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Diseases » Skin rash » Tests
 

Diagnostic Tests for Skin rash

Contents
  1. Skin rash: Introduction
  2. Symptoms of Skin rash
  3. Diagnosis
  4. Failure to Diagnose
  5. Alternative Diagnoses
  6. Misdiagnosis
  7. Complications

Skin rash Tests: Book Excerpts

Skin rash Diagnosis: Book Excerpts

Diagnosis of Skin rash: medical news summaries:

The following medical news items are relevant to diagnosis of Skin rash:

Diagnostic Tests for Skin rash: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Skin rash.

RASH--DISTRIBUTION: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there are any exudates, a smear and culture for fungi and routine bacteria should be done. Skin scrapings may be examined microscopically with a saline or potassium hydroxide preparation to rule out scabies and fungi. A Wood's lamp examination is very useful in diagnosing various fungi. All isolated lesions should be biopsied.

Diffuse rashes require routine CBC, sedimentation rate, urinalysis, chemistry panel, ANA test, and VDRL test. If there is fever, blood cultures should probably be done. Skin biopsies in consultation with a dermatologist should be done in a timely fashion. Patch testing and intradermal skin testing should be done when appropriate. A dark field examination may be necessary. GI series and barium enemas may be necessary to look for GI neoplasms, Crohn's disease, and ulcerative colitis.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RASH--MORPHOLOGY: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

This can be found under Rash--Distribution.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS ANI: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If the physical examination is normal, examination with an anoscope is essential. Sigmoidoscopy should also be done but is not adequate to detect hemorrhoids, anal fissures, and fistulas. If these are negative, a trial of antifungal creams (Lotrimin®, etc.) should be given before other expensive diagnostic tests are ordered. A Scotch tape test and stool for ovum and parasites are useful, especially in children.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS, GENERALIZED: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there is an associated skin rash, microscopic examination of a potassium hydroxide preparation of curetted burrows will be helpful. Additional examinations include Wood's lamp evaluation, a patch test, and skin biopsies. Therapeutic trials for scabies, fungal disease, or other disorders, however, are justified if testing is not economically feasible. Routine laboratory tests for the various systemic diseases that may cause pruritus include a CBC, sedimentation rate, urinalysis, chemistry panel, ANA assay, thyroid profile, and serum protein electrophoresis. A bone marrow examination and lymph node biopsy may be useful. A dermatologist, hematologist, or endocrinologist may help solve the diagnostic dilemma. Further workup may include plain films of the chest and abdomen and CT scans of the abdomen and pelvis. A bone scan may be useful in diagnosing metastatic carcinoma. HIV testing may be indicated if the patient has a history of high-risk sexual behavior.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS, VULVAE: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there is a discharge, microscopic examination of a potassium hydroxide preparation and saline preparation is necessary. A smear and culture of the discharge should be done for bacteria and fungi. Scrapings of the burrows for scabies may be useful. Skin biopsy may help diagnose the cause of a rash. Lesions should be biopsied also. If senile vaginitis is suspected, serum FSH and estradiol and a Pap smear may help determine if there is estrogen deficiency. A gynecologist should be consulted in all difficult diagnostic problems.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Papular rash: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pustular rash: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pruritus: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of  perfumes)?

Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.

Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, mottled: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check the capillary refill time. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Butterfly rash: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus [LE])?

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vesicular rash: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.

Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin turgor, decreased: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol?

Next, take the patient’s vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he’s in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/
minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, start an I.V. line for fluids.

Evaluate the patient’s level of consciousness (LOC) for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Also, check his jugular veins for flatness, and monitor his urine output.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, clammy: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 564.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

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.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Papular rash: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.

Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pustular rash: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pruritus: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after hefalls asleep. (Generally, pruritus related to dermatoses prevents—but doesn’t disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or use of perfumes)?

Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have any pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history.

Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, mottled: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check capillary refill. Palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Assess motor and sensory function.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Butterfly rash: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body. (See Butterfly rash: Causes and associated findings.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Café-au-lait spots: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient or his parents when the café-au-lait spots first appeared. Also ask about a family history of these spots and of neurofibromatosis. Review the patient’s history for seizures, frequent fractures, or mental retardation.

Inspect the skin, noting the location and pattern of the spots. Look for distinctive skin lesions, such as axillary freckling, mottling, small spherical patches, and areas of depigmentation. Large lesions should be measured along the longest axis. A Wood’s light examination may help visualize lesions in pale-skinned individuals. Check for subcutaneous neurofibromas along major nerve branches, especially on the trunk. Also check for bony abnormalities, such as scoliosis or kyphosis.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vesicular rash: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has treated the rash with a topical medication, what type did he use and when did he last apply it? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies and recent infections, insect bites, or exposure to allergens.

Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin turgor, decreased: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol?

Next, take the patient’s vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he’s in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, start an I.V. line for fluids.

Evaluate the patient’s level of consciousness for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Check his neck veins for flatness and monitor his urine output.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, bronze: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by asking the patient when the hyperpigmentation first appeared. Has its hue changed? When was he last exposed to the sun or artificial tanning source? Also, ask about a history of infection, illness, surgery, or trauma. Does he have abdominal pain, weakness, fatigue, diarrhea, or constipation? Has he recently lost weight? If the patient is receiving maintenance therapy for adrenal insufficiency, has his dosage been increased?

Examine the mucosa, gums, and scars for hyperpigmentation. Check for signs of dehydration and for abdominal distention, loss of body hair, and tissue and muscle wasting. Palpate for hepatosplenomegaly.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, clammy: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Check for abdominal distention and increased muscle tension.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

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.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pruritus: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

The physical examination includes a thorough examination of the skin in adequate lighting. Direct special attention to skin areas not easily observed or reached by the patient. Such areas may reveal a primary skin disorder or evidence of a systemic disease because some disorders present in particular areas. For example, scabies involves the interdigital webs, volar wrists, and genitalia, whereas atopic dermatitis occurs in the antecubital or popliteal fossae. Pityriasis rosea typically has a “herald patch” on the trunk. Fungal infections tend to occur in warm, dark, moist body surfaces (e.g., genitalia, feet, and inguinal folds).

Be able to recognize the classic signs of common skin disorders. Dematographism and wheals typically indicate uticaria (hives) (Chapter 13.7). Flat-topped polygonal papules with delicate white lines (“Wickham’s straiae”) are characteristic of lichen planus. Silver plaques on an erythematous base with a positive Auspitz sign (punctuate bleeding of the scale after blunt scraping) are characteristic of psoriasis. The application of lateral pressure on superficial, crusting lesions resulting in dislodging the epidermis, referred to as Nikolsky’s sign, indicates pemphigus foliaceus. The differential diagnosis of lymphadenopathy includes mycosis fungoides (Chapter 15.1). Pustular or lesions over hair follicles is a sign of folliculitis. Pay attention to new unscratched lesions because chronically excoriated skin from any cause has similar secondary changes. If lesions are present in unreachable areas, a systemic disease should be considered. In addition to the skin, examine other organ systems for organomegaly, lymphadenopathy, goiter, pregnancy, and signs of anemia or psychiatric disorders.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Rash Accompanied by Fever: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Examine the lesions and their distribution carefully. Classify the rash as petechial, maculopapular, vesiculobullous, erythematous, or urticarial. Note the distribution of the rash. For instance, rubella and rubeola generally begin on the face and spread to the trunk, whereas RMSF petechiae tend to occur on the ankles and wrists first.

 B. Conduct a general physical examination. Areas of particular concern are:

 1. Head, eyes, ears, nose, and throat. The presence of Koplik’s spots is pathognomic for rubeola. The discovery of a tick lends support to the diagnosis of RMSF. Sinusitis may represent a source for meningococcemia. Pharyngitis in a young adult with diffuse erythema may be caused by C. haemolyticum. Mucous membrane swelling may indicate early anaphylaxis.

 2. Lung examination. Expiratory wheezing, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis. Evidence of pneumonia is consistent with psittacosis and mycoplasma.

 3. Cardiac examination. Cardiovascular collapse is associated with meningococcemia and other sepsis. A new murmur (Chapters 7.6 and 7.7) may indicate subacute bacterial endocarditis in a patient with subungual or scleral petechiae.

 4. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea. A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

 5. Joint examination and extremities. A petechial rash near the ankles and wrists is suggestive of RMSF. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis and other rheumatologic conditions as well.

6. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

Testing

 should be directed by illnesses suspected, with life-threatening illnesses being tested for on reasonable suspicion. A complete blood count is generally useful, although life-threatening sepsis often presents without significant elevation of white blood count. In general, a blood culture should be obtained in all patients with petechial rashes and in those with signs of cardiovascular collapse.

Diagnostic assessment

Based on history and physical examination, the likelihood of various illnesses can be assessed. Patients who appear toxic should be treated as septic until initial laboratory and culture results can be evaluated (4).


References

1. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.

