
elastic fibers containing sebaceous and sweat
gland, hair follicles, and terminals of the
cutaneous nerves.
dermis
consists of spongy connective tissue with
energy-storing adipocytes (fat cells).
SUBCUTANEOUS TISSUE
Melanocytes are freely distributed along?
cytoplasm
protects DNA mutation caused by ultraviolet rays
melanin
brown pigment
Eumelanin
black pigment
Pheomelanin
ORIGINAL LESION
Exact site
Duration
Appearance
Distribution
Progression
SYMPTOMS
Pruritus
Pain
Burning
SETTING AND TIMING OF ATTACKS
Occupation
Topical agents
Drug history
Season of year
Environment
Distribution of Lesions:
Acne Vulgaris
face, chest, back
Distribution of Lesions:
Atopic Dermatitis
Body folds
Distribution of Lesions:
Photosensitive Eruptions
sun exposed area
Distribution of Lesions:
Pityriasis Rosea
90% sun covered area
Distribution of Lesions:
Psoriais
Predisposed to trauma
Distribution of Lesions:
Seborrheic dermatitis
Sebaceous in origin
These lesions are small
and itchy at first.
It can be due to
cutaneous larva
migrants of dog
or cat hookworm
Serpiginous
lesions
•Surface Features
- Normal or smooth
- Scaly
- Keratinous
- Crust
- Warty, papillomatous
- Umbilicated
- Lichenified
Shape of Lesions
Round
Oval
Irregular
Pedunculated
Yellow
Cholesterol deposits
Solar elastosis
Carotenemia
Xanthomas
→ Xanthalesma
→ Eruptive
Xanthogranulomas
Adnexal tumors and hyperplasias with
sebaceous differentiation
Necrobiosis lipoidica
Capillaries [Yellow-Brown Background]
Drugs/Deposits
→ Tophi
→ Quinacrine
Red
Vasodilation
Gray
Post inflammatory hyperpigmentation [Dermal]
→ Erythema dyschromicum perstans
Drugs/Deposits
→ Argyria
→ Chrysiasis
→ Mercury deposits
→ Combined melanocytic nevus
→ Traumatic tattoos
Green
Pseudomonas infection
→ Characterized with a “fruity smell”
Tattoo
Chloroma
Green hair due to copper deposits
Blue
Ceruloderma
Dermal melanocytosis
→ Mongolian spot
→ Nevus of Ota
Dermal melanocytomas
→ Blue nevi
Cyanosis
Ecchymoses
Venous congestion
→ Venous malformations
Drugs/Deposits
→ Minocycline
→ Traumatic tattoos
Brown
Pigmented lesion
→ Lentigines
→ Seborrheic keratosis
→ Junctional, compound and congenital
melanocytic nevi
→ Café-au-lait spot
→ Dermatofibromas
→ Melanoma
→ Pigmented actinic keratosis, Bowen’s disease
Post inflammatory hyperpigmentation
[Epidermal]
Melasma
Phytophotodermititis
Drug-induced hyperpigmentation
→ Cyclophosphamide
Metabolic
→ Addison’s disease
Black
Necrosis of the skin
→ Vasculitis (Wegener’s granulomatosis)
→ Thrombosis (DIC, monoclonal
cryoglobulinemia)
→ Emboli (Ecythma gangrenosum)
→ Vasospasm (Severe Reynaud’s phenomenom)
→ Vascular compromise (Atherosclerosis,
calciphylaxis)
→ Eschar (Anthrax)
Cutaneous melanoma
Traumatic tattoos
Hyperpigmentation of the proximal nail fold of
the finger
HUTCHINSON’S
SIGN IN
MELANOMA
T/F
Hair is dead and can not be nourished, hair
products can only provide temporary benefits to
the look and feel of hair
T
T/F
All organic or all natural shampoos can not
really clean hair
T
T/F
With modern shampoos hair can be washed as
often as necessary
T
T/F
Shampoos do not interfere with hair growth
T
T/F
Amount of lather in a shampoo does not affect
its cleaning ability
T
T/F
More expensive shampoos do not necessarily
outperform inexpensive ones
T
T/F
Shampoos do not build up on hair but
conditioning agents and styling products do
T
T/F
Hair is weaker when wet
T
responsible for the color
of the hair
Melanin granules
•
Caused by exogenous re infection of a previously sensitized
individual
•
Usuallly occurs on the hands or feet
•
Starts as a small asymptomatic papule or pustule
•
The become hyperkeratotic, slowly increasing in size
•
May discharge pus
TB
verrucosa curtis
Persistent and progressive form of cutaneous TB
Small sharply defined red brown lesions, with a scaly or friable
surface.
