Skin, Hair and Nails

Question 1

Examining a lump: overview

Answer 1

Any raised lesion or lump should be inspected and palpated. Note: position, distribution, colour, shape, size, surface, edge, nature of the surrounding skin, tenderness, consistency, temperature, and mobility.

Question 2

Examining a lump: which layer is the lump in?

Answer 2

Does it move with the skin? (epidermal or dermal).
Does the skin move over the lump? (subcutis).
Does it move with muscular contraction? (muscle/tendon).
Does it move only in one direction? (tendon or nerve).
Is it immobile? (bone).

Question 3

Examining a lump: additional characteristics to consider

Answer 3

Consistency
Fluctuation
Fluid thrill
Translucency
Resonance
Pulsatility
Compressibility
Reducibility

Question 4

Examining a lump: additional characteristics to consider, consistency

Answer 4

e.g. stony, rubbery, spongy, soft.

Consistency doesn’t always correlate with composition- a fluid-filled lump will feel hard if it is tense.

Question 5

Examining a lump: additional characteristics to consider, fluctuation

Answer 5

Press one side of the lump. The other sides may protrude.

If the lump is solid, it will bulge at the opposite side only.

Question 6

Examining a lump: additional characteristics to consider, fluid thrill

Answer 6

This can only be elicited if the fluid-filled lesion is very large.
Examine by tapping on one side and feeling the impulse on the other, much as you would for ascites.

Question 7

Examining a lump: additional characteristics to consider, translucency

Answer 7

Darken the room and press a lit pen torch to one side of the lump.
It will ‘glow’, illuminating the whole lump in the presence of water, serum, fat, or lymph.
Solid lumps will not transilluminate.

Question 8

Examining a lump: additional characteristics to consider, resonance

Answer 8

Only possible to test on large lumps.

Percuss as you would any other part of the body, and listen (and feel) if the lump is hollow (gas-filled) or solid.

Question 9

Examining a lump: additional characteristics to consider, pulsatility

Answer 9

Can you feel a pulse in the lump?
Consider carefully if the pulse is transmitted from an underlying structure or if the lump itself is pulsating.
Use 2 fingers and place one on either side of the lump.
If the lump is pulsating, it will be expansile, and your fingers will move up and outwards, away from each other.
If the pulse is transmitted from a structure below, your fingers will move upwards but not outwards.

Question 10

Examining a lump: additional characteristics to consider, compressibility

Answer 10

Attempt to compress the lump until it disappears.
If this is possible, release the pressure and watch for the lump reforming.
Compressible lumps may be fluid-filled or vascular malformations.
This is not reducibility.

Question 11

Examining a lump: additional characteristics to consider, reducibility

Answer 11

A feature of hernias.
Attempt to reduce the lump by manoeuvring its contents into another space (e.g. back into the abdominal cavity).
Ask the patient to cough and watch for the lump reforming.

Question 12

Examining a lump: auscultation

Answer 12

You should always listen with a stethoscope over any large lump, you could gain important clues regarding its origin and contents.
Listen especially for: vascular bruits, bowel sounds.

Question 13

Examining an ulcer: overview

Answer 13

The approach to examining an ulcer is similar to any other skin lesion.
Consider the site and size, as well as whether there are single or multiple lesions.
Border.
Depth.
Base.
Surrounding skin.

Question 14

Examining an ulcer: border

Answer 14

Assess the morphology of the border.
Sloping: these ulcers are usually shallow and a sloping edge implies that it is healing (e.g. venous ulcers).
Punched out: this is full-thickness skin loss and typical of neuropathic ulceration and vasculitic lesions.
Undermined: these extend below the visible edge creating a ‘lip’; typical of pyoderma gangrenosum and infected ulceration such as TB.
Rolled: here, the edge is mounded but neither everted or undermined and implies proliferation of the tissues at the edge of the ulcer; base cell carcinoma typically has a rolled edge which is often described as pearly in colour with thin overlying vessels.
Everted: here the tissues at the edge of the ulcer are proliferating too fast, creating an everted lip; this is typical of neoplastic ulceration.
Most venous ulcers have a sloping order; arterial ulcers classically look ‘punched out’; pyoderma gangrenosum and some pressure sores manifest an undermined border, meaning that the process extends beneath the edges of the actual ulcer.
The border in PG also has a characteristic violaceous hue.
If there is a rolled or heaped up edge, consider the possibility of a neoplastic ulcer: most types of skin cancer and some benign neoplasms can present with ulceration.

Question 15

Examining an ulcer: depth

Answer 15

Ulcers are loosely divided into superficial and deep.

Visible bone or tendon at the base certainly implies a deep ulcer, but use your judgement.

Question 16

Examining an ulcer: base

Answer 16

Healing ulcers have granulation tissue at the base- this appears moist, beefy red, and usually forms a cobble-stoned surface.
Some ulcers will have surface slough, yellow or brown material which is sometimes mistaken for pus.

Question 17

Examining an ulcer: surrounding skin

Answer 17

Look for signs of chronic venous disease (e.g. peripheral oedema, varicose veins, haemosiderin deposition, lipodermatosclerosis, atrophie blanche) and arterial insufficiency (loss of hair, shiny, erythematous skin, cool peripheries).
Check peripheral pulses and capillary refill time if arterial disease is suspected.
Assess the quality of surrounding skin: there may be incipient ulceration elsewhere or other damage to the skin such as blistering.
Check that there is no cellulitis, but bear in mind that eczema (gravitational or contact) is very common around chronic leg ulcers.
If arterial or venous disease are possibilities, the ankle brachial pressure indices should be checked to confirm or refute an arterial component and to establish whether compression can be used safely.

Question 18

Examining an ulcer: venous ulceration

Answer 18

Venous hypertension causes fibrin to be laid down at the pericapillary cuff (lipodermatosclerosis), interfering with the delivery of nutrients to the surrounding tissues.
There may be brown discolouration (haemosiderin deposition), eczema, telangiectasia and, eventually, ulcer formation with a base of granulation tissue and serous exudate.
Venous ulcers occur at the medial or lateral malleoli especially.
These ulcers will often heal with time and care.

Question 19

Examining an ulcer: arterial ulceration

Answer 19

Along with other symptoms and signs of leg ischaemia, there may be loss of hair and toenail dystrophy.
Chronic arterial insufficiency may lead to deep, sharply defined, and painful ulcers which will not heal without intervention to restore blood supply.
Arterial ulcers especially appear on the foot or mid-shin.