Dermatological History

History Components

1. Establishing a good relationship with the patient (introduction& Permission)
2. Personal Data
3. Chief Complaints or presenting symptom
4. History of Present Illness
5. Review of systems
6. Past medical and surgical history
7. Family history