Dermatological History-Taking

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Patients presenting with dermatologic issues often have non-specific symptoms that are difficult to diagnose, and it is important to take a thorough history in order to narrow down the differential diagnosis.

On this page: Presenting Complaints Past Medical History Family History Social History Substance History Systems Review

Presenting Complaints

Rash
Site, onset, associated symptoms, exposures
Site
E.g. face, scalp, flexor / extensor surfaces
Onset
Days / weeks / years
Character
Redness, spots, blisters
Change in Appearance
Recent growth, colour change
Associated Symptoms
Pruritis, pain, bleeding, discharge, fever
Timing
Duration, frequency, constant / fluctuant
Exposures
Medications, cosmetics, detergents, sunlight
Alleviating Factors
Eg. creams
Skin Lumps / Lesions
Site, onset, change in appearance, exposures
Site
E.g. sun-exposed areas, face
Onset
Days / weeks / years
Character
Lump / bump, blister
Change in Appearance
Recent growth, colour change
Associated Symptoms
Pain, pruritis, bleeding, discharge
Timing
Duration
Exposures
Sun
Pruritis (Itch)
Site, onset, associated symptoms, exposures
Site
E.g. face, scalp, flexor / extensor surfaces
Onset
Days / weeks / years
Associated Symptoms
Rash, pain, bleeding, discharge, fever
Timing
Duration, frequency, constant / fluctuant
Exposures
Medications, cosmetics, detergents, sunlight
Alleviating Factors
Eg. creams
Pain
SOCRATES
Site
Localised / generalised, unilateral / bilateral
Onset
Sudden / gradual, situation, following trauma
Character
Burning, sharp, dull
Radiation
To any other site
Associated Symptoms
Redness, swelling, lumps, fevers
Timing
Duration, frequency, constant / fluctuant
Exposures
Medications, cosmetics, detergents, sunlight
Alleviating Factors
Eg. creams
Severity
On a scale of 1-10, with 10 being the worst
Alopecia
Bleeding
Discharge
Systemic Symptoms
Fevers / rigors, malaise

Past Medical History

Family History

Social History

Substance History

Systems Review

General
Weight Change
Appetite Change
Fevers / Recent Illnesses
Night Sweats
Fatigue / Malaise / Lethargy
Cardio-Respiratory
Chest Pain
Dyspnoea
Palpitations
Peripheral Oedema
Cough
Lightheadedness / Collapse
Gastrointestinal
Abdominal Pain
Nausea / Vomiting
Constipation
Diarrhoea
Blood in Bowel Motions
Indigestion
Neurological
Headache
Seizures
Changes in sight, hearing, smell or taste
Lightheadedness / Collapse
Dizziness / Vertigo
Genitourinary
Changes in Urine Output
Polyuria / Oliguria / Anuria
Urine Colour
Haematuria
UTI Symptoms
Dysuria, frequency, flank pain
Obstructive Symptoms
Urgency, hesitancy, dribbling, nocturia
Uraemic Symptoms
Fatigue, pruritis, anorexia, nausea, restless legs
Musculoskeletal
Recent Trauma
Pain
Stiffness
Swelling