Physical Diagnosis Midterm - Skin, Hair And Nails

Front 1

Major functions of the skin

Back 1

- Homeostasis
- Heaviest single organ in body, 16% of body weight.
- Provides boundaries for body fluid, protects underlying tissues from microorganisms, harmful substances and radiation.
- Modulates body temp, synthesizes vitamin D

Front 2

Layers of skin

Back 2

- epidermis
- dermis
- subcutaneous tissue

Hair, nails, and sebaceous and sweat glands are appendages of skin.

Front 3

Vellus hair

Back 3

Short, fine, less pigmentation

Front 4

Terminal hair

Back 4

Coarser, pigmented (scalp/eyebrows)

Front 5

Nails

Back 5

Protect distal ends of fingers/toes

Front 6

Sebaceous glands

Back 6

Contained in the dermis, present all surfaces except palms/soles, produce a fatty substance secreted onto skin surface through hair follicles.

Front 7

Sweat glands

Back 7

Contained in the dermis, includes eccrine and apocrine glands.

Front 8

Eccrine glands

Back 8

Widely distributed, open directly onto skin surface, help control body temp

Front 9

Apocrine glands

Back 9

Found in axilla and groin, stimulated by emotional stress.

Front 10

Detection of suspicious moles

Back 10

- patient education
- skin cancers are most common cancers in US
- most prevalent on hands, neck, and head
- patients initially detect nearly 1/2 of melanomas
- 30% of melanomas are missed by providers

Front 11

Basal cell carcinoma

Back 11

- comprises 80% of skin cancers
- shiny and translucent
- grow slowly and rarely metastasize

Front 12

Squamous cell carcinoma

Back 12

- comprise 16% of skin cancers
- crusted, scaly, and ulcerated, can metastasize

Front 13

Melanoma

Back 13

- comprises 4% of skin cancers
- rapidly increasing in frequency, spread rapidly

Front 14

HARRM Risk factors for melanoma

Back 14

- History of previous melanoma
- Age over 50
- Regular dermatologist absent
- Rapid mole changing
- Male gender

Front 15

Additional risk factors for melanoma

Back 15

≥50 common moles
≥1-4 atypical or unusual moles (especially if dysplastic)
Red or light hair
Actinic lentigines, macular brown or tan spots (usually on sun exposed areas)
Heavy sun exposure (especially severe childhood sunburns)
Light eye or skin color (especially freckles/burns easily)
Family history of melanoma

Front 16

ABCDE Screening moles

Back 16

A - asymmetry
B - border irregularity
C - color variation (blue or black)
D - diameter ≥6 mm or different from other moles, especially changing, itching, or bleeding
E - elevation, enlargement, evolution

Front 17

Macule

Back 17

- flat, non-palpable, circumscribed, less than 1cm
- brown, red, purple, white, tan color
- freckles, moles, Café-Au-Lait spot)

Front 18

Patch

Back 18

- flat non to minimally palpable, irregular shape, a macule that is >1cm
- Vitiligo, port-wine marks, Café-Au-Lait spot)

Front 19

Papule

Back 19

- elevated, palpable, firm, circumscribed, <1 cm
- brown, red, pink, tan, bluish-red color

Front 20

Plaque

Back 20

- elevated, flat topped, firm, rough, a superficial papule >1cm
- psoriasis, seborrheic and actinic keratosis)

Front 21

Wheel

Back 21

- elevated, irregular-shaped area of cutaneous edema, solid, transient, changing, variable diameter
- pink with lighter colored center
- urticaria, insect bite

Front 22

Nodule

Back 22

- elevated, firm, circumscribed, palpable, deeper in dermis, 1-2 cm diameter
- erythema nodosum, lipoma

Front 23

Tumor

Back 23

elevated, solid, may or may not be demarcated, >2cm. (neoplasms)

Front 24

Vesicle

Back 24

- elevated, circumscribed, superficial, filled with serous fluid, < 1cm
- blister, varicella

Front 25

Bulla

Back 25

- vesicle >1cm in size
- blister, pemphigus vulgaris

Front 26

Pustule

Back 26

- elevated, superficial, similar to vesicle but filled with purulent fluid (pus)
- acne, impetigo

Front 27

Cysts

Back 27

- elevated circumscribed, palpable, encapsulated, filled with liquid or semisolid
- sebaceous cyst

Front 28

Scale

Back 28

- heaped up keratinized cells, flaky exfoliation, irregular; variable thickness, moisture, and size
- silver, white, tan
- psoriasis, exfoliative dermatitis)

Front 29

Crust

Back 29

- dried serum, blood, or purulent exudate; slightly raised, varies in size
- brown, red, black, tan, or straw
- scab, abrasion, eczema

Front 30

Lichenification

Back 30

- rough, thickened epidermis, accentuated skin markings, often of flexor aspects of extremities
- chronic dermatitis

Front 31

Keloid

Back 31

- irregularly shaped, elevated progressively enlarging scar
- grows beyond wound boundaries, caused by excessive collagen formation.

