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276 PHYSICAL EXAMINATION
4+ Severe pitting oedema. 8 mm depression that can last more than 2 minutes.
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UNIT 2
FIGURE 8.17 Assessment of skin turgor
Turgor
E
Palpate the skin turgor, or elasticity, which reects the skin’s state of hydration.
1. Pinch a small section of the consumer’s skin between your thumb and
forenger. The anterior chest, under the clavicle, and the abdomen are
optimal areas to assess.
2. Slowly release the skin.
3. Observe the speed with which the skin returns to its original contour when
released (
N
When the skin is released, it should return to its original contour rapidly.
Decreased skin turgor is present when the skin is released and it remains
A
Figure 8.17).
pinched, and only slowly returns to its original contour.
Dehydration, or lack of uid in the tissues, is the main cause of decreased skin
P
turgor. The ageing process and scleroderma can also decrease the turgor of the
skin.
Increased turgor or tension causes the skin to return to its original contour too
A
quickly.
Increased turgor can be indicative of connective tissue disease caused by an
P
increase of granulation tissue.
Oedema
E
Palpate the skin for oedema, or accumulation of uid in the intercellular spaces.
1. Firmly imprint your thumb against a dependent portion of the body, such as
the arms, hands, legs, feet, ankles or sacrum.
2. Release the pressure.
3. Observe for an indentation on the skin.
4. Rate the degree of oedema. Pitting oedema is rated on a 4-point scale
Figure 8.18).
(
5. Check for symmetry and measure circumference of affected extremities.
0+
0 mm 2 mm 4 mm 6 mm 8 mm
0+ No pitting oedema
1+ Mild pitting oedema. 2 mm depression that disappears rapidly.
2+ Moderate pitting oedema. 4 mm depression that disappears in 10–15 seconds.
3+ Moderately severe pitting oedema. 6 mm depression that may last more than 1 minute.
FIGURE 8.18 Pitting oedema grading scale
N
Oedema is not normally present.
Oedema is present if the skin feels puffy and tight. It can be localised in one area
A
(Figure 8.19) or generalised throughout the body. There are many different types
of oedema (Table 8.2).
Localised oedema may be due to dependency; however, generalised or bilateral
P
oedema is caused by increased hydrostatic pressure, decreased capillary osmotic
AND PR EVENT ION (CDC)/ DR LYLE CON RAD.
COUR TESY OF TH E CENTER S FOR DISE ASE CONT ROL
FIGURE 8.19 Assessment of pitting
oedema
pressure, increased capillary permeability or obstruction to lymph ow. This
occurs in congestive heart failure or kidney failure.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
1+ 2+ 3+ 4+
INTEGUMENTARY 277
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TABLE 8.2 Types of oedema
TYPE DESCRIPTION
Pitting Oedema that is present when an indentation remains on the skin after applying
pressure
Non-pitting Oedema that is rm with discolouration or thickening of the skin; results when serum
proteins coagulate in tissue spaces
Angioedema Recurring episodes of noninammatory swelling of skin, brain, viscera and mucous
membranes (Figure 8.20); onset may be rapid, with resolution requiring hours to days
Dependent Localised increase of extracellular uid volume in a dependent limb or area
Inammatory Swelling due to an extracellular uid effusion into the tissue surrounding an area of
inammation
Noninammatory Swelling or effusion due to mechanical or other causes not related to congestion or
inammation
Lymphoedema Oedema due to the obstruction of a lymphatic vessel
FIGURE 8.20 Angioedema of the lips
PUTTING IT IN CONTEXT
CHAPTER 8
Evaluation of oedema
Mrs Johnstone is a 68-year-old woman with a history of asthma and diabetes. She has not
had any issues with wounds or skin concerns before. She presents to the clinic to have her
many moles assessed, and you notice her feet and ankles are signicantly swollen. Upon
asking, Mrs Johnstone says her ankles have been swollen for the last 2 days, but are not
painful. On assessment you note her left ankle oedema is 2+ and her right is 3+. She states
she has never had this before. As a healthcare professional you will need to decide what to
do next.
