Module 4a GIT General Signs PDF

Module 4a: GIT General Physical Signs Dear Student In this module we will look at the general gastrointestinal (GIT) physical signs By the end of this session you will be able to: Identify and describe general signs related to the gastrointestinal conditions Understand the mech...

Module 4a: GIT General Physical Signs Dear Student In this module we will look at the general gastrointestinal (GIT) physical signs By the end of this session you will be able to: Identify and describe general signs related to the gastrointestinal conditions Understand the mechanisms (where appropriate) that give rise to these signs Describe physiological mechanisms governing these abnormal signs Describe the appropriate examining techniques to elicit specific clinical signs when assessing for specific GIT pathology Describe expected findings and variations related to GIT disease that may be found on general examination Differentiate a sign from a symptom Understanding and clarifying concepts The words ‘signs’ and ‘symptoms’ are used interchangeably by many people. However, there are important differences that affect their use in the field of medicine. What is a sign? A sign is an objective physical manifestation of a disease. It is an objective finding, something one can observe and measure. For example; A rapid pulse, a high temperature, a low blood pressure, bruising, an open wound, etc. are all signs. Signs give a more definite indication of the presence of a particular disease. What is a symptom? A symptom is subjective feeling from the patient point of view. A symptom is what the patient experiences about the disease. Symptoms can only be experienced; they are not able to be observed or measured objectively. For example; Pain is a symptom. I do not know you are having pain unless you tell me. So, in the simplest form, signs are observations of the doctor and symptoms are the experiences of the patient. Patients commonly have complaints (symptoms). These symptoms may or may not be accompanied by abnormalities on examination (signs) or on laboratory testing. Conversely, asymptomatic patients may have signs or laboratory abnormalities, and laboratory abnormalities can occur in the absence of symptoms or signs. UCT Clinical Skills MBChB Year 2 Page 1 of 25 Module 4a: GIT General Signs  A. ACANTHOSIS NIGRICANS 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Acanthosis nigricans is a skin condition characterized by areas of dark, velvety discoloration in body folds and creases. The affected skin can become thickened. 3. What medical conditions are associated with this sign? Cushing’s disease Diabetes mellitus Hypothyroidism Prostate/ ovarian cancer 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection of the skin: dark, velvety hyperpigmentation in body folds and creases. Paying attention to the neck, the armpits, groin, navel, forehead, and other areas. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? It is associated with endocrine dysfunction, especially insulin resistance and hyperinsulinemia, as seen in diabetes mellitus. This activates the insulin-like growth factor receptors, which leads to proliferation of keratinocytes, fibroblasts, and other cells in the skin. Activation of other growth factor receptors such as fibroblast growth factor receptors or epidermal growth factor receptor can also be responsible. UCT Clinical Skills MBChB Year 2 Page 2 of 25 Module 4a: GIT General Signs  B. ANGULAR STOMATITIS/CHEILITIS 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Inflammation of the angles/corners of the lips, that may present with maculopapular, vesicular or scaly lesions on the skin in the corners of the mouth. 3. What medical conditions are associated with this sign? Risk factors for development of this condition include: lip licking drooling hypesalivation malocclusion Down syndrome orthodontic treatment denture use anatomical volume loss in the aging face resulting in lip overlap nutritional deficiency hypervitaminosis A, atopic dermatitis, HIV primary immunodeficiency syndromes conditions requiring pharmaceutical immunosuppression and diabetes mellitus. 