Transcript Taking a history & terminology Dr Iain Henderson GP
Taking a history & terminology Dr Iain Henderson GP Scotstoun Hospital Practitioner, Western Infirmary Basic Dermatology Day
Diagnosis of skin disease
• In medicine in general it is said that 80% of the diagnosis comes from taking a good history, 16% from a good examination and only 4% from investigations.
Dermatology being such a visual specialty, the percentages of the first two may differ but the 96% of diagnoses from these still hold true.
Presenting complaint
Timing and site • Duration?
• Where did it start?
• Does it come and go?
Nature of lesion/rash • What did it originally look like and has it changed?
• Has it spread locally or elsewhere?
Presenting complaint
Symptoms • Does it itch? • Is it tender to touch?
• Was there preceding pain e.g. in herpes zoster (shingles)?
Relieving/exacerbating factors • Does anything make it worse e.g. heat, sunlight?
• Does anything make it better?
Age
History taking
Past medical history
• Has the patient had a skin problem before?
• Is this the same?
• Do they have a systemic disease e.g. diabetes which may have accompanying skin features e.g. necrobiosis lipoidica?
• Has there been any recent viral or bacterial illness e.g. guttate psoriasis after a streptococcal throat?
History taking
Drug history
• Have they tried any topical treatments themselves?
• Have they helped or made it worse?
• Ask about cosmetics in case they contain sensitisers causing dermatitis.
• What prescribed and over the counter oral medications have they taken? Important if one suspects a drug eruption.
Family and social history
• Ask if there is a family history of atopy. Other conditions such as psoriasis may have a genetic component.
• Do other family members or close contacts have a similar condition?
• Occupation and hobbies e.g. in contact dermatitis. Does it get better on holiday and away from work?
• Alcohol intake may be a factor e.g. psoriasis or may interact with some of the drug treatments.
• Smoking e.g. in palmar-plantar pustulosis or squamous cell carcinoma of the lip in pipe smokers.
• Travel to sunny climes and tropical regions may lead to increase sun damage to the skin and exotic infections.
• Psychological e.g. parasitosis, dermatitis artefacta
Clinical examination
Look • Good light • Magnifying glass • Whole skin/nails if necessary Feel • Surface palpation with finger tips –smooth, uneven or rough?
• Deep palpation by squeezing – soft, firm or hard?
• Scratch • Pick
Clinical examination
Describe, describe, describe!
• Site involved • Number – single or multiple?
• Distribution – symmetrical or assymmetrical?
- unilateral, localised or generalised?
- sun exposed areas?
• Arrangement e.g annular, linear, discrete, grouped, disseminated etc?
Terminology
Macule Patch Papule Nodule Plaque
Vesicle Bulla Pustule Abscess
Macule
- small flat skin discolouration
Patch
- a larger flat area of skin discolouration
Papule
- elevated skin lesion less than 0.5cm in diameter
Nodule
- elevated skin lesion more than 0.5cm in diameter
Plaque
- elevated flat topped lesion
Vesicle -
A small blister <10mm in diameter. This is filled with clear fluid and lies in the epidermis or the dermo-epidermal junction.
Bulla Pustule -
A blister >10mm in diameter.
A blister filled with a visible collection of pus. Not all pustules are signs of infection.
Abscess -
A localized collection of pus >1cm in diameter.
Lesion due to a broken surface
• Erosion - A superficial break in the skin, involving the epidermis but not the dermis therefore heals without scarring.
• Ulcer - A circumscribed area of skin loss down to and involving the dermis. It will therefore heal with scarring.
• Fissure - A linear split in the skin which can extend down into the dermis.
• Excoriation – Localised damage due to scratching with linear erosins and crusts
Weal A transient elevated lesion i.e. papule or plaque which is compressible due to dermal oedema. It is usually red or white in colour.
Cyst – A papule or nodule lined with an epithelial wall and filled with fluid, pus or keratin.
Crust – dried exudate Scale visible and palpable flakes of grouped epidermal cells
Lichenification –
Thickening of epidermis with increased skin markings due to persistent rubbing
Pedunculated –
stalk –like lesion
Papillomatous –
surface has minute round or finger –like projections
Filiform –
rough finger –like projections
Summary
• History – similar to most medical conditions • Examination – Look and feel • Describe