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256 PHYSICAL EXAMINATION
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URGENT FINDING
UNIT 2
Areas of ecchymosis are often signs of trauma that could be the result of physical abuse,
but are often presented as resulting from an injury or ‘clumsiness’ from the consumer.
Ecchymotic areas at the base of the skull or on the face, buttocks, breasts or abdomen
should warrant a high index of suspicion for abuse, especially if found in children or
pregnant women, as should burns (e.g. cigarettes, iron) and belt buckle or bite marks. In
addition, lacerations, scars, haematomas and puncture wounds should carry a high index of
suspicion. Patterned injuries, such as those caused by ropes or chains, need to be
investigated further.
Signs of physical abuse can also be present in the hair. Hair that is singed or unusually
kinked may have been exposed to re. Alopecia can be caused by repeated pulling.
Describe injuries in relation to type, age (old/new) and anatomical location.
Any signs of abuse should be investigated further and referred as necessary. Check
your responsibilities for mandatory reporting with your state/territory or federal law. Further
information relating to investigating possible abuse can be found in Chapter 3.
Bleeding, ecchymosis and vascularity
E
Inspect the skin for evidence of bleeding, ecchymosis or increased vascularity.
N
Normally, there are no areas of increased vascularity, ecchymosis or bleeding.
A
Bleeding from the mucous membranes, previous venipuncture sites or lesions
should be considered abnormal.
P
Spontaneous bleeding can be indicative of clotting disorders, trauma or use of
antithrombolytic agents such as warfarin or heparin.
A
Petechiae are violaceous (red-purple) discolourations of less than 0.5cm in
Signs of abuse when assessing integumentary system
diameter (see
evaluate for petechiae in the mucous membranes and axillae.
P
Petechiae can indicate an increased bleeding tendency or embolism; causes
include intravascular defects or infections.
Purpura is a condition characterised by the presence of conuent petechiae or
A
conuent ecchymosis over any part of the body (see
P
Purpura or peliosis is characterised by haemorrhage into the skin and can be
caused by decreased platelet formation. Lesions vary, depending on the type of
purpura; pigmentation changes may become permanent.
Ecchymosis is a violaceous discolouration of varying size, also called a
A
black-and-blue mark (see
discolourations are deeper in colour.
Figure 8.6A). Petechiae do not blanch. In dark-skinned individuals,
Figure 8.6B).
Figure 8.6C). In dark-skinned consumers, these
C. Acanthosis nigricans
FIGURE 8.5 continued Skin colour abnormalities
SCIENCE PHOTO LIBRARY
D. Albinism. Note the lack of colouration.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
SHUTTERSTOCK.COM/K ATE PLOTNIK
E. Vitiligo
TOCK.COM/INTEK1
IS
INTEGUMENTARY 257
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P
Ecchymosis is caused by extravasation of blood into the skin as a result of
trauma; it can also occur with heparin or warfarin use or liver dysfunction.
An erythematous dilation of small blood vessels is abnormal (see Figure 8.6D).
A
P
This erythematous dilation describes a telangiectasia. Erythematous dilations
tend to appear on the face and thighs; they occur more frequently in women.
Spider angiomas are bright red and star-shaped (see Figure 8.6E). There is often
A
a central pulsation noted with pressure, and this pressure results in blanching in
the extensions. Most often, these lesions are noted on the face, neck and chest.
They are a type of telangiectasia.
P
Causes of spider angiomas include pregnancy, liver disease and hormone
therapy. They are normal in a small percentage of the population and are more
prevalent in women.
Venous stars are linear or irregularly shaped, blue vascular patterns that do not
A
blanch with pressure (
Figure 8.6F). These are often noted on the legs near veins or
on the anterior chest.
P
Venous stars are caused by increased venous pressure in the supercial veins.
Cherry angiomas are bright red, circumscribed areas that may darken with age
A
Figure 8.6G). They can be at or raised and may show partial blanching with
(see
pressure. Most often, they are found on the trunk.
P
These vascularities are of unknown aetiology and are pathologically insignicant
except for cosmetic appearance.
A bright red, raised area that has well-dened borders and does not blanch with
A
pressure is abnormal (see
P
Strawberry haemangiomas, or strawberry marks, are congenital malformations of
Figure 8.6H).
closely packed, immature capillaries. This condition is also known as naevus
vascularis. They regress as the child grows and are usually gone in a few years.
