Dermatology history taking Flashcards
PC & HPC questions
Open question
Where is the affected area(s)?
When did it start? Acute (e.g. infection) or gradual (e.g. psoriasis)?
Has it changed over time? How has it changed?
Is it always there or does it come and go? Flare ups?
Does anything make it better or worse? Any triggers?
Is it painful? Itchy? Any bleeding? Discharge? Blistering?
Any other symptoms associated with it? (e.g. fever, malaise)
Has it ever happened before? Was it the same? What treatment was used (dose, duration, success)?
PMH questions
Other skin conditions
Skin cancer
Atopy (eczema, asthma, hay fever)
Autoimmune diseases (diabetes, inflammatory bowel disease)
Medication & allergies questions
For the presenting complaint (including creams, ointments, steroids etc), were they effective (did the treatment work)?
Other medication (prescribed, OTC, contraception)
Herbal remedies
Recent changes to medication
Do they take their medication as prescribed
Allergies! (and how they react)
FH questions
Skin conditions
Skin cancer
Atopy
SH questions
Occupation (is it related to their job? e.g. hairdressers – irritant contact dermatitis)
Smoking (cigarettes per day, for how many years)
Alcohol (units per week)
Recreational drugs
Pets
Travel (where to, how long for, exposure to infectious diseases)
Sun exposure (including use of sunbeds/tanning booths)
Contacts (been in contact with anybody with an infectious disease?)
Cosmetics, toiletries, washing detergents and cleaning products (any recent changes in products used?)
Stress
Systemic reviews: cardiovascular, respiratory, GI, GU, neurological, MSK
Cardiovascular (chest pain, palpitations)
Respiratory (breathlessness, cough, sputum)
Gastrointestinal (nausea, vomiting, change in weight, appetite, bowel habits)
Genitourinary (difficulty passing urine, incontinence)
Neurological (vision changes, headaches, fits, falls, confusion)
Musculoskeletal (bone, joint or muscle pain)
Closing pieces
Summarise (also do this throughout taking the history)
ICE
Ideas – what do you think it is?
Concerns – what are you worried about?
Expectations – what are you hoping to gain from today?
Impact on quality of life (how does it affect the patient’s daily life)
Any questions?
Thank the patient
