Dermatological History Taking – OSCE Guide

If you'd like to support us and get something great in return, check out our bank of 500+ OSCE Stations. You might also be interested in our OSCE Checklist PDF Booklet, Clinical Skills App and our OSCE Flashcard Collection which contains over 2500 cards.


Taking a dermatological history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a history of a skin lesion or rash in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.
You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Presenting complaint

UseΒ open questioningΒ to explore the patient’sΒ presentingΒ complaint:

  • β€œWhat’s brought you in to see me today?”
  • β€œTell me about the issues you’ve been experiencing.”

Provide the patient with enoughΒ timeΒ to answer and avoid interrupting them.

Facilitate the patient toΒ expandΒ on theirΒ presentingΒ complaintΒ if required:

  • β€œOk, can you tell me more about that?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

Patients with rashes and skin lesions can present with a wide variety of associated symptoms which we’ve summarised below.

Key dermatological symptoms

Key dermatological symptoms include:

  • Rash
  • Skin lesion
  • Pain
  • Itch
  • Bleeding
  • Discharge
  • Blistering
  • Systemic symptoms: fever, malaise, weight loss and arthralgia.

SOCRATES

TheΒ SOCRATESΒ acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Site

Ask about theΒ locationΒ of the symptom:

  • β€œWhere is the skin lesion?”

Onset

ClarifyΒ howΒ andΒ whenΒ the symptom developed:

  • β€œWhen did you first notice the skin lesion?”

Character

Ask about theΒ specificΒ characteristicsΒ of the symptom:

  • β€œHow does the skin lesion feel when you touch it?”
  • “How many of the skin lesions are there?”
  • “What shape are the skin lesions?”

Radiation

Ask if the symptomΒ movesΒ anywhereΒ else:

  • β€œDoes the pain spread anywhere else?”

Associated symptoms

Ask if there are other symptoms which areΒ associatedΒ with the primary symptom:

  • β€œAre there any other symptoms that seem associated with the rash?”
  • “Have you noticed the skin lesion itching or bleeding?”

Time course

Clarify how the symptom hasΒ changedΒ overΒ time:

  • β€œHow has the rash changed over time?”
  • “How has the skin lesion changed over time?”
  • “Have you had a rash like this in the past?”

Exacerbating or relieving factors

Ask if anything makes the symptomΒ worseΒ orΒ better:

  • β€œDoes anything seem to make the rash worse?”
  • β€œDoes anything make the rash better?”

Severity

Assess theΒ severityΒ of the symptom by asking the patient to grade it on a scale of 0-10:

  • β€œOn a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Treatments

Ask the patient if they have tried any treatments for the problem already:

  • “Have you tried any treatments for your rash?”
  • “Did they make any difference?”

Previous episodes

Ask the patient if they have previously experienced similar episodes of the problem:

  • “Have you ever had a rash like this in the past?”
  • “What happened the last time?”

Ask the patient if they tried any treatments for the previous episode:

  • “Did you try any creams or tablets to treat the problem last time?”
  • “Did the treatment work?”

Contact history

Clarify if the patient has recently had any contact with infectious diseases (e.g. chickenpox):

  • “Have you been in contact with anyone recently who had an infectious disease or skin problems like yours?”

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’sΒ ideas,Β concernsΒ andΒ expectationsΒ (often referred to asΒ ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’sΒ ideasΒ about the current issue:

  • β€œWhat do you think the problem is?”
  • β€œWhat are your thoughts about what is happening?”
  • β€œIt’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s currentΒ concerns:

  • β€œIs there anything, in particular, that’s worrying you?”
  • β€œWhat’s your number one concern regarding this problem at the moment?”
  • β€œWhat’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes toΒ gainΒ from the consultation:

  • β€œWhat were you hoping I’d be able to do for you today?”
  • β€œWhat would ideally need to happen for you to feel today’s consultation was a success?”
  • β€œWhat do you think might be the best plan of action?”

Summarising

SummariseΒ what the patient has told you about theirΒ presenting complaint. This allows you toΒ check your understandingΒ of the patient’s history and provides an opportunity for the patient toΒ correctΒ anyΒ inaccurate information.

Once you haveΒ summarised, ask the patient if there’s anything else that you’veΒ overlooked. Continue toΒ periodically summariseΒ as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly statingΒ what you have discussed so farΒ andΒ what you plan to discuss next. Signposting can be a useful tool whenΒ transitioningΒ between different parts of the patient’s history and it provides the patient with time toΒ prepareΒ for what is coming next.

Signposting examples

Explain what you have covered so far:Β β€œOk, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next:Β β€œNext I’d like to discuss your past medical history and then explore what medications you currently take.”