2. Drolet BA, Baselga E, Esterly NB. Painful, purpuric plaques in a child with fever. Arch Dermatol 1997;133(12):1500–1501.

3. Anonymous. Fever, nausea, and rash in a 37-year-old man [clinical conference]. Am J Med 1998;104(6):596–601.

4. Dellinger RP. Current therapy for sepsis. Infect Dis Clin North Am 1999;13(2):
495–509.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Maculopapular Rash: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Carefully examine the lesions and their distribution.

 1. A rash that is on the face and spreading to the trunk is characteristic of measles or rubella. Many viral illnesses have a predilection for the trunk.

 2. A maculopapular rash occurring on the palms initially should prompt concern about syphilis. RMSF rash also occurs on the palms; usually, however, this rash is not raised until 3 or so days into the course of illness and it is accompanied by purpura on the ankles and wrists. Disseminated gonorrhea lesions are usually on the fingers and quickly become pustular. Meningococcemia can spread widely, but can present as a macule with central petechiae, which progressively becomes nodular.

 B. Conduct a general physical examination. Areas of particular concern are:

 1. Head, eyes, ears, nose, and throat. Although measles is becoming rare, the presence of Koplik’s spots is pathognomic for the illness. A common location for ticks is in the scalp hair, and the discovery of a tick lends support to the diagnosis of RMSF. Rarely, meningococcemia will be a complication of sinusitis, and often it develops following complaints of pharyngitis. Mucous membrane swelling may indicate early anaphylaxis.

 2. Lung examination. Wheezing on examination, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis.

 3. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea (Chapter 10.9). A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

 4. Joint examination. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis as well.

5. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

Testing

Tests are generally selected according to the most likely cause of the rash, with a complete blood count (CBC) being the most commonly ordered test.

 A. A CBC is often useful. Increased neutrophils may indicate a bacterial infection; especially when immature neutrophils are present. The CBC is not a sensitive indicator for these infections, however. A relatively normal white blood count does not exclude serious infections (3). Lymphocytosis may indicate a viral infection. Increased eosinophils are occasionally seen with allergic reactions. Myelogenous leukemias generally present with abnormalities on CBC.

 B. Other testing should be performed on the basis of the most likely causes of the rash.

1. Consider syphilis testing in all cases, especially in those patients with palmar rashes.

 2. Consider a smear and culture of any pustules, especially if meningococcemia or gonococcemia is suspected.

 3. Cerebrospinal fluid examination is useful if meningococcemia is suspected; it is usually negative in RMSF, despite headache, back stiffness, and other signs.

Diagnostic assessment

 Although no one key is seen to diagnosing a maculopapular rash, history is the most important key (4). The presence or absence of a fever aids in narrowing the diagnostic field to infectious versus noninfectious causes. The age of the patient aids in determining whether the rash is likely the result of a common viral childhood illness versus an illness more often associated with adults (e.g., syphilis). The exposure history helps in ruling in or out diseases common in selected geographic areas (e.g., RMSF on the United States east coast or dengue fever in Central America). Nevertheless, a careful and thorough physical examination is required as well as judicious use of laboratory testing.


References

1. Schwarzenberger K. The essentials of the complete skin examination. Med Clin North Am 1998;82(5):981–999.

2. Granier S. Recognizing meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information. BMJ 1998;
316(7127):276–279.

3. Kuppermann N. Clinical and hematological features do not reliably identify children with unsuspected meningococcal disease. Pediatrics 1999;103(2):E20.

4. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Vesicular and Bullous Eruptions: Testing
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. The Tzanck smear is used to diagnose viral dermatoses: herpes simplex, herpes zoster, KVE, and varicella. Select an early intact vesicle without infection or trauma; remove the blister top and scrape the floor lightly with a scalpel; smear the material on a clean glass slide; air dry and fix; stain with Wright or Giemsa stain. A positive test is the presence of multinucleated giant cells (2).

B. Biopsy of the edge of the blister and subsequent immunofluorescent staining is helpful for diagnosing pemphigus vulgaris, bullous pemphigoid, and EMB (3).

Diagnostic assessment

The presence or absence of a toxic appearance guides the clinician initially. History that includes age, season of onset, special precipitators, whether the lesions are itchy, and the duration of lesions then further assists in classification. Finally, the appearance of the lesions and their distribution further reduce candidate illnesses. It is important to remember that significant and occasionally life-threatening illnesses present as vesiculobullous lesions.


