Diagnostic Tests for Bowen's disease: Online Medical Books
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SKIN THICKENING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
In cases of diffuse thickening of the skin, a thyroid profile with T
3
, T
4
, and TSH should be done. This should also identify hypothyroidism. A positive ANA test with a speckled pattern will help identify scleroderma, but a skin biopsy should also be done. An antisclerodermal antibody titer is also useful if available. Esophageal motility studies will be helpful in early diagnosis. A skin biopsy will help identify many of the other conditions mentioned above. Urine for porphyrins will help identify porphyria.
Source:Algorithmic Diagnosis of Symptoms and Signs, 2003
Skin, scaly:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.
Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails.
Source:Professional Guide to Diseases (Eighth Edition), 2005
Skin, scaly:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.
Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails.
Source:Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Squamous cell carcinoma:
Diagnosis
(Handbook of Diseases)
An excisional biopsy offers definitive support for a diagnosis of squamous cell carcinoma. Other appropriate laboratory tests depend on systemic symptoms.
Skin, scaly:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.
Source:Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Intoeing and Outtoeing:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Intoeing
At birth, the foot normally turns inward10–20 degrees. By 2 yrs of age, the foot normally turns outward10–20 degrees.
Foot
Metatarsus Adductus
Medial deviationof forefoot that is thought to occur from in utero positioning.Lateral aspect of forefoot is convex and curves inward, whereasnormally it should be straight.
If foot comes into neutral positionwith passive motion, manual exercises are usually all that are requiredfor correction.
Serial casting should be consideredwith moderate-to-severe foot angulation or inflexibility.
Talipes Equinovarus (Clubfoot)
Deformitycharacterized by adduction of forefoot, turning inward of hindfoot,plantar flexion of ankle (equinus), and high arch (cavus) at midfoot.Foot cannot be passively moved into neutral position.
Spinal dysraphism and arthrogryposismay be associated findings.
Imbalance of Abductor and Adductor Muscles of the Great Toe
Imbalancepulls big toe and sometimes forefoot into varus position. Gap existsbetween first and second toes, but this gap narrows with walking.
This condition may be noted in earlyinfancy but usually resolves spontaneously by 2–3 yrs ofage.
Knee and Leg
Internal Tibial Torsion
Tibia rotatesinward in relation to femur in this disorder, which is thought toarise from in utero positioning. At birth normal children have 0–20degrees of internal tibial torsion. Natural history of this conditionis slow derotation, so that by 7 yrs of age, normal position oftibia is 0–40 degrees of external tibial torsion with averageof 20 degrees.
Tibial torsion can be assessed by measuringthe thigh-foot angle, which is the angle formed by the foot in relationto the thigh with child in prone position and knee flexed to 90degrees (Fig. 34.1).Thigh-foot angle that is ≤0 degrees indicates internal tibialtorsion.
Torsion of lower leg also can be assessedby visualizing both malleoli with knees flexed to 90 degrees. Normally,medial malleolus is anterior to lateral malleolus in normal adultalignment. If lateral malleolus is in a plane in front of medialmalleolus, and feet and hips are normal, internal tibial torsionis present. Resolution usually occurs with onset of walking andrunning.
If significant torsion persists beyond2–3 yrs of age or is severe at any age, orthopedic consultationis recommended.
Fig. 34.1.
Bowlegs (Genu Varum)
Angular deformity at knee where tibia isadducted in relation to femur.
Physiologic Bowing
Physiologicbowing of tibia secondary to in utero positioning may not be noticeduntil child begins walking.
Distance between knees with medialmalleoli held together when child is in supine position with hipsand knees in extension is estimation of severity. Distance of <10cm indicates mild bowing, and child can be observed. Distance of >10cm indicates more severe bowing, and referral to an orthopedic physicianis indicated.
Rickets
Can causesevere bowing of lower extremities. Other findings include rib prominence (rachiticrosary), fragile bones, and widening of wrists.
Radiography of knee can usually distinguishrickets from physiologic bowing. Radiologic changes in rickets includeloss of normal zone of provisional calcification with fraying andcupping of metaphyseal areas, demineralization of bones with lossof normal cortical architecture, and loss of epiphyseal definition.
See further discussion of rickets in Chap. 59, Seizures.
Blount Disease
Dysplasiaof medial aspect of proximal tibial epiphysis, which results indisruption of proximal growth plate and bowing of lower legs.
Can be unilateral or bilateral andshould be suspected when bowing worsens or fails to improve spontaneouslyduring second year of life.
