Acne Vulgaris

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Black heads or white heads
| Papules or pustules or nodular lesions on the face and/or trunk
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Area of distribution (face, back, shoulders, upper chest)
| Age of onset
| Is it cyclical or non-cyclical
| Aggravating factors (menses, stress)
| History of scarring
| History regarding facial hygiene
| History of excessive oiling of hair
| Dietary history (eating excess dairy products or oily substances)
| History of excessive hair growth or hair removal required in the facial area (to rule out
hirsutism if the patient regularly removes facial hair)
| Menstrual history, whether cycles are regular or not
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
Personal Notes
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

LOCAL EXAMINATION
Describe the lesion:
| Type of lesion (comedones/papules/pustules/nodules)
| Number of lesions
| Area of distribution
| Any scars present
| Surrounding erythema
| Any accompanying hirsutism

2 Clinical Corner
DIAGNOSIS Personal Notes
| Acne
| Type (mostly acne vulgaris or drug induced acne)
| Grade of acne

CLINICAL POINTERS
Grading of acne:
Grade Image Description
Grade 1 Comedones are predominant (black heads
and white heads)

Grade 2 Paulo-pustular lesions are predominant

Grade 3 Nodular inflammatory lesions are present

Grade 4 Nodulo-cystic type

Acne Vulgaris 3
 Psoriasis

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Reddish colored skin lesions
| Itching
| Silvery white scales
| Scalp lesions may be present
| Nails changes may be present
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset (insidious or acute)
| Area of distribution (elbows, knees and other extensor surfaces, scalp)
| Associated with itching or not
| Any oral involvement, burning sensation while eating food (absent in psoriasis, present
in lichen planus)
| Any associated loss of hair from a particular region of the scalp
| Any changes observed in the nails (development of pits or thinning of the nail plates)
| Any complaint of joint pain
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
Personal Notes
| Any history of drug allergies
Menstrual history:
| The last menstrual period of the patient (important to rule out pregnancy, since
certain drugs used for psoriasis are teratogenic)
| Are the menses regular or not
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

Psoriasis 5
 LOCAL EXAMINATION Personal Notes
Describe the lesion:
| Primary lesions - papules, plaques, pustules (in pustular psoriasis)
| Secondary lesions - excoriations, scaling (silvery white)
| Number of lesions
| Area of distribution
| Total body surface area involved
| Surrounding erythema
| Examination of the nails
| Examination of the scalp
Clinical tests:
| Grattage test and Auspitz sign
| Koebner’s phenomenon

DIAGNOSIS
| Psoriasis
| Type of psoriasis
| Body surface area involved

CLINICAL POINTERS
1. Grattage test:
Scales in a psoriatic plaque can be accentuated by grating with a glass slide
2. Auspitz sign: 3 steps:
` Step A: Gently scrape lesion with a glass slide - This accentuates the silvery scales
(Grattage test positive). Scrape off all the scales
` Step B: Continue to scrape the lesion - A glistening white adherent membrane
(Burkley’s membrane) appears
` Step C: On removing the membrane, punctate bleeding points become visible - positive
Auspitz sign
3. Koebner phenomenon/isomorphic response:
It is described as the appearance of new skin lesions on lines of trauma

6 Clinical Corner
 Lichen Planus

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Purple colored lesions over the skin
| Itching
| Burning sensation in the mouth
| Nails changes may be present
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset (insidious or acute)
| Area of distribution (flexor surfaces)
| Associated with itching or not
| Any oral involvement, burning sensation while eating food
| Any loss of hair from one particular region of the scalp (scarring alopecia)
| Any changes observed in the nails (absence or thinning or tenting of the nail plates)
| Any complaint of joint pain
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Menstrual history:
Personal Notes
| The last menstrual period of the patient (important to rule out pregnancy)
| Are the menses regular or not
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

LOCAL EXAMINATION
| Describe the lesion:
| Primary lesions - papules, plaques which are polygonal and plane topped
| Secondary lesions - excoriations
| Number of lesions

