TDP: 1st Practical (Integumentary)

Integumentary System

On a skin exam, what are you examining on patient’s skin?

• Color changes (make sure to ask patient as well—cyanosis, jaundice)

• Moisture (dryness, sweating, oiliness)

• Temperature (use back of your fingers)

• Texture (rough, smooth, scaly, )

• Mobility (lift fold of skin; note ease or not)

• Turgor (lift fold of skin; note speed of return)

If there are abnormal findings on a patient’s skin, what are you documenting?

• Location

• Size (use a ruler to measure in cm or mm)

• Number (single or multiple)

• Distribution (local, general, symmetrical, sun-exposed)

• Configuration (shape)

• Texture (smooth, fleshy, warty, scaly)

• Color (erythema, hypo/hyperpigmented, skin-colored, pallor)

Describe this lesion

Location

Size

Number

Distribution

Configuration (annular: ring-like)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Coalescing: early process of merging)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Confluent: have already merged early on)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Crescentic)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Discoid/Nummular: coin-shaped)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Discrete)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Geographic)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Grouped)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Gyrate)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Herpetiform: grouped vesicles)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Linear/striate)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Morbilliform: generalized, small dusky-red macules)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Reticular: netlike)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration (Target/Bullseye)

Texture

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Scaly)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Indurated: firm or hardened)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Friable: easily bleeds or broken)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Verrucous: warty)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Fluctuant: compressible and fluid-filled)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Umbilicated: central depression)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Pedunculated: attached by stalk)

Color

Describe this lesion

Location

Size

Number

Distribution

Configuration

Texture (Sessile: attached w/o stalk)

Color

Inspect patient’s skin sitting down

• Hair and scalp (distribution, texture, quantity)

• Head and neck (forehead, eyebrows, eyelids, eyelashes, conjunctivae, sclerae, nose, ears, cheeks, lips, oral cavity, chin, beard)

• Upper back

• Shoulders

• Arms

• Hands

• Fingernails

• Chest

• Abdomen

• Anterior thighs, legs

• Feet and toes (including soles, interdigital areas, and toenails)

Palpate patient’s skin sitting down

• Fingernails

• Chest

• Abdomen

• Anterior thighs and legs

• Feet and toes (including soles, interdigital areas, and toenails)

Inspect patient’s skin standing up

• Lower back

• Posterior thighs and legs

• Breasts*

• Axillae*

• Genitalia* (including axillary and pubic hair)

*sensitive areas won’t be done in lab

What are the screening criteria for melanoma?

A - Asymmetry (each side of mole)

B - Border irregularity

C - Color variation (more than 2 colors)

D - Diameter (> 6mm)

E - Evolving in size, symptoms, or morphology

What kind of lesion is this?

Classification: Primary

Type: Macule

Definition: Flat, non-palpable change in color of skin

Size: < 1 cm

Example: Freckles, lentigo, pityriasis versicolor

What kind of lesion is this?

Classification: Primary

Type: Patch

Definition: Flat, non-palpable change in color

Size: > 1 cm

Example: Vitiligo, eczema, psoriasis

What kind of lesion is this?

Classification: Primary

Type: Papule

Definition: Small, solid, elevated

Size: < 1 cm

Example: Acne, insect bites, warts

What kind of lesion is this?

Classification: Primary

Type: Nodule

Definition: Solid, elevated (bumpy)

Size: > 1 cm

Example: Cysts, lipomas, dermatofibroma

What kind of lesion is this?

Classification: Primary

Type: Plaque

Definition: Elevated, flat-topped

Size: > 1 cm

Example: Psoriasis, lichen planus

What kind of lesion is this?

Classification: Primary

Type: Tumor

Definition: Large, solid mass

Size: Usually > 2 cm

Example: Skin cancers, benign tumors

What kind of lesion is this?

Classification: Primary

Type: Pustule

Definition: Elevated lesion containing pus

Size: Usually < 1 cm

Example: Acne pustules, folliculitis

What kind of lesion is this?

Classification: Primary

Type: Vesicle

Definition: Small blister containing clear fluid

Size: < 1 cm

Example: Herpes simplex, contact dermatitis

What kind of lesion is this?

Classification: Primary

Type: Bulla

Definition: Large blister containing clear fluid

Size: > 1 cm

Example: Bullous pemphigoid, burns

What kind of lesion is this?

