Terminal Learning Objectiveslides.jsomtc.org/SOMPYL0J/SOMPYL0J.pdfpetechiae, or ecchymosis. JSOMTC, SWMG(A) Slide 51 Recording Your Findings Describe the findings: 25‐year‐old

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Slide 1JSOMTC, SWMG(A)

SOCMPhysical Exam of the Skin,

Hair, and NailsPFN: SOMPYL0J

Hours: 1.0


Terminal Learning Objective Action: Communicate knowledge of “Physical Examination of the Skin, Hair, and Nails”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% IAW course standards on the formative quizzes and the Physical Exam Practical Test grade sheet


References

Bates’ Guide to Physical Examination And History Taking (11th edition; 2013; Lynn S. Bickley)

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Reason

The integumentary system is often a window that we can look into, finding problems with the other systems of the body.

Failure to recognize these problems could lead to a catastrophic end, while on the other hand recognizing these problems could be the first step to a sound treatment.


Agenda

Define the key terms related to the physical exam of the skin, hair, and nails

Communicate the steps in examining the skin

Identify the basic types of lesions

Communicate the inspection of hair and nails, and how to record exam findings


The Key Terms Related to the Physical Exam of the Skin, Hair, and Nails

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Vocabulary Development

Mobility ‐ the ease with which a fold of skin moves (by grasping the fold and lifting)

Turgor ‐ the resistance of the skin to deformity, or the speed in which a fold of skin returns into place after checking for mobility

Metastasize ‐ to invade distant structure of the body



Basal cell carcinoma ‐ lesion arising in the lowest, or basal, level of the epidermis

Squamous cell carcinoma ‐ lesion in the upper layer of the epidermis

Melanoma ‐ lesion arising from the melanocytes of the epidermis

Nevus (nevi plural form) ‐ congenital circum‐scribed area of the skin due to pigmentation



Pallor ‐ paleness, lack of color

Edema ‐ the generalized condition in which the body tissue contains an excessive amount of fluid

Induration ‐ hardened tissue

Sclerosis ‐ the hardening, or induration, of an organ or tissue

Intertrigo ‐ skin chafing in or under folds of skin

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Umbilicate ‐ dimpled, pitted, or shaped like a navel

Acral ‐ pertaining to the extremities

Coalesce ‐ to fuse, to run or grow together

Violaceous ‐ purple or violet discoloration

Heliotrope / heliotropic ‐ violaceous rash

Associated with dermatomyositis

Often seen as discoloration of the eyelids, forehead and nasolabial folds



Nasolabial folds ‐ commonly known as "smile lines" or "laugh lines”

Vellus hair ‐ short, fine, inconspicuous, and relatively unpigmented hair

Terminal hair ‐ coarser, thicker, more conspicuous, and usually pigmented hair



Classic signs of inflammation:

Calor ‐ heat

Dolor ‐ pain

Rubor ‐ erythema or redness

Tumor ‐ swelling

Functio laesa ‐ loss, or disturbance, of function

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Steps in Examining the Skin


The Skin Exam

Beginning the examination

Changes in the skin, hair, or nails

Any:

• Rashes

• Sores

• Lumps

• Itching

You may defer further questions about the skin until the physical examination


The Skin Exam

Steps of the examination

Begin with general survey

Continue through physical examination

Inspect entire surface – everywhere

Use good light – natural if possible

Correlate findings of skin with those of mucous membranes

Be able to Identify

• Skin color

• Patterns and types of lesions

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The Skin Exam

Inspection and palpation

Color:

• Ask if any changes

• Assess discoloration

General discoloration / areas of discoloration

Oxyhemoglobin and pallor in its absence

Moisture

• Dry vs. diaphoretic

• Oily


The Skin Exam

Skin color, changes in pigmentation:

Widespread increase in melanin may be caused by Addison’s disease


The Skin Exam

Changes in Pigmentation

Cyanosis – bluish color

• Readily visible in:

Fingers / fingernails

Toes / toenails

Lips / oral mucosa

Erythema – reddish color / hue

• Can be caused by:

Increased dermal blood supply, infection, etc.

