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  • Primary lesions are uncomplicated abnormalities which represent the initial pathologic change. Secondary changes reflect progression of disease such as excoriation, infection, or keratinization.
  • The physician must search for the primary lesion, look at the morphology and grouping to reach a diagnosis, and must know the pattern of emergency dermatologic conditions.
  • The clinician must recognize, and communicate to the patient, that there are times when it is difficult to narrow the final diagnosis to a single entity.

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An emergency physician may be faced with a vast range of dermatologic problems in a busy emergency department (ED). At any given time, there may be a case of simple urticaria or a more serious presentation of Stevens–Johnson syndrome (SJS) waiting to be seen. The role of the emergency physician is not necessarily to diagnose every dermatologic “zebra” but rather to distinguish the benign from the malignant and those conditions which need urgent care from those which do not. Recognizing these distinctions necessitates expertise and significant experience. In the following pages, we outline an approach that will assist the emergency physician in making these decisions. We hope to simplify an approach for the novice physician and expand the realm of diagnosable pathology for the more experienced physician.

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History

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Physicians are taught, early in training, that the key to any successful diagnosis is a thorough history and physical. One must have a systematic approach to provide appropriate care in a timely fashion. Any systematic approach is designed to be applied broadly knowing that certain patients will need additional evaluations. Sometimes, we visualize one problem and assume that it is the primary reason for the patient's visit to the ED. In fact, it is prudent to ask the patient specifically and not make assumptions as their concerns may be more extensive or entirely different. The history component can be broken down to a series of questions including:

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  1. What specifically prompted the patient to seek medical care? What do they think is causing the rash?

  2. Where are the lesions? Where did the lesions originate?

  3. When did the lesions first develop and what has been the progression of the rash?

  4. Was there any prodrome to the lesions? What are the associated symptoms?

  5. How does it feel? Does it itch, hurt, sting, etc.?

  6. What made it better or worse? What treatment was applied?

  7. How is the patient's general health including allergies? What medications do they take regularly or intermittently?

  8. What kind of exposures have they had, including occupation (applicable for adolescent population), travel, foods, and contacts?

  9. Family history of any skin-related disorders?

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Physical

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Dermatology is a visual specialty and diagnosis relies heavily on careful inspection of the skin. The examination should be performed in a well-lit area where you can examine the entire skin surface including mouth, scalp, and nails. Physical examination depends largely on inspection. Palpation of the rash confirms consistency and depth. The entire ...

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