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PHYSICAL DIAGNOSIS:

Examination of the Skin


by Ma. Socorro W. Toledo, MD, FPDS

A. General Characteristics
B. 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.

(cont d.)

II. Palpation:
a. Temperature:
Normal = Afebrile to touch / Not cold to touch
(Objective measure: Temperature)
b. Turgor
Normal = Prompt return after finger pressure
Abnormal= Delayed return after finger pressure
c. Degree of moisture:
Normal = No dryness, no excess moisture
Abnormal = Dry (hypohidrosis, anhidrosis)
or Moist (hyperhidrosis)

A. Gen. Char.

(cont d.)

d. Hardness /Sclerosis or Laxity

Normal skin = (-) sclerosis, (-) laxity

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

B. Presence / Absence
of Skin Lesion
Normal
= No
skin lesions
I. PRIMARY SKIN
LESIONS
(arise de novo)
A. Flat lesions
1. Macule 2. Patch
B. Raised or palpable lesions
1. Papule
5. Vesicle
2. Nodule
6. Bulla
3. Tumor
7. Wheal
4. Plaque
8. Pustule

I.A. Flat lesions


1. Macule: A flat lesion <1.0 cm in greatest
dimension
2. Patch: A flat lesion 1.0 cm or more in
greatest dimension

I.B. Raised or palpable


lesions
1. Papule*: A solid or cystic elevation, or
palpable lesion <1.0 cm in diameter
2. Nodule*: A solid or cystic elevation, or
palpable lesion 1.0 cm or more but
less than 2.0 cm in diameter
*May be rounded, ovoid or ellipsoidal

I.B. Raised or palpable


lesions (cont d.)
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 (cont d.)
5. Vesicle: A noncystic, transparent fluidfilled lesion <1.0 cm in diameter
6. Bulla: A noncystic, transparent fluidfilled lesion 1.0 cm or more in greatest
dimension
Blisters = fluid-filled skin lesions
= vesicles & bullae

I.B. Raised or palpable


lesions (cont d.)
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 body
2. Generalized
B. Color
1. Skin-colored
2. Erythematous (pink, bright/ dusky red, violaceous)
3. Hyperpigmented (brown, gray, black )
4. Hypopigmented (whitish) vs. white
5. 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 surfaces
Flexures or intertriginous areas
Sun-exposed areas
Truncal
Acral (ears, tip of nose, hands, feet)
Dermatomal

II. Other Features (contd.)


E . Secondary Lesions

a. Scales
b. Crusts
c. Excoriations
d. Erosions
e. Ulcers

e. Fissures
f. Lichenification
g. Atrophy
h. Scars

C. Skin Appendages:
HAIR
&
NAILS
1. HAIR
A. Loss or Excess
NORMAL
= No hair loss
= No hypertrichosis / No hirsutism (females)
ABNORMAL

1. Hair Loss (alopecia)


= patchy vs. diffuse
= scarring vs. non-scarring

2. Hair Excess
a. Hypertrichosis (localized / generalized)
b. Hirsutism (in females only)

C. Skin appendages:
1. HAIR (cont d.)

B. Check for structural abnormalities


Normal = No structural abnormalities
e.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 UNIT
A. Nail Plate
Normal:
1. (-) nail dystrophy (No structural deformities/
shape)
Ex. No thickening
Ex. No pits
Ex. No vertical/ horizontal lines or grooves
Ex. No clubbing
2. (-) No color changes (Normal = transparent)

No abormalities in

C. Skin Appendages:
2. NAIL UNIT (contd.)
B. Nail Bed
Normal = (-) 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
Nasal
Conjunctival
Genital
Anal / 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 / hyperpigmentation
2. Palpation:
Temperature: Afebrile/ not cold to touch
Turgor: 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. Mucosa
Normal = No oral / nasal /
conjunctival / genital / anal / perianal
lesions

Instructions for PD
A. Yellow pad paper will be provided.
activity:
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.