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steps in dermatology diagnosis

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Show Notes

Slide 1 :

1 Steps in Dermatology Diagnosis Iqbal Bukhari, Associate Prof. Department of Dermatology King Faisal Univeristy and King Fahd Hospital of the University Dammam, Saudi Arabia

Slide 2 :

2 The longer your differential, The weaker your diagnostic clutch

Slide 3 :

3 THE ART OF QUESTIONING What does the History do? It confirms or weakens your initial impressions. A baby with bullous lesions suggest a diagnosis of urticaria pigmentosa and history since birth supports the diagnosis. It deletes untenable diagnostic hypothesis. Blisters on the dorsal aspect of a patient’s hands suggest porphyria cutanea tarda, history of a burn yesterday excludes this diagnosis. It suggest new diagnoses. History of diabetes mellitus may elicit a sudden awareness of bullous dermatosis of diabetes.

Slide 4 :

4 - It awakens you to derivative or secondary diagnoses. Atopic child with flaring after contact with a wool rug suggest an irritant dermatitis. - It finds causes. It provides diagnostic guidance in management, history of bullae following sulfa changes your periscription approach. - Connect the history of your working diagnosis. The stomatitis patient must tell you about toothpaste, dentures, lozenges, mouthwash, chewing gum, breath fresheners, cinnamon cookies, dental visits, cigarettes, cigars, snuff, of pain pills, antihistamines, tranquilizers, sleeping pills, and artificial sweeteners.

Slide 5 :

5 THE ART OF LOOKING One must be curious and look at things not brought to your attention by the patient as moles, dry skin, hyperhidrosis, overlooked areas: -pull back the ears. -look at mouth carries, leukoplakia, or candidiasis, Koplic spots, sialorrhea or xerostomia, lichen planus. -Fingernails reveal the past 5 months, toenail the past 18 months.

Slide 6 :

6 The First look Best made without benefit of history. The Second look Use it now to look at details of the lesions. The Global Look Insist on seeing as much as possible of the patient’s skin distribution satellite lesions. The Magnified Look Optivisor loupe with a power of 2.7x The tactile Look Early scleroderma, granuloma annulare, rough skin, lymph nodes, nerves of leprosy, lesion bound down, elastosis, extent of a lipoma.

Slide 7 :

7 The Positional Look Changing the position of the patient will show atrophic areas of the skin on the abdomen only when the patient is supine. Pedal papules of herniated fat only when the patient is standing. Glomus tumors evident only with the arm dependent. Cross-lighting or even subdued lighting is essential for seeing spotting lichen spinulous, regrowth of hair, faint vitiligo.

Slide 8 :

8 The Informed Look Nits in the scalp of the patient with generalized pruritus. Buccal mucosal lesion of lichen planus in the patient with strange excoriated lesions. Herpetic lesion in the patient with erythema multiforme. Tinea pedis in the patient with dyshidrosis.

Slide 9 :

9 The Manipulative Look It means manuevers one can do to improve the art of looking. Remove scales if erosion or ulcers lie beneath. Scrape a scaling lesion for capillary bleeding of the Auspitz sign. Subsect an eschar to see if there is pus below. Shave off the top layer of nail plate to see how deep the pigments is. Inject Xyclocaine or saline into a suspect basal cell carcinoma to enhance its gross morphology. Apply vinegar for 2 minutes to genital skin to visualize warts.

Slide 10 :

10 The Diascopic Look Viewing the lesion under oil or through a glass slide pressed against the skin is valuable. Maybe combined to give a better, view past the epidermis. Wickham’s striae of lichen planus distorted nail fold capillaries of collagen diseases. Glass-slide pressed against the skin exposes more of the dermal changes: telangiectasia, granulomas, apple jelly nodule of lupus vulgaris.

Slide 11 :

11 The Wood’s Light Look Using the ultraviolet light in Wood’s light. With a wavelength peaking at about 360 nm. Wood’s light depends on the three essentials : totally dark room, totally dark adapted retina, light operating at full power. One must wait several minutes in the dark for the eye to adapt and for the lamp to reach full power. Erytrasma its coral-red emission. Tinea capitis with its greenish hues. Subtle hypopigmentation by accentuating the contrast between melanized and hypomelanized skin. Ash-leaf macules Compliance in taking tetracycline since the drug is excreted in the sebum and can thus be visualized at the follicular pores. Detection of fluorescent contact sensitizers on the skin. Monitor the use of creams and lotion containing fluorescent drugs or compounds.

