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Dermatological skin examination

Assessing lesions

  • Distribution and size

    • e.g. acral (distal), central, flexor/extensor, localised/generalised, dermatomal, follicular, seborrhoeic

  • Characteristics (SEC)

    • Shape, e.g. circular, linear, annular, irregular
    • Edge and elevation, e.g. well-demarcated, ill-defined, raised/flat
    • Colour, e.g. erythematous, depigmented/pigmented, purpuric

  • Secondary features

    • e.g. crust, scale, pigmentation, keratosis, lichenification, erosion, excoriation, fissure, ulceration

Definitions in dermatology

<1 cm >1 cm
Flat Macule Patch
Plaque (palpable)
<0.5 cm >0.5 cm
Raised Papule
Vesicle (fluid-filled)
Pustule (pus-filled)
Nodule
Bulla (fluid-filled)

Introduction

  • Wash hands
  • Introduce self;
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Get a chaperone
  • Expose patient to underwear

General inspection

  • Patient: well/unwell, pain/discomfort
  • Describe the pattern of any rash: site, number of lesions, distribution pattern

Hands

  • Nails
    • Psoriatic nail changes (pitting, onycholysis, subungual hyperkeratosis)
  • Hands

Upper limbs

  • Anterior arms
  • Ask patient to put hands behind head
    • Posterior arms
    • Axilla

Head and neck

  • Scalp: look through hair and behind ears
  • Face
  • Inside mouth

Torso

  • Chest
  • Abdomen
  • Back
  • β€˜At this point, I would also like to look at the genital region.’

Lower limbs

  • Legs
  • Feet and toe nails

To complete

  • Thank patient and restore clothing
  • β€˜To complete my examination, I would examine any suspicious moles with a dermatoscope and perform other relevant system examinations (e.g. vascular for an arterial ulcer).’ 
  • Summarise and suggest further investigations you would consider after a full history

Try some questions

What is Nikolsky’s sign?

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What are the skin findings in dermatomyositis?

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What is the definition of erythroderma?

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What are the different types of psoriasis?

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Try some OSCE stations

  1. Try a normal exam first
  2. Psoriasis
  3. Actinic keratosis
  4. Eczema
  5. Neurofibromatosis
  6. Find more OSCE stations here

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