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92 Cards in this Set

  • Front
  • Back

Muehrcke's lines = severe hypoalbuminemia < 2.2g/dL; 2 or more paired transverse white bands.


Peripheral edema is a common complaint.


Differential Dx includes:


- heart failure


- renal failure


- decompensated liver failure (often with secondary renal dysfunction)


- hypoalbuminemia


- nephrotic syndrome = preserved function, but lost in urine

Mees' lines = arsenic poisoning, cancer chemotherapy or heavy metal poisoning; depressed lines

Beau's lines

Nail pitting = severe psoriasis

Terry's nails = hypo pigmentation caused by cirrhosis of the liver or CHF

Lindsay's nails = half- and half; lightening of proximal half of nail; associated with renal failure

Onycholysis = hyperthyroidism (graves + psoriasis) separation from nail bed

Koilonychia = spooning of nails by iron deficiency or malnutrition


Can be caused by chronic GI bleed that leads to associated iron deficiency.


Severe anemia also produces pallor of hands and mucosa

Digital clubbing = hypoexmia for some duration of time (months or years); distance across DIP joint is less than the diameter of the nail bed; conditions associated:


- cystic fibrosis


- intersitial lung disease


- lung cancer


- COPD (usually have lung cancer too)


- congenital heart disease


- hepatic cirrhosis


- inflammatory bowl disease

Basal cell carcinoma = flesh colored or pearl papule, central ulceration, telangectasias, low grade, but malignant

Actinic keratosis = exposed skin, premalignant

squamous cell carcinoma = fungating lesion

Melanomas

Livedo reticularis = lacy pattern network, occlusion of dermal and subnormal venues and/or arterioles which may be vasospastic and transient (cold, Raynaud's syndrome) or more persistent:


- form of vasculitis


- cholesterol embolism (hx of recurrent miscarriage and stroke-like phenomenon)


- DIC


- antiphosppholipid syndrome (APS)


- common finding with exposure of skin to cold temperature, but at normal temperatures and widely distributed = abnormal


-

Vitiligo = antibody against melanocyte, consider other autoimmune disorders and hypothyroidism

Mechanics hands = thickened callouses throughout with decimation, associated with antisynthase syndrome (dermatomyositis)

Malar Rash of SLE

Lupus Vulgaris (tuberculosis) - papule that ulcerates from sin inoculation of TB

Blastomycosis = ulcerated raised lesion that is fungated, mimics squamous cell carcinoma


- presents with fever and classically involves the lung, sin, bone, GU system and brain


- takes 21 to 100 days for incubation

erythema chronic migrans = Lyme disease = clearing along the edges, target, not painful, very susceptible to antibiotics at this point


- febrile illness w/focal skin lesion, headache without meningismus and regional LAD

Secondary Spyhilis = hand and foot papular raised ulcerated lesions, not painful

Herpes Zoster = painful vesicular burning dermatomal pain, does not cross the midline, can involve the face

Erythema gangrenosum (pseudomonas bacteremia) = infection with gram negative bacillus, invades vascular structures

What are the symptoms of iron deficiency anemia?

What are the findings of endocarditis?

osler node = embolization of immune complex producing small vessel vasculitis - painful, raised 
splinter hemorrhages can also be caused by trichinosis
- associated with IV drug abuse 
- inflammatory mono arthritis and febrile illness associated
-...

osler node = embolization of immune complex producing small vessel vasculitis - painful, raised


splinter hemorrhages can also be caused by trichinosis


- associated with IV drug abuse


- inflammatory mono arthritis and febrile illness associated


- paraspinous abscess often leads to back pain and paralysis (vs drug seeking)

Where can xanthomas occur?

tendon xanthomas is indicative of familial hyperlipidemia

tendon xanthomas is indicative of familial hyperlipidemia

What are the different forms of psoriasis?

plaque psoriasis occurs over extensor surfaces

plaque psoriasis occurs over extensor surfaces

What are the findings for dermatomyositis?

Gottron's papules = over MCP or PIP joints 
mechanics hands = subtype of dermatomyositis

Gottron's papules = over MCP or PIP joints


mechanics hands = subtype of dermatomyositis

What are the findings for tuberous sclerosis?

Higher incidence of cancer than normal patient population.
Angiofibromas look a lot like acne but they are firm, not pustular, blanch.
Shagreen patch = subcutaneous CT.

