Skin, hair and nails, Vitals

Skin

Heaviest single organ of the body

Accounting for ~16% of body weight

Functions:

Secretion

- Ex: Sebum

Heat regulation

Absorption

Protection

From radiation, microorganisms, the elements, of the organs

Excretion

Sweat allows our bodies to rid itself of waste

Sensation

Nerve endings that contain stimuli

Three Layers of Skin:

Epidermis - no vessels

Dermis - big layer, BV, nerves, sweat glands and hair follicles. Provide nutrients

Subcutaneous tissues: adipose tissue, provides storage and insulations

Sebaceous Glands:

oil glands secrete sebum and come out of hair follicles, spare palms and soles.

Sweat glands

1. Apocrine (lives deeper and secrete into hair follicle area, can be in genital and airmpit area and

2. eccrine (secrete directly onto the surface)

Melanin

Brownish pigmentation of the skin

Genetically determined

Increases with exposure to the sun

Carotene

Golden yellow pigment

Exists in the subcutaneous fat and in heavily keratinized areas

Oxyhemoglobin

Bright red pigmentation

Predominant in the arteries and capillaries

Deoxyhemoglobin

Darker and somewhat bluish pigment

Ex: cyanosis

OPQRST in derm

onset: new? What is the setting/location

provocation/palliative: what makes it better or worse?

quality: is the pain dull, burning or aching?

radiation: Where is it spreading? viral rashes tend to spread

severity: itching severity, 1-10 scale, nocturnal awakenings?

time: have you had it before, seasonally?

Common Derm Complaints

Skin lesions/rash/moles

Dry skin

Itching

Erythema (redness) to the skin

Bruising

Hair loss

Changes in nails

Personal Medical History: Derm

Recent travel? Outdoors a lot/recently?

Severe sunburns as a child?

Previous skin problems and treatments/biopsies?

Recent hospitalizations or surgeries?

Allergic skin reactions prior?

Recent viral or bacterial illness?

Are you pregnant? Are your menstrual periods regular?

Do you see a dermatologist?

Personal and Social History: Derm

Do you sunbathe/tan?

Do you perform skin self-examination once a month?

Exposed to chemicals or irritants that may harm the skin?

Long periods in one position? Important to know for elderly, can develop ulcers

Exposure to extreme temperatures?

Body piercings/tattoos?

Anything new? Changed?

- Ex: scents, lotions, detergents, creams

Smoking and/or drinking alcohol?

Stress in your life?

Family History

Exposure to sick contacts or rash?

Family history of skin conditions

Skin cancers? Melanoma is the worst to have

History of keloids?

Skin Exam: Prepare/set up

Adequate lighting

Examination equipment

- Ex: ruler

Change into a gown

- Maintain privacy with a drape

- Take off shoes/socks

Wash and warm your hands

Examine the patient while seated

- always tell the patient to get on exam table, not bed

Approach to the Skin Exam

Head-to-toe approach, full body exam

Hair/scalp

- Inspect

- Palpate

Skin/Nails

- Inspect, then palpate

- Face and neck

- Arms and Hands (including nails) and webbed areas

- Trunk and groin

- Legs and feet (including nails) and webbed areas

Skin Mobility and Turgor

Skin inspection

Color

Skin Type

Integrity

Hair distribution

Lesions:

- Types: Primary vs. Secondary vs. Vascular Lesions

- Note:Location, distribution, pattern/configuration, shape, size, color, number, ABCDE

Skin Type - Fitzpatrick Scale

Type I and II more likely to get skin cancer

Skin Exam - Palpation

Temperature and Moisture - use the back of hands to examine and check from head to feet

Texture and thickness

Mobility and turgor - mobility is how much the skin moves, turgor is the ability to come back to normal, pulling up skin then letting go.

Swelling (Edema) and pitting edema (in legs push in and let go, how long does the indent go.

Skin Lesions

Primary Lesions: develop on previosly nl skin

- Ex: Macule, patch, papule, plaque, nodule, pustule, vesicle, bulla, wheal, etc.

Secondary Lesions: primary lesions that have changed, i.e starts with hive then you itch and now have escoriasion

- Ex: Erosion, scar, ulcer, fissure, etc.

Vascular lesions: BV that is comprimised: could be dt truama or congenital

- Reddish-blue lesions

Primary lesions: Macule

A flat, non-palpable lesion measuring < 1 cm.