Gyrate shapes may be observed due to involution in one area with
expansion on another
Diascopy reveals an apple jelly color
Usually found over the head and neck area
May lead to disfigurement
Lupus vulgaris
•
Direct extension of tubercle bacilli from an
underlying infected lymph node or bone to the
skin
•
Common sites:
Side of the neck, supraclavicular fossae & axillae
•
There is fluctuant swelling which suppurates &
ulcerates
•
Heals on Tx but leaves considerable scarring
Scrofuloderma
•
Chronic granulomatous infection, involving primarily the skin and the
nerves
•
Diverse manifestation depending on the type of leprosy the patient
has
•
Indeterminate, Tuberculoid , borderline tuberculoid , Lepromatous
Mycobacterium
leprae
•
Systemic infection caused by Treponema pallidum
•
Passes through 4 distinct clinical phases: 1 0 chancre, Secondary stage
(skin eruption), latent period, Tertiary stage (Neuro, CVS Sy )
Syphilis
Skin findings in Lupus Erythematosus
Malar rash
Discoid Lupus
Photosensitivity
Oral ulcers
Systemic findings in Lupus Erythematosus
Arthritis
Serositis
Renal disorder
Hematologic disorder
Neurologic disorder
Positive anti nuclear
antibody
Anti dsDNA or anti
Smith
antibody
•
Exemplified by development of bilateral malar erythema, transient,
follow sun exposure
•
Erythema may be accompanied by telangiectasias , erosions,
dyspigmentations and epidermal atrophy
Acute Cutaneous LE
•
Photosensitive
•
Lesions confined to sun exposed areas
•
Annular in configuration, raised borders and central clearing
•
Maybe present in patients receiving hydrochlorthiazide , terbinafine,
Ca channel blockers, NSAIDs, anti His, griseofulvin
Subacute Cutaneous LE
•
Most common skin manifestation of lupus
•
Erythematous, violaceous plaques, some scaling, atrophic changes,
follicular plugging, and dyspigmentation maybe observed
Discoid Lupus
•
Cutaneous fibrosis excessive accumulation of collagen
•
Unknown cause
•
Types:
•
Localized
•
Morphea
•
Generalized
•
Linear
•
Systemic cutaneous and internal organ fibrosis
Scleroderma
Symmetrical, thickening, tightening and
induration of the skin
Initially involves the digits and may later spread
to involve the entire extremity, face and torso
Systemic Sclerosis
Scleroderma
Furrows
radiate from the
mouth which
becomes shrunken.
Scleroderma.
Matt like
telangiectasia may
occur in what
syndrome?
CREST syndrome
•
Female preponderance approx 2:1, peak incidence 5 th to 6 th decade
•
Proximal, symmetric muscle weakness
•
Elevated serum levels of muscle derived enzymes
•
Abnormal electromyogram
•
Abnormal muscle biopsy
•
Cutaneous disease compatible w Dermatomyositis
•
18 to 32% may develop a malignancy
•
Arthralgia , dysphagia , myocarditis , pericarditis , calcinosis in the skin
or muscle (40% of affected children)
Dermatomyositis
symmetriclal
violaceous to dusky
erythematous
eruption over the
periorbital area
Heliotrope Sign
•
Heterogenous group of CTD characterized by easy bruisability , joint
hypermobility , cutaneous hyperextensibility
•
11 subtypes
•
Abnormalities in the collagen structure irregularities in the
diameter of the fibrils, irregular collagen shapes
•
Mitral valve prolapse , aortic dilatation with insufficiency, arterial
rupture
Ehlers
Danlos Syndrome
firm, non-tender, movable subcutaneous masses
Rheumatoid nodules
•
Autosomal dominant
•
1 in 3000 live births, de novo mutations in 30 50% of cases, 90% of
these mutations occur in the paternally derived chromosome
•
Café au lait spots –> 6
•
Axillary freckling Crowe’s sign
•
Lisch nodules
•
Neurofibromas
•
Abnormal expression of a tumor suppressor gene neurofibromin
•
CNS tumors in 3 10%, occ visceral tumors, cong pulmonary stenosis ,
idiopathic interstitial pulmonary fibrosis, renal artery stenosis and
hypertension
Classic
Neufibromatosis
•
Autosomal Dominant, 1 in 10000 live births
•
Epilepsy
•
Adenoma sebaceum angiofibromas
•
Mental retardation (50%)
•
CNS cerebral tumors
•
Eye retinal gliomas
•
Kidney renal cysts, angiomyolipomas
•
CVS rhabdomyomas
•
Defect in the gene code for hamartin and tuberin , proteins
which are probably tumor suppressors
Tuberous sclerosis
