Necessary Elements of a Dermatologic History and Physical Evaluation

Janet M. Cole, Deanna Gray-Miceli

Disclosures

Dermatology Nursing. 2002;14(6) 

In This Article

Introduction

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 ).

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 Table 2 ). Morphology is described in terms of size, color, consistency, configuration, margination, and surface characteristics (Sams & Lynch, 1996).

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.

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.

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