Systemic enquiry

AΒ systemicΒ enquiryΒ involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples ofΒ symptomsΒ you couldΒ screen forΒ in eachΒ systemΒ include:

  • Systemic: fevers (e.g. cellulitis)
  • Cardiovascular: peripheral oedema
  • Respiratory: wheeze, dyspnoea (e.g. anaphylaxis)
  • Gastrointestinal: abdominal pain and diarrhoea (e.g. Crohn’s disease)
  • Neurological: confusion (e.g. meningococcal sepsis)

Travel history

Ask the patient if they have recently been travelling and consider if this may have relevance to their presenting complaint (e.g. erythema migrans after visiting a location with potential tick exposure).


Past medical history

Ask if the patient has anyΒ medicalΒ conditions:Β 

  • β€œDo you have any medical conditions?”
  • β€œAre you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assessΒ howΒ wellΒ controlledΒ the disease is and whatΒ treatment(s)Β the patient is receiving. It is also important to ask about anyΒ complicationsΒ associated with the condition includingΒ hospitalΒ admissions.

Ask if the patient has previously undergone anyΒ surgeryΒ orΒ proceduresΒ (e.g. excision of skin lesion):

  • β€œHave you ever previously undergone any operations or procedures?”
  • β€œWhen was the operation/procedure and why was it performed?”

Sun exposure

Assess the patient’s previous sun exposure (including sunbed use) to determine skin cancer risk.

Ask the patient how their skin reacts to sun exposure to help determine their skin type using the Fitzpatrick scale.

Ask if the patient’s symptoms seem to worsen (e.g. systemic lupus erythematosus) or improve (e.g. psoriasis) after sun exposure.

Allergies

Ask if the patient has anyΒ allergiesΒ and if so, clarifyΒ what kind of reactionΒ they had to the substance (e.g. mild rash vs anaphylaxis).

Examples of relevant medical conditions

Medical conditions relevant to dermatological disease include:

  • Previous skin cancer or other dermatological conditions
  • Atopy
  • Diabetes (e.g. acanthosis nigricans, scleroderma diabeticorum, necrobiosis lipodica)
  • Inflammatory bowel disease (e.g. pyoderma gangrenosum, erythema nodosum)
  • Other medical conditions requiring systemic immunosuppression (increased risk of skin cancer)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • β€œAre you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
Medication examples

Medications prescribed to patients with dermatological disease include:

  • Emollients
  • Ointments
  • Topics steroids
  • Antibiotics
  • Systemic immunosuppressants (e.g. biologics)

Relevant over the counter purchases which may cause or worsen dermatological symptoms:

  • Skincare products
  • Soaps
  • Cosmetics

Family history

Ask the patient if there is anyΒ familyΒ history of dermatological disease:

  • β€œDo any of your parents or siblings have any skin problems?” 

Clarify at whatΒ age the diseaseΒ developedΒ (disease developing at a younger age is more likely to be associated with genetic factors):

  • β€œAt what age did your father develop melanoma?”

Social history

Explore the patient’sΒ socialΒ historyΒ to both understand theirΒ socialΒ contextΒ and identify potentialΒ dermatological risk factors.

General social context

Explore the patient’sΒ general social contextΒ including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)
  • if they have recently changed any cleaning products which coincide with the development of their symptoms

Smoking

Record the patient’sΒ smokingΒ history, including the type and amount of tobacco used.

Smoking is a risk factor for skin cancer and significantly impacts general skin health.

Alcohol

Record theΒ frequency,Β typeΒ andΒ volumeΒ ofΒ alcoholΒ consumed on a weekly basis.

Recreational drug use

Ask the patient if they useΒ recreationalΒ drugs and if so determine the type of drugs used and their frequency of use.

Intravenous drug use is associated with an increased risk of cellulitis and necrotising fasciitis at injection sites. Intravenous drug users are also more likely to be infected by HIV and hepatitis B/C, all of which can present with dermatological manifestations.

Diet

Ask if the patient has recently changed their diet or noticed that certain food types seem to trigger their symptoms (e.g. rash associated with coeliac disease).

Occupation

Ask about the patient’s currentΒ occupationΒ to clarify what their job role involves.

Ask if the patient’s skin problems seem to be worse when they’re working and if the problems improve when they have some time off.

Clarify if the patient is exposed to any skin irritants or other hazardous substances in their work.


Closing the consultation

SummariseΒ theΒ keyΒ pointsΒ back to the patient.

Ask the patient if they have anyΒ questionsΒ orΒ concernsΒ that have not been addressed.

Thank the patientΒ for their time.

Dispose of PPE appropriately and wash your hands.


 

Print Friendly, PDF & Email