How to diagnose

1. Anamnese

Because the patient main complaint is red patches, so we do anamneses

based on the following steps:

1) Ask the patient identity, such as name, age, address, work

2) Ask the patient what caused them to come to the doctor (main
complaint). In this scenario the main complaint is red patches, so we
ask about :
a. Duration : how long she/he had?
b. Onset : ask whether the red patches arise suddenly or gradually
c. Characteristic red patches : it is pain? It is heat? It is itch? It is
intermittent? it is permanent or periodically? How the red patches
chronological? Is the patches getting worse or getting better?
d. What makes the red patches worsened or improved?
3) Ask the patient about another complaint, such as :
a. Fever, Anorexia, dysphagia, malaise, headache, arthralgia,
myalgia, difficulty opening the mouth
b. Bleeding manifestations : petechiae, ecchymosis, epistaxis,
hematemesis, melena
c. Chills
d. Seizures
e. Respiratory system disorders: coughing, dyspneu
f. Gastrointestinal disorders : nausea, vomiting, abdominal pain,
diarrhea with/without mucus/blood, constipation
g. Urogenital system disorders : the color of urine, oliguria, dysuria
h. Skin rash : at the onset, location, deployment
4) Ask about the patient history of illness : whether the patient felt the
same complaints? Whether the patient has an illness now? Whether
the patient ever had a previous illness?
5) Ask about the patients family history of illness : whether the patients
family there who had the same complaints? Whether the patients
family is suffering from an illness?
6) Ask about the environment condition : whether people around him
suffered the same complaint? If the environmental conditions are
 clean or not? If she/he neighborhood is being attacked by the disease
is endemic?
7) Ask about the immunization history
8) Ask about the travel history or have ever lived in endemic areas of
certain diseases.
9) Ask a history of contact with disease with symptoms
10) Ask a history of contact with animals
11) Ask treatment history had ever received.

2. Physical examination
A thorough dermatologic examination should include all visible body
surfaces. Thus, you should be evaluating not only the skin, hair and nails,
but also the mucous membranes (mouth, eyes, nose, genitalia). An entire
body examination is usually unnecessary for a readily identified localized
process, but many findings may be missed if you do not actively search
beyond the most apparent pathology, or that which the patient points out.
The examination is best performed in a room with bright overhead
light. You should also have a flashlight at hand; a ruler and magnifying
glass are frequently necessary. The patient should disrobe completely
except for a gown.
The following outline provides a systematic approach to use each time
you perform a skin examination:
I. Note the overall appearance of the patient and skin. Is the patient
healthy or illappearing? Is there an abnormal color to the skin? (i.e.,
paleness in anemia, yellow hue in jaundice, blue in cyanosis) Do
you see a generalized process involving a large part of the body
surface?
II. Inspect each part of the body. Do so in the same order each time, as
you would in a general physical examination. A head-to-toe
approach is suggested here.
A. Scalp and hair. If the patient has a full head of hair, you may
need to part it in several areas to see the scalp well. Hair bands
should be removed so that the hair is loose. In evaluating hair,
especially note any areas of alopecia (hair loss) or thinning.
B. Face, including eyes, nose, and mouth. In examining the eyes,
have the patient look in all directions to reveal conjunctival
 lesions. In the nose, examine the outer 4 nostrils and the nasal
septum (using a flashlight). Mouth findings are often subtle and
you should always use a flashlight here. Have the patient move
the tongue to either side so that the inner cheeks can be
visualized; also inspect the palate and all surfaces of the tongue.
C. Ears and neck. Inspect the outer ear, the external ear canal and
behind the ears. After examining the neck, feel for any enlarged
lymph nodes locally, as well as elsewhere.
D. Chest and abdomen. Remember to inspect the axillae and under
the breasts, and in skin folds of obese patients.
E. Back and buttocks. Also examine the intergluteal cleft and
perianal region.
F. Arms, hands, fingernails. Inspect the sides of the fingers and
web spaces, and distinguish lesions on the dorsum of the hand
from those on the palms. The presence of palmar, usually along
with plantar (sole) lesions is characteristic of certain diseases.
When examining nails also look at the surrounding (periungual)
area and the cuticles.
G. Legs, feet, toenails. The groin folds should be inspected at this
time. Evaluate the feet in the same manner as the hands,
including interdigital areas and the soles.
H. Genitalia. Inspect the pubic area and labia in women, and the
pubic area, scrotum and penis in men. An uncircumcised male
should retract the foreskin.
III. Description
Lesions found in each of the above areas should be characterized
carefully. Your observations and descriptions are crucial here. A
magnifying glass may be helpful, especially for smaller lesions.
You should note all the following characteristics of the lesions
upon inspection:
A. Number and distribution. There may be one or more lesions in a
localized area, or numerous in several areas. The distribution
often suggests an etiology. For example, a systemic process
such as a viral illness or drug ingestion would be more likely to
 cause a generalized eruption than a localized one. An eruption
confined to one dermatome (the cutaneous distribution of a
single spinal nerve root) is classic for zoster. Lesions on sun
exposed areas, such as the face, backs of the hands and upper
chest suggest photosensitivity (sun-induced) reaction.
B. Arrangement or configuration. Do the lesions form a pattern
which can be described? For instance, an involved area with
well-demarcated linear borders often suggest a contact
dermatitis. Other configurations may be labeled annular
(circular) or serpiginous (wavy). Often, the arrangement is
random, forming no particular pattern.
C. Size of individual lesions. If several lesions are present, they
may be similar in size, or there may be a range of sizes. If the
latter, you should indicate the range (i.e. 5- 15 millimeters).
D. Color. The following terms are most commonly used in
describing colors of skin: 1. Flesh-colored no change from
surrounding normal skin. 2. Hypopigmented lighter in color
than surrounding skin. 3. Hyperpigmented darker in color
than surrounding skin. Hyperpigmented lesions are usually
various shades of brown from the pigment melanin. 4.
Erythematous red. Different lesions may vary from pale to
very bright to deep red in color, and this should be indicated in
your description. 5. Violaceous purple. Skin lesions may also
come in many other colors, including white, pink, blue, black,
yellow and gray. Noting uniformity (or non-uniformity) of
color is important. A lesion may have an erythematous ring
around the periphery with a flesh colored center. Another lesion
may be a uniform light brown or it may be unevenly colored
shades of brown; both could be rightly labeled hyperpigmented,
but a more precise description is necessary to distinguish the
two.
 E. Shape. Individual lesions are most commonly round or oval,
but may also be linear or other shapes. Next inspect the borders.
Are they well-demarcated or indistinct, even or jagged? Also
note the three-dimensional shape. A lesion may be raised above
the level of the skin, even with it, or depressed below the
surface; or it may be a combination, such as with raised edges
and a central ulceration. Some common shapes of raised lesions
are dome-shaped, flat-topped and filiform (fingerlike). At the
skin surface a lesion may also be broad-based or pedunculated
(on a stalk).
F. Surface characteristics. Examples are smooth, rough, shiny,
dull, waxy and verrucous (warty).

