Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

Dermatological History

A detailed and structured dermatological history is essential for identifying symptoms related to the skin, hair, and nails. This type of history helps recognize conditions such as inflammatory, infectious, autoimmune, allergic, and neoplastic disorders. A thorough, patient-centered approach aids in understanding the patient’s primary complaint, associated symptoms, and relevant medical history.

Presenting Complaint

The dermatological history begins by identifying the patient’s main concern. Common complaints related to the skin, hair, and nails include:

  • Rash
  • Pruritus (itching)
  • Lesions or sores
  • Changes in pigmentation
  • Hair loss (alopecia)
  • Nail changes
  • Dryness or scaling
  • Swelling
  • Burning or tingling sensations

History of Present Illness

A detailed history of the present illness delves into the characteristics, onset, progression, and associated factors regarding the patient’s symptoms.

Rash

Rashes are one of the most common presentations in dermatology. Assessing the details of the rash is crucial:

  • Onset: Is the rash acute or chronic? Acute rashes often point to infections or allergic reactions, while chronic rashes suggest inflammatory or autoimmune conditions such as psoriasis or eczema.
  • Location: The location of the rash can provide important diagnostic clues. For example, facial and upper body rashes may indicate rosacea or lupus, while a rash on the palms and soles could point to syphilis or hand-foot-and-mouth disease.
  • Distribution: Is the rash localized or widespread? Symmetrical distribution may suggest systemic conditions, whereas localized rashes are often due to contact dermatitis or localized infections.
  • Appearance: Ask the patient to describe the color, size, shape, and texture of the rash. Is it red, scaly, or blistering? Psoriasis often presents with red, scaly plaques, while eczema is characterized by dry, itchy patches.
  • Pattern: A rash that spreads from a central point (e.g., erythema migrans in Lyme disease) or presents in a linear distribution (e.g., poison ivy contact dermatitis) can be diagnostic.
  • Itching or pain: Pruritic rashes suggest conditions like eczema, allergic reactions, or scabies, while painful rashes may indicate herpes zoster or cellulitis.
  • Triggers: Ask if the rash worsens with heat, sun exposure, or specific substances (e.g., perfumes, soaps). This information can help identify conditions like photoallergic dermatitis or contact dermatitis.

Pruritus (Itching)

Itching is a frequent symptom of both local and systemic conditions.

  • Onset: Is the itching acute or chronic? Acute pruritus may be due to allergic reactions or contact dermatitis, while chronic pruritus suggests systemic conditions like liver disease, renal failure, or diabetes.
  • Location: Localized pruritus often results from insect bites, fungal infections, or dermatitis, whereas generalized itching could suggest systemic causes.
  • Relief: Have any interventions, such as antihistamines, moisturizing creams, or cool compresses, provided relief? Persistent itching despite treatment may point to underlying systemic disease.

Lesions or Sores

Lesions can vary widely in appearance and origin. Key questions include:

  • Type: Is the lesion a macule, papule, vesicle, pustule, or nodule? Each type suggests different diagnoses—macules are seen in conditions like vitiligo, while vesicles and pustules are common in varicella or herpes simplex infections.
  • Size: Measure or estimate the size of the lesion. Larger lesions may suggest malignancy or more severe infection.
  • Color: Pigmented lesions (brown, black, or blue) should be assessed for asymmetry, border irregularities, and color variations, all of which are concerning for melanoma.
  • Pain or bleeding: Painful lesions may indicate infection or trauma, while non-healing or bleeding lesions warrant investigation for potential skin cancers.

Changes in Pigmentation

Skin pigmentation changes may be related to systemic diseases or localized conditions.

  • Hyperpigmentation: Darkened areas of skin can be seen in conditions such as Addison’s disease or post-inflammatory hyperpigmentation.
  • Hypopigmentation: Lightened areas of skin can be seen in vitiligo or following inflammation (post-inflammatory hypopigmentation).
  • Jaundice: Yellowing of the skin and sclera suggests liver dysfunction or hemolytic anemia.

Hair Loss (Alopecia)

Hair loss can occur due to a variety of factors, ranging from stress to autoimmune disorders.

