Dermatological Examination

The importance of general examination:

• Helps to determine the most body system should be stressed during systems examination.
• With proper history the general examination may be enough to obtain the diagnosis OR a short list of diagnoses.

A. General Examination Components

1. General patient condition
2. Face
3. Fever
4. Pallor
5. Jaundice
6. Cyanosis
7. Lymph nodes enlargement
8. Hands, Digits & Nails
9. Mouth, Oral cavity & Tongue
10. Temperature
11. Pulse rate
12. Blood pressure
13. Respiratory rate

1. The general condition of the patient

• Well
• unwell
• ill
• In pain
• cachexic
• Consciousness level
• delirium
• orientation

2. Face

• A specific diagnosis can sometimes be made by inspecting the face

1. Acromegalic
2. Down Syndrome
3. Cushingoid
4. Parkinsonian

2. Fever

• High grade fever
• In history if it is there should be analyzed regarding its course (continuous, intermittent, remittent), association (rigors, sweating), timing (nocturnal), reliving (antipyretic drugs)

3. Pallor

• Indicates anemia (low hemoglobin concentration)
• Skin, mucous membranes

4. Jaundice

• Yellowish discoloration of the sclera of the eyes, mucous membrane, and skin
• Types of jaundice ?
  1. Prehepatic
  2. Hepatic
  3. Post hepatic
• If it is associated with pallor → indicates prehepatic
• if it is associated with pruritus → indicates post hepatic
• If it is associated with fever → may indicates hepatic (viral hepatitis )

5- Cyanosis

• Bluish discoloration of the extremities and tongue
• If more than 50 g/L of deoxygenated hemoglobin is present in the capillary blood, the skin will have a bluish tinge.
• If the tongue is involved → central (cardiopulmonary) cyanosis
• If the digits only involved → peripheral (vasoconstriction) cyanosis
• Raynaud’s phenomena → connective tissue diseases
• Can cyanosis and pallor concomitant together in the same patient?

6- Lymphadenopathy

Complete examination of all LN groups

1. Localized
2. Generalize
3. Discrete or Matted
4. Tender
   • If it is generalized and associated with pallor $\to$ may indicates lymphoma
   • If it is tender $\to$ may indicates infections

7- Hands, Digits and Nails

• Tremors
• Fine of stretched hands→ hyperthyroidism
• Rest tremors → Parkinsonism
• Intention tremors→ cerebellar ataxia
• Sweating and erythema → hyperthyroidism

• Digits bluish discoloration and ulcers→ Raynaud’s phenomenon as part of scleroderma

• Nail changes may indicate dermatological or systemic diseases

• Dermatological changes might be due nail infection as onycholysis or a part of generalized dermatological diseases as psoriasis or lichen planus

• Clubbing fingers → chronic diseases (pulmonary , hepatic ,cardiac, )

koilonychia

Clinical Presentation of Moderate to Severe Fingernail Psoriasis

Nail Matrix Features

• Pitting
• Leukonychia
• Crumbling

Nail Bed Features

• Subungual hyperkeratosis
• Onycholysis
• Splinter hemorrhages

Clubbed fingers

10- Mouth, Oral cavity & tongue

• Angular cheilitis → anemia
• Smooth tongue →
• Hairy tongue→
• Deviation of the tongue→
• Ulcers →
• Ulceration of the mucous membranes→
• Dental cavities →
• Leukoplakia →

Angular cheilitis

13. Temperature

Measure the core temperature using thermometers

1. Digital
2. Mercury Sites
3. Mouth → 36.8 c
4. Axilla → 36. 4 c
5. Rectum → 37.3 c

14. Pulse Rate

• Peripheral arteries ➤ Carotid arteries ➤ Upper extremities→ radial , brachial , ➤ Lower extremities → femoral , popliteal , dorsalis pedis ,

• Use the index and middle finger , don’t use thumb?

