PHYSICAL DIAGNOSIS: Examination of the Skin by Ma. Socorro W. Toledo, MD, FPDS

General Characteristics Presence/ Absence of SKIN LESIONS

C. Skin Appendages 1. HAIR 2. NAIL UNIT = NAIL PLATE/ BED/ FOLDS

D. MUCOSA = oral/ nasal/ conjunctival/ genital/ anal

A. General Characteristics:I. Inspection: General color Normal : (-) pallor (-) jaundice (-) erythema(-) hyperpigmentation

A. Gen. Char. (contd.)II. Palpation:Temperature: Normal = Afebrile to touch / Not cold to touch(Objective measure: Temperature)b. TurgorNormal = Prompt return after finger pressureAbnormal= Delayed return after finger pressure

c. Degree of moisture: Normal = No dryness, no excess moistureAbnormal = Dry (hypohidrosis, anhidrosis) or Moist (hyperhidrosis)

A. Gen. Char. (contd.)d. Hardness /Sclerosis or Laxity Normal skin = (-) sclerosis, (-) laxity

Abnormal skin: Sclerotic Skin is hardened like scarred tissue (Ex. scleroderma)Lax Skin can be stretched to a great extent (Ex.cutis laxa)

B. Presence / Absence of Skin LesionNormal = No skin lesions I. PRIMARY SKIN LESIONS (arise de novo)A. Flat lesions 1. Macule 2. PatchB. Raised or palpable lesions1. Papule5. Vesicle2. Nodule6. Bulla3. Tumor7. Wheal4. Plaque8. Pustule

I.A. Flat lesions 1. Macule: A flat lesion

I.B. Raised or palpable lesions1. Papule*: A solid or cystic elevation, or palpable lesion

I.B. Raised or palpable lesions (contd.)3. Tumor*: A solid or cystic elevation, or palpable lesion 2.0 cm or more in diameter

4. Plaque: A slightly raised lesion, wider than it is high (mesa-like), 1.0 cm or more in greatest dimension

*May be rounded, ovoid or ellipsoidal

I.B. Raised or palpable lesions (contd.)5. Vesicle: A noncystic, transparent fluid-filled lesion

I.B. Raised or palpable lesions (contd.)7. Wheal: An evanescent papule or plaque that disappears within 24 hours

8. Pustule: A small, circumscribed raised lesion containing purulent exudate. Pus, composed of leucocytes with or without cellular debris, may contain bacteria or may be sterile.

II. Describe other features

A. Location 1. Localized state what part of body2. Generalized

B. Color 1. Skin-colored 2. Erythematous (pink, bright/ dusky red, violaceous)3. Hyperpigmented (brown, gray, black ) 4. Hypopigmented (whitish) vs. white5. Others: yellow, orange, etc.

II. Other Features (contd.)C. Shape of individual lesions:- linear- round, oval, annular (ring-like) - arciform (like an arc), - polycyclic (confluent rings)- serpiginous (snake-like) - reticular ( lace-like)

D. Pattern (Vs. No pattern random distribution)

Extensor surfacesFlexures or intertriginous areasSun-exposed areas TruncalAcral (ears, tip of nose, hands, feet)Dermatomal

II. Other Features (contd.)

E . Secondary Lesions

a. Scales e. Fissuresb. Crusts f. Lichenificationc. Excoriationsg. Atrophyd. Erosions h. Scarse. Ulcers

C. Skin Appendages: HAIR & NAILS1. HAIRA. Loss or ExcessNORMAL = No hair loss = No hypertrichosis / No hirsutism (females)ABNORMAL1. Hair Loss (alopecia) = patchy vs. diffuse= scarring vs. non-scarring2. Hair Excessa. Hypertrichosis (localized / generalized) b. Hirsutism (in females only)

C. Skin appendages:1. HAIR (contd.)Check for structural abnormalitiesNormal = No structural abnormalitiese.g. (-) nodules (-) brittle hair C. Describe hair color - white (vitiligo)- premature graying - red-brown (malnutrition)D. Check for infestations Normal = No lice; no nits

C. Skin Appendages:2. NAIL UNITNail PlateNormal: 1. (-) nail dystrophy (No structural deformities/ No abormalities in shape)Ex. No thickeningEx. No pitsEx. No vertical/ horizontal lines or grooves Ex. No clubbing 2. (-) No color changes (Normal = transparent)

C. Skin Appendages:2. NAIL UNIT (contd.)B. Nail BedNormal = (-) nail bed lesions

C. Nail Folds: Skin around nails Normal = No lesions on theproximal and lateral nail folds

D. Mucosa (see areas below*)

Normal = No oral/nasal/ etc. lesions Abnormal = Describe lesions, location, distribution, etc.

*AREAS:Oral buccal / palatal / gingival / lingual and sublingual areas NasalConjunctival GenitalAnal / perianal

IN SUM: Use the above outline to report the physical examination of the skin. In a NORMAL patient, the skin findings are as follows:

A. General Characteristics: 1. Inspection (general color): (-) pallor / jaundice / erythema / hyperpigmentation2. Palpation: Temperature: Afebrile/ not cold to touchTurgor: Prompt return after finger pressure(-) Hyperhidrosis, (-) Hypohidrosis(-) Sclerosis (-) Skin laxity

B. Presence/Absence of Skin Lesions

NORMAL = No skin lesions: No macules/patches, papules/ plaques/ nodules/ tumors, blisters (vesicles or bullae), pustules, wheals.

C. Skin Appendages 1.Hair = Color _____; (-) hair loss or excess(-) structural abnormalities (-) No easy breakage (-) nits

2.Nail unit = No lesions on the nail plate/ bed/ folds

D. MucosaNormal = No oral / nasal / conjunctival / genital / anal / perianal lesions

Instructions for PD activity:

A. Yellow pad paper will be provided.Write name, date, year level and section.

B. Slides of clinical cases will be flashed. Answer BRIEFLY.Give only pertinent data: Primary & secondary lesions, pattern (if any), distribution.

Instructions (cont.):

Total = 20 cases. One minute per case.

5 minutes for last slide: Normal P.E. of the skin

Immediate feedback: Answers will be discussed after the activity.

Check your own papers > Hence no erasures allowed.