References

1. Robin KL, Piette WW. Cutaneous manifestations of systemic diseases. Med Clin North Am 1998;82(6):1359–1379, vi–vii.

2. Brodell RT, Helms SE, Devine M. Office dermatologic testing: the Tzanck preparation. Am Fam Physician 1991;44(3):857–860.

3. Gellis SE. Bullous diseases of childhood. Dermatol Clin 1986;4(1):89–98.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Papular rash: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Fully evaluate the papular rash: note its color, configuration, and location on the patient’s body. Then complete a whole-body examination of the patient’s skin, hair, and nails.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pustular rash: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Assess the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pruritus: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Observe the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, mottled: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check capillary refill. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Butterfly rash: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vesicular rash: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, bronze: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the mucosa, gums, and scars for hyperpigmentation. Check for signs of dehydration and for abdominal distention, loss of body hair, and tissue and muscle wasting. Palpate for hepatosplenomegaly.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, clammy: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Take vital signs and perform a cardiovascular assessment. Then proceed with the remainder of a complete physical assessment. Be sure to examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, scaly: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

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.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin Lesions and Rashes: Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Classificationof skin lesions into 1 of the 9 types described above is helpfulin diagnosis. Knowledge of specific skin lesions, especially theirmorphology and distribution, is necessary for diagnosis. Age ofchild, mode of inheritance, whether child is well or ill, presenceof fever and other systemic symptoms, and nature of primary lesionhelp narrow diagnostic possibilities. In most cases, history andphysical exam are diagnostic.
  • Most important tests to confirm someof disorders discussed above include the KOH preparation; bacterial,viral, and fungal cultures; PCR; and skin biopsy, including immunepathology and electron microscopy, if necessary.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Papular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient's body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

    Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pustular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

    Examine the entire skin surface, noting if it's dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pruritus: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents—but doesn't disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?

    Ask the patient how he cleans his skin and clothes. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient's general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history. Ask about abdominal pain and the appearance of stools.

    Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses. Note any jaundice. Check for hepatomegaly or abdominal pain.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin, mottled: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn't in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it better? Does anything make it worse? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

    Take the patient's vital signs. Observe the patient's skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check the capillary refill time. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Butterfly rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

    Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Vesicular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask your patient when the rash began, how it spread, and whether it has occurred before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.

    Examine the patient's skin, noting if it's dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they're flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky's sign).

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin turgor, decreased: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol? How much fluid, especially water, does he ingest daily?

    Next, take the patient's vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he's in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, insert an I.V. catheter for fluid administration.

    Evaluate the patient's level of consciousness for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Also, check his jugular veins for flatness, and monitor his urine output.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin, clammy: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 562.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

    Next, take the patient's vital signs and pulse oximetry. Examine the pupils for dilation and check his level of consciousness. Note respiratory rate. Assess for respiratory distress. Auscultate the heart and lungs. Place the patient on a cardiac monitor and assess heart rhythm. Also, check for abdominal distention and increased muscle tension.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Rash - Case 9-2: 7-Week-Old Girl: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 37.0°C; RR, 43/min; HR, 180 bpm; BP, 113/53 mm Hg
    Height, 50th percentile; weight, 50th percentile
    The physical examination was remarkable for a hemangioma of the left occiput, a hematoma of the tip of the tongue, and two ecchymotic areas on the right mandible, each about 1 cm in diameter. She had three 3- to 4-cm ecchymotic areas on the left back. A caf é-au-lait macule (1 cm) was seen on the left thigh. Lungs were clear. Cardiac examination revealed tachycardia but no murmurs, rubs, or gallops. There was no hepatosplenomegaly and no prominent adenopathy. Neurologically she was alert, crying, and moving all extremities. Funduscopic examination revealed right retinal hemorrhages. The rest of her examination was normal.

    VI. Diagnostic Studies

    Laboratory analysis revealed 18,800 WBCs/mm3, with 39% segmented neutrophils, 49% lymphocytes, and 11% monocytes. The hemoglobin was 11.4 g/dL, and there were 406, 000 platelets/mm 3. PT and PTT were normal. Electrolytes, BUN, and creatinine were normal. Alkaline phosphatase was 270 mU/mL. Other liver function studies were as follows: alanine aminotransferase, 100 IU/L; aspartate aminotransferase, 220 IU/L; and γ-glutamyltransferase, 46 IU/L. Examination of the cerebrospinal fluid revealed 8 WBCs/mm 3and 5,250 red blood cells/mm3. The glucose concentration was 60 mg/dL, and the protein concentration was 36 mg/dL. There were no organisms on Gram staining of the CSF.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Diagnosis of Skin rash

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