• Rate → normal , tachy or bradycardia

• Regular or irregular

• Detect the character of pulse is it weak thready ,strong , synchronize , radio femoral delay

• Collapsing pulse → hyperdynamic circulations (anemia , pregnancy , thyrotoxicosis )

15- Blood Pressure

• Using the symphmomanometer (digital or mercury)
• Palpation method → systolic pressure
• It is better to use the two method simultaneously start by palpation method
• Pulse pressure → systolic pressure - diastolic pressure < 60 mmHg

16. Respiratory rate

• Count it for full minute
• Count it while you are pretending takink pulse rate to reduce patient stress ?
• Comment is it normal
• Shallow , deep , apneao , regular or irregular

17. Neck pulsation

1. Arterial
2. Venous

How we can differentiate?

B. Systems Examination

• The four gold standards of clinical examinations are:
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
• The importance and application of each standard differs from one system to other

The Importance of the Four Examination Standards in Different Systems

• General Examination $\to$ Inspection $>$ Palpation
• CVS $\to$ Auscultation $>$ Inspection $>$ Palpation $>$ Percussion
• Res $\to$ Auscultation $>$ Percussion $>$ Palpation $>$ Inspection
• GIT $\to$ Palpation $>$ Percussion $>$ Inspection $>$ Auscultation
• Muscle $\to$ Inspection $>$ Palpation
• Integumentary system $\to$ Inspection $>$ Palpation
• CNS $\to$ Inspection $>$ Palpation

The Skin Exam

• The Total Body Skin Exam (TBSE) includes inspection of the entire skin
• surface, including:

1. the scalp, hair, and nails
2. the mucous membranes of the mouth, eyes, anus, and genitals

TBSE

• Do not forget the so-called “hidden areas” - places on the skin where lesions may be easily missed

1. Conchal bowl (concavity adjacent to the external auditory meatus), auditory canal, postauricular creases
2. Medial canthi (angular junction of the eyelids), alar (nasal) grooves
3. Intergluteal cleft and perianal skin
4. Interdigital spaces

Indications for a TBSE

1- Personal history of skin cancer

2- Increased risk for melanoma I-Two first-degree relatives with melanoma II- Over 100 nevi (moles)

3- Patient with concerning or changing growth

4- New rash on body

5- New patient with undiagnosed skin condition

6- Follow-up patients with extensive skin conditions such as psoriasis

Essential elements for the skin exam

• Adequate lighting
• Undressed patient, in a gown - Preferably without makeup, watches, jewelry
• Privacy
• Ruler
• Magnifying glass
• An open mind about what you are seeing

Getting started

1- Lighting

• The skin exam should be performed with adequate lighting
  • natural sunlight is best
  • if windows are in the exam room, open the blinds
  • the best artificial source is high-intensity incandescent light
• If lighting is too low, turn on as many lights as possible and position the patient directly under available lights

2- Undressed patient

• You cannot diagnose what you cannot see
• Before starting the skin exam, ask the patient to undress to their bra and underwear and put on a gown with the opening to the back
• Put down a chux or exam table paper so their bare feet don’t touch the floor
• Tell the patient you will step out, and ask if they would like a chaperone during the exam
  • If you expect to examine the breasts or genitalia of an opposite-gender patient, bring a chaperone regardless
• Draw the curtain and step out of the room

3- Patient modesty

• Undressed patients feel very vulnerable
• Avoid keeping them waiting too long while undressed
• Offer a second gown or blanket if it is cold
• Before untying a gown or moving it, ask permission
• Ask the patient to expose the area being examined, and cover the area after it has been examined
• Say out loud what part of the body you want to examine next
  • e.g., “Okay, now let’s look at your chest and abdomen”
  • The patient will usually move the gown accordingly

4- Sanitize your hands

• The skin exam is tactile as well as visual
• You must palpate lesions to tell if they are raised, flat, or atrophic
• Many dermatologists prefer to use gloves for moist areas (groin, axilla) or oozing, crusted lesions
• Keep hands clean and nails trimmed
• Remember to sanitize your hands before and after every skin exam

Tools we use

1-Ruler

• Accurately records the size of a lesion on successive examinations
• Measure in the longest axis first, then in the perpendicular axis
  • e.g., this papule is 6x4 mm

2- A penlight is used for side lighting

• Detects atrophy and fine
• wrinkling
• Distinguishes
  • Flat from raised lesions
  • Whether lesions are solid or fluid-
  • filled
• Also helps look inside the mouth