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Reticulate Net-like

Scale A flake on the skin surface, composed of stratum

corneum cells (corneocytes), shed together rather

than individually

Scar The fibrous tissue resulting from the healing of a

wound, ulcer or certain inflammatory conditions

Serpiginous Snake-like

Stria(e) A stretch mark

Targetoid Target-like

Telangiectasia Dilated blood vessels

Ulcer A deep loss of skin, extending into the dermis or

deeper; usually results in scarring

Umbilication A depression at the centre of a lesion

Verrucous Wart-like

Vesicle A small blister (<0.5 cm)

Wheal A transient (<24 hours), itchy, elevated area of

skin resulting from dermal oedema that

characterises urticaria

Xerosis Mild/moderate dryness of the skin

erythema multiforme, Stevens–Johnson syndrome and toxic

epidermal necrolysis), infective (such as bullous impetigo and

herpes simplex infection) and inherited (for example, epidermolysis

bullosa) disorders. An annular (ring-like) morphology may be seen

in granuloma annulare (Fig. 14.6C), subacute cutaneous lupus

erythematosus, and fungal infections (‘ringworm’).

288 • The skin, hair and nails

extravasation and entrapment in the collagen and elastic fibres

of the dermis.

The tint of the erythema may be helpful: a violaceous hue

distinguishes lichen planus; a beefy-red or salmon-pink colour

often typifies psoriasis; and a heliotrope (pink–purple) colour is

a feature of dermatomyositis, especially on the eyelids.

Macular purpura may be the result of thrombocytopenia or

capillary fragility, but palpable purpura (often painful) usually

indicates vasculitis (Fig. 14.7A) and necessitates exclusion of

vasculitic inflammation in other organs. Purpura elicitable by

pinching the skin (‘pinch purpura’) may be indicative of AL

(light-chain) amyloidosis (Fig. 14.7B).

The vascular contribution to the colour of a rash can be pivotal

in diagnosis since erythematous and purpuric eruptions usually

have very different underlying causes. It is not sufficient to describe

a rash as ‘red’ or ‘pink’; it is essential to demonstrate whether

or not a rash blanches on direct pressure or when the skin

is stretched. Blanchable redness (erythema) indicates that the

red blood cells causing the colour remain within blood vessels;

non-blanchable redness (purpura) is the result of erythrocyte

Fig. 14.4 Necrobiosis lipoidica diabeticorum.

Fig. 14.5 Lichen planus. A Discrete flat-topped papules on the wrist.

B Wickham striae, visible on close inspection. C A white lacy network of

striae on the buccal mucosa.

A

B

C

Fig. 14.6 Rash morphology. A Koebner response. B Pemphigoid.

C Granuloma annulare.

A

B

C

The physical examination • 289

14

There are also a number of subtle clinical signs that can be of

great diagnostic help in common rashes, such as the distinctive

silver-coloured scale that appears when psoriasis is scratched

with a wooden orange stick (Fig. 14.8AB), the urtication that

develops when the pigmented lesions of urticaria pigmentosa

(a form of cutaneous mastocytosis) are rubbed (Darier’s sign),

the separation of epidermis on applying a shearing force in

pemphigus (Nikolsky’s sign), and the very earliest lesions of

lichen planus glinting in reflected light like stars in the night sky

(Fig. 14.8C).

Scratch marks (excoriations) indicate an itchy rash. In any

pruritic eruption it is prudent to look specifically for the burrows

of scabies (Fig. 14.9) on the hands and feet, as well as testing

for dermographism and examining for lymphadenopathy (p. 33),

as urticaria and lymphoma are also important causes of itch.

Fig. 14.7 Purpura. A Cutaneous vasculitis. B AL (light-chain) amyloidosis.

A B

Fig. 14.8 Clinical signs in the diagnosis of skin disease. A Psoriasis

before rubbing the surface. B After surface rubbing. C Lichen planus

showing light reflection from small early lesions.

A B

C

Fig. 14.9 Scabies burrows.

290 • The skin, hair and nails

Fig. 14.10 Lesion morphology. A Malignant

A B melanoma. B Seborrhoeic keratosis.

Fig. 14.11 Basal cell carcinoma. A Viewed with the naked eye. B Dermatoscopy highlights distinctive telangiectasia.