A burgundy, red or violaceous macular/vascular patch that is located along the
A
course of a peripheral nerve is abnormal (Figure 8.6I).
P
This macular/vascular patch is a port-wine stain, or naevus ammeus. The
port-wine stain is composed of mature, but thin-walled, capillaries. The lesion is
usually present at birth and is frequently located on the face. A port-wine stain
can be indicative of underlying disorders, such as Sturge-Weber syndrome.
In light-skinned individuals, a purple to black discolouration is abnormal
A
(
Figure 8.6J). In dark-skinned individuals, very dark to black discolouration
is abnormal.
CHAPTER 8
A. Petechiae B. Purpura C. Ecchymosis
FIGURE 8.6 Bleeding, ecchymosis and vascular abnormalities of the skin
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
ALAMY STOCK PHOTO/MEDISCAN
SCIEN CE PHOTO L IBRARY/ DR M. A. ANSA RY
ALAMY STOCK PHOTO/SCOTT CAMAZINE
258 PHYSICAL EXAMINATION
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UNIT 2
P
These ndings can indicate different stages of necrosis, or tissue death.
Conditions that starve the affected body part of oxygen, whether in acute or
chronic situations, can cause necrosis. Diabetes mellitus, disseminated
intravascular coagulation, acute hypovolaemia, and severe electric charge are
some of the conditions that can cause necrosis.
Dark brown or blackened areas of skin that are oedematous and painful are
A
abnormal (see
Figure 8.6K). These areas may drain a thin liquid that has a sweet,
foul odour. Crepitus may be palpated in the affected areas.
ALAMY STOCK PHOTO/MEDISCAN
D. Telangiectasia usually occurs in women and
on the face.
ALA MY STOCK P HOTO/N ATIONAL G EOGRAP HIC IMAGE
COLLECTION
G. Cherry angioma
ALAMY STOCK PHOTO/MEDISCAN
E. Spider angioma
SCIEN CE PHOTO L IBRARY/ DR P MARA ZZI
H. Strawberry haemangioma
F. Venous star
SCIENCE PHOTO LIBRARY
I. Naevus ammeus
ALAMY STOCK PHOTO/MEDICSHOTS
J. Necrosis
FIGURE 8.6 continued Bleeding, ecchymosis and vascular abnormalities of the skin
ENCE SOURCE/CLINICAL PHOTOGRAPHY, CENTRAL MANCHESTER
SCI
UNIV ERSIT Y HOSPITA LS NHS FOU NDATION T RUST, UK
K. Gas gangrene
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
INTEGUMENTARY 259
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P
Gas gangrene, or clostridial myonecrosis, is a Gram-positive infection that affects
skeletal muscles that have decreased oxygenation. The clostridia organisms are
endogenous to the gastrointestinal tract and are also found in the soil.
Consumers who experience circulatory compromise, such as in diabetes mellitus,
arterial insufciency, trauma and constricting casts, are at risk for developing gas
gangrene. Consumers who have contaminated wounds and decreased vascularity
to the affected area are also at risk for developing gas gangrene.
HEALTH EDUCATION
Evaluating skin lesions
A simple approach to teaching people how to decide to seek medical review for skin lesions
is an essential tool for nurses. The following ABCDE mnemonic for evaluating skin lesions is
easy to remember.
> A (Asymmetrical): Is the lesion asymmetrical?
> B (Borders): Are the borders of the lesion irregular?
> C (Colour): Is the colour of the lesion uneven, irregular or multicoloured?
> D (Diameter): Has the lesion’s diameter changed recently?
> E (Elevation): Has the lesion become elevated?
If the answer is ‘yes’ to any of the questions in this evaluation, consumers should be
referred to or advised to go to their medical ofcer or skin lesion/cancer clinic for further
assessment.
CHAPTER 8
Lesions
E
1. Inspect the skin for lesions, noting the anatomic location. Lesions can be
localised, regionalised or generalised. They can involve exposed areas or skin
folds (see
2. Note the grouping or arrangement of the lesions: discrete, grouped,
conuent, linear, annular, polycyclic, generalised or zosteriform
(see
3. Inspect the lesions for elevation (at or raised).
4. Using a ruler, measure the lesions.
5. Describe the colour of the lesions.
6. Note any exudate for colour or odour.
7. Note the morphology of the skin lesions. Skin lesions can be primary,
originating from previously normal skin, or secondary, originating from
primary lesions. For specic descriptions of primary lesion morphology, see
Figure 8.8. For specic descriptions of secondary lesion morphology, refer to
Figure 8.9.