Slide 12 :

12 .The earliest signs of pigment return in treated vitiligo. . Also look at urine, stool, and blood extract under Woods light if porphyria is suspected. Urine Direct Wood’s lights inspection : Reddish-orange fluorescence indicative of large amount of porphyrins (urophorphyrin or coproporphyrin). 2 - Stool Direct Woods light inspection will show fluorescence if large amounts of pophyrin present. 3. Red Blood Cells Wood’s light examination of whole blood extraction. Lower layer will show intense red fluorescence in patient with erythropoietic protoporphyria or hepatic erythropoietic porphyria.

Slide 13 :

13 The Deeper Look Do a biopsy! The Longitudinal Look Look at the patient’s lesions next week, next month, 3 months later. Never approach a patient with a look of indifference.

Slide 14 :

14 THE ART OF THINKING Such thinking can be enriched by certain conscious maneuvers. Keep your initial list of diagnosis possibilities small. Three or four diagnoses are about all the brain can effectively process. Challenge your brain with questions. Transpose the lesion to another site. This generates new thoughts. Transpose the lesion to another age group, sex occupation.

Slide 15 :

15 Imagine that the history is wrong, ? forgetful?, ? factitial ? Has it been there for months, not days? Generate new ideas. Think of the various causes of the skin disease: contactants?, drugs?, infection?. Think of new test. Don’t be inhibited from doing a palmar biopsy, an HIV antibody. Don’t lock into one diagnosis. Keep reading and dipping into your atlases, text, and journals. Be confident.

Slide 16 :

16 HOW TO MAKE A DIAGNOSIS See and touch (with gloves when needed) Patterning the distribution, are the photo areas specially involved? Limited to the seborrhoeic zone? Favor the stasis areas? Zosteriform, unilateral, quadratic, banded? Mouth, conjuctiva, glans penis, vagina? Separate the toes nails, scalp for pediculi, pubic hair for pediculi. Islands of uninvolved skin as seen in the erythroderma of pityriasis rubra pilaris?

Slide 17 :

17 Patient with a hand eruption may fail to show you the scalling crusted lesions of scabis on the penis. Behind the ears, close eyelid, back must not be neglected. The most useful magnification for detailed clinical inspection is 3X to 4X. The single lens hand-held magnifier is the simplest and least expensive. To go to binocular system, use of the headband-mounted Optivisor with a magnification of 2.75X is recommended.

Slide 18 :

18 Excellent visualization of the skin, and particularly of pigmented lesions, is obtained by using the Dermatoscope. Placing a drop of mineral oil on the skin surface covered with glass, the epidermis becomes translucent , it magnifies 10 power. Transilluminate the nose, ear, or finger to determine extent of a mass Using a strong red light is preferable, since only the red wavelengths penetrate through the corium. Viewing the skin with an 8X hand lens following the applications of mineral oil permits early recognition of epidermal atrophy, One can see the normally hidden subpapillary vascular channels.

Slide 19 :

19 For viewing the capillaries, the nail fold is ideal, nail fold capillary microscopy: Place a drop of mineral oil on the nail fold of the fourth finger. Hold the ophthalmoscope (set at +40) close, but not in contact with oil. one visualizes normal capillaries as thin regularly spaced loops in a row perpendicular to the nail.

Slide 20 :

20 4. In scleroderma the loops are enlarge and dilated, disorganized absent in areas. 5. In lupus erythematosus the loops are tortous and meandering, but not dilated resemble glomeruli. 6. Not suitable for capillary study in black-skinned persons or in nail folds traumatized by manual labor or by curricular manipulation.

Slide 21 :

21 Practical points: To mark lesions or patch and skin test sites invisibly use fluorescent marking pens. The patient does not see the marks, but you do under Wood’s light. Anatomic rubber stamps provide appropriate regional outline imprints in your chart. To measure the volume of a pressure sore, cover it with a tight, adhesive film. Inject an isotomic saline, measuring amount of saline to fill the cavity, trace with pen the circumference on the plastic film before removing it. Photograph the patient and project the Kodachrome on a large screen.