8 Clinical Corner
| Area of distribution
| Total body surface area involved
Personal Notes
| Surrounding erythema
Clinical tests:
| Magnifying lens with oil drop on lesion: whitish linear streaks (Wickham's striae)
| Koebner's phenomenon
Describe nail changes:
| Thinning of nail plate
| Absence of nail plate
| Tenting of the nail
| Pterygium
Describe hair follicle lesion:
| Scarring alopecia with perifollicular blue-gray hue

DIAGNOSIS
| Lichen planus
| Body surface area involved
| Oral cavity involvement
| Any nail or hair changes

CLINICAL POINTERS
Koebner phenomenon/isomorphic response:
It is described as the appearance of new skin lesions on lines of trauma
It is seen in:
` Psoriasis
` Lichen planus
` Vitiligo
Lesions of lichen planus:

Lichen Planus 9
 Systemic Lupus Erythematosus

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order, with respective durations)
| Rash on face
| Oral ulcers
| Hair loss
| Joint pain
| Chest pain/breathlessness
| Abnormal body movements
| Altered sensorium
History of present illness:
Describe the chief complaint using following pointers:
| Duration
| Onset
| Progression
| Distribution of rash
| Describe the rash in the patient's own language
| Aggravating factors (ex: sunlight)
| Relieving factors
| Associated with oral ulcers/burning sensation in the mouth
| Associated with hair loss (generalized or from one particular region of the scalp)
| Is there associated joint pain? If present,
a. Which joints are affected
b. Bilaterally symmetrical or not
c. Any history of morning stiffness
d. If present, for how long does the morning stiffness last
| Any systemic complaints, like:
Personal Notes
a. Fever
b. Chest pain
c. Breathlessness
d. Abnormal body movements
e. Altered sensorium
f. Bleeding from any site
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Last menstrual period (in female patients)
| Menses are regular or not
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of similar complaints in other family members
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature

Systemic Lupus Erythematosus 11

 ` Respiratory rate
Personal Notes
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

LOCAL EXAMINATION
Describe the skin lesion:
| Reddish coloured rash on the cheeks and dorsum of nose (in butterfly pattern), sparing
the nasolabial fold
| Any discoid rash
| Any scarring/non scarring alopecia
Examination of the affected joints:
| Enumerate the affected joints
| Any swelling/redness present
| Any joint tenderness/rise in skin temperature around the joint
| Any joint deformity

SYSTEMIC EXAMINATION
Important in a case of SLE
| Respiratory system examination:
` Check for bilateral symmetry
` Check air entry bilaterally
` Breath sounds
` Any added sound
| Cardiovascular system examination:
` Check for heart sounds
` Any heart murmurs
` Any added sounds (like pericardial rub in pericarditis)
| Abdominal examination:
` Check for abdominal movement
` Soft/rigid abdomen
` Any guarding, tenderness or rigidity
` Any organomegaly
` Any palpable abdominal lump

12 Clinical Corner
| Nervous system examination:
Personal Notes
` Check for consciousness and orientation
` Higher mental function evaluation
` Motor system evaluation
` Sensory system evaluation

DIAGNOSIS
| Systemic lupus erythematosus
| Any associated complications

CLINICAL POINTERS
2019 EULAR/ACR diagnostic criteria:
| Entry criterion:
Positive ANA (Antinuclear Antibody) at a titer of ≥1 : 80. This is mandatory to proceed
with further diagnostic considerations since ANA is positive in about 95% of SLE patients.
| Additive criteria:
Once the ANA is positive, points are assigned based on clinical and immunologic findings.
The minimum score to classify a patient as having SLE is 10 points.
| Clinical domains:
1. Constitutional Symptoms (e.g., fever) - 2 points
2. Neuropsychiatric Symptoms (e.g., seizures, psychosis) - 3 to 5 points
3. Mucocutaneous Symptoms:
– Oral ulcers, non-scarring alopecia (2 points each)
– Acute or chronic cutaneous lupus (6 to 10 points)
4. Serositis (pleuritis, pericarditis) - 6 points
5. Musculoskeletal: Joint involvement, synovitis, or tenderness in two or more joints
- 6 points
6. Renal: Proteinuria >500 mg/day or equivalent - 4 to 10 points
| Immunologic domains:
1. Anti-dsDNA or anti-Smith antibodies - 6 points
2. Low complement levels (C3, C4) - 4 points
3. Antiphospholipid antibodies - 2 points
4. Direct Coombs test (in the absence of hemolytic anemia) - 4 points