TABLE 8.1 Anatomic locations of various skin lesions
LESION LOCATION
Basal cell carcinoma Medial and lateral canthi, nasolabial fold
Rosacea Face
Acne vulgaris Face, back, shoulders, chest
Table 8.1).
Figure 8.7).
Furuncle Nose, neck, face, axillae, buttocks
Lesions resulting from light exposure (squamous cell
carcinoma, solar lentigo, solar keratosis)
Seborrhoeic keratosis, spider angioma Face, trunk, upper extremities
Impetigo, verruca vulgaris (warts) Arms, legs, buttocks, face, hands, ngers, knees
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Forehead, cheeks, tops of the ears, neck, dorsal surface of hands and forearms,
lateral arms
>>
260 PHYSICAL EXAMINATION
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TABLE 8.1 continued>>
LESION LOCATION
Herpes zoster
UNIT 2
Kaposi’s sarcoma Widespread: trunk, head, tip of nose, periorbital, penis, legs, palms, soles
Erythema nodosum Lower legs
Stasis dermatitis Sock area
Cutaneous moniliasis
Adult atopic eczema Mainly exor surfaces of the body
Psoriasis
Contact dermatitis
Pediculosis pubis Pubic and axillary areas
Along the cutaneous spinal nerve tracks, almost always unilateral
Moist folds behind the ears, under the breasts, in the axilla, umbilicus, along the
inguinal and pudendal regions, in the gluteal and perineal areas
Mainly scalp, elbows, extensor surfaces of the body (rarely on the face and skin folds)
Affects surfaces in contact with irritating agents
CLINICAL REASONING
Practice tip: Wound evaluation
If a wound is present, the following assessment process should be undertaken (Benbow,
2016). Assess:
1. the person (examine all areas of the skin for signs of scarring, dermatological disorders,
skin changes, condition of skin, nails and hair of the extremities, skin colour temperature,
pulse, capillary rell and oedema)
2. the region around the wound
3. the current dressing (type, condition, time since last changed)
4. exudate (colour, amount, odour)
5. wound base and edge (measure the borders of the wound with a centimetre ruler)
6. periwound skin
7. management of the wound to date, knowledge levels and related problems.
Draw a picture in your notes to depict necrotic areas, drains and other features.
Describe location in relation to anatomical landmarks.
Wound assessment should take a holistic, person-centred view. A useful framework to
undertake this is the 9 Cs of wound care (Baranoski, Ayello & Langemo, 2008):
> Cause of the wound
> Clear picture of what the wound looks like
> Comprehensive picture of the consumer
> Contributing factors
> Communication with other healthcare practitioners
> Continuity of care
> Centralised location for wound care information
> Components of the wound care plan
> Complications of the wound.
INTEGUMENTARY 261
LESIONS EXAMPLES LESIONS EXAMPLES
A.
Discrete:
individual,
separate,
and distinct
B.
Grouped:
lesions are
clustered
Confluent:
lesions
merge and
run together
C.
Linear or
serpiginous:
lesions that
form a line
or snakelike
shape
F.
Polycyclic
or targetoid:
lesions
arranged
in concentric
circles
resembling
a bull's-eye
Eruptions from
drug reactions
such as urticaria,
erythema
multiforme
G.
Generalized:
scattered over
the body
H.
Zosteriform:
linear arrange-
ment along a
nerve root
E.
Annular:
lesions
arranged
in a circular
pattern
Insect bites Herpes
simplex
Childhood
exanthema
Ringworm
Poison ivy,
dermatitis,
hookworm
Herpes zoster
Measles
D.
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CHAPTER 8
FIGURE 8.7 Arrangement of lesions
262 PHYSICAL EXAMINATION
A.
Macule:
Localized changes in skin
color of less than 1 cm
in diameter
Example:
Freckle
B.
Patch:
Localized changes in skin
color of greater than 1 cm
in diameter
Example:
Vitiligo, stage 1 of pressure
ulcer
NONPALPABLE
D.
