Inspect the Skin

Inspect the skin and sclera for jaundice. Whenever possible, the patient should be evaluated for jaundice in natural light because incandescent light frequently masks the existence of icterus. Jaundice becomes apparent when the serum bilirubin level exceeds 2.5 mg/dL in adults or 6 mg/dL in neonates. Figure 17-5 shows a patient with jaundice. Notice the scleral icterus as well as the yellow discoloration of the skin. Hyperbilirubinemia can also result in intense generalized pruritus.

Inspect for spider angiomas. Spider angiomas have a high degree of sensitivity in patients with alcoholic cirrhosis but are nonspecific because they also occur in pregnancy and collagen vascular disorders (see Fig. 8-75).

Figure 17-6 shows the leg of a patient with pyoderma gangrenosum. Notice the necrotic, undermined ulceration with pus. These tender ulcerations, commonly on the lower extremities, are associated with inflammatory bowel disease, especially ulcerative colitis. In general,

Figure 17-6 Pyoderma gangrenosum.

the clinical course of pyoderma gangrenosum follows the course of the bowel disease. This condition is also seen in patients with rheumatoid arthritis, myeloid metaplasia, and chronic myelogenous leukemia.

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