"Marked facial pallor, with circumoral cyanosis. Palms cold and moist. Cyanosis in nailbeds of fingers and toes. One raised blue-black nevus, 1 x 2 cm, with irregular border on right forearm. No rash."

"Facial plethora. Skin icteric. Spider angioma over anterior torso. Single pearly papule with depressed center and telangiectasias, 1 x 1 cm, on posterior neck above collarline. No suspicious nevi. Nails with clubbing but no cyanosis."

Suggests central cyanosis and possible melanoma

Suggests possible liver disease and basal cell carcinoma

Observe the skin and related structures during the General Survey and throughout the rest of your examination. The entire skin surface should be inspected in good light, preferably natural light or artificial light that resembles it. Correlate your findings with observations of the mucous membranes. Diseases may manifest themselves in both areas, and both are necessary for assessing skin color. Techniques of examining these membranes are described in later chapters.

Artificial light often distorts colors and masks jaundice.

To make your observations more astute, acquaint yourself now with some of the skin lesions and colors that you may encounter.

See Table 4-1, Basic Types of Skin Lesions (pp. __-__), and Table 4-2, Skin Colors (p._).


Inspect and palpate the skin. Note these characteristics:

Color. Patients may notice a change in their skin color before the clinician does. Ask about it. Look for increased pigmentation (brownness), loss of pigmentation, redness, pallor, cyanosis, and yellowing of the skin.

The red color of oxyhemoglobin and the pallor due to a lack of it are best assessed where the horny layer of the epidermis is thinnest and causes the least scatter: the fingernails, the lips, and the mucous membranes, particularly those of the mouth and the palpebral conjunctiva. In dark-skinned persons, inspecting the palms and soles may also be useful.

Pallor due to decreased redness is seen in anemia and in decreased blood flow, as in fainting or arterial insufficiency.

Central cyanosis is best identified in the lips, oral mucosa, and tongue. The lips, however, may turn blue in the cold, and melanin in the lips may simulate cyanosis in darker-skinned people.

Causes of central cyanosis include advanced lung disease, congenital heart disease, and abnormal hemoglobins.

Cyanosis of the nails, hands, and feet may be central or peripheral in origin. eripheral cyanosis may be caused by anxiety or a cold examining room.

Cyanosis in congestive heart failure is usually peripheral, reflecting decreased blood flow, but in pulmonary edema it may also be central. Venous obstruction may cause peripheral cyanosis.

Look for the yellow color of jaundice in the sclera. Jaundice may also appear in the palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane, and skin. To see jaundice more easily in the lips, blanch out the red color by pressure with a glass slide.

Jaundice suggests liver disease or excessive hemolysis of red blood cells.

For the yellow color that accompanies high levels of carotene, look at the palms, soles, and face.

Moisture. Examples are dryness, sweating, and oiliness.

Temperature. Use the backs of your fingers to make this assessment. In addition to identifying generalized warmth or coolness of the skin, note the temperature of any red areas.

Texture. Examples are roughness and smoothness.

Mobility and Turgor. Lift a fold of skin and note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor).

Lesions. Observe any lesions of the skin, noting their characteristics:

■ Their anatomic location and distribution over the body. Are they generalized or localized? Do they, for example, involve the exposed surfaces, the intertriginous (skin fold) areas, or areas exposed to specific allergens or irritants such as wrist bands, rings, or industrial chemicals?

■ Their arrangement. For example, are they linear, clustered, annular (in a ring), arciform (in an arc), or dermatomal (covering a skin band that corresponds to a sensory nerve root; see pp. - )?

■ The type(s) of skin lesions (e.g., macules, papules, vesicles, nevi). If possible, find representative and recent lesions that have not been traumatized by scratching or otherwise altered. Inspect them carefully and feel them.

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