Clinical Skills Skin Hair Nails etc.

Visual, palpation, pt interview

Goals:
1. identify lesion
2. det possible cause
3. refer to MD when appropriate

Visual inspection:
1. uniformity, color
2. presence of lesion:
-type, shape, single or mult, local or generalized, discolored?

Palpation:
does skin blanche (redness goes away & comes back)
solid or fluid?
warmth?

NOT all lesions should be palpated esp if inflamm present

when did it begin?
where appeared first?
has it changed? how?
pain or tenderness? pruritis?
was there a trigger?
treatment tried? successful?

5 causes
1. inflamm
2. infectious
3. infestations
4. cutaneous drug rxn
5. skin cancer

Primary: arise from normal skin, can be flat & non-palpable to elevated solid or fluid filled

Macule: flat lesion (freckle)

Papule: solid elevated, >0.5cm

Plaque: flat elevated larger than 1cm (a bunch of papules)

nodule: greater than 0.5cm in width and depth, deeper and firmer than papule (lymph nodes)

Wheal: transitory papule/plaque due to edema, hives or urticaria

vesicle: blister less than 0.5cm, fluid filled

Bulla: blister more than 0.5cm, fluid filled

Pustule: vesicle filled with pus

results from changes in primary lesion, loss of skin surface.

Crust: exudate from a lesion that has dried on the skin (scab)

Scale: aggregate of loose hyperkeratotic cells - usually appear white and dry ie psoriasis

Fissure: a thin tear of epidermis.. may extend to dermis

Erosion: wider than fissure but limited to epidermis

Ulcer: destruction of epidermis w/ or w/o dermal injury that exposes dermis

lesions, rash, develop due to a sub in contact w/ skin

irritant: ie soaps, detergents, acid, base, cosmetics (within hours of exposure)

Allergic: plant resins, metal, latex (takes days to dev)

inflamm affecting butt, genitalia, perineum
affects children and adults

Diapers hold moisture and fecal matter against skin... can present as patches, vesicles, erosions, and possible ulcerations

disseminated rash (macules) that progress into papules, vesicles, pustules, and crust

transmitted via contact or airborne droplets... infection present 2days before onset until vesicles form crust

affects elderly (65yo) and immune compromised pts.

vesicular lesions w/ erythema confined to a single area of skin
often have neuropathic pain. Antiviral therapy may be necessary

cutaneous BACTERIAL infection (staph aureus and strep species)

Mainly affects kids. Transmitted by break in skin, poor hygiene, humid environment etc

Present as vesicles and/or pustules around NOSE AND MOUTH

Ecthyma is severe ulcerative impetigo

Candidiasis: infections due to Candida albicans -- part of normal flora in skin, GI, vagina

occurs in warm moist areas of skin: groin, toes, axillae

erythemetous patches w/ scaling; vesicles = severe

fungi that live on dead keratinized cells of epidermis

can infect skin, hair, nails

lesions vary according to site

tinea capitis = scalp
tinea corporis = (ring worm) body
tinea cruris = genitalia
tinea faciale = face/neck
tinea manus = hands
tinea pedis = feet
tinea unguium = nails

louse borne infestations: lice

intense pruritis

all drugs can cause these rxns (2-3% hospitalized pt)

topical is most common

Types:
1. urticaria, angioedema, anaphylaxis
2. exanthematous eruption
3. fixed eruptions
4. stevens johnson syndrome
5. photosensitivity

ass. w/ food & drug allergies

rapid onset (hrs)

Can be severe = anaphylaxis [hypotension, flushing, diff breathing]

Urticaria = large wheals (hives) and pruritis

subsides within 24hr of removing offending agent

ass. w/ drug allergies
delayed onset (2days - 3 weeks)

extensive rash w/ macules and papules
symmetrically on trunk and extremities

subsides in 2-3days

ass. w/ drug or food allergies

single lesion w/ erythema - progress from macule to bulla
onset within 8hrs of drug/food

lesion remains as long as exposure continues.

most ass. w/ drug therapy

lesions widespread, incl mucous membrane. Rash leads to sloughing of the epidermis, appears similar to 3rd degree burns. Must prevent/treat infections of lesions.

Toxic epidermal necrolysis = most severe

Basal Cell; Squamous Cell; Melanoma

tumor of basal epidermal layer

presents as single shiny paple or nodule; could be ulcerative

tumor arising from outer epidermal layer

presents as single lesion, red scaly elevated, may become ulcerative. can grow large and metastasize

Malignant tumor of melanocytes
can arise from preexisting moles or new lesions.