Higher incidence of cancer than normal patient population.


Angiofibromas look a lot like acne but they are firm, not pustular, blanch.


Shagreen patch = subcutaneous CT.

What are the findings for Von Recklinghausen's disease?

Lisch nodules are diagnostic of neurofibromatosis.
NF1 patients are at increased risk of malignant transformation of nerve sheath tumors and increased risk of rhabdomyosarcoma and other soft tissue sarcomas.

Lisch nodules are diagnostic of neurofibromatosis.


NF1 patients are at increased risk of malignant transformation of nerve sheath tumors and increased risk of rhabdomyosarcoma and other soft tissue sarcomas.

What are the findings for Ehlers-Dalos syndrome, classic form?

Should not be painful

Should not be painful


+ Gorlin sign = hyper extensibility

What is onycholysis? What is associated with?

separation of nail plate from hyponychium.


Seen in trauma, psoriasis and hyperthyroidism.

What characterizes psoriasis?

characterized by erythematous, sharply demarcated papillose and round plaques with silvery micaceous scale.

What is a periungal fibroma? What else should you look for with this finding?

Flesh-colored papillose of nail folds (both toes and fingers) seen in 50% of pt with tuberous sclerosis.


Look for angifibromas of the face, ash leaf spots and Shagreen patches.


Angiomyolipoma of the kidney can effect 80% of pt and are large producing abdominal pain

What is arachnodactyly? What disease is it associated with? What are other findings?

long thin fingers associated with Marfan syndrome. Other findings include:
- long limbs
- ectopic lentis
- spine and chest deformities
- mitral valve prolapse (no chest pain, not an emergency)
- skin striae

long thin fingers associated with Marfan syndrome. Other findings include:


- long limbs


- ectopic lentis


- spine and chest deformities


- mitral valve prolapse (no chest pain, not an emergency)


- skin striae


+ Steinberg thumb

What is a major concern with Marfan Syndrome patients?

Aortic root dilation predisposing to aortic dissection - causes a chest pain and is a medical emergency

What are Dupuytren's contractures?

Shortened and fibrotic hand flexor tendons are associated with alcohol abuse.

Shortened and fibrotic hand flexor tendons are associated with alcohol abuse.

What are the findings in alcoholism?

- often malnourished +/- cirrhosis
- hypertension
- Dupuytren's contractures
enlarged lacrimal and parotid glands
- exophthalmos
- alcholoic cardiomyopathy
- Tom Wolfe's sign = full head of hair
- lab findings: high normal MCV, elevated serum uric...

- often malnourished +/- cirrhosis


- hypertension


- Dupuytren's contractures


enlarged lacrimal and parotid glands


- exophthalmos


- alcholoic cardiomyopathy


- Tom Wolfe's sign = full head of hair


- lab findings: high normal MCV, elevated serum uric acid, high GGT



Herpes zoster of face - presentation, treatment

crusted rash on the ophthalmic distribution of CNV, does not cross midline


begins with pain followed in 1-2 days by vesicular rash that becomes crusted.


Treat with systemic anti-viral drugs (acyclovir) and consult ophthalmologist

Recurrent HSV usu presents with oral and peri-oral lesions

oral manifestations of secondary syphilis (condyloma lata) usu not painful

What are the findings of spondyloarthropathy?

findings:


- asymmetric joint involvement


- few joints involved (oligoarthritis)


- sausage digit (dactylitis)



What are the Ddx of spondyloarthropathy?

- reactive arthritis (ex: following STD or scrape)


- inflammatory bowel disease


- ankylosing spondylitis


- psoriatic arthritis (5-7% develop arthritis)

What is CREST syndrome?

Calcinosis cutis (little white bumps of calcium)


Raynaud's phenomenon


Esophageal dysmotility


Sclerodactyly (fingers curl due to tightening of CT)


Telangectasias




All part of Limited Scleroderma = hardening of skin

Secondary syphilis - presents with rash and constitutional symptoms. First lesion is painless and can be missed.