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Perform a thorough examination of the lips for the following: bleeding red swollen cracked blistered itching scaly painful UCT Clinical Skills MBChB Year 2 Page 3 of 25 Module 4a: GIT General Signs  5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Aetiology and Pathophysiology The aetiology of angular cheilitis is multifactorial and may involve interplay of physical conditions promoting a moist environment at the oral commissures and infectious agents. Although C albicans can exist harmoniously in the oral cavity, it is thought to contribute to the pathophysiology of angular stomatitis. A higher incidence of C albicans in affected individuals versus unaffected control patients and observed improvement of the condition with anti-candidal treatment supports this supposition. Other pathogens implicated in angular stomatitis include methicillin-sensitive S aureus, Streptococcus and gram-negative bacteria. The basic pathophysiology leading to angular stomatitis/cheilitis is maceration of the skin in the commissures, which disrupts the epidermal barrier. Such disruption provides a breeding environment for fungi and bacteria. Licking sore lips exacerbates things because salivary amylase damages the barrier. C. APTHOUS ULCERATION 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A recurrent round or oval sore or ulcer inside the mouth on an area where the skin is not tightly bound to the underlying bone, such as on the inside of the lips and cheeks or underneath the tongue. 3. What medical conditions are associated with this sign? Emotional stress and lack of sleep Mechanical trauma, for example, self-inflicted bite Nutritional deficiency, particularly of vitamin B, iron, and folic acid Certain foods, including chocolate Certain toothpastes: this may relate to sodium laureth sulfate (the foaming component of toothpaste) Menstruation Certain medications, including nicorandil, given for angina Viral infections UCT Clinical Skills MBChB Year 2 Page 4 of 25 Module 4a: GIT General Signs  4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection- ask the patient to open the mouth wide, and thoroughly examine the tongue for any abnormalities, these may include discoloration, and or sores. Aphthous ulcers typically begin as erythematous macules (reddened, flat area of mucosa) which develop into ulcers that are covered with a yellow-grey fibrinous membrane that can be scraped away. A reddish "halo" surrounds the ulcer. The size, number, location, healing time, and periodicity between episodes of ulcer formation are all dependent upon the subtype of aphthous stomatitis. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The cause is not entirely clear but is thought to be multifactorial. It has been suggested that aphthous stomatitis is not a single entity but rather a group of conditions with different causes. Multiple research studies have attempted to identify a causative organism, but aphthous stomatitis appears to be non-contagious, non-infectious, and not sexually transmissible. The mucosal destruction is thought to be the result of a T cell (T lymphocyte) mediated immune response which involves the generation of interleukins and tumour necrosis factor alpha. Mast cells and macrophages are also involved, secreting along with the T cells. D. ASTERIXIS 1. What does this sign look like? (see video on Vula) 2. How do I describe this sign using medical terminology? Asterixis (flapping tremors) is a motor disturbance marked by intermittent lapses of an assumed posture, because of intermittency of sustained contraction of groups of muscles. 3. What medical conditions are associated with this sign? Common causes- hepatic encephalopathy, renal failure, metabolic encephalopathy, and Wilson’s disease 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Refer to video above. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The exact mechanism by which asterixis occurs remains unknown. A leading theory suggests interruption of the posture pathway in the rostral reticular formation and abnormal joint proprioception. The lapse of posture has been termed “negative clonus” because, during tonic muscle contraction (i.e., posture), a short EMG silent period precedes the tremor. The patient struggles to maintain posture while posture control repetitively vanishes. UCT Clinical Skills MBChB Year 2 Page 5 of 25 Module 4a: GIT General Signs  E. CANDIDIASIS 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A yeast infection that is caused by a fungal microorganism, most often the fungus Candida albicans, which gives a white appearance. 3. What medical conditions are associated with this sign? Antibiotic use, which causes an imbalance in natural vaginal flora Pregnancy Uncontrolled diabetes An impaired immune system (immunocompromised individuals) Taking oral contraceptives or hormone therapy that increase estrogen levels Diabetes type 2 Acquired Immunodeficiency Syndrome (AIDS) Sjogren's Syndrome - oral candidiasis Polyendocrine deficiency syndrome type 1 - chronic candida infections 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Vaginal candidiasis: perform vaginal examination for a white discharge, often described as clotted cream / cottage cheese, usually non-offensive Oral candidiasis - Inspection of the mouth (including under dentures) showing white plaques or erythematous patches. Healthcare providers rely on your medical history, symptoms, physical examinations, and laboratory tests to diagnose invasive candidiasis. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The ability of C. albicans to infect such diverse host niches is supported by a wide range of virulence factors and fitness attributes. Several attributes, including the morphological transition between yeast and hyphal forms, the expression of adhesins and invasions on the cell surface, thigmotropism, the formation of biofilms, phenotypic switching and the secretion of hydrolytic enzymes are considered virulence factors. Additionally, fitness attributes include rapid adaptation to fluctuations in environmental pH, metabolic flexibility, powerful nutrient acquisition systems and robust stress response machineries. UCT Clinical Skills MBChB Year 2 Page 6 of 25 Module 4a: GIT General Signs  F. CLUBBING 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A physical sign characterized by bulbous enlargement of the distal ends of one or more fingers or toes. 3. What medical conditions are associated with this sign? Cardiac: o Infective endocarditis o Cyanotic Heart Disease o Atrial Myxoma G.I.T: o Primary biliary cirrhosis o Ulcerative Colitis o Chron’s Disease Respiratory: o Lung Abscess o Bronchiectasis o Cystic Fibrosis o Lung Cancer Other: o Benign mesothelioma o Hyperthyroidism o Neurogenic tumours o Familial Pachydermoperiostosis (PDP) o Primary hypertrophic osteoarthropathy (PHO) 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? There are two methods you could assess for clubbing: a) Ask patients to hold up their hands and place the nails of the thumb together. Then look at the diamond shape opening, if it is present this is known as Schamroth’s window. In clubbing the angle due to clubbing causes for it to not be present. b) Massage the nail bed and feel if it is soft and spongy, then bring the nail up to eyelevel to assess the angle of the nail and nail bed. UCT Clinical Skills MBChB Year 2 Page 7 of 25 Module 4a: GIT General Signs  5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The mechanism is not fully understood but believed to do with the being a disruption in the pulmonary circulation that leads to megakaryocytes entering the circulation whole as opposed to usual fragment, there is then deposition in the circulation of extremities that results in platelet growth released and therefore proliferation of muscle cells and fibroblast. G. DUPYTREN’S CONTRACTURE 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A condition in which one or more fingers become permanently bent in a flexed position. 3. What medical conditions are associated with this sign? Thyroid Problems Liver Disease Epilepsy Diabetes 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection- thickening of the flexion contractures in the fingers and measure the feeling in their thumbs and fingers. Palpation- examine the hands, wrists, and fingers for swelling or tenderness, palm areas to check for nodules Ask the patient to try to place both hands flat on a table, to determine patients range of motion in their fingers, to see if they can straighten them all the way. Perform other tests to assess how well: o patient can grasp items with their hands. o patient you can pinch items with their fingers. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected. The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal joints affected before the proximal interphalangeal joints. UCT Clinical Skills MBChB Year 2 Page 8 of 25 Module 4a: GIT General Signs  In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases a person's ability to hold objects. People may report pain, aching, and itching with the contractions. H. ECCYMOSIS (BRUISING) 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Ecchymosis (bruise) refers to the skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels. What medical conditions are associated with this sign? Trauma Amyloidosis Lymphocytic leukaemia Clotting factor deficiency: Haemophilia Vit K deficiency Scurvy Defective platelet action Hereditary haemorrhagic telangiectasia Cushing’s syndrome 3. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection: Ecchymosis may appear as bright red, black, blue, purple, or a combination of the above colours. It usually consists of non-elevated, rounded, and irregular areas that increase in intensity over 3–4 days post-surgery/trauma and will diminish and become yellow as they disappear. It may take 2–3 weeks for complete resolution. UCT Clinical Skills MBChB Year 2 Page 9 of 25 Module 4a: GIT General Signs  4. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The ecchymosis cascade includes mechanism of colour changes Blood vessels rupture ↓ Red blood cells die and release haemoglobin ↓ Macrophages (white blood cells) degrade haemoglobin via phagocytosis ↓ Haemo > bilirubin = bluish-red colour ↓ Bilirubin > hemosiderin = golden-brown colour I. ERYTHEMA NODOSUM 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A skin disorder of acute onset with eruption of red, tender nodules and plaques, predominantly over the lower extremities, especially the extensor surfaces. 3. What medical conditions are associated with this sign? Inflammatory disease Infection- streptococcal, tuberculosis Sarcoidosis Rheumatoid disorders 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? UCT Clinical Skills MBChB Year 2 Page 10 of 25 Module 4a: GIT General Signs  immunological immune stimuli reaction complex formed immune complex deposition in subcutaneousand connective erythema nodusum lesion tissue J. GLOSSITIS 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Inflammation of the tongue characterized by loss of the surface papillae, a condition that gives the affected area a smooth, erythematous appearance. 3. What medical conditions are associated with this sign? Diseases Infections Certain diseases can cause glossitis, Bacterial, viral, and fungal infections can especially those where nutritional all cause glossitis. deficiencies occur, such as celiac However, oral herpes, which is a viral disease, protein-calorie deficiency, infection, and fungal yeast infections are vitamin B12 malnutrition, and among the most likely infections to cause pernicious anemia, glossitis. Carcinoid syndrome Diseases that Other: attack the immune system, such as Vitamin B12 deficiency Sjögren’s Syndrome, can cause changes in the mouth that lead to glossitis UCT Clinical Skills MBChB Year 2 Page 11 of 25 Module 4a: GIT General Signs  4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection- thoroughly examine the patients mouth and tongue, for any abnormalities on the tongue surface and look for blisters or bumps on the tongue or gums. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Micronutrient deficiency impedes mucosal proliferation As cell of the tongue papillae have a high turnover, deficiencies in micronutrients needed for cell proliferation or cell membrane stabilization may lead to depapillation. Nutritional deficiency is also thought to change the pattern of microbial flora, thus contributing to glossitis. K. GYNAECOMASTIA 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A benign proliferation of glandular tissue in the male breast, clinically presenting as a firm disc of tissue underlying the nipple. 3. What medical conditions are associated with this sign? Hepatic cirrhosis Hyperthyroidism Radiotherapy Renal failure and dialysis Hypogonadism Testicular tumours 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Clinical examination: Palpation Gynecomastia is the enlargement of glandular tissue rather than fatty tissue. It is typically symmetrical in location with regard to the nipple and may have a rubbery or firm feel. Gynecomastia usually occurs on both sides but can be unilateral in some cases. The enlargement may be greater on one side even if both sides are involved. Tenderness and sensitivity may be present, although there is typically no severe pain. UCT Clinical Skills MBChB Year 2 Page 12 of 25 Module 4a: GIT General Signs  5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Mainly caused by the following situations which favour increased oestrogen activity in the granular tissue of the breast, leading to proliferation: high level of circulating oestrogen Increases in the oestrogen: testosterone ratio androgen insensitivity L. JAUNDICE 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Yellowing of the skin, sclera and mucous membranes caused by an increase in bilirubin levels in the blood. 3. What medical conditions are associated with this sign? Liver cirrhosis Acute pancreatitis Haemochromatosis Liver, gallbladder, and pancreatic cancer Hepatitis- viral and toxic Malaria Porphyria 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Clinical examination- inspection for yellow discoloration of the body by exposing the patient. Inspect the eyes, as this is the first area to indicate if patient is jaundiced. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The condition is divided into three forms, depending on what has caused the bilirubin to accumulate. The different types of jaundice are described below. Pre-hepatic jaundice – Here, the bilirubin level is disrupted prior to transportation of blood to the liver. Examples of conditions that cause this type of jaundice are haemolytic anaemia and sickle cell disease. Hepatocellular jaundice – Here, the disrupted bilirubin is caused by disease in the liver and examples of conditions that cause this include liver cirrhosis and Gilbert’s syndrome. UCT Clinical Skills MBChB Year 2 Page 13 of 25 Module 4a: GIT General Signs  Post-hepatic jaundice or obstructive jaundice – Here, bile and therefore the bilirubin contained inside, is obstructed, and prevented from draining into the digestive system from the gallbladder. Examples of factors that may cause this are tumours and gallstones. M. LEUKONYCHIA 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Partial or complete whitening of the nail plate due to abnormal vasculature of the nailbed. 