A B

Morphology of lesions

Lesions should be measured and described according to

their anatomical location, colour, symmetry, surface texture,

consistency, demarcation of margin, and whether they are

freely mobile or attached to underlying tissue (p. 32). Remember

to examine the regional lymph nodes. If a pigmented lesion

demonstrates a variable outline and colour variation, the possibility

of malignant melanoma must be considered (Fig. 14.10A). It

is reassuring to see hair growing out of pigmented lesions, as

this usually indicates a benign process such as a melanocytic

naevus. An irregularly roughened, jagged surface texture is

often indicative of sunlight-induced damage (actinic keratosis),

whereas the surface of a seborrhoeic keratosis (Fig. 14.10B) has

a smoother feel. The consistency of a lesion is often of diagnostic

help: for example, the firm, button-like quality of a dermatofibroma

is very characteristic; neurofibromas are rather soft; calcium

deposits are hard; and cysts fluctuate and transilluminate. Basal

cell carcinoma, the most common malignant tumour, is usually

smooth (but may ulcerate); on inspection, it exhibits a milky,

pearlescent colour (which may glint) and irregular telangiectasia

(Fig. 14.11).

Hair and nail signs

General physical examination should always include the hair

and nails. Is there excess hair, either in a masculine distribution

(hirsutism) or not (hypertrichosis), or hair loss (alopecia)? Hirsutism

may be a marker for hyperandrogenism, and hypertrichosis

may be seen in malnutrition states, malignancy and porphyria

cutanea tarda. Discrete, coin-sized areas of hair loss, with small

‘exclamation mark’ hairs at the periphery, are characteristic of

alopecia areata (Fig. 14.12), an autoimmune disorder that may

coexist with other autoimmune disorders. Diffuse, pronounced

hair shedding (telogen effluvium) may be a physiological response

to severe illness, major surgical operations or childbirth, and

may be accompanied by transverse grooves on the finger nails,

which gradually grow out normally (Beau’s lines; see Fig. 3.7B).

Common abnormalities of the nails associated with underlying

disease are covered on page 24 and in Box 3.4 and Fig. 3.7.

The physical examination • 291

14

Fig. 14.12 Alopecia areata.

Fig. 14.13 Nail appearances in systemic diseases. A The typical linear pattern of dermatomyositis with Gottren’s papules on the dorsum of the hand.

B Nail-fold telangiectasia in dermatomyositis, viewed through the dermatoscope. C Yellow nail syndrome in a patient with lymphoedema and pleural

effusions.

A

B

C

Fig. 14.14 Dermatoscope.

Some rare diseases produce specific nail appearances,

such as the ‘ragged cuticles’ and abnormal capillary nail-bed

loops associated with dermatomyositis (Fig. 14.13AB), and the

progressive thickening and opacification of nails in yellow nail

syndrome (Fig. 14.13C).

Supplementary examination techniques

It is often necessary to complement naked-eye observation of the

skin with assisted examination techniques, such as dermatoscopy,

diascopy and Wood’s lamp.

Dermatoscopy

A dermatoscope consists of a powerful light source (polarised or

non-polarised) and a magnifying lens, and enables considerably

more cutaneous anatomical detail to be seen (Fig. 14.14).

292 • The skin, hair and nails

Fig. 14.15 Patch testing.

Dermatoscopy is particularly useful in the assessment of

pigmented lesions but is also often of great help in assessing

other skin tumours, hair disorders and certain infections (scabies,

viral warts and molluscum contagiosum).

Diascopy

The pressure of a glass slide on the skin will compress the

cutaneous blood vessels and blanch the area of contact. If blood

is still visible through the glass, it is because red blood cells have

extravasated (purpura). When granulomatous disorders (such as

sarcoidosis or granuloma annulare) are diascoped, they typically

manifest a green–brown (‘apple jelly’) colour.

Wood’s lamp

Examination of the skin using an ultraviolet light (Wood’s lamp) is

useful in two clinical situations: it enhances the contrast between

normal skin and under- or overpigmented epidermis (making

conditions such as vitiligo and melasma easier to see); and it can

identify certain infections by inducing the causative organisms

to fluoresce (such as erythrasma, pityriasis versicolor and some

ringworm infections).

Investigations

After clinical examination, specific investigative techniques may

be necessary in some cases to enable a precise diagnosis.

Skin biopsy

This involves a sample of skin being removed, under local

anaesthesia, and subjected to histological or immunohistochemical

examination in the laboratory. However, clinicopathological

correlation is usually necessary.

Mycology

A fungal infection can be confirmed (or refuted) by scraping

scale from the surface of a rash with a scalpel blade, clipping

samples of nail or plucking hair, and undertaking microscopic

examination and culture.