- Ex: freckles, flat moles

Primary lesion: Patch

Same as a macule, but > 1 cm

- Ex: Vitiligo

Primary Lesion: Papule

•A solid, elevated, palpable lesion measuring < 1 cm

- Ex: Elevated nevus, wart, insect bite, acne

primary lesions: nodule

•Solid, firm, rounded elevation of the skin, usually > 1 cm

•Typically extends into deep skin layers

- Ex: Cyst, tumor, lipoma

Primary Lesion: Vesicle

Small circumscribed elevation of the epidermis containing clear fluid, < 1 cm in diameter

- Ex: herpes simplex, herpes zoster, allergic contact dermatitis

Primary Lesion: Bulla

A circumscribed elevation of the epidermis containing clear fluid >1 cm in diameter

- Ex: 2nd degree burn

Primary Lesion: Plaque

A solid flat elevated lesion, usually >1 cm

- Ex: Psoriasis

Primary Lesion: Wheal

A circumscribed, raised lesion consisting of dermal edema

- Ex: hives, mosquito bite

Primary Lesion: Pustule

Small palpable collection of pus

- Ex: Acne, impetigo

Primary lesions: Comedone

The plugged opening of a sebaceous gland at pore/follicle

- Ex: Acne

- White (closed)

- Black (open)

Primary Lesion: Furuncle and carbuncle

Furuncle: Skin abscesses at the hair follicle and surrounding tissues

Carbuncle: ØMultiple furuncles form a carbuncle

Secondary Lesions: Erosion

Loss of the superficial epidermis, the surface is moist but does not bleed

- Ex: Rupture of a vesicle in chicken pox

Secondary lesion: Ulcer

Full-thickness loss of the epidermis with damage to the dermis

Important, especially in bed-bound patients.

May bleed and scar

- Ex: venous stasis ulcers, syphilitic chancre

Secondary Lesion: Crust

Dried exudate overlying and impaired epidermis

- Ex: Impetigo

Secondary Lesion: Scale

Accumulation of loose fragments exfoliated epidermis

- Ex: Dandruff or psoriasis

Secondary lesion: Lichenification

Thickening and roughening of the skin with increased visibility of the normal skin furrows

- Ex: atopic dermatitis

Secondary Lesion: Atrophy

Thinning of the skin with the loss of the normal skin furrows

- Skin looks shinier and more translucent

- Seen in aging

Secondary Lesion: Excoriation

An abrasion or scratch mark.

May be linear or rounded.

Secondary Lesion: Scar

Replacement of destroyed tissue with a more fibrous tissue

Secondary Lesion: Keloid

Firm, hypertrophic mass of scar tissue that extends beyond the area of injury

Secondary Lesion: Fissure

A linear crack in the skin

- Ex: Angular cheilitis

Vascular lesions: Petechiae and Purpura

Petechiae: Reddish-purple macules <4 mm

Purpura: Reddish-purple macules, 4 mm - 10mm

Vascular lesions: Ecchymosis

Purple or blue macules caused by trauma, fade over time, >10mm

Vascular Lesions: Hematoma

Localized collection of blood creating an elevated ecchymosis.

Vascular lesions: Telangiectasia

Fine, irregular blood vessels

Vascular lesions: Spider angioma

Central red macule with radiating spider-like arms

Vascular lesions: cherry angioma

small red papule

Descriptions Should Include

Size

Number

Distribution

Configuration

Texture

Color

Blanchable? - when you take your finger and push on lesions and turns white , if you push down and color does not change then damaged bv present

Distribution of Lesions

Configuration of Lesions

Geographic: resembles the outline of a map

Reticular: lesions with a "net-like" arrangement

Umbilicated: skin nodule with a central depression

Vegetative: the proliferation of papillomatous masses

Verruca: wart

Nevi/Skin Lesion Evaluation

ABCDEFG's:

◦Asymmetry

◦Border irregularity

◦Color variation

◦Diameter > 6 mm, bigger than an eraser

◦Evolution/Elevation, changed overtime?

◦Family history of melanoma, Firm to Palpation

◦Growing progressively

Basal Cell Carcinoma

Slow-growing and locally invasive

Translucent (pearly)papule or nodule with a depressed center and rolled edges

Caused by the sun

Most common cutaneous malignancy

Squamous Cell Carcinoma

Grows slightly quicker and more aggressively than a BCC

Looks firmer, redder, sometimes more ulcerated

Caused by the sun exposure

malignant melanoma

Most deadly skin cancer

Develops in melanocytes

Pre-cancerous Lesions

Actinic Keratosis:

Superficial flattened erythematous papules covered by a dry scale

May be round or irregular

Pink or tan

Vary in size

Most common premalignant skin lesion

Responsible for 60% of Squamous Cell Carcinoma

Common Benign Neoplasm

Seborrheic Keratosis

- Brown, raised, "stuck on" lesions

- "Velvety"

Age Related Skin Changes

- Epidermal thinning (atrophy)

- Changes in melanocytes

- Reduced elasticity

- Blood vessels become more fragile: Causes easy bleeding and bruising

- Sebaceous glands produce less oil: Dryer skin

- Sweat glands produce less sweat: Not as easily able to regulate temperature

- Subcutaneous fat layer (insulation and padding) thins: More prone to getting more injuries with trauma and ulcers

What is the translucent part of the nail called?

Nail plate

What is the part of the nail that is covered by the proximal nail fold?

Nail root

What supports the nail and contains blood vessels?

Nail bed

What is the thick layer of epithelium at the base of the nail called?

Cuticle

What is the white half moon at the base of the nail called?

Lunula

What are the lateral folds of the nail referred to as?

Paronychial edge

What is the intersection between the nail and the skin on the finger called?

