Ferri's Color Atlas and Text of Clinical Medicine

1254 Pages·2008·158.33 MB·English

by  Fred F. Ferri

Ferri’s
Color Atlas
and Text of

CLINICAL
MEDICINE
Fred F. Ferri, M.D., F.A.C.P.
Clinical Professor
Alpert Medical School at Brown University
Providence, Rhode Island
FM_X4919_i-xiv.indd iii 10/10/08 10:18:02 AM
1600 John F. Kennedy Blvd.
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FERRI’S COLOR ATLAS AND TEXT OF CLINICAL MEDICINE ISBN: 978-1-4160-4919-7
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Notice
Knowledge and best practice in this fi eld are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the practitioner, relying on
their own experience and knowledge of the patient, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety
precautions. To the fullest extent of the law, neither the Publisher nor the Authors assumes any
liability for any injury and/or damage to persons or property arising out of or related to any
use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Ferri, Fred. F.
Ferri’s color atlas and text of clinical medicine / Fred F. Ferri. -- 1st ed.
p. ; cm.
ISBN 978-1-4160-4919-7
1. Clinical medicine--Handbooks, manuals, etc. 2. Clinical medicine--Atlases. I.
Title. II. Title: Color atlas and text of clinical medicine.
[DNLM: 1. Clinical Medicine--Atlases. 2. Clinical Medicine--Handbooks. WB 17 F388f
2009]
RC55.F466 2009
616--dc22 2008034698
Acquisitions Editor: Druanne Martin
Developmental Editor: Liliana Kim
Publishing Services Manager: Frank Polizzano
Senior Project Manager: Peter Faber
Design Direction: Karen O’Keefe - Owens
Marketing Manager: William Veltre
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
FM_X4919_i-xiv.indd iv 10/10/08 10:18:03 AM
Preface
The goal of this book is to be a comprehensive, current, and The book is divided in 14 sections ranging from disorders of
clinically relevant medical resource. The idea of this work began skin and subcutaneous tissues to infectious diseases. Each sec-
while contemplating the enormity of material one needs to tion follows a similar format, which consists of an initial de-
master in clinical medicine. Although there are several text- scription of the normal anatomy and physiology followed by
books available on clinical medicine and a vast number of es- diagnostic tests and procedures, and descriptions and illustra-
tablished atlases dealing primarily with dermatological disor- tions of various disorders pertinent to that section. The format
ders, there are no established books that combine the and size of this book are designed to be a handy refresher of
information contained within a traditional textbook with the important clinical, anatomic, laboratory and radiographic signs.
visual imagery of a color atlas. This book aims to provide such There are 352 chapters, 3031 illustrations and over 100 tables,
a combination. boxes and algorithms, each specifi cally selected to illuminate
Visuals are the critical language of medical education. The the assessment of clinical disorders. In summary, it is unlike any
old adage of “A picture is worth a thousand words” is certainly other existing book in both scope and content, and certainly
true in medicine. Recognition of disorders from illustrations deserves a unique place in any medical library.
remains crucial to early diagnosis and treatment, both of which I hope that this book fulfi lls your every expectation, pro-
are usually essential to improve prognosis. In creating this vides valuable support to the learning of clinical medicine, and
book, care was taken to include the classic examples of com- serves as an effective resource in daily clinical practice.