Systemic Lupus Erythematosus 13

 Vitiligo

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Depigmented patches over different regions of the body
| White hair/eye lashes etc
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset (insidious or acute)
| Age of onset (childhood/adult life)
| Course (rapid progression/gradual)
| Area of distribution
` Small, isolated patches (focal vitiligo)
` Face, head and distal extremities (acro-facial vitiligo)
` Mucosal surfaces
` Segmental, not crossing the midline (segmental vitiligo)
| Symmetrical/asymmetrical distribution
| Any history of thyroid dysfunction (associated with vitiligo)
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
Personal Notes
| Any history of drug allergies
Menstrual history:
The last menstrual period of the patient (important to rule out pregnancy, since certain
drugs given for treatment are teratogenic)
Are the menses regular or not
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

Vitiligo 15
 LOCAL EXAMINATION Personal Notes
Describe the lesion:
| Primary lesions - depigmented, chalky white patches
| Well defined margins
| Number of lesions
| Area of distribution
| Symmetrical/asymmetrical distribution
| Whether the lesions cross the midline or not
| Total body surface area involved
| Comment on the presence of leukotrichia and distribution of leukotrichia
| Comment on any mucosal involvement

DIAGNOSIS
| Vitiligo
| Type of vitiligo
| Whether associated with leukotrichia or not
| Body surface area involved

CLINICAL POINTERS
1. Koebner phenomenon/isomorphic response:
It is described as the appearance of new skin lesions on lines of trauma
It is seen in:
` Psoriasis
` Lichen planus
` Vitiligo
2. Types of vitiligo:
` Focal vitiligo
` Segmental vitiligo
` Vitiligo vulgaris
` Acro-facial vitiligo
` Mucosal vitiligo
` Universal vitiligo

16 Clinical Corner
 Personal Notes

FOCAL SEGMENTAL ACRO FACIAL GENERALIZED UNIVERSAL

Vitiligo 17
 Scabies

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Itching all over body
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset (insidious or acute)
| Area of distribution (generally all throughout the body)
` Web spaces of fingers
` Inner aspects of wrist, forearm and arm
` Axillary region
` Nipples
` Umbilicus
` Genitalia and groins
` In infants, face is also involved
| Any diurnal variation (increased nocturnal pruritus)
| History of similar complaints amongst family members
| Any history suggestive of immunocompromised state (more susceptible to Norwegian
scabies) - like patient is on steroids, diagnosed HIV, diabetic patient etc
Past medical history:
Personal Notes
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Ask about personal hygiene, bathing frequency and regular washing of clothes
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Ask about history of itching amongst family members
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature

Scabies 19
 ` Respiratory rate
Personal Notes
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

LOCAL EXAMINATION
Describe the lesion:
| Primary lesion - papules, vesicles in palms and soles in infants
| Secondary lesion - excoriations
| Special lesion - burrows
| Area of distribution
| Check whether face is involved or not (not involved in adults, involved in infants)

DIAGNOSIS
| Scabies

CLINICAL POINTERS
Distribution of lesions of scabies:
Along circle of Hebra:
| Web spaces of fingers
| Inner aspects of wrist, forearm and arm
| Axillary region
| Nipples
| Umbilicus
| Genitalia and groins
| In infants, face is also involved