Slide 22 :

22 SMELL: . The odor of rotten fish (trimethylaminuria) may not be present unless the patient is challenged with an oral dose of 4 teaspoons of choline obtained at health food stores. generated by bacteria. There is a congenital or acquired inability to degrade the malodorous gas, trimethylamine, generated by the gut bacteria and absorbed from the gut. Punget odor diagnostic of unwashed unperfumed axilla or perineum skin. bacteria generate the odor by acting upon apocrine sweat. In rare instances, hydradenitis suppurativa, may be the source of the axillary or genital odor. Malodolous feet are diagnostic of bacteria overgrowth in the presence of hyperhydrosis.

Slide 23 :

23 - “Bad breath” suggest a diagnosis of gingivitis or failure to brush or floss food particles or can be a sign of the presence of pus. - Nose as a result of an intranasal foreign body, ear with infection, vagina in Gardenella vaginitis with bacterial growth.

Slide 24 :

24 SOAK Soaking the skin in tap water will often reveal the presence of a hidden wart soaking the skin in 5% acetic acid (vinegar) solution brings genital warts into full display. Soaking the hands provides information on the autonomic function. Soaking off crust and debris may reveal the presence of a unsuspected ulcer. Milia, furrows, and small cysts also show focal whitening upon application of vinegar.

Slide 25 :

25 The skin of children with cystic fibrosis wrinkles within a couple of minutes upon immersion in tap water. This wrinkling occurs far more rapidly than in normal children and a “3-minute bowl of water” test might be a cheap diagnostic screening test. The wrinkling of the skin experienced on immersion of the hands in warm water depends on an intact sympathetic pathway.

Slide 26 :

26 SCRAPE Scape for a KOH,for staining, for culture. diagnostic sign of dermographism, darier’s sign of mastocytosis, or the pseudodarier sign of smooth muscle growths. Blister base for the Tzanck test. Swab the vagina for Trichomonas. Scrape for Sarcoptes mite. Scrape under the fingernails of factitial dermatitis patients for incriminated epidermal shreds.

Slide 27 :

27 Any specimen obtain by your scraping can be permanently mounted by simply adding a drop of cyanoacrylate glue and a coverslip great for making teaching slides. Physical fragmentation of hair by hammering the specimen placed between metal surfaces (e.g., two halves of razor blade) allows instant visualization of any fungi present. Xylene is used for clearing. Direct examination of specimens cleard with KOH (or NaOH) 10 to 30% heated for 30 seconds is the most widely used method.

Slide 28 :

28 Tap-water moistened gauze is firmly rubbed over the affected area of scalp. Broken hairs are removed from the gauze , KOH examination and culture for analysis of suspect cases tinea capitis. This beats plucking! Tzanck smear test (the Netherlands technique) Take scarpings from the base of vehicles, pustules, or erosion, smear on glass slides, and air dry. Fix in methanol. Look for characteristic herpetic-induced nuclear changes in epidermal cells but cannot distinguish between varicella-zoster and herpes simplex infection.

Slide 29 :

29 The clinical diagnosis of elastosis perforans serpiginosa is supported by microscopic examination of a potassium hydroxide (10 %) treated scraping of a representative keratotic papule. It reveals matted hyphae-like fibers which can be stained with Giemsa. Insert and rotate dental burr in crusted or ulcerative lesion to sample for stab culture, plating, or direct smear. Valuable in diagnosis of leishmaniasis, leprosy, yaws, and anthrax.

Slide 30 :

30 STRIP Strip off layers of stratum corneum with simple Scotch tape. Better precoated adhesive microscope slides. Visualization of the undersurface, hair follicles, Demodex presents is facilitated by adding a drop of xylene and a coverslip. The slides are best viewed after stainings. Giemsa or Gram for bacteria, PAS for fungi. Diagnosis of pinworm infestation by Scotch tape stripping of perianal area several hours after retiring or early in morning before bowel movement. Scotch tape is placed sticky side out over the end of the glass slide and pressed firmly against mucocutaneous surface after spreading anal folds. Pinworm eggs, female worms, part of them will be seen on microscopic examination.

Slide 31 :

31 The Gillette Super Blue Blade provides full-thickness biopsies of stratum corneum , search for fungi, acari and foreign bodies. The Gillette Super Blue Blade provides an excellent surface of cut tissue for touch preparation in the evaluation of tumors, inflammation, or microorganisms.

