Dermatology: History Taking & Examination Flashcards
Outline the structure of a dermatological history
- History presenting compliant
- Systems review
- PMH
- Medications & allergies
- FH
- Social history
- Impact on QoL & ICE
What questions should you ask in history of presenting complaint?
- Nature (tend to split into inflammatory/rash and lesions)
- Site
- Duration
- Initial appearance and evolution
- Symptoms (itch, pain, bleeding, discharge, blistering)
- Aggravating & relieving factors
- What, if any, treatments they have tried and whether they have been effective (be sure to clarify how much/how often taking, how long tried for)
- Any contact with infectious disease/anyone else with the rash
- Any changes to cleaning/washing products, skin care, diet etc…
- Any recent travel
- Any recent stress
- Had anything like this before
*NOTE: itching is PRURITUS
What questions should you ask in systems review?
- Nail changes
- Hair changes
- Weight loss
- Lethargy
- Fever
- Arthralgia
- Lumps or bumps anywhere
- Bowels & bladder
What questions should you ask in PMH?
- History of atopy
- History of sun burn/sunbathing/sunbed use (ask if burn easily to help clarify skin type)
- History of skin cancer or precancer
- Systemic diseases
What should you ask in medications & allergies?
- Ensure asked about previous and current treatments for presenting complaint and whether they are effective
- Other medications (think about how long they have been on them as may be side effect)
- Allergies (and what happened)
What should you ask in medications & allergies?
- Ensure asked about previous and current treatments for presenting complaint and whether they are effective
- Other medications (think about how long they have been on them as may be side effect)
- Allergies
What should you ask in family history?
- FH of skin disease (any skin disease but maybe ask specific dependent on complaint e.g. ask about cancer specifically)
- FH of atopy
- FH of autoimmune disease (relevant in e.g. vitiligo)
What should you ask in social history?
- General social: who live with & are they well, type of accommodation, support at home
- Occupation (if appropriate, enquire specifically about sun exposure or contacts/irritants exposure)
- Whether symptoms change when away from work
- Alcohol history
- Smoking history
- Illicit drug history
What should you ask in impact on QoL & ICE?
- Explore impact on QoL
- Ideas
- Concerns
- Expectations
Briefly outline how to carry out dermatological examination/examination of skin rash or lesions
- General inspection (of patient & surroundings)
- Closer inspection of lesion
- Palpation
- Systemic examination
What should you look for in general inspection part of dermatological examination?
- Can you see the lesion/rash? The distribution? Does it look severe?
- General inspection of surroundings:
- Medical: bandages, topical medications, oral medications, IVs, prescription charts
- Mobility aids: wheelchairs, walking aids
What should you look for in the closer inspection part of dermatological examination?
*HINT: SCAM
- Site, size & distribution
- Colour & configuration (shape & relationship of individual skin lesions to one another)
- Associated changes (e.g. surface features)
- Morphology/ form (e.g. patch, plaque etc…)
What should you assess for in the palpation part of dermatological examination?
- Texture (smooth or rough)
- Elevation/depression
- Crust (are you able to remove this and see underlying tissue e.g. psoriasis)
- Temperature
- Consistency (hard, firm or soft)
- Fluctuance (hold lesion either side then apply pressure to centre to see if sides bulge outwards as in fluid filled masses)
- Mobility
- Tenderness
What should you assess for in the systemic part of your dermatological examination?
- Hands: nail pitting, onycholysis, koilonychia
- Elbows: psoriatic plaques, xanthomas, rheumatoid nodules
- Hair & scalp: hair loss (patchy. diffuse or total), hirsutism, hypertrichosis, scalp psoriasis, seborrheic dermatitis
- Mucous membranes: hyperpigmented macules (pathonogmonic for Peutz-Jeghers syndrome), bullae (pemphigus vulgaris)
- Lymphadenopathy
- Joints: swelling, tenderness
Remind yourself of ABCDE assessment for pigmented lesions
ABDE rules
- Asymmetry
- Irregular border (1. pattern in which lesions extends out in surrounding skin e.g. can you draw nice smooth line around it or is it wiggly? 2. Definition of the border- is the border distinct or are there areas where it merges/fades into surrounding skin? Poorly defined more likely to be aggressive malignancy)
- Multi-coloured (difference between different colours and different degrees of pigmentation)
- Diameter >0.6cm
- Evolution (of all of the above)
State some examples of descriptors you could use for site & distribution
State some examples of descriptors you could use for configuration
- *Generalised: all over body*
- *Widespread: extensive*
- *Localised: restricted to one area of skin only*
- *Photosensitive: sun exposed areas e.g. face, neck, back of hands*
- *NOTE: linear may imply Koebner’s phenomenom (**appearance of new skin lesions of a pre-existing dermatosis on areas of cutaneous injury in otherwise healthy skin) which is specific to psoriasis, lichen planus & vitiligo*
State some examples of descriptors you could use for colour
- *Hypopigmented: paler skin due to melanocyte or melanin depletion or dysfunction (e.g. in pityriasis versicolour)*
- *Depigmentation: are of skin which is completely white due to absence of melanin (e.g. vitilogo)*
- *Erythema due to increased blood supply to skin/vasodilation*
- *Purpura due to small blood vessels bleeding into dermis*
State some examples of descriptors you could use for surface features
*Fissure: sharply defined linear or wedge shaped tear in epidermis withabrupt walls
State some examples of descriptors you could use for morphology
- *Macule: non-palpable area of discolouration <2cm*
- *Patch: non-palpable area of discolouration/macule that is >2cm*
- *Plaque: palpable flat lesion usually >1cm. Most are raised but some may be thickened without being visible raised*
- *Papule: raised palpable lesion and <0.5cm*
- *Nodule: raised palpable lesion and >0.5cm (up to~1cm)*
- *Pustule: pus containing lesion <0.5cm*
- *Abscess: localised accumulation of puss*
- *Vesicle: raised, clear fluid-filled lesion <0.5cm*
- Bulla: raised, clear fluid-filled lesion >0.5cm in diameter*
- *Wheal: oedematous papule or plaque due to dermal oedema*
- *Annular: ring shaped*
- *Lichenification: thickening of skin with exaggerated skin markings*
- Discoid/nummular: circular or coin shaped*
- *Comedone: open (black) or closed (white)*
State some examples of hair findings
State some examples of nail findings
Brief summary of all morphological terms (need to know them all)
