Dermatological History Taking – OSCE Guide

geekymedics.co m/dermatology-history-taking-osce-guide/

Jacob Michie February 23, 2017

Taking a dermat ological hist ory 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.

Int roduce yourself – name/role

Confirm pat ient det ails – name/DOB

Explain t he need t o t ake a hist ory

Gain consent

Ensure t he pat ient is comfort able

Presenting complaint
It ’s import ant t o use open quest ioning t o elicit t he pat ient ’s present ing complaint

“So what’s brought you in today?”   or  “Tell me about your symptoms”

Allow t he pat ient t ime t o answer, t rying not t o int errupt or direct t he conversat ion

Facilit at e t he pat ient t o expand on t heir present ing 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?

Int ermit t ent or cont inuous – is the skin problem always present or does it come and go?

Durat ion of t he sympt om if int ermit t ent – minutes/hours/days/weeks/months/years

Locat ion/dist ribut ion:

Where is the skin problem?

Number of lesions?
Is it spreading?

Precipit at ing fact ors – are there any obvious triggers for the symptom?

Relieving fact ors – does anything appear to improve the symptoms (e.g. steroid cream)?

Associat ed feat ures – 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 t reat ment for t his skin problem (did it work?):

Prescribed medication
Over the counter medication

Cont act hist ory – has the patient been in contact with an infectious skin problem (e.g.
chickenpox)?

Sun exposure (including sunbed 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
It ch
Bleeding
Discharge
Blist ering
Syst emic sympt oms –  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 sympt om, clarify t he det ails of t he 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 – does 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

Expect at ions – gain an understanding of what the patient is hoping to achieve from the consultation

Summarising
Summarise what the patient has told you about their present ing complaint .

This allows you to check your underst anding regarding everything the patient has told you.

It also allows the patient to correct  any inaccurat e informat ion 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
Signpost ing involves explaining t o t he pat ient :

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

Ot her medical condit ions – 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 t reat ment s – creams / ointments / UV therapy / antibiotics / biologics

Regular medicat ion – including length of treatment (paying particular attention to those started
around the time of the skin problem)

Ant ibiot ics 

Over t he count er drugs 

Cosmet ics
Herbal remedies

ALLERGIES (a common cause of rashes) – ensure to document these clearly

Family history
Skin condit ions – e.g. psoriasis / hereditary hemorrhagic telangiectasia

Skin cancer

At opy – eczema / asthma / hay fever

Social history
Occupat ion:

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

Recreat ional drug use – e.g. cellulitis from IV drug injection sites

Living sit uat ion:

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)
Act ivit ies 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 t he pat ient t ravel t o?

How long was t he pat ient t here?

Is t he pat ient aware of any exposure t o infect ious 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 

Respirat ory – 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

Musculoskelet al – Bone and joint pain / Muscular pain 

Closing the consultation

Thank t he pat ient

Summarise t he hist ory