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Necessary Elements of a Dermatologic History and Physical


Evaluation
Janet M. Cole, Deanna Gray-Miceli
Dermatology Nursing. 2002;14(6)

The skin is the largest and most visible organ of the body. A large percentage of primary care visits are dermatology
related. The skin reflects the internal well-being of the body and can develop manifestations of systemic illness. The
nurse's ability to recognize and accurately describe lesions can lead to prompt diagnosis and treatment of conditions,
helping the patient to avoid discomfort, systemic illness, or death. To accurately describe skin findings, the nurse
should know the names and defining characteristics of several important primary lesions (Dains, Baumann, &
Scheibel, 1998) (see ).
Table 1. Primary Skin Lesions

When lesions are found it is important to record their distribution, arrangement, and morphology (Sams & Lynch,
1996). Describing the distribution is valuable because many skin diseases have characteristic locations that may
provide clues to diagnosis. Arrangement patterns are also important clues. Some typical patterns include linear,
grouped, oval, round, annular, iris, polygonal, serpiginous, umbilicated, zosteriform, and morbilliform (see ).
Morphology is described in terms of size, color, consistency, configuration, margination, and surface characteristics
(Sams & Lynch, 1996).

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Table 2. Arrangement Patterns

Secondary skin lesions are lesions that have changed from their primary appearance due to natural evolution,
scratching, secondary infection, or treatment. Some examples are scale, crust, erosion, ulcer, lichenification, scar,
keloid, excoriation, fissure, and atrophy.
In the primary care setting there are two ways skin lesions may come to the attention of a clinician. They may be the
reason the person is seeking care, the chief complaint, or they may be found incidentally while performing a general
physical examination.
Taking a history first and then performing a physical examination is the accepted way to gather information in general
medicine and in specialty practices. In dermatology, many authors advocate making a brief initial physical assessment
before conducting the history (Dains et al., 1998; Fitzpatrick, Johnson, Polano, Suurmond, & Wolff, 1994; Sams &
Lynch, 1996). Others recommend examination and history taking concurrently (Bates, Bickley, & Hoekelman, 1995;
Jackson, Alghareeb, Alaradi, Ibrahim, & Tomi, 1999) (see Figure 1). Figure 1 represents an innovative form which also
contains guiding information to help providers maximize coding levels for examinations, thereby improving practice
income. The form in Figure 1 can be completed by the patient in the waiting area. It begins with a reassurance of
confidentiality and at the end, includes a description of what can be expected in a "full body exam," a part of a
dermatological visit that sometimes causes anxiety. The form enables the patient to record his/her health history in an
unhurried manner. Listing specific examples of potential problems in a check-off format, helps assure that all pertinent
health information can be reviewed efficiently. Page 2 of the form creates a uniform format for multiple practitioners to
quickly review previous visits and record their findings. It facilitates asking about the progress of past problems and
modify in plans to improve patient outcomes.
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Figure 1.

Sample History and Physical Form


After an initial examination, history taking will be more focused and productive. This approach also facilitates prompt
intervention if there is a life-threatening condition.
If the patient presents with a rash, the clinician must immediately ask three questions:
1. Do you have a fever?
2. Are you having difficulty breathing or swallowing?
3. If there is a fever, is the rash tender and is there mucosal involvement?
Fever. In viral rashes, fever is not uncommon and usually the condition is not life threatening. However, fever in the
presence of irritability, hypotension, a septic appearance, and a petechial or macular rash may point to
meningococcemia, a medical emergency.
Allergic Reaction. Swelling of the airway and/or of the tongue, lips, face, and extremities, as well as coughing,
wheezing, and shortness of breath can be caused by angioedema from an allergic reaction. Treatment should be
instituted quickly to control the allergic response and prevent possible anaphylaxis.
Fever, Tender Rash With Mucosal Involvement. Stevens-Johnson syndrome or toxic epidermal necrolysis presents
with a tender morbilliform rash with fever, conjunctivitis, oral mucosal ulcers, and diarrhea. This is a life-threatening
condition requiring immediate hospitalization. The impending exfoliation of large areas of skin requires patient support
in a burn unit. If the person's rash is not an emergency, continue with the exam.
Demographic Information

Usually collected at the front desk. Name, address, phone number, age, gender, ethnicity, marital status, occupation,
education, and religious preference.
History