Bourneville’s Disease
Intradermal
or
subcutaneous
nodules
Occur over
avascular areas
May discharge a
chalky material
Tophi
Cutaneous complications of diabetes
Image
•
Small, brown, well demarcated, shallow depressions with atrophic
appearance
•
Less than 1 cm in diameter
•
Bilaterally located on the pretibial area, asymmetric
•
Most common cutaneous manifestation of DM
•
May herald the microvascular complications of DM
Diabetic
dermopathy
Well circumscribed yellow brown patches with epidermal atrophy
commonly found over the shins
Necrobiosis
Lipoidica
•
•
Rapid onset painless,
tense blisters on
hands and feet
•
Trauma and
microvascular disease
may play a role
•
Spontaneous healing
in 2 5 weeks
Diabetic bullae
•
Peripheral neuropathy leads to unnoticed trauma
•
Vascular complications may lead to ulcers and
complicate ulcer healing
•
Risk of amputation goes up 8x once these develop
Diabetic Neurotropic Ulcers
•
African Americans and Hispanics > Caucasians
•
Associated with obesity, insulin resistance
•
Hyperpigmented velvety plaques of the flexures
•
Genetic sensitivity of the skin to hyperinsulinemia
•
Malignant form a/w gastric ACA
Acanthosis
nigricans
•
Deposition of lipids in the skin & elsewhere
•
Results from hyperlipidemia caused by a primary genetic defect or
secondary to defective metabolism
Lipid disorders
Xanthomas consists of?
foam cells
Tissue macrophages which have
phagocytosed the lipid part of lipoproteins deposited in tissues
Foam cells
flat, yellow plaques around the eyes
Xanthelasma
•
sudden appearance of myriad of yellow
papules/nodules over the buttocks, thighs,
arms, forearms, back & chest
•
Often found in chylomicronemia
Eruptive xanthoma
•
Reddish yellow nodules usually localized over the extensor surfaces
of the elbows, knuckles, knees and buttocks
•
Common in familial dysbetalipoprotenemia
Tuberous xanthoma
Xanthoma
Planum
Familial
dysbetalipoprotenemi
a
Xanthoma
tendinosum
Familial
hypercholesterolemi
a
Clinical presentations of xanthomas
pic
Secondary causes of hyperlipidemia
pic
Thyroid dermopathy (pretibial
Symmetric, non pitting yellow brown waxy papules/plaques
Due to increased hyaluronic acids in dermis
Rare usually associated with Graves disease
Thyroid disorders
red,soft , moist and hot
addisonian hyperpigmentation i.e. not affect the mucous
membranes.
Diffuse thinning of scalp hair
Rapid nail growth and onycholysis
Generalised pruritus and urticaria
Palmar erythema and facial flushing.
Hyperhidrosis or increased sweating.
Hyperthyroidism
Dry, cool skin
Generalized myxedema
Yellow hue from carotenemia
Purpura from delayed wound healing
Alopecia, madarosis
Hypothyroidism
Associated with zinc deficiency
Inherited as AR
Triad:
circumorificial
/ acral dermatitis
alopecia
diarrhea
Inadequate Zn intake:
anorexia nervosa
vegetarian diet
parenteral
alimentation
Acrodermatitis Enteropathica
Reduced zinc absorption in Acrodermatitis
enteropathica is due to:
coeliac disease
pancreatic insufficiency
cystic fibrosis
severe infantile diarrhea
alcoholism
Niacin deficiency (B 3
Photodistributed erythema that becomes scarlet and
hyperpigmetned Casal’s necklace well demarcated
band around the neck. Peri anal and oral inflammation
and erosions
Peripheral neuropathy with dysthesias
Pellagra
•
Spongy gingiva, with bleeding and erosions
•
Petechiae, ecchymosis
•
Corckscrew hairs, follicular hyperkeratosis
Scurvy
Vitamin C deficiency
Sudden appearance of dark colored thickened, velvety skin, which
start as hyperpigmented macules and patches which progress to
palpable plaques
Skin tags are often found in the affected areas
Oral cavity may be involved
Tripe palms altered dermatoglyphics
Malignant Acanthosis
nigricans
the sudden eruption of multiple seborrheic keratosis caused by a
malignancy
Tan to black, popular growths oftentimes with a warty surface
Sign of
Leser Trélat
Very rare condition characterized by the rapid growth of long fine
lanugo type hair
Face commonly affected
Most frequent associated malignancy in females is colorectal CA,
followed by lung CA and breast CA. In men it is Lung CA
Hypertrichosis
Lanuginosa Aquisita
•
