By M. Umbrak. Joint Military Intelligence College.

Because disorders in other systems frequently affect the skin purchase accutane 40 mg with mastercard skin care secrets, ask about the history of cardiovascular order accutane 20mg mastercard acne scar laser treatment, 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. The general survey should provide an indication of the patient’s overall skin condition, including color, visible lesions, mois- ture, and perspiration. As each section of skin is inspected and palpated, there are basic considerations. These include the skin’s color, moisture, texture, turgor, and any lesions. Color Color is highly variable among individuals of all racial and ethnic backgrounds. Color vari- ation is even found among an individual’s own various body regions, depending on several factors, including general exposure to the elements. For instance, coloring is typically darker in exposed areas and calluses may be slightly darkened or have a yellow hue. Some patients develop a vascular flush over their face, neck, chest, and extremity flexor surfaces when they are exposed to warm environments or emotional disturbances. Changes in color can also indicate a systemic disorder. Cyanosis, caused by decreased oxyhemoglobin binding, may indicate pulmonary or heart disease, a hemoglobin abnor- mality, or merely that the patient is cold. Observe for cyanosis in the nail beds, lips, and oral mucosa. Jaundice indicates an elevation in bilirubin and often is evident in the sclera and mucous membranes before obvious in the skin. Pallor can indicate decreased circula- tion to an area or a decrease in hemoglobin.

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Chemotherapy Pain therapy affected discount accutane 5 mg without a prescription acne information, but the plexus lesion can also be confined to the upper plexus or the whole plexus buy accutane 10 mg with visa acne home remedies. Birth injuries are tractional lesions and may affect upper portion (Erbs type) or lower portion (Klumpkes type). Pain is a frequently associated feature of brachial plexus trauma and is worst with root avulsion, where it may be the source of constant pain. Phrenic nerve conduction studies should be performed if a C4 root lesion is suspected. Neonatal brachial plexopathy: Occurs in less than 1% of cases in industrialized countries. Most commonly affects the upper plexus: C5/6, sometimes with C7. The diaphragm can be involved in 5% of cases, and bilateral lesions occur in 10–20%. Risks: high birth weight, prolonged labor, shoulder dystocia, difficult forceps delivery. Associated features: fractures of humerus or clavicle. Half of the patients show complete or partial improvement within 6 months. Aberrant regeneration can occur in any traumatic plexus injury, leading to innervation of other muscle groups either with or without motor function. Others: “Burner” syndrome Sudden forceful depression of the shoulder, occurs in US football. Transient sudden dysesthesia occurs in the whole limb, but may remain longer in upper trunk distribution. Clinical: upper extremities, asymmetric, with weakness of the lower motor neuron. Asymmetric distribution with shoulder and elbow focus. Differential diagnosis from ALS: slower development (2–6 years). Laboratory: Associated with anti-asialo-GM1 antibodies (10% to 20%) Serum CK: Mildly elevated Electrodiagnostic: EMG with denervation and reinnervation. NCV: Normal Differential diagnosis: Primary muscular atrophy (PMA), ALS, primary lateral sclerosis. Laboratory, genetic analysis Imaging: plain bone X ray, CT, MRI, adjacent structures: lung, ribs Electrophysiology: NCV, EMG, more difficult to establish conduction block over the brachial plexus Sympathetic function: sweat tests Table 7. NCV studies Sensory Brachial Plexus Trunk Cord Peripheral nerve Upper Lateral Lateral antebrachial cutaneous nerve Upper Lateral Median to first and second digit Upper Posterior Radial to base of the thumb Middle Posterior Posterior antebrachial cutaneous nerve Middle Lateral Median to second digit Middle Lateral Median to third digit Lower Medial Ulnar to fifth digit Lower Medial Dorsal ulnar cutaneous Lower Medial Medial antebrachial cutaneous nerve Motor Upper Lateral Musculocutaneous nerve Upper Posterior Axillary nerve Upper Suprascapular nerve Middle Posterior Radial nerve Lower Medial Ulnar nerve Other studies: F waves, spinal nerve root stimulation (electrical or magnetic), needle EMG of distal and paraspinal muscles. Therapy Conservative therapy is aimed at pain management and inclusion of physio- therapy to avoid contractures and ankylosis. If no improvement can be expect- ed, muscle transfer to facilitate function can be considered. The traumatic brachial plexus lesion is often a matter of controversy. Gener- ally speaking a period of four months is considered appropriate to wait for the recovery of neurapraxia. Suturing and grafting may lead to innervation of proximal muscles, but rarely reaches distal muscles. New developments show that avulsed roots can be reimplanted. Prognosis Chaudry V (1998) Multifocal motor neuropathy. Sem Neurol 18: 73–81 References Chen ZY, Xu JG, Shen LY, et al (2001) Phrenic nerve conduction study in patients with traumatic brachial plexus palsy. Muscle Nerve 24: 1388–1390 Eisen AA (1993) The electrodiagnosis of plexopathies. In: Brown WF, Bolton CF (eds) Clinical electromyography, 2nd edn. Butterworth Heinemann, Boston London Oxford, pp 211–225 Kori SH, Foley KM, Posner JB (1981) Brachial plexus lesions in patients with cancer. Neurology 31: 45–50 Millesi H (1998) Trauma involving the brachial plexus. In: Omer GE, Spinner M, Van Beek AL (eds) Management of peripheral nerve disorders.