Chief Complaint. In patient's own words. The nurse gains a sense of direction about which triage questions to ask.
History of Present Illness. "OLDCARTS" - onset, location, duration, characteristics, associated symptoms, relieving
factors, timing, severity; medications and treatments tried.
Medical history. General health, illnesses, surgeries, hospitalizations, blood transfusions, immunizations, emotional
status, psychiatric history, medications, and allergies.
Family history. Do any other family members have the same condition, other skin conditions? Do parents, siblings, or
children have cancer, diabetes, hypertension, heart disease, or stroke?
Health habits. Tobacco, alcohol, recreational drug use; diet, exercise, exposure to toxins; sexual exposures/habits.
Travel. Domestic and international in the last year.
Occupation. Although mentioned in the demographic section, it may be useful to review it here, especially if the
symptoms seem to point to a contact dermatitis.

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Hobbies. Gardening, crafts, etc. Skin care routines. Frequency and temperature of showers and baths; types of
cosmetics, soaps, oils, and products used. Home remedies, sun exposure.
Hair and nail care. Products and routines.
General. Fever, chills, desired weight, fatigue.
Diet. Appetite, restrictions, supplements, vitamins.
Skin, hair, and nails. Rashes, pigment changes, pruritus, easy bruising; change in hair texture, quantity, distribution;
nail changes.
Head and neck. Injuries, headaches, dizziness, loss of consciousness.
Eyes. Visual changes, trauma, eye diseases.
Ears. Tinnitus, hearing loss, pain, vertigo.
Nose. Congestion, nose bleeds, post-nasal drip.
Mouth and throat. Sore throat, hoarseness, ulcers; dental problems, hygiene/condition of teeth.
Gastrointestinal. Heartburn, indigestion, ulcers, pain, bowel changes, bloating.
Endocrine. Recent weight change, heat or cold intolerance, frequent thirst or urination, hair changes, increased hat,
glove or shoe sizes.
Respiratory. Cough, shortness of breath, dyspnea on exertion, night sweats.
Cardiovascular. Chest pain, palpitations, edema, or claudication.
Genitourinary. Flank pain, urgency, dysuria, hematuria, or discharge.
Musculoskeletal. Joint pain, heat and swelling.
Neurologic. Weakness, fainting, change in coordination, memory loss.
Psychiatric. Anxiety, depression; changes in mood, concentration, sleep patterns, eating; suicidal thoughts.
The room should be warm, preferably lit with diffuse bright daylight. An astutely observant eye, a sensitive touch, a
small flexible, metric ruler, a hand-held magnifying lens, a small flashlight and perhaps a Wood's light should be
available.
It is best to have the patient change into a gown, leaving only his/her underwear on. A paper drape sheet will help the
patient feel covered as different areas of the body are examined and redraped. The best light in which to examine skin
is daylight. Artificial light, including fluorescent, changes the appearance of skin and lesions.
Examination of the skin includes mucous membranes, hair, and nails. The involvement of any or all of these areas
provides diagnostic information. Physical assessment of the skin is done systematically, first with a general overview to
assess skin symmetry, the existence and distribution of any lesions and, second, a lesion-specific exam.
Begin with the head. Be sure to examine the mucous membranes in the eyelids, nose, and thoroughly in the mouth buccal, pharyngeal, sub-lingual as well as the tongue. Next examine the neck, arms, hands, chest and abdomen, legs,
back, back of legs, feet, including soles and between the toes, buttocks, and genital area. Careful attention should be
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paid to areas where skin contacts other skin (intertriginous areas). Skin and mucous membranes should be carefully
inspected for color, symmetry, uniform appearance, hygiene, and lesions. Any abnormalities should be described in
terms of whether they are primary or secondary lesions. Next, descriptive adjectives regarding characteristics,
exudates, pattern, location, and distribution can be added. After inspection, any lesions should be gently palpated to
test for tenderness and consistency. Note temperature, moisture, texture, turgor, and fragility.
Hair. Texture, color, quantity, distribution, brittleness, diffuse hair loss, pattern thinning, patchy loss, and excessive hair
in females should be noted. Observe for broken hair shafts, chemical or mechanical (pulling, twisting). Note the
presence of nits or parasites. Examine the scalp for scales, crusts, or lesions. Inspect facial hair distribution, quantity,
texture, hirsutism in females.
Nails. Length, color, configuration, symmetry, hygiene, thickness, deformities, new hyperpigmented band, pitting, and
splinter hemorrhages should be noted.
Complete descriptions of all findings should be documented to facilitate making diagnoses and plans of care, as well
as providing a baseline against which to measure the patient's progress.
Recent changes in the practice of medicine in this country have occurred because third-party insurance carriers can
restrict their insured persons from seeing some specialists before they see their "primary care provider." People with
dermatologic concerns will be seen first in pediatric, family practice, and in some internal medicine practices. Nurses
who are knowledgeable about primary and secondary skin lesions and the specific terminology used to describe them
can help the practitioner to make an accurate diagnosis, creating better patient outcomes and less morbidity.
Additionally, the nurse can use this understanding to better instruct the patient in self-care measures, including how to
avoid recurrences of the skin problem.
A better understanding of dermatologic conditions by primary care providers should underscore the subtleties inherent
in the specialty. Even in common situations, such as the management of acne, the best results for the patient in terms
of improvement of symptoms, shortening the course of treatment, and fewer permanent side effects, such as scars,
could be expected through management by the best-educated specialist, the dermatologist.
Due to the fact that the skin is so visible and people often know when something has changed with their skin, the point
can be made that dermatologists should be considered as primary care providers. Additionally, there are potentially
serious, even life-threatening conditions identifiable by the dermatologist that the lay person and even another doctor
might not recognize (Kirsner & Federman, 1995). As long as the people who are paying for health insurance have no
authority to select the plans they are paying for, most people will have to endure some degree of restricted access to
medical care.
It is unfair and unrealistic to expect general providers to develop expertise in many specialties, especially when this
country has so many well-educated specialists. However, as long as today's health care insurance system prevails, it
will be helpful for the nurse to become more knowledgeable about skin conditions that may cause patients to seek
medical care.
CME Information

