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266 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
Rosacea that is red or purple on the lower nose and is accompanied by
A
thickening of the affected skin and enlargement of the follicular orices is
abnormal (
This condition is rosacea rhinophyma. The cause is unknown, although it is
P
Figure 8.10H).
aggravated by alcohol, spicy foods, hot liquids, sunlight, extremes in
temperature, exercise and stress.
A
Reddish salmon-coloured macular lesions are abnormal.
Elevated purple to brown lesions (in light-skinned consumers) and bluish lesions
A
(in dark-skinned consumers) that are spongy, painful and pruritic are abnormal
Figure 8.10I).
(
Both of these abnormal ndings are typical lesions of Kaposi’s sarcoma. The
P
reddish-salmon lesions are early ndings, and the purplish or bluish lesions are
more advanced lesions. Kaposi’s sarcoma is a neoplastic disorder that is thought
to have a genetic, hormonal and viral aetiology. It is frequently found in
consumers infected with the AIDS virus, immunocompromised consumers and
older adults.
Pruritic, silvery scales of the epidermis that have clearly demarcated borders and
A
underlying erythema are abnormal. These lesions are circular and are found
primarily on the elbows, knees and behind the ears, but can be found in other
areas as well (see
The aetiology of psoriasis is unknown, but it has a genetic component and may
P
Figure 8.10J).
be aggravated by cold weather, trauma and infection.
On rare occasions, psoriasis can progress to pustular psoriasis (see
Figure 8.10K).
Erythema develops throughout the body, especially in exural areas. Pustules
develop over the erythema and can easily rupture. The consumer is often febrile.
Death can ensue from sepsis.
A chronic supercial inammation of the face, scalp, buttocks or extremities that
A
evolves into pruritic, red, weeping, crusted lesions is abnormal (see
Eczema, also known as atopic dermatitis, is a multifaceted disease process that is
P
Figure 8.10L).
often associated with asthma and allergic rhinitis. The aetiology is unknown,
and a family history of related disorders is usually noted.
It is abnormal to have oedema and erythema along with red, pruritic vesicles
A
that may discharge an exudate that leads to crusting (see Figure 8.10M).
This describes allergic contact dermatitis. The consumer must come in direct
P
contact with the irritant to develop the dermatitis. Contact dermatitis is also
caused by metals such as nickel, detergents, cosmetics, rubber, topical
medications, food, shampoo, hair dye and clothing.
K. Pustular psoriasis
FIGURE 8.10 continued Common skin lesions
PREVENTION
COUR TESY OF TH E CENTE RS FOR DISE ASE CON TROL AN D
L. Eczema
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
PREVENTION.
COUR TESY OF TH E CENTER S FOR DISE ASE CONT ROL AND
M. Allergic contact dermatitis
INTEGUMENTARY 267
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Red, pruritic papules or vesicles with S-shaped or straight-line burrows are
A
abnormal (
Scabies is caused by the parasitic Sarcoptes scabiei mite, and may be visible as a
P
Figure 8.10N). These lesions can be intensely pruritic.
small, dark area within the vesicle. It is highly contagious and can sometimes be
spread through infected clothing or bedding. It is endemic in many
resource-poor communities where there is poor sanitation, overcrowding and
social disruption.
Red papules, vesicles, open sores, and crusting on the face, in the mouth, or on
A
the genitalia are abnormal (
Herpes simplex virus I is usually responsible for these lesions, which are more
P
Figure 8.10O).
common on the face and in the mouth. After the initial exposure, the consumer
can often predict an outbreak because of the presence of numbness, burning,
itching or soreness at the eruption site.
Red macular and papular lesions that are intensely pruritic are abnormal
A
Figure 8.10P).
(see
Varicella, or chickenpox, usually starts on the trunk and proceeds to the
P
extremities. Papules progress to thin-walled vesicles, pustules and crusts. The
consumer may exhibit all of the different lesions simultaneously. Varicella is
caused by the varicella -zoster virus, which is highly contagious, especially in
children.
Red, extremely painful vesicles with paraesthesia that are closely grouped in a
A
dermatomal pattern are abnormal (see
Herpes zoster, or shingles, is caused by a reactivation of the varicella zoster virus.
P
Figure 8.10Q).
The virus remains dormant after the initial varicella inoculation. It frequently
occurs in elderly individuals. The lesions are similar to those of varicella, but
they tend to develop more slowly.
