Chapter 6: Skin, Hair, and Nails Flashcards
Physical Exam Components: Skin
Perform overall inspection of entire skin surface.
During evaluation of each organ system, evaluate the overlying skin for color, uniformity, thickness, symmetry, hygiene, lesions, odors.
Palpate skin surfaces for the following:
Moisture
Temperature
Texture
Turgor
Elasticity
Physical Exam Components: Hair
Inspect hair for the following:
Color
Distribution
Density
Palpate hair for texture and fragility.
Physical Exam Components: Nails
Inspect for pigmentation of nail plates and nail beds; length; symmetry; surface changes (ridging, beading, pitting, peeling).
Inspect and palpate proximal and lateral nail folds for redness, swelling, pain, exudate, growths (warts, cysts, tumors), shape of lunulae.
Palpate nail plate for texture, firmness, thickness, uniformity, adherence to nail bed.
Measure nail base angle.
Observe the cuticles for color, vasculature, integrity.
Anatomy & Physiology: Skin Functions
The skin performs integral functions:
Protects against microbial/foreign substance invasion and minor physical trauma
Restricts body fluid loss; provides a restrictive barrier
Regulates body temperature
Provides sensory perception via free nerve endings and specialized receptors
Produces vitamin D from precursors in the skin
Contributes to blood pressure regulation through constriction of skin blood vessels
Repairs surface wounds by exaggerating the normal process of cell replacement
Excretes sweat, urea, and lactic acid
Expresses emotions
Anatomy & Physiology: Skin Layers
Epidermis: outer most layer
Includes stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale
Dermis: connective tissue layer
Elastin, collagen, reticulin fibers, sensory nerve fibers, autonomic motor nerve
Hypodermis: subcutaneous layer
Heat, insulation, shock absorption, reserve of calories
Appendages
Eccrine and apocrine sweat glands, sebaceous glands, hair, nails
Anatomy & Physiology: Infants and Children
Vernix caseosa, a mixture of sebum and cornified epidermis, covers the newborn’s body at birth.
Subcutaneous fat is poorly developed in newborns, predisposing them to hypothermia.
Lanugo is the fine silky hair that covers the newborn’s body, particularly on the shoulders and back.
Desquamation of stratum corneum may be present at birth or very shortly afterward.
Eccrine glands function after 1 month.
Apocrine glands do not function.
Anatomy & Physiology: Adolescents
Apocrine glands enlarge and become active. Increased axillary sweating and body odor
Increased sebum production in response to increased hormone levels, primarily androgen. Oily appearance predisposing the individual to acne
Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents, and on the face of males.
Anatomy & Physiology: Pregnant Patients
Increased blood flow to skin, especially that of the hands and feet, results from peripheral vasodilation and increased numbers of capillaries.
Acceleration of sweat and sebaceous gland activity occurs.
Spider angiomas and cherry hemangiomas that are present may increase in size.
Skin thickens; fat is deposited in subdermal layers.
Skin stretching, increased pigmentation, nevi changes
Anatomy & Physiology: Older Adults
Sebaceous and sweat gland activity decreases: results in dry skin and less perspiration.
Epidermis thins and fragility increases.
Loss of collagen and decreasing elasticity causes wrinkles.
Subcutaneous tissue decreases.
Gray hair from decreased melanocytes occurs.
Scalp and body hair decrease; baldness.
Facial hair develops in women.
Nail growth slows.
