Sandbox:Shalinder

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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 [disease name] usually appear [general appearance].

Vital Signs

  • High-grade / low-grade fever
  • 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 examination of patients with usually shows:
    • cardinal feature of atopic dermatitis is severe pruritus.
    • An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
    • Dry skin, especially in winter, is characteristic of atopic dermatitis
  • 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
  • The clinical presentation at various ages can be described as follows:
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
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)
  • Xerosis is prominent
Atopic stigmata

(associated cutaneous findings seen in atopic dermatitis patients)

  • White dermographism
  • Keratosis pilaris
  • Palmar hyperlinearity
  • Pityriasis alba
  • Periorbital darkening and Dennie-Morgan infraorbital folds
  • Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
  • Infra-auricular and retro-auricular fissuring
  • Nipple eczema
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 [disease name] is usually normal.

OR

  • Abnormalities of the head/hair 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 examination of patients with [disease name] is usually normal.

OR

Lungs

  • Pulmonary examination of patients with [disease name] 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

  • Cardiovascular examination of patients with [disease name] 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
  • S1
  • S2
  • S3
  • S4
  • 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

  • Abdominal examination of patients with [disease name] is usually normal.

OR

Back

  • Back examination of patients with [disease name] is usually normal.

OR

  • Point tenderness over __ vertebrae (e.g. L3-L4)
  • Sacral edema
  • Costovertebral angle tenderness bilaterally/unilaterally
  • Buffalo hump

Genitourinary

  • Genitourinary examination of patients with [disease name] is usually normal.

OR

  • A pelvic/adnexal mass may be palpated
  • Inflamed mucosa
  • Clear/(color), foul-smelling/odorless penile/vaginal discharge

Neuromuscular

  • Neuromuscular examination of patients with [disease name] 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 examination of patients with [disease name] is usually normal.

OR

  • Clubbing
  • Cyanosis
  • Pitting/non-pitting edema of the upper/lower extremities
  • Muscle atrophy
  • Fasciculations in the upper/lower extremity

References

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