General Appearance & Skin
Many clinicians begin the exam by observing general appearance and then inspecting of the nails and skin of the hands. These areas can yield many clues to health and disease and can facilitate patient comfort and build rapport as you move through the rest of the exam.
As you complete any other part of the physical exam you should carefully examine the skin in that area of the body. Ask your patient or ask permission to move the gown and drape to adequately expose the skin, and consciously stop to observe for any lesions. Early identification of a melanoma can save your patient’s life.
Observing general appearance
You’ll already have carefully observed your patient as you interviewed them. Take a conscious moment to pause and consider what you have seen. For example,
- At first glance, do they look well or ill? This first impression of “sick” can help to establish the urgency of the situation.
- Are there nonverbal cues suggesting anxiety, discomfort, or pain?
- What is the level of consciousness? Is your patient alert, or are they sleepy or confused?
- How do they use speech and language? Are there any unusual features that suggest a neurologic or mental health disorder?
- Are there signs of poor nutrition, such as wasting around the temples or loose clothing or jewelry?
- Are there signs of poor perfusion, such as confusion or in lighter skinned individuals, pallor of the skin?
- Are there bruises or injuries that might suggest child abuse or intimate partner violence?
Normal skin has many variations, but almost everyone has at least one skin lesion. Many, like freckles or moles, are not associated with any disease. You’ll learn more about normal and abnormal skin findings in Winter quarter. For now, practice describing the skin lesions that you observe using the terms in the table below.
Describing a person’s skin tone can be important in dermatology since skin conditions may appear differently in different skin tones. Medicine does not have a formal, consistent way of describing skin color, so it is best to describe it using language that your patient prefers and relates to. Some options are to describe skin tones using color names, like pale pink, light tan, light brown, medium brown, or dark brown. Avoid using food analogies, racial proxies and terms rooted in colorism e.g. “fair”. Lesions can be compared to the patient’s natural skin color, referencing more pigmentation or less pigmentation than the unaffected skin. Also remember that darker skin tones and lighter skin tones show redness (erythema) in different ways. It is important to intentionally learn how similar skin findings are observed in a variety of skin tones.
You’ll see in your training that more melanated tones are markedly underrepresented in medical texts and slides, a problem addressed in an upcoming block session on health equity in dermatology. Brown Skin Matters is one useful resource to see photos of skin disorders as they appear in those with darker skin. Mind the Gap is another.
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Basic descriptive terms for cutaneous lesions. (adapted from A. Nast et al. British Journal of Dermatology (2016) 174, pp1351–1358) |
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| TERM | DEFINITION FOR THIS TERM | ADDED DESCRIPTORS FOR COMPLETENESS |
| Macule | A flat, circumscribed, nonpalpable lesion that differs in color from the surrounding skin. It can be any color or shape. | The average diameter, shape, color and border should be described. |
| Papule | An elevated, solid, palpable lesion that is ≤ 1 cm in diameter. | The average diameter, shape, color, topography (surface characteristics, e.g., flat topped) and border should be described; degree of elevation and consistency or feel can be included. |
| Plaque | A circumscribed, palpable lesion > 1 cm in diameter; most plaques are elevated.ᵃ Plaques may result from a coalescence of papules. | The average diameter, shape, color, topography and border (e.g., well demarcated vs. ill defined) should be described; degree of elevation and consistency or feel can be included. |
| Nodule | An elevated, solid, palpable lesion > 1 cm usually located primarily in the dermis and/or subcutis. The greatest portion of the lesion may be exophytic or beneath the skin surface. | The average diameter, shape, color, topography and border should be described; degree of elevation and consistency or feel can be included. |
| Wheal | A transient elevation of the skin due to dermal edema, often pale centrally with an erythematous rim. | There are no surface changes. |
| Vesicle | A circumscribed lesion ≤ 1 cm in diameter that contains liquid (clear, serous or hemorrhagic). | ‘Small blister’ |
| Bulla | A circumscribed lesion > 1 cm in diameter that contains liquid (clear, serous or hemorrhagic). | ‘Large blister’ |
| Pustule | A circumscribed lesion that contains pus. | |
| Crust | Dried serum, blood or pus on the surface of the skin. | |
| Scale | A visible accumulation of keratin, forming a flat plate or flake. | Types of scale:
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| Erosion | Loss of either a portion of or the entire epidermis. | It may arise following detachment of the roof of a blister, e.g. bullous impetigo. |
| Excoriation | A loss of the epidermis and a portion of the dermis due to scratching or an exogeneous injury. | It may be linear or punctate |
| Ulcer | Full-thickness loss of the epidermis plus at least a portion of the dermis; it may extend into the subcutaneous tissue. | The size, shape and depth should be described as well as the characteristics of the border, base and surrounding tissue. |
| ᵃ There is ongoing discussion as to whether non-elevated, but palpable, lesions such as those of morphoea should be termed plaques; the authors included such lesions as plaques, hence the statement that most, but not all, plaques are elevated. | ||
Knowledge Check
Video of complete skin exam.
This would be performed for skin cancer screening in those at risk and for patients with a CC related to the skin. We won’t practice this in Immersion but you may have a chance to do one in your Primary Care Practicum.
References & resources
A. Nast et al. British Journal of Dermatology (2016) 174, pp1351–1358
G. Singh et al. British Journal of Dermatology (2022) 187, pp1001–1002
