Examination of the skin can be considered in two settings: incidental examination during the course of a complete physical examination, and dedicated examination in situations where disease of the skin is known to be present. In the former, the skin is not inspected in its entirety. Instead, overlying segments of skin are sequentially examined as the various internal organs are evaluated. This approach is practical, but it is inadequate for evaluation of known dermatologic disease. In a complete dermatologic examination the skin is inspected, in its entirety, as a single step. This includes evaluation of the hair, nails, and mucous membranes of the mouth and genitalia. The general principles discussed below pertain to both types of examination.
The patient must be undressed to allow the examiner to carry out an adequate examination. An examiner cannot simply have the patient unbutton a shirt or lift a pant leg and expect to see clearly the nature and extent of the pathology present. The examiner should also remember that a hospital gown is really a type of clothing and this too must not be allowed to interfere with adequate skin exposure. A gown pushed to one side or momentarily lifted more often than not leaves portions of the skin in shadows or causes awkward positioning for the examiner. In most instances a patient’s underwear may be left on, but even this should be removed if there is any possibility that additional lesions would otherwise remain un examined.
Inadequate lighting is perhaps the most common cause for an inadequate skin examination. In the hospital, bedside lighting is more usually designed for reading than for medical examination. Thus, in most circumstances the patient should be moved to a dedicated examination room where adequately bright overhead and side lighting will be available. Even conventional outpatient examination rooms may be rather poorly lit. If this occurs, the examiner should request that additional bright, portable lamps be provided.
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