I. OVERVIEW
An initial assessment for patients with skin disorders should be approached as you would any patient. A comprehensive assessment of a dermatologic condition includes the history given by the patient (subjective data) and the findings of the physical examination of the integumentary system (objective data). The patient history and physical examination should also occur in an appropriately private area to ensure privacy and dignity, preferably with natural lighting. A preliminary history of a dermatologic problem can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (
Box 2-1).
Skin provides an opportunity for visual inspection. This makes inspection the most important part of the physical examination of the skin. Physical examinations should be done in an orderly manner to insure important diagnostic clues are not missed. The initial key impression of whether the patient appears ill or not is important to note at the beginning of the physical examination.
Lesions can be defined as primary or secondary. Primary lesions are structural changes in the skin that have specific, visual characteristics and develop without any preceding skin changes (
Table 2-1). Secondary lesion is one that has changed due to natural progression or due to physical factors such as rubbing or scratching (
Table 2-2). Special or “other” lesions are those that occur in the skin only and in the skin most often or can be perceived most easily on the skin (
Table 2-3).
Specific terminology is used to describe the characteristics of skin lesions (number, color, type of lesion, configuration, distribution pattern, which can then be documented). These descriptive clues aid in diagnosing and managing the patient by healthcare providers. It is important to use generally accepted descriptive terminology for verbal and written documentation to ensure continuity and to assist health care providers to interpret the findings. The general examination of the skin considers normal variants and general changes in the skin. A wide range of normal variations exist in the skin across the life span, which may be due to age, genetic factors, and environmental influences (
Table 2-4).
II. PATIENT HISTORY (SUBJECTIVE DATA)
A. The traditional approach to assessment in general is to take the history prior to performing a physical examination. However, in dermatology, some providers prefer to do this
is in a reverse order to expedite the process. A preliminary history helps to establish rapport and engages the patient in the process. Then, moving to physical examination allows appropriately chosen selective questions to be asked subsequently. The general history of current illness is ideally obtained by allowing patient to use their own words regarding his/her skin condition. This gives the provider a sense of direction as to which triage questions to ask. Initially, try to allow the patient to talk uninterrupted. This preliminary history can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (
Box 2-1). Answers to these questions provide a great deal of information about how the condition has started and evolved over time. Review of systems is indicated by the acute or chronic current condition. Symptoms often drive how far one will go in looking for an etiology. Treatment is so key as oftentimes, regardless
whether over-the-counter or prescription medications, it can be the very thing causing or contributing to the problem.
B. Information regarding other family members with similar symptoms, past medical history, previous and current drug therapy (including all over-the-counter preparations like herbs, vitamins, and natural supplements), occupation, and social history are all important parts of the initial interview.
1. Family history is important. Conditions such as psoriasis, eczema, skin cancer, or even keratosis pilaris have a genetic tendency. Patients may claim that another family member shares similar symptoms. For example, the diagnosis of atopic dermatitis is supported when the child presenting with chronic pruritic rash in antecubital fossa has a family history of atopic diseases (asthma, hay fever, and atopic dermatitis).
2. Medical history is significant, including illnesses—particularly chronic illness, which may manifest in the skin—and surgical procedures, for example, if the patient presents with diffuse hair loss or perhaps an unusual rash that may be due to an unresolved strep infection or recent infections occupied by high fever. In another scenario, a past history of chickenpox is helpful in evaluating the patient suspected with herpes zoster.
3. Medication history and medication allergy can take time to update in a comprehensive manner. Then for example, obtaining information regarding current prescription therapy or medicines recently used, including all topicals; systemic medications including steroids; vitamins, and dietary supplements complementary or over-the-counter medications; and home remedies. Drugs or medications can cause multiple types of skin conditions.
4. Occupational history is important in skin disease when patients have occupation-associated symptoms or those which improve over a weekend or resolve while on vacation. In conditions such as occupational contact dermatitis, significant short- and long-term disability, and legal issues may coexist.
Only gold members can continue reading.
Log In or
Register to continue
Related
Full access? Get Clinical Tree
Psychosocial Effects and Nursing Interventions for Dermatological Disease and Psychodermatoses
Connective Tissue Disorders
Acne and Other Disorders of the Glands
Disorders of Pigmentation and Dermatologic Considerations in Ethnic Skin
Biologic Therapies for Dermatology Conditions
Cutaneous Manifestations of Systemic Disease
Dermatologic Conditions in Children
Dermatologic Diagnostic Tests and Procedures