Dermatological History-Taking
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
Past Medical Issues
Diabetes, inflammatory bowel disease
Skin Conditions
Diagnosis, severity, management
Atopy
Asthma, allergies, atopic dermatitis
Skin Cancers
When, type, management
Current Medications
Indication, when started, side effects
Topical Agents
Drugs, creams, ointments
Allergies
Allergen, reaction, severity
Relationship with the Sun
Tans / burns, amount of exposure, sunscreen
Family History
Skin Conditions
Atopic eczema, psoriasis, ichthyosis, keratoderma
Skin Cancers
BCC, SCC, melanoma
Social History
Living Situation
Where, who they live with, cleanliness
Social Supports
Family, friends
Infected Contacts
E.g. with chickenpox, scabies
Pets
New pets, pet allergies
Recent Travel
When, where, sun exposure
Occupation
Exposure to toxins
Hobbies
E.g. gardening
Substance History
Alcohol
Average per day / week, CAGE
Smoking
Pack-years, years since quitting
Recreational drugs
Especially IV drug use
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