  • Pattern: Is the hair loss patchy or diffuse? Patchy hair loss often suggests alopecia areata, while diffuse thinning may indicate telogen effluvium or androgenic alopecia.
  • Duration: Hair loss that occurs rapidly may suggest an autoimmune or infectious cause, while gradual hair thinning is more commonly seen in conditions like male or female pattern baldness.
  • Associated symptoms: Scalp redness, scaling, or pustules can suggest conditions like seborrheic dermatitis or tinea capitis (fungal infection).

Nail Changes

Nail changes can provide insights into systemic and dermatologic diseases.

  • Discoloration: Yellow nails may indicate fungal infections, while pitting can be seen in psoriasis.
  • Shape changes: Clubbing of the nails is associated with chronic lung disease, while spoon-shaped (koilonychia) nails suggest iron deficiency anemia.
  • Fragility: Brittle nails may be due to systemic diseases or nutritional deficiencies.

Past Medical History

A review of the patient’s medical history can provide insights into predisposing conditions for integumentary disorders:

  • Eczema, Psoriasis, or Acne: A history of these conditions is important, especially if the patient reports flare-ups or uncontrolled symptoms.
  • Autoimmune diseases: Conditions such as lupus or dermatomyositis can manifest with skin rashes and other cutaneous signs.
  • Skin Cancer: A personal history of basal cell carcinoma, squamous cell carcinoma, or melanoma increases the risk for recurrence or new lesions.
  • Allergies: A history of allergic rhinitis, asthma, or food allergies may indicate atopic dermatitis or allergic contact dermatitis.

Family History

Certain skin conditions have a genetic predisposition, making family history important:

  • Psoriasis: A family history of psoriasis increases the likelihood of the patient developing the condition.
  • Atopic Dermatitis (Eczema): Eczema tends to run in families, often alongside other atopic conditions like asthma or allergic rhinitis.
  • Skin Cancer: A family history of melanoma, particularly in first-degree relatives, increases the patient’s risk.

Social History

The social history is key in identifying lifestyle and environmental factors that may contribute to integumentary disorders:

  • Sun Exposure: Prolonged exposure to ultraviolet (UV) rays increases the risk of skin cancers. Ask about sunburns, use of tanning beds, and whether the patient uses sun protection (sunscreen, clothing).
  • Occupational Exposures: Jobs that involve exposure to chemicals, dyes, or irritants can increase the risk of contact dermatitis or occupational skin disease.
  • Hygiene Practices: Inquire about bathing habits, use of personal care products, and frequency of shaving, as these may contribute to conditions like folliculitis or irritant dermatitis.
  • Tattoos or Piercings: These practices increase the risk for skin infections, allergic reactions, or keloid formation.

Environmental and Occupational Exposures

Environmental factors often play a significant role in skin conditions.

  • Contact with allergens or irritants: Frequent exposure to substances such as nickel, latex, or certain soaps and cosmetics can lead to contact dermatitis.
  • Climate: Dry, cold climates may worsen conditions like eczema, while hot and humid environments can exacerbate fungal infections.
  • Insect bites: Bites from mosquitoes, ticks, or bedbugs can cause localized skin reactions or transmit diseases such as Lyme disease or scabies.

Observation

Observation is a critical first step in examining the integumentary system, providing essential visual cues that can guide the rest of the physical examination. It allows the clinician to assess the condition of the skin, hair, and nails, as well as to detect signs of systemic diseases, infections, or localized trauma.

Systematic Approach:

Perform a systematic, head-to-toe examination to ensure all regions are assessed.

  • Scalp and Hairline
  • Face and Neck
  • Chest and Abdomen
  • Back and Buttocks
  • Upper and Lower Extremities
  • Palms, Soles, and Nail Beds

Specific Areas of Focus

  • Scalp and Hair: Part the hair to inspect the scalp for erythema, scaling, lesions, or alopecia. Note the texture, distribution, and condition of the hair.
  • Nails: Check the nail beds for color, shape, and texture. Clubbing, pitting, or changes in nail color may indicate systemic diseases, such as lung disease, psoriasis, or cardiac issues.
  • Mucosal Surfaces: Examine the oral mucosa, lips, and tongue. Look for ulcerations, pigmentary changes, or lesions, as these can offer clues to systemic conditions like anemia or vitamin deficiencies.

