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
Vesicle A small blister (<0.5 cm)
Wheal A transient (<24 hours), itchy, elevated area of
skin resulting from dermal oedema that
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
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
Fig. 14.6 Rash morphology. A Koebner response. B Pemphigoid.
The physical examination • 289
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
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.
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.
290 • The skin, hair and nails
Fig. 14.10 Lesion morphology. A Malignant
A B melanoma. B Seborrhoeic keratosis.
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
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
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
Supplementary examination techniques
It is often necessary to complement naked-eye observation of the
skin with assisted examination techniques, such as 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
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).
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.
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
After clinical examination, specific investigative techniques may
be necessary in some cases to enable a precise diagnosis.
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.
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
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.
Mr Thomson, 45 years old, presents with a 4-month history of intense
• 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.
• 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
Full blood count, renal, liver and thyroid function tests, ferritin level and
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.
• 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.
• 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
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
• Arrange for a chaperone, if necessary.
• 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:
• Distribution: symmetry, pattern.
• Specific features, e.g. scale, signs of infection/infestation.
• Carry out a specific examination of a lesion:
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16 The patient with mental disorder 319
17 The frail elderly patient 329
18 The deteriorating patient 339
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Presenting problems and definitions 298
The physical examination of newborns 299
Timing and efficacy of the routine neonatal examination 299
Cardiovascular examination 301
The physical examination of infants beyond the newborn period 307
Obtaining a history from children compared with adults 307
Common presenting symptoms 308
Normal growth and development 310
Physical examination techniques in children 312
Cardiovascular examination 315
OSCE example case 1: Cyanotic episodes 317
Integrated examination sequence for the newborn child 318
15.1 Classification of newborn infants
• Extremely preterm: <28 weeks
• Preterm: <37 weeks (<259th day)
• Post-term: >42 weeks (>294th day)
Heart rate Absent <100 bpm >100 bpm
Muscle tone Flaccid Some flexion of
Colour Blue, pale Pink body, blue
Add scores for each line; maximum score is 10.
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
Ask the mother and look in the maternal notes for relevant
• Is there a family history of significant illness (e.g. diabetes,
• What were the outcomes of any previous pregnancies?
• Did the mother take medications or other drugs?
• What did antenatal screening tests show?
• What was the birthweight, gestation at birth and mode of
• Was there prolonged rupture of the fetal membranes or
• 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?
• Has the infant passed meconium and urine since
• In later infancy, what are the specific signs and systems
and developmental progress, depending on the presenting
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.
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 is tachypnoea (respiratory rate) >60 breaths
per minute with intercostal and subcostal indrawing, sternal
recession, nasal flaring and the use of accessory muscles.
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 is a bluish-purple discoloration of the hands and feet
and is a normal finding, provided the newborn is centrally pink.
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
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.
• Observe whether the baby looks well and is well grown.
• plethora (suggesting polycythaemia).
• Note any dysmorphic features.
• Auscultate the heart and palpate the abdomen if the baby
• If the baby cries, does the cry sound normal?
The skin may look normal, dry, wrinkled or vernix-covered in
healthy babies. There may be meconium staining of the skin
Prominent capillaries commonly cause pink areas called ‘stork’s
beak marks’ at the nape of the neck, eyelids and glabella (Fig.
15.1). Facial marks fade spontaneously over months; those
on the neck often persist. Milia (fine white spots) and acne
neonatorum (larger cream-coloured spots) are collected glandular
secretions and disappear within 2–4 weeks. Erythema toxicum
is a common fleeting, blanching, idiopathic maculopapular rash
of no consequence, affecting the trunk, face and limbs in the
Document any trauma such as scalp cuts or bruising.
Dense capillary haemangiomas (port wine stains) will not
fade. Referral to a dermatologist is advisable, as laser treatment
may help in some cases. Around the eye they may indicate
Sturge–Weber syndrome (a facial port wine stain with an
underlying brain lesion, associated with risk of later seizures,
cerebral calcification and reduced cognitive function). Melanocytic
naevi require follow-up and treatment by a plastic surgeon or
dermatologist. A Mongolian blue spot (Fig. 15.2) is an area of
bluish discoloration over the buttocks, back and thighs. Easily
mistaken for bruising, it usually fades in the first year.
Jitteriness is high-frequency tremor of the limbs, and is common
in term infants in the first few days. It is stilled by stimulating the
infant and is not associated with other disturbance. If jitteriness is
excessive, exclude hypoglycaemia, polycythaemia and neonatal
abstinence syndrome (drug withdrawal). Infrequent jerks in light
sleep are common and normal; regular clonic jerks are abnormal.
Identifying abnormal body structure (dysmorphism) is subjective
because of human variability. Individual features may be minor and
isolated, or may signify a major problem requiring investigation
and management. A recognisable pattern of several dysmorphic
features may indicate a ‘dysmorphic syndrome’ such as Down’s
syndrome (p. 36). Use caution and sensitivity when discussing
possible dysmorphism with parents of a newborn child.