History of Present Illness: Skin
Changes in skin
Temporal sequence
Symptoms
Location
Associated symptoms
Recent exposure
Apparent cause
Travel history
Treatment response
Adjustment to problem
Medications
Trauma
Bites
History of Present Illness: Hair
Changes in hair
Occurrence
Associated symptoms
Exposure
Infestation
Nutrition
Treatment
Adjustment
Medication
History of Present Illness: Nails
Changes in nails
Recent history
Associated symptoms
Temporal sequence
Exposure
Treatment response
Medications
Past Medical History: Skin and Hair
Skin
Previous skin problems
Lesions, treatments
Tolerance to sunlight, number of sunburns
Diminished or heightened sensitivity to touch
Cardiac, respiratory, liver, endocrine, or other systemic disease
Pruritis
Hair
Previous hair problems
Systemic problems
Past Medical History: Nails
Previous nail problems
Nail injury
Bacterial, fungal, or viral infection
Systemic problems
Associated skin disorder
Congenital anomalies
Respiratory, cardiac, endocrine, hematologic, or other systemic diseases
Past Medical History: family
Current or past dermatologic diseases or disorders in family members
Allergic hereditary diseases: asthma, allergic rhinitis
Familial hair loss or pigmentation patterns
Past Medical History: personal and social history
Skin, hair, nail care habits
Skin self-examination
Exposure to environmental/occupational hazards
Recent psychologic or physical stress
Use of alcohol, tobacco, or recreational drugs
Sexual history
History for Infants
Temperature
Nutrition/feeding habits
Allergies
Birthmarks
Common rashes
Worrisome rashes
Bathing/hygiene practices
Sun exposure; sunscreen use
Appropriate attire
Temperature/humidity of home
History for Children and Adolescents
Eating habits and types of food
Food allergies
Allergic disorders
Sun exposure
Exposure to infectious diseases; rashes
Pets or animal exposure
Outdoor exposures
Skin injury history
Chronic hair-pulling or manipulation
Nail-biting
History for Pregnant Patients
Weeks of gestation or postpartum
Hygiene practices
Presence of skin problems before pregnancy
Effects of pregnancy on preexisting conditions
Rashes
History for Older Adults
Increased or decreased sensation to touch or the environment
Changes in skin with aging
Generalized chronic itching, irritants
Susceptibility to skin infections
Healing response: delayed or interrupted
Frequent falls: cuts, bruises
History of chronic medical conditions
Medications and polypharmacy
Physical Examination: Skin Inspection
Adequate lighting is essential.
Body sweep
Exposure
Draping
Color and uniform appearance
Skin lesions
Thickness
Symmetry
Hygiene
Physical Examination: Skin Palpation
Moisture
Minimal perspiration or oiliness should be present.
Temperature
Use the dorsal surface of your hands or fingers
Texture
Smooth, soft, and even
Turgor
Altered if the patient is substantially dehydrated or if edema is present
Elasticity
Moves easily when pinched, and returns to place immediately when released
Physical Examination: Skin Lesions
Characteristics:
Size (measure all dimensions)
Shape
Color
Blanching
Texture
Elevation or depression
Attachment at base
Exudates
Configuration
Location and distribution
Physical Examination: Hair Inspection and Palpation
Inspection
Texture
Color
Distribution
Quantity
Palpation
Texture
Lesions
Physical Examination: Nail Inspection and Palpation
Inspection
Color
Length
Configuration
Symmetry
Cleanliness
Palpation
Hardness
Smoothness
Thickness
Adhesion to nail bed
Infants and children skin inspection/palpation
Expected color changes
Jaundice or hyperbilirubinemia
Birthmarks
Lesions/defects associated with systemic conditions
Contour distortions
Skin creases indicating congenital abnormalities
Pinch skin for test of turgor
Blanching
Adolescents skin inspection
Examination is same as for adults.
Increased oiliness and perspiration
Acne
Maturational changes
Physical Examination: Pregnant Patients
Skin inspection:
Striae gravidarum (stretch marks)
Telangiectasias/hemangiomas
Cutaneous tags
Increased pigmentation
Palmar erythema
Itching
Altered hair growth
Physical Examination: Older Adults
Inspect for:
Skin changes
Breakdown over bony prominences
Lesions
Hair changes
Nail changes
Skin: Inflammatory and Infectious Conditions
Eczematous dermatitis
Most common inflammatory skin disorder
Irritant contact dermatitis
Allergic contact dermatitis
Atopic dermatitis
Folliculitis
Inflammation and infection of the hair follicle and surrounding dermis
Furuncle (boil)
Deep-seated infection of the pilosebaceous unit
Cellulitis
Diffuse, acute, infection of the skin and subcutaneous tissue
Tinea (dermatophytosis)
Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair
Pityriasis rosea
Self-limiting inflammation of unknown cause
Psoriasis
Chronic and recurrent disease of keratinocyte proliferation
Rosacea