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The Skin Exam

Changes in Pigmentation

Jaundice

• Sign, not a disease

• Affects the skin and sclera

• Caused by increased bilirubin

Increased hemolysis / liver disease


The Skin Exam

Inspection and palpation (cont’d)

Temperature

Texture

• Rough / smooth

Mobility and turgor

•Mobility = lift skin‐fold

• Turgor = Release skin‐fold: speed it returns

Lesions


The Basic Types of Lesions

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Skin Lesions

Recognition of specific lesions is essential to make a diagnosis

Specific types of lesions are seen in individual disease processes

Correct terminology is required to document the condition and to communicate findings to a consultant, if needed


Skin Lesions

Note

Type of lesion

Location / distribution

Pattern / shapes

Review their appearance in a well‐illustrated textbook of dermatology

Whenever you see a skin lesion, look it up in such a text


Skin Lesions

Primary Lesions

Represents early stage of the lesion

How they look when they start, prior to evolving

Secondary Lesions

Represents a later stage after the lesion has evolved or been altered

May help determine where in the skin the process is occurring

• e.g., epidermis, dermis, fat

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Types of Skin Lesions

Primary lesions

Macule

Patch

Papule

Plaque

Nodule

Cyst

Vesicle

Bulla

Pustule

Secondary lesions

Scar

Keloid

Excoriation

Scale

Crust

Lichenification

Fissure

Erosion

Ulcer

Atrophy

Tumor


Primary Skin Lesions

Flat, nonpalpablelesions with change to skin color:

Macule – small / up to 1.0 cm

Patch – large / 1.0 cm or larger

Macule

Patch



Palpable elevated with solid mass:

Papule – up to 1.0 cm

Nodule – larger than 0.5 cm

• Marble‐like lesion, often deeper and firmer than papule

Plaque – 1.0 cm or larger• Often formed by coalescence of papules

Cyst – nodule (> 0.5 cm )

• Filled with expressible material

• Liquid or semisolid

Papule Nodule

Plaque Cyst

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Palpable elevated with fluid ‐filled cavities:

• Vesicle ‐ Up to 1.0 cm

• Bulla ‐ 1.0 cm or larger

Filled with serous fluid

• Pustule ‐ size irrelevant

Filled with pus

• Burrow ‐ 5‐15 mm

Tunnels in epidermis

Curving line; ends at vesicle

May include other lesions

Vesicle Bulla / Vesicle

Pustule Burrow


Secondary Skin Lesions

Causes include:

Evolved from primary lesion

From external forces

Scale – thin, dead, exfoliated epidermis

Crust – dried residue of exudates:

Pus

Serum

Blood

Scale

Crust



Lichenification:

Thickening of epidermis

Roughening of the skin

Increased visibility of furrows

Usually from rubbing or scratching

Scars – connective tissue from injury site or disease

Keloids ‐ hypertropic scar• Extends beyond border of original injury

Lichenification

Scarring Keloid Scarring

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Secondary Skin Lesions Depressed

Erosion

• Superficial loss of epidermis

• Non‐scarring

• Surface is moist / no bleeding

Excoriation – linear or punctate erosion from scratching

Fissure – linear crack in skin • Extends into dermis

Ulcer‐ necrosis of epidermis / dermis

• May extend into subcutaneous

• Can bleed and leave scar

Erosion Excoriation

Fissure Ulceration



Wheal – localized area of skin edema

Examples:

• “Hives”

• Insect bite

• Wheal from a sensitivity test –injection



Tumor

Characteristics

• Elevated, but with depth too

• Solid

• > 2 cm diameter

Examples

• Malignancy

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Atrophy

Characteristics

• Thinning of epidermis

• Translucent

• Loss of skin markings

Example

• Age‐related changes

• Medication side effect


Skin Lesions

Patterns and shapes include:

Linear (line)

Clustered (grouped)

Geographic

Serpiginous

Annular/arciform


Vascular Skin Lesions

Petechiae

Purpura

Ecchymosis

Telangiectasia

Hemangioma

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Petechiae

Characteristics

• Red‐purple color

• Non‐blanching

• < 0.5 cm diameter

Examples

• Infections

• Vascular defects



Purpura

Characteristics


• Non‐blanching

• > 0.5 cm diameter

Examples

• Infection

• Vascular defect



Ecchymosis

Characteristics


• Non‐blanching

• > 2 cm diameter

Examples

• Vascular wall destruction

• Trauma

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Inspection of the Hair and Nails, and How to Record Exam Findings