Plaque:
Solid, elevated lesion
greater than 0.5 cm
in diameter
Example:
Psoriasis, eczema,
pityriasis rosea
E.
Nodules:
Solid and elevated; however,
they extend deeper than
papules into the dermis or
subcutaneous tissues,
0.5-2.0 cm
Example:
Lipoma, erythema nodosum,
cyst, melanoma, hemangioma
Wheal:
Localized edema in the
epidermis causing irregular
elevation that may be red
or pale
Example:
Insect bite, hive, angioedema
FLUID-FILLED CAVITIES WITHIN THE SKIN
H.
Vesicle:
Accumulation of fluid between
the upper layers of the skin;
elevated mass containing
serous fluid; less than 0.5 cm
Example:
Herpes simplex, herpes
zoster, chickenpox, scabies
I.
J.
K.
Bullae:
Same as a vesicle only
greater than 0.5 cm
Example:
Contact dermatitis, large
second-degree burns,
bullous impetigo, pemphigus
Pustule:
Vesicles or bullae that
become filled with pus,
usually described as less
than 0.5 cm in diameter
Example:
Acne, impetigo, furuncles,
carbuncles, folliculitis
Cyst:
Encapsulated fluid-filled or
a semi-solid mass in the
subcutaneous tissue or
dermis
Example:
Sebaceous cyst, epidermoid
cyst
G.
F.
Tumor:
The same as a nodule only
greater than 2 cm
Example:
Carcinoma (such as advanced
breast carcinoma); not basal cell
or squamous cell of the skin
C.
Papule:
Solid, elevated lesion less
than 0.5 cm in diameter
Example:
Warts, elevated nevi,
seborrheic keratosis
PALPABLE
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UNIT 2
FIGURE 8.8 Morphology of primary lesions
INTEGUMENTARY 263
A.
B.
C.
D.
E.
H.
I.
J.
Scales:
Flaking of the skin's surface
Example:
Dandruff, psoriasis, xerosis
Lichenification:
Layers of skin become
thickened and rough as a
result of rubbing over a
prolonged period of time
Example:
Chronic contact dermatitis
Crust:
Dried serum, blood, or pus
on the surface of the skin
Example:
Impetigo, acute eczematous
inflammation
Atrophy:
Thinning of the skin surface
and loss of markings
Example:
Striae, aged skin
Erosion:
Loss of epidermis
Example:
Ruptured chickenpox vesicle
Scar:
Fibrous tissue that replaces
dermal tissue after injury
Example:
Surgical incision
Keloid:
Enlarging of a scar past
wound edges due to excess
collagen formation (more
prevalent in dark-skinned
persons)
Example:
Burn scar
Excoriation:
Loss of epidermal layers
exposing the dermis
Example:
Abrasion
F.
Fissure:
Linear crack in the epidermis
that can extend into the dermis
Example:
Chapped hands or lips,
athlete's foot
G.
Ulcer:
A depressed lesion of
the epidermis and upper
papillary layer of the dermis
Example:
Stage 2 pressure ulcer
ABOVE THE SKIN SURFACE
BELOW THE SKIN SURFACE
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CHAPTER 8
FIGURE 8.9 Morphology of secondary lesions
N
A
No skin lesions should be present except for freckles, birthmarks or moles
(naevi), which may be at or elevated.
A non-palpable lesion that is less than 2 cm in size, light brown in colour, and
appearing on the face, arms or hands is abnormal (Figure 8.10A).
This non-palpable lesion describes a lentigo. It is a hyperpigmented disorder
P
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
that occurs in body areas that are exposed to the sun. They can increase in size
as the person ages.
A. A lentigo occurs in sun-exposed areas
of the body
FIGURE 8.10 Common skin lesions
OF PEDIATRICS, GEORGETOWN UNIVERSITY.
CLINI CAL ASS OCIATE PR OFESSO R, DEPAR TMENT
COUR TESY OF RO BERT A. SI LVERMA N, M.D.,
264 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Practice tip: MRSA infections
The incidence of skin and soft tissue infections caused by methicillin-resistant
Staphylococcus aureus (MRSA) has signicantly increased in the outpatient population
(called Community-Associated MRSA). MRSA is carried by approximately 30% of the
population (either on their skin or in their nose or mouth), and is often not a problem for healthy
people (Turnidge, Coombs, Daley, Nimmo & Australian Group of Antimicrobial Resistance
(AGAR) participants, 2000–14, 2016). However, in some circumstances, it has the ability to
cause outbreaks of infection that can cause serious poor health outcomes or worse. Deaths
due to MRSA infections have occurred in young and old alike (Turnidge et al., 2016).