Neisseria meningitidis = produces epidermic meningits and often diffuse purpuric lesions (petechial rash)

o Acral lentiginous melanoma
with nail bed involvement the nail plate may have dark brown discoloration (due to melanin).
o Beau’s lines
transverse grooved (e.g. depressed) lines parallel to lunula occurring after serious medical illness, post-surgical and/or severe infections.
o Clubbing
produced by soft tissue growth at the nail bed and identified by noting a greater anterior-posterior distance at the nail bed as compared to the same distance at the distal interphalangeal joint (also creates a nail-finger angle >180 degrees). Clubbing typically occurs in response to thoracic disease, including cyanotic congenital heart disease, cystic fibrosis, pulmonary fibrosis, lung cancer, and severe hepatic cirrhosis (with hepato-pulmonary syndrome). Although reported in severe COPD, other pathology (e.g. lung cancer) must be excluded before accepting COPD as the sole cause.
o Koilonychia (aka spooning of nail)
the nail curves upward away from nail bed (concave instead of the normal convex appearance). This is a classic finding in iron deficiency anemia.
o Lindsay’s nails
also termed half-and-half nails, the proximal portion of the nail is pale/whitish while the distal 20-60% of the nail is brown, pink or reddish. Lindsay’s nails are associated with renal failure.
o Mees’ lines
transverse white band parallel to the lunula. Originally described with arsenic intoxication, may also be seen with thallium as well as after acute medical conditions such as lymphoma and malaria. The current most common etiology is following cancer chemotherapy (a poison of sorts).
o Muehrcke’s lines
two or more paired transverse white bands associated with severe hypoalbuminemia (usually < 2.2 g/dL).
o Nail pitting
small depressions in nail that are present in up to 50% of patients with psoriasis (usually more severe cases).
o Onycholysis
irregular separation of the nail plate from the hyponychium. Can be traumatic in origin, but also seen in psoriasis and hyperthyroidism.
o Periungual fibroma (aka Koenen tumor)
flesh-colored papule of nail folds (toes > hands) seen in ~50% of patients with tuberous sclerosis (see below under skin).
o Quitter’s nail
heavy cigarette smoking leads to orange-brown discoloring of the nails and fingers holding the cigarette. A normal proximal nail with distal discoloration indicates smoking cessation; chronicity of abstinence can be estimated by understanding that nail growth is 0.8-1.0 mm per week.
o Splinter hemorrhages
small brown or red streaks perpendicular to the lunula, and often involving the distal nail. These are most commonly traumatic in origin, but classically a consequence of microembolism from infectious endocarditis. They are also reported in scleroderma and trichinosis.
o Terry’s nails
proximal paleness of nail with only 1-2 mm of preserved pink distal border (appears dark). Terry’s nails were originally described with liver cirrhosis, but can also be seen in other severe medical conditions (e.g. heart failure, poorly controlled diabetes, hepatitis).
o Arachnodactyly (aka spider fingers)
long fingers that are associated with Marfan syndrome. The wrist circumference is less than the distance encompassed by the subject’s 5th finger and thumb.
o Bouchard’s node
bony protuberance of proximal IP joint without findings of inflammation -this is a finding in osteoarthritis.
o Boutonniere deformity
produced by extension at the distal IP joint and flexion at the proximal IP joint -a finding in severe, chronic rheumatoid arthritis.
o Dupuytren’s contractures
shortening of the finger flexors in the palm, may be idiopathic in origin but also associated with alcohol abuse and alcoholic cirrhosis.
o Heberden’s node
bony protuberance of distal IP joint without findings of inflammation -this is a finding in osteoarthritis.
o Janeway lesion
painless red macular lesion of palms/soles produced by embolism, usually due to infectious endocarditis.
o Joint hypermobility
ability to dorsiflex 5th finger > 90 degrees with forearm flat and/or passive apposition of the thumb to the flexor aspect of forearm; these findings suggest classic Ehlers-Danlos syndrome
o Large, fleshy hands
consider acromegaly if rings no longer fit (see below)
o Mechanic’s hands
thickened, cracked and dirty-appearing palmar skin mimicking those of a manual laborer suggests the anti-synthetase syndrome variant of dermatomyositis.
o Osler node
originally described in subacute bacterial endocarditis, these are painful red raised lesions of the ventral surface of fingers/toes caused by immune complex deposition.
o Pallor
