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There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.

—Sir William Osler, 1903

INTRODUCTION TO CHAPTER

The physical examination was a major tool in the diagnosis of disease prior to the widespread availability of diagnostic laboratory tests and imaging. Many evaluations and diagnoses are now made in the absence of an extensive physical examination and history.1,2 Most skin diseases, however, are still diagnosed on the basis of a careful physical examination and history.

Typically the history and physical examination for the skin is done in the same sequence and manner as with any other organ system. In some cases it is helpful to examine the patient after taking only a brief history so the questions for the patient can be more focused.3

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 erythematous or vasculitis are suspected, a detailed or comprehensive history may be needed.

History of Present Illness (HPI)

Ask about:

  • Initial and subsequent morphology and location(s) of lesions

  • Symptoms (eg, itch, pain, tenderness, burning)

  • Date of onset and duration

  • Severity and factors causing flares

  • Medications (including over-the-counter products) used for treatment and response to treatment

  • History of previous similar problem.

If the patient's chief complaint is a skin tumor/growth, the following additional questions should be added. With the increasing incidence of skin cancer, these questions could be added in any patient's history:

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

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

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

  • Is there a history of sunscreen use?

It is also important to determine the patient's Fitzpatrick skin type, as this helps to identify patients at risk for skin cancer (Table 3-1). Patients should be asked if they burn easily or tan after their initial exposure to sunlight.4 The patient's response determines his or her Fitzpatrick skin type. Typically there is a correlation between a patient's Fitzpatrick skin type and his or her skin color.

Table 3-1.Fitzpatrick skin types.

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