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Fingers clubbing

Fattened appearance of distal phalynx with loss of angle between proximal edge of nail
and skin. Associated with (but not pathognomonic for) COPD, cystic fibrosis, hypoxia, and a number
of other disease states.


Causes
1. Infective endocarditis
2. lung abscess
5. chronic liver disease 4. Bronchectaisis 3. lung carcinoma
Grades
1. loss of angle
2. loss of angle + fluctuation
3. Drum stick appearanc
4.Hypertrophic pulmonary osteoarthropathy
proliferation of tissue
Splinter hemorrhage
small linear splinter hemorrhage is seen here
subungually on the left thumb
the Linear hmg. Is parallel to the long axis of
nails
Causes
1. vasculitis trauma
2. Infective endocarditis


Xanthomata also
xantheolasma


Yellow deposits on the area
Caused by intracutanaus cholesterol deposits

*indicate type I or II hyperlipidemia

Tendon =type II hyperlipidemia

pallor and tuboeruptive=Type III hyperlipidemia
Yellow deposits apparent above
and below eyes, due to infiltration
with fat laden cells
Localised
deposition of the
lipid in the tendon
of the palm of the
hand
Fat deposition in the
knees
Pitting Edema

Swelling in the limb and if you press the swelling there will be slor &
Redill
Causes:
1. right sided heart failure 2. hepatic cirrhosis
3. GI malabsorption 4-nephrotic syndrome
pitting unilateral: lower limb edema:
DVT Compression on large vans by tumor or enlarged L.N
pectus excavatum
.
Localized depression of the low end of sternum
give cosmetic effects
the cause could be due to lung restriction or
due chronic child respiratory illness or rickets
Carcinoma of the Breast
elevation of the breast and retraction of the
nipple
Peutz-Jegher Syndrome

discrete, brown-black lesion around the mouth and
buccal mucosa
it indicates hamartomatous polyps of the Bowel and
colon
inherited Autosomal dominant
Hereditary hemorrhagic
telangictasia

. multiple small hmg. Involving the lips
_associated mostly with Osler-weloer synd.
It is autosomal dominant and mostly associate with
arteriovenous malformation in the liver and GI
bleeding
prophyria cutanea trada
Porphyria cutanea tarda can be inherited as a dominant trait or acquired due to
liver disease. Sun exposed areas develop blistering (vesicles and bullae),
erosions and ulcerations, fragile skin, pigmentary changes, and scarring.
The cause mostly is:
_ prophyrine metabolism disorder as in alcoholism and Hepatitis
Spider nevi

numerous small vessels look like spider legs distributed over the chest
founding Neck, arm, chest.

causes 1. liver cirrhosis 2. viral hepatitis 3. pregnancy

DDX1. Campbell de Morgan bodies 2. hereditary Hmg telangectaisia
*spider nevi opposite venous stars
Sclera Icterus

Yellow discoloration of the sclera
occurs in tissue containing elastin
causes 1 . hemolysis 2. obstructive Jaundice
when Billirubin level exceed 2-5 mg/dl
Periorbital purpura

black-red discoloration in the peri orbital area
(amyloidosis)

Abdominal distention
.
distended abdomen umbilicus pointed downward
causes
1.fetus 2. fluid 3. fat 4. flatulence 5.
Tumor
Caput medusa
Dilated, tortuous, superficial veins radiating upwards from the umbilicus. Portal
hypertension has caused recanalization of the umbilical vein, allowing the
formation of this collateral


DDx :inferior vena cava obstruction
Spleenomegaly
Massively enlarged spleen, the result of extramedullary
hematopoiesis, is outlined above.
This patient's left upper quadrant appears more full than
the corresponding area on the right
causes
1.infection, hepatitis 2.hemlaytic anemia
4. portal hypertension 3. SLE
Digital infarction
Causes:
abnormal globulin
And osteoarthritis
Thrombocytopenic purpura

hmg into the skin
causes:
1-increase platelets destruction as, in :
a-immuno thrompocytopenic pupura
b-loss of blood
2- decrease in platelet formation as Bone marrow Aplasia
*found in liver diseases and hemophilia
Rheumatoid arthritis
Fingers
1.swan neck deformity
2. Z deformity of thumb
3.Bounyonnirtr deformity

Wrist :
1. ulnar deviation of metacarpophalangeal Joints
2. palmar subluxation of fingers
Chronic inflammation of the MCP joints
has lead to their
deformity, with deviation of fingers
towards the ulnar aspect of the upper
extremity

Osteoarthritis
1- distal interphalangeal Joint= Hebradns nodes
2- proximal interphalngeal Joint=Bouchards nodes
Rheumatoid vasculitis
vasculitis appears around nail folds

indicate active disease

D.Dx
2. infective endocarditis 1. SLE. & Rheumatoid Arthritis
Psoriatic nail
Onycholysis (separation of nails from the bed)and
discoloration of fingernails

Causes: psoriasis and thyrotoxicosis
Gouty tophi
Site :
1. helix of the ear 2. Synovium 3.Forearum
Pathology:
urate deposition with inflammatory cell surrounding it
Indicate presence of chronic recurrent infection
Causes :
1- increase urate synthesis 2. decrease urate excretion