20 Clinical Corner
Clinical picture of scabies:
Personal Notes

Scabies 21
 Tinea

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Skin lesion with intense itching (along with location)
| Hair changes
| Nail changes
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset
| Area of lesion (Ex: buttocks, genital area, face, abdomen etc)
| Associated with itching or not
Describe hair changes:
| Scalp lesion
| Associated with localized region of hair loss
Describe nail changes:
| Yellowish discoloration
| Nail plate thickening
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
Personal Notes
| Any history of drug allergies
Personal history:
| Ask about personal hygiene, bathing frequency and regular washing of clothes
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Ask about history of itching amongst other mlfamily members
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

Tinea 23
 LOCAL EXAMINATION Personal Notes
Describe the lesion:
| Primary lesion - Annular plaque with central clearing and peripheral raised erythematous
margins
| Number of lesions
| Area of distribution
| Check whether face is involved or not (not involved in adults, involved in infants)
Describe nail changes:
| Yellowish discoloration
| Subungual hyperkeratosis
| Subungual hyperkeratotic tunneling
Describe hair changes:
| Scarring/non scarring alopecia present or not
| Easy breakage of hair
| Black dot/gray patch
| Favus
| Kerion

DIAGNOSIS
| Tinea (depending upon the region of infection):
` Tinea facie (face)
` Tinea barbae (beard)
` Tinea manuum (hand)
` Tinea corporis (body)
` Tinea pedis (foot)
` Tinea cruris (groin)

CLINICAL POINTERS
Types of tinea capitis:
1. Black dot: Non inflammatory type, endothrix, non scarring alopecia

24 Clinical Corner
2. Gray patch: Non inflammatory type, ectothrix, non scarring alopecia
Personal Notes

3. Kerion: Raised, spongy lesions with scarring alopecia

4. Favus: Yellow cup shapped crusting, scarring alopecia

Tinea 25
 Sexually Transmitted Infections

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order, with respective durations)
| Discharge from urethra (in males)
| Discharge from cervix/vaginal (in females)
| Genital ulcer
| Genital warts
| Lower abdominal pain
History of present illness:
Describe urogenital discharge using the following pointers:
| Duration
| Describe discharge:
a. Amount
b. Color
c. Odor
d. Consistency (purulent/mucoid/curdy/frothy or not)
e. Blood stained or not
f. Does it stain the underwear
g. Whether associated with pruritus
| Severity (whether interfering with routine activities or not)
Personal Notes
| Is it worsening or not
| Is it associated with dysuria/dyspareunia
| Any history of constitutional symptoms
| Whether it is associated with lower abdominal pain or back pain (danger sign, points
towards pelvic inflammatory disease)
| History of multiple sexual partners
| History of recent unprotected sexual intercourse
| Any symptoms in the partner
| Contraceptive usage (whether barrier protection is used)
Describe genital ulcer using the following pointers:
| Duration
| Site
| Onset
| Progression- change in the size and shape of the ulcer over a period of time
| Whether associated with pain
| Any history of discharge from the ulcer
` Serous
` Purulent
` Haemorrhagic
| Any history of trauma
| Any associated diseases:
` Diabetes
` Sickle cell anemia
` Tuberculosis
` Varicose veins
` Systemic malignancy
` AIDS
` Past history of similar ulcer
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)

Sexually Transmitted Infections 27

| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
Personal Notes
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Last menstrual period (in female patients)
| Menses are regular or not
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of similar complaints in the patient's partner
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
` Pallor
` Icterus
` Cyanosis
` Clubbing
` Lymphadenopathy
` Pedal edema
| Describe any characteristic facie (if present)