If the oedema is severe enough, it can prohibit the evaluation of pathological conditions
that are manifested by colouration changes. Two plus (2+) oedema warrants referral if it is
newly onset. Signicant, severe oedema (3+ to 4+) warrants immediate evaluation. In Mrs
Johnstone’s case, she would qualify for a priority referral to have this investigated. Oedema
can cause local issues with skin and limbs, but may also be a marker for cardiac concerns
as well.
Examination of the hair
Inspection
Colour
E
Inspect scalp hair, eyebrows, eyelashes and body hair for colour.
N
Hair varies from dark black to pale blond depending on the amount of melanin
present. As melanin production diminishes, hair turns grey. Hair colour may also
be chemically changed.
Patches of grey hair that are isolated or occur in conjunction with a scar are
A
abnormal.
Patches of grey hair not associated with ageing can be indicative of nerve
P
damage.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
278 PHYSICAL EXAMINATION
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UNIT 2
Distribution
E
Evaluate the distribution of hair on the body, eyebrows, face and scalp.
N
The body is covered in vellus hair. Terminal hair is found in the eyebrows,
eyelashes and scalp, and in the axilla and pubic areas after puberty. Males may
experience a certain degree of normal balding and may also develop terminal
facial and chest hair. Native Americans, Asians and those from the Pacic Rim
may have a light distribution of hair.
The absence of pubic hair, unless purposefully removed, is abnormal in the
A
adult.
Diminished or absent pubic hair may be indicative of endocrine disorders, such
P
as anterior pituitary adenomas, or chemotherapy.
Male or female pattern baldness (alopecia) may be abnormal in some
A
individuals if associated with pathology. Alopecia areata is a circumscribed bald
area (see
Androgenetic alopecia is a common, progressive hair loss that is caused by a
P
combination of genetic predisposition and androgenetic effects on the hair
follicle; however, alopecia may be secondary to chemotherapy and radiation,
infection, stress, drug reactions, lupus and traction. A pathological aetiology of
alopecia should be ruled out.
Total scalp baldness, or alopecia totalis, is abnormal.
A
Autoimmune diseases, emotional crisis, stress or heredity can cause alopecia
P
totalis.
Hair loss in linear formations is abnormal (see
A
Linear alopecia can be caused by frequent pressure on hair follicles leading to
P
their inability to produce new hair. In addition, traction alopecia can be caused
by the use of curlers and wearing the hair in a tightly pulled ponytail, whereby
traction is continually applied. This is common among individuals who wear
cornrows.
Excess facial and body hair is abnormal (see Figure 8.21C).
A
Hirsutism is manifested by excessive body hair. It is indicative of endocrine
P
disorders such as hypersecretion of adrenocortical androgens and polycystic
ovary syndrome. In women, this disorder is manifested as excess facial and chest
hair.
Hirsutism can also result as a side effect of medications such as cyclosporin.
P
Figure 8.21A).
Figure 8.21B).
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
UN IVE RSI TY.
A. Alopecia areata B. Linear alopecia developed in this man from
FIGURE 8.21 Abnormalities of the head and scalp
URTE SY OF ROBER T A. SILVER MAN, M.D., C LINICA L ASSOCI ATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
CO
C. Hirsutism caused by the drug cyclosporin
daily wearing of his military uniform cap.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
INTEGUMENTARY 279
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Areas of broken-off hairs in irregular patterns with scaliness, but no infection,
A
are abnormal (see
Trichotillomania is the manipulation of the hair by twisting and pulling, leading
P
Figure 8.21D).
to reduced hair mass. This can be an unconscious action or a sign of psychiatric
illness.
Broken-off hairs with scaliness and follicular inammation are abnormal (see
A
Figure 8.21E). The area may be painful and purulent with boggy nodules.
Tinea capitis (ringworm) is a fungal infection, frequently caused by
P
dermatophytic trichomycosis.
The scalp is covered with yellow-brown scales and crusts. The scalp may be oily.