Front 32

Excoriation

Back 32

- loss of epidermis, linear or hollowed-out crusted area
- abrasion, scratch

Front 33

Fissure

Back 33

- linear crack or break form epidermis to dermis; small, deep, red
- athletes foot, cheilosis

Front 34

Ulcer

Back 34

- loss of epidermis and dermis; concave; red, white, or reddish blue
- decubitus ulcer, statis ulcer

Front 35

Erosion

Back 35

- loss of all or part of epidermis, depressed, moist; follows rupture of vesicle or bulla
- larger than fissure
- varicella

Front 36

Inspect and palpate skin

Back 36

Note characteristics of:
Color
Moisture
Temperature
Texture
Mobility and turgor
Lesions

Front 37

When inspecting color, look for:

Back 37

- increased pigmentation, loss of pigmentation
- redness, pallor (decreased redness of skin found in anemia and decreased blood flow), cyanosis, and yellowing

Red color (normal) of oxyhemoglobin best assessed at fingertips, lips, and mucous membranes.

Abnormal could be sign of anemia, hypoxia/cyanosis, ischemia

In dark-skinned people, palms and soles
For central cyanosis, look in lips, oral mucosa, and tongue.

Front 38

Vitiligo

Back 38

- depigmented macules, usually face, hands, feet extensor surfaces
- hereditary disorder due to lack of melanin.

Front 39

Cafe-au-lait spot

Back 39

slightly but uniformly pigmented macule or patch with mildly irregular boarders

Front 40

Cyanosis

Back 40

- somewhat bluish color of the skin, lips, oral mucosa, or nails.
Cause: due to poor oxygenation of tissues
Either centrally form lack of oxygenated blood or peripherally from lack of circulation to tissues or venous return.

Front 41

Jaundice

Back 41

yellowing of the skin, most easily seen in sclera.

Causes: liver disease, hemolysis of red blood cells

Front 42

Skin moisture

Back 42

Dryness, sweating, and oiliness
Dryness: hypothyroidism, renal disease
Oiliness: acne
Sweating: hyperhidrosis

Front 43

Skin temperature

Back 43

Use back of fingertips and hand
Identify warmth or coolness of skin
Increased warmth: infection (cellulitis), increased vascularity, fever
Cold: ischemic to tissues, Raynaud’s syndrome, hypothyroidism, shock

Front 44

Skin texture

Back 44

Roughness or smoothness
Roughness: renal disease, hypothyroidism, ichthyosis
Smoothness: CREST syndrome

Front 45

Skin mobility and tugor

Back 45

Lift fold of skin
Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor)
Mobility decreased – edematous states
Mobility increased – age, collagen-elastin diseases
Turgor decreased – dehydration
Turgor increased – edematous states

Front 46

Skin lesions

Back 46

Note characteristics
Anatomic location and distribution
Many skin diseases have a typical distribution
Psoriasis – knees, elbows, extensor surfaces
Candida infections – intertriginous areas (groin, armpits, areas that are always moist)
Eczema – flexor surfaces
Pityriasis rosea – back and chest in “Christmas tree pattern”

Front 47

Skin lesion patterns and shapes

Back 47

Many lesions occur is a typical pattern and shapes
Shapes: annular, serpiginous (worm like), oval, round
Patterns: dermatomal (shingles), clustered, linear

Front 48

Skin lesion types

Back 48

Type of lesion (macules, plaque, nodule/papule just depending on size, vesicles)

Front 49

Skin lesion color

Back 49

Many skin lesions have the same predictable coloring
Café-Au-Lait spot (brown, tan)
Psoriasis (silvery and red base)

Front 50

Flat, non-palpable lesions with changes in skin color

Back 50

Macule—Small flat spot, up to 1.0 cm
Patch—Flat spot, 1.0 cm or larger

Front 51

Palpable elevations: solid masses

Back 51

Papule
Plaque
Nodule
Cyst
Wheal - urticaria

Front 52

Palpable elevations with fluid-filled cavities

Back 52

Vesicle, bulla, pustule

Front 53

Burrow (scabies)

Back 53

Slightly raised tunnel in the epidermis
Commonly found on the finger webs and on the sides of the fingers
Looks like a short, linear or curved gray line and may end in a tiny vesicle
Look for the burrow of the mite that causes scabies