Observation of Skin Tone and Pigmentation

Changes in skin tone or pigmentation can be indicative of local or systemic pathology.

  • Hyperpigmentation: Darkened patches of skin, seen in conditions like Addison’s disease or post-inflammatory hyperpigmentation.
  • Hypopigmentation: Areas of skin that have lost pigment, common in conditions like vitiligo or post-inflammatory hypopigmentation.
  • Jaundice: Yellowing of the skin and eyes due to elevated bilirubin levels, typically seen in liver disease.
  • Cyanosis: A bluish tint to the skin, often seen in areas with poor circulation or oxygenation, such as in severe respiratory or cardiovascular conditions.

Skin Conditions

Skin observation provides valuable information about both local and systemic health. Conditions affecting the skin can be manifestations of underlying systemic diseases, allergic reactions, or infections.

  • Erythema (Redness): Redness of the skin often indicates inflammation, infection, or trauma. Erythema is seen in conditions such as cellulitis, lupus, and dermatitis. In autoimmune diseases like lupus, erythema can be widespread, particularly over sun-exposed areas.
  • Ecchymosis (Bruising): Bruises indicate bleeding under the skin, often due to trauma or a bleeding disorder. For example, extensive bruising could suggest clotting abnormalities or anticoagulant use, while localized bruising near joints may suggest trauma or injury, such as a ligament tear.
  • Ulceration and Rash: Open sores or rashes may point to systemic conditions such as diabetes, which impairs circulation and delays healing. Rashes can also indicate infection (e.g., impetigo), autoimmune conditions (e.g., psoriasis), or allergic reactions.
  • Skin Atrophy and Sclerosis: Thinning of the skin may be due to aging, chronic disuse, or systemic diseases like corticosteroid overuse. Sclerosis (skin hardening) is often seen in conditions like scleroderma, which affects the skin, connective tissues, and musculoskeletal system.

Lesions and Skin Abnormalities

Skin lesions come in various forms, each indicative of specific dermatologic conditions or systemic diseases. Careful observation and description of these abnormalities are crucial for diagnosis.

Evaluation of Skin Lesions

When assessing skin lesions, the ABCDE criteria are used to evaluate the characteristics of pigmented lesions such as moles, which can indicate malignant changes (e.g., melanoma).

  • A – Asymmetry: One half of the lesion differs from the other.
  • B – Border: Irregular, notched, or blurred edges.
  • C – Color: Variations in color, including tan, brown, black, red, white, or blue.
  • D – Diameter: Lesions larger than 6 mm (about the size of a pencil eraser).
  • E – Evolution: Changes in size, shape, color, or symptoms (e.g., itching, bleeding).

Note: Patients with high-risk profiles, such as those with fair skin, a history of sunburns, or a family history of melanoma, should undergo regular skin cancer screenings.

Types of Skin Lesions

Skin lesions can be broadly categorized into primary and secondary types based on their origin. Primary lesions arise from previously normal skin, while secondary lesions develop over time, often as a result of the evolution of primary lesions or from external factors such as scratching or infection. Below, we will explore each category in detail.

Primary Lesions

Primary lesions are the initial, visible alterations in the skin that occur due to a pathological process. These can be the first indicators of a dermatological condition and include a range of lesion types based on their size, texture, and content (fluid-filled or solid).

Primary Lesion TypeDescriptionExamples/Conditions
MaculesFlat, non-palpable changes in skin color, smaller than 1 cmFreckles, vitiligo
PatchesFlat, non-palpable color changes larger than 1 cmVitiligo, large birthmarks
PapulesRaised, solid lesions smaller than 1 cmPsoriasis, warts
PlaquesRaised, solid lesions larger than 1 cmPsoriasis, eczema
NodulesLarger, deeper solid lesions that can extend into the dermis or subcutaneous tissueLipomas, rheumatoid nodules
VesiclesFluid-filled lesions smaller than 1 cmChickenpox, herpes simplex
BullaeFluid-filled lesions larger than 1 cmBullous pemphigoid, second-degree burns
PustulesSmall, pus-filled lesionsAcne, impetigo
WhealsTransient, raised, erythematous areas due to dermal edemaHives (urticaria), insect bites

Secondary Lesions

Secondary lesions develop from primary lesions as a result of external factors such as scratching, infection, or changes in the healing process. These lesions often indicate the progression or complication of a skin condition and include scars, ulcers, and scales.