Hyponychium

Nail examination Inspect for:

◦Shape and Size

◦Brittleness

◦Hemorrhages

◦Lines and grooves

◦Clubbing - COPD commonly have this

◦Pitting

◦Masses/Lesions

◦Pigmentation within the nail bed - possible skin cancer under nail bed

◦Trauma

Nail exam

Palpate for texture and consistency

Capillary Refill < 2 seconds

Clubbing

◦The distal phalanx of each finger is rounded and bulbous

- commonly seen in pts with underlying lung issues

Onychomycosis

◦Thickened yellow hypertrophic nail growth due to fungal infection

Onycholysis

◦Painless separation of the nail plate from the nail bed

Paronychia

◦Inflammation and infection of the soft tissue of the nail (paronychia area) around the proximal and lateral nail folds

◦Folds become erythematous, swollen, tender (infected)

Terry's Nails

◦Mostly whitish with a band of reddish brown, seen in aging, cirrhosis, CHF, diabetes

Leukonychia

◦White color changes of the nail

◦Partial or complete

Beau's Lines

◦Transverse depressions in the nails associated with acute or severe illness

◦Grow out with time

Pitted nails

◦Psoriasis, psoriatic arthritis

Hair Types

Two Types of Hair:

Vellus

- Aka Peach fuzz

- Short, fine, unpigmented, inconspicuous

Terminal

- Coarse, thicker, more conspicuous, pigmented

- Mature hair

Hair Anatomy

ØHair follicles: contain papilla that provides nutrients

ØArrector pili muscle- smooth muscle hair is attached to

Hair inspection

Inspect and Note:

◦Hair quantity

◦Hair distribution

◦Hair texture

◦Hair color

◦Loss of hair

Scalp and Hair

- Inspect the scalp for any lesions, rashes, scaling, etc.

- Feel for any lumps or bumps

- Hair Texture

- Oily

- Brittle

- Dandruff

Hirsutism

Common in PCOS where more androgen hormones are produces.

Alopecia Areata-

"spot baldness"

Telogen Effluvium-

uniformed hair thinning

Trichotillomania

"hair pulling disorder"

Male Pattern Baldness

Androgen related

General Survey

oBegins at the opening moments of the encounter and is before you conduct your physical examination

oSimple observations play an important role in the general survey of the patient

oPay attention to how the patient walks, how the patient is dressed, the tone of the patient's voice, etc.

oNarrow in on and greater appreciate any of these findings as you start the assessment and PE

oSome characteristics include body habitus, posture, mood and alertness, facial coloration, dentition and conditioning of the tongue and gingiva, color of the nail beds and muscle bulk

- helps make a decision as to whether or not the patient is sick or not

General Appearance

oApparent state of health

oLevel of consciousness

oSigns of distress

oSkin color and obvious lesions/rashes

oDress, grooming and personal hygiene

oFacial expressions

oBody odors

oPosture, gait and motor skills

What are common causes of fatigue/weakness?

Infection, hypothyroidism, anemia, nutritional deficiency, cancer, chronic cardiometabolic disease.

What is the difference between weakness and fatigue?

Weakness refers to loss of muscle power, while fatigue is a general sense of tiredness.

What should be assessed when a patient presents with fatigue/weakness?

A full history and detailed questions about the patient's situation.

What does rapid/acute weight change suggest?

Changes in body fluids.

What is weight gain?

When caloric intake exceeds caloric expenditure over time.

What can contribute to weight gain?

Medications such as antidepressants, OCPs, insulin, and steroids.

What is clinically significant weight loss?

A loss of more than 5% of usual body weight over 6 months.

What are some causes of significant weight loss?

Diabetes, hyperthyroidism, HIV/AIDS, cancer, eating disorders, drug use, cigarette smoking, medications, physical disability.

What should be assessed in a patient with weight loss?

The patient's dietary and caloric intake.

What is one of the most common complaints in patients?

Pain.

What are the two types of pain?

Acute pain and chronic pain.

How is pain sometimes regarded in clinical settings?

As a fifth vital sign.

oFevers, chills and night sweats

oFever --> abnormal elevation in body temperature

oDid they actually measure their temperature? Do they really have a fever or they just feel like they have a fever?

oDistinguish between patient having the chills and patient actually shivering

oFeeling cold and shivering --> rising temperature while feeling hot and sweating --> falling temperature

oMenopause, Tuberculosis, Cancer can cause night sweats

oSystemic infection like sepsis can cause shivering chills

oCertain medications like Tylenol, NSAIDs, steroids can mask a fever

oImportant to inquire about travel (especially outside the US), sick contacts, medications, etc.

Causes of weight gain

hypothyroidism, metabolic syndrome, Cushing's syndrome, medications, binge eating disorder

Causes of weight loss

include cancer, DM, hyperthyroidism, depression, eating disorders (Anorexia Nervosa), diuresis

BMI calculation

BMI: (Weight (lbs) x 700 / height (inches) / height (inches))

BMI: Weight (kg) / height (m^2)