mon medical disorders in detail. Rare disorders were also in-
cluded because they are often discussed for purposes of differ-
ential diagnosis and because they are frequently referenced in
the medical literature and on medical board exams. As such, Fred F. Ferri, MD, FACP
this book endeavors to provide the student and the newly Clinical Professor
qualifi ed doctor with a guide to the diagnosis of common Alpert Medical School
clinical disorders, and the more experienced physician with a Brown Unversity
guide to less common, but still important, diseases. Providence, Rhode Island
v
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Acknowledgments
I gratefully acknowledge the generosity of the many colleagues Kittichai Promrat, M.D., Hemchand Ramberan, M.D., Chaitanya
listed below who have lent text material to this book. It is V. Reddy, D.O., Victor I. Reus, M.D., Harlan G. Rich, M.D., Luther
important for me to be scrupulous in acknowledging these K. Robinson, M.D., Jason M. Satterfi eld, Ph.D., Sean I. Savitz,
valuable sources of information. If I left anyone out, it is not M.D., Jack L. Schwartzwald, M.D., Catherine Shafts, D.O., Madhavi
out of immodesty or unintended claims of original material Shah, M.D., Harvey M. Shanies, M.D., Ph.D., Deborah L. Shapiro,
but simply an oversight given the myriad of sources involved M.D., Grace Shih, M.D., Mark Sigman, M.D., Joanne M. Silvia,
in this project: M.D., Clifford Milo Singer, M.D.,U. Shivraj Sohur, M.D., Ph.D.,
Jennifer Souther, M.D., Michelle Stozek Anvar, M.D., Julie Anne
Sonya S. Abdel-Razeq, M.D., Philip J. Aliotta, M.D., M.S.H.A., Szumigala, M.D., Dominick Tammaro, M.D., Iris Tong, M.D.,
F.A.C.S., George O. Alonso, M.D., Srividya Anandan, M.D., Gowri Margaret Tryforos, M.D., Eroboghene E. Ubogu, M.B.B.S. (Hons.),
Anandarajah, M.D., Mel L. Anderson, M.D., F.A.C.P, Etsuko Aoki, Sean H. Uiterwyk, M.D., Nicole J. Ullrich, M.D., Ph.D., Hannah
M.D., Ph.D, Patricia Arean, Ph.D., Vasanthi Arumugam, M.D., Vu, D.O., Tom J. Wachtel, M.D., Marc S. Weinberg, M.D., Dennis
Amaar Ashraf, M.D., Udeep Kaur Aulakh, M.D., C.M., F.R.C.P.C., M. Weppner, M.D., F.A.C.O.G., Laurel M. White, M.D., David P.
Michael G. Benatar, M.B.Ch.B., D.Phil., Agnieszka K. Bialikiewicz, Williams, M.D., Marie Elizabeth Wong, M.D., Wen-Chih Wu,
M.D., Jeffrey M. Borkan, M.D., Ph.D., Kelly Bossenbrok, M.D., M.D., Beth J. Wutz, M.D., John Q. Young, M.D., M.P.P., Cindy
Lynn Bowlby, M.D., Mandeep K. Brar, M.D., Joanna Brown, M.D., Zadikoff, M.D., Scott J. Zuccala, D.O., F.A.C.O.G.
Robert Burd, M.D., Jonathan Burns, M.A., M.D., Steven Busselen,
M.D., Gaurav Chaudhary, M.D., Kara Chew, M.D., Maria A. I also extend a special thanks to the authors and contribu-
Corigliano, M.D., F.A.C.O.G., Karoll J. Cortez, M.D., John E. tors of the following texts who have lent multiple pictures and
Croom, M.D., Ph.D., Alicia J., Curtin, Ph.D., G.N.P., Claudia L. text material to this book:
Dade, M.D., George T. Danakas, M.D., F.A.C.O.G., Alexandra
Degenhardt, M.D., Christine M. Duffy, M.D., M.P.H., Jeffrey S. Abeloff MD: Clinical Oncology, ed 3, Philadelphia, 2004, Elesevier
Durmer, M.D., Ph.D., Jane V. Eason, M.D., Stuart Eisendrath, Besser CM, Thorner MO: Comprehensive Clinical Endocrinol-
M.D., Pamela Ellsworth, M.D., Gregory J. Esper, M.D., Marilyn ogy, ed 3, St. Louis, Mosby, 2002
Fabbri, M.D., Mark J. Fagan, M.D., Gil M. Farkash, M.D., Timothy Crawford, MH, DiMarco JP, Paulus WJ [eds]: Cardiology, ed 2,
W. Farrell, M.D., Mitchell D. Feldman, M.D., M. Phil., Tamara G. St. Louis, Mosby, 2004
Fong, M.D., Ph.D., Glenn G. Fort, M.D., M.P.H., Rebekah Leslie Cohen J, Powderly WG: Infectious Diseases, ed 2, St. Louis,
Gardner, M.D., Genna Gekht, M.D., Paul F. George, M.D., David Mosby, 2004