A
Oedema may be present (see
Seborrhoeic dermatitis is caused by increased production of sebum by the scalp.
P
Figure 8.21F).
Lesions
E
1. Don gloves and lift the scalp hair by segments.
2. Evaluate the scalp for lesions or signs of infestation.
N
The scalp should be pale white to pink in light-skinned individuals and light
brown in dark-skinned individuals. There should be no signs of infestation or
lesions. Seborrhoea, commonly known as dandruff, may be present.
Abnormal manifestations include head lice.
A
Head lice (pediculosis capitis) may be distinguished from dandruff in that
P
dandruff can be easily removed from the scalp or hair, whereas nits (see
8.21G
), which are the lice larvae, are attached to the hair shaft and are difcult to
remove. Both seborrhoea and head lice may cause itching.
Figure
CHAPTER 8
D. Trichotillomania
F. Seborrhoeic dermatitis
FIGURE 8.21 continued Abnormalities of the head and scalp
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
COUR TESY OF RO BERT A. SI LVERMA N, M.D., CLI NICAL AS SOCIATE
E. Tinea capitis
URTE SY OF THE CE NTERS FO R DISEAS E CONTRO L AND
PREVENTION (CDC)/SUSAN LINDSLEY
CO
G. Head lice
URTE SY OF ROBE RT A. SILVE RMAN, M. D., CLINIC AL ASSO CIATE
CO
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
ALAMY STOCK PHOTO/BLICKWINKEL
280 PHYSICAL EXAMINATION
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PUTTING IT IN CONTEXT
UNIT 2
As the school nurse in a primary school, you are asked to assess the skin of each rst-grade
student after a parent noties the school that their child has been diagnosed with school
sores. You discover that seven children have blister-like sores, some of which appear to
be lled with pus, others have extensive scab formation. As you are aware this condition is
extremely contagious, you call the affected children’s parents to pick up their children and
seek treatment. Many parents are at a loss as how to manage this issue, particularly if their
child has good hygiene practices. You know treatment is to kill the bacteria that cause the
infection, which is usually treated with topical or oral antibiotics.
> What information do you need to give to parents in this situation? (Consider
prevention-related information for children who have not yet been infected, as well as
treatment and isolation requirements based on local guidelines.)
> What are your responsibilities for the wellbeing of the entire school? Children at many
schools have segregated lunch and play areas. (Consider your responsibility here in
relation to this being a communicable condition, and one that also has stigma associated
with it.)
> What are local methods of managing an impetigo outbreak in your schools and childcare
centres?
Palpation
Texture
E
1. Palpate the hair between your ngertips.
2. Note the condition of the hair from the scalp to the end of the hair.
N
Hair may feel thin, straight, coarse, thick or curly. It should be shiny and
resilient when traction is applied and should not come out in clumps in your
hands.
Brittle hair that easily breaks off when pulled or hair that is listless and dull is
A
abnormal.
Brittle, dull hair or hair that is broken off can be indicative of malnutrition,
P
hyperthyroidism, use of chemicals such as permanents, or infections secondary
to damage of the hair follicle.
Dealing with impetigo in school-based populations (school sores)
Examination of the nails
Inspection
Colour
E
1. Inspect the ngernails and toenails, noting the colour of the nails.
2. Check capillary rell by depressing the nail until blanching occurs.
3. Release the nail and evaluate the time required for the nail to return to its
previous colour.
4. Perform a capillary rell check on all four extremities.
N
Normally, the nails have a pink cast in light-skinned individuals and are brown
in dark-skinned individuals. Capillary rell is an indicator of peripheral
circulation. Normal capillary rell may vary with age, but colour should return
to normal within 2–3 seconds.
White striations or dots in the nail bed are abnormal (Figure 8.22A).
A
Leukonychia (Mees bands) may result from trauma, infections, vascular diseases,
P
psoriasis and arsenic poisoning.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
INTEGUMENTARY 281
160°
160° or less
Diamond-
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An entire nail plate that is white is abnormal.
