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Table of Contents
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.
Presenting complaint
UseΒ open questioningΒ to explore the patientβsΒ presentingΒ complaint:
- βWhatβs brought you in to see me today?β
- βTell me about the issues youβve been experiencing.β
Provide the patient with enoughΒ timeΒ to answer and avoid interrupting them.
Facilitate the patient toΒ expandΒ on theirΒ presentingΒ complaintΒ if required:
- βOk, can you tell me more about that?β
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 weβve 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 patientβs 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:
- βWhere is the skin lesion?β
Onset
ClarifyΒ howΒ andΒ whenΒ the symptom developed:
- βWhen did you first notice the skin lesion?”
Character
Ask about theΒ specificΒ characteristicsΒ of the symptom:
- βHow 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:
- βDoes the pain spread anywhere else?β
Associated symptoms
Ask if there are other symptoms which areΒ associatedΒ with the primary symptom:
- βAre 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:
- βHow 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:
- βDoes anything seem to make the rash worse?β
- βDoes anything make the rash better?β
Severity
Assess theΒ severityΒ of the symptom by asking the patient to grade it on a scale of 0-10:
- βOn a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain youβve ever experienced?β
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 patientβsΒ 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 patientβsΒ ideasΒ about the current issue:
- βWhat do you think the problem is?β
- βWhat are your thoughts about what is happening?β
- βItβs clear that youβve given this a lot of thought and it would be helpful to hear what you think might be going on.β
Concerns
Explore the patientβs currentΒ concerns:
- βIs there anything, in particular, thatβs worrying you?β
- βWhatβs your number one concern regarding this problem at the moment?β
- βWhatβs the worst thing you were thinking it might be?β
Expectations
Ask what the patient hopes toΒ gainΒ from the consultation:
- βWhat were you hoping Iβd be able to do for you today?β
- βWhat would ideally need to happen for you to feel todayβs consultation was a success?β
- βWhat do you think might be the best plan of action?β
Summarising
SummariseΒ what the patient has told you about theirΒ presenting complaint. This allows you toΒ check your understandingΒ of the patientβs history and provides an opportunity for the patient toΒ correctΒ anyΒ inaccurate information.
Once you haveΒ summarised, ask the patient if thereβs anything else that youβveΒ 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 patientβs 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 βOk, so weβve talked about your symptoms, your concerns and what youβre hoping we achieve today.β
What you plan to cover next:Β βNext Iβd like to discuss your past medical history and then explore what medications you currently take.β
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
- βDo you have any medical conditions?β
- βAre you currently seeing a doctor or specialist regularly?β
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):
- βHave you ever previously undergone any operations or procedures?β
- βWhen was the operation/procedure and why was it performed?β
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:
- βAre you currently taking any prescribed medications or over-the-counter treatments?β
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:
- βDo any of your parents or siblings have any skin problems?βΒ
Clarify at whatΒ age the diseaseΒ developedΒ (disease developing at a younger age is more likely to be associated with genetic factors):
- βAt what age did your father develop melanoma?β
Social history
Explore the patientβsΒ socialΒ historyΒ to both understand theirΒ socialΒ contextΒ and identify potentialΒ dermatological risk factors.
General social context
Explore the patientβsΒ 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 patientβsΒ 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 patientβs 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.