Physical Diagnosis: Skin, Hair, and Nails

Anatomy and Physiology of Skin

• Skin functions: regulates body temperature, protects underlying tissues, aids in excretion, synthesizes vitamin D, and provides sensation
• Skin layers: epidermis, dermis, superficial fascia, and deep fascia
• Skin appendages: hair, nails, sebaceous glands, and sweat glands
• Hair types: vellous (fine, unpigmented) and terminal (coarser, pigmented)
• Nail function: protects distal ends of fingers and toes
• Sebaceous glands: produce fatty substances, found everywhere except palms and soles
• Sweat glands: eccrine glands (widely distributed, helps control body temperature) and apocrine glands (found in axilla and groin, stimulated by emotional stress)

Health History

• Common skin symptoms: hair loss, nail changes, rash, pruritus, moles, and growths
• Questions to ask patients:
  • Have you noticed any changes in your skin, hair, or nails?
  • Have you had any rashes, sores, or lumps?
  • Have you had any new moles?

Techniques of Examination

• Inspect the skin in a systematic order, including:
  • Anterior and posterior surfaces of the body
  • Behind the ears, axillary, under the breasts, inguinal regions, genitalia, and intergluteal crease
  • Palms and soles, web spaces (interdigital areas)
  • Hair distribution and condition
  • Nails
• Use a dermoscope in good light, preferably natural light
• Palpate the skin, noting characteristics such as:
  • Color
  • Moisture
  • Temperature
  • Texture
  • Mobility and turgor
  • Lesions

Tips for Skin Examination

• Conduct the examination in a private space with the patient's permission
• Ensure the patient is comfortable and ask if they would like a chaperone present
• Inspect and palpate the skin, using the palm of the hand and fingers
• Wash hands before and after the examination

Inspection

• Inspect skin for:
  • Rashes
  • Lesions
  • Bruises
  • Nevi
  • Color changes
  • Scars
• Inspect specific areas, including:
  • Upper and lower back
  • Shoulders, arms, and hands
  • Chest and abdomen
  • Anterior and posterior thighs and legs
  • Feet and toes
  • Axillae and inguinal areas
  • Scalp, face, and neck

Palpation

• Palpate the skin, noting:
  • Tenderness
  • Lesions
  • Temperature
  • Texture
  • Mobility and turgor
• Palpate the scalp, hair, and nails

Lesions

• Primary lesions: develop as a direct result of the disease process
• Secondary lesions: result from changes in primary lesions
• Characteristics of lesions: number, size, color, texture, shape, location, and configuration
• DANGER SIGNS: ABCDE (Asymmetry, Border irregularity, Color variation, Diameter, Elevation and Enlargement)

Evaluating the Bedbound Patient

• Bedbound patients are susceptible to skin damage and ulceration due to pressure sores
• Inspect the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels

Recording the Physical Examination

• Use sentences or phrases to describe findings, such as color, skin temperature, and nail condition

Learn about the anatomy and physiology of the skin, how to perform a correct skin examination, and identify normal and abnormal findings of skin, hair, and nails.