Slide 32 :

32 SLIT A slit and squeeze can express all sorts of materials for diagnosis, extending throught milia, microcysts, molluscom contagiosum to leprosy. Use a no. 11 scalpel tip. Diagnosis of molluscum contagiosum by light microscopic demonstation of virions. slit open the molluscum, extract the pearly core, squash it between two glass slides. Add a drop of Sedi-Stain and a coverslip. Scan under high magnification for tiny dark particles that are stained molluscum virions. may also be seen within the molluscum bodies which are distinctive oval-shaped infected keratinocytes with flattened displaced nuclei.

Slide 33 :

33 SLIT-SKIN SMEAR IN LEPROSY Many technique are available. Incise skin, squeeze between thumb and finger, scrape. Snip a small piece of skin and crush on slide. Press slide against lesions, making 10 successive smears. Scrape nasal mucosa or smear from ulcer. Blow nose content into sheet of cellophane, and smear mucus with cotton swab. Air dry - fix in heat for 5 minutes or hold over flame. Ziehl-Neelsen stain or fluorescent stain. Read as beaded red rods lying singly or in clumps against a blue background.

Slide 34 :

34 Biopsy If the skin changes is not homogenous, the larger excisional biopsy wins. it provides more information , fewer negative reports. A superficial biopsy may miss the deeper plasma cell infiltrate of syphilis, the malignant cells of melanoma, or underlying panniculiti, Eosinophilic fasciitis and neocrotizing fasciitis . go for the gold. Go deep. Avoid unnecessary trauma to the skin specimen. Cut cleanly. Fix at once. In a widespread heterogenous eruption, multiple biopsies needed. No superficial biopsies on melanoma suspects.

Slide 35 :

35 REMEMBER Stain with hematoxylin for DNA Eosin for the cytoplasm and connective tissue Collagen with van Gieson’s stain Elastin with verhoeff, reticulum with Gomori silver nitrate Carbohydrate with alcian blue, colloidal iron, toludine blue, periodic acid-Schiff (PAS) Protein (amyloid) with Congo red , crystal violet Lipid with Sudan black B Melanin and mineral with Fontana-Masson (for melanin) Dopa reaction (for tyrosinase)

Slide 36 :

36 Pearl’s Prussian blue (for iron) Von Kossa (for calcuim) Alizarin red S (for calcuim) Mast cells with Giemsa Microorganism with Gram (bacteria), Ziehl-Neelsen (mycobacterial), Fite (lepra bacillus), Warthin-Starry (spirochetes, Donovan bodies, cat scratch bacteria), Gomori’s methenamine (fungi), silver nitrate.

Slide 37 :

37 AVOID THE PITFALLS Biopsy Technique Do not clamp, squeez, mince, compress. Lift the specimen out by piercing it with the 26-gauge needle Fixation Avoid a large specimen and thus inadequate penetration of the fixative.

Slide 38 :

38 HAIR STUDY Hair Pluck: Do not shampoo for a week before accurately assess telogen phase. Clamp 50 to 60 hairs with hemostat and foecibly extract. Cut hairs at upper side of hemostat Place hair bulb ends on double-sided tape or between slides Count number of anagen hairs and number of telogen hairs Normal: 85% anagen and 15% telogen Telogen effluvium: more than 20% telogen Trichotillomania: no telogen hairs present Grasp cluster of hairs between left thumb and ring fingers. exert sliding traction. If more than four hairs come out. It favors diagnosis of telogen effluvium, alopecia areata, or hereditary thinning.

Slide 39 :

39 HAIR COUNTS Patient collects all hair in sinks, comb, brush, and shoulders, label the day and the shampoo used. Do this for 14 consecutive days. Check bulb type, shaft abnormalities, and morphology of distal tip. Normal loss: 50 to 100 hairs a day and 200 to 250 hairs on days of shampoo. If shampoo is done daily, normal loss is 100 hairs a day. PART WIDTH Make coronal parts with patient’s comb Compare width with that in occipital area if widened parts then there is significant hair loss

Slide 40 :

40 HAIR GROWTH WINDOW Shave 2 by 2 cm area of scalp Cover with Op-site or Duoderm for 7 days. Physician removes dressing and measures hair length. Normal: Hair should be 2.5 mm long. HAIR FEATHERING Grasp distal 2 to 3 cm end of hairs Give brisk pull. Appearance of short broken hairs is indicative of hair shaft defect

Slide 41 :

41 VIEWING HAIR When plucked, entire exclamation-point hair visible, alopecia areata CONTRAST Part hair Place index card Short miniature hairs can be readily seen. Good for evaluating hair growth stimulants.