SLE
Butterfly rash of the face

Features:
1.moon face 2.vasalitis
4. Alopecia 3. pallor
Goiter




neck swelling

causes of neck swelling:
*midline 1.Gorter 2. Thyroglossal cyst 3.submental L.N.
*lateral 1. L.N. 2. Salivary glands

feature of Thyrotoxicosis :
2. onycholysis 1. palmar erythema
4. exopthalmos 3.Gynecomastia
Exophthalmus
protrusion of the eye ball from the orbits
Complications:
1.chemosis 2. conjunctivitis 3. corneal ulcer
4.optic atrophy 5. opthalmoplegia
Causes:
2. Graves disease 1. tumor of the orbit
Cushing Syndrome
1.moon face
2. central "truncal" obesity
3.Brusing
4.Buffalo hump
5.erythema & acne
causes :
1. exogenous ACTH administration
2. congenital Adrenal hyperplasia
3. ACTH 2nry to hyperpituitarisim
Striae
Broad, slightly pigmented, linear marks associated with multiple clinical
conditions. In this case, the axillary region striae are related to prior
weight loss
Most common cause is cushings syndrome(increase the steroid) and
in steroidal therapy
Addisons disease
pallor crease pigmentations

Causes:
adernocortical hypofunction

Features:
1.cachexia 2. vitiligo
Down Syndrome
1. oblique orbital fissures
2. small simple ears
3. mouth hanging open.
4. protruded tongue
5. short hand and broad
Rickets
1. frontal Bossing
2. Bowing of ulna and femur
Causes:
1. vit. D deff. 2. hypophosphatemia
Facial Palsy
1. dropping of mouth corner
2. flattened nasolabial fold
3. sparing of the forehead
Cause:
Upper motor neuron lesion due to tumor or vascular lesion .

Facial palsy
3 ABNORMALITIES:
1-loss of forehead wrinkle
2-LOSS ability to close eye
3-decreased naso-labial fold prominence
on left
4-LOSS ability to raise corner of mouth
CLINICAL IMPRESSION:
LMN OF LEFT 7TH CRANIAL NERVE
Jonway lesion
Flat, painless, erythematous lesions seen on
the palm of this patient's hand Frequently

Seen in infective endocarditis
Onychomycosis
Fungal infection causing deformity of the
fingernail
DX: THROMBOSIS
ABNORMALITIES:
1-Right upper extremity DVT
2- MUSCLE WASTING
3- 2-LINE CATHETER
PHYSICAL ABNORMALITY:

1-Left Axillary Adenopathy
2- CAMBOLE DE MORGAN BODIES
Oslers nodules




Seen in infective endocarditis
Painful, erythematous nodules
Marfans Syndrome. (Tall stature)
Describe: Long limbs and pectus excavatum
1. Aortic regurgitation
2. High arched plate
3. thoracic kyphosis
cause inherited clt disorder.
Erythema nodosum
Causes:
Sterptococcus b infection,TB and leprosy

And associated with INFLAMMATORY BOWEL
SYNDROME


PYODERMA GANGRENOSUM
Associated with INFLAMMATORY BOWEL
SYNDROME
SUBCUTANOUS NODULES
MAINLY CAUSED BY RHEUMATOID ARTHRITIS
IRITIS
MAINLY associated with INFLAMMATORY
BOWEL SYNDROME & CONNECTIVE
TISSUE DISEASES
Horner's Syndrome :
Loss of sympathetic nervous system input to (in this case)left eye .

Note that left pupil is smaller than right. Also that left eyelid covers a greater portion of
eye than on right
(known as ptosis). The etiology in this case was itiopathic, though it can be
associated with tumors
occurring at the apex of the lung, among other things .
PALMER ERYTHEMA
Redness of thinner and hypothinner with whitish
appearance in the middle of the palm
Causes : pregnancy,thyrotoxicosis,chronic liver
diseaseetc
KOILONYCHIA
SPOON SHAPE NAILS

MAINLY CAUSED BY IRON DEFICIENCY ANEMIA
LEUKONYCHIA
THE CAUSE IS HYPOALBUMINIMIA IN
CHRONIC LIVER DISEASES
Arcus senilis puple
Deposition of the lipid in the corneal stroma

The cause is Hyperlipidemia

Dupuytrens contraction
thickening of the palmar facia. In this case severe enough
that
it limits finger extensions


Causes: alcoholic cirrhosis , pancreatitis or occupitional
acromegaly

gynecomastia


.
Breast development in men, often related to relative increase in estrogen
levels. In this case ,
associated with advanced liver disease or androgen decrease .
hypothyrodisim
MYXIDEMA







PHYSICAL ABNORMALITY:
CYANOSIS

WHAT DO YOU LOOK NEXT FOR?
WARMTH OF THE HAND?? Or under the
tongue for central cyanosis??
D V T
Right Lower
Extremity DVT
Left Lower
Extremity DVT

Left Lower Extremity
DVT : Note diffusely
swollen left leg. Skin
changes
on left are due to
chronic venous
insufficiency
VARICOSE VEINS