OS 203: Skin, Muscles, Bones

History and Physical Examination of the Integumentary System Clarita C. Maao, MD, MP, FPDS
I. II. Outline Introduction Primary or Elemental Lesions A. Basic Lesions B. Modified Lesions C. Special Lesions Secondary Lesions A. Scale B. Crust C. Excoriation D. Lichenification E. Erosion F. Ulceration G. Pigmentation H. Fissure I. Atrophy J. Scar Distribution A. Extent of Involvement B. Pattern C. Characteristic Patterns of Distribution Arrangement A. Annular B. Grouped C. Linear D. Zosteriform E. Confluent F. Gyrate G. Polycyclic Shape A. Round B. Oblong C. Irregular D. Pedunculated Color Texture Moisture Induration Borders A. Defined B. Poorly-defined C. Active Approach to Dermatologic Diagnosis A. Initial Clinical Impression B. Physical Examination C. Dermatologic History

EXAM 1
June 27, 2013
The diagnosis and management of common skin disorders is not particularly difficult and allows the doctor to play detective more than any other branch of medicine. The general principles and methodology used in the detection and diagnosis of skin disorders are the same as those utilized for the study of diseases in other parts of the body.

III.

Terminologies Primary or Elemental Lesions

1. Basic Lesions a. Macule Localized change in the color of the skin with no elevation or infiltration, less than 1 cm. in diameter. Ex.: Freckles b. Papule A small solid elevated lesion which may be flattopped, conical, polyhedral when related to hair follicle, smooth or scaly Less than 1 cm. diameter Ex.: Insect bites Modified Lesions a. Nodule A solid elevated lesion of the skin whose greater portion is situated deeper in the skin or subcutaneous tissue >5 mm in diameter Trichoepithelioma, Neurofibroma b. Tumor A larger and deeply circumscribed solid growth of infiltrations of the skin whether benign or malignant, whose greater portion projects above the surface of the skin c. Plaque A large flat solid elevation usually of an irregular geometric pattern Fungal lesions, Psoriasis d. Patch A large, unelevated lesion similar to a macule Birthmarks e. Cyst A closed sac lined by epidermal or adnexally-derived epithelium filled with either liquid, semisolid or keratin materials f. Vesicle A small collection of fluid either in the epidermis or between the epidermis and dermis Chickenpox, small blisters g. Bulla A collection of fluid larger than a vesicle, the roof of which may be a part of the epidermis or the whole of the epidermis Large blisters h. Pustule A superficial collection of pus in the skin, which may be formed as a result of purulent change in a vesicle Folliculits Special Lesions a. Wheal

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VII. VIII. IX. X. XI.

XII.

Introduction Skin
Part of the whole being and changes in it may reflect systemic of psychological disorders Accurate observation of the skin may therefore assist in the diagnosis of general disease Many patients with skin disease think that because their lesion is on the surface, it should be easy to diagnose and treat, any failure to do so, implies that his doctor is no good. The doctor who treats skin diseases is at a disadvantage compared with his colleagues in medicine. He deals with an organ which can be seen and felt, and it is impossible to tell somebody that he is improving when actually he is not. Few doctors, other than those who are trained for it, have confidence in their ability to diagnose and treat skin conditions, and this lack of confidence is soon conveyed to the patient.

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A transient aberration of the skin caused by edema in the dermis and surrounding capillary dilation Commonly known as hives Milium A papule of about 1-2 mm in diameter which contain sebaceous or cornified material and has no opening or communication with the outside Comedo A plug of sebum or keratin retained in a pilosebaceous follicle because of closure of its opening by esxcessive cornification May have a black dot of oxidized fat visible on its top Ex.: Whitehead, blackhead Burrow An excavation or passageway in the epidermis that is of variable length usually serpentine A characteristic sign of an animal infestation Scutulum A shallow cup-or saucer-shaped crust distinctive of favic infection Telangiectasia Grossly visible dilations of new formations of small blood vessels Hemorrhages Extravasations of blood which may be better subclassified as petecchiae, ecchymoses, varices, and hematoses Papilloma Finger-like projections

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longstanding inflammation which destroys the elasticity of the skin Atrophy Thin whitened, slightly sunken epidermis which wrinkles easily when subjected to lateral pressure Consists of epidermal or dermal tissue damage as well as skin appendages Scar A new connective tissue formation to replace destruction of the dermis and/ or subcutaneous tissue Hypertrophic (elevated); atrophic (depressed)

Distribution
a. b. Extent of involvement i. Circumscribed, Regional, Generalized Pattern i. Symmetrical, exposed areas, sites of pressure, intertriginous areas Characteristic patterns of distribution i. Scabies o webs of fingers, toes, wrists, armpits, beneath breasts, buttocks, scrotal areas, penis, thighs, peri-umbical ii. Psoriasis o scalp, elbows, knees nails, extensor surfaces iii. Photocontact dermatitis o skin exposed to sunlight, back of hands, face, V of neck, sparing area beneath the chin iv. Secondary syphilis o neck, palms, soles, mucous membranes v. Herpes zoster o unilateral dermatomal distribution o Grouped vesicles vi. Seborrheic dermatitis o scalp, eyebrows, eyelashes, nasolabial folds, post-auricular areas, glabella