R. Gifford, M.D., M.P.H., AnnGene A. Giustozzi, M.D., M.P.H., Ferri F: Ferri’s Clinical Advisor 2007, St. Louis, Mosby, 2007
Cindy Gleit, M.D., Geetha Gopalakrishnan, M.D., Nancy R. Graff, Grainger RG, Allison D: Grainger & Allison’s Diagnostic Radio-
M.D., Rebecca A. Griffi th, M.D., Joseph Grillo, M.D., Mohammed logy, a textbook of Medical Imaging, ed 4, Philadelphia,
Hajjiri, M.D., Michele Halpern, M.D., Mustafa A. Hammad, M.D., Churchill Livingstone, 2001
Sajeev Handa, M.D., Mike Harper, M.D., Taylor Harrison, M.D., Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman
Christine Hartley, M.D., Sharon S. Hartman Polensek, M.D., MH [eds]: Rheumatology, ed 3, St. Louis, 2003, Mosby
Ph.D., Christine Healy, D.O., Jennifer Roh Hur, M.D., Jason Johnson RJ, Feehally J: Comprehensive Clinical Nephrology,
Iannuccilli, M.D., Richard S. Isaacson, M.D., Jennifer Jeremiah, ed 2, St. Louis, Mosby, 2000
M.D., Michael P. Johnson, M.D., Kohar Jones, M.D., Daniel Mckee PH, Calonje E, Granter SR [eds]: Pathology of the skin
Keplon, M.D., Powell H. Kazanjian, M.D., Wan J. Kim, M.D., with clinical correlations, ed 3, St. Louis, Mosby, 2005
Melvyn Koby, M.D., David Kurss, M.D., F.A.C.O.G., Cindy Lai, Silverberg SG—Principles and Practice of Surgical pathology and
M.D., Suzette M. LaRoche, M.D., Joseph J. Lieber, M.D., Chun cytopathology, ed 4, Philadelphia, Churchill Livingstone, 2006
Lim, M.D., Ph.D.,Mara Linscott, M.D., Russell Linsky, M.D., Zeena Swartz MH: Textbook of Physical Diagnosis, ed 5, Philadelphia,
Lobo, M.D., Richard Long, M.D., Michael Maher, M.D., Achraf A. Saunders, 2006
Makki, M.D., M.Sc., Joseph R. Masci, M.D., Daniel T. Mattson, White GM, Cox NH [eds]: Diseases of the skin, a color atlas and
M.D., M.S.C. (Med.), Maitreyi Mazumdar, M.D., M.P.H., Kelly A. text, ed 2, St. Louis, Mosby, 2006
McGarry, M.D., Lynn McNicoll, M.D., Shalin B. Mehta, M.D., Yanoff M, Duker JS: Ophthalmology, ed 2, St. Louis, Mosby, 2004
Lonnie R. Mercier, M.D., Brad Mikaelian, M.D., Dennis J. Young NS, Gerson SL, High KA [eds]: Clinical Hematology,
Mikolich, M.D., F.A.C.P., F.C.C.P., Michele Montandon, M.D., St. Louis, Mosby, 2006
Takuma Nemoto, M.D., James J. Ng, M.D., Melissa Nothnagle,
M.D., Judith Nudelman, M.D., Gail M. O’Brien, M.D., Carolyn J.
O’Connor, M.D., Alexander B. Olawaiye, M.D., Michael K. Ong, Fred F. Ferri, MD, FACP
M.D., Ph.D., Steven M. Opal, M.D., Christina A. Pacheco, M.D., Clinical Professor
Mina B. Pantcheva, M.D., Pranav M. Patel, M.D., Steven Peligian, Alpert Medical School
D.O., Peter Petropoulos, M.D., F.A.C.C., Paul A. Pirraglia, M.D., Brown Unversity
vii
M.P.H., Maurice Policar, M.D., Arundathi G. Prasad, M.D., Providence, Rhode Island
FM_X4919_i-xiv.indd vii 10/10/08 10:18:04 AM
1
Section 1: Skin and subcutaneous tissues
Chapter 1 The structure and function of skin
● The skin or integument is a double-layered membrane cover- ● The skin can be divided into two parts, the epidermis (outer
ing the exterior of the body and is continuous with the mu- layer) and dermis (inner layer), which rests on and is at-
cous membranes lining the body’s orifi ces. It shows a marked tached to the subcutaneous fat (Fig. 1–1).
variation in thickness, measuring from less than 1 mm (on ● The epidermis is comprised of four clearly defi ned layers, or
the eyelid) to more than 4 mm (on the back). The wide strata (Fig. 1–2):
range of properties of the skin is summarized in Box 1–1. 1. Basal layer (stratum basale, stratum germinativum): my-
cotic activity of keratinocytes is confi ned to this layer, result-
ing in an epidermal turnover time of approximately
Box 1–1 Properties of the skin 4 weeks. Melanocytes, which produce melanin pigment, are
• Maintains integrity of the body found in this layer.
