Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 4. Skin, Hair, and Nails

EQUIPMENT

image Centimeter ruler (flexible, clear)

image Flashlight with transilluminator

image Wood’s lamp (to view fluorescing lesions)

image Handheld magnifying lens (optional)

EXAMINATION

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Cutaneous Color Changes

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TECHNIQUE

FINDINGS

 

Pigmented nevi. Nonpigmented striae. Freckles. Birthmarks.

UNEXPECTED:Dysplastic, precancerous, or cancerous nevi. Chloasma. Unpigmented skin. Generalized or localized color changes. Vascular skin lesions. Vascular changes.

imageThickness

EXPECTED:Thickness variations, with eyelids thinnest, areas of rubbing thickest. Calluses on hands and feet.

UNEXPECTED:Atrophy. Hyperkeratosis. Corns.

imageSymmetry

EXPECTED:Bilateral symmetry.

imageHygiene

EXPECTED:Clean.

Palpate skin

 

imageMoisture

EXPECTED:Minimal perspiration or oiliness. Increased perspiration (associated with activity, environment, obesity, anxiety, excitement) noticeable on palms, scalp, forehead, axillae.

UNEXPECTED:Damp intertriginous areas.

image Temperature

Palpate with dorsal surface of hand or fingers.

EXPECTED:Cool to warm. Bilateral symmetry.

imageTexture

EXPECTED:Smooth, soft, and even. Roughness resulting from heavy clothing, cold weather, or soap.

UNEXPECTED:Extensive or widespread roughness.

imageTurgor and mobility

EXPECTED:Resilience.

Gently pinch skin on forearm or in sternal area, and release.

UNEXPECTED:Failure of skin to return to place quickly.

image

 

Inspect and palpate lesions

 

image Size

Measure all dimensions.

image Shape

image Color

Use Wood’s lamp to distinguish fluorescing lesions.

image Blanching

image Texture

Transilluminate to determine presence of fluid.

image Elevation/depression

image Pedunculation

image Exudate

Note color, odor, amount, and consistency of lesion.

image Configuration

Check lesion for annular, grouped, linear, arciform, or diffuse arrangement.

image Location/distribution

Check lesion for generalized/localized, body region, patterns, or discrete/confluent.

UNEXPECTED:See table on pp. 3639

Primary Skin Lesions

Description

Examples

Macule

 

Flat, circumscribed area that is a change in skin color; less than 1 cm in diameter

Freckles, flat moles (nevi), petechiae, measles, scarlet fever

Measles. From Habif, 2004.

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Papule

 

Elevated, firm, circumscribed area less than 1 cm in diameter

Wart (verruca), elevated moles, lichen planus

Lichen planus. From Weston et al, 1996.

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Patch

 

Flat, nonpalpable, irregular-shaped macule more than 1 cm in diameter

Vitiligo, port-wine stains, mongolian spots, café au lait spots

Vitiligo. From Weston et al, 1991.

image image

Plaque

 

Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter

Psoriasis, seborrheic and actinic keratoses

Plaque. From Habif, 2004.

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Wheal

 

Elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter

Insect bites, urticaria, allergic reaction

Wheal. From Farrar et al, 1992.

image image

Nodule

 

Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter

Erythema nodosum, lipomas

Hypertrophic nodule. From Goldman and Fitzpatrick, 1999.

image image

Tumor

 

Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter

Neoplasms, benign tumor, lipoma, hemangioma

Hemangioma. From Weston et al, 1996.

image image

Vesicle

 

Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter

Varicella (chickenpox), herpes zoster (shingles)

Vesicles caused by varicella. From Farrar et al, 1992.

image image

Bulla

 

Vesicle greater than 1 cm in diameter

Blister, pemphigus vulgaris

Blister. From White, 1994.

image image

Pustule

 

Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid

Impetigo, acne

Acne. From Weston et al, 1996.

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Cyst

 

Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material

Sebaceous cyst, cystic acne

Sebaceous cyst. From Weston et al, 1996.

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Telangiectasia

 

Fine, irregular red lines produced by capillary dilation

Telangiectasia in rosacea

Telangiectasia. From Lemmi and Lemmi, 2000.

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TECHNIQUE

FINDINGS

HAIR

 

Inspect hair over entire body

 

imageColor

EXPECTED:Light blond to black and gray, with alterations caused by rinses, dyes, and permanents.

imageDistribution/quantity

EXPECTED:Hair present on scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, pubic area, and around nipples. Scalp hair loss in adult men, adrenal androgenic female-pattern alopecia in adult women.

UNEXPECTED:Localized or generalized hair loss, inflammation, or scarring. Broken/absent hair shafts. Hirsutism in women.

Palpate for texture

 
 

EXPECTED:Coarse or fine, curly or straight, shiny, smooth, and resilient. Fine vellus covering body; coarse terminal hair on scalp, on pubis, on axillary areas, and in male beard.

UNEXPECTED:Dryness and brittleness.

NAILS

 

Inspect nails

 

imageColor

EXPECTED:Variations of pink with varying opacity. Pigment deposits in persons with dark skin. White spots.

 

UNEXPECTED:Yellow or green-black discoloration. Diffuse darkening. Pigment deposits in persons with light skin. Longitudinal red, brown, or white streaks or white bands. White, yellow, or green tinge. Blue nail beds. Blue-black discoloration.

imageLength/configuration/symmetry

EXPECTED:Varying shape, smooth and flat/slightly convex, with edges smooth and rounded.

UNEXPECTED:Jagged, broken, or bitten edges or cuticles. Peeling. Absence of nail.

imageCleanliness

EXPECTED:Clean and neat.

UNEXPECTED:Unkempt.

imageRidging and beading

EXPECTED:Longitudinal ridging and beading.