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Secondary or Consecutive Lesions

a. Scale Heaped up horny layer or dead epidermis which may develop as a result of inflammatory changes May be fine, coarse, powdery, adherent, invisible brought out by gently scraping the lesion E.g. exfoliative erythroderma skin failure Crusts Result if serum, pus, blood dry on the skin Excoriation Superficial loss of skin and mucous membrane Usu. due to scratching Lichenification Thickened and infiltrated yellowish-brown or reddish brown skin with exaggerated lines or folds produced by long standing or continued external irritation Erosions A superficial loss of the epidermis down to the basal layer which heals without leaving a scar Ulceration Deeper loss of skin and mucous membranes Open sores, pressure ulcers, diabetic ulcer, tropic ulcer Pigmentation Widespread increase or decrease in melanin, but may also be used to describe large areas of discoloration due to iron pigments or foreign materials Fissure A crack in the skin extending through the upper dermis and resulting from marked drying and

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Arrangement
a. Grouped

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Linear

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Annular

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Polycyclic

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Zosteriform

Shape
a. b. c. d. Round Oblong Irregular Pedunculated

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Confluent

Color
If diffuse: brown, reddish brown, ivory white, purplish If circumscribed: red, orange, yellow, green, brown, black Scaling N.B. reddish erythematous

Texture
f. Gyrate Palpating or touching of lesions Smooth/rough Soft/doughy/firm/hard Temperature change- cold/warm

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Moisture
Wet/dry

Induration
Hardening Presence/absence Umbilicated nodules: molluscum contagiosum

Borders
Defined

Target lesions: Erythema Muiltiforme

Poorly-defined

Masklike facies: Scleroderma

Active borders

Heliotrope rash/Gottrons papules: Dermatomyositis

Unique Features
Burrows: scabies

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Discoid rash: Lupus erythermatosus

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Approach to Dermatologic Diagnosis

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Initial Clinical Impressions

Does the patient appear ill? Do a general survey of the patient

Mucous membranes Candida Steven Johnsons Syndrome j. Back Hypopigmented Psoriasis (plaques with silvery scales) k. Hands Rashes Contactant, Photocontact Dermatitis l. Feet Alipunga (Tenia pedis) Hyperkeratosis Insist on a complete examination this will provide clues to a complete diagnosis (ex. Allergic contact dermatitis secondary to nail polish may manifest in eyelids). Familiarize yourself with the terminology and type of lesion/appearance if the lesion a basis for communication and referrals. Having identified the type of lesion, learn from its distribution. Look at the arrangement of the lesions. Examine the individual affected areas as to its shape, color, texture, moisture, induration, and borders. Look for unique features.

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Dermatologic History
A dermatologic history simply completes the general medical history and should emphasize the following parts: 1. Present dermatologic illness When did the lesions start? Do the lesions itch, burn or hurt? Where on the body did it start? How has it spread? Are the lesions transient or consistently there? Did you have similar lesions before? How have the individual lesions changed? What factors aggravate the skin lesions? Are the members of the family with similar lesions? Have you applied any oil or any herbal preparations? What treatments have been tried/used? General history Did you experience fever, sweats, chills, headaches, nausea, vomiting, fatigue, anorexia, weight loss, or malaise? Review of systems Did you experience chest pain, difficulty of breathing, abdominal pain, changes in bowel movement, dysuria, hematuria, edema, or cyanosis? Any experiences of joint parts? Past Medical/Dermatological History Do you have any other illness? Have you undergone any operations? Do you have any food or drug allergy? Do you smoke, drink alcohol, or take drugs? Do you have asthma, allergic rhinitis, or eczema? Have you had history of measles, chicken pox, or other skin problems? Family medical history Do any of your family or household members have similar skin lesions?

Physical Examination
1. 2. Examine the patient preferably under daylight or in a well-lighted room and comfortable temperature and condition. In examining the skin, one evaluates in detail the following: a. Smooth skin turgor b. Intertriginous skin Armpit, neck (skin next to each other)moistureprone to fungal infection, candida c. Hairy areas Dandruff (may be due to fever, or cold weather) Parasites d. Mucous membranes Singaw e. Nails f. Hair Texture Deformities g. Scalp Alopecia areata/circular baldness (bald spot in scalp) Alopecia totalis (total scalp baldness; even eyebrow loss) Mites Acneiform eruptions Density or no. of hair strands Matted (may be caused by secretions of parasites) h. Face Acne Melasma or Chloasma faciei (hyperpigmentation) Alopecia areata (on eyebrows) Trichoepithelioma Plaques Neonatal acne

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Do any of your family members have asthma, allergic rhinitis, or eczema? Is there a history of skin cancer or any cancers in the family? Is there a history of diabetes, thyroid problems, or tubercolosis in the family? Social history What kind of work do you do? Are you frequently exposed to the sun? Do you frequently hold chemicals, detergents, or rubbing alcohol? Have you traveled to any other province or country recently? Do you frequently sleep together with the rest of the members of the family? Sexual history Are you married? Are there any extramarital sexual relationships? If you do, do your partners have similar symptoms or do they have any sexually-transmitted disease? Dermatological history checklist Any progression of the eruption since onset? Any seasonal occurrence or evidence of atpoy? Any factors which aggravate symptoms or objective signs? Any improvement when away from home or work? Any venereal contacts? Any psychosomatic contacts? Any epidemic in family or associates? Any systematic signs or symptoms? Any unusual exposure to environmental conditions?

Final Diagnosis

Background of the Individual

Final Diaganosis

Contributory/Aggravatin g Factors

END OF TRANSCRIPTION Van: I changed the order of how it was presented in class kasi parang mas logical siya for me in this way. HEHE. Anyway, sorry for being late kasi this does not have any old transes. Basahin ninyo yung mga e-books on Derma sa buddy CDs. Helpful siya!:) Good luck sa atin sa OSCE and lets all detox awesomely! Ron: Sorry din at na-late. Tingin na rin kayo ng pictures sa internet or sa mga libro, or sa ppts na inupload ni Abby Lim para mas maalala nyo yung mga terms dito. Anyway, good luck sa Derma exam! Dom-1-8

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