Radiographs of knee show irregularfragmentation of medial aspect of proximal tibia and beaking ofmetaphysis.
Knock Knees (Genu Valgum)
Knees angulateaway from midline, but toes turn in. Tibias are abducted in relationto femurs.
Common in children 2–6 yrsof age.
With knees held together and childsupine, distance between medial malleoli is measured. If distanceis >10 cm, condition may require orthopedic management.Otherwise, spontaneous resolution often occurs by 8 yrs of age.
Hip
Increased Femoral Anteversion
Laxity ofligaments around hip joint contributes to femoral anteversion, whichoccurs primarily in girls, usually 3–7 yrs of age. Allindividuals have some degree of anteversion, which is forward positionof femoral head in relation to femoral shaft. In adults normal anteversionangle is 10–15 degrees, whereas in developing child itis somewhat wider.
Femoral anteversion may be assessedby measuring hip rotation (Fig.34.2).
With child in prone position and hips in fullextension with knees flexed to 90 degrees, legs are rotated throughaxis of hip joint.
In girls from middle of childhood on,mean medial rotation of hip is about 40 degrees, with normal rangeof 15–60 degrees, whereas in boys mean rotation is about50 degrees, with normal range of 25–65 degrees.
In both girls and boys from middleof childhood on, mean lateral rotation of hip is about 45 degreeswith normal range of 25–65 degrees.
If lateral rotation is >25degrees, normal gait usually can be achieved. With <15–20degrees of lateral rotation, compensation is difficult and gaitmay be abnormal.
Femoral anteversion tends to improveuntil 7–9 yrs of age. In severe cases, rotational osteotomymay be indicated.
Fig. 34.2.
Outtoeing
Foot
Calcaneovalgus Foot
Thoughtto arise from in utero positioning and characterized by hyperdorsiflexionand varying degrees of eversion and forefoot abduction. Can be unilateralor bilateral and is often associated with external tibial torsion.
Passive exercises with plantar flexionand inversion are all that is usually required for correction.
Spasticity
Increasedresistance to joint movement and usually accompanied by hyperreflexia. Anklesare in equinus position, and feet are in valgus position.
Common causes include hypoxic-ischemicencephalopathy, cerebral palsy, head trauma, bacterial meningitis,and stroke.
Hypermobile Pes Planus
Children with flexible flat feet are usuallyasymptomatic. In non–weight-bearing position, normal mediallongitudinal arch is visible, but with weight bearing, arch is nolonger visible and shift in weight medially causes foot to pointoutward.
Knee and Leg
External Tibial Torsion
Attributedto in utero positioning and is often associated with calcaneovalgusfoot. It is much less common than internal tibial torsion.
Thigh-foot angle of ≥40 degreesindicates excessive external tibial torsion, which begins to improvewith walking and usually resolves by 2–3 yrs of age.
Medial malleolus is also noted to bemore anterior than lateral malleolus with knee in 90 degrees offlexion.
External tibial torsion may developin compensation for excessive femoral anteversion.
If severe at any age, orthopedic consultationis recommended.
Hip
Femoral Retroversion
Much lesscommon than femoral anteversion. It may be noted in early childhoodand is usually bilateral.
There is excessive lateral rotationof hips, usually to 60–80 degrees, and limited medial rotationof 10–30 degrees. Entire lower extremity rotates outward.Functional impairment does not usually occur, but if severe, surgerymay be necessary.
Diagnostic Approach
Historyand physical exam can usually reveal causes of intoeing and outtoeing.
It is important to note age of childbecause many of these disorders present at specific ages. Metatarsusadductus, talipes equinovarus, and calcaneovalgus deformity areusually noted at birth; internal tibial torsion, external tibialtorsion, and bowed legs in infancy; and knock knees, femoral anteversion,and femoral retroversion in childhood.
Radiography is useful, especially withsuspected rickets or Blount disease.
Source:The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Skin, scaly:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, detergents, dryer sheets, cosmetics, skin lotion, and hair preparations he uses.
Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails. Then assess the skin over the remaining areas of the body.
Source:Nursing: Interpreting Signs and Symptoms, 2007
SKIN THICKENING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
If myxedema is suspected, a thyroid-stimulating hormone (TSH) test and
FT4 test can be ordered. If
scleroderma is suspected, order an ANA, anticentromere antibody titer or a
skin biopsy. Urine for porphyrins will help to identify porphyria. Carcinoid
syndrome can be identified by a urine test for 5-hydroxyindole acetic acid
(HIAA).
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