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Skin Examination for Medical Student OSCE

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1. Introduce, identify, explain, consent, WASH HANDS!

2. Check for pain

3. Inspect

   1. Colour - erythema

   2. Shape – macule (flat area of discolouration), plaque (raised, flat top)

   3. Size – papule (<5mm elevation of skin), nodule (>5mm elevation)

   4. Surface

      1. Vesicle (blister <5mm)

      2. Bulla (blister >5mm)

      3. Pustule (blister containing pus)

      4. Scale (flaky keratin)

      5. Crust (dried exudate)

   5. Site – exact position / nearest bony prominence. Flexor/extensor surface, asymmetrical / symmetrical distribution

   6. Nature – scaling / lichenification / crusting, excoriation / ulceration / scarring / erosion)

   7. Edge (irregular / well-defined)

4. Palpation

   1. Temperature and texture

   2. Lymph nodes – malignancy

   3. Pedal pulses (ulcers)

5. Rest of body

   1. Inspect for further distribution, including elbows, soles of feet, knees, flexor creases (eczma)

   2. Nails and hair – psoriasis, tinea capitis, alopecia, Wickham’s striae

6. Differential diagnosis

   1. Psoriasis

Chronic, itchy, inflamed, red, raised areas. 2% of the population. Alcohol, ?-blockers, lithium, NSAIDs and antimalarials can exacerbate. Commonest form = discoid / plaque psoriasis. Salmon-coloured plaques + silvery scales on extensor surfaces (elbows, knees, lower back) + scalp, often itchy. Also:

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      1. Guttate – mostly teens, with multiple drop-like lesions after streptococcal throat infection

      2. Pustular – small pustules all over body / just on palms, soles, other small areas.

The various forms can involve nails (in 50% - pitting, ridging, onycholysis – distal nail separated from nail bed - and hyperkeratosis) and joints (in 7%).

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   1. Eczma

Many kinds of dermatitis (skin inflammation), including:

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      1. Atopic – commonest – collection of hereditary diseases, including asthma, hay fever and atopic dermatitis. Chronic, dry, itchy, inflamed skin ? redness, cracking, weeping, crusting, excoriations, sometimes with lichenification. Mostly in infants and children, often improving in early teens. In infants: usually presents after 6 weeks, affecting face, forehead, chest and extensor surfaces. In children – flexor surfaces e.g. antecubital and popliteal areas, + face, neck, back, ankles, wrists.

      2. Contact

      3. Allergic

      4. Seborrhoeic

      5. Stasis dermatitis

   2. Moles and melanomas (also see ulcers section – BCCs and SCCs) Malignant tumour of melanocytes, most originating from skin (some from benign naevi). Linked to sunburn, sunbeds and BRAF gene mutations, but caused by UV. Backs of men, legs of women. = Most lethal skin cancer, early detection important: check for moles with ABCDE:

      1. Asymmetry

      2. Border irregularity

      3. Colour irregularity

      4. Diameter enlarging / >5mm

      5. Evolving shape/size/colour/itching/bleeding

? Excisional biopsy for histology and tumour thickness (‘Breslow’s thickness’), then surgical excision. <1mm thickness ? 90% 5 year survival; >4mm ? 50% 5 year survival. Wide local excision (WLE): 1cm margin of normal skin removed for each mm thickness, to maximum radius 3cm. Preventative measures: sun protection: avoid excessive exposure (e.g. 11am-3pm); sun-protective clothing; sunscreen >SPF30

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by: Admin
Total views: 0
Word Count: 814
Date: Fri, 22 Jan 2010 Time: 4:07 PM
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