3. What medical conditions are associated with this sign? Trauma to the nail base Hereditary Hypalbuminaemia Hepatic cirrhosis Chronic renal failure Congestive heart failure Diabetes mellitus 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspect patients nails for discolouration. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Unclear mechanism. Hereditary: a defect in keratinization of the cells of the nail plate and underlying matrix is the cause. Liver disease: a form of leukonychia known as Terry’s nails, where the white is proximally and the brown distally has been associated with DM, CCF and liver disease. The distal brown portion is thought to be caused by the deposition of melanin. UCT Clinical Skills MBChB Year 2 Page 14 of 25 Module 4a: GIT General Signs  N. LEUKOPLAKIA 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Leukoplakia is a condition in which thick, white, or grayish patches form usually inside your mouth. 3. What medical conditions are associated with this sign? Injury to the inside of your cheek, such as from biting Rough, uneven teeth Dentures, especially if improperly fitted Inflammatory conditions of the body Long-term alcohol use Human immunodeficiency virus Human papilloma virus Squamous cell carcinoma (head and neck) 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Oral examination: Inspection Leukoplakia can occur on your gums, the inside of your cheeks, under or on your tongue, and even on your lips. The condition is marked by unusual-looking patches inside your mouth. These patches can vary in appearance and may have the following features: White or grey colour Thick, hard, raised surface Red spots (rare) Redness may be a sign of cancer. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Tobacco and areca nut use, either alone or in combination are the most common risk factors for oral leukoplakia, but some oral leukoplakias are idiopathic. Some leukoplakias arise within fields of precancerised oral epithelium in which the keratinocytes may be at different stages of cytogenetic transformation. Leukoplakias may unpredictably regress, may remain stable, or may progress to carcinoma. UCT Clinical Skills MBChB Year 2 Page 15 of 25 Module 4a: GIT General Signs  There is a greater risk of carcinomatous transformation of idiopathic leukoplakia, of non-homogenous leukoplakia, of leukoplakia affecting the floor of the mouth; the ventrolateral surface of the tongue and the maxillary retromolar and adjoining soft palate (collectively called high-risk sites), of leukoplakia with high-grade epithelial dysplasia, and of leukoplakia in which the keratinocytes carry cytogenetic alterations associated with carcinomatous transformation. Although there appears to be some link between human papillomavirus (HPV) and oral leukoplakia, there is little evidence to support a causal relationship either between HPV infection and oral leukoplakia or between HPV-infected leukoplakic keratinocytes and their carcinomatous transformation. O. MUSCLE WASTING 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Also referred to as muscle atrophy. This term refers to loss of muscle tissue. 3. What medical conditions are associated with this sign? Amyotrophic lateral sclerosis (ALS): Also called Lou Gehrig’s disease, it includes several types that damage the motor nerve cells that control the muscles. Multiple Sclerosis (MS): by causing harmful inflammation in the nerve fibres. Arthritis: refers to inflammation of the joints that causes pain and stiffness Myositis: The term myositis refers to inflammation of the muscles. This condition causes muscle weakness and pain. People can develop myositis after a viral infection or as a side effect of an autoimmune condition. Common conditions: o Radiculopathy o Peripheral neuropathy o Peripheral vascular disease Neurological problems (Motor neuron disease) An injury or condition can damage the nerves that control the muscles, resulting in a condition called neurogenic muscle atrophy. UCT Clinical Skills MBChB Year 2 Page 16 of 25 Module 4a: GIT General Signs  4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Physical examination- inspection of the body by palpating the affected area and compare with the opposite side Patients history- considering social history 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Underlying mechanisms related to: Lower motor neuron disorders Disuse atrophy Myopathy Peripheral vascular disease P. PALLOR 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Pallor is the paleness of skin and mucous membranes, due to the reduced amount of oxyhaemoglobin or decreased peripheral perfusion. It may also be visible as pallor of the conjunctivae of the eyes on physical examination also more evident on the face and palms. 