Taking a dermatological history is an important skill that is often assessed in the OSCE setting. It usually involves taking a history of a skin lesion or rash, and it’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough history of any skin problem. Check out the dermatology history taking OSCE mark scheme here.
Introduction
Introduce yourself – name / role
Confirm patient details – name / DOB
Explain the need to take a history
Gain consent
Ensure the patient is comfortable
Presenting complaint
It’s important to use open questioning to elicit the patient’s presenting complaint
“So what’s brought you in today?” or “Tell me about your symptoms”
Allow the patient time to answer, trying not to interrupt or direct the conversation
Facilitate the patient to expand on their presenting complaint if required
“Ok, so tell me more about the rash” “Can you explain what that pain was like?”
History of presenting complaint
Onset:
- When did the skin problem start?
- Was the onset acute or gradual?
Course – has the rash/skin lesion changed over time?
Intermittent or continuous – is the skin problem always present or does it come and go?
Duration of the symptom if intermittent – minutes / hours / days / weeks / months / years
Location / distribution:
- Where is the skin problem?
- Number of lesions?
- Is it spreading?
Precipitating factors – are there any obvious triggers for the symptom?
Relieving factors – does anything appear to improve the symptoms (e.g. steroid cream)?
Associated features – are there other symptoms that appear associated (e.g. fever/malaise)?
Previous episodes – has the patient experienced this problem previously?
- When?
- How long for?
- Was it the same or different than the current episode?
Previous or current treatment for this skin problem (did it work?):
- Prescribed medication
- Over the counter medication
Contact history – has the patient been in contact with an infectious skin problem (e.g. chickenpox)?
Sun exposure (including sun bed use)
- Important when considering skin cancer in the differential diagnosis
- Ask the patient about how their skin reacts to sun exposure to help determine their skin type (Fitzpatrick scale)
Key dermatology symptoms:
- Pain
- Itch
- Bleeding
- Discharge
- Blistering
- Systemic symptoms – fever / malaise / weight loss / arthralgia
If any of these symptoms are present, gather further details as shown above (Onset / Duration / Course / Severity / Precipitating factors / Relieving factors / Associated features / Previous episodes)
Pain
If pain is a symptom, clarify the details of the pain using SOCRATES
- Site – where is the pain ?
- Onset – when did it start? / sudden vs gradual?
- Character – sharp / dull ache / burning
- Radiation – does the pain move anywhere else?
- Associations – other symptoms associated with the pain?
- Time course – worsening / improving / fluctuating / time of day dependent
- Exacerbating / Relieving factors – anything make the pain worse or better?
- Severity – on a scale of 0-10, how severe is the pain?
Ideas, Concerns and Expectations
Ideas – what are the patient’s thoughts regarding their symptoms?
Concerns – explore any worries the patient may have regarding their symptoms
Expectations – gain an understanding of what the patient is hoping to achieve from the consultation
Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient:
- What you have covered – “Ok, so we’ve talked about your symptoms and your concerns regarding them”
- What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”
Past medical history
Skin disease:
- Skin cancer
- Atopy – eczema / hay fever / asthma
- Other dermatological conditions
Other medical conditions – many of which can have dermatological manifestations
- Diabetes – acanthosis nigricans / scleroderma diabeticorum / necrobiosis lipoidica diabeticorum
- Inflammatory bowel disease – pyoderma gangrenosum / erythema nodosum
Drug history
Skin treatments – creams / ointments / UV therapy / antibiotics / biologics
Regular medication – including length of treatment (paying particular attention to those started around the time of the skin problem)
Antibiotics
Over the counter drugs
Cosmetics
Herbal remedies
ALLERGIES (a common cause of rashes) – ensure to document these clearly
Family history
Skin conditions – e.g. psoriasis / hereditary hemorrhagic telangiectasia
Skin cancer
Atopy – eczema / asthma / hay fever
Social history
Occupation:
- Are the skin problems worse at work?
- Do the skin problems improve when the patient is off from work?
- Is the patient exposed to any skin irritants or other hazardous substances?
Smoking – How many cigarettes a day? How many years have they smoked for?
Alcohol – How many units a week? – type / volume / strength of alcohol
Recreational drug use – e.g. cellulitis from IV drug injection sites
Living situation:
- Own home/care home – adaptations / stairs?
- Who lives with the patient? – is the patient supported at home?
- Any carer input? – what level of care do they receive?
- Any recent changes at home that could be related to skin problems (e.g. new detergent causing allergic reaction to clothing)
Activities of daily living:
- Is the patient independent and able to fully care for themselves?
- Can they manage self hygiene / housework / food shopping?
Travel history
Where did the patient travel to?
How long was the patient there?
Is the patient aware of any exposure to infectious disease?
Sun exposure – was the skin problem worsened by sun exposure? (e.g. facial rash in lupus)
Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. arthralgia in psoriatic arthritis).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.
Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain
GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence
CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
Musculoskeletal – Bone and joint pain / Muscular pain
Closing the consultation
Thank the patient
Summarise the history