Herpes zoster that involves the ophthalmic branch of the fth cranial nerve is
P
called herpes zoster ophthalmicus. Anterior uveitis, keratitis, optic neuritis and
retinal necrosis are possible complications of this condition. These consumers
need to be evaluated by an ophthalmologist within 24 hours.
Flat, purpuric macules or atypical target lesions that are widespread and/or
A
located on the thorax and progress to blistering are abnormal (
These lesions are characteristic of Stevens-Johnson syndrome. Medications such
P
Figure 8.10R).
as phenytoin, sulfonamides and penicillin are frequently the causative agent.
Serious complications can occur with this condition if not diagnosed and treated
early.
An excessive enlarging of a scar past wound edges is abnormal.
A
Keloids are formed from excess collagen formation.
P
CHAPTER 8
N. Scabies O. Herpes simplex virus I
FIGURE 8.10 continued Common skin lesions
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
UN IVE RSI TY.
UN IVE RSI TY.
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
UN IVE RSI TY.
P. Varicella
268 PHYSICAL EXAMINATION
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UNIT 2
A maculopapular rash that is brownish pink and starts around the ears, face and
A
neck and then progresses over the trunk and limbs is abnormal (see
Rubeola (measles) is a viral infection that is highly contagious, and is
P
Figure 8.10S).
characterised by high fever, cough, rash, and Koplik’s spots (whitish-blue spots
with a red halo) on the buccal or labial mucosa.
Rubella (German measles) displays a ne, pinkish, macular rash that becomes
A
conuent and pinpoint after the second day (see Figure 8.10T).
Rubella is an RNA virus in nature and spreads from the face and neck to the
P
trunk.
Flesh-coloured, hyperkeratotic papules that have black dots on them are
A
abnormal.
Common warts, or verruca vulgaris, are viral in origin. The black dots represent
P
thrombosed blood vessels. Warts that occur on the feet are called plantar warts
Figure 8.10U).
(
Discrete, esh-coloured, dome-shaped papules that are slightly umbilicated in
A
the centre (
This describes molluscum contagiosum, a self-limiting viral infection. The
P
Figure 8.10V) are abnormal.
papules may be found anywhere on the body except the palmar and plantar
surfaces. When found on the genitalia of children, sexual abuse must be
considered.
A esh-coloured or brown pedunculated nodule is abnormal.
A
Skin tags, or achrochordon, are benign nodules (
P
Figure 8.10W). They are
frequently removed if they are in an area that receives repeated movement such
as a bra line, or if they are annoying to the consumer.
Small, pinkish-brown papules that are slightly raised and retract beneath the
A
skin when compressed are abnormal.
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
UN IVE RSI TY.
Q. Herpes zoster R. Stevens-Johnson syndrome
PREVENTION.
COUR TESY OF TH E CENTER S FOR DISE ASE CONT ROL AND
T. Rubella
FIGURE 8.10 continued Common skin lesions
PREVENTION
COUR TESY OF TH E CENTER S FOR DISE ASE CONT ROL AND
S. Rubeola
URTE SY OF ROBE RT A. SILV ERMAN, M .D., CLINI CAL ASS OCIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
U. Plantar wart
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
V. Molluscum contagiosum
INTEGUMENTARY 269
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https://t.me/medicina_free
These are dermatobromas, or benign papules. Occasionally, they may also be
P
scaly in appearance.
Pruritic, red wheals (urticarial rash) that vary in size from very small to large and
A
are sometimes accompanied by maculopapular eruptions, vesicles and bullae are
abnormal (
Urticaria can be acute or chronic in nature. This itchy skin lesion is linked to
P
Figure 8.10X).
histamine release within the body (Figure 8.10Y). Exposure to food, drugs,
infections, chemicals and physical stimuli (pressure, sun, cold weather or water,
exercise) are among the causes of urticaria.
Lesions that are brownish-tan, red, white, blue, pink, purple or grey and that have
A
irregular borders and notching are abnormal. These lesions can be at or elevated.
Malignant melanoma (Figure 8.10Z) is a cancerous lesion that is associated with
P
repeated sun exposure. Those individuals with light skin and blue eyes are
particularly at risk for malignant melanoma. These neoplastic lesions can also be
related to precancerous lesions such as naevi.