Chronic inflammatory skin disorder
Herpes zoster (shingles)
Varicella-zoster viral infection
Herpes simplex
Type 1: associated with oral infection
Type 2: associated with genital infection
Tick-borne diseases that can lead to multisystemic failure
Lyme disease
Rocky Mountain Spotted Fever
Colorado Tick Fever
Skin: Cutaneous Reactions
Drug eruptions
Cutaneous reactions to medications
Acanthosis nigricans
Nonspecific reaction pattern associated with obesity, certain endocrine syndromes or malignancies, or as an inherited disorder
Skin: Malignant/Neoplastic
Basal cell carcinoma
Most common form of skin cancer
Squamous cell carcinoma
Second most common skin cancer
Malignant melanoma
Lethal form of skin cancer that develops from melanocytes
Kaposi sarcoma
Neoplasm of the endothelium and epithelial layer of the skin
Commonly associated with human immunodeficiency virus (HIV) infection
Hair Disorders
Alopecia areata
Sudden, rapid, coin-shaped loss of hair, usually from the scalp or face
Scarring alopecia
Replacement of hair follicles with scar tissue
Traction alopecia
Hair loss that is the result of prolonged, tightly pulled hairstyles
Hirsutism
Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas
Nails: Infection
Paronychia
Inflammation of the paronychium
Onychomycosis
Fungal infection of the nail
Nails: Injury
Ingrown nails
Nail pierces lateral nail fold; grows into the dermis
Nail avulsion
Subungual hematoma
Trauma to the nail plate severe enough to cause immediate bleeding and pain
Onycholysis
Loosening of the nail plate from the nail bed that begins at the distal groove
Nails: Changes Associated With Systemic Disease
Koilonychia (spoon nails)
Central depression of the nail with lateral elevation of the nail plate
Beau lines
Transverse depression in the nail bed
White banding (Terry nails)
Whitening of the proximal half to three-quarters of the nail bed
Psoriasis
Chronic and recurrent disease of keratinocyte proliferation
Nails: Periungual Growths
Warts
Epidermal neoplasms caused by viral infection
Digital mucous cysts
Cystlike structures that contain a clear jelly-like substance
Abnormalities in Pregnant Patients
Polymorphic eruption of pregnancy
Benign dermatosis that usually arises in the third trimester of a first pregnancy
Abnormalities in Infants and Children
Seborrheic dermatitis
Chronic, recurrent, erythematous scaling eruption localized in areas where sebaceous glands are concentrated
Miliaria rubra (prickly heat)
Caused by blocked sweat ducts and trapped sweat beneath the skin
Newborn acne
Common childhood rashes
Impetigo
Common, contagious superficial skin infection
Acne vulgaris
Impaction and obstruction of the outflow of sebum
Chickenpox (varicella)
Acute, highly communicable disease common in children and young adults
Measles (rubeola)
Measles virus infects by invasion of the respiratory epithelium
German measles (rubella)
Mild, febrile, highly communicable viral disease
Hair-pulling (trichotillomania)
Loss of scalp hair caused by physical manipulation
Patterns of injury in physical abuse
Bruises, burns, lacerations, hair loss, anogenital warts (under 2 years of age)
Abnormalities in Older Adults
Stasis dermatitis
Occurs on the lower legs in some patients with venous insufficiency
Actinic keratosis
Atypical squamous cells confined to the upper layers of epidermis
Physical abuse in older adults
Physical abuse, neglect, sexual abuse, psychologic abuse, financial abuse, violation of rights
Fluorescing lesions are best distinguished using a(n):
Incandescent lamp
Magnifying glass
Transilluminator
Wood’s lamp
ANS: D
Rationale: Fluorescing lesions (e.g., some tinea lesions) show a characteristic yellow-green color under a Wood’s lamp.
Which objective findings would you expect to see in folliculitis?
Acute onset of tender red nodule
Acute onset of papules and pustules
Pale, erythematous, and macular
Telangiectasia, erythema, and papules
ANS: B
Rationale: In folliculitis, there is an acute onset of papules and postulates associated with deep folliculitis. Primary lesions are small pasta shells 1 to 2 cm in diameter.
The adipose tissue in the hypodermis serves to:
Provide sensory input
Generate heat and insulate
Create tensile strength
Restrict water loss
ANS: B
Rationale: The hypodermis layer consists of adipose tissue that serves to generate heat and to provide insulation, shock absorption, and a reserve of calories.
Koilonychia (spoon nails) are a central depression of the nail with lateral elevation of the nail plate. This is commonly seen with which systemic diseases?
A. Iron deficiency anemia, syphilis
B. Diabetes mellitus and hypothyroidism
C. Chronic congestive heart failure and cirrhosis
D. Psoriasis and hyperthyroidism
ANS: A
Rationale: Koilonychia is associated with iron deficiency anemia, syphilis, fungal dermatosis, and hypothyroidism.