28 Clinical Corner
 LOCAL EXAMINATION Personal Notes
Local genital examination:
| Comment on anatomy of external genitalia
| Whether any visible discharge is seen or not. Describe discharge:
` Color
` Odor
` Consistency (curdy/frothy or not)
` Blood stained or not
| Whether any excoriation marks are present
Per speculum examination:
| Is the discharge coming from the cervix or the vagina
| Take an endocervical swab/a high vaginal swab respectively
| Comment on discharge
` Color
` Odor
` Consistency (curdy/frothy or not)
` Blood stained or not
| Comment on position and nature of cervix (strawberry cervix in trichomonas vaginalis)
Describe genital ulcer:
| Number
| Site (in relation to a bony landmark)
| Extent
| Size (approximate)
| Shape
| Temperature
| Tenderness
| Margin of ulcer
| Edge of the ulcer
| Floor of the ulcer
| Discharge: Character, amount and smell

DIAGNOSIS
| Urogenital discharge/Genital ulcer/genital warts
| Most probable etiological agent

Sexually Transmitted Infections 29

 CLINICAL POINTERS Personal Notes
Differentiating between the various causes of vaginal discharge:
1. Physiological discharge:
` Colorless
` Odorless
` Not associated with pruritus
` Does not worsen
` Does not stain the underwear
` Not associated with lower abdominal pain
2. Pathological discharge:
Trichomoniasis Candidiasis Bacterial vaginosis
Chief complaint Foul smelling frothy Pruritus Foul smelling discharge
discharge
Other symptoms Associated with Splash dysuria may be No pruritus/dysuria/
pruritus/dysuria/ present dyspareunia
dyspareunia
Discharge Profuse, frothy, foul Curdy white cottage Off white/gray, profuse,
smelling, yellowish green cheese discharge, scanty foul smelling discharge
(rotten fish)
Cervix Strawberry cervix No characteristic No characteristic
feature feature

Approach to genital ulcer:

| Single, non tender ulcer - Syphilis, Donovanosis, LGV
| Multiple, tender ulcers - Chancroid, genital herpes
| Beefy red ulcer that bleeds on touch - Donovanosis
| Inguinal lymph nodes not involved - Donovanosis
| Bilateral non tender inguinal lymph nodes, rubbery in consistency - Syphilis
| Bilateral tender inguinal lymph nodes - Chancroid, LGV
| Bubo present - Chancroid

30 Clinical Corner
 Leprosy

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order, with respective durations)
| Skin lesions on various regions of the body
| Decreased sensations over the lesions
| Patient can present with various deformities
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset
| Number of lesions
| Area of distribution (face, limbs etc)
| Bilaterally symmetrical or asymmetrical
| Are the lesions hypopigmented/hyperpigmented/same as the color of skin
| Are the lesions associated with decreased sensations
| Any history of hair loss over the lesion
| Any history of decreased sweating over the lesion
| Any history of bleeding from nose or increased nasal crusting
| Any history of pedal edema
| Any history of loss of hair from the eyebrows
| Any history of pins and needles sensation in the hands and feet
| Any history of deformities:
Personal Notes
` Nose deformity
` Clawing of the hand
` Foot drop
` Inability to blink eyelids
` Any ulceration on the feet
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of similar complaints amongst family members
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation

32 Clinical Corner
Comment on:
Personal Notes
` Pallor
` Icterus
` Cyanosis
` Clubbing
` Lymphadenopathy
` Pedal edema
| Describe any characteristic facie (if present)

LOCAL EXAMINATION
Describe the lesion:
| Hypopigmented, erythematous annular plaque
| Central clearing
| Describe margins
| Associated with loss of sensation
| Loss of hair over skin lesion
| Describe anatomical distribution of the skin lesions
| Bilaterally symmetrical or not
| Any peripheral nerve thickening
| Any deformity:
` Saddle nose
` Clawing of hand
` Foot drop
` Lagophthalmos
` Lateral madarosis
| Any trophic ulcers (if present, describe the ulcer)

DIAGNOSIS
| Leprosy
| Stage of leprosy according to Ridley Jopling Classification
| Any nerve involvement
| Any deformity present

CLINICAL POINTERS
Clinical differentiation between various types of leprosy:
1. Tuberculoid Leprosy (TT)
a. 1-3 lesions
b. Annular plaques with central clearing