Risk factors are close living quarters (e.g. childcare centres, sporting groups, military
barracks, dormitories, prisons and other institutions) and poor hygiene (e.g. sharing towels,
bedsheets, sports equipment, handling soiled clothes and other personal items, and skin contact).
All suspect lesions or wounds need to be cultured for MRSA. MRSA is a notiable
condition required to be reported by doctors, hospitals and laboratory technicians.
Reporting is condential.
Intertriginous exudative patches that are beefy red in colour, well demarcated,
A
pruritic and erythematous are abnormal.
Moniliasis, also known as candidiasis, is a yeast infection that may invade
P
numerous areas of the body but normally occurs in the axillae, inframammary
areas, groin, and gluteal regions (
A pink to red papulosquamous annular lesion with raised borders that expands
A
peripherally and has a clearing centre is abnormal.
Tinea corporis is caused by Trichophyton, a dermatophyte (fungal) infection
P
Figure 8.10C).
(
Toe web lesions that are macerated and have scaling borders are abnormal.
A
Tinea pedis (athlete’s foot) is very common and often erupts in the third and
P
fourth interdigital spaces; with time, the lesions will spread over the plantar
surface. Tinea pedis is caused by Trichophyton mentagrophytes (
Vesicles or bullae that measure 1 to 2cm and become pustular and rupture
A
easily, discharging straw-coloured uid, are abnormal. The purulent drainage
becomes thick as it dries, producing light brown or golden or honey-coloured
Figure 8.10E).
crusts (
Figure 8.10B).
Figure 8.10D).
PREVENTION
COUR TESY OF TH E CENTER S FOR DISE ASE CONT ROL AND
B. Moniliasis
FIGURE 8.10 continued Common skin lesions
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
COUR TESY OF RO BERT A. SI LVERMA N, M.D., CLI NICAL AS SOCIATE
C. Tinea corporis
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
D. Tinea pedis
INTEGUMENTARY 265
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Impetigo is usually caused by group A streptococcus or Staphylococcus aureus and
P
is highly contagious. It is typically found in children in summer, and can be
associated with poor hygiene, crowding, contact sports and minor skin trauma
that is untreated.
A diffuse red area that is warm, oedematous, painful and indurated is abnormal
A
(
Figure 8.10F).
These ndings suggest cellulitis, an acute bacterial infection (usually
P
staphylococcal or streptococcal) of the skin and subcutaneous tissues. Cellulitis
can result from trauma to the skin, foreign bodies in the skin and underlying
infection.
A lesion that starts as a tender, deep red papule and develops into a
P
well-dened,
erythematous and painful mass with purulent material is
abnormal. This describes a furuncle, commonly called a boil. It can be a rm or
uctuant lesion. Furuncles are usually caused by staphylococci.
A at or raised lesion with a black interior is abnormal.
A
A comedo, or blackhead, is usually seen on the face, chest, shoulders or back.
P
Comedones are due to increased keratinisation in the hair follicle from an
unknown aetiology. They are associated with acne.
Comedones accompanied by pustules (with yellow or white centres), red papules
A
(Figure 8.10G), nodules and cysts are abnormal.
Acne vulgaris usually occurs in the middle to late teen years and is caused by an
P
inammation of the sebaceous follicles. Acne vulgaris is associated with
hormonal changes. It can be located on the face, chest, shoulders and back.
Lesions that appear punched out may be present from scarring of previously
active acne lesions.
CHAPTER 8
E. Impetigo
H. Rosacea rhinophyma
FIGURE 8.10 continued Common skin lesions
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
COUR TESY OF RO BERT A. SI LVERMA N, M.D., CLI NICAL AS SOCIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
F. Cellulitis
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
I. Kaposi’s sarcoma
G. Acne papules and nodules visible on a
child’s face
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
COUR TESY OF RO BERT A. SI LVERMA N, M.D., CLI NICAL AS SOCIATE
J. Psoriasis
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
CO
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