The General Physical Examination

FIGURE 4.1 Giant hairy patch over the lower back in a patient with occult spinal dysraphism.

EXTREMITIES

Note any limb deformities, contractures, edema, or color changes. Any variation from the normal in the size or shape of the hands, feet, or digits, as well as deformities, joint changes, contractures, pain or limitation of movement, localized tenderness, wasting, clubbed fingers, or ulcerations may be significant. Edema may be evidence of congestive heart failure or cardiomyopathy. Arthropathy may be a sign of connective tissue disease, sarcoidosis, or Whipple’s disease. Painless arthropathy (Charcot joint) occurs when a joint is deafferented; painless enlargement of the shoulder has been reported as the presenting manifestation of syringomyelia. Decreased peripheral pulses occur in Takayasu’s disease as well as atherosclerosis. Acrocyanosis occurs in ergotism. Palmar erythema may be a clue to alcohol abuse. Diseases of the nervous system are found in association with such skeletal and developmental anomalies as syndactyly, polydactyly, and arachnodactyly.

SKIN

A careful examination of the skin can provide important evidence regarding the nature of a neurologic condition. Findings of possible neurologic relevance include the following: spider angiomas in alcohol abuse; erythema chronicum migrans in Lyme disease; purpura and petechiae in thrombotic thrombocytopenic purpura, meningococcemia, and Rocky Mountain spotted fever (all of which may have prominent neurologic manifestations); livedo reticularis in antiphospholipid syndrome and cryoglobulinemia; hyperpigmentation in Nelson’s syndrome, carotenemia or Addison’s disease; and the numerous dermatologic manifestations of the neurocutaneous syn dromes (see Chapter 53

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