Male Pattern Baldness

Inspection of the Hair Inspect the hair, note the:

Quantity – normal loss: 50 to 100 per day

Texture

Distribution

Alopecia, note hair loss:

• Diffuse / localized

• Patchy / total

• Permanent hair loss ‐androgenetic alopecia

Male‐ and female‐pattern baldness

Cicatricial alopecia ‐scarring

Female Pattern Baldness


Traction Alopecia

Inspection of the Hair

Alopecia

Temporary hair loss

Small patches ‐ alopecia areata

• Round / oval patches of loss

• No inflammation at the scalp

Entire scalp ‐ alopecia totalis

Entire body ‐ alopecia universalis

Where hair is pulled tightly ‐traction alopecia

• Associated with hair styles

Alopecia Areata Alopecia TotalisUniversalis

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Inspection of the Nails Nails

Inspect and palpate the fingernails and toenails

• Often overlooked in the exam

• Sequence – when to check fingernails and toenails

• Check nails individually and compare bilaterally

Note the color, shape, texture, thickness and lesions:

• Missing fingers or toes, or their nails

Anonychia – rare genetic disorder

Anonychia


Average growth0.12” (3mm) per

Month

Inspection of the Nails

Nails

Inspecting the nail for color, shape, texture, thickness

Normal nail growth rate:

• Average 0.12 inch (3 mm) per month

• Dependent upon many factors

• Fingernails grow up to four times faster than toenails; complete re‐growth:

Fingernails 3 to 6 months

Toenails 12 to 18 months


The Inspection of the Nails

Beau's Lines Mees' Line Terry's Nails

Spooning Clubbing Psoriasis

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Recording Your Findings

History

Initial event / Prior events

Patterns / Recurrent configurations

Duration of evolution

Age of patient

Events / Exposures

Associated symptoms

Prior treatments / Results

These points augment “SAMPLE” Hx



Inspection

Types of lesions

Distribution / Pattern

Infectious clues

Nail plate involvement

Pigmentation changes

Note: Survey for all lesions



Palpation

Texture

Thickness

Elasticity

Temperature

Tenderness

Caution: Is it potentially communicable?

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The “ABCD” method for assessing moles

A ‐ Asymmetry

B ‐ Borders irregular, especially notching

C ‐ Color variations, especially mixtures of black blue and red

D ‐ Diameter > 6mm

E ‐ Evolving/Ephemeral

DC

BA


Recording Your Findings Styles of recording

Full sentences (early on)

Phrases (similar to bullets)

Examples:

The patient’s skin is warm, pink, and moist. The hair and nails are normal with no signs of alopecia. The nails do not have any sign of clubbing, deformity, or discoloration.

Color pink. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymosis.



Describe the findings:

25‐year‐old female patient that complains of hair loss for the last 10 months

25 y/o ♀ c/o hair loss x 10 mo.

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Describe the findings

27 y/o ♂ c/o painful rash x 2 days



Describe the findings

30 y/o ♂ c/o dry scaly rash x several weeks

Pt has hx of psoriasis



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Questions?


Terminal Learning Objective

Action: Communicate knowledge of “Physical Examination of the Skin, Hair and Nails”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Agenda

Define the key terms related to the physical exam of the skin, hair, and nails

Communicate the steps in examining the skin

Identify the basic types of lesions

Communicate the inspection of hair and nails, and how to record exam findings

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Reason

The integumentary system is often a window that we can look into, finding problems with the other systems of the body. Failure to recognize these problems could lead to a catastrophic end, while on the other hand recognizing these problems could be the first step to a sound treatment.


Break

Documents

Terminal Learning Objectiveslides.jsomtc.org/SOMPYL0J/SOMPYL0J.pdfpetechiae, or ecchymosis. JSOMTC, SWMG(A) Slide 51 Recording Your Findings Describe the findings: 25‐year‐old