Leprosy 33
 c. Well defined raised margins
Personal Notes
d. Side profile: Saucer right way up
2. Borderline Tuberculoid (BT)
a. 3-10 skin lesions
b. Satellite lesions
c. Ill defined margins
3. Borderline (BB)
a. 10-30 skin lesions
b. Polymorphic lesions
c. Dimorphous margins
i. Inner border punched out
ii. Outer border sloping outwards (inverted saucer appearance)
4. Borderline Lepromatous (BL)
a. Numerous, bilateral, almost symmetrical skin lesions
b. Bilateral asymmetrical nerve thickening
5. Lepromatous Leprosy (LL)
a. 
Symmetrical, ill defined macules, papulonodular lesions, diffuse infiltration and
thickening of skin
b. Symmetrical bilateral nerve thickening
c. Epistaxis, nasal crusting
d. Pedal edema
e. Leonine facies
f. Madarosis
g. Glove and stocking peripheral neuropathy

34 Clinical Corner
 Immunobullous Disorders

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Fluid filled lesions/erosions/crusting in various regions of the body
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset
| Age of onset (congenital/acquired)
| Type of lesion:
` Clear fluid filled lesions
` Erosions
` Crusting
| Area of distribution (pemphigus foliaceus is distributed in seborrheic areas, pemphigus
vulgaris has no specific area of distribution)
| How easily do the lesions rupture
| Do the erosions show tendency to heal
| Do the erosions show tendency to extend
| Is it associated with burning sensation in the mouth
| Any history of recent drug intake (drug induced pemphigoid)
 ` Penicillamine
Personal Notes
` Rifampicin
` Captopril
| Any known malignancy:
` Non Hodgkin's lymphoma
` Chronic lymphocytic leukemia
` Castleman's disease
` Thymoma
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any history of similar complaints amongst family members
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature

36 Clinical Corner
| BMI
Personal Notes
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
` Pallor
` Icterus
` Cyanosis
` Clubbing
` Lymphadenopathy
` Pedal edema

LOCAL EXAMINATION
Describe the lesion:
| Primary lesions: Vesicles/bullae
| Secondary lesions: Erosions/crusting
| Roof of vesicles and bullae- is it thin roofed or not
| Area of distribution of lesions
| Any lesions in the oral cavity
| Comment on evidence of any overlying secondary infection
| Comment on body surface area involved
Clinical tests:
| Nikolsky sign: Tangential pressure applied to skin separates upper layers from lower
layers
| Bulla spread sign: Unilateral pressure is applied over the bulla which results in extension
of the margin of the bulla

DIAGNOSIS
| Bullous disorder
| Immunobullous/mechanobullous

Immunobullous Disorders 37
| Congenital/acquired
Personal Notes
| With or without oral lesions
| Most likely diagnosis (ex: pemphigus vulgaris)

CLINICAL POINTERS
Pemphigus foliaceus vs Pemphigus vulgaris:
Pemphigus foliaceus Pemphigus vulgaris
Subcorneal split Suprabasal split
Mucosa of oral cavity not involved Mucosa of oral cavity involved
(no oral lesions)
Generally bullae are not seen on examination as Bullae may be seen on examination
they rupture easily

Bullous pemphigoid vs Pemphigus vulgaris:

Bullous pemphigoid Pemphigus vulgaris
Subepidermal split Suprabasal split
Nikolsky sign negative Nikolsky sign positive
Round regular borders seen on Irregular angulated borders seen
bulla spread test on bulla spread test

38 Clinical Corner
 Pityriasis Versicolor

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Itching, scaling and hypopigmented spots over the trunk region
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset
| Area of distribution (generally the upper half of trunk)
| Colour of spots (hypopigmented/hyperpigmented)
| Is it associated with itching
| Is it associated with scaling
Past medical history:
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Ask about general hygiene
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
Personal Notes
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any other family member having similar complaints
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
` Pallor
` Icterus
` Cyanosis
` Clubbing
` Lymphadenopathy
` Pedal edema

