H and P

• Meeting the patient
• Examination

• Knock before entering
• respect
• Introductions
• Identify yourself (name and title)
• Shake hands?
• Always start formally
• “Who did you bring with you today?”
• “Bedside manner”
• Appear calm, organized, confident
• Take your time
• Be there
• Listen-your patient will give you the answers
• Eye contact
• Know when to be quiet

• Physical exam is traditionally done from patient’s right side
• Make sure your patient is comfortable
• Room temperature
• Draping
• Equipment
• Tell them what you are doing
• Clear instructions
• Be gentle but don’t be afraid to cause discomfort
• Organize your physical exam

• Apparent state of health - Acutely or chronically ill, frail, or fit and robust
• Level of consciousness - Is the patient awake, alert, and responsive to you and others in the env’t
• Signs of distress - Cardiac or respiratory, Pain, Anxiety or depression
• Development - Sexual, Body habitus – ex: boy with arm length down to his knees
• Motor activity - Posture, gait , Speech
• Appearance - Odors, hygiene, grooming; Facial expressions

• Baseline indicators of patient’s health status
• Can do all at the beginning of exam or spread out with respective organ systems
• Often will have them done for you by other staff-if something doesn’t seem right repeat them yourself (important)

• Number of cardiac cycles per minute
• Anywhere you feel arterial pulsation
• Carotid, brachial, radial, femoral, etc.
• Auscultate apical
• Pads of 2nd and 3rd fingers on flexor surface of lateral wrist
• Count pulsations (rate), note rhythm, amplitude (strong or weak), contour
• Normal HR=50-90 bpm

• Number of respiratory cycles/minute (regularity and depth, ease of breathing)
• Inspection
• Observe the rise and fall of chest, also make note of regularity, rhythm, depth and ease of breathing
• Normal respiratory rate=14-20

Peripheral measurement of cardiovascular function

Blood pressure is the force in the arteries when the heart beats (systolic pressure) and when the heart is at rest (diastolic pressure).

• Size does matter!
• Upper arm and brachial artery
• Can use forearm and radial pulse if necessary or even lower extremity (always record where BP was measured)

• Must use appropriate size cuff
• Too wide=underestimate BP
• Too narrow=overestimate BP
• Adults-choose a cuff with a bladder width that is about 40% limb circumference, bladder length should be about 80% of limb circumference
• Children-bladder width should not exceed ⅔ length of the upper arm

• Proper position of patient, limb, cuff and stethoscope
• Find palpable systolic blood pressure first
• Put cuff on, feel radial artery, inflate cuff till you cant find it anymore
• Inflate cuff 20-30 mmHg above palpable systolic pressure, then slowly deflate listening for Korotkoff sounds

• Normal = <120/<80
• Prehypertension - 120-139/ 80-89
• Hypertension stage 1 = 140-150/ 90-99
• Hypertension stage 2 = >= 160/ >= 100

Gola for diabetes mellitus is <130/80

• Routes-oral, rectal, axillary, tympanic
• Route choice will depend on age of patient and clinical setting
• Tympanic membrane shares blood supply with hypothalamus
• Tympanic requires proper technique
• With glass thermometers wait 3 minutes, rectal insert 1 1/2 inches.
• Rectal temps average 1° higher, and axillary temps 1° lower than PO (oral)
• Normal variation may be up to 101°

• Measured on platform & electronic scales, infants lying supine
• Infants: pounds and ounces
• Stadeometer: Height device on scale
• Infants length measured supine
• Calibrate equipment
• Measure infants on same scale dressed the same (especially if concerned with weight/ example: diaper)
• Plot height & weight on standard graphs
• Body Mass Index (BMI)-ratio of weight to height (kg/m²)

• Often considered the 5th vital sign
• Numeric scale 0-10
• Assessing changes
• Pictorial scale
• Kids

• Ch-character
• L-location
• O-onset
• R-radiation – pain move anywhere
• I-intensity
• D-duration
• E-event (precipitating)
• P-provacating factors
• P-palliative factors
• A-associated symptoms (Review of systems)
• P-previous episodes

• Changes in skin, hair or nails?
• Location? Generalized vs. local
• Temporal sequence?-onset, duration, etc.
• Associated symptoms?
• Pruritus, pain, exudate, bleeding, color changes, fever, fatigue, weight gain, arthralgias
• Recent exposures? Toxins, around others with a rash? Have they traveled?
• What have they tried? At home to make better?
• Meds-OTC/prescription?
• Hygiene products – shampoo etc

• Inquire about:
• Previous problems with skin, hair, or nails
• Tolerance to sunlight
• Cardiac, respiratory, liver, hematologic, rheumatologic, endocrine (thyroid) or other systemic diseases
• Nutrition

• History of dermatologic diseases
• Psoriasis, eczema, infestations, infections, melanoma, or other skin cancers
• Allergic hereditary diseases
• Familial hair loss
• History of autoimmune diseases
• Systemic lupus erythematous, Rheumatoid arthritis, etc.
• History of endocrine diseases
• Thyroid, diabetes mellitus

