Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Chapter 8 Skin, Hair, and Nails Physical Examination Preview Skin Perform overall inspection of entire skin surface. During evaluation of each organ system, evaluate the overlying skin for the following characteristics: Color Uniformity Thickness Symmetry Hygiene Lesions Odors Skin (Cont.) Palpate skin surfaces for the following: Moisture Temperature Texture Turgor Mobility Hair Inspect hair for the following: Color Distribution Quantity Palpate hair for texture. Nails Inspect for the following: Pigmentation of nails and beds Length Symmetry Ridging, beading, pitting, peeling Measure nail base angle. Nails (Cont.) Inspect and palpate proximal and lateral nail folds for the following: Redness Swelling Pain Exudate Warts, cysts, tumors Nails (Cont.) Palpate nail plate for the following: Texture Firmness Thickness Uniformity Adherence to nail bed Anatomy and Physiology Skin: Functions The skin is a stratified structure composed of several functionally related layers that perform the following integral functions: Protect against microbial and foreign substance invasion and minor physical trauma Retard body fluid loss by providing a mechanical barrier Regulate body temperature through radiation, conduction, convection, and evaporation Skin: Functions (Cont.) Provide sensory perception via free nerve endings and specialized receptors Produce vitamin D from precursors in the skin Contribute to blood pressure regulation through constriction of skin blood vessels Repair surface wounds by exaggerating the normal process of cell replacement Excrete sweat, urea, and lactic acid Express emotions Skin Layers Epidermis Dermis Hypodermis Appendages Epidermis Outermost part of skin Avascular and depends on the underlying dermis for its nutrition Two major layers Stratum corneum Protects the body against harmful environmental substances and restricts water loss Cellular stratum Keratin cells are synthesized Basement membrane Lies beneath the cellular stratum and connects the epidermis to the dermis Dermis Richly vascular connective tissue layer Separates epidermis from cutaneous adipose tissue Components Elastin, collagen, and reticulin fibers Provide resilience, strength, and stability Sensory nerve fibers Provide sensations of pain, touch, and temperature Autonomic motor nerve Innervate blood vessels, glands, and the arrectores pilorum muscles Hypodermis Connects dermis to underlying organs Subcutaneous layer filled with fatty cells Functions Generates heat Provides insulation Provides shock absorption Provides calorie reserve Appendages Eccrine sweat glands Open directly onto the surface of the skin and regulate body temperature through water secretion Distributed throughout the body except at the lip margins, eardrums, nail beds, inner surface of the prepuce, and the glans penis Appendages (Cont.) Apocrine sweat glands Larger and located more deeply than the eccrine glands In response to emotional stimuli, secrete a white fluid containing protein, carbohydrate, and other substances Secretions from these glands are odorless Body odor produced by bacterial decomposition of apocrine sweat Found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears Appendages (Cont.) Sebaceous glands Secrete sebum, a lipid-rich substance that keeps the skin and hair from drying out Secretory activity, which is stimulated by sex hormones (primarily testosterone), varies according to hormonal levels throughout the life span Appendages (Cont.) Hair Formed by epidermal cells that invaginate into the dermal layers Melanocytes in the shaft provide its color Adults have two kinds of hair: vellus―short, fine, soft, and nonpigmented terminal―coarser, longer, thicker, and usually pigmented Males and females have about the same number of hair follicles that are stimulated to differential growth by hormones Appendages (Cont.) Nails Epidermal cells are converted to hard plates of keratin. Highly vascular nail bed lies beneath the plate, giving the nail its pink color. Stratum corneum layer of skin covering the nail root is the cuticle, or eponychium. Soft tissue surrounding the nail border is the paronychium. Infants and Children Skin of infants and children appears smoother than that of adults because: Of the absence of coarse terminal hair Skin has not been subjected to years of exposure to the elements Desquamation of stratum corneum may be present at birth or very shortly afterward. Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth. Subcutaneous fat is poorly developed in newborns, predisposing them to hypothermia. Infants and Children (Cont.) Lanugo is the fine silky hair that covers the newborn’s body, particularly on the shoulders and back. Shed within 10 to 14 days Most of the infant’s hair is shed by about 2 to 3 months of age, to be replaced by more permanent hair with a new texture and often a different color. Eccrine glands function after 1 month. Apocrine glands do not function. Less oily texture Inoffensive perspiration Adolescents Apocrine glands enlarge and become active. Increased axillary sweating and sometimes body odor Increased sebum production in response to increased hormone levels, primarily androgen Oily appearance and predisposing the individual to