Sandbox:Shalinder

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:

• 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:

• 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:

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

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 is often secondarily infected with Staphylococcus aureus
  • intensely pruritic erythematous papules and vesicles with exudation and crusting
• Subacute or chronic atopic dermatitis:
  • the skin is infiltrated, dry and often lichenified with scales and fissures. In severe cases the disease can develop into erythroderma
  • dry, scaly, or excoriated erythematous papules
  • Skin thickening from chronic scratching (lichenification) 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 affect the creases (antecubital and popliteal fossae), with erythema and exudation.
    • Over the following few weeks, lesions usually localize 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.
    • Lichenification is seldom seen in infancy
    • highly pruritic, red, scaly, crusted, and sometimes weeping patches on both cheeks and on the extensor parts of the extremities
    • Eczematous changes of the scalp and wheal formation
    • napkin area is generally spared
    • scalp, cheeks and extensor side of the extremities are the most commonly involved areas. Flexural areas may also be involved, especially the neck fold
    • midline of the face and the tip of the nose, in particular, are always spared (Yamamoto’s sign).
    • pruritic, red, scaly, and crusted lesions on the extensor surfaces and cheeks or scalp ,  sparing of the diaper area, vesicles,
  • older children and adolescents (2 to 16 years):
    • Xerosis is often generalized. The skin is flaky and rough.
    • Lichenification is characteristic of childhood AD
    • eczematous and exudative
    • Pallor of the face is common
    • erythema and scaling occur around the eyes
    • Dennie-Morgan folds (ie, increased folds below the eye) are often seen
    • Flexural creases, particularly the antecubital and popliteal fossae, and buttock-thigh creases are often affected.
    • Excoriations and crusting are common
    • papulation rather than exudation
    • flexural areas, especially the antecubital and popliteal fossae
    • volar aspect of the wrists, ankles, and neck.
    • Thickened plaques show lichenification and excoriation
    • black children, follicular papular lesions are prominent and striking and hypopigmentation and hyperpigmentation
    • flexural areas of the skin, especially the cubital and knee folds, the wrists and ankles, and the face and hands. Dry skin and fissuring behind the ears or on the earlobe are also characteristic signs of the disease
    • lichenified plaques in a flexural distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists, ankles, and neck ,  sides of the neck may show a reticulate pigmentation, the so-called "atopic dirty neck"
  • adults (from puberty onwards):
    • few or no skin problems since infancy
    • or may have suffered a chronic relapsing course with periods of remission
    • diffuse with an underlying background of erythema
    • face is commonly involved and is dry and scaly
    • Xerosis is prominent
    • A brown macular ring around the neck is typical but not always present(localized deposition of amyloid)
    • Lichenification occurs in the flexural
    • the flexural areas are still affected and eczema is often present on the hands and feet.
    • facial involvement is common, especially the forehead and periorbital regions.
    • wrists, hands, ankles, feet, fingers, and toes are often involved
    • localized and lichenified,  skin flexures ,  Less frequently, the dermatitis may involve the face, neck, or hands
• Atopic dermatitiss can can be div

• 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

• 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

• 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

• 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 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