• Skin/hair/nail care habits? products
• Exposure to hazards?
• Occupational, recreational
• Recent stress?
• Alcohol/recreational drug/tobacco use?
• Sexual history? To estimate risk

• Inspection
• Always start with this
• Lighting (daylight, overhead, tangential)
• Exposure-you don’t have x-ray vision! Need to get their clothes off
• Percussion – use fingers to cause sound waves to bounce of what is below
• Palpation - feeling
• Your dermatology finger
• Pads of your fingers
• Auscultation – listening with stethescope

• Color changes
• Hyperpigmentation, hypopigmentation, pallor, erythema, jaundice, cyanosis, ecchymosis (bruising)
• Brown, black, blue, salmon. . .
• Lesions
• Measure (with device) in centimeters
• Palpation
• moisture/dryness
• Warmth-dorsum of hand, symmetry
• Texture
• Turgor (should be able to "tent" and it should return back to normal) - example --> dehydration and edema
• Lesions

• Inspect hair
• Color
• Distribution
• Quantity
• Palpate
• Texture
• Hair isn’t just on your head-make note of all hair bearing areas

• Inspect
• Color
• pink
• Length
• Configuration
• Symmetry
• Cleanliness
• Palpate
• Nail plate
• Nail bed
• Clubbing

• Primary or secondary (later evolution)
• Names often used inaccurately
• Good description is essential IMPORTANT
• Characteristics
• Location and distribution
• Localized, regional, diffuse
• Discrete or confluent
• Size, shape, color, texture, elevation or depression, pedunculation, exudates, configuration (annular, discoid, grouped, linear, arciform)

• Macule
• Papule
• Wheal
• Nodule
• Tumor
• Vesicle
• Bulla
• Pustule
• Cyst
• Telangiectasia
• Scale
• Lichenification
• Erosion
• UlcerExcoriation
• Fissure
• Scar
• Keloid
• Crust
• Atrophy

• Flat, circumscribed change in color of skin; less than 1 cm = marcule
• Examples: Freckles (ephilides), flat moles (nevi), petechiae

• If > 1 cm then is called a Patch
• Examples: Vitiligo, Mongolian spots

• Elevated, firm, circumscribed; less than 1 cm
• ≥ 1cm=Plaque
• Wart (verruca), elevated nevi
• Psoriasis, seborrheic keratosis
• Maybe very subtle

• Elevated (palapable), irregular shaped area of cutaneous edema
• Hives (urticaria), insect bites

In NC=“Whelp”

• Elevated, firm, circumscribed; deeper in dermis than papule
• >.5 cm
• Ex: lipoma (fatty, tumor), erythema nodosum

• Elevated, solid, deeper in dermis
• >2cm
• Neoplasms, lipoma

• Elevated, circumscribed, NOT into dermis
• Serous (clear) fluid
• <1cm
• Varicella (chicken pox), Herpes simplex

• Elevated, circumscribed, superficial
• > 1 cm
• Serous fluid
• Blister, pemphigus vulgaris, bullous pemphigoid

• Elevated, superficial
• Purulent material (has pus in it)
• Impetigo, acne

• Elevated, circumscribed, encapsulated (wall around them)
• Dermis or subcutaneous layer
• Fluid or semi-solid
• Epidermal inclusion cyst, cystic acne

• Fine, irregular
• Capillary dilation
• Rosacea, Generalized Essential Telangiectasia

• Evolution of primary lesions
• Maybe due to trauma of primary lesion (scratching, picking, etc.)
• Can obscure primary lesion, making identification difficult

heaped-up, heratinized, flaky

• Rough, thickened epidermis
• (due to chronic scratching)

• Loss of part of epidermis, depression, moist
• Rupture of vesicle

Loss of epidermis and dermis

Excoriation - loss of epidermis, linear (scratch)

Fissure - linear crack from epidermis into dermis (moist or dry) (deaper scratch)

• Scar - fibrous tissue following surgical incision or injury
• Keloid - irregular-shaped, elevated, grows beyond borders of wound

• Crust - dried serum, blood, or purulent exudate
• Example of impetigo

Atrophy - thinning of skin surface, loss of skin markings (stretch marks)

•General- Ms. Hills is well nourished, well developed, and appears her stated age. She is well groomed and in no acute distress.

•Vital Signs-Temp 98.6°, Pulse 82 and regular, Respirations 12 and unlabored, BP 114/68 both arms, seated; Ht 5’8”, Wt 110, BMI 16.7


•Skin/Hair/Nails-Skin is warm, dry, and soft throughout, turgor with instant recoil. No rashes or abnormal lesions noted. Hair is soft, silky, and well groomed with normal distribution. Nail beds pink without clubbing. Nails smooth, well attached, nontender, without deformity or pitting.