Chapter 3: History and Physical Examination of the Skin, Hair, and Nails

INTRODUCTION TO CHAPTER

The physical examination was a primary tool in the diagnosis of most diseases prior to the widespread availability of diagnostic laboratory tests and imaging.¹ Many skin diseases are currently diagnosed on the basis of a short history and physical examination.

Typically, the history and physical examination for skin problems are done in the same sequence and manner as with any other organ system. However, in some cases, it is helpful to examine the patient after taking only a brief history, so that the questions for the patient can be more focused.

The history and physical examination play an important part in establishing rapport, confidence, and trust in the patient–clinician relationship. In this chapter, information on the challenges and opportunities in the care of select populations will be covered.

SELECTED KEY POINTS FOR HISTORY OF CUTANEOUS DISORDERS

A problem-focused history is sufficient for most common skin disorders. If the patient has systemic complaints, or if diseases such as lupus erythematosus or vasculitis are suspected, a detailed or comprehensive history may be needed.

History of Present Illness (HPI)

• Initial and subsequent morphology of the lesions.

• Location of lesion(s).

• Symptoms (e.g., itch, pain, tenderness, burning).

• Date of onset/duration.

• Severity-current and in the past.

• Factors causing flares.

• Use of medications, including over-the-counter prod­ucts.

• Response to prior treatment.

• History of previous similar outbreaks.

If the patient's main complaint is a skin tumor or growth, the following additional questions should be added.

• What changes have occurred in size and appearance of the lesion?

• Is there a history of spontaneous or trauma-induced bleeding of the lesion?

• Is there a history of sunburns or tanning bed use?

• What is the history of use of sunscreens?

It is also important to determine the patient's Fitzpatrick skin type, as this helps to identify patients at risk for skin cancer. The patient should be asked if they burn easily or tan after initial exposure to approximately 45–60 minutes of sunlight in early summer.² The patient's response determines the Fitzpatrick skin type.

• Skin type I: Always burns, never tans.

• Skin type II: Usually burns, tans with difficulty.

• Skin type III: Sometimes burns, tans normally.

• Skin type IV: Rarely burns, tans easily.

• Skin type V: Very rarely burns, tans easily.

• Skin type VI: Never burns, tans darkly.

Typically, there is some correlation between a patient's Fitzpatrick skin type and skin color. However, there are patients with darker skin tones who do experience sunburns and sun damage.

If indicated, the patient should also be ...