Writing Up the Physical Examination

Listed here are examples of the writeup for the examination of the skin.

• There are oval plaques with well-defined borders and silvery scales symmetrically present on the elbows, knees, scalp, and gluteal cleft. The plaques in the scalp are along the hairline. The scales are large. Examination of the nails reveals pitting of the nail plates. The hair is of normal texture.

• There is an annular lesion 3-4 cm in diameter on the right forearm. Scale is present on the narrow (1- to 2-mm), raised, erythematous border. The central area is slightly hypopigmented. The hair and nails are unremarkable.

• There is a linear bullous eruption along the lateral aspect of the left leg. The eruption consists of bright red edematous papules and bullae. There are no lesions on the palms or soles or in the mouth.

• A wide variety of lesions are seen on the face, shoulders, and back. The predominant lesions are pustules on an inflammatory base. Many pustules are present, and several have become confluent over the chin and forehead. Open and closed comedones are present on the face, especially along the nasolabial folds. Inflammatory papules are present on the lower cheeks and chin. Large abscesses and ulcerated cysts are present over the upper shoulder areas. Numerous scars are present over the face and upper back.

• A diffuse erythematous maculopapular rash is present on the trunk. Some excoriations are present over the shoulders and chest. The hair and nails are unremarkable.

• Examination of the skin reveals several types of lesions. The main lesions are small papules in the antecubital and popliteal fossae. The papules in some areas have become confluent, and plaques are present. On the dorsum of the feet, eczema is present with erythema, weeping, crusting, and scaling. Lichen-ification of the anogenital area, especially the scrotum, is present.

• The skin is slightly cool and dry. Scattered lentigines are present over the trunk. The hair is very fine and soft. There is loss of the lateral one third of the eyebrows. No nail abnormalities are present.

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