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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.
Introduction
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
Use open questioning to explore the patient’s presenting complaint:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, 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
The SOCRATES 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 the location of the symptom:
- “Where is the skin lesion?”
Onset
Clarify how and when the symptom developed:
- “When did you first notice the skin lesion?”
Character
Ask about the specific characteristics of the symptom:
- “How 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 symptom moves anywhere else:
- “Does the pain spread anywhere else?”
Associated symptoms
Ask if there are other symptoms which are associated with the primary symptom:
- “Are 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 has changed over time:
- “How 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 symptom worse or better:
- “Does anything seem to make the rash worse?”
- “Does anything make the rash better?”
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
- “On 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’s ideas, concerns and expectations (often referred to as 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’s ideas about the current issue:
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
- “It’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 current concerns:
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number one concern regarding this problem at the moment?”
- “What’s the worst thing you were thinking it might be?”
Expectations
Ask what the patient hopes to gain from the consultation:
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
- “What do you think might be the best plan of action?”
Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to discuss your past medical history and then explore what medications you currently take.”
Systemic enquiry
A systemic enquiry 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 of symptoms you could screen for in each system 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 any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. excision of skin lesion):
- “Have you ever previously undergone any operations or procedures?”
- “When 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 any allergies and if so, clarify what kind of reaction 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:
- “Are 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 any family history of dermatological disease:
- “Do any of your parents or siblings have any skin problems?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors):
- “At what age did your father develop melanoma?”
Social history
Explore the patient’s social history to both understand their social context and identify potential dermatological risk factors.
General social context
Explore the patient’s general social context 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’s smoking 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 the frequency, type and volume of alcohol consumed on a weekly basis.
Recreational drug use
Ask the patient if they use recreational 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 current occupation 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
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