LOCAL EXAMINATION
Describe the lesion:
| Primary lesions - hypopigmented, perifollicular macules
| Distributed symmetrically over the trunk
| Associated with fine scaling
| Number of lesions
| Symmetrical

40 Clinical Corner
 DIAGNOSIS Personal Notes
| Fungal skin infection
| Most likely pityriasis vericolor

CLINICAL POINTERS
Confirmation of diagnosis:
| KOH mount: Spaghetti and meatball appearance
| Wood's lamp examination: Yellow fluorescence
Besnier sign/coup de angle sign:
| Fine scaling is initially not visible. But after scratching with fingers, the scaling becomes
more prominent.
Clinical picture:

Pityriasis Versicolor 41
 Atopic Dermatitis

HISTORY
Personal Notes
Demographic profile:
1. Name
2. Age
3. Sex
4. Education
5. Occupation
6. Residential address
Chief complaints: (according to chronological order)
| Itching and raised lesions over body
History of present illness:
Describe the chief complaint using the following pointers:
| Duration
| Onset
| Age of onset (infancy/childhood adult)
| Type of lesion: Vesicular, with discharge/hardened (lichenified) with deep cracks
| Area of distribution
` Infant: Face, scalp and extensor aspect of extremities
` Child and adult: Flexor surfaces
| Frequency of symptoms
| Is it associated with itching
| Excessive dryness of skin
| Any fish like scaling
| Any eye problems (blurring of vision)
| Any associated history suggestive of atopy
` Allergies
` Swelling of face and lips
` Asthma
| Family history of allergic disorders
Past medical history:
Personal Notes
| Any history of chronic illnesses like diabetes mellitus, hypertension, hypo/
hyperthyroidism, asthma (if present, write in brief about treatment received and
compliance)
| Any history of tuberculosis in the past (if present, write in brief about treatment
received and compliance)
| Any history of previous hospitalization/blood transfusion/surgeries
| Any history of drug allergies
Personal history:
| Vegetarian/non vegetarian
| Diet and appetite
| Bowel and bladder habits
| Sleeping habits
| Any known history of substance abuse (if smoking history is present, mention pack
years or smoking index, if alcohol history is present calculate the number of grams of
alcohol intake in a week)
Family history:
| Any other family member having similar complaints
| Any history of chronic illnesses amongst family members (like diabetes, hypertension,
thyroid disorders)
| Any history of tuberculosis contacts

GENERAL PHYSICAL EXAMINATION

| General condition: Consciousness, orientation to time, place and person
| Comment on the built and stature
| BMI
| Vitals:
` Blood pressure
` Pulse
` Temperature
` Respiratory rate
` Oxygen saturation
Comment on:
| Pallor
| Icterus
| Cyanosis
| Clubbing
| Lymphadenopathy
| Pedal edema

Atopic Dermatitis 43
 LOCAL EXAMINATION Personal Notes
Describe the lesion:
1. In infantile phase:
a. Papulovesicular exudative lesions on face, scalp and extensor surface of extremities
2. In childhood phase:
a. Red, scaly, excoriated papules with lichenification
b. On flexor surfaces
3. In adult phase:
a. Lichenification in flexors
| Comment on evidence of any overlying secondary infection (bacterial/viral)
| Comment on body surface area involved
| Other skin features:
` Xerosis
` Ichthyosis (fish like scales)
` White dermographism

DIAGNOSIS
| Atopic Dermatitis
| In infantile/childhood/adult phase
| With or without any secondary infections

CLINICAL POINTERS
Ophthalmic manifestations in atopic dermatitis:
| Keratoconus
| Shield cataract
| Dennie Morgan's lines
| Lateral madarosis
Diagnostic criteria of atopic dermatitis (Hanifin and Rajka):
1. Pruritus
2. Typical morphology and distribution of skin lesions
3. Chronic or chronically relapsing dermatitis
4. Personal/family history of atopy
White dermographism:
On stroking skin, white line appears due to vasoconstriction.

44 Clinical Corner