Basal cell carcinomas (
A
Figure 8.11A) and squamous cell carcinomas (Figure 8.11B)
are abnormal. They may appear as scaly sores, ulcers, or pearly/waxy skin that do
not heal or change back to ‘normal’ looking skin, to a raised nodule or papule
on the skin varying in colour from reddish tan, pale or bright pink, or many
other colours all the way through to dark brown or black lesions (Mayo Clinic,
2021a; Mayo Clinic, 2021b).
Basal cell carcinomas and squamous cell carcinomas are both malignant carcinomas
P
of the epidermal layers of the skin. They most often only inltrate locally; however, if
not treated may metastasise to other areas of the body. They are most often linked to
disgurement from surgery related to removal of the carcinoma (AIHW, 2016). Both
of these types of cancers are easily treated when small.
Perifollicular papules are abnormal.
A
CHAPTER 8
W. Skin tags
Y. Exanthematous drug eruption
FIGURE 8.10 continued Common skin lesions
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
UN IVE RSI TY.
URTE SY OF ROBER T A. SILVER MAN, M.D., C LINICA L ASSOCI ATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
CO
UN IVE RSI TY.
X. Urticaria
URTE SY OF ROBER T A. SILVER MAN, M.D., C LINICA L ASSOCI ATE
CO
UN IVE RSI TY.
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
Z. Malignant melanoma
URTE SY OF ROBER T A. SILVER MAN, M.D., C LINICA L ASSOCI ATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
UNIVERSIT Y
270 PHYSICAL EXAMINATION
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https://t.me/medicina_free
UNIT 2
ALAMY STOCK PHOTO/SCIENCE PHOTO LIBRARY
A. Basal cell carcinoma
ALAMY STOCK PHOTO/SCIENCE PHOTO LIBRARY
B. Squamous cell carcinoma
FIGURE 8.11 Basal cell and squamous cell carcinomas
Pseudofolliculitis barbae, or ingrown hair, is caused by hair tips that penetrate
P
into the skin rather than exiting through the follicular orice. It usually occurs
in the beard area, particularly in African American men, because their hair may
be curly and leave the skin at a sharp angle.
Pustules at the opening of the hair follicle are abnormal.
A
Folliculitis is an inammation of the hair follicle. Infecting agents may be
P
bacterial or fungal, and the resulting inammation is named for the causative
agent (e.g. staphylococcal folliculitis, tinea barbae).
HEALTH EDUCATION
Skin self-assessment and warning signs
Teach the consumer to check moles and other lesions in front of a mirror once a month
for the warning signs. If the mole or lesion is on a posterior surface, the consumer should
ask a partner to check it on a monthly basis. A photo can be taken for future comparisons.
Consumers with a personal or family history of skin cancer should have a skin examination
every 6–12 months by a qualied professional.
Danger signs in potentially cancerous lesions
1. Rapid change in size
2. Change in colouration
3. Irregular border or buttery-shaped border
4. Elevation in a previously at mole
5. Multiple colourations in a lesion
6. Change in surface characteristics, such as oozing
7. Change in sensation, such as pain, itching or tenderness
8. Change in surrounding skin, such as inammation or induration
9. Bleeding or ulcerative appearance in a mole
Consumer referral is required for any of the above-mentioned abnormal ndings because
of the risk of carcinoma.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
INTEGUMENTARY 271
Wound Healing
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https://t.me/medicina_free
CLINICAL REASONING
Wound healing
Wound healing for normal wounds goes through four phases (see Figure 8.12). This includes
re-epithelialisation in the proliferative phase, which is the migration of epithelial
cells inwards from the wound edges and from any surrounding hair follicles or eccrine
glands. Scab formation may prohibit re-epithelialisation because of diminished moisture.
Granulation tissue is a combination of inammatory cells, new vessels and white
blood cells that forms a matrix at the base of the wound. The granulation tissue provides a
foundation on which re-epithelialisation occurs.
CHAPTER 8
Bleeding
Fibroblast
Macrophage
Blood vessel
FIGURE 8.12 Wound healing
Blood clot
Inammatory
Fibroblast
proliferating
Subcutaneous fat
Scab
Proliferative
Remodelling
Freshly healed
epidermis
Freshly healed
dermis
Scar formation may take several months. New scars are thick, darkened and vascular in
appearance. Over time, the scar tissue attens and becomes less vascular; however, old
scars remain slightly darker or discoloured compared with the surrounding tissue.
Try to view as many wounds as possible (even by looking at wounds on the internet
and in your textbooks) and identify the tissue you can see and describe this in practice
progress notes.