Autosomal dominant inherited disorder
•
Intestinal hamartomatous polyps in association with macular melanin
deposition on the skin and mucous membranes
•
Significant overall increased lifetime risk of intestinal and
extraintestinal malignancy
Peutz
Jeghers syndrome
Up to 50% of patients with PG have
inflammatory bowel disease
•
12% of patients with ulcerative colitis and 2% of
patients with Crohn’s disease will develop the
condition
•
Severity and extent of ulceration in PG link to
the activity of the underlying disease
•
Can heal with effective treatment of the
underlying bowel disease
Pyoderma
gangrenosum
Causes of
Pyoderma
Gangrenosum
Crohn’s Disease
•
Ulcerative Colitis
•
Rheumatoid
Arthritis
•
Behcets
Syndrome
•
Monoclonal
gammopathies
•
Hypogammaglobulin
aemia
•
Plasma cell
dyscrasias
•
Multiple myeloma
•
Acute leukemia
•
Polycythaemia rubra
Wood grain pattern on the skin, serpiginous,
polycyclic erythematous, pruritic lesions
Fast growing
90% associated with internal malignancy
Most common is lung CA
Erythema
gyratum repens
Port wine stain ophthalmic branch of Trigeminal nerve
•
Ipsilateral leptomeningeal angiomas progressive
calcification and degeneration of the underlying cerebral
cortex
•
Seizure disorders, contralateral hemiparesis , and ipsilateral
ocular involvement with angiomatosis of the choroid and
glaucoma.
Sturge
Weber Syndrome
•
Acute nodular, tender, erythematous eruption, usually limited to the
extensor aspects of the lower legs
•
May occur in association with several systemic diseases or drug
therapies (sulfa drugs, OCP’s, strep, fungal, viral infxns , sarcoidosis,
inflammatory bowel diseases, pregnancy)
Erythema
nodosum
•
Acute immunoglobulin A mediated disorder characterized by
generalized vasculitis involving the small vessels of the skin, GIT, GUT,
joints and rarely the lungs and the CNS
•
Headache, anorexia and fever, followed by purpura over the legs,
with abdominal pain and vomitting
Henoch
Schonlein Purpura
An exaggerated forward thrust may be the result of abnormality of the cervical spine. Adue to fusion of the cervical vertebrae.
Klippel-Feil syndrome
a slight but constant rhythmic tremor of the head occurs
Parkinson‟s disease
sudden, unexpected head movements, often accompanied by facial grimaces
Habit spasm
there is a too and fro bobbing of the head synchronous with the heart beat
Musset’s sign=Aortic insufficiency
sudden, jerky movements of the head
Chorea
large size and bulging forehead
Hydrocephalus
from premature synostosis of coronal and sagittal sutures; with marked exophthalmos; vacant expression
Tower skull or steeple head
prominent fontal bosses and some exophthalmos
Apert‟s syndrome
skull has a flattened or squared appearance
Rickets
enlargement of the cranial vault; shape of the head resembles that of an acorn
Paget‟s disease
single or multiple
Sebaceous cysts
causes a marked prominence of the forehead
Osteoma of frontal bone
Bulging, prominent, rounded mass, usually partially collapsible and pulsating
Encephalocele
no connection to CNS
Glioma
multiple osteomas, fibromas, epidermoid cysts, and intestinal polyps.
Gardner syndrome
marked swelling of the forehead “Pott’s puuffy tumor”.
Frontal sinusitis
What is the highest temp?
a. Oral
b. Axillary
c. Rectal
d. Tympanic
C.Rectal
Rectal temperature are 0.4 to 0.5 degrees
Celsius higher than Oral
How long will it take for the thermometer to
equilibrate when placed under the tongue with
digital thermometer?
A. 1 minute
B. 2 minutes
C. 3 minutes
D. 4 minutes
C. 3 minutes
For oral temperature, glass thermometers
recording usually takes about 3 to 5 minutes
Intermittent fever
A. Little variations per episode
B. With complete resolution between episode
C. Abating each day but no complete resolution
D. Febrile episodes last for a couple of days separated by afebrile intervals with the same length.
B. With complete resolution between episode
- Remittant fever
A. Little variations per episode
B. With complete resolution per episode
C. Abating each day but no complete
resolution
D. Febrile episodes last for a couple of days
separated by afebrile intervals with the same
length.
