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A thorough symptom analysis is essential and should include details regarding the onset and progression of the skin change generic 50mg viagra soft otc; anything the patient believes may trigger viagra soft 50 mg sale, exacerbate buy viagra soft 50mg mastercard, or relieve the problem buy viagra soft 100mg low cost; how it has changed since first noticed cheap viagra soft 100mg with visa; and all associated symptoms, such as itching, malaise, and so on. When a patient has a skin complaint, it is important to 12 Copyright © 2006 F. Skin 13 include a wide range of other integumentary symptoms in the review of systems. For instance, ask whether the patient has recently experienced any of the following: dryness, pruritus, sores, rashes, lumps, unusual odor or perspiration, changes in warts or moles, lesions that do not heal, or areas of chronic irritation. Establish whether the patient has noticed any changes in the skin’s coloration or texture. Determine what the patient believes caused or contributed to the problem, any self-treatment and the response, and any distress caused by the complaint. Even minor and self-limited skin problems can cause a great amount of anxiety owing to their visibility and their uncomfortable symptoms, such as burning, oozing, or itching. Past Medical History The past medical history should include details on any previous dermatologic illnesses. Ask about infectious diseases associated with skin changes, such as chicken pox, measles, impetigo, pityriasis rosea, and others. Identify chronic skin problems, such as acne vulgaris or rosacea, psoriasis, and eczema. Determine the history of any previous skin treatments, biopsies, or procedures, as well as general surgical history. Because disorders in other systems frequently affect the skin, ask about the history of cardiovascular, respiratory, hepatic, immunologic, and endocrine dis- orders. Identify any recent exposures to others who have been ill and/or who have had obvi- ous skin problems that might have been contracted. Many medications affect the skin, and a list of all prescribed and over-the-counter agents should be obtained, including herbal and nutritional supplements. Table 2-1 includes a nonexhaustive list of medications with potential adverse skin effects. Finally, ask the patient how he or she generally tolerates expo- sure to the elements, such as heat, cold, and sun, to determine whether environmental exposure is responsible for or may contribute to the patient’s complaint. Family History The family history should include the occurrence of such skin diseases as eczema, psoria- sis, and skin cancer, as well as other disorders commonly associated with skin problems, such as cardiovascular, respiratory, hepatic, immunologic, and endocrine disorders. Habits Investigate habits related to skin, hair, and nail care. Identify any chemicals used in groom- ing, as well as potential exposures encountered through work and recreational activities. Identify occupational, daily living, and recreational activities that could be responsible for lesions resulting from friction, infestations, environmental extremes (heat/cold/sun), and other variables. Dietary history is helpful for identifying the potential sources of atopic reactions. PHYSICAL EXAMINATION Order of the Exam During the general examination of the skin, compare side to side for symmetry of color, texture, temperature, and so on. There are many situations in which additional equipment, such as a magnifier, Copyright © 2006 F. Skin 15 measuring device, flashlight/transilluminator, and Wood’s (ultraviolet) lamp, are helpful. The progression for the skin exam can be completed in a systematic head-to-toe fashion, or by region as other systems are being examined and are uncovered. Regardless of the sequencing or system chosen, the exam of the skin consists of both inspection and palpa- tion. Privacy is an important consideration because any area being examined must be com- pletely bared. As the skin is examined, it is important to keep in mind the structures underlying the skin and the amount of exposure a particular area is likely to receive. This can help to explain any particular “wear and tear” patterns, scars, calluses, stains, and/or bruises. For instance, an eczematous rash on the area of the nipple and/or areola should always trigger consideration of Paget’s disease, a malignant breast condition (see Plate 20). As the history is obtained, a general survey is performed to determine the patient’s gen- eral status. Notice the posture, body habitus, obvious respiratory status, and whether the patient is guarding or protecting any area of the skin.