A
Leukonychia totalis may result from hypocalcaemia, hypochromic anaemia,
P
leprosy, hepatic cirrhosis and arsenic poisoning.
A brown colour in the nail plate is abnormal.
A
Melanonychia may result from Addison’s disease and malaria.
P
Bluish nails are abnormal.
A
Bluish nails may result from cyanosis, venous stasis, and sulfuric acid poisoning.
P
Red or brown linear streaks in the nail bed are abnormal (
A
Splinter haemorrhages can result from subacute bacterial endocarditis, mitral
P
Figure 8.22B).
stenosis, trichinosis, cirrhosis and nonspecic causes.
It is abnormal for the proximal end of the nail bed to be white and the distal
A
portion to be pink.
Lindsey’s nails (half-and-half nails) can result from chronic renal failure and
P
hypoalbuminaemia.
A yellow or white hue in a hyperkeratotic nail bed is abnormal (
A
Onychomycosis is a fungal infection of the nail.
P
Figure 8.22C).
Shape and conguration
E
1. Assess the ngernails and toenails for shape, conguration and consistency.
2. View the prole of the middle nger and evaluate the angle of the nail base
(
Figure 8.23).
3. Have the consumer bring the distal phalanges together, as illustrated in
Figure 8.24. Note the position of the nail beds in relation to each other.
N
The nail surface should be smooth and slightly rounded or at. Curved nails are
a normal variant. Nail thickness should be uniform throughout, with no
splintering or brittle edges. The angle of the nail base should be approximately
160°. Longitudinal ridging is a normal variant. There is a diamond-shaped
opening at the base of the nail beds in nails that are normal when assessed,
as in
Figure 8.24.
CHAPTER 8
A. Leukonychia B. Splinter haemorrhages
FIGURE 8.22 Abnormal colour changes of the nail bed
A. Normal nail angle B. Curved nail variant of normal
FIGURE 8.23 Evaluate the angle of the nail base
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
C. Onychomycosis
shaped
opening
FIGURE 8.24 Assess the conguration of the nail beds
COUR TESY OF RO BERT A. SI LVERMA N, M.D., CLI NICAL AS SOCIATE
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN UNIVERSITY.
282 PHYSICAL EXAMINATION
180°
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UNIT 2
An angle of the nail base greater than 160°, along with sponginess of the nail
A
bed, is abnormal.
Nail beds that do not meet medially and do not have a diamond-shaped opening
A
at their base are abnormal (Figure 8.25).
Clubbing can result from longstanding hypoxia and lung cancer.
P
Thin nail plates with cuplike depressions and concave, or spoon-shaped, nails
A
are abnormal (see
Koilonychia can result from iron deciency anaemia, chronic infections,
P
Figure 8.26A).
malnutrition or Raynaud’s disease.
Separation of the nail from the nail bed is abnormal.
A
Onycholysis can result from hypo- and hyperthyroidism, repeated trauma,
P
Raynaud’s disease, syphilis, eczema and acrocyanosis.
Painful, red swelling of the nail fold is abnormal (
A
Paronychia can be caused by Candida albicans, bacteria, and repeated exposure of
P
Figure 8.26B).
the nails to moisture.
Purpura or ecchymosis under the nail plate is abnormal (
A
Subungual haematoma is caused by trauma to the digit and nail, leading to
P
Figure 8.26C).
haemorrhage into the matrix and nail bed.
The distal portion of the nail plate may become embedded in periungual tissues
A
Figure 8.26D). The periungual tissues may become inamed and have purulent
(
discharge.
Onychocryptosis (ingrown nail) is caused by growth of the distal nail plate into
P
periungual tissues, secondary to increased lateral nail pressure, resulting in
trauma to the tissues.
Nails that become white, thin and curved under the free edge are abnormal.
A
A. Early clubbing
FIGURE 8.25 Clubbing
A. Koilonychia
FIGURE 8.26 Examples of abnormalities of the shape and conguration of the nail
OF PEDIATRICS, GEORGETOWN UNIVERSITY.
