Next, we're going to move on
with the dermatologic exam.
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.
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.
That will also include the scalp,
the nails the mucosal surfaces etc.
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 patientâ€™s modesty.
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.
So, if I saw just some papules or macules,
with some excoriations in her anti-cubital fossa,
I'd be thinking about atopic dermatitis.
Whereas on the extensor surfaces,
I may be thinking more about
something like psoriasis.
So, attending to those areas is important.
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.
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.
Iâ€™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.
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.
In this case we're just going to focus on
looking at the mucosal surfaces of the mouth
and the eyes.
So just grab my light.
Open up. Great. I'm looking
at the buccal surfaces,
the upper pallet, the uvula and your
tongue you can stick out please too.
And then I would likewise look under
her conjunctiva, bottom and top.
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 surfaceâ€™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.
Next up, let's make sure that
we can use the right language,
to describe, what we find.
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.
So, the proper terminology
for a non-palpable lesion,
that is smaller than a centimeter, is a, â€œMacule.â€
If it's larger than a centimeter,
we would instead of using macule,
we would refer to it as a, â€œPatch.â€
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, â€œPapule,â€
greater than a centimeter is called a, â€œPlaque.â€
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, â€œVesicle,â€ you could
also use the term blister to describe that.
Greater than a centimeter, we
would use the term, â€œBulla.â€
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, â€œNoduleâ€
and if greater than a centimeter,
we use the term, â€œTumor,â€
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.
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.
A lesion that is smaller than three
millimeters, is referred to as a â€œPetechiae,â€
whereas if it's larger you can use either
the term, â€œEcchymosisâ€ or a â€œPurpura,â€
which is just a larger area
of bleeding into the skin.
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, â€œPalpable purpura,â€
because normally a purpura is just flat
and you don't feel it under your fingertips.
So, those give us the right language
to be used to describe different
lesions that we may find.