• Protects from injurious stimuli 2. Prickle cell layer (stratum spinosum): contains polyhe-
• Absorbs and excretes liquids dral cells with intercellular attachments and Langerhans
• Regulates temperature cells (specialized antigen-presenting cells involved in con-
• Waterproofs
tact hypersensitivity)
• Absorbs ultraviolet light
3. Granular cell layer (stratum granulosum): characterized
• Metabolizes vitamin D
• Detects sensory stimuli by loss of cell nuclei and acquisition of dense keratohyalin
• Provides cosmetic functions granules
• Acts as a barrier against microorganisms 4. Keratin layer (stratum corneum): acellular layer contain-
ing keratin fi brils. It serves as a protective barrier. Its thick-
From McKee PH, Calonje E, Granter SR (eds): Pathology of the Skin With
ness varies with location (maximum thickness on palms
Clinical Correlations, 3rd ed. St. Louis, Mosby, 2005.
and soles, minimum thickness at fl exural sites).
Stratum corneum Fig 1–1
Cross section through the skin, showing the
Melanocytes
Hair structures in the epidermis and subcutaneous
Sebaceous gland Basal cell layer tissues.
Arrector pili muscle Dermal papillae Basement membrane (From Swartz Swartz MH: Textbook of Physical Diag-
nosis, 5th ed. Philadelphia, WB Saunders, 2006.)
EPIDERMIS
DERMIS
SUBCUTANEOUS
TISSUE
Apocrine gland Hair follicle Eccrine gland Fat tissue
Blood vessels
2
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1
Chapter 1: The structure and function of skin
● The dermis is the fi brous part of the skin, which provides
strength. It supports the epidermis and is composed of a fi -
brous connective tissue component (collagen and elastic
fi bers) in intimate association with ground substance.
Within the dermis are the epidermal appendages (sur-
rounded by a connective tissue sheath), blood vessels and
nerves, and a cellular component, including mast cells, fi -
broblasts, myofi broblasts, and macrophages. Smooth mus-
cle is also represented in the erector pili muscles.
Fig 1–2
Normal skin from the fi ngertip showing the clearly defi ned layers of the
epidermis.
(From McKee PH, Calonje E, Granter SR [eds]: Pathology of the Skin With
Clinical Correlations, 3rd ed. St. Louis, Mosby, 2005.)
3
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2
Section 1: Skin and subcutaneous tissues
Chapter 2 Evaluation of skin disorders
A. HISTORY AND PHYSICAL EXAMINATION
● Table 2–3 provides a differential diagnosis of vesiculobul-
● The initial step in the dermatologic evaluation involves ob- lous diseases.
taining a detailed dermatologic history. Box 2–1 lists perti- ● Proper diagnosis will often require direct palpation of the
nent questions. lesion(s) and other maneuvers, such as picking the crust off
● When examining the patient, it is essential to detail the skin moist skin lesions, scratching a scaly rash, squeezing the le-
lesions, their distribution, and characteristics. sion, and applying linear pressure and rubbing to elicit a
● Classically, skin lesions have been classifi ed as primary or dermatologic response. Also, a scalpel is commonly used to
secondary: pare keratinized lesions.
● Primary lesions represent the initial basic lesion.
● Secondary lesions may result from evolution of the pri-
mary lesions or may result from scratching or infection.
● The proper terminology for describing these lesions is given
in Boxes 2–2 and 2–3.
● For diagnostic purposes, it is also important to note the
Box 2–2 Primary skin lesions
distribution of the skin lesions. Figure 2–1 illustrates the
Macule—small spot, different in
classic distribution of common skin dermatoses.
color from surrounding skin, that is
● Table 2–1 describes the differential diagnosis of common
neither elevated nor depressed be-
maculopapular diseases. low the skin surface
● Table 2–2 lists common eczematous disorders and differen-
tiates them by history and location.