Front 54

Secondary skin lesions

Back 54

Scale, Crust, Lichenification, Scars, Keloids, Erosion, Excoriation, Fissure, Ulcer

Front 55

Vascular and purpura lesions

Back 55

Spider angioma, spider vein, hemangioma, petechia (smaller), purpura (larger), ecchymosis

Front 56

Janeway lesion

Back 56

Small nontender hemorrhagic macular to nodular lesions present on the palms and soles of patients with infectious endocarditis. (septic emboli)

Front 57

Osler nodes

Back 57

Similar to Janeway however they are erythematous tender and slightly raised, more common on the fingers and toes

Front 58

Squamous cell carcinoma

Back 58

Location: Appear on sun exposed areas, typically fair skinned and older than 60 yo.
Pattern: none
Type: papule to tumor, with scaling/crusting or ulceration
Color: reddened

Front 59

Actinic keratosis

Back 59

Superficial, flattened papules covered by a dry scale; round or irregular; tan, brown, or grayish. Appears on sun exposed skin, and can develop into SCC

Front 60

Basal cell carcinoma

Back 60

Mostly fair skinned, >40 yo, slow growing seldom metastasizes
Location: Face
Pattern: none
Type: nodule, occasionally depressed center
Color: pearly to gray, with telangiectasia

Front 61

Seborrheic keratosis

Back 61

Common, benign, “stuck on lesion”
Location: typically trunk and face
Pattern: symmetric to none
Types: papule to plaque, texture: greasy/velvety
Color: brown, tan, yellow, gray

Front 62

Melanoma

Back 62

Remember ABCD

Front 63

Benign nevus

Back 63

Common mole, may arise over time, usually unchanged in ABCD’s.
Round, defined boarders, uniform color, flat or raised

Front 64

Corn and callus

Back 64

Toughened areas of skin due to repeated friction exposure
Location: typical feet and hands
Pattern: none
Types: scale
Color: skin colored to yellowed

Front 65

Lentigo (sun spot)

Back 65

Benign pigmented spot
Location: sun exposed areas, dorsal hands, arms, face
Pattern: irregular
Type: macule with defined boarders
Color: tan to brown

Front 66

Wart

Back 66

Viral infection of the skin (HPV)
Location: any (typically hands, feet, genitalia)
Pattern: grouped to single
Type: papule to domed to tumor
Color: flesh colored with cauliflower appearance

Front 67

Dermatofibroma

Back 67

Benign slow growing firm lesion
Location: any
Pattern: none
Type: roundish nodule, dimples or involutes with squeezing
Color: usually brown or tan

Front 68

Rosacea

Back 68

Chronic erythema of nose and face with acne-like lesions and telangiectasia. Onset 30-60 yo.

Front 69

Psoriasis

Back 69

Location: mainly extensor surfaces
Pattern: irregular
Type: plaque, papule
Color: silvery on a erythematous base
Auspitz sign – Pulling off the scale causes bleeding

Front 70

Pityriasis rosea

Back 70

Benign self limiting rash
Location: trunk
Pattern: “christmas tree”, annular
Type: maculopapular, scaly
Color: reddish, tan
Herald Patch

Front 71

Eczema

Back 71

Location: mainly flexor surfaces
Pattern: area
Type: dry, scaling, fissured, lichenification, maculopapular
Color: skin colored to slightly red

Front 72

Tinea versicolor

Back 72

Infection of the skin due to fungus (Tinea)
Location: usually trunk
Pattern: diffuse
Type: macular, scaly
Color: tan

Front 73

Molluscum contagiosum

Back 73

Due to a viral infection of the skin
Location: typically extremities to any
Pattern: may form in autoinoculation patterns
Type: dome shaped vesicle with central umblication
Color: flesh colored or translucent

Front 74

Folliculitis

Back 74

Infection of the hair follicle typically by Staph or Strep
Location: any
Pattern: grouped to none
Type: pustules
Color: red

Front 75

Herpes zoster (shingles)

Back 75

Reactivation of Varicella Zoster causing painful rash
Location: typically trunk or face
Pattern: dermatomal
Type: vesicles
Color: clear vesicles on erythematous base

Front 76

Varicella zoster (chicken pox)

Back 76

Infection of Varicella
Location: begins trunk and spreads peripherally
Pattern: crops with different stages of healing
Type: vesicle
Color: clear vesicle on red base “dew on a rose petal”

Front 77

Acne

Back 77

Location: face, chest, back
Pattern: variable
Type: pustules, closed and open comedones, papules, cysts
Color: red

Front 78

Inspect and palpate hair

Back 78

Note quantity, distribution and texture.

