Badanie fizykalne Układu Powłokowego | Integumentary System examination

Inspection

Inspection is a critical first step in examining the integumentary system, providing essential visual cues that can guide the rest of the physical examination. It allows the clinician to assess the condition of the skin, hair, and nails, as well as to detect signs of systemic diseases, infections, or localized trauma. 

Systematic Approach: 

Perform a systematic, head-to-toe examination to ensure all regions are assessed.

• Scalp and Hairline
• Face and Neck
• Chest and Abdomen
• Back and Buttocks
• Upper and Lower Extremities
• Palms, Soles, and Nail Beds

Specific Areas of Focus

• Scalp and Hair: Part the hair to inspect the scalp for erythema, scaling, lesions, or alopecia. Note the texture, distribution, and condition of the hair.
• Nails: Check the nail beds for color, shape, and texture. Clubbing, pitting, or changes in nail color may indicate systemic diseases, such as lung disease, psoriasis, or cardiac issues.
• Mucosal Surfaces: Examine the oral mucosa, lips, and tongue. Look for ulcerations, pigmentary changes, or lesions, as these can offer clues to systemic conditions like anemia or vitamin deficiencies.

Skin Inspection

Changes in skin tone or pigmentation can be indicative of local or systemic pathology.

• Hyperpigmentation: Darkened patches of skin, seen in conditions like Addison’s disease or post-inflammatory hyperpigmentation.
• Hypopigmentation: Areas of skin that have lost pigment, common in conditions like vitiligo or post-inflammatory hypopigmentation.
• Jaundice: Yellowing of the skin and eyes due to elevated bilirubin levels, typically seen in liver disease.
• Cyanosis: A bluish tint to the skin, often seen in areas with poor circulation or oxygenation, such as in severe respiratory or cardiovascular conditions.

Skin Conditions

Skin observation provides valuable information about both local and systemic health. Conditions affecting the skin can be manifestations of underlying systemic diseases, allergic reactions, or infections.

• Erythema (Redness): Redness of the skin often indicates inflammation, infection, or trauma. Erythema is seen in conditions such as cellulitis, lupus, and dermatitis. In autoimmune diseases like lupus, erythema can be widespread, particularly over sun-exposed areas.
• Ecchymosis (Bruising): Bruises indicate bleeding under the skin, often due to trauma or a bleeding disorder. For example, extensive bruising could suggest clotting abnormalities or anticoagulant use, while localized bruising near joints may suggest trauma or injury, such as a ligament tear.
• Ulceration and Rash: Open sores or rashes may point to systemic conditions such as diabetes, which impairs circulation and delays healing. Rashes can also indicate infection (e.g., impetigo), autoimmune conditions (e.g., psoriasis), or allergic reactions.
• Skin Atrophy and Sclerosis: Thinning of the skin may be due to aging, chronic disuse, or systemic diseases like corticosteroid overuse. Sclerosis (skin hardening) is often seen in conditions like scleroderma, which affects the skin, connective tissues, and musculoskeletal system.

Lesions and Skin Abnormalities

Skin lesions come in various forms, each indicative of specific dermatologic conditions or systemic diseases. Careful observation and description of these abnormalities are crucial for diagnosis.

Evaluation of Skin Lesions

When assessing skin lesions, the ABCDE criteria are used to evaluate the characteristics of pigmented lesions such as moles, which can indicate malignant changes (e.g., melanoma).

A – Asymmetry: One half of the lesion differs from the other.

B – Border: Irregular, notched, or blurred edges.

C – Color: Variations in color, including tan, brown, black, red, white, or blue.

D – Diameter: Lesions larger than 6 mm (about the size of a pencil eraser).

E – Evolution: Changes in size, shape, color, or symptoms (e.g., itching, bleeding).

Note: Patients with high-risk profiles, such as those with fair skin, a history of sunburns, or a family history of melanoma, should undergo regular skin cancer screenings.

Types of Skin Lesions

Skin lesions can be broadly categorized into primary and secondary types based on their origin. Primary lesions arise from previously normal skin, while secondary lesions develop over time, often as a result of the evolution of primary lesions or from external factors such as scratching or infection. Below, we will explore each category in detail.

Primary Lesions

Primary lesions are the initial, visible alterations in the skin that occur due to a pathological process. These can be the first indicators of a dermatological condition and include a range of lesion types based on their size, texture, and content (fluid-filled or solid).

Secondary Lesions

Secondary lesions develop from primary lesions as a result of external factors such as scratching, infection, or changes in the healing process. These lesions often indicate the progression or complication of a skin condition and include scars, ulcers, and scales.

Nail and Hair Abnormalities

Observing changes in nails and hair can provide insight into systemic diseases, nutrient deficiencies, and dermatologic disorders.

Nail Changes:

• Clubbing: Rounded, bulbous enlargement of the nail beds associated with chronic hypoxia or lung diseases.
• Koilonychia (Spoon Nails): Thin, concave nails seen in iron deficiency anemia.
• Pitting: Small depressions on the nail surface, often seen in psoriasis.
• Onycholysis: Separation of the nail from the nail bed, observed in fungal infections or trauma.

Hair Changes:

• Alopecia: Hair loss can be diffuse or patchy. Diffuse hair thinning may be due to systemic issues like thyroid dysfunction or malnutrition, while patchy hair loss (alopecia areata) suggests an autoimmune process.
• Hirsutism: Excessive hair growth in women, often due to hormonal imbalances (e.g., polycystic ovary syndrome).

Palpation

Palpation of the skin and underlying structures can provide additional information on the nature of skin abnormalities. It allows for the detection of tenderness, warmth, texture, and swelling.

• Tenderness: Tender areas suggest inflammation, infection, or trauma. Localized tenderness can indicate cellulitis, while diffuse tenderness may be associated with systemic conditions like lupus or vasculitis.
• Temperature: Palpating the skin to detect warmth can indicate infection or inflammation, such as in cellulitis, whereas cool skin may suggest vascular insufficiency.
• Texture: Assessing whether the skin feels thickened (as in scleroderma) or thin (as in chronic corticosteroid use) provides clues to systemic diseases.
• Swelling and Edema: Edema can indicate fluid retention due to systemic conditions such as heart failure or localized trauma. Palpation of non-pitting vs. pitting edema helps differentiate the underlying cause.

Abnormal Findings in Skin and Structure

Abnormal findings to be aware of during physical examination include:

• Skin Atrophy: Thinning or wasting of the skin, common in chronic vascular insufficiency or aging.
• Scarring: Assess for hypertrophic or keloid scarring, which can indicate abnormal healing processes.
• Lymphadenopathy: Enlarged lymph nodes near areas of infection or malignancy.
• Rashes with Specific Patterns: Rashes that follow specific anatomical patterns can be highly diagnostic, such as the butterfly rash across the cheeks in lupus or the dermatome distribution of a herpes zoster rash.
• Skin Atrophy: Thinning or wasting of the skin, common in chronic vascular insufficiency or aging.