Patch testing

Patch testing (Fig. 14.15) is performed to establish whether a

contact allergy is the cause of an individual’s rash. It involves

applying putative allergens to the patient’s skin, leaving the test

patches undisturbed for 2 days, removing them and then reading

the final result after 4 days. A positive result is indicated by an

inflammatory reaction at the site of the patch.

OSCE example 1: Pruritus

Mr Thomson, 45 years old, presents with a 4-month history of intense

itch disturbing his sleep.

Please examine his skin

• Introduce yourself to the patient and clean your hands.

• Ask him to undress to underwear.

• Carry out a general inspection, observing for scratch marks (and

whether they are symmetrical), colour and dryness of the skin,

presence of a rash, pallor, jaundice, exophthalmos or goitre.

• Palpate the pulse for tachycardia and atrial fibrillation.

• Examine the hands and insteps for scabietic burrows, fine tremor,

thyroid acropachy and koilonychia.

• Examine the abdomen for an enlarged liver or spleen.

• Examine the mouth for a smooth tongue or angular cheilitis.

• Test for dermographism.

• Examine for lymphadenopathy.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Intense pruritus may be caused by dermatoses such as scabies and

dermatitis herpetiformis, but also by systemic disorders such as

polycythaemia, iron deficiency, liver or renal dysfunction, hyper- or

hypothyroidism, and lymphoma.

Suggest investigations

Full blood count, renal, liver and thyroid function tests, ferritin level and

chest X-ray.

Investigations • 293

14

OSCE example 2: Pigmented lesion

Ms Forsythe, 55 years old, presents with a 6-week history of a

changing pigmented lesion on her right calf.

Please examine her skin

• Introduce yourself to the patient and clean your hands.

• Ask her to undress to underwear.

• Carry out a general inspection of the skin, estimating her Fitzpatrick

skin type, and observing for signs of actinic damage and for other

lesions that might require close assessment.

• Observe the lesion on her calf for size, symmetry, regularity of

margins, variation of pigmentation and ulceration.

• Palpate the lesion.

• Examine for enlargement of regional lymph nodes.

• Examine the abdomen for an enlarged liver.

• Undertake a similar examination of any other suspicious lesions.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Any changing lesion should raise suspicion of malignant melanoma,

although melanocytic naevi, seborrhoeic keratoses, dermatofibromas,

haemangiomas and pigmented basal cell carcinomas can cause

diagnostic confusion.

Suggested investigations

If, after examination, there is still suspicion regarding the malignant

potential of the lesion, it should be excised for histological examination.

Integrated examination sequence for the skin

• Prepare the patient:

• Arrange for privacy.

• Arrange for a chaperone, if necessary.

• Remove sufficient clothing.

• Remove makeup and wigs, if face and scalp are being examined.

• Carry out a general examination of the skin:

• Look for excoriations, xerosis (dry skin), actinic damage and

suspicious lesions, for example.

• Carry out a specific examination of a rash:

• Extent.

• Distribution: symmetry, pattern.

• Morphology.

• Colour.

• Erythema/purpura.

• Specific features, e.g. scale, signs of infection/infestation.

• Mouth, hair and nails.

• Regional lymph nodes.

• Carry out a specific examination of a lesion:

• Site, size, colour.

• Symmetry.

• Surface texture.

• Consistency.

• Mobility.

• Pattern of vasculature.

• Regional lymph nodes.

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Section 3

Applying history

and examination skills

in specific situations

15 Babies and children 297

16 The patient with mental disorder 319

17 The frail elderly patient 329

18 The deteriorating patient 339

19 The dying patient 347

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15

Babies and children

Ben Stenson

Steve Cunningham

Babies 298

The history 298

Maternal history 298

Pregnancy history 298

Birth history 298

Infant’s progress 298

Presenting problems and definitions 298

The physical examination of newborns 299

Timing and efficacy of the routine neonatal examination 299

General examination 299

Cardiovascular examination 301

Respiratory examination 302

Abdominal examination 303

Neurological examination 304

Limbs 305

Weighing and measuring 306

Final inspection 307

The physical examination of infants beyond the newborn period 307

Older children 307

The history 307

Obtaining a history from children compared with adults 307

Common presenting symptoms 308

Past medical history 310

Birth history 310

Vaccination history 310

Developmental history 310

Drug history 310

Family and social history 310

Systematic enquiry 310

The physical examination 310

Normal growth and development 310

Physical examination techniques in children 312

The acutely unwell child 313

General examination 313

Ears, nose and throat 314

Cardiovascular examination 315

Respiratory examination 315

Abdominal examination 315

Neurological examination 315

Spotting the sick child 315

Child protection 315

OSCE example case 1: Cyanotic episodes 317

OSCE example 2: Asthma 317

Integrated examination sequence for the newborn child 318

298 • Babies and children

BABIES

15.1 Classification of newborn infants

Birthweight

• Extremely low: <1000 g

• Very low: <1500 g

• Low: <2500 g

• Normal: ≥2500 g

Gestational age

• Extremely preterm: <28 weeks

• Preterm: <37 weeks (<259th day)

