Objective examination (Status praesens objectivus)

The examination follows the common rules accepted in all clinics. The size, hardness, mobility and tenderness of all palpable lymph nodes are determined. The osteo-muscular system is inspected and the tone of the muscles determined. The condition of the respiratory organs is determined by asking the patient whether he has any complaints on the part of these organs, by examination of the nose and nasopharynx, and by percussion and auscultation. The patient is asked whether he complains of any circulatory disorders; the heart borders are determined, the heart sounds auscultated, the blood pressure is measured, and the character of the pulse determined. The same procedure is applied with respect to the alimentary organs: collection of complaints, inspection (oral cavity and abdomen) and palpation (abdomen, liver, spleen). In examination of the genitourinary system, attention is focused on the frequency of nicturition, the appearance of the urine, Pasternatskii's sign, the development of the genitals, and the character and periodicity of menstruation. The condition of the endocrine system and the neuro-psychic sphere is determined (emotional mobility, working capacity, sleep, function of the cerebrospinal nerves, the character of skin and tendon reflexes).

Dermatological status. Inspection of the healthy skin areas, mucous membranes and the skin appendages helps in studying the skin lesion for which purpose as well as for the inspection of eruption it should be conducted in adequately diffused daylight or good electric illumination, with a 'daylight' lamp among others. It is necessary to determine the colour of the skin and visible mucous membranes, the elasticity and tensility of the healthy skin, the turgor of the muscles and subcutaneous fat, the condition of the sebaceous and sweat glands, nails and hair, the character of pigmentation, the presence of scars, naevi, etc. A change in the colour of the skin may be linked with various disturbances in the function of some organs and systems (e. g. the skin is dark-coloured in Addison's disease, yellow in infectious hepatitis). The tensility and elasticity of the skin are tested by palpating it and gathering in a fold; the presence or absence of adhesion with the underlying tissues is determined by displacing the skin.

Of no small importance is the test for dermographism, i.e. the response of the neurovascular apparatus of the skin to mechanical stimulation, which demonstrates the properties of the vasomotor innervation of the patient's skin. The appearance of a red line in response to stroking of the skin with a blunt object (the edge of a wood spatula, the edge of the handle of a neurological hammer) and its disappearance in two or three minutes without leaving a trace are evidence of normal dermatographia. Red diffuse dermographism is encountered in eczema and psoriasis, white dermographism in patients with prurigo and exfoliative dermatitis; stable white or mixed, rapidly changing to white dermographism occurs in patients with neurodermitis, and urticarial dermatographia (wide, oedematous, conspicuously elevated red lines appearing in response to even weak mechanical stimulation of the skin and sometimes disappearing in 40 to 60 minutes) is encountered in patients with urticaria and prurigo.

 

It is advisable to describe the lesions of the skin and mucous membranes ( status localis ) in succession, according to a definite scheme, which makes this rather difficult problem simpler. It is expedient to note first whether the eruption is inflammatory or not. The most manifestations of skin diseases are of an inflammatory character. Next it should be recorded to which group of inflammation the lesions can be related: acute inflammatory (with predominance of the exudative component of the inflammation) or non-acute inflammatory (with predominance of the proliferative component). After that, the localization of the eruption is described and the prevalent distribution of the elements noted. Many dermatoses are marked by a favoured localization, which, however, is only of auxiliary significance in establishing the diagnosis. Attention is next focused on the spread of the affection, which may be localized, disseminated, generalized, universal of the type of erythroderma, symmetrical or asymmetrical.

The primary and secondary morphological lesions are then recorded and their properties described: colour, borders, shape, configuration, surface, consistency, and interrelationship. An experienced dermatologist notices not only the colour of the lesions, but the hues of the colouring, which is often valuable in establishing the diagnosis. The borders of the morphological lesions may be clear-cut or poorly defined, sharp or smooth. In the description of the shape of the lesions, the physician gives their volumetric characteristics, e.g. he notes whether papules are flat, conical or semispherical, etc. In configuration the lesions may be round, oval, polygonal or polycyclic, micro- or macroscalloped, etc. In consistency they may be ligneous, firm-elastic, soft, dough-like. The surface of the lesions may be smooth, rough, knotty, etc. According to their interrelationship, the lesions may be isolated from each other or confluent; in the first case it is said that the eruption is focal in arrangement. If the eruption is arranged in circles, semi-circles, ovals, arcs it is said that it is of a regular grouping. Irregular grouping is that in which the lesions occur in a definite area but do not form a geometrical pattern. A systematized eruption is that in which the lesions are arranged along the distribution of nerves (herpes zoster), blood vessels, dermatomeres, etc. When the morphological lesions are arranged at random, no regular pattern is formed.

The primary and secondary morphological lesions and their clinical characteristics form the basis for the dermatological diagnosis.

Special dermatological methods of examination are scraping, palpation, diascopy, tests for the isomorphic reaction, dermatographia, pilomotor reflex, and skin tests.

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