C. Abating each day but no complete
resolution
- Battles signs
a. Classic traumatic bruising behind the
mastoid bone
b. Present in congenital Myopathy
c. Periorbital bruising
d. Dramatic expression
a. Classic traumatic bruising behind the
mastoid bone
-The face appears expressionless with sunken cheeks, bilateral ptosis, and inability to elevate the corners of the mouth, due to muscle weakness.
Myopathic face
A postural dizziness or an increase in heart rate of 30 beats/minute has a sensitivity of 97% and a specificity of 96 for a blood loss >630mL. If not associated with dizziness, a postural hypotension in any degrees is of less value.
A. True
B. False
B. False
Sensitivity is 13.2%
8.Fat distribution as in waist to circumference or waist to hips ratio is less reliable to identify cardiovascular diseases than BMI.
A. TRUE
B. FALSE
B. FALSE
If the BMI is >35 kg/m2, measure the patients
waist circumference just above the hips. Risk for
diabetes, hypertension and cardiovascular
disease increase significantly
Acute diff in diastolic pressure of >20mmhg
between the 2 arms indicate aortic dissection.
A. TRUE
B. FALSE
Aortic difference of more than 10 to 15 mmHg
occurs in aortic dissection
B. FALSE
Aortic difference of more than 10 to 15 mmHg
occurs in aortic dissection
- Muerhrckes line seen in chronic:
A. Diabetes
B. Hypertension
C. Renal disease
D. Hypoalbuminemia
D. Hypoalbuminemia
This is the highest intra-atrial pressure
produced during ventricular contraction?
A. Systolic pressure
B. Diastolic pressure
A. Systolic pressure
Auscultatory sound heard after deflating the
cuff
a. murmur
b. borborygni
c. korotkoff
c. korotkoff
- causes of wide pulse pressure except
a. anxiety
b. anemia
c. pregnancy
d. polycythemia
d. polycythemia
Pulse pressure is increased in:
Fever, anemia, hyperthyroidism etc.
The exaggeration of the normal respiratory
variation in systolic blood pressure characterized
by decrease in inspiration and increase in
expiration.
A. Pulsus paradoxus
B. Bainbridge anomaly
D. Pulsus Alternans
A. Pulsus paradoxus
flattened non palpable circumscribed
discoloration with diameter of <=0.5 cm
Macule
Raised palpable lesion <= 0.5mm. This may
or may not have discoloration.
A. Macule
B. Patches
C. Papule
D. Vesicle
C. Papule
Lesion >0.5 cm,usually developed from
papule
Plaque
Raised, palpable lesion >0.5 cm in diameter
that goes deep down the dermis.
a.vesicle
b.nodule
c.tumor
d.plaque
b.nodule
Raised, circumscribed edematous plaque,
pruritive pale or pink in color. transient
Wheal
>0.5 cm lesion in 2nd degree burn
a. vesicle
b. bullae
c. cyst
d. wheals
b. bullae
Raised and enveloped lesion that contains
fluid or semisolid material
A. Pustule
B. Cyst
C. Purpura
D. Petechiae
B. Cyst
Skin extravasation of red cells, which, based
on size, may be presented as ecchymoses:
A. Pustule
B. Cyst
C. Purpura
D. Petechiae
C. Purpura
Reddish or purplish discoloration if the skin
that is microscopic, <0.5 cm and in clusters
a. Purpura
b. Petechiae
c. Ecchymoses
b. Petechiae
Reddish to purplish in color that are larger
than petechiae
Answer: Ecchymosis
These are vascular telangiectasias. They
blanch when they are compressed.
A. Spider angiomas
B. Venous spiders
C. Ecchymosis
D. Excoriations
A. Spider angiomas
Mav Lu went to the ER with a 4 day hx of
unrecalled fever that persisted throughout the
day, he also complained of epigastrc pain with a
scale of 5/10 that was unrelieved wby food
intake, symptoms persist for few days. a few
hours prior to admission, the patient had an
episode of projectile vomiting (200cc), thus he
went to the ER. What is the chief complaint of
the px?
Answer: Vomiting
Dr. Nat Bril wants to know the patient’s
smoking pack years, what question should he
not ask?
A. Average number of sticks per day
B. When did he start smoking
C. When did he stop
D. How many sticks can he tolerate
D. How many sticks can he tolerate
You are a 2nd year medical student who’s interviewing a patient with the tendency to talk a lot and overshare. Which of the following would you not include in Socioeconomic History?