COUR TESY OF ROB ERT A. SILV ERMAN, M. D.,
B. Clubbing seen from a lateral view
B. Paronychia C. Subungual haematoma
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
CLINI CAL ASS OCIATE PROFESS OR, DEPAR TMENT
C. Established clubbing
INTEGUMENTARY 283
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Eggshell nails may be caused by systemic diseases, medications, dietary
P
deciencies, nervous disorders or sleeping with the hand sted.
Nails that atrophy, shrink and fall off are abnormal (Figure 8.26E).
A
Onychatrophia may result from injury to the nail matrix and from systemic
P
diseases.
Nails that
A
hypertrophy (become abnormally thick and overgrown) are
abnormal.
Onychauxis is caused by systemic infection, electrolyte imbalance and hereditary
P
predisposition.
A nail that is split or brittle with lengthwise ridges is abnormal (
A
Onychorrhexis may result from trauma to the nail, toxic exposure to solvents or
P
Figure 8.26F).
harsh nail ling.
Palpation
Texture
E
1. Palpate the nail base between your thumb and index nger.
2. Note the consistency.
N
The nail base should be rm on palpation.
A spongy nail base is an early indication of clubbing.
A
Clubbing is the result of impaired tissue oxygenation over a prolonged period of
P
time, as in chronic bronchitis, emphysema and heart disease. See Chapters 13
and 14 for further information.
CHAPTER 8
D. Ingrown nail
FIGURE 8.26 continued Examples of abnormalities of the shape and conguration of the nail
EVALUATION OF HEALTH ASSESSMENT AND
PHYSICAL EXAMINATION FINDINGS
In the evaluation phase of a health assessment, the focus is on ensuring the data
gathered is complete, accurate and documented appropriately (see case study as
an example of the focused assessment; see Chapter 22 for a comprehensive health
assessment). In evaluating the data you should:
> draw on your critical thinking and problem-solving skills to make sound clinical
decisions
> act on abnormal data (include communicating ndings to other health
professionals)
> ensure documentation reects the outcomes of the clinical decisions/actions
taken. (Refer to Chapter 3, which discusses in detail why documentation is so
important and how this may be undertaken in different health settings.)
The case study that follows steps you through this process.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
E. Onychatrophia
F. Onychorrhexis
PROFESSOR, DEPARTMENT OF PEDIATRICS, GEORGETOWN
COUR TESY OF ROB ERT A. SILV ERMAN, M .D., CLINIC AL ASSO CIATE
UN IVE RSI TY.
284 PHYSICAL EXAMINATION
UNIT 2
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THE CONSUMER WITH HERPES ZOSTER
This case study illustrates the application and objective
documentation of the skin, hair and nails assessment.
Mrs Amrita Singh presents with an abdominal rash.
HEALTH HISTORY
CONSUMER PROFILE 62-year-old married female of Indian descent (identies as Hindi)
CHIEF COMPLAINT ‘I have this painful rash on my lower belly.’
HISTORY OF THE PRESENT
ILLNESS
CASE STUDY
PAST HEALTH HISTORY MEDICAL HISTORY Hypothyroidism, age 52
Four days ago, Mrs Singh reported burning right lower quadrant (RLQ) pain, malaise, and a 37.5°C temperature.
The pain started as a 1–2/10 and progressed over the next 24 hours to 8/10. She denied radiation of pain,
or nausea, vomiting, diarrhoea, constipation. She denies history of Crohn’s disease, ulcerative colitis, and
diverticulitis; and still has appendix. Ibuprofen did not help the pain. Nothing made the pain worse. Consumer
was concerned and went to the local ED, fearful of appendicitis. She had blood work and an abdominal CT scan,
which were negative. Consumer was sent home with instructions to follow up with her GP. Last night, Mrs Singh
noted a rash on her lower abdomen and presents today for evaluation.