Papule—small ((cid:2)5 mm diame-
ter) circumscribed solid elevation
on the skin
Plaque—large ((cid:3)5 mm) superfi -
Box 2–1 Dermatologic history cial fl at lesion, often formed by a
A. Initial questions confl uence of papules
1. When did the skin lesion(s) or rash start?
2. What did it look like when if fi rst started, and how has it
changed? Nodule—large (5-20 mm)
3. Where did it start, and where is it located now? circumscribed solid skin elevation
4. What treatments, especially over-the-counter self-remedies
has the patient tried? What was the effect of each of these
treatments?
5. Are there symptoms (e.g., itching, pain)?
Pustule—small circumscribed
6. What is the patient’s main concern about the rash
skin elevation containing purulent
(e.g., itching, pain, cancer)?
material
7. How is the skin lesion(s) or rash affecting the patient’s life?
8. Are other family members concerned or affected?
9. Has the patient ever had this skin lesion(s) or rash before?
If so, what treatment worked? Vesicle—small ((cid:4)5 mm)
10. What does the patient think caused the skin lesion(s) or rash? circumscribed skin blister
containing serum
B. Follow-up questions
1. Does the patient have a history of chronic medical
problems?
2. What is the patient’s social history, including occupation Wheal—irregular elevated
(chemical exposures), hobbies, alcohol and tobacco use, edematous skin area, which
and any underlying interpersonal or family stress? often changes in size and shape
3. What medications is the patient taking, acutely or
chronically, including birth control pills and over-the-counter
medications?
4. Does the patient have any underlying allergies? Bulla—large ((cid:5)5 mm) vesicle containing free fl uid
5. Is there a family history of hereditary or similar skin Tumor—large nodule, which may be neoplastic
diseases? Cyst—enclosed cavity with a membraneous lining, which
6. Will the patient’s education or fi nancial status infl uence contains liquid or semisolid matter
treatment considerations? Telangiectasia—dilated superfi cial blood vessel
Modifi ed from Goldstein BG, Goldstein AO: Practical Dermatology, From Goldstein BG, Goldstein AO: Practical Dermatology, 2nd ed.
4 2nd ed. St. Louis, Mosby, 1997. St. Louis, Mosby, 1997.
Ch01-13_X4919_001-046.indd 4 10/9/08 2:20:59 PM
2
Chapter 2: Evaluation of skin disorders
Box 2–3 Secondary skin lesions
Scale—superfi cial epidermal Crust—dried exudate, a “scab”
cells that are dead and cast off
from the skin
Erythema—skin redness
Erosion—superfi cial focal loss Hypopigmentation—decreased skin pigment
of part of the epidermis; lesions Excoriation—superfi cial, often linear, skin erosion caused by
usually heal without scarring scratching
Depigmentation—total loss of skin pigment
Atrophy—decreased skin thickness caused by skin thinning
Lichenifi cation—increased skin markings and thickening with
Ulcer—focal loss of the induration secondary to chronic infl ammation caused by
epidermis extending into the der- scratching other irritation
mis; lesions may heal with scarring Scar—abnormal fi brous tissue that replaces normal tissue
after skin injury
Hyperkeratosis—abnormal skin thickening of the superfi cial
layer of the epidermis
Fissure—deep skin split extend-
Edema—swelling caused by accumulation of water in tissue
ing into the dermis
Hyperpigmentation—increased skin pigment
From Goldstein BG, Goldstein AO: Practical Dermatology, 2nd ed. St. Louis, Mosby, 1997.
Acne vulgaris Atopic dermatitis Photosensitive eruptions
Pityriasis rosea Psoriasis Seborrheic dermatitis
Fig 2–1
Typical distributions of common skin conditions.
5
(From Swartz MH: Textbook of Physical Diagnosis, 5th ed. Philadelphia, WB Saunders, 2006.)