Slide 42 :

42 SCALP BIOPSY Avoid skin over temporal and occipital arteries. Inject lidocaine (1% with epinephrine, 1.5 ml) intradermally. Wait 20 minutes for vasoconstrictor effect Obtain full-thickness 6-mm punch Close with 4-0 proline suture Halve specimen for routine and immunofluorescence studies.

Slide 43 :

43 DOUBLE STICK TAPE On a glass slide for systematic examination of the hair, cuticular structure, changes in diameter associated with disease, malnutrition, and cytotoxic agents. can be permanently stored by simply adding a large coverslip. (An alternative is the use of Durotok slides).

Slide 44 :

44 SEX CHROMATIN DETERMINATION FROM HAIR Look for solid dark chromatin body in nuclei (oil immersion 1250X) 56% of hair shealth cells will show sex chromatin body in women, but only 2% in males.

Slide 45 :

45 SEBACEOUS GLANDS The easiest way to assess sebum secretion is to place a glass slide on the skin, remove it, and observe the amount of visible oil. Application of cigarette paper to the skin, the oil absorbed becomes apparent as spots on the paper.

Slide 46 :

46 SWEAT GLANDS Its significance extends from classifying ectodermal defects to assessing autonomic denervation due to surgery or disease such as the neuropathy of diabetes mellitus. The usual stimulant in the test is heat or exercise. But in the office diagnosis is missed unless the patient is carefully queried. In children with ectodermal defects injection of 0.05 ml of 1% acetylcholine or pilocarpine prior painting of the skin with iodine solution followed by application of starch. The purple dots indicate sweating.

Slide 47 :

47 VESSELS To see blood vessel patterning, press on skin with blunt probe or curet ring. Subpapillary plexus filling time: Pressure on the surface of the skin causes pallor and empties subpapillary venous plexus. Sudden release is followed by filling of the plexus and a normal return of color in 1 to 2 seconds. Elevations of limb: well above heart level results in balanching. Upon dropping the limb to well below heart level, flushes within 5 seconds, and this fades after 15 seconds.

Slide 48 :

48 Prick histamine: 1:1000 into skin. Wheal develops within 3 minutes but does not develop on ischemic skin or may take over 5 minutes. A light stroke to the skin in some disorders results in development of whiteness some 10 to 15 seconds later. Such white demographism may be due to a release of local vasconstrictor agents in the upper dermis, or a response of contractile elements in the capillary pericytes following stretch, or swelling of endothelial cells. It is typically seen in atopic eczema.

Slide 49 :

49 GENERAL PRINCIPALS IN LAB TESTS Order diagnostic test only when the results can enhance your awareness of the nature and extent of your patient’s disease, can affect your therapy, can allay the patients real fears, can protect you from the threat of a malpractice suit, can provide necessary confirmation.

Slide 50 :

50 Be aware of the limitations: False-positives in healthy patients or in patients with other disease False-negatives in patients who have the disease in its early or late stages or in an atypical form. Laboratory error as mislabeling, misreading.

Slide 51 :

51 Don’t forget that drugs interact not only with each other but also with laboratory test. Medication can lead to false laboratory values. The elevated thyroid test results in patients taking oral contraceptives are an an example. The fasting state is mandatory for test such as serum iron and serum triglycerides. restrict bananas when testing the urine for 5-hydroxyindoleacetic acid excretion.

Slide 52 :

52 Sensitivity indicates how often the test is positive in disease (PID) i.e. the proportion of patients with the disease in question. Specificity indicates how often the test is normal in health.

Slide 53 :

53 ROUTINE HEALTH PROFILE: Here are a few of the dermatologic diagnosis that may spring into your mind when you scan the data on your patient’s health profile or chemscreen.

Slide 54 :

Slide 55 :

55 It pays to think zinc when looking at a strange dermatitis. Order a plasma level determination, but be sure that rubber stoppers are not used and that the specimen doesn’t hemolyze. Red cells and rubber stopper are zinc rich.

