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When faced with a patient who presents with a skin disorder, history-taking is usefully
divided into two sessions. Initial questions should be aimed at determining the site,
onset and evolution of the lesions.
- Which areas are affected?
- When did it first appear?
- How has it progressed?
At this point, the patient is examined and a clinical diagnosis established.
The second history-taking session is directed specifically at identifying possible
causative or aggravating factors, results of previous treatments and relevant general
information.
- Are there factors in the patient’s recent history which could have triggered the
lesions (e.g. stress, environmental contacts)
- Has the patient previously been treated for this disorder? What were the outcomes? Is
noncompliance an issue?
- Is there a family history of this condition?
- Have lifestyle issues been considered?
Examinaton 
The most important rule is to always examine the entire skin. Patients generally love
to show you a ‘sample’ of their lesions - a trouser leg raised or a sleeve
discreetly rolled up. Resist temptation, and get the patient to undress properly. Placate
the protester who says he or she doesn’t have the problem elsewhere on the body: most
often they do!
Note the general distribution - some lesions prefer one area to another - elbows and
knees are classic sites for psoriasis. Then, examine the lesions more closely. A
time-honored approach is to identify a primary lesion - macules, vesicles, weals, papules,
plaques, etc. This is helpful in a rudimentary sort of way but most diagnoses rest on
pattern recognition. We can recognize a blue jay and know at a glance that it is not a
magpie - not by some algorithm that analyses its beak shape and its feather color, or the
length of its legs. The problem of pattern recognition is the fundamental truth that you
must have seen the pattern before and be able to give it a name. It is impossible to
diagnose a disease if you have never heard of it: experience is all important.
Peter Hull MD, FRCPC, FFDerm(SA)
DERMATOLOGY EDITOR |