Hypotonia (reduced tone) may be obvious when you handle an
infant. Term infants’ muscle tone normally produces a flexed
posture at the hips, knees and elbows. Hypotonic infants may
lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia
or sepsis, or may be due to a specific brain, nerve or muscle
problem. Preterm infants have lower tone than term infants and
This first clinical assessment of a neonate is made immediately
after birth. Tone, colour, breathing, heart rate and response
to stimulation are each scored 0, 1 or 2 (Box 15.2), giving a
maximum total of 10. Healthy neonates commonly score 8–10 at
1 and 5 minutes. The score predicts the need for, and efficacy of,
resuscitation. A low score should increase with time; a decreasing
score is a cause for concern. Persistently low scores at 10
minutes predict death or later disability. Neonates with scores
of less than 8 at 5 minutes require continued evaluation until it
The physical examination of newborns
Timing and efficacy of the routine
Examine a newborn with the parents present. There is no ideal
time. If it is performed on day 1, some forms of congenital heart
disease may be missed because signs have not developed. If
it is delayed, some babies will present before the examination
with illness that may have been detectable earlier. Around 9%
of neonates have an identifiable congenital abnormality but most
are not serious. Always record your examination comprehensively
to avoid problems if illness or physical abnormality is identified
later. Fewer than half of all cases of congenital heart disease
or congenital cataract are detected by newborn examination.
Examine babies and infants in a warm place on a firm bed or
examination table. Have a system to avoid omitting anything, Fig. 15.1 Stork’s beak mark.
Separated cranial sutures with an obvious gap indicate raised
intracranial pressure. Rarely, the cranial sutures are prematurely
fused (synostosis), producing ridging, and the head shape
is usually abnormal. Abnormal head size requires detailed
investigation, including neuroimaging.
• Inspect the eyebrows, lashes, lids and eyeballs.
• Gently retract the lower eyelid and check the sclera for
• Test ocular movements and vestibular function:
• Turn the newborn’s head to one side; watch as the
eyes move in the opposite direction. These are called
doll’s-eye movements and disappear in infancy (see
• Hold the infant upright at arm’s length and move in a
horizontal arc. The infant should look in the direction of
movement and have optokinetic nystagmus. This
response becomes damped by 3 months.
Harmless yellow crusting without inflammation is common after
birth in infants with narrow lacrimal ducts.
Term infants usually fix visually.
Eye infection gives a red eye and purulent secretions. An abnormal
pupil shape is usually a coloboma (a defect in the iris inferiorly
that gives the pupil a keyhole appearance, Fig. 15.4). This can
also affect deeper structures, including the optic nerve, and lead
to visual impairment. It can be associated with syndromes, as
can microphthalmia (small eyeballs). Large eyeballs that feel hard
when palpated through the lids suggest congenital glaucoma
• Hold the baby in your arms. Turn your body from side to
side so that the baby will open their eyes.
Subcutaneous fat necrosis causes palpable firm plaques, often
with some erythema under the skin. If extensive, there can be
associated hypercalcaemia that may require treatment. Blisters
or bullae are usually pathological.
• Note the baby’s head shape (Box 15.3) and any swellings.
• Feel the anterior fontanelle (Fig. 15.3). Is it sunken, flat or
• Palpate the cranial sutures.
Transient elongation of the head is common from moulding
during birth. Caput succedaneum is soft-tissue swelling over
the vertex due to pressure in labour. Overriding cranial sutures
Cephalhaematoma is a firm, immobile, usually parietal swelling
caused by a localised haemorrhage under the cranial periosteum.
It may be bilateral, and periosteal reaction at the margins causes
a raised edge. No treatment is required. Do not confuse this
with the boggy, mobile, poorly localised swelling of subgaleal
haemorrhage (beneath the flat sheet of fibrous tissue that caps the
skull), which can conceal a large blood loss and is life-threatening
Fig. 15.2 Mongolian blue spot.
Microcephalic (small-headed) Small cranial vault
Megalencephalic (large-headed) Large cranial vault
Hydrocephalic (water-headed) Large cranial vault due to
Brachycephalic (short-headed) Flat head around the occiput
Dolichocephalic (long-headed) Head that looks long relative to
Plagiocephalic (oblique-headed) Asymmetrical skull
Fig. 15.3 The fetal skull from above.
The physical examination of newborns • 301
Cleft palate may involve the soft palate or both hard and soft
palates. It can be midline, unilateral or bilateral and may also
involve the gum (alveolus). Cleft lip can appear in isolation or
in association with it. Refer affected infants early to a specialist
multidisciplinary team. Micrognathia (a small jaw) is sometimes
associated with cleft palate in the Pierre Robin syndrome,
with posterior displacement of the tongue and upper airway
A ranula is a mucous cyst on the floor of the mouth that
is related to the sublingual or submandibular salivary ducts.
Congenital ranulas may resolve spontaneously but sometimes
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