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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 usee.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 

RespiratoryDyspnoea / 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

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