Slide 56 :

56 PEARLS Most test do not have sharp cut-off points between normal and abnormal. Infants and young children have their own normal ranges. Pregnancy, Contraceptives increase: T4, fasting state for iron-binding capacity, potassium, lipids, blood sugar, B12, folate levels. Caffeine elevate catecholeamine levels. A traumatic venipuncture produce hemolysis and invalidate coagulation test, as well as give spurious high values for serum AST and ALT, LDH, acid phosphatase, bilirubin, and magnesium. Urethral catherization, sex, menstruation cause few red cells in urine. Some values show circadian rhythms (e.g., eosinopilis low in afternoon at the same day. Hand clenching with torniquet increases potassium).

Slide 57 :

57 Color of sweat: Brown: ochronosis Red: rifampin Blue: copper Blue-black: chromhidrosis

Slide 58 :

58 How can I keep up? Read, read, read: Journal of AAD BJD Archives of dermatology International journal of dermatology Pediatric Dermatology

Slide 59 :

59 Review, review, review: Advance in Dermatology, Vols 1-6, Year Book Publishers Current Problems in Dermatology, Vols, 1-6, Year Book Publishers Seminars in Dermatolody, Vols, 1-8 W.B. Sauders Co.

Slide 60 :

60 Listen, listen, listen: Dialogue in dermatology American academy of dermatology International Meetings

Slide 61 :

61 THE COMPLETE DIAGNOSTICIAN’S BOOKSHELF Textbook of Dermatology Cutaneous Side Effects of Drugs Pediatric Dermatology Disease of Hair and Scalp Nail Disorders Skin Signs of Systemic Disease

Slide 62 :

62 DO NOT GIVE UP UNTIL YOU HAVE TRIED THE BIG TEN Kenalog IM Dapsone Chloroquine clarithromycin Petoxyphilline Methotrexate Cyclosporine Zinc Thalidomide Optimism

Slide 63 :

63 if you commonly limit yourself to rare diagnoses, you will rarely be right!

Slide 64 :

64 Q&A 1-What does the History do?3 Confirms or weakens the impression Deletes untenable diagnostic hypothesis Suggest new diagnosis 2-Fingernails reveal the past ------, toenail the past ------- 5 months and 18 months

Slide 65 :

65 3-Uses of The Wood’s Light ?5 Evaluate the pigmentary changes Detection of florscent contact sensitizers Porphyrins in teeth Ash leaf macules Tetracycline compliance

Slide 66 :

66 4-what information will you get when you view the skin with an 8X hand lens following the applications of mineral oil? 2 Epidermal atrophy See subpapillary vascular channels 5-when do you transilluminate the nose, ear, or finger ? When you suspect a mass. 6-Soaking the skin in tap water will often reveal the presence of ----------- hidden wart

Slide 67 :

67 7.Contraindication to nail biopsy?3 DM Peripheral vascular disease Immunocompromise patient 8.The prenatal diagnosis of heritable skin disease?5 EB ICHY XP NEUROFIB BLOOM`S

Slide 68 :

68 9.Skin temperature is lower over ? Joints 10.Smoking a cigarette lowers the temperature of hands by how many degrees? 3c 11.Caffeine elevate catcholamines 12.Color of sweat: Brown: ochronosis Red: rifampin Blue: copper Blue-black: chromhidrosis

Slide 69 :

69 We saw a nail so loose We called it onycholysis It was hanging by a cuticle We called it onycholysis totalis It was a nail so black We called it onycholysis totalis noir It was twisted and thick We called it onycholysis totalis noir et dystrophica It was cause of unknown We called it onycholysis totalis noir et dystrophica idiopathica The patient asked if it is cancer We replied gravely, “No it’s only onycholysis totalis noir et idiopathica benigna.” It had never been seen before So now we call it onycholysis totalis noir et dystrophica idiopathica benigna of Shelley. Diagnosis is so easy, once you get the hang of it !!!!!!!! Just for reading:

Slide 70 :

70 So when all else fails, consider one of these diagnoses: DUO Dermatitis of undetermined origin Q dermatitis Analogous to Q fever WK syndrome “Who knows” syndrome Dermatitis incognito A disease traveling incognito Dermatitis nonrecollecta You know the diagnosis, but can’t quite remember _______’s disease Insert patient’s name

Slide 71 :

71 Thank you

	consultant@dermatologyclinics.net 1 Years ago. Category: Dermatology

Tags:	Dermatology

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