of nail beds and palms is associated with severe anemia (hemoglobin < 7.0 g/dL); however, the conjunctivas are a better site for pallor assessment.
o Swan neck deformity
produced by extension at the proximal IP joint and flexion at the distal IP joint -a finding in severe, chronic rheumatoid arthritis.
o Actinic keratosis
pre-malignant lesion typically seen over sun-exposed areas.
o Basal cell carcinoma
low grade cancer with typical appearance: papule with translucent and “umbilicated” border, central ulceration and telangiectasia.
o Dermatomyositis findings
Gottron’s papules/sign (red, often scaly papules over the MCPs and PIPs; the term Gottron’s sign is applied to similar finding of the fingers, elbows and knees.); Heliotrope rash (violet discoloration of upper eyelids); Shawl sign (widespread, flat, reddened area over upper back, shoulders and posterior neck); V sign (similar to shawl sign, except that reddened skin conforms to a V-neck sweater pattern of the anterior chest)
o Hyperextensibility
defined as ability to stretch the skin >4 cm at forearm or neck before feeling resistance; this is a finding in Ehlers-Danlos syndrome
o Hyperpigmentation
must consider the patient’s background race/ethnicity and sun exposure. That said, diffuse hyperpigmentation may be seen with primary adrenal failure (aka Addison’s disease), hemochromatosis and hyperthyroidism.
o Livedo reticularis
mottled/reticulated, red-blue lacy skin discoloration with central pallor associated with small vessel vascular processes (see below).
o Malar red rash
one of the diagnostic criteria for systemic lupus erythematosus (and the genesis of the term lupus: Latin for wolf)
o Melanoma
malignant tumor of melanocytes with multiple manifestations (e.g. lentiginous, nodular). Important to recall that melanomas occur on skin without striking sun exposure (e.g. vulva) and remember ocular site.
o Neurofibromas
non-tender, soft, fleshy, sessile or pedunculated skin tumors; if present in great number should consider Von Recklinghausen’s disease and seek café-au-lait macules and axillary freckles (aka Crowe sign).
o Psoriasis
common disease (1-2% of population) most commonly manifested as red plaques with silvery scales of the extensor surfaces of arms and legs, as well as trunk and scalp. Other types include guttate, pustular, inverse and erythrodermic.
o Squamous cell carcinoma
often occur on sun-exposed skin (70%) and also associated with chronic scarring and inflammation, these usually begin as a nodule that often grows into a fungating lesion.
o Thin skin with visible small vessels
a finding in Ehlers-Danlos syndrome type 4, a condition associated with arterial rupture (e.g. aortic dissection).
o Tuberous sclerosis
characteristic skin findings include hypopigmented, often elliptical macules (aka ash-leaf spots), flesh-colored or red papules of central face that may mimic acne vulgaris (angiofibromas -previously adenoma sebaceum), periungual fibromas and Shagreen patch (flesh-colored, orange-peel-like connective tissue plaque, usually located on the lower back) -important to recognize as these patients usually have epilepsy, cognitive and neuropsychiatric disorders, an increased risk of cancer, a distinctive renal lesion (angiomyolipoma) and a risk of developing cystic lung disease (confirm with TSC gene test).
o Vitiligo
focal loss of melanin usually due to autoimmune condition; consider other autoimmune conditions.
o Xanthomas (tuberous, eruptive and tendon)
nodular, papular and tumorous lesions that may be confused with rash and/or infection, these are findings in hyperlipidemia, esp. familial variants.
• Blastomycosis
skin is the 2nd most common organ involved; the lesions may appear verrucous, ulcerate and closely mimic squamous cell cancer.
• Ecthyma gangrenosum
hemorrhagic vesicles or pustules that evolve into necrotic ulcers, these are a manifestation of infectious vasculitis due to Pseudomonas aeruginosa bacteremia.
• Erythema chronicum migrans
painless, rounded, slowly expanding red lesions with central clearing (may be target-like) at site of tick bite in early Lyme disease.
• Herpes zoster
manifestation of recurrent VZV infection, begins with burning dysesthesias of involved dermatome followed in a few days by vesicular dermatomal rash that does not cross the midline. Over time the rash will crust and fade, but the neuropathic pain may persist for many weeks.
• Lupus vulgaris (aka tuberculous chancre)
due to primary bacillus inoculation in non-sensitized host, it usually involves the face and hands, often in the setting of previous local minor trauma. Begins as a nodule that ulcerates with induration.
• Secondary syphilis
multiple presentations, rash often involves the palms and soles.