ISTOCK.COM/TTSZ
CLINICAL REASONING
Practice tip: Stages of pressure ulcers
Uniform standards for staging pressure ulcers are used for consumers with pressure areas
on any portion of the body. Ensuring you use the correct staging to refer to the wound
is essential in ensuring accurate communication and management of the wound across
multiple health practitioners.
> Stage 1 In light-skinned consumers, the area is reddened, but the skin is not broken;
in dark-skinned consumers, the pigmentation is enhanced (Figure 8.13A).
> Stage 2 Epidermal and dermal layers have sustained injury (Figure 8.13B).
> Stage 3 Subcutaneous tissues have sustained injury (Figure 8.13C).
> Stage 4 Muscle tissue and perhaps bone have sustained injury (Figure 8.13D).
>>
272 PHYSICAL EXAMINATION
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https://t.me/medicina_free
UNIT 2
>>
COURTESY OF EMORY UNIVERSITY HOSPITAL, ATLANTA, GEORGIA.
A. Stage 1
URTESY OF EMORY UNIVERSITY HOSPITAL, ATLANTA, GEORGIA
CO
C. Stage 3
FIGURE 8.13 Pressure ulcers
URTESY OF EMORY UNIVERSITY HOSPITAL, ATLANTA, GEORGIA.
CO
B. Stage 2
COURTESY OF EMORY UNIVERSITY HOSPITAL, ATLANTA, GEORGIA
D. Stage 4
CLINICAL REASONING
Practice tip: Identifying burns
A consumer with burns frequently has varying degrees of injury on the body. Parts of
the body may have rst-degree burns, and other parts may have second-, third- or
fourth-degree burns.
Once burns have been identied, estimation tools should be used to calculate the
total body surface area (TBSA%) affected, and this is used to make decisions of clinical
management and resuscitation volumes of uid given in the rst 24 hours post-burn. This
is an essential component of physical assessment. Different burns estimation tools are
available for use, and will vary depending on local practice, age and BMI (body mass index)
of the consumer, and whether the burns are small and scattered or large and grouped
together. Care must be taken to be as accurate as possible with these calculations as they
can signicantly impact on the resuscitation and outcomes of the consumer in recovery.
For example, the following suggestions are made to use the best placed tool to assess
the following burns in a consumer:
For large burns use Rule of 9s (if BMI of consumer is <30, and patient is an adult),
modied Lund-Browder (if BMI is 30–39.9, may be used for both adults and paediatrics)
(
Figure 14A and B) or Rule of 7s (if BMI is >40) [not widely used in Australia].
For small scattered burns use the palmar method (total hand surface of consumer is
approximately 1% of consumer’s body surface) (
(Victorian Adult Burns Service, 2022; Pham, Collier & Gillenwater, 2018)
Figure 14C).
>>
INTEGUMENTARY 273
1% 0.5% 0.8% 0.5%
AdultPaediatric
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
>>
A B Anterior Posterior
Relative percentage of body surface area (% BSA) affected by growth
Age
Body part 0 yr 1 yr 5 yr 10 yr 15 yr
a = ½ of head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½
b = ½ of 1 thigh 2 ¾ 3 ¼ 4 4 ¼ 4 ½
c = ½ of 1 lower leg 2 ½ 2 ½ 2 ¾ 3 3 ¼
CHAPTER 8
A. Rule of 9s (for adults) and B. Lund-Browder chart (for children)
C. Palmar method
FIGURE 8.14 Tools for estimating extent of burns
SHUTTERSTOCK.COM/BL AMB
The following descriptions and photographs will assist you in identifying burn injuries:
> Epidermal (Figure 8.15A): the epidermis is injured or destroyed; there may be some damage to
the dermis; hair follicles and sweat glands are intact; the skin is red and dry; painful, no blisters.
> Partial thickness (supercial dermal or mid dermal) (Figure 8.15B): the epidermis and upper
layers of the dermis are destroyed; the deeper dermis is injured; hair follicles, sweat glands and
nerve endings are intact; the skin is red and blistery with exudate; painful. Blisters are present.
> Deep dermal partial thickness (Figure 8.15C): the epidermis and dermis are destroyed;
subcutaneous tissue may be injured; hair follicles, sweat glands and nerve endings are
destroyed; the skin is white, red, black, tan or brown with a leathery-looking appearance;
painless because nerve endings are destroyed.
