1 Reason The integumentary system is often a window that we can - - PDF document

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Slide 1 JSOMTC, SWMG(A)

SOCM Physical Exam of the Skin, Hair, and Nails PFN: SOMPYL0J

Hours: 1.0

Slide 2

JSOMTC, SWMG(A)

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

Slide 3

JSOMTC, SWMG(A)

References

 Bates’ Guide to Physical Examination And

History Taking (11th edition; 2013; Lynn S. Bickley)

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Slide 4

JSOMTC, SWMG(A)

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

• ther hand recognizing these problems could

be the first step to a sound treatment.

Slide 5

JSOMTC, SWMG(A)

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

Slide 6 JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

Vocabulary Development

 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

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JSOMTC, SWMG(A)

Vocabulary Development

 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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JSOMTC, SWMG(A)

Vocabulary Development

 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

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JSOMTC, SWMG(A)

Vocabulary Development

 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

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JSOMTC, SWMG(A)

Vocabulary Development

 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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Slide 13 JSOMTC, SWMG(A)

Steps in Examining the Skin

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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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Slide 16

JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

The Skin Exam

 Skin color, changes in

pigmentation:

• Widespread increase in

melanin may be caused by Addison’s disease

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JSOMTC, SWMG(A)

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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Slide 19

JSOMTC, SWMG(A)

The Skin Exam

 Changes in Pigmentation

• Jaundice
• Sign, not a disease
• Affects the skin and sclera
• Caused by increased bilirubin

 Increased hemolysis /

liver disease

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JSOMTC, SWMG(A)

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

Slide 21 JSOMTC, SWMG(A)

The Basic Types of Lesions

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Slide 22

JSOMTC, SWMG(A)

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

Slide 23

JSOMTC, SWMG(A)

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

Slide 24

JSOMTC, SWMG(A)

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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Slide 25

JSOMTC, SWMG(A)

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

Slide 26

JSOMTC, SWMG(A)

Primary Skin Lesions

 Flat, nonpalpable

lesions with change to skin color:

• Macule – small / up to

1.0 cm

• Patch – large / 1.0 cm
• r larger

Macule Patch

Slide 27

JSOMTC, SWMG(A)

Primary Skin Lesions

 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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Slide 28

JSOMTC, SWMG(A)

Primary Skin Lesions

 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

Slide 29

JSOMTC, SWMG(A)

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

Slide 30

JSOMTC, SWMG(A)

Secondary Skin Lesions

 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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Slide 31

JSOMTC, SWMG(A)

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

Slide 32

JSOMTC, SWMG(A)

Secondary Skin Lesions

 Wheal – localized area

• f skin edema
• Examples:
• “Hives”
• Insect bite
• Wheal from a

sensitivity test – injection

Slide 33

JSOMTC, SWMG(A)

Secondary Skin Lesions

 Tumor

• Characteristics
• Elevated, but with depth too
• Solid
• > 2 cm diameter
• Examples
• Malignancy

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Slide 34

JSOMTC, SWMG(A)

Secondary Skin Lesions

 Atrophy

• Characteristics
• Thinning of epidermis
• Translucent
• Loss of skin markings
• Example
• Age‐related changes
• Medication side effect

Slide 35

JSOMTC, SWMG(A)

Skin Lesions

 Patterns and shapes

include:

• Linear (line)
• Clustered (grouped)
• Geographic
• Serpiginous
• Annular/arciform

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JSOMTC, SWMG(A)

Vascular Skin Lesions

 Petechiae  Purpura  Ecchymosis  Telangiectasia  Hemangioma

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JSOMTC, SWMG(A)

Vascular Skin Lesions

 Petechiae

• Characteristics
• Red‐purple color
• Non‐blanching
• < 0.5 cm diameter
• Examples
• Infections
• Vascular defects

Slide 38

JSOMTC, SWMG(A)

Vascular Skin Lesions

 Purpura

• Characteristics
• Red‐purple color
• Non‐blanching
• > 0.5 cm diameter
• Examples
• Infection
• Vascular defect

Slide 39

JSOMTC, SWMG(A)

Vascular Skin Lesions

 Ecchymosis

• Characteristics
• Red‐purple color
• Non‐blanching
• > 2 cm diameter
• Examples
• Vascular wall

destruction

• Trauma

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Slide 40 JSOMTC, SWMG(A)

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

Slide 41

JSOMTC, SWMG(A)

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

Slide 42

JSOMTC, SWMG(A)

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 Totalis Universalis

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Slide 43

JSOMTC, SWMG(A)

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

Slide 44

JSOMTC, SWMG(A)

Average growth 0.12” (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

Slide 45 JSOMTC, SWMG(A)

The Inspection of the Nails

Beau's Lines Mees' Line Terry's Nails Spooning Clubbing Psoriasis

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JSOMTC, SWMG(A)

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

Slide 47

JSOMTC, SWMG(A)

Recording Your Findings

 Inspection

• Types of lesions
• Distribution / Pattern
• Infectious clues
• Nail plate involvement
• Pigmentation changes

Note: Survey for all lesions

Slide 48

JSOMTC, SWMG(A)

Recording Your Findings

 Palpation

• Texture
• Thickness
• Elasticity
• Temperature
• Tenderness

Caution: Is it potentially communicable?

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Slide 49

JSOMTC, SWMG(A)

Recording Your Findings

 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

D C B A

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JSOMTC, SWMG(A)

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.

Slide 51

JSOMTC, SWMG(A)

Recording Your Findings

 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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Slide 52

JSOMTC, SWMG(A)

Recording Your Findings

 Describe the findings

• 27 y/o ♂ c/o painful

rash x 2 days

Slide 53

JSOMTC, SWMG(A)

Recording Your Findings

 Describe the findings

• 30 y/o ♂ c/o dry scaly

rash x several weeks

• Pt has hx of psoriasis

Slide 54

JSOMTC, SWMG(A)

Recording Your Findings

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Slide 55 JSOMTC, SWMG(A)

Questions?

Slide 56

JSOMTC, SWMG(A)

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%

• n the written exam IAW course standards

Slide 57

JSOMTC, SWMG(A)

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

20

Slide 58

JSOMTC, SWMG(A)

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.

Slide 59

JSOMTC, SWMG(A)

Break