Sandbox:Shalinder: Difference between revisions

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===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with atopic dermatitis usually appear normal.  


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*Vitals signs in atopic dermatitis patients are usually within normal limits.
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
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*  
*  
*  
*  
* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with atopic dermatitis is usually normal.
OR
 
* Abnormalities of the head/hair may include ___
* Abnormalities may include:
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with atopic dermatitis is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
 
===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with atopic dermatitis is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with atopic dermatitis is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
 
===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
* Abdominal examination of patients with atopic dermatitis is usually normal.
OR
*[[Abdominal distention]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with atopic dermatitis is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Genitourinary examination of patients with atopic dermatitis is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Neuromuscular examination of patients with atopic dermatitis is usually normal.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)
 
===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with atopic dermatitis is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 15:15, 3 October 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]

Overview

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

History and Symptoms

History

Patients with atopic dermatitis may have a positive history of:[1]

  • cutaneous hyper-reactivity to diverse environmental stimuli:
    • exposure to food and inhalant allergens
    • changes in physical environment (including humidity, pollution etc)
    • irritants
    • microbial infection
    • stress
  • personal or family history of type I hypersensitivity
  • asthma
  • allergic rhinitis

Common Symptoms

Common symptoms of atopic dermatitis include:[2]

  • Pruritus
  • Chronic or relapsing dermatitis
  • Distribution of rash on:
    • Facial and extensor surfaces in infants and young children
    • Flexure lichenification in older children and adults
  • Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis)

Less Common Symptoms

Less common symptoms of atopic dermatitis include:[3]

  • Facial pallor/facial erythema
  • Xerosis (especially in winter)
  • Nonspecific dermatitis of the hands and feet
  • Food intolerance
  • Itch when sweating

References

  1. ↑ Leung DY (June 2013). "New insights into atopic dermatitis: role of skin barrier and immune dysregulation". Allergol Int. 62 (2): 151–61. doi:10.2332/allergolint.13-RAI-0564. PMID 23712284.
  2. ↑ Deleuran, M.; Vestergaard, C. (2014). "Clinical heterogeneity and differential diagnosis of atopic dermatitis". British Journal of Dermatology. 170: 2–6. doi:10.1111/bjd.12933. ISSN 0007-0963.
  3. ↑ Rudikoff D, Lebwohl M (June 1998). "Atopic dermatitis". Lancet. 351 (9117): 1715–21. doi:10.1016/S0140-6736(97)12082-7. PMID 9734903.

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Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Physical Examination

The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.

Appearance of the Patient

  • Patients with atopic dermatitis usually appear normal.

Vital Signs

  • Vitals signs in atopic dermatitis patients are usually within normal limits.

Skin

  • Primary findings:
    • Severe pruritus- cardinal feature of atopic dermatitis
    • Eczematous lesions- location of lesions has age-specific patterns
    • Xerosis (especially during winters)
    • Lichenification
    • An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
  • Eczema:
    • Acute atopic dermatitis:
      • The skin is erythematous with papules and vesicles, and can usually get infected with Staphylococcus aureus
      • Lesions presents as intense pruritic erythematous papules and vesicles with exudation and crusting
    • Subacute or chronic atopic dermatitis:
      • The skin is dry, infiltrated and usually lichenified with scales and fissures. In severe cases the disease can lead to erythroderma
      • Lesions are dry, scaly, or excoriated erythematous papules
      • Lichenification (chronic scratching may result in skin thickening) and fissuring may develop over time
    • Age-specific patterns:
Infants and young children(zero to two years)
  • Earliest lesions:
    • Presents with erythema and exudation of the creases(antecubital and popliteal fossae)
  • Over the following few weeks:
    • highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the extensors of the lower legs
  • Lesions are ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques.
  • The most commonly involved areas:
    • Scalp, cheeks and extensor side of the extremities.
    • Flexural areas, especially the neck fold, may be involved
  • Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
  • Diaper area is generally spared
  • Lichenification is uncommon in infancy
Older children and adolescents (2 to 16 years)
  • Lichenification is characteristic of childhood AD
  • Areas involved:
    • Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases
    • Volar aspect of the wrists and ankles may be involved
    • "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
  • Thickened plaques show lichenification and excoriation
  • Xerosis is generalized
  • Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes is often seen
  • Centrofacial pallor is common
  • Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retroauricular fissuring)
  • In African-American children, follicular papular lesions are prominent and striking and hypopigmentation and hyperpigmentation
Adults (from puberty onward)
  • Lesions are more localized and lichenified.
  • Areas involved:
    • Facial involvement is common, especially the forehead and periorbital regions.
    • Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
  • A brown macular ring around the neck may be present (localized deposition of amyloid)- "Atopic dirty neck"
  • Xerosis is prominent
  • Associated symptoms with atopic dermatitis:
Atopic stigmata

(associated cutaneous findings seen in atopic dermatitis patients)

  • Atypical vascular responses
    • Centrofacial pallor
    • delayed blanch response
  • Skin
    • Keratosis pilaris
    • Palmar hyperlinearity
    • Pityriasis alba
    • ichthyosis
  • Ocular/periorbital
    • Periorbital darkening and Dennie-Morgan infraorbital folds
    • Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
  • Other
    • Infra-auricular and retro-auricular fissuring
    • Nipple eczema
    • White dermographism
    • Perifollicular accentuation
  • Clinical phenotypes of atopic dermatitis:
    • Localized and morphological variants of atopic dermatitis are present in both children and adults.
    • These variants can present as only clinical feature of atopic dermatitis or can present in association with age related manifestations.
  • Localized variants:
    • Atopic hand eczema:
      • Atopic hand eczema typically affects volar wrists and dorsum of the hands.
      • one-third of patients with atopic hand eczema, also reports foot eczema.
      • Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
      • Most common in adults exposed to wet environments
    • Eyelid eczema :
      • Some patients of atopic dermatitis, may present with eyelid eczema alone
      • associated with lichenification and presence of Dennie-Morgan lines
    • Atopic cheilitis:
      • Also known as lip eczema or cheilitis sicca
      • Presents as dryness, peeling, and fissuring of the lips
Different phenotypes of atopic dermatitis
  • Acute vs chronic eczema
  • Intrinsic vs extrinsic atopic eczema
  • Early onset vs late onset
  • Mild vs severe eczema
  • Increased IgE vs non-atopic
  • S. aureus infection/colonization, disseminated viral or fungal infections e.g. EH, molluscum contagiosum, Malassezia
  • Associated with ichthyosis, keratosis pilaris, palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
Localized variants Morphological variants
  • Hand eczema
  • Juvenile palmar and plantar dermatitis
  • Eyelid dermatitis
  • Atopic cheilitis
  • Periorificial dermatitis
  • Nipple dermatitis
  • Nummular eczema
  • Atopic prurigo
  • Lichen planus-like
  • Pityriasis alba
  • HEENT examination of patients with atopic dermatitis is usually normal.
  • Abnormalities may include:

Neck

  • Neck examination of patients with atopic dermatitis is usually normal.

Lungs

  • Pulmonary examination of patients with atopic dermatitis is usually normal.

Heart

  • Cardiovascular examination of patients with atopic dermatitis is usually normal.

Abdomen

  • Abdominal examination of patients with atopic dermatitis is usually normal.

Back

  • Back examination of patients with atopic dermatitis is usually normal.

Genitourinary

  • Genitourinary examination of patients with atopic dermatitis is usually normal.

Neuromuscular

  • Neuromuscular examination of patients with atopic dermatitis is usually normal.

Extremities

  • Extremities examination of patients with atopic dermatitis is usually normal.

References

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