> Full thickness (Figure 8.15D): the epidermis and dermis are destroyed; subcutaneous
tissue, muscle and bone may be injured; hair follicles, sweat glands and nerve endings
are destroyed; the skin is white, red, black, tan or brown with exposed and damaged
subcutaneous tissue, muscle or bone; painless.
>>
274 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
https://t.me/medicina_free
UNIT 2
>>
ALAMY STOCK PHOTO/SCIENCE HISTORY IMAGES
A. Epidermal
TOCK.COM/LUX_D
IS
B. Supercial dermal partial thickness
COUR TESY OF ROB ERT A. SILV ERMAN, M .D.,
CLINI CAL ASSO CIATE PRO FESSOR , DEPARTM ENT OF
PEDIATRICS, GEORGETOWN UNIVERSITY.
FIGURE 8.16 Ichthyosis vulgaris
TOCK.COM/INTEK1
S
C. Deep dermal partial thickness
SCIEN CE PHOTO L IBRARY/ DR P MARA ZZI
D. Full thickness
FIGURE 8.15 Types of burns
Palpation
Moisture
E
Palpate all non-mucous membrane skin surfaces for moisture using the dorsal
surfaces of the hands and ngers.
N
Normally, the skin is dry with a minimum of perspiration. Moisture on the skin
will vary from one body area to another, with perspiration normally present on
the hands, axilla and face, and in between the skin folds. Moisture also varies
with changes in environment, muscular activity, body temperature, stress, and
activity levels. Body temperature is regulated by the skin’s production of
perspiration, which evaporates to cool the body.
Excessive dryness of the skin,
A
corneum and associated pruritus, is abnormal.
Hypothyroidism and exposure to extreme cold and dry climates can lead to
P
xerosis.
Very dry, large scales that are light coloured or brown are abnormal (Figure 8.16).
A
Ichthyosis vulgaris is a skin abnormality originating from a keratin disorder. It
P
can be associated with atopic dermatitis.
Diaphoresis is the profuse production of perspiration.
A
Causes include hyperthyroidism, increased metabolic rate, sepsis, anxiety
P
and pain.
xerosis, as evidenced by aking of the stratum
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
INTEGUMENTARY 275
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https://t.me/medicina_free
Temperature
E
Palpate all non-mucosal skin surfaces for temperature using the dorsal surfaces of
the hands and ngers.
N
Skin surface temperature should be warm and equal bilaterally. Hands and feet
may be slightly cooler than the rest of the body.
Hypothermia is a cooling of the skin, and may be generalised or localised.
A
Generalised hypothermia is indicative of shock or some other type of central
P
circulatory dysfunction. Localised hypothermia is indicative of arterial
insufciency in the affected area.
Generalised hyperthermia is the excessive warming of the skin and may be
A
generalised or localised.
Generalised hyperthermia may be indicative of a febrile state, hyperthyroidism,
P
or increased metabolic function caused by exercise. Localised hyperthermia may
be caused by infection, trauma, sunburn or windburn.
Tenderness
E
Palpate skin surfaces for tenderness using the dorsal surfaces of the hands and
ngers.
N
Skin surfaces should be nontender.
Tenderness over the skin structures can be discrete and localised or generalised.
A
Discrete tenderness may indicate a localised infection such as cellulitis, and
P
generalised tenderness can indicate systemic illness such as lymphoma or
allergic reaction.
CHAPTER 8
Texture
E
1. Evaluate the texture of the skin using the nger pads.
2. Evaluate surfaces such as the abdomen and medial surfaces of the arms rst.
3. Compare these areas to areas that are covered with hair.
N
Skin should normally feel smooth, even and rm, except where there is
signicant hair growth. A certain amount of roughness can be normal.
Roughness can occur on exposed areas such as the elbows, the soles of the feet
A
and the palms of the hands.
Roughness can be due to wool clothing, cold weather, occupational exposures,
P
or the use of soap. In addition, generalised roughness can be associated with
systemic diseases such as scleroderma, hypothyroidism and amyloidosis.
Localised thickening and roughness can be a result of chronic pruritus
(
lichenication) due to scratching, which causes a thickening of the
epidermis.
Areas of hyperkeratosis and increased roughness that are found in the lower
A
extremities are abnormal.
This type of texture change may be indicative of peripheral vascular disease,
P
which causes abated circulation and diminished nourishment of cutaneous
layers.
The skin can feel very soft and silk-like.
A
Generalised softness can result from hyperthyroidism secondary to elevated
P
metabolism.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
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