The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher.
Jannetti Publications, Inc. East Holly Avenue Box 56, Pitman, NJ; phone (856) 256-2300.
References

1. Bates, B., Bickley L.S., & Hoekelman, R.A. (1995). A guide to physical examination and history taking.
Philadelphia, PA: J.B. Lippincott Co.
2. Dains, J.E., Baumann, L.C., & Scheibel, P. (1998). Advanced health assessment and clinical diagnosis in
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primary care. St. Louis, MO: Mosby.


3. Fitzpatrick, T.B., Johnson, R.A., Polano, M.K., Suurmond, D., & Wolff, K. (1994). Color atlas and synopsis of
clinical dermatology. New York: McGraw-Hill, Inc.
4. Jackson, R., Alghareeb, M., Alaradi, I., & Tomi, Z. (1999). The diagnosis of skin disease. Dermatology Nursing,
11 (4), 275-283.
5. Kirsner, R.S., & Federman, D.G. (1995). Managed care: The dermatologist as a primary care provider. Journal
of the American Academy of Dermatology, 33, 535-537.
6. Sams, W.M. Jr., & Lynch, P.J. (1996). Principles and practice of dermatology. New York: Churchill-Livingstone,
Inc.
7. Hill, M. (1998). Dermatological nursing essentials: A core curriculum. Pitman, NJ: Dermatology Nurses'
Association. Hill, M. (1994). Skin disorders. St. Louis, MO:
8. Mosby Year Book, Inc. Mir, A. (1997). Atlas of clinical skills. London, England: W.B. Saunders, Ltd. Wang, J.I.
(2002). Seminar: Coding in a dermatologic practice. Presented at the Dermatology Nurses' Association
Convention, February 24, 2002, New Orleans, LA.
Acknowledgments
Ms. Cole wishes to acknowledge and thank Drs. Jonathan Gold, Sammy Hutman and Roy Stern of The Dermatology
Center of North Jersey, Clifton, NJ, for many years of generous teaching and for sharing their dermatological expertise
and wisdom. Their encouragement was indispensable during the years of study toward becoming a Nurse Practitioner.
Thank you so much. She also wishes to thank Dr. Christopher Sciales and the dermatologists of Livingston and
Warren Dermatology, NJ, for their kindness and continued support of her as she begins her Nurse Practitioner career.
Dermatology Nursing. 2002;14(6) 2002 Jannetti Publications, Inc.

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