A. Age
B. Occupation
C. Biking and hiking hobbies
D. Marital Status
A. Age
Dr. Bea performed ROS. Which should not
be included in Review off Related Systems
A. Blurring vision
B. Ringing of the ear
C. Dysuria
D. Wheezing
D. Wheezing
Dr. Bea performed ROS. Which should not
be included in Review off Related Systems
A. Blurring vision
B. Ringing of the ear
C. Dysuria
D. Wheezing
In which will
you classify your answer?
A. HPI
B. Personal history
C. Gen data
D. Physical exam
D. Physical exam
__________ is a complete, clear, and
chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.
HISTORY OF PRESENT ILLNESS
You are a second year medical student and
you have studied properly for History and PE. A
patient came to you with a chief complaint of
“For chemotherapy”. For you, chief complaint
should be?
A. Ask the patient more about the
chemotherapy
B. Let it be because you are only a second year
student
C. Place cancer as chief complaint
D. None of the above
A. Ask the patient more about the
chemotherapy
Dr. Tan perform history and p.e., which of
these is a symptom.
A.bluish discoloration
B.hematoma
C.difficulty of breathing
C.difficulty of breathing
Which is not included in the general data?
A. Age
B. Religion
C. Marital status
D. No. Of children
D. No. Of children
includes all elements of health history and
complete physical examination.
Comprehensive
You are interviewing a 6’8 285lbs man. And
told you that before he went to africa 2 years
ago he got a vaccine for yellow fever. What part
of patient history should it be included in
A. HPI
B. Personal
C. Past Medical History
D. Socio
C. Past Medical History
Strong pulsation at uvula with synchronous
heart beat
A. Quincy
B. Vincents angina
C. Lenards angina
D. Aortic insufficiency
D. Aortic insufficiency
This gives the patient an impassive, sphinx -
like expression?
A. Scleroderma
B. Parkinson’s
C. Leprosy
D. Grave’s syndrome
B. Parkinson’s
Saddle nose deformity is one characteristic
of?
A. Lupus erythematosus
B. Acne rosea
C. Rhinophyma
D. Leprosy
D. Leprosy
The descriptive term “coup de sabre” is indicative of
A. Romberg’s disease
B. Saddison disease
C.Graves disease
D.Hodgkins disease
A. Romberg’s disease
Associated to tetany, elicited by tapping
sharply with the finger just in front of the external
auditory meatus over the facial nerve.
Chvostek’s sign
Syndrome characterized by white forelock,
deafness heavy eyebrow and broad-based nose
- Waardenberg Syndrome
Syndrome due to increased adrenal
hormone production with round or moon face with red cheeks
a. Nephrotic Syndrome
b. Marfan’s syndrome
c. Cushing’s Syndrome
d. Gradenigo Syndrome
c.Cushing’s Syndrome
This may cause atrophy of the trapezius and
sternocleidomastoid muscle.
A. Wryneck
B. Rhabdomyosarcoma
C. Poliomyelitis
D. Torticollis
C. Poliomyelitis
Aortic insuffiecency or trachea tug, can be
pulsate with placing finger over the carotid
arteries -
olivers sign
Suddenly lose patches of hair and often
awaken in the morning to find a handful of hair
on the pillow and a bald spot on the scalp where
their hair fell out.
alopecia aerata
Hematoma along mastoid bone or temporal
bone fracture
Battle’s sign
“Rangades” a small, linear scar coming from
the mouth to the nose is characterized as:
A. Congenital syphilis
B. Congenital herpes
C. Congenital leprosy
D. Congenital tb
A. Congenital syphilis
- Pigmented spots on oral and buccal mucosa,
diagnosed with peutz-jeghers disease, which of
the following is the other symptom
A.Colonic malignancies
B. Multiple intestinal polyps
C. Biliary atresia
D. Liver cirrhosis
B. Multiple intestinal polyps
Multiple osteoma of skull, fibroma,
epidermoid cyst, intestinal polyps associtaed
with?
A.
B. Acromegaly
C. Gardner’s syndrome
D. Peutz-Jegher’s
C. Gardner’s syndrome
Presence of port wine nevus and bruit in the
ipsilateral skull is in present in:
A. Struge-weber syndrome
B. Virchow’s
C. Von recklinghausen disease
D. Hodgkin’s
A. Struge-weber syndrome
28 yrs old mechanic with a mass at the right
upper lateral neck anterior to the
sternocleidomastoid. Mass is tense, firm and
non tender, does not move up upon swallowing.
What is likely the diagnosis?