Secondary Lesion TypeDescriptionExamples/Conditions
ScalesFlakes or plates representing excess dead epidermal cellsPsoriasis, seborrheic dermatitis
CrustsDried serum, blood, or pus on the skin surfaceImpetigo, scab after abrasion
ScarsFibrous tissue replacing normal tissue after injuryKeloid, post-surgical scars
UlcersLoss of skin extending into the dermis or deeper tissuesDiabetic foot ulcer, venous stasis ulcer
FissuresLinear cracks in the skin extending into the dermisAthlete’s foot, cheilosis (cracks in the corners of the mouth)
ErosionsLoss of superficial epidermis that does not extend into the dermisAfter rupture of a vesicle or bulla, abrasions

Nail and Hair Abnormalities

Observing changes in nails and hair can provide insight into systemic diseases, nutrient deficiencies, and dermatologic disorders.

Nail Changes:

  • Clubbing: Rounded, bulbous enlargement of the nail beds associated with chronic hypoxia or lung diseases.
  • Koilonychia (Spoon Nails): Thin, concave nails seen in iron deficiency anemia.
  • Pitting: Small depressions on the nail surface, often seen in psoriasis.
  • Onycholysis: Separation of the nail from the nail bed, observed in fungal infections or trauma.

Hair Changes:

  • Alopecia: Hair loss can be diffuse or patchy. Diffuse hair thinning may be due to systemic issues like thyroid dysfunction or malnutrition, while patchy hair loss (alopecia areata) suggests an autoimmune process.
  • Hirsutism: Excessive hair growth in women, often due to hormonal imbalances (e.g., polycystic ovary syndrome).
Nail or Hair ConditionDescriptionAssociated Conditions
ClubbingBulbous enlargement of nail bedsChronic hypoxia, lung disease
KoilonychiaSpoon-shaped nailsIron deficiency anemia
PittingSmall depressions on nail surfacePsoriasis
OnycholysisSeparation of nail from nail bedFungal infections, trauma
AlopeciaHair loss (diffuse or patchy)Autoimmune disorders, thyroid disease
HirsutismExcessive hair growth in womenPolycystic ovary syndrome, Cushing’s

Palpation

Palpation of the skin and underlying structures can provide additional information on the nature of skin abnormalities. It allows for the detection of tenderness, warmth, texture, and swelling.

  • Tenderness: Tender areas suggest inflammation, infection, or trauma. Localized tenderness can indicate cellulitis, while diffuse tenderness may be associated with systemic conditions like lupus or vasculitis.
  • Temperature: Palpating the skin to detect warmth can indicate infection or inflammation, such as in cellulitis, whereas cool skin may suggest vascular insufficiency.
  • Texture: Assessing whether the skin feels thickened (as in scleroderma) or thin (as in chronic corticosteroid use) provides clues to systemic diseases.
  • Swelling and Edema: Edema can indicate fluid retention due to systemic conditions such as heart failure or localized trauma. Palpation of non-pitting vs. pitting edema helps differentiate the underlying cause.

Abnormal Findings in Skin and Structure

Key abnormal findings to be aware of during observation include:

  • Skin atrophy: Thinning or wasting of the skin, common in chronic vascular insufficiency or aging.
  • Scarring: Assess for hypertrophic or keloid scarring, which can indicate abnormal healing processes.
  • Lymphadenopathy: Enlarged lymph nodes near areas of infection or malignancy.
  • Rashes with Specific Patterns: Rashes that follow specific anatomical patterns can be highly diagnostic, such as the butterfly rash across the cheeks in lupus or the dermatome distribution of a herpes zoster rash.

Diagnostic Tests and Procedures

Skin Biopsy

A skin biopsy involves removing a small sample of skin tissue for examination under a microscope. It is used to diagnose various skin conditions, including cancers, infections, and inflammatory diseases.

How is it Performed?

A small piece of skin is removed after local anesthesia is applied. The sample is then sent to a lab for histopathological analysis.