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Before treatment with phlebotomy buy 20 mg accutane fast delivery skin care clinic, patients may be taken off diuretics and encouraged to lose weight and stop smoking cheap 10 mg accutane overnight delivery skin care over 50. A 21-year-old man presents to the emergency department for evaluation of pain and fever. One week ago, the patient was involved in a head-on motor vehicle accident; he was not wearing a seat belt. At that time, the patient underwent an emergent resection of his spleen. The patient states that for the past 2 days, he has been experiencing swelling and redness of his incision site, as well as fever. On physical examination, the patient’s temperature is 102° F (38. Diffuse swelling and induration is noted at his incision site, and diffuse erythema surrounds the incision. Laboratory values are remarkable for a white blood cell (WBC) count of 26,000/mm3 and a differential with 50% neutrophils and 22% band forms. Which of the following statements regarding neutrophilia is true? Neutrophilia is usually defined as a neutrophil count greater than 1,000/mm3 B. Thrombocytosis is commonly associated with splenectomy, but splenectomy has no association with neutrophilia C. Serious bacterial infections are usually associated with changes in the number of circulating neutrophils, as well as the presence of younger cells, but they are not associated with changes in neutrophil morphology D. With serious bacterial infections, characteristic morphologic changes of the neutrophils include increased numbers of band forms and increased numbers of cells with Dohle bodies and toxic granulations Key Concept/Objective: To know the definition and morphologic characteristics of neutrophilia Neutrophilia, or granulocytosis, is usually defined as a neutrophil count greater than 10,000/mm3. Neutrophilia most often occurs secondary to inflammation, stress, or corti- costeroid therapy. Serious bacterial infec- tions and chronic inflammation are usually associated with changes in both the number of circulating neutrophils and their morphology. Characteristic changes include increased numbers of young cells (bands), increased numbers of cells with residual endoplasmic retic- ulum (Dohle bodies), and increased numbers of cells with more prominent primary gran- ules (toxic granulation). These changes are probably caused by the endogenous production of granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor and are also seen with the administration of these growth factors. A 61-year-old woman visits your clinic for a follow-up visit. She has been coming to you for several weeks with complaints of diffuse rash, intermittent fevers, persistent cough, and dyspnea. Laboratory results were significant only for a WBC count of 15,000/mm3 with 40% eosinophils. You have completed an extensive workup for underlying allergy, connective tissue disease, malignancy, and parasitic infection, with negative results. A bone marrow biopsy revealed hypercellular marrow with eosinophils constitut- ing 50% of the marrow elements. Your working diagnosis is hypereosinophilic syndrome (HES). Which of the following statements regarding HES and eosinophilia is true? The criteria used to diagnose HES are an unexplained eosinophil count of greater than 1,500/mm3 for longer than 6 months and signs or symptoms of infiltration of eosinophils into tissues B. The term HES is often used for patients with chronic eosinophilia resulting from parasitic infection C. Eosinophilia is defined as an eosinophil count greater than 500/mm3 D. Long-term corticosteroid therapy is the only available therapy for HES Key Concept/Objective: To understand HES Evaluation of the patient with eosinophilia (i. The term HES is often used for patients with chronic eosinophilia of unknown cause. The cri- teria used to diagnose HES are an unexplained eosinophil count of greater than 1,500/mm3 for longer than 6 months and signs or symptoms of infiltration of eosinophils into tissues. If symptoms involving the lungs or the heart are present, prednisone at a dosage of 1 mg/kg/day should be given for 2 weeks, followed by 1 mg/kg every other day for 3 months or longer. If this treatment fails or if an alternative is necessary to avoid steroid side effects, hydroxyurea at a dosage of 0. Studies suggest that treatment with imatinib mesylate is effective. Alternative agents include interferon alfa, cyclosporine, and etoposide.

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