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Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 08 : Skin, Hair, and Nails
This review discusses examination of the skin hair and nails.
Before the exam, gather the necessary equipment: a clear, flexible centimeter ruler; flashlight with transilluminator; handheld magnifying glass or dermatoscope; and Wood’s lamp.
To examine the skin, perform the following.
Use inspection and palpation to examine the skin. Make sure you have adequate lighting, preferably with daylight.
- During inspection, expose the skin completely. As you finish inspecting each area, remember to redrape or cover the patient for warmth and modesty.
- Inspect the skin in two ways.
- First, perform a brief overall visual sweep of the entire skin surface. This helps identify the distribution and extent of any lesions, assess skin symmetry, detect differences among body areas, and compare sun-exposed areas with areas that were not exposed to the sun.
- Second, observe the skin as each part of the body is examined.
- When evaluating the skin and mucous membranes in each part of the body, note six characteristics.
- The first characteristic is color, which can vary from dark brown to light tan with pink or yellow overtones.
- The second characteristic is uniformity. The skin should be uniform in color overall with no localized areas of discoloration. However, the skin may have sun-darkened areas as well as darker skin around the knees and elbows.
- The third characteristic is thickness, which varies over the body. The thinnest skin is on the eyelids. The thickest is at areas of pressure or rubbing, such as the elbows, soles, and palms.
- The fourth characteristic is symmetry. Normally, the skin appears bilaterally symmetrical.
- The fifth characteristic is hygiene, which may contribute to skin condition.
- The final characteristic is the presence of any lesions, which are any pathologic skin change or occurrence.
- During inspection, also palpate the skin to determine five characteristics.
- First, palpate to detect moisture. Minimal perspiration or oiliness should be present. Even intertriginous areas should display little dampness.
- Second, use the dorsal surface of your hands to assess temperature. The skin may feel cool to warm but should be bilaterally symmetrical.
- Third, check the texture, which should be smooth, soft, and even. However, roughness on exposed skin or areas of pressure may occur.
- Finally, evaluate the last two characteristics, turgor and mobility, by pinching up a small section of skin on the forearm or sternum, releasing it, and watching for it to immediately return to place.
- If a lesion is present, inspect and palpate it fully. Remember: Not all lesions are cause for concern, but they should all be examined.
First, describe its size (measured in centimeters in all dimensions), shape, color, texture, elevation or depression, and attachment at the base.
- If the lesion has exudates, note their color, odor, amount, and consistency.
- If there is more than one lesion, describe their configuration as annular (or ring-shaped), arciform (or bow-shaped), grouped, linear, or diffuse.
- Record the lesions’ location and distribution, noting whether they appear generalized or localized, affect a specific body region, form a pattern, and are discrete or confluent.
- Use a light and magnifying glass to determine the lesion’s subtle details, including color, elevation, and borders.
- To see if fluid is present in a cyst or mass, transilluminate it in a darkened room. A fluid-filled lesion transilluminates with a red glow; a solid lesion does not.
- To further identify a lesion, shines a Wood’s lamp on the area in a darkened room. Look for the well-demarcated hypopigmentation of vitiligo, the hyperpigmentation of café au lait spots, and the yellow-green fluorescence that suggests fungal infection.
To examine the hair, perform the following.
- To assess the hair, palpate its texture. Scalp hair may be coarse or fine and curly or straight. It should be shiny, smooth, and resilient.
- During palpation, also inspect the hair for three characteristics: color, distribution, and quantity.
- Hair color ranges from very light blond to black to gray.
- Hair distribution and quantity vary with genetics. Hair commonly appears on the scalp, lower face, neck, nares, ears, chest, axillae, back, shoulders, arms, legs, toes, pubic area, and around the nipples.
To examine the nails, perform the following.
- Use inspection and palpation to assess the nails. Ask yourself: Are the nails dirty, bitten to the quick, or unkempt? Or are they clean, smooth, and neat? The condition of the hair and nails provides clues to the patient’s self-care, emotions, and social integration.
- Inspect the nails for six characteristics: color, length, condition, configuration, symmetry, and cleanliness.
- Although nail shape and opacity can vary greatly, the nail bed color should be pink. Pigment deposits may appear in the nail beds of dark-skinned patients.
- The nail length and condition should be appropriate—not bitten down to the quick. The nail edges should be smooth and rounded, with no peeling or jagged, broken, or bitten nail edges or cuticles.
- In configuration, the nail plate should appear smooth and flat or slightly convex. It should have no ridges, grooves, depressions, or pits.
- The nails should appear bilaterally symmetrical.
- The nails should be clean, smooth, and neat.
- Measure the nail-base angle by placing a ruler across the nail and dorsal surface of the finger and checking the angle formed by the proximal nail fold and nail plate.
- The nail-base angle should measure 160 degrees.
- If the nail-base angle is 180 degrees or more, clubbing is present, which suggests a cardiopulmonary or other disorder.
- Inspect and palpate the proximal and lateral nail folds for redness, swelling, pain, and exudate as well as warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.
- Palpate the nail plate for four characteristics: texture, firmness, thickness, and adherence to the nail bed.
- The texture of the nail plate should be hard and smooth.
- The nail base should be firm—not boggy.
- The nail thickness should be uniform. Thickened nails may result from tight-fitting shoes, chronic trauma, or a fungal infection. Nail thinning may accompany a nail disease.
- The nail should adhere to the nail bed when you gently squeeze the patient’s nail between your thumb and fingerpad.