A. Thymus
B. Thyromegaly
C. Thyroglossal duct cyst
D. Branchial cleft cyst
D. Branchial cleft cyst
A 6 month old infant was brought in for
consultation. A soft, collapsible, light transmitting
tumor on the neck measuring 6 x 6 inches. Most
likely diagnosis
A. Cystic hygroma
B. Hemangioma
C. Rhabdomyosarcoma
D. Chemodectoma
A. Cystic hygroma
Fusion of cervical
vertebrae
Klippel-Feil syndrome
Acorn shape of the head
Paget’s disease
A massive face with craggy eyebrows,
prominent nose and enlarged lower jaw
indicates
a. Acromegaly
b Cushings
c. Alpert
d. Steeple Head
a. Acromegaly
A term used to describe a depressed positioning of the pinna two or more standard deviations below the population average.
Low set ears
Low set ears can be associated with conditions such as:
→ Down’s syndrome and Turner syndrome.
→ Noonan syndrome
→ Patau syndrome
It is usually bilateral, but can be unilateral in Goldenhar syndrome.
Low set ears
- Deposits of uric acid crystals characteristic of gout
- Appear as hard nodules in helix or antihelix
- Occasionally discharge white chalky crystals
Tophus
• Small chronic, painful, tender nodule in the helix of the ear.
Chondrodermatitis Helicis
- More common on auricle than BCC
- Usually in older men and those exposed to too much sunlight
- Usually on posterior and superior portion of pinna.
- More exophylic.
Squamous cell carcinoma
- More common on the face
- Occur later in life than SCC
Basal cell carcinoma
• More endophylic and tends to burrow subcutaneously beyond the visible limits of the tumor.
Basal cell carcinoma
- Most common causes of hearing loss
- Neurosensory hearing loss
Chronic otitis media
- Thomas willis described a woman “who, although she was deaf, whenever a drum was beaten in the room, heard every word clearly”
- Often seen in otosclerosis
Paracusia Willisii
• Tinnitus
• Vertigo
→ Most common cause of the patient’s seeking care
• Hearing loss
Meniere’s syndrome
erosion of the nasal bones may result in the typical “saddle nose”
Syphilis
nose is red, large and bulbous
Rhinophyma
“butterfly” lesion on the nose with wings extending out over the cheeks
Lupus erythematosus
marked reddening of the tip of the nose
Acne rosacea
- Teeth that are pitted and stained yellow, brown, or black
- Caused by the presence of fluoride in drinking water
Mottled enamel or fluorosis
- Gums are soft, tender and spongy
- Teeth often so loose that they can be plucked out with finger
Scurvy
• Caused by:
→ Acute monomyelocytic leukemia
→ Or by medication like phenytoin
Hyperplasia of the gums
- A long ridge of the bone felt along the inside the mandible in the floor of the mouth
- Most prominent from canine (cuspid) to second molar.
Torus mandibularis
• Underdevelopment of the mandible associated with median cleft palate
Pierre Robin syndrome
→ Tongue is slightly red
→ Slightly flurry coating
→ Raspberry tongue/ strawberry tongue
→ bright red coloration and prominent papillae
Scarlet fever
tongue is heavily coated and furred and often covered with brownish sores
Typhoid fever
covered with firm, white, indurated lesions that resemble attached crust
Leukoplakia
acutely inflamed, painful, and so swollen that it protrudes, preventing a patient from closing the mouth
Ludwig’s Angina
with conspicuous furrows in the dorsal surface of the tongue
Fissured tongue
- typical whitish patches on the border of the tongue
- Tongue Tide
- Caviar tongue
Oral hairy leukoplakia
• Striking in appearance
• Commonly seen in nervous patient
Appearance changes daily
Geographic tongue
• Has groove and markings like those in an surface of the scrotum
Scrotal tongue
Tongue is:
→ Small
→ Irregular shaped
→ Round or oval areas of black or brown pigmentation
Addison’s disease
• Sublingual or gum ulcer
Chronic adult Histoplasmiosis
• Caused by herpes simplex virus
• Painful vesicular lesions
• Associated with systemic manifesttaion:
→ Fever
→ Malaise
→ Lymphadenopathy
Herpetic stomatitis
- Caude by coxsackie A virus
- Occur particularly in children under 4 years of age
- Sudden onset of fever, sore throat and shallow pharyngeal ulcers
- Occur usually during the summer
Herpangina
- Cluster of small, dilated varicose veins and may occupy the whole surface of the tongue
- Round shaped and black color have suggested a resemblance to caviar
Caviar tongue
- A cystic swelling in the floor on the mouth under the tongue and alongside the molar teeth is due to a blocked sublingual gland
- Cyst usually is single, moderately tense and filled with thick, clear mucous
Ranula