Asymmetry
Border irregular
Color changed/mottled
Diameter >6mm
Enlargement over time

visual inspection: uniformity, texture, color

Interview:
when did the abnormality begin?
where did it first appear?
has it changed? how?
pain? tenderness?
treatment? successful?

-infected hair follicle by:
bacteria: staph aureus, pseud aerugin
fungal: dermatophytes

-deep seated folliculitis (furuncle, boil)
coalescene of furuncles = carbuncle
often caused by S.aureus MRSA

-Loss of hair: localized, entire scalp, eyebrows, entire body

Causes: anemia, chem toxins, hereditary, infection, drugs, endocrine disorders

Male pattern of hair on women

Causes: uncommon adrenal, endocrine, ovarian disorders

Inspection: evaluate for uniformity, shape, color, growth, swelling, infl, trauma, tenderness

Interview:
when did the abnormality begin?
where did it first appear?
has it changed? how?
pain? tenderness?
treatment? successful?

fungal infection of nail: candida

presents: thickened cracking nail; rising of nail from nail bed; yellowish

Changes in vision, onset?
blurry vision or diff seeing?
redness, itchiness?
discharge?
trauma to eye, irritant?
relatives w/ conjunctivitis?
recent cold, sinus infection or flu?

inspect eye and accessory structures
-position, shape, color, symmetry, movement

examine pupil: equal, round, reactive to light

examine extraoccular muscles: extra-ocular muscles intact, eye movement should be parallel

Visual acuity: vision chart

Visual fields: peripheral vision test

Palpation of eye: evaluate eye integrity and structure

Opthalmoscopic exam: evaluate retina and optic disc

open angle or closed angle
-ass. w/ optic neuropathy
-result of ocular pressure

infection and or inflamm of conjunctivae via bacterial, viral or allergy

accompanied by discharge; thin and clear (allergic or viral) OR thick and purulent (bacterial)

1. wash hands, stand at mirror
2. tilt head back, pull down lower lid of eye with index finger
3. squeeze dropper so that the correct number of drops fall into eye
4. close eye for 2-3min, tip head down as though looking at floor
5. repeat in the other eye if the drop is prescribed for both eyes
6. if prescribed for more than 1drop wait ~5min in btw

changes in hearing? onset? redness? pain? discharge? trauma? irritant? relatives with otitis? young kids? recent cold, sinus infection or flu?

symmetrical, size, placement
no redness or inflamm
no lesions or discharge
presence of cerumen (ear wax) not excessive

Palpation: free from pain or tenderness; no lesions or enlarged lymph nodes

visualize the auditory canal and tympanic membrane -- free of redness swelling inflamm, lesions foreign bodies discharge

test for hearing loss;

Cause: chronic otitis media, aging, meds

acute otitis media (bacterial or viral)
otitis media w/ effusion

Otitis externa:
inflamm and infection of auditory canal; result from long exposure to moisture (swimmer's ears); ear drops used to treat

1. wash hands
2. warm the drops by holding bottle in hand for a few min.
3. if drops are cloudy, shake well for 10sec
4. draw medication into dropper, or hold dropper top bottle w. dropper tip down
5. tilt affected ear up or lie on your side
6. pull ear back and up for adults ----kids younger than 3yo pull back and down! to open ear canal
7. place correct # of drops into ear
8. replace cap or dropper into bottle (do not rinse or wipe off)
9. gently press on ear flap and keep head tilted up for several mins or insert cotton plug in your ear to the medicine coat your ear

facial pain? location? congestion? discharge? rhinorrhea? history of allergies? fam history? time of year? meds? rebound nasal congestion?

Nares oval and symmetric; columella present at midline

Nasal cavity and mucosa: no inflamm; drainage or lesions

Sinuses: no facial swelling
palpate --> no pain or tenderness

acute or chronic sinus infection
systemic antibiotic used to treat and intranasal decongestants

inflamm condition caused by inhaled allergenic materials
seasonal or perennial
fam history is common
use intranasal agents for relief and prevention

1. wash hands
2. blow nose before using spray
3. insert bottle tip into one nostril. press on the other side of your nose with one finger to close it off.
4. keep head upright
5. breathe in quickly while squeezing the bottle
6. repeat in other nostril