Nails

1. MR Spiess

2. Shape Color Flexbility Growth rate: ~6 months from the cuticle to free edge, 0.1mm/day Nail Exam

3. Pink/Red: polycythemia, SLE, carbon monoxide poisoning, angioma , malnutrition Colors White: anemia, cirrhosis, DM, chemo, renal failure Yellow: Amyloidosis, yellow nail syndrome, median/ulnar nerve injury, thermal injury, jaundice, DM Green/Black: solvents, trauma, chronic Pseudomonas infection

4. Water drop test: imagine placing a drop of water on the nail. If it would not fall off it is spooned Causes: Iron deficiency DM Protein deficiency especially in sulfur-containing amino acids (cysteine or methionine) Spooned nails ( koilonychia )

5. Causes: Iron deficiency, folic acid deficiency, protein deficiency Central nail ridge

6. Cuticle usually normal Associations: Severe arterial disease Severe malnutrition Repetitive trauma Central nail canal/ heller’s fir tree deformity

7. Endocrine Conditions: DM, thyroid disease, Addison’s Nail beading

8. Sandpaper/dull appearance Seen in: Psoriasis Chemical exposures Lichen planus Autoimmune diseases Rough

9. Slow growth produces thickness Causes: Onychomycosis Chronic eczema PVD Yellow nail syndrome Psoriasis Nail thickening

10. Associated with: Thyrotoxicosis, trauma, contact dermatitis, chemicals, porphyria cutanea tarda onycholysis

11. Angle between nail plate and fold greater than 180 degrees clubbing

12. Causes: Cardiac/Pulmonary (80%): R to L shunts, endocarditis, pericarditis, lung CA, bronchiectasis, lung abscess, empyema, pulmonary fibrosis. NOT COPD GI (5%): IBD, celiac, neoplasms (esophagus, liver, bowel) Hyperthyroidism (1%) CLubbing

13. Associated with trauma, IE, scleroderma, trichinosis, pityriasis rubra pilaris , psoriasis, renal failure Splinter hemorrhage

14. Proximal paleness extending at least half-way up (often eliminating the lunula ) with a dark band distally. Seen in states of stress (liver disease, CHF, DM2, advanced age) Terry’s nails

15. Pale proximal (edema and anemia) in kidney and liver disease. In renal disease there is a brown transverse distal brown transverse band at the junction of the erythema and free edge Lindsay’s nails/half and half nails

16. Transverse depressed ridges caused by growth arrest. S een in severe infection, MI, hypotension/shock, hypocalcemia , post-surgical, malnutrition, some chemotherapies Beau’s lines

17. Due to edema to the nail plate. Usually 2 or more on one nail. Seen in states of decreased protein synthesis or increased protein loss, hypoalbunemia (<2.2), nephrotic syndrome and certain chemotherapies. Don ’ t move and d isappear when albumin increases. Muehrcke’s lines ( leukonychia striata )

18. Transverse white lines (usually one per nail, no depressions) that often will disappear if pressure is applied. Heavy metal poisoning (strong association with arsenic and thallium), chemo, severe illness Mees ’ lines

19. Non-specific sign for psoriasis, alopecia areata , eczema, lichen planus pitting

20. Distal nicotine stains with demarcation and no staining proximally seen when a patient quits smoking or changes to a lower tar tobacco. Quitter’s nail

21. Periungal telangiectasias : strong association with CVD: SLE, dermatomyositis , scleroderma periungal Mucus cyst Fibroma Paronychia Herpetic Whitlow

22. Seen on palms, soles, mouth but when occurs within the nail a clue is that it involves the periungal region Acral lentiginous melanoma

23. Pope’s Hand (Hand of Benediction) hands Claw Hand What nerve is affected?

24. Bouchard’s and Heberden’s Nodes hands

25. Boutonniere Deformity hands Swan Neck Deformity Ulnar Deviation

26. What would you expect this person to have?

27. Turner’s Syndrome Holt- Oram Syndrome Down’s Syndrome Edwards Syndrome Fragile X

28. C) Down’s Syndrome

29. What is causing this? 62yo F with history of proximal muscle weakness, weight loss and dysphagia

30. dermatomyositis Periungal telangiectasias Gottron’s papules

31. The Stanford 25 – stanfordmedicine25.stanford.edu Published presentation on nail exam – Mark Williams, MD at UVA references