Classification: Primary

Type: Wheal

Definition: Elevated, transient, erythematous

Size: Variable

Example: Urticaria (hives), allergic reactions

What kind of lesion is this?

Classification: Primary

Type: Cyst

Definition: Encapsulated, fluid, or semisolid

Size: Variable

Example: Epidermoid cysts, piloidal cyst

What kind of lesion is this?

Classification: Secondary

Type: Scale

Definition: Flakes of keratin

Example: Psoriasis, seborrheic dermatitis

What kind of lesion is this?

Classification: Secondary

Type: Crust

Definition: Dried serum, blood, or pus

Example: Impetigo, eczema

What kind of lesion is this?

Classification: Secondary

Type: Excoriation

Definition: Linear erosion from scratching

Example: Pruritus, scabies

What kind of lesion is this?

Classification: Secondary

Type: Fissure

Definition: Linear crack or split

Example: Eczema, xerosis

What kind of lesion is this?

Classification: Secondary

Type: Erosion

Definition: Loss of epidermis

Example: Abrasion, bullous disorders

What kind of lesion is this?

Classification: Secondary

Type: Ulcer

Definition: Loss of epidermis AND dermis

Example: Venous stasis ulcer, pressure ulcer

What kind of lesion is this?

Classification: Secondary

Type: Lichenification

Definition: Thickened skin with accentuated lines

Example: Chronic eczema

What kind of lesion is this?

Classification: Secondary

Type: Atrophy

Definition: Thinning of the skin

Example: Steroid use, chronic sun damage

What kind of lesion is this?

Classification: Secondary

Type: Scar

Definition: Fibrous tissue

Example: Post-surgical, post-acne

What kind of lesion is this?

Classification: Secondary

Type: Keloid

Definition: Thick, raised scar (extending beyond original site)

Example: Keloid scars

What kind of lesion is this?

Classification: Secondary

Type: Sclerosis

Definition: Hardening of skin

Example: Scleroderma, morphea

What kind of lesion is this?

Type: Petechaie

Definition: Pinpoint, non-blanching red or purple spots

Size: 1-4 mm

What kind of lesion is this?

Type: Purpura
Definition: Non-blanching red or purple spots

Size: 4 mm - 1 cm

What kind of lesion is this?

Type: Ecchymosis
Definition: Large non-blanching area

Size: > 1 cm

What kind of lesion is this?

Type: Telangiectasia
Definition: Dilated superficial blood vessels

Size: Variable

What kind of lesion is this?

Type: Furnucle
Definition: Infection of hair follicle

What kind of lesion is this?

Type: Carbuncle
Definition: Group of collected furnucles

What kind of lesion is this?

Type: Abscess
Definition: Collection of pus in tissue

What kind of lesion is this?

Type: Cellulitis
Definition: Infection of dermis and subcutaneous tissue

What kind of lesion is this?

Type: Dermatographia
Definition: Raised wheals after scratching skin

What kind of lesion is this?

Type: Abrasion
Definition: Superficial loss of epidermis

What kind of lesion is this?

Type: Contusion
Definition: Bruising without skin break

What kind of lesion is this?

Type: Laceration
Definition: Irregular cut or tear in skin

Inspect the patient’s hair

• Observe for hair loss or thinning

• Inspect scalp for erythema, scaling, bruising, tenderness, bogginess, scarring

• Observe hair width part at various sections of scalp

Perform the hair pull test

Instructions

• Grasp ~50-60 hairs with thumb and index/middle finger

• Pull away from scalp

Results

• Positive test if > 10% (>6) hairs pulled out

• Telogen Effluvium (hair shedding)

Perform the hair tug test

Instructions

• Hold a group of hairs in one hand

• Pull along hair shaft with other hand

Results

• If hair breaks, then abnormal (hair fragility)

Examine the patient’s nails

Examine all labeled parts, and compare hands.

Note shape

• Nail pitting (dents on nail plate) → Psoriasis

• Beau lines (lines across nail plate) → High fever/sepsis, stress, malnutrition

• Muehrcke lines (paired lines across) → Hypoalbuminemia

• Clubbing (enlargement of distal finger + increased nail curvature) → Lung, cystic fibrosis, congenital heart disease

• Koilonychia (concave, spoon-shaped) → Iron deficiency anemia

• Onychomycosis (fungal infection) → Dermatophytes, diabetes

Note color

• Terry nails (white) → Cirrhosis

• Subungual hematoma (black spot) → Injury

*red box in photo = epidermal layer under the nail plate