acne Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents, and on the face of males Pregnant Women Increased blood flow to skin, especially that of the hands and feet, results from peripheral vasodilation and increased numbers of capillaries. Acceleration of sweat and sebaceous gland activity occurs. Assist in dissipating the excess heat caused by the increased metabolism during pregnancy Vascular spiders and hemangiomas that are present may increase in size. Pregnant Women (Cont.) The skin thickens, and fat is deposited in the subdermal layers. Because of increased fragility of connective tissues, separation may occur with stretching. Most (about 90%) pregnant women have some degree of skin darkening beginning in early pregnancy. Face, nipples, areolae, axillae, vulva, perianal skin, and umbilicus Older Adults Sebaceous and sweat gland activity decreases and results in drier skin and less perspiration. Epidermis thins and flattens, giving the skin a parchment appearance. Dermis is less elastic; loss of collagen and elastic fibers causes wrinkled appearance of epidermis. Older Adults (Cont.) Subcutaneous tissue also decreases, giving joints and bony prominences a sharp, angular appearance. Hollows in thoracic, axillary, and supraclavicular regions deepen Gray hair is due to a decrease in the number of functioning melanocytes. Axillary and pubic hair production declines due to reduced hormonal functioning. Older Adults (Cont.) Hair follicle size changes, and terminal scalp hair progressively transitions into vellus hair, causing age-associated baldness in both men and women. Opposite transition, from vellus to terminal, occurs in the hair of the nares and on the tragus of men’s ears. Nail growth slows because of decreased peripheral circulation. Nails, particularly the toenails, become thicker, brittle, hard, and yellowish. Review of Related History History of Present Illness: Skin Changes in skin Temporal sequence Symptoms Location Associated symptoms Recent exposure Apparent cause Travel history Treatment response Adjustment to problem Medications History of Present Illness: Hair Changes in hair Occurrence Associated symptoms Exposure Nutrition Treatment Adjustment Medication History of Present Illness: Nails Changes in nails Associated symptoms Temporal sequence Exposure Treatment response Medications Past Medical History: Skin Previous skin problems Sensitivities, allergic reactions, or disorders Lesions, treatments Tolerance to sunlight Diminished or heightened sensitivity to sensory stimuli Cardiac, respiratory, liver, endocrine, or other systemic disease Past Medical History: Hair Previous hair problems Hair loss, thinning, growth, unusual growth, brittleness, breakage, or treatments Systemic problems Thyroid or liver disorder Severe illnesses Malnutrition Associated skin disorder Past Medical History: Nails Previous nail problems Nail injury Bacterial, fungal, or viral infection Systemic problems Associated skin disorder Congenital anomalies Respiratory, cardiac, hematologic, or other systemic diseases Family History Current or past dermatologic diseases or disorders in family members Allergic hereditary diseases: asthma, hay fever Familial hair loss or coloration patterns Personal and Social History Skin care habits Cleansing routine, soaps, oils, lotions Cosmetics, home remedies, sun screens Recent changes in skin care habits Skin self-examination Nail care habits Exposure to environmental or occupational hazards Recent psychological or physical stress Use of alcohol, tobacco, or recreational drugs Infants Feeding history Diaper history Types of clothing and washing practices Bath practices Dress habits Temperature/humidity of home Rubbing head against external surfaces Children Eating habits and types of food: sweets Exposure to communicable diseases Allergic disorders: eczema, urticaria, pruritus Pets or animal exposure Outdoor exposures: camping, hiking, picnics Skin injury history: cuts, unexplained injuries Chronic manipulation of hair Nail biting Pregnant Women Weeks of gestation or postpartum Hygiene practices Exposure to irritants Presence of skin problems before pregnancy Effects of pregnancy on preexisting conditions Psoriasis may remit; condylomata acuminata commonly become larger and more numerous. Older Adults Increased or decreased sensation to touch or the environment Generalized chronic itching, irritants Susceptibility to skin infections Healing response: delayed or interrupted Frequent falls: cuts, bruises History of diabetes mellitus or peripheral vascular disease Hair loss history: gradual or sudden Examination and Findings Equipment Centimeter ruler (flexible, clear) Wood’s lamp (to view fluorescing lesions) Flashlight with transilluminator Handheld magnifying lens (optional) Skin Examination of the skin is performed by inspection and palpation. The most important tools are your own eyes and powers of observation. When gross inspection leaves you uncertain, a handheld magnifying glass or dermatoscope may help. Inspection Adequate lighting is essential. Daylight provides the best illumination for determining color variations, particularly jaundice. Tangential lighting is helpful in assessing contour. Body sweep Room temperature Exposure Draping Inspection (Cont.) Color and uniform appearance Look for localized areas of discoloration Thickness Varies over the body Symmetry Hygiene Inspection (Cont.) Presence of lesions Nevi (moles) Vary in size and degree of pigmentation Present on most persons regardless of skin color Most nevi are harmless May occur anywhere on the body Inspection (Cont.) Presence of lesions Nevi (moles) (Cont.) Dysplastic Tend to occur on the upper back in men and on the legs in women Palpation Moisture Minimal perspiration or oiliness should be present. Temperature Use the dorsal surface of your hands or fingers. Texture Smooth, soft, and even Turgor Altered if the patient is substantially dehydrated or if edema is present Mobility Move easily when pinched, and return to place immediately when released Skin Lesions Lesions Any pathologic skin change or occurrence Types: Primary ‒ those that occur as initial spontaneous manifestations of a pathologic process Secondary ‒ those that result from later evolution of or external trauma to a primary lesion Skin Lesions (Cont.) Characteristics Size (measure all dimensions) Shape Color Texture Elevation or depression Attachment at base Pedunculated ‒ having a stalk Sessile ‒ without a stalk Skin Lesions (Cont.) Characteristics (Cont.) Exudates Color Odor Amount Consistency Configuration Annular (rings) Grouped Linear Arciform (bow-shaped) Skin Lesions (Cont.) Characteristics (Cont.) Location and distribution Generalized or localized Region of the body Patterns Discrete or confluent Examination Tools A small, clear, flexible ruler is necessary for measuring the size of lesions. Centimeters are preferred. Try to measure size in all dimensions (i.e., height, width, and depth) when possible. Use a light for closer inspection of a particular lesion to detect its nuances of color, elevation, and borders. A ×5 to ×10 handheld magnifying lens is useful in evaluating the subtle details of a lesion. Examination Tools (Cont.) Transillumination may be used to determine the presence of fluid in cysts and masses. Darkened room Fluid-filled lesions will transilluminate with a red glow, whereas solid lesions will not. Wood’s lamp can be used to evaluate epidermal hypopigmented or hyperpigmented lesions, and to distinguish fluorescing lesions. Darkened room Hair Fine vellus hair covers the body. Coarse terminal hair occurs on the scalp, pubic, and axillary areas, on the arms and legs (to some extent), and in the beard of men. Look for hirsutism in women—growth of terminal hair in a male distribution pattern on the face, body, and pubic area. May be a sign of an endocrine disorder Inspection Color Varies from very light blond to black to gray and may show alterations with rinses, dyes, or permanents Distribution Symmetric or asymmetric Inspect feet and toes for hair loss that may indicate poor circulation or nutritional deficit Quantity Varies according to individual genetic makeup Palpation Texture Palpate the scalp hair for dryness and brittleness that could indicate a systemic disorder. Note whether the hair shafts are broken off or are completely absent. Nails The condition of the fingernails can provide important insight to the patient’s sense of self. The condition of the hair and nails gives a clue about the patient’s level of self-care and some sense of emotional order and social integration. Nail edges should be smooth and rounded. Examine the proximal and lateral nail folds for redness, swelling, pus, warts, cysts, and tumors. Inspection (Cont.) Color Length Configuration Symmetry Cleanliness Palpation (Cont.) Hardness, smoothness, and uniform thickness Test for adhesion to nail bed Infants and Children Inspection and palpation of skin for: Expected color changes Jaundice or hyperbilirubinemia Defects signaling systemic conditions Contour distortions Skin creases indicating congenital abnormalities Lesions indicating internal problems Pinch skin for test of turgor Adolescents Examination same as for adult Inspect for: Increased oiliness and perspiration Acne Maturational changes Pregnant Women Inspect for: Striae gravidarum (stretch marks) Telangiectasias/hemangiomas Cutaneous tags Increased pigmentation Palmar erythema Itching Altered hair growth Older Adults Inspect for: (Cont.) Skin changes Breakdown over bony prominences Lesions Hair changes Nail changes Abnormalities Skin: Inflammatory and Infectious Conditions Eczematous Dermatitis Most common inflammatory skin disorder: Irritant contact dermatitis Allergic contact dermatitis Atopic dermatitis Skin: Inflammatory and Infectious Conditions (Cont.) Folliculitis Inflammation and infection of the hair follicle and surrounding dermis Skin: Inflammatory and Infectious Conditions (Cont.) Furuncle (boil) Deep-seated infection of the pilosebaceous unit Skin: Inflammatory and Infectious Conditions (Cont.) Cellulitis Diffuse, acute, infection of the skin and subcutaneous tissue Tinea (dermatophytosis) Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair Skin: Inflammatory and Infectious Conditions (Cont.) Pityriasis rosea Self-limiting inflammation of unknown cause Psoriasis Chronic and recurrent disease of keratin synthesis Skin: Inflammatory and Infectious Conditions (Cont.) Rosacea Chronic inflammatory skin disorder Herpes zoster (shingles) Varicella-zoster