History taking and Physical exam Flashcards
Key areas in history taking?
- onset
- duration
- nature of symptoms
- quality of life
- patient language
- patient pre-conception and expectations
- past history
- drugs
- family history
- occupation and hobbies
Onset?
how, where, what kind of lesions started
Duration?
how long have you had the lesion
- beware as patients may only describe lesions which bother them
Nature of symptoms?
e.g. itch
1. what time
2. where on body
3. how severe (i.e. how it affects usual activities normal for age: sleep, work
4. who else is scratching
5. exacerbation factors.
Quality of life?
How the disease impacts on their life and self image
- Never to be under estimated!
Patient language?
Be careful not to just buy into terms patients tell you, but rather insist on description of what actually erupted;
e.g. ‘i had fungus,’ ‘she is usually troubled by allergy,’ ‘zipele,’ ‘zidzolo’ etc.
Patient preconception and expectations?
If any, take note of what they think might have caused their problem or what it is, their fears and expectations
e.g. ‘my friends told me its a cancer, ‘can I pass it to my child?’ ‘is it curable?’)
Past history?
- general problems
- DM, TB - past skin problems
- significant allergies
Drugs?
To ask in history taking
- Systemic and topical
- Prescribed and OTC
e.g. contraceptives, appetite enhancers, anti-pain, sleeping pills - cosmetics
- traditional
Family history?
- Some disorders are infectious
- others have strong genetic backgrounds
Occupation and hobbies?
The skin is frequently affected by materials encountered at work and in the home
Examination?
- Always in good light (ideally open day sunlight!!!)
- Examine from head to toe as a rule
- where this is not realistically possible, have at least an overall look of the affected area. - For some diseases, look for relevant areas
e.g, nails in psoriasis, palate in HIV/AIDS patients
What is a primary skin lesion?
Basic lesions of the skin are called primary lesions.
- its the first change of the skin
What is a secondary lesion?
They may undergo a variety of changes to become secondary lesions
e.g. patches of eczema becoming infected to form crusts.
In what case can lesions be primary in one condition but secondary in another?
e.g a macule may occur primarily in vitiligo, but be a secondary change in post-inflammatory hyperpigmentation of acne (following healing of acne papules)
In relation to normal skin level and contour skin lesions could be?
- Flat and at same level as normal skin
- Raised above normal skin
- Depressed beneath skin level
- Basic changes on the skin surface
- Fluid filled
- Changes due to vascular tissues
Steps in identifying lesions?
Primary Morphology
- Establish whether lesions are raised or not.
- Palpation is a must for this!! - Whether a solid mass or contains fluid.
- Size of the lesion
- No clear consensus
- 1 cm used to demarcate macule from a patch in other textbooks, as opposed to 0.5 cm in others.
Flat lesions?
- macule
- patch
- erythema
- erythroderma
Macule?
a flat localised change in skin color, up to 1 cm in diameter
Patch?
a large macule more than 1 cm in diameter.
Erythema?
blanchable reddening of the skin due to dilatation of blood vessels
NB: An erythema equivalent in the mucous membrane is called enanthema
Erythroderma?
generalised redness of the skin surface involving more than 90% of the skin
- Occurs over days or a few weeks.
Name Raised lesions?
- papule
- plaque
- nodule
- tumor
- cyst
- wheal/urticaria/hive
- scar
- comedo
Papule?
a solid raised area of the skin up to 1 cm in diameter.
Plaque?
a solid raised area of the skin more than 1 cm
Koebner phenomenon?
the appearance of new skin lesions on previously unaffected skin secondary to trauma
Where is Koebner phenomenon seen?
- psoriasis
- vitiligo
- lichen planus
- flat warts
Nodule?
solid area of the skin larger than 1 cm in both diameter and depth
- Can be epidermal, epidermal -dermal, dermal, etc
Types of nodules?
- exophytic nodule
- grows outward beyond the surface epithelium from which it originates - endophytic
- grows below the surface epithelium
Tumor?
bigger nodules often referred to as tumours
Cyst?
circumscribed, epithelial lined cavity, that may contain fluid or solid material
- contains secretory cells
Wheal/Urticaria/Hive?
edema of the skin due to extravasation of plasma from vessel wall in the upper dermis characterized by erythema and disappearance within hours
Scar?
proliferation of fibrous tissue that replaces previously normal collagen as a result of healing
Types of scars?
- hypertrophic
- keloidal
- atrophic
Hypertrophic scar?
elevated but does not extend beyond margins of previous wound.
Keloidal scar?
elevated but exceeds the margins with web-like extensions
Atrophic scar?
thin depressed plaques within margins
Comedo?
hair follicle infundibulum that is dilated and plugged by keratin and lipids.
e.g. Open comedone vs Closed comedone
Depressed lesions?
- striae/strecth marks
- atrophy
- erosion
- ulcer
- fissure
Striae?
linear depressions of the skin resulting from rapid stretching of the skin (which causes changes to underlying reticular collagen)
Atrophy?
thinning and depression of the skin due to decrease in number of epidermal or dermal cells
Erosion?
superficial defect resulting in loss of epidermis or mucous membrane.
- Unless secondarily infected, heals with no scar
Ulcer?
defect involving all epidermis and at least part of dermis.
- Heals with scarring
Fissure?
a slit/cut in the skin with linear epidermal and dermal loss.
Lesions causing basic changes on the skin surface?
- crust
- scale
- keratoderma
- excoriation
- lichenification
Crust?
hardened deposits of dried blood, serum or purulent exudate on the skin.
Scale?
a flat plate or flake of excess epidermal cells from the horny skin layer
- Usually produced by abnormal keratinization.
Describe scales?
Accumulation of thickened horny layer keratin
1. readily detached fragments
2. thickening of epidermis,
3. fine white silvery in psoriasis,
4. large fisk like in ichthiosis
Keratoderma?
excessive hyperkeratosis of the stratum corneum resulting in thickening of the skin, usually of the palms and soles
Excoriation?
linear erosion or ulcer due to scratching
Lichenification?
thickened area of skin with accentuated markings resulting from repeated rubbing or scratching of the skin
Fluid filled lesions?
- vesicle
- blister
Vesicle?
fluid filled lesion of up to 1 cm in diameter
Blister?
Types of blisters?
Larger vesicle is a blister (bullae)
1. Epidermal - flaccid and easily destroyed
2. Dermal - firm and tense.
Lesions with collections of pus?
- abscess: any localised collection of pus.
- pustule: visible well circumscribed collection of pus less than 1 cm in diameter.
- furuncle: If located around a hair follicle
- carbuncle: a collection of furuncles
Changes due to vascular tissue?
- purpura
- petechiae
- telangiectasia
- ecchymoses (bruise)
Pupura?
reddening of the skin due to extravasation of erythrocytes
- Unlike erythema, purpuric lesions do not blanch.
Petechiae?
small pin point purpuric macules.
Telangiectasia?
visible dilatation of small cutaneous blood vessels
Echymoses?
larger accumulation of blood in skin or deeper tissues.
Lesion?
term for area of disease, small
Eruption/rash?
widespread
What are lesions and rashes?
- composed of lesions due to primary pathology
- or due to secondary factors:
e.g. scratching, infection > lichenification or ulceration
Describe different Shapes/configurations of skin lesions?
- nummular - round/coin like
- annular - ring like
- circinate - circular
- arcuate - curved
- discoid - disc like
- gyrate - wave-like
- retiform/reticulate - net like
- targetoid - target/bullseye
- polycyclic - formed from coalescing/ incomplete rings
- grouped - together in a group
- linear - in a straight line
O SCALES?
Outline (border)
- regular, irregular, well defined
Size (number)
- multiple, singular
Colour
Arrangement
Localisation
Efflorescence
Shape
