Assessment of the Integumentary System – Advanced

by Stephen Holt, MD, MS

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    00:01 Next, we're going to move on with the dermatologic exam.

    00:04 Now, this is as you might imagine a potentially very sensitive part of the exam, because we really need to see every square inch of our patient's skin.

    00:12 So, top to bottom, front to back, including orifices and any crevices, to make sure that there's nothing, no pathology in those areas, depending of course, on what exactly you're looking for.

    00:24 That will also include the scalp, the nails the mucosal surfaces etc.

    00:28 So, turning over to our patient, I would have her fully gowned and comfortable, while we're walking through each part of the exam, I wouldn't just have her sitting naked on a table, we would instead just look at each area as we need to, to protect our patient’s modesty.

    00:44 So, we'll go ahead and start with just looking at the arms, so, putting the arms out to the sides, I'm looking at the flexor surfaces of the arm and then I'll flip around and look at the extensor surfaces of the arm, knowing the regional anatomy in which particular disease processes may afflict certain areas, can help you to focus in on the focal versus the global part of the dermalogic exam.

    01:04 So, if I saw just some papules or macules, with some excoriations in her anti-cubital fossa, I'd be thinking about atopic dermatitis.

    01:12 Whereas on the extensor surfaces, I may be thinking more about something like psoriasis.

    01:16 So, attending to those areas is important.

    01:18 It's also really important that we look in the interdigital spaces there, sometimes people can even have a melanoma brewing in there and down at the toes, that's where you may find evidence of, a fungal infection tinea pedis, with interdigital maceration, between the fifth and fourth or fourth and third toes.

    01:36 We're also going to be looking at her nail beds themselves, it's important to take a look at the nail beds and the nail plates as they may be harbingers of systemic disease, you can find half and half nails there, in the setting of kidney disease, terry's nails in the setting of cirrhosis, muehrcke's lines, in the setting of hypoalbuminemia, there's really a lot of different things, that you could find, if you go looking for it there.

    02:00 I’ve done the same thing with her right arm, then her left leg and her right leg and I already mentioned the toes as well.

    02:08 Next up, we'll take a look at mucosal surfaces and if the patient was concerned about a sexually transmitted infection or if there was concerns in that regard, then of course we would perform a mucosal exam involving the vagina and the intergluteal cleft posteriorly.

    02:24 In this case we're just going to focus on looking at the mucosal surfaces of the mouth and the eyes. b So just grab my light.

    02:32 Open up. Great. I'm looking at the buccal surfaces, the upper pallet, the uvula and your tongue you can stick out please too.

    02:43 And then I would likewise look under her conjunctiva, bottom and top.

    02:49 There's a lot of different things that may present on the skin, but actually, may have more clues, if you look in the mucosal surface’s things like Stevens-Johnson syndrome, bolus benfagoid and pemphigus vulgaris, can be distinguished, by the fact that the latter is more likely to have much continuous involvement, so it's really important to not neglect looking at the mucosal surfaces.

    03:12 Next up, let's make sure that we can use the right language, to describe, what we find.

    03:17 So, in this case I can tell you that we're right down here on her foreleg, identifying a flat hyper-pigmented lesion, we're obviously not going to just use the term lesion, we need to be more descriptive than that.

    03:28 So, the proper terminology for a non-palpable lesion, that is smaller than a centimeter, is a, “Macule.” If it's larger than a centimeter, we would instead of using macule, we would refer to it as a, “Patch.” If on the other hand if I ran my thumb over this and it was palpable, instead of using the word macule, we would call it a, “Papule,” greater than a centimeter is called a, “Plaque.” If on the other hand, I rubbed it again, and it had fluid in it, so it's both palpable and appears to be fluid filled, the proper term is a, “Vesicle,” you could also use the term blister to describe that.

    04:04 Greater than a centimeter, we would use the term, “Bulla.” If, it was not only enlarged, but it was very firm and appeared to have a sub-dermal component, at that point we would use the term, “Nodule” and if greater than a centimeter, we use the term, “Tumor,” though admittedly the term tumor, has a lot of a lot of baggage that comes along with it, so sometimes we don't necessarily use that term, we would just describe the size of the lesion.

    04:30 Lastly, I should mention that, certainly people can have evidence of bleeding into the skin and there's different terms to describe that as well.

    04:37 A lesion that is smaller than three millimeters, is referred to as a “Petechiae,” whereas if it's larger you can use either the term, “Ecchymosis” or a “Purpura,” which is just a larger area of bleeding into the skin.

    04:51 If somebody has an inflammatory lesion, involving like a vasculitis with inflammation of blood vessels, with extravasation of blood into the skin, we could call that, “Palpable purpura,” because normally a purpura is just flat and you don't feel it under your fingertips.

    05:05 So, those give us the right language to be used to describe different lesions that we may find.

    About the Lecture

    The lecture Assessment of the Integumentary System – Advanced by Stephen Holt, MD, MS is from the course Assessment of the Integumentary System (Nursing).

    Included Quiz Questions

    1. Muehrcke’s lines
    2. Terry’s nails
    3. Half and half
    4. Splinter hemorrhages
    1. Macule
    2. Papule
    3. Patch
    4. Plaque
    1. Bulla
    2. Plaque
    3. Nodule
    4. Vesicle
    5. Macule

    Author of lecture Assessment of the Integumentary System – Advanced

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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