Examination of Nails For Systemic Diseses

The nails should be examined for the following:

• Pallor
• Koilonychia: Spoon-shaped deformity of the nail which is present in iron deficiency anemia.
• Onychia: Deformity of the nail e.g. following fungal or tuberculous infection.
• Discoloration: This occurs in Raynaud’s disease and silver and mercury poisoning.
• Clubbing and cyanosis: Clubbing is bulbous enlargement of soft parts of the terminal phalanges with both transverse and longitudinal curving of the nails. The swelling of the terminal phalanges in clubbing occurs due to interstitial edema and dilation of the arterioles and capillaries. Cyanosis is a bluish discoloration of the nails due to increased amount of reduced hemoglobin (more than 5 mg%)in capillary blood.
• Hemorrhages: This may be present under the nail beds in SBE and bleeding disorders.
• Trophic changes: Ribbing, brittleness and often falling of nails may occur in syringomyelia, leprosy and tabes dorsalis.

Examination of Skin For manifestation of Systemic Disease

Examination of skin often gives important clues to local or systemic diseases. The following features should be noted:

Color: It may be pale, flushed, cyanosed, yellow, etc.

Pigmentation: Pigmentation may occur in several diseases. Some common medical conditions associates with pigmentation are:

• Endocrine: Addison’s disease, Cushing’s disease, thyrotoxicosis.
• Deficiency: Pellagra, Kwashiorkor.
• Infections: Kala azar, chronic malaria, secondary syphilis, tuberculosis, leprosy, etc.
• Metabolic: Hemochromatosis.
• Skin disease: Neurofibromatosis, lichen planus, acanthosis nigricans, etc.
• Miscellaneous: Malignancy, pernicious anemia, exposure to sun rays or radiations.

Hypopigmentation: Hypopigmented patches may occur in leprosy, leukoderma, albinism, fungal infections of skin, etc.

Eruptions: Various types of eruptions may occur as follows:

• Macules: (Not raised above the skin). This may occur in typhoid, syphilis and purpura. If they are not generalized they are called roseollar.
• Papules: (Raised tiny nodules): This may occur in measles, chicken-pox, smallpox, and following drugs like sulfonamides.
• Pustules: These are papules containing pus.
• Nodules: (Large papules solitary projection from the skin). This may occur in erythema nodosum, leprosy, tuberculosis, secondary syphilis.
• Vesicles: (Small blisters). This may occur in herpes, chicken-pox and smallpox..
• Wheat: (Elevated patches on the skin with center paler than the periphery), Allergy.
• Café-Au-Lait patches: Dark brown patches resembling coffee in milk. They are considered significant if they are more than 5 in number. They are seen in:
  • Neurofibromatosis (regular outline without deep indentations).
  • Albright’s syndrome (irregular outline with deep indentations).

Hemorrhagic: Hemorrhage under the skin is classified as follows:

• Petechiae: Tiny hemorrhage less than 1 mm in diameter.
• Purpura: Hemorrhage 2-5 mm in diameter.
• Ecchymosis: Hemorrhage more than 5 cm in diameter.
• Hematoma: Hemorrhage large enough to produce elevation of skin.

Causes of hemorrhage under the skin:

• Deficiency: Vitamin deficiency, scurvy.
• Infection: Meningococcal meningitis, SBE, HIV.
• Hematological: Thrombocytopenia, acute leukemia, chronic lymphatic leukemia, chronic myeloid leukemia (in terminal phase) platelet dysfunction and aplastic anemia.

Type of Skin

• Dry skin: This is seen in myxedema and dehydration.
• Moist skin: This occurs when there is profuse perspiration as in shock, following myocardial infarction, crisis of pneumonia and thyrotoxicosis.
• Thick skin: This occurs in Myxedema, acromegaly and scleroderma.
• Thin skin: This occurs in old people and following wasting diseases.
• Pinched skin: suggests dehydration.

Hair: Changes in hair that occurs in some of the diseases are as follows:

• Falling of hair: Following infectious fevers e.g. typhoid.
• Patchy hair loss: Alopecia areata, syphilis.
• Loss of outer third of the eyebrows: Leprosy, Myxedema.
• Absence of axillary, pubic and facial hair: Hypopituitarism, hypogonadism.
• Excessive hair growth in women: Cushing’s syndrome, adrenocortical syndrome.

What Can Cause Pallor

Pallor is paleness of skin and mucous membrane either as a result of diminished circulating red blood cells or diminished blood supply.

Causes

1. Anemia
2. Shock
3. Peripheral vascular diseases

Sites where anemia is detected:

1. Lower palpebral conjunctiva
2. Tongue
3. Soft palate
4. Palm and nails

Checklist for General Examination of A Patient

The general examination of the patient must be done systematically, noting the following:

1. Built
2. Body proportions
3. Nutrition
4. Decubitus
5. Clubbing
6. Cyanosis
7. Jaundice
8. Pallor
9. Lymphadenopathy
10. Edema
11. Skin, hair and nails
12. Vertebral column
13. Joints
14. Temperature
15. Pulse
16. Blood pressure
17. Respiration