Diagnoses:

  • Skin cancer (melanoma, basal cell carcinoma, squamous cell carcinoma)
  • Psoriasis
  • Dermatitis
  • Fungal or bacterial infections
  • Autoimmune skin diseases (e.g., lupus)

Patch Testing

Patch testing is used to diagnose allergic contact dermatitis by identifying specific substances that cause skin reactions. Small patches containing potential allergens are applied to the skin and checked for reactions.

How is it Performed?

Patches containing potential allergens are applied to the patient’s back for 48 hours. The skin is checked for reactions after 48 and 96 hours.

Diagnoses:

  • Allergic contact dermatitis
  • Sensitivities to metals, fragrances, latex, and chemicals

Wood’s Lamp Examination

Wood’s lamp examination uses ultraviolet light to detect certain skin conditions, including infections and pigment disorders. The affected areas may fluoresce under UV light.

How is it Performed?

A Wood’s lamp is used in a darkened room to examine the skin. Certain infections or pigment changes will fluoresce under the light.

Diagnoses:

  • Fungal infections (e.g., tinea)
  • Vitiligo
  • Bacterial infections (e.g., erythrasma)

Dermoscopy

Dermoscopy is a non-invasive imaging technique used to examine skin lesions, particularly pigmented ones, at a magnified level. It helps in the diagnosis of skin cancers and other skin disorders.

How is it Performed?

A dermatoscope, which is a magnifying tool with a light, is placed on the skin to provide a clearer view of structures under the surface.

Diagnoses:

  • Melanoma and other skin cancers
  • Benign moles (nevi)
  • Seborrheic keratosis
  • Vascular lesions

Tzanck Smear

A Tzanck smear is used to diagnose viral skin infections, particularly herpes simplex and varicella-zoster (shingles). It involves examining cells from a skin lesion under a microscope.

How is it Performed?

A sample of cells is collected by scraping the base of a vesicle or blister. The sample is stained and examined for multinucleated giant cells, characteristic of viral infections.

Diagnoses:

  • Herpes simplex virus (HSV)
  • Varicella-zoster virus (shingles, chickenpox)

Skin Culture

A skin culture is used to detect bacterial, fungal, or viral infections. Samples are taken from the affected area of the skin and cultured in a lab to identify the specific organism causing the infection.

How is it Performed?

A sterile swab or scraping is used to collect a sample from the skin. The sample is then sent to a lab for culture and identification of pathogens.

Diagnoses:

  • Bacterial infections (e.g., cellulitis, impetigo)
  • Fungal infections (e.g., ringworm, candidiasis)
  • Viral infections (e.g., herpes simplex)

Direct and Indirect Immunofluorescence

Immunofluorescence testing is used to diagnose autoimmune skin diseases by detecting antibodies in the skin or bloodstream that are attacking skin cells.

How is it Performed?

  • Direct immunofluorescence: A skin biopsy is taken, and the tissue is treated with fluorescent dyes to detect antibodies deposited in the skin.
  • Indirect immunofluorescence: A blood sample is tested for circulating antibodies that react against skin proteins.

Diagnoses:

  • Pemphigus vulgaris
  • Bullous pemphigoid
  • Lupus erythematosus
  • Dermatitis herpetiformis

Nail and Hair Biopsy

Nail or hair biopsies are used to diagnose disorders affecting these parts of the integumentary system, including infections, tumors, and inflammatory diseases.

How is it Performed?

A small portion of the affected nail or hair is taken for examination under a microscope. This is often done using a punch biopsy tool.

Diagnoses:

  • Onychomycosis (fungal infection of the nails)
  • Alopecia areata
  • Psoriasis of the nails
  • Nail tumors

Sputum Cytology (for Hair or Skin-related Tumors)

Sputum cytology is used when there is suspicion of cancer or infection affecting the deeper layers of the skin, hair, or nails. Cells from the skin or hair are examined microscopically for signs of abnormal growth.

How is it Performed?

Samples are collected through swabs or scrapings from lesions or tumors, then sent to a laboratory for cytological analysis to detect abnormal or cancerous cells.

Diagnoses:

  • Infectious lesions causing abnormal cell growth
  • Skin cancers (e.g., melanoma)