The final step is palpation. Carefully run your index finger over the
lesion and note the texture of the surface (i.e. rough or smooth). At
times you may only be able to distinguish a slightly raised lesion
from a flat one by careful palpation with your eyes closed. Next
determine the consistency by pressing on the lesion and then
palpating it between your fingers. Terms used to describe
consistency include rock-hard, firm, rubbery, fluctuant and soft.
Also note how far the lesion extends below the skin surface by feel.
If a lesion is completely below the surface, is it fixed in place (thus
attached to the epidermis and/or dermis) or freely moveable (thus
completely underlying the skin)? Lastly, subtle changes in the feel
of the skin surrounding a lesion (i.e. an apparently small
malignancy to the eye) may indicate more extensive involvement
of the area, and may have important therapeutic implications.

3. Laboratory examination

Most diagnoses of scabies infestation are made based upon the

appearance and distribution of the rash and the presence of burrows.
Whenever possible scabies should be confirmed by isolating the mites, ova
or feces in a skin scraping. Scrapings should be made at the burrows,
especially on the hands between the fingers and the folds of the wrist.
Alternatively, mites can be extracted from a burrow by gently pricking
open the burrow with a needle and working it toward the end where the
mite is living. The extracted mite then can be identified by microscopy.

The following is a suggested method for collecting and examining

skin scrapings:

Scrapings are best performed at the end of the burrows in non-

excoriated and non-inflamed areas using a sterile scalpel blade containing
a drop of mineral oil. The mineral oil enhances the adherence of the mites
to the blade and can then be transferred to a glass slide. An additional 1-2
drops of mineral oil can be added to the slide, followed by a coverslip for
microscopic examination. Skin scrapings should be screened at 40x or
100x magnification and then evaluated at 200 to 400x magnification for
confirmation.

http://www.siumed.edu/medicine/dermatology/student_information/skinph
ysicalexam.pdf
https://www.cdc.gov/dpdx/scabies/dx.html