Front 79

Alopecia areata

Back 79

Clearly demarcated round or oval patches of hair loss, usually affecting young adults and children.
No visible scaling or inflammation, no broken shafts

Front 80

Trichotillomania

Back 80

Hair loss from pulling, plucking, or twisting hair.
Hair shafts are broken and of varying lengths.
More common in children, often in settings of family or psychosocial stress.

Front 81

Tinea capitis (ringworm)

Back 81

Round scaling patches of alopecia. Hairs are broken off close to the surface of the scalp. Mimics seborrheic dermatitis.

Front 82

Inspect and palpate nails

Back 82

Note color and shape, lesions. Longitudinal bands of pigment may be a normal finding in people with darker skin.

Front 83

Paronychia

Back 83

A superficial infection of the proximal and lateral nail folds adjacent to the nail plate.
The nail folds are often red, swollen, and tender.
Most common infection of the hand, usually from Staphylococcus aureus or Streptococcus species.
Arises from local trauma due to nail biting, manicuring or frequent hand immersion in water.

Front 84

Clubbing of the fingers

Back 84

Bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold.
The angle increases to 180° or more, and the nail bed feels spongy or floating.
Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies

Front 85

Onychomycosis

Back 85

Nail is thickened and discolored: white, black, yellow or green.
Nail can become brittle, with pieces breaking off or coming away from the toe or finger completely.
If left untreated, the skin can become inflamed and painful underneath and around the nail.
There is usually no pain or other bodily symptoms
People experience significant psychosocial problems due to the appearance of the nail

Front 86

White spots (leukonychia)

Back 86

Trauma to the nails is commonly followed by non-uniform white spots that grow slowly out with the nail.
Spots in the pattern illustrated are typical of overly vigorous and repeated manicuring.
The curves in this example resemble the curve of the cuticle and proximal nail fold.

Front 87

Transverse linear depressions (Beau's lines)

Back 87

Bilateral transverse depressions of the nail plates resulting from temporary disruption of proximal nail growth from systemic illness.
Timing of the illness may be estimated by measuring the distance from the line to the nail bed
nails grow approximately 1 mm every 6 to 10 days
Seen in severe illness, trauma, and cold exposure if Raynaud's disease is present.

Front 88

Mee's lines

Back 88

Transverse white bands that cross the nail parallel to lunula.
Seen with arsenic poisoning, heart failure, Hodgkin’s disease, chemotherapy, carbon monoxide poisoning, and leprosy

Front 89

Pitting

Back 89

Punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix. Associated with psoriasis

Front 90

Subungual hemorrhage

Back 90

A collection of blood beneath the nail due to trauma. If there is not a broken bone underneath it, you can simply remove it. If there is a fracture of the nail plate, and you drain this out, you’ve just opened it up for infection! BAD.

Front 91

AIDS and skin conditions

Back 91

Hairy leukoplakia, Kaposi's sarcoma, herpes simplex virus (HSV), human papillomavirus (HPV), cytomegalovirus (CMV), molluscum contagiosum, candidiasis, squamous cell carcinoma, psoriasis (often severe), seborrheic dermatitis (often severe)

Front 92

Diabetes and skin conditions

Back 92

Acanthosis nigricans, candidiasis, neuropathic ulcers, peripheral vascular disease

Front 93

Dyslipidemia and skin conditions

Back 93

Xanthomas (tendon, eruptive, and tuberous), xanthelasma (may occur in healthy people)

Front 94

Hypothyroidism and skin conditions

Back 94

Dry, rough, and pale skin; coarse and brittle hair; myxedema; skin cool to touch; thin and brittle nails

Front 95

Hyperthyroidism and skin conditions

Back 95

Warm, moist, soft, and velvety skin; thin and fine hair; vitiligo; pretibial myxedema (in Graves' disease); hyperpigmentation (local or generalized)

Front 96

Chronic renal disease and skin conditions

Back 96

Pallor, pruritus, hyperpigmentation, uremic frost

Front 97

Liver disease and skin conditions

Back 97

Jaundice, spider angiomas and other telangiectasias, palmar erythema

Front 98

Peripheral vascular disease and skin conditions

Back 98

Dry, scaly, shiny atrophic skin; dystrophic, brittle toenails; cool skin; hairless shins; ulcers; pallor; cyanosis; gangrene

Front 99

Pregnancy and skin conditions

Back 99

Melasma, increased pigmentation of areolae, linea nigra, palmar erythema, varicose veins, striae, spider angiomas, hirsutism

Front 100

Rocky mountain spotted fever and skin conditions

Back 100

Erythematous rash that begins on wrists and ankles, then spreads to palms and soles; becomes more purpuric as it generalizes