- Small, bluish-white spots surrounded by a thin, red margin, appear on the area of the mucous membrane of the cheek opposite molars, near the opening of the parotid duct
- Pathognomonic(sign) of measles
- Appear before the skin eruption
- Permit the early diagnosis of the disease
Koplik’s spots
- Presence of Mucous patches (white, sharply circumscribed areas seen on the mucous membranes of the mouth near the bases of the gums, 0.5 to 1 cm in diameter)
- Present on the palate or anywhere on the mucous membrane of the buccal cavity
Secondary syphilis
- Involve the oral mucosa before skin lesions appear
- Grayish-white papules that coalesce and are surrounded by a reticulated area
Lichen planus
- A hard, bony, benign midline tumor of the hard palate
- Interfere with the wearing of an upper denture
Torus palatinus
Palate is usually “high and arched”
Marfan’s and Turner syndrome
- Infection of the tonsil and gums
- Unilateral and causes necrosis
- A dirty, yellow exudate that leaves a bleeding surface when removed
- Mistaken for both Diphtheria and syphilis
Vincent’s angina
- May complicate acute tonsillitis or dental sepsis
- Patient commonly has a high fever, dysphagia, and a rigidity of the neck
- Rigid neck, combined with spasm of the buccal muscles producing “locked jaws”, has led to the false diagnosis of “tetanus”. Because patient can’t open the mouth widely, the physician may be unable to see the abscess but may feel the swelling by inserting a finger into the mouth
Peritonsillar abscess (Quinsy)
- Uvula is enlarged, pendulous and semi translucent
- Enlarge uvula frequently produces a shallow, irritating cough, which is worse at night when the recumbent position allows the uvula to touch the base of the tongue
Inflammation of the pharynx or fauces
• Uvular pulsation synchronous with the heart beat (described by Muller, 1971)
Aortic insufficiency
- Produces creamy patches that reveal a raw, bleeding surface when the patch is scraped off
- Prone to occur in patients who are receiving broad-spectrum antibiotics or immunosuppressive therapy
Moniliasis
Characteristically produces hoarseness, and a high-pitched, musical, or brassy cough
Involvement of the recurrent laryngeal nerves
Macular brown-black areas, most marked at gingiva in individuals with dark skin pigmentation
Normal
Macular brown areas on buccal mucosa, skin pigmentation present
Addison’s disease
Macular lesions about lips and buccal mucosa
Peutz-Jeghers Syndrome
Gray-black stippling at gingival margins
Heavy metal poisoning
Hx of lead, bismuth, or mercury exposure; dental amalgam(silver) patches under mucosa, blue-black
Amalgam tattoo
Brown-gray mucosal spots, usually with “bronzing” of the skin
Hemochromatosis
Brown macules on mucosa or tongue, precocious puberty, fibrous bone
Albright syndrome
Red-purple macule or papule, may be part of widespread angiomatosis (Osler-Weber-Rendu disease
Hemangioma
Solitary brown macule or papule
Nevus
Solitary brown macule or papule, erythema, may ulcerate
Melanoma
Pain; thick white patches (leave bleeding ulcerated area if removed)
Candidiasis
Discomfort, Translucence
Secondary Syphilis
Pain in mucosa, palate, oropharynx, history of oral sexual contact
Gonorrhea
Pain at dental margins. inflammation, loss of interdental papillae
Fusospirochetosis
Pain, friable surface, inflammation, ulceration due to chemicals, heat, or mechanical or electrical injuries
Trauma
Discomfort; multiple gray-white papules that may vesiculate and ulcerate; may precede skin lesions
Lichen planus
Raised plaque, fissuring, some erythema, pain not present with early lesions; usually occurs in heavy smokers
Leukoplakia
Raised plaque, fissuring, ulceration; usually occurs in heavy smokers and alcohol drinkers
Carcinoma
Painful “cold sores” of lips, mouth, and gingiva
Herpes virus
Herpangina, eruption in pharynx posteriorly
Cocksackie virus
Usually involves buccal mucosa with erythema
Drug reaction
Painful, lips also involved, skin lesions usually present
Erythema multiforme
(Stevens-Johnson syndrome)
May precede skin lesions
Pemphigus
One to three painful, round, shallow lesions; no induration
Aphthous stomatitis
Usually single lesion, causes moderate discomfort, indurated, of moderate depth, on gums, tongue, or mucosa
Tuberculosis or histoplasmosis
Painless, solitary, round, deep, indurated
Syphilis chancre
May be multiple, causes moderate discomfort, deep, of varying size, usually little induration
Granulocytopenia
Painful, irregular, usually singular, minimal induration
Trauma
Minimal pain early, of variable size and shape, marked induration
Carcinoma