UNEXPECTED:Longitudinal ridging and grooving with lichen planus. Transverse grooving, rippling, and depressions. Pitting.

Palpate nail plate

 

imageTexture/firmness/thickness/uniformity

EXPECTED:Hard and smooth with uniform thickness.

UNEXPECTED:Thickening or thinning.

imageAdherence to nail bed

EXPECTED:Firmness.

Gently squeeze between thumb and finger.

UNEXPECTED:Separation. Boggy nail base.

Measure nail base angle

 

Inspect fingers when patient places dorsal surfaces of fingertips together.

EXPECTED:160-degree angle.

UNEXPECTED:Clubbing.

Expected finding.

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Clubbing.

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Inspect and palpate proximal and lateral nail folds

 

UNEXPECTED:Redness, swelling, pus, warts, cysts, tumors, and pain.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Eczematous dermatitis

Subjective Data:Itching may or may not be present; those with atopic dermatitis often report allergy history (allergic rhinitis, asthma).

Objective Data:Acute: erythematous, pruritic, weeping vesicles; subacute: erythema and scaling; chronic: thick, lichenified, pruritic plaques. Atopic dermatis: during childhood lesions involve flexures, the nape, and the dorsal aspects of the limbs. In adolescence and adulthood lichenified plaques affect the flexures, head, and neck.

Folliculitis

Subjective Data:Acute onset of papules and pustules associated with pruritus or mild discomfort; may have pain with with deep folliculitis.

Objective Data:Primary lesion small pustule 1 to 2 cm in diameter that is located over a pilosebaceous orifice and may be perforated by a hair. Pustule may be surrounded by inflammation or nodular lesions. After the pustule ruptures, a crust forms.

Tinea (dermatophytosis)

Subjective Data:Pruritus.

Objective Data:Papular, pustular, vesicular, erythematous, or scaling lesions. Possible secondary bacterial infection. Hyphae on microscopic examination of skin scraping with KOH solution.

Basal cell carcinoma

Subjective Data:Persistent sore or lesions that has not healed; crusting; itching.

Objective Data:Shiny nodule that is pearly or translucent; may be pink, red, white, tan, black, or brown growth with a slightly elevated rolled border and a crusted indentation in the center.

Squamous cell carcinoma

Subjective Data:Persistent sore or lesion that has not healed or that has grown in size; crusting and/or bleeding.

Objective Data:Elevated-growth with a central depression wartlike growth; scaly red patch with irregular borders; open sore.

Malignant melanoma

Subjective Data:New mole or preexisting mole that has changed or is changing; history of melanoma, dysplastic or atypical nevi; family history of melanoma.

Objective Data:Characteristic asymmetry, irregular borders, variegated colors, and is growing or larger than 6 mm (see ABCDs of Melanoma on p. 49).

Hirsutism

Subjective Data:Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas.

 

Objective Data:Presence of thick, dark terminal hairs in androgen-sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttock, inner thigh, linea.

Paronychia

Subjective Data:Acute: history of nail trauma or manipulation; acute onset. Chronic: History of repeated exposure to moisture, e.g., through hand-washing. Evolves slowly initially with tenderness and mild swelling.

Objective Data:Redness, swelling, tenderness at lateral and proximal nail folds. Possible purulent drainage under cuticle. Acute or chronic (with nail rippling).

Oncychomycosis

Subjective Data:Yellow, crumbling nail.

Objective Data:Distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed.

Redness and swelling where nail pierces the lateral nail fold and grows into the dermis.

AIDS TO DIFFERENTIAL DIAGNOSIS

Cutaneous Manifestations of Two Pathogens That May Be Used in Biologic Warfare

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Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

SKIN

 

Inspect hands and feet of newborns for skin creases

 

EXPECTED:Number of creases is indication of maturity of newborn; the older the gestational age, the more creases.

 

UNEXPECTED:Single transverse crease across palm frequently seen in infants with Down syndrome.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Seborrheic dermatitis

Subjective Data:Thick greasy scalp scales or body rash.

Objective Data:Thick, yellow, adherent crusted scalp, ear, or neck lesions.

Impetigo

Subjective Data:Lesion, typically on the face, that itches and burns.

Objective Data:Honey-colored crusted or ruptured vesicles.

Miliaria (“prickly heat”)

Subjective Data:Parent reports rash noted while undressing infant.

Objective Data:Irregular, red, macular rash on covered areas.

Chickenpox (varicella)

Subjective Data:Fever, headache, sore throat, malaise.

Objective Data:Pruritic maculopapular skin eruption that becomes vesicular in a matter of hours.

German measles (rubella)

Subjective Data:Fever, coryza, sore throat, cough.

Objective Data:Koplik spots on buccal muscosa; generalized light pink to red maculopapular rash.

SAMPLE DOCUMENTATION

Objective.Skin: Dark pink maculopapular lesions on face, torso, extremities; large urticarial wheal on right cheek. No excoriation or secondary infection. Turgor resilient. Skin uniformly warm and dry. No edema.

Hair: Curly, black, thick with female distribution pattern. Texture coarse.

Nails: Opaque, short, well-groomed, uniform, and without deformities. Nail bed pink. Nail base angle 160 degrees. No redness, exudates, or swelling in surrounding folds and no tenderness to palpation.

From American Academy of Dermatology, 2005.

The ABCDs of Melanoma

Characteristics that should alert you to the possibility of malignant melanoma:

A Asymmetry of lesion. One half of a mole or birthmark does not match the other.

B Borders. Edges are irregular, ragged, notched, or blurred. Pigment may be streaming from the border.

C Color. The color is not the same all over and may have differing shades of brown or black, sometimes with patches of red, white, or blue.

D Diameter. The diameter is larger than 6 mm (about the size of a pencil eraser) or is growing larger.

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