viral infection Skin: Inflammatory and Infectious Conditions (Cont.) Herpes simplex Type 1: associated with oral infection Type 2: associated with genital infection Herpes Zoster Skin: Cutaneous Reactions Drug eruptions Immunologically mediated cutaneous reactions to medications Acanthosis nigricans Nonspecific reaction pattern associated with obesity, certain endocrine syndromes or malignancies, or as an inherited disorder Skin: Biologic Warfare Anthrax Spore-forming bacterium Bacillus anthracis Pruritic macule or papule that enlarges into a round ulcer by day 2 Central necrosis develops with a painless ulcer covered by black eschar Smallpox Variola virus Flat red lesions that evolve at the same rate Lesions become vesicular, then pustular and crust Skin: Malignant/Neoplastic Basal cell carcinoma Most common form of skin cancer Squamous cell carcinoma Second most common skin cancer Skin: Malignant/Neoplastic (Cont.) Malignant melanoma Lethal form of skin cancer that develops from melanocytes Kaposi sarcoma Neoplasm of the endothelium and epithelial layer of the skin caused by Kaposi sarcoma herpes virus 8 Commonly associated with human immunodeficiency virus (HIV) infection Hair Disorders Alopecia areata Sudden, rapid, patchy loss of hair, usually from the scalp or face Scarring alopecia Skin disorders of the scalp or follicles result in scarring and destruction of hair follicles and permanent hair Hair Disorders (Cont.) Traction alopecia Prolonged tension of the hair from traction breaks the hair shaft Hirsutism Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas Nails: Infection Paronychia Inflammation of the paronychium Onychomycosis Fungal infection of the nail Nails: Injury Ingrown nails Nail pierces lateral nail fold; grows into the dermis Subungual hematoma Trauma to the nail plate severe enough to cause immediate bleeding and pain Leukonychia punctata White spots in the nail plate Nails: Injury (Cont.) Median nail dystrophy Nail deformity as result of nail picking or biting habit Onycholysis Loosening of the nail plate with separation from the nail bed that begins at the distal groove Nails: Changes Associated with Systemic Disease Koilonychia (spoon nails) Central depression of the nail with lateral elevation of the nail plate Beau lines Transverse depression in the nail bed Nails: Changes Associated with Systemic Disease (Cont.) White banding (Terry nails) Transverse white bands Psoriasis Chronic and recurrent disease of keratin synthesis Nails: Periungual Growths Warts Epidermal neoplasms caused by viral infection Digital mucous cysts Cystlike structures that contain a clear jelly-like substance Infants and Children Seborrheic dermatitis Little known about etiology Condition most commonly occurs in infants within the first 3 months of life Miliaria (prickly heat) Caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity Impetigo Common, contagious superficial skin infection Infants and Children (Cont.) Acne vulgaris Impaction and obstruction of the outflow of sebum Chickenpox (varicella) Acute, highly communicable disease common in children and young adults Infants and Children (Cont.) Measles (rubeola) Measles virus infects by invasion of the respiratory epithelium German measles (rubella) Mild, febrile, highly communicable viral disease Infants and Children (Cont.) Hair pulling (trichotillomania) Loss of scalp hair can be caused by physical manipulation Patterns of injury in physical abuse Bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries Skin and hair abnormalities may be the most visible clues in detecting this problem Pregnant Women Pruritic urticarial papules and plaques of pregnancy (PUPPP) Benign dermatosis that usually arises late in the third trimester of a first pregnancy Herpes gestationis (pemphigoid gestationis) Rare autoimmune disorder of pregnancy Not related to the herpes virus infection Older Adults Stasis dermatitis Occurs on the lower legs in some patients with venous insufficiency Solar keratosis (actinic keratosis) Squamous cell carcinoma confined to the epidermis Physical abuse in older adults Look for bruising, burns, abrasions, or areas of tenderness Particularly on hidden areas such as the axillae, inner thighs, soles of the feet, palms, and abdomen Question 1 The nail base angle should measure: A. 120 degrees B. 140 degrees C. 160 degrees D. 180 degrees Question 2 Fluorescing lesions are best distinguished using a(n): A. Incandescent lamp B. Magnifying glass C. Transilluminator D. Wood’s lamp Question 3 Which of the following objective findings would you expect to see in folliculitis: A. Acute onset of tender red nodule B. Acute onset of papules and pustules C. Pale, erythematous and macular D. Telangiectasia, erythema and papules Question 4 The adipose tissue in the hypodermis serves to: A. Provide sensory input B. Generate heat and insulate C. Create tensile strength D. Restrict water loss Question 5 Koilonychia (spoon nails) are a central depression of the nail with lateral elevation of the nail plate. This is commonly seen with which of the following systemic diseases: A. Iron deficiency anemia, syphilis B. Diabetes mellitus and hypothyroidism C. Chronic congestive heart failure and cirrhosis D. Psoriasis and hyperthyroidism