3. What medical conditions are associated with this sign? Iron deficiency Anaemia Leukaemia Chronic renal disease Rheumatoid arthritis 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? During inspection: clinical examination of the lips, mucous membranes (palpebral conjunctiva, mouth) and fingernails. If dark skin toned, inspect the plans and soles. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? When red-pink tones from oxygenated haemoglobin in blood are lost, skin takes on colour of connective tissue (collagen) which is mostly white. UCT Clinical Skills MBChB Year 2 Page 17 of 25 Module 4a: GIT General Signs  Q. PALMAR ERYTHEMA 1. What does this sign look like? 2. How do I describe this sign using medical terminology? A symmetrical and slightly warm reddened area on the thenar and hypothenar eminences of the palm, it may have a mottled appearance or blanching when pressed. 3. What medical conditions are associated with this sign? Primary palmar erythema: o Hereditary - rare o Pregnancy related – common o Senile Secondary palmar erythema: o Chronic liver disease o Auto immune – rheumatoid arthritis 60% o Neoplastic o Endocrinological- thyrotoxicosis 18% and diabetes 4% develop palmar erythema Other: including infections, atopic dermatitis, primary or metastatic brain cancer, smoking and chronic obstructive lung disease. 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection- ask patient to supinate both hands Assess – both hand for colour, temperature, and perfusion. Application of pressure to the palms (blood vessels) causes temporary improvement. Release of pressure causes rapid re-filling of the vessels. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? To some individuals, palmar erythema is normal or is a sign of underlying disease. The redness of palmar erythema is due to increased dilatation of surface capillaries in the hand. UCT Clinical Skills MBChB Year 2 Page 18 of 25 Module 4a: GIT General Signs  R. PETECHIA (PIN-HEAD-BRUISES) 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Petechiae are pinpoint, round spots that appear on the skin because of bleeding. 3. What medical conditions are associated with this sign? Blood and immune disorders: Haemolytic-uremic syndrome Idiopathic thrombocytopenic purpura Leukaemia Thrombocytopenia Vasculitis Many infections with bacteria, viruses, or fungi: Viral haemorrhagic fevers like Ebola, and yellow fever Viral infections like cytomegalovirus, endocarditis, and the flu Bacterial infections such as meningitis, and strep throat Sepsis A lack of vitamin C (scurvy) or vitamin K in your diet may lead to petechiae. 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Petechiae are flat and look like pinpoint-sized red, brown, or purple dots. Clumps of them on your skin look like a rash. But unlike many rashes when you press on the spots, they do not turn white. If the spots are larger and red or purple, there may be another type of bleeding problem called purpura these signs must not be confused. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Petechiae are formed when tiny blood vessels called capillaries break open. When these blood vessels break, blood leaks into your skin. Infections and reactions to medications are two common causes of petechiae. UCT Clinical Skills MBChB Year 2 Page 19 of 25 Module 4a: GIT General Signs  S. PRURITIS (SCRATCH MARKS) 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Pruritus, also known as Itchy skin, is an irritating and uncontrollable sensation that makes you want to scratch to relieve the feeling. 3. What medical conditions are associated with this sign? Internal disorders: bile duct obstruction, cirrhosis, anaemia, leukaemia, thyroid disease, lymphoma, kidney failure Nervous system disorders: diabetes, multiple sclerosis, shingles, neuropathy Skin conditions: psoriasis dermatitis, eczema, chickenpox, measles, fungal rashes, scabies Medications: antifungals, narcotic agents, anticonvulsants, antibiotics (especially sulfa-based antibiotics) 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? History and physical examination are central to the evaluation of pruritus. Most pruritic conditions can be diagnosed based on the presence of associated dermatitis, the distribution of the itching or rash, or a history of recent exposure to exogenous causes. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? UCT Clinical Skills MBChB Year 2 Page 20 of 25 Module 4a: GIT General Signs  T. SKIN PIGMENTATION 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Disorders of pigmentation present as skin that is discoloured, blotchy, or darker or lighter than normal. They occur when the body produces too little (hypopigmentation) or too much (hyperpigmentation) melanin. 3. What medical conditions are associated with this sign? Liver disease Skin cancer Chronic renal disease Vitiligo Albinism Chediak-Higashi syndrome Hermansky-Pudlak syndrome 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Inspection: assess the skin tone, texture, and colour. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Abnormal pigmentation of the skin can also be a result of adverse reactions to medications due to drug deposition in the skin, increased melanin production, or drug-induced post inflammatory changes although the disorder has implications to the quality of life, it is not associated with morbidity or mortality, it affects both men and women, equally. The classification of congenital hypo pigmentary diseases that result from a defect in the production of pigment (melanin) due to dysfunction of pigment cells (melanocytes) in the skin, the eyes, and/or the ears. Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes that occurs when melanocytes die or malfunction. UCT Clinical Skills MBChB Year 2 Page 21 of 25 Module 4a: GIT General Signs  U. SPIDER NAEVI 1. What does this sign look like? (Image source: Talley & O’Connor, 2014, p. 189) 2. How do I describe this sign using medical terminology? Spider naevi is a type of telangiectasis (swollen blood vessels) found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider's web. 3. What medical conditions are associated with this sign? Liver disease Liver failure Liver cirrhosis Hormonal changes: oestrogen (e.g. oral contraceptive pill) or pregnancy may enlarge pre-existing naevi or cause multiple naevi to form 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? Application of pressure to the centre of the blood vessel causes temporary improvement. Release of pressure causes rapid re-filling of the vessels. Inspection and location- Spider angiomas are commonly found in the distribution of the superior vena cava, the face, neck, upper part of the trunk, and arms. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? The pathogenesis of spider nevi is still unclear. Their occurrence is supposed to be related to dilatation of pre-existent blood vessels rather than true vascular proliferation. Increased plasma levels of oestrogen, vascular dilation, and neovascularisation are possible aetiologies. UCT Clinical Skills MBChB Year 2 Page 22 of 25 Module 4a: GIT General Signs  V. XANTHOMATA 1. What does this sign look like? 2. How do I describe this sign using medical terminology? Xanthomas are papules or nodules of the skin or mucous membranes that contain lipids. UCT Clinical Skills MBChB Year 2 Page 23 of 25 Module 4a: GIT General Signs  3. What medical conditions are associated with this sign? Diabetes mellitus Liver disease Hyperlipidaemia hypercholesterolemia Hypothyroidism Late-stage kidney disease Sarcoidosis HIV 4. How do I elicit this sign during physical examination? OR: What is the surface anatomy involving this sign? During clinical examination: ask the patient to expose the body (maintain privacy and respect at all times) and carefully inspect and palpate for small, yellowish papules that may be present in various parts of the body. 5. What is the underlying mechanism (physiology; macro-pathology) that gives rise to this sign? Xanthomas are well circumscribed lesions in the connective tissue of the skin, tendons or fasciae that predominantly consist of foam cells; these specific cells are formed from macrophages as a result of an excessive uptake of low density lipoprotein (LDL) particles and their oxidative modification. UCT Clinical Skills MBChB Year 2 Page 24 of 25 Module 4a: GIT General Signs  References 1. Textbooks Dennis, Bowden, and Cho: Mechanisms of Clinical Signs Lippincott, Williams, and Wilkins: guide to physical examination and history taking Talley & O’Connor’s Clinical Examination: General principles of physical examination 2. Online links https://www.medicalnewstoday.com/articles/325316 https://epomedicine.com/?s=pallor https://www.ncbi.nlm.nih.gov/books/NBK366/ https://emedicine.medscape.com/article/1105946-overview https://www.medicinenet.com/image-collection/xanthomatosis_1_picture/picture.htm https://www.ncbi.nlm.nih.gov/pubmed/24781043 https://en.wikipedia.org/wiki/Dupuytren%27s_contracture https://www.webmd.com/skin-problems-and-treatments/what-are-petechiae#1 https://www.sciencedirect.com/topics/medici4ne-and-dentistry/ecchymosis https://europepmc.org/article/med/22505902 UCT Clinical Skills MBChB Year 2 Page 25 of 25 Module 4a: GIT General Signs