• Term: 37–42 weeks

• Post-term: >42 weeks (>294th day)

15.2 Apgar score

Clinical score 0 1 2

Heart rate Absent <100 bpm >100 bpm

Respiratory

effort

Absent Slow and

irregular

Good: strong

Muscle tone Flaccid Some flexion of

arms and legs

Active movement

Reflex

irritability

No

responses

Grimace Vigorous crying,

sneeze or cough

Colour Blue, pale Pink body, blue

extremities

Pink all over

Add scores for each line; maximum score is 10.

bpm, beats per minute.

Reproduced with permission of International Anesthesia Research Society from

Current researches in Anesthesia & Analgesia Apgar V 1953; 32(4), permission

conveyed through Copyright Clearance Center, Inc.

A baby is a neonate for its first 4 weeks and an infant for its first

year. Neonates are classified by gestational age or birthweight

(Box 15.1).

The history

Ask the mother and look in the maternal notes for relevant

history:

Maternal history

Is there a family history of significant illness (e.g. diabetes,

hereditary illnesses)?

What were the outcomes of any previous pregnancies?

Pregnancy history

How was maternal health?

Did the mother take medications or other drugs?

What did antenatal screening tests show?

Birth history

What was the birthweight, gestation at birth and mode of

delivery?

Was there prolonged rupture of the fetal membranes or

maternal pyrexia?

Was there a non-reassuring fetal status during delivery or

meconium staining of the amniotic fluid?

Was resuscitation required after birth?

What were the Apgar scores (Box 15.2) and the results of

umbilical cord blood gas tests?

Infant’s progress

Has the infant passed meconium and urine since

birth?

In later infancy, what are the specific signs and systems

and developmental progress, depending on the presenting

problem?

Presenting problems and definitions

Infants cannot report symptoms, so you must recognise the

presenting problems and signs of illness, which are non-specific

in young infants. Always take the concerns of parents seriously.

Pallor

Always investigate pallor in a newborn, as it implies anaemia or

poor perfusion. Newborn infants have higher haemoglobin levels

than older children and are not normally pale. Haemoglobin levels

of <120 g/L (<12 g/dL) in the perinatal period are low. Preterm

infants look red because they lack subcutaneous fat.

Respiratory distress

Respiratory distress is tachypnoea (respiratory rate) >60 breaths

per minute with intercostal and subcostal indrawing, sternal

recession, nasal flaring and the use of accessory muscles.

Cyanosis

Bluish discoloration of the lips and mucous membranes due

to hypoxia is difficult to see in newborn infants unless oxygen

saturation (SpO2) is <80% (normal is >95%). Causes include

congenital heart disease and respiratory disease, and cyanosis

always needs investigation (p. 28).

Acrocyanosis

Acrocyanosis is a bluish-purple discoloration of the hands and feet

and is a normal finding, provided the newborn is centrally pink.

Jaundice

Many newborns develop jaundice in the days after birth. Look for

yellow sclerae in newborns with coloured skin or you may miss

it. Examine the baby in bright normal light. Normal physiological

jaundice cannot be distinguished clinically from jaundice from

a pathological cause. Do not use clinical estimates instead of

measurements to evaluate jaundice.

The physical examination of newborns • 299

15

but avoid an overly rigid approach as you may be unable to

perform key elements if you unsettle the baby. Do things that

may disturb the baby later in the examination.

Examination sequence

• Observe whether the baby looks well and is well grown.

• Look for:

• cyanosis

respiratory distress

pallor

plethora (suggesting polycythaemia).

Note posture and behaviour.

Note any dysmorphic features.

Auscultate the heart and palpate the abdomen if the baby

is quiet.

If the baby cries, does the cry sound normal?

Skin

Normal findings

The skin may look normal, dry, wrinkled or vernix-covered in

healthy babies. There may be meconium staining of the skin

and nails.

Prominent capillaries commonly cause pink areas called ‘stork’s

beak marks’ at the nape of the neck, eyelids and glabella (Fig.

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