Ch01-13_X4919_001-046.indd 5 10/9/08 2:21:04 PM
2
Section 1: Skin and subcutaneous tissues
TABLE 2–1 Common maculopapular diseases
Feature Psoriasis Pityriasis rosea Tinea versicolor Seborrheic dermatitis Lichen planus
Color Dull red Pinkish yellow Reddish brown Pinkish yellow Violaceous
Scale Abundant Fine, adherent Fine Greasy Shiny, adherent
Induration 1(cid:6)* 0 0 1(cid:6) 1(cid:6)
Face lesions Rarely Rarely Occasionally Common Rarely
Oral lesions 0 0 0 0 2(cid:6)
Nail lesions 4(cid:6) 0 0 0 Rarely
From Swartz MH: Textbook of Physical Diagnosis, 5th ed. Philadelphia, WB Saunders, 2006.
TABLE 2–2 Common eczematous diseases*
Parameter Contact dermatitis Atopic dermatitis Neurodermatitis Stasis dermatitis
History Acute, localized to specifi c History in patient or family Chronic, in same areas, Varicosities, past history of
area member of asthma, hay associated with anxiety thrombophlebitis or cellulitis
fever, or eczema
Location Areas of exposure to Eyelids, groin, fl exural Head, lower legs, arms Lower legs
allergen areas
From Swartz MH: Textbook of Physical Diagnosis, 5th ed. Philadelphia, WB Saunders, 2006.
TABLE 2–3 Vesiculobullous diseases*
Dermatitis Epidermolysis
Parameter Pemphigus vulgaris herpetiformis bullosa† Bullous pemphigoid
Age of patient (yr) 40-60 Children and adults Infants and children 60-70
Initial site Oral mucosa Scalp, trunk Extremities Extremities
Lesions Normal skin at margins Erythematous base Bullae produced by Normal skin at
trauma margins
Sites Mouth, abdomen, scalp, Knees, sacrum, back, Hands, knees, elbows, Trunk, extremities
groin elbows mouth, toes
Groupings 0‡ 4(cid:6) 1(cid:6) 0
Weight loss Marked None None Minimal
Duration 1 or more years Several years Normal lifetime Months to years
Pruritus 0 4(cid:6) 0 (cid:7)
Oral pain 4(cid:6) 0 (cid:7) (cid:7)
Palms, soles involved No No Yes Yes
Typical lesion Flaccid bulla Grouped vesicles Flaccid vesicles Tense bull
From Swartz MH: Textbook of Physical Diagnosis, 5th ed. Philadelphia, WB Saunders, 2006.
B. DIAGNOSTIC TESTS AND PROCEDURES
tion, size, and condition of the specimen to be obtained. Local
COLLECTION OF SPECIMEN anesthesia is adequate for all skin biopsies. A technique for in-
Various techniques include curettage, shave biopsy, punch bi- jection of local anesthetic is shown in Figure 2–3. Collection of
opsy, snip or scissors biopsy, incisional biopsy, and complete a nail specimen for culture in suspected onychomycosis is
excision (Fig. 2–2). The preferred method varies with the loca- shown in Figure 2–4.
6
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2
Chapter 2: Evaluation of skin disorders
A B
Fig 2–2
Plantar wart. A, Note the keratotic lesion with the yellow center and areas of hemorrhage within. B, After excision.
(From Swartz MH: Textbook of Physical Diagnosis, 5th ed. Philadelphia, WB Saunders, 2006.)
C
A
D
B
Fig 2–4
Collection of nail for culture. The subungual debris is the most valuable
material for culture. After cutting back the nail, a curette may be used.
Fig 2–3 Clippings of the nail may be added to the culture.
Injection of local anesthetic. Using a fi ne needle, local anesthetic (LA) is (From White GM, Cox NH [eds]: Diseases of the Skin: A Color Atlas and
fi rst infi ltrated along one edge of the planned ellipse. Typically, the nee- Text, 2nd ed. St. Louis, Mosby, 2006.)
dle would be advanced from its insertion point A to point B, then LA is
injected as the needle is slowly withdrawn but without fully removing it
from the skin (thus avoiding the discomfort of a second needleprick at
point A). This is repeated from point A to C to give a V- or wedge-
shaped area of anesthesia. After waiting several minutes, the LA is infi l-
trated from B to D and then from C to D, areas B and C at this point
being anesthetized.
(From White GM, Cox NH [eds]: Diseases of the Skin: A Color Atlas and
Text, 2nd ed. St. Louis, Mosby, 2006.)
7
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