Malaria, age 35 and multiple times since
Eczema since age 12
SURGICAL HISTORY Nil
ALLERGIES Denies medication, bee sting/insect, food and environmental
MEDICATIONS Levothyroxine 100mcg orally in the morning
Hydrocortisone valerate 0.2% cream BD prn to affected areas
++
500mg orally BD prn
Ca
Ibuprofen 200–600mg orally prn 6 hourly
COMMUNICABLE DISEASES Denies
INJURIES AND ACCIDENTS Wrist fracture age 12 when she fell jumping over a ditch, grew up in
remote area of India, little access to health care; mother ‘made’ up a
splint for her; never had medical care for the fracture
SPECIAL NEEDS Denies
BLOOD TRANSFUSIONS Denies
CHILDHOOD ILLNESSES Not sure – had a few illnesses with rashes and fever
IMMUNISATIONS No immunisations as a child due to economic status; believes she was
fully immunised at age 26 when she immigrated to Australia with her
husband.
SOCIAL HISTORY ALCOHOL USE Denies
TOBACCO USE Denies
DRUG USE Denies
DOMESTIC AND INTIMATE
PARTNER VIOLENCE
SEXUAL PRACTICE Husband of 40 years only partner
TRAVEL HISTORY Mrs Singh has often visited poorer parts of India during her adult life, and
States she was ‘hit with a stick’ or st (demonstrates closed st) by her
father growing up; he would frequently ‘discipline’ her and her siblings,
and became angry easily with all his children and his wife; denies sexual
abuse
grew up in very poor area with few amenities.
>>
INTEGUMENTARY 285
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>>
HEALTH HISTORY
WORK ENVIRONMENT She lived in India until her mid-20s, working with her father’s animals and
farming, then with her husband’s family in the food markets in Delhi. Often,
she was miles from public transportation and medical care. Once she
immigrated to Australia, she cared for home and children, but visited India
often to care for older relatives and assist her husband’s family business
importing foods to Australia and New Zealand.
HOME ENVIRONMENT Currently resides in an older 1-level house with all modern appliances;
has lived in various houses throughout her life, ranging from mud-hut
houses, to wooden houses with no running water or any appliances
CHAPTER 8
HOBBIES AND LEISURE
ACTIVITIES
STRESS Has extended family who want to immigrate to Australia to live with
EDUCATION Primary school year 5 equivalent, but undertook some night classes in
ECONOMIC STATUS ‘We are comfortable and have everything we need, but I am not sure we
MILITARY SERVICE Denies
RELIGION Hindi
CULTURAL BACKGROUND Indian (Kutch region)
ROLES AND RELATIONSHIPS Married for 40 years to husband. ‘He is a wonderful husband. I am very
Enjoys cooking for family, watching television and reading
her and her husband and family, but is concerned about being able to
cope with the extra people and expense, even though she feels obliged
to assist. ‘I am required to help them, all our family, my husband has
promised.’
Australia once immigrated for language, numeracy and literacy
can support all our family if they move to Australia.’
lucky; other girls in my village did not have such a good match. Now we
live here in Australia and my children have many opportunities we did
not have in my village.’ Enjoys relationships with 4 daughters and one son
and her 3 grandchildren, who live within 10km of her house. Her youngest
daughter still resides at home – this causes some issues with her and her
husband as this daughter does not want to marry or study, but wishes to
travel around the world, doing work that allows her to come and go as
she pleases.
HEALTH MAINTENANCE
ACTIVITIES
CHARACTERISTIC PATTERNS OF
DAILY LIVING
SLEEP Has difculty falling asleep and staying asleep; never tried any sleep aid
DIET Mostly Indian food, some meat but prefers vegetables and rice, curries
EXERCISE Walks 30–60 minutes daily, weather permitting
STRESS MANAGEMENT ‘I pray.’
USE OF SAFETY DEVICES Wears seat belt
HEALTH CHECK-UPS ‘In the past, I always had medical checks when we came home from
States her schedule changes daily. The most important times of her day
are the time she spends caring for her family.
and savouries
India; now, I just seek medical care when I am sick ... really sick.’
>>
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