Remote Primary Health Care Manuals

Skin examination

Well lit area.
Wear gloves.

Attention

  • Consider who is the most culturally appropriate person to perform a skin examination — based on preference, gender, kinship
  • Only do full examination when necessary — in many cases a targeted examination is best

What you do

Ask about (OLD CARTS)

O nset — slow or sudden, associated with injury or event, food or drug use
L ocation — where is it
D uration — how long has it been there, had it before, changing over time
C haracteristics — itchy, bleeding, painful, red, swollen, crawling sensation
A ggravating factors — what makes it worse (eg worse when touched)
R elief — what helps
T ried — what have they already tried, what worked before
S igns and symptoms (other) — done anything lately that’s different, travel, contact with people with a rash, recent weight loss/gain, joint pain, feeling unwell, fever, cough, eating and drinking (what and how much), medicines used

Do full head-to-toe exam

  • Ask person to undress, leave underwear on
  • Don’t forget to look inside mouth and at soles of feet
  • Ask about lesions on scalp, areas covered by underwear. Check with consent

Look and check for

  • Overall condition and colour of skin
  • Condition of hair and nails
  • Any differences in colour or appearance of arms, legs, hands, feet. Compare sides
  • Hydration — skin turgor. Lightly pinch loose piece of skin
    • Does skin return to normal straight away or stay pinched
  • Any swelling or redness
    • Oedema — legs, feet, hands, bottom, face. Does pressing leave a dent (pitting)
    • Sores, lumps or rashes
  • Burns, scars or bruises
  • Blanching — press skin with piece of glass (eg slide) or acrylic (eg clear plastic ruler) and note if rash fades

Bleeding into skin appears as red-purple blotches/spots that don't blanch under pressure — note if lesions are raised. Pinpoint lesions are petechiae, larger lesions are purpura

Swollen nodes

  • Look at neck for lumps, swelling, any obvious pulsating
  • Palpate (feel) head and neck with both hands. Take care with the elderly, infant’s fontanelle — especially if less than 18 months
  • Start at tip of chin, feel around under jaw to below ears, then feel down muscles at each side of neck to end of collarbone — Figure 7.1
  • Gently feel behind ears for enlarged nodes, move along to nape of neck, gently follow muscle line down to shoulders
  • Also feel axillae (armpits) and groin

Figure 7.1   

Lymph nodes in neck.

Feel skin temperature — hot, sweaty, cold, clammy

Rash or lesion

  • Colour — red, purple, pale, multi-coloured, blanching or not
  • Size of lesions, distribution over body
  • Any of  
    • Acanthosis nigricans — dark, velvety discoloration in folds of skin usually in the back of the neck, armpit, groin. May indicate insulin resistance — Figure 7.2
    • Atrophy — loss of thickness of epidermis, dermis, other tissue
    • Blister/vesicle — skin bleb filled with fluid
    • Crust — dried serum, thick mass of skin scales, or both
    • Cyst — deep fluid-filled cavity
    • Erosion — partial loss of epithelium or mucous membrane
    • Erythema — redness
    • Excoriation — scratch marks scoring epidermis
    • Fissure — crack or split in epidermis
    • Lichenification — thickening of skin surface, looks like leather
    • Macule — flat spot. Can see but can’t feel it
    • Nodule — lump deeply set in skin
    • Papule — small, dome-shaped, may be skin coloured
    • Plaque — raised solid flat spot, usually larger than 1cm
    • Pustule — skin bleb filled with pus
    • Scale — flaky
    • Ulcer — total loss of skin or mucous membrane

Figure 7.2 Acanthosis nigricans 

Acanthosis nigricans.jpg

© Medical Journal of Australia. Used with permission

Lump or mass

  • Location — involves skin, muscle, tendon, bone
  • Movement — easy/hard to move, loose, fixed to surrounding structures
  • Size — draw around edge with pen, then measure
    • Shape — regular/irregular, a/symmetrical (un/even), defined/diffuse edges
    • Shade — dark, light, variegated (multi-coloured), different colours
  • Signs of inflammation — red, painful, pus, crusting, dry, moist
  • Surface edge and consistency — looks different to skin around it
  • Feel — hard, soft, smooth, rough, fluctuant (like liquid) in boil/cyst

When assessing for melanoma — look for

  • A symmetry — uneven
  • B order — irregular
  • C olour — uneven
  • D iameter — more than 5mm
  • E volving — changing size and colour

Do 

  • Measure and describe clearly in file notes
  • Take digital photo (with consent) with paper measuring tape, ruler, or paper with measurements beside
  • Keep a copy with file notes, email to specialist for further advice