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History taking Physical examination

Hannah K Damar

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Preliminary history

Physical exam:
◦ Identify the morphology of the lesion ◦ Configuration, distribution

Primary
secondary

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Consider clinicopathologic correlation Follow up history Laboratory test

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Let the patient talk uninterrupttedly Clarify : Duration ◦ Symptoms ◦ Distribution ◦ Treatment Expand the history ◦ Confirm diagnose ◦ Differential diagnose ◦ Underlying disease/ condition/past medications

Why. Where. When. How History of the present illness  What is your skin problem?  Does it itch?  How long?  How you treated it?  Where it begin?  Why it could happen? .What. Who.

 Onset and evolution ◦ When it start ◦ Getting better or worse ◦ Is it the first time? Repeatedly?  Symptoms ◦ Does it itch? ◦ Does it pain? ◦ Do you have fever?  Treatment to date ◦ Ask for “ Over the counter” preparation .

 Review of systems ◦ Photosensitivity ◦ Hair loss ◦ Mouth ulcers  Family history ◦ Atopic diseases ◦ Inherited diseases  Social history / Skin exposure history ◦ Expose to blood product ◦ Expose to chemical substance ◦ Hobby .

Special occasion  contact dermatitis    Skin exposure history . at work & at play Industrial dermatitis  worker’s disability Outdoor activities Detective – type search .

inhalation.photo / UV )  Trauma  Endocrine  Malignancy  Others ( Inherated . food /drug & herbs.Skin problem in Indonesia  Infection  Infestation  Allergy ( contact.

KEY POINTS  Complete skin examination at the first visit The entire skin surface should be examined as well as hair. nails and mucosal surfaces  Good lighting ( natural lighting/ flourescent/ side light) Describe the morphology of the eruption  Ask approval for examination .

Tools     Lighting Magnifying lens/ hand held lens Wood’s light ( UV 365nm) Dermatoscope Lesions need to be looked for .

Start by examining the affected areas  need to examine the entire skin surface Reason : Lesions that may accompany the presenting complaint Unrelated but important incidental findings  Colour  Contour = primary & secondary skin lesion  Distribution  Configuration  Development .spreading .

        Red Pale Brown Black Yellow Bluish Green Wood’s Lamp: Golden yellow Coral red Green .

Woods lamp M canis fluorescence .

brown-red macular patches.The typical appearance of erythrasma is welldemarcated. The skin has a wrinkled appearance with fine scales .

What to inspect and palpate ?  Characterize the appearance  Consider clinicopathologic correlation .

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 Palpation helps to: ◦ Assess texture and consistency ◦ Evaluate tenderness ◦ Reassure patients that they are not contagious .

 Diascopy  a test for blanchability  applying pressure (finger or glass slide) observe color changes Dimple sign  lateral compression causes the central portion of lesion to dimple Nikolsky’s Sign  the top layers of the skin slip away from the lower layers when slightly rubbed Darier’s sign  a change observed after stroking the skin it becomes swollen. itchy and red Auspitz’s Sign  simply bleeding after psoriatic scales have been removed     .

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     . ) Skin scrapings or nail clippings for mycology Skin swabs and smears for bacteria yeast & viral infections. Skin biopsy (histology & direct immuno fluoresc.    Patch testing Prick test (Type 1 hypersensitivity reactions) Photopatch Testing Photo Testing Dermoscopy for pigmented lesions to diagnose melanoma.

•Colour .The two halves of your mole do not look the same. •Diameter . with more than one shade.45 Dermatoscope examination .75 •Highly suggestive 5.The edges of your mole are irregular. blurred or jagged.Your mole is wider than 6mm in diameter (the size of a pencil eraser) •Suspicious 4.•Asymmetry. •Border.The colour of your mole is uneven.

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Racket nails: the distal phalanx is shorter & wider than normal Congenital abnormalities: o Anonychia o Micro- (complete absence) or Macronychia o Onychoheterotopia (abnormally situated nail) o Racket nail o Leuconychia totalis (completely white nail) .

bed . Beau's lines: Transverse ridges on nails Longitudinal ridges  Trachyonychia: Means roughness of nails  Pachyonychia: Thickening of nail plate  Onychorrhexis: Nail separates at lunula & is shed partially or completely  Onychomadesis: Complete shedding of nail. begins distally or laterally  Onycholysis: Detachment of nail from its nail.

Gastrointestinal . Idiopathic -Unilateral clubbing -Unidigital clubbing Longitudinal brownish streaks Others:  Egg-shell nails: In avitaminosis A  Quincke's sign: Increased capillary pulsations  Brittle nails : Iron deficiency anemia . Endocrine CNS.

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After prolonged tetracycline therapy Green nails: .Chloroquine or mepacrine therapy .In congestive heart failure Splinter haemorrhages .Yellow nail syndrome .Infection with pseudomonas spp. Blue nails: .Blue lunules in Wilson's disease Red half moons: .White nails: Patchy white discolouration Yellow nails: .

THANK YOU .