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Colon cancer Key Concept/Objective: To be able to distinguish inflammatory bowel disease from other disor- ders purchase 50 mg viagra soft with amex, and to be able to distinguish between Crohn disease and ulcerative colitis The diagnosis of inflammatory bowel disease is suggested by the fact that the patient’s symptoms developed over a number of months buy 100mg viagra soft overnight delivery, that the patient has an oral aphthous ulcer safe 50 mg viagra soft, that fecal leukocytes are present purchase 100mg viagra soft, that the patient has experienced weight loss and has anemia cheap 50mg viagra soft with mastercard, and by the possibility that the patient’s brother has a similar problem. The presence of nocturnal symptoms and fecal leukocytes eliminates irritable bowel syndrome. The long course makes acute appendicitis unlikely, though either irritable bowel syndrome or acute appendicitis can occur in patients with inflammatory bowel disease. The history is not suggestive of colon cancer, especially given this patient’s young age and in the absence of an inherited polyposis syndrome. The factors favoring a diagnosis of Crohn dis- ease over that of ulcerative colitis at this stage in the evaluation include the association of smoking with the onset of symptoms. Crohn disease is strongly associated with smoking, but smoking decreases the risk of ulcerative colitis. In addition, the negative results on flexible sigmoidoscopy essentially eliminate ulcerative colitis from consideration. A 33-year-old woman with Crohn disease presents with a flare of disease activity consisting of fever, right lower quadrant pain, weight loss of more than 10% of body weight, guaiac-positive diarrhea, and macro- cytic anemia. Her disease is limited to the small intestine and terminal ileum. Her examination is sig- nificant for a temperature 100. Which of the following statements is true for this patient? The anemia is probably caused by folate deficiency B. Sulfasalazine is first-line therapy and will probably be sufficient to control her symptoms C. An aminosalicylate will be required to control this flare D. Corticosteroids will be necessary to control her symptoms E. She should be hospitalized and given infliximab Key Concept/Objective: To understand the treatment of inflammatory bowel disease This patient has moderate to severe Crohn disease, as judged on the basis of her fever, weight loss, abdominal pain without obstruction, and ability to continue oral intake. Sulfasalazine is unlikely to deliver much anti-inflammatory activity to the small bowel because sulfasalazine is poorly hydrolyzed into its component sulfa and active salicylate moieties until it comes into contact with colonic bacteria. Aminosalicylate would be help- ful, but for symptoms of this severity, a corticosteroid will be necessary. Infliximab, an anti–tumor necrosis factor monoclonal antibody, is an option for treatment of severe Crohn disease in patients who are not responsive to salicylates, antibiotics, or steroids. Unless the small bowel mucosal disease is very extensive, the macrocytic anemia is most likely caused by a deficiency of vitamin B12, which is absorbed in the terminal ileum. Two 28-year-old men with inflammatory colonic disease are seen in clinic; one has ulcerative colitis and the other has Crohn disease. Each is concerned about complications of his disease. Which of the following is a correct assessment of these two patients? Each may have arthritis in both HLA-B27–related and non–HLA- B27–related distributions 8 BOARD REVIEW B. Kidney stones can occur in each but are more common in patients who have ulcerative colitis C. Sclerosing cholangitis in a spectrum from mild to severe can occur in ulcerative colitis but not in Crohn disease D. Erythema nodosum and peripheral joint manifestations of colitis sec- ondary to inflammatory bowel disease follow a course independent of the bowel disease and should be treated with NSAIDs E. These two men have toxic megacolon, which is a complication unique to ulcerative colitis Key Concept/Objective: To know the extraintestinal manifestations of inflammatory bowel dis- ease Inflammatory bowel disease is associated with peripheral joint arthritis and other condi- tions, such as erythema nodosum, that are not HLA-B27–associated and whose manifesta- tions correlate with those of inflammatory bowel disease. NSAIDs worsen inflammatory bowel disease and can lead to bowel disease becoming refractory. Arthritis of the axial skeleton is HLA-B27–related and progresses independently of intestinal disease. Kidney stones are seen primarily in Crohn disease of the small intestine and are caused by increased oxalate absorption associated with malabsorption of intestinal fat and the bind- ing of calcium to fatty acids. Cholangitis occurs in both ulcerative colitis and Crohn coli- tis.

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CLINICAL APPROACH As with other pathologies discount 100 mg viagra soft with mastercard, the medical history should be detailed in the evaluation of cel- lulite viagra soft 50mg cheap. The patient should be questioned regarding the age at which cellulite appeared purchase viagra soft 100 mg, prior occurrence of trauma discount 50mg viagra soft, liposuction or injections in the affected area purchase viagra soft 50 mg with mastercard, history of prior 12 & HEXSEL ET AL. Other aspects that should be researched are sedentarism, diet, psychosomatic factors, smoking, prior pregnancy, and the behavior of cellulite during pregnancy. Although smoking and circulatory problems are frequently cited as causative agents of cellulite, in the experience of the present authors, in a sample of 1200 patients with advanced cellulite, the vast majority were neither smokers (more than 80%) nor those hav- ing varicose veins or other circulatory problems. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 13 Figure 4 (A) Relaxed skin tension lines mapped on a body scheme. The left half shows the frontal view and the right half, the back view. Table 2 Classification of Cellulite Classification Evaluation results Degree or stage 0 There is no alteration to the skin surface Degree or stage I The skin of the affected area is smooth while a subject is standing or lying down, but undulations on the skin surface can be seen on pinching the skin or during muscle contraction (Fig. Cellulite can be better observed with the application of the pinch test, in which the skin in the area to be examined is pinched between the thumb and index finger to form a fold by skinfold plicometry or through the contraction of the muscles in the Figure 5 First degree cellulite, in which there are no alterations to the skin surface in a standing position and with relaxed gluteous muscles. Alterations are found under the pinch test applied to the skin of the affected area. DEFINITION, CLINICAL ASPECTS, ASSOCIATED CONDITIONS, AND DIFFERENTIAL DIAGNOSIS & 15 Figure 6 ‘‘Orange peel’’ or ‘‘mattress’’ appearance of second degree cellulite. Overhead or tangential illumination of the patient facilitates the visualization of cellulite (29). There are significant differences in the appearance of cellulite, depending on the position and the method used for its classification. For this reason, the standing position is recommended for the examination of a patient with cellulite. Palpation should always be performed to check the elasticity of the skin (6) and sub- cutaneous tissues. However, at present there are no exact parameters for the classification of skin elasticity. Venous or lymphatic insufficiency may, in theory, aggravate cellulite and should also be checked during the physical examination (35). One should make note of the presence of varicose and telangiectatic leg veins as well as any pitting edema or induration of the skin. A Doppler or duplex ultrasound examination of the superficial venous system will also help to classify the significance of venous insufficiency. Even if venous insuffi- ciency is not found to be an etiologic factor in the pathogenesis of cellulite, its presence or absence will help direct appropriate treatment regarding graduated compression. Figure 7 Third degree cellulite, showing raised and depressed areas and modules plus orange peel or mattress appearance. AGGRAVATING FACTORS A number of clinical conditions or circumstances frequently accompany or aggravate cel- lulite, especially obesity, localized fatty accumulations, and skin flaccidity. Obesity promotes a generalized increase in body weight (skeletal, muscular, intersti- tial fluid, organ hypertrophy, etc. After a return to the original baseline weight is achieved, an increased accumulation of fat is observable (36). The clinical manifestation of localized adiposity is an increase in the ill-defined symmetrical and bilateral diffuse volume, owing to an increase in the adipose tissue (29). The localized increase in adipose tissue in the subcutaneous tissue leads to the aggravation of cellulite lesions by contribut- ing to a worsening of the irregular undulations of the skin. The increase in fat volume leads to an augmentation of tension forces within the fat lobules. This tension is projected to the skin surface and aggravates the depressions, causing an effect similar to that of a stuffed quilt (29). These alterations contribute to the appearance of the mechanical and circulatory alterations that occur in cellulite. Greater thickness of the subcutaneous fat in the affected areas may be seen by histopathological examination and can be measured by special instruments or by the pinch test (Fig. This study demonstrates the protrusion of adi- pose tissue into the dermis when the volume of subcutaneous fat is augmented, which explains the mattress-like appearance (31). Flaccidity is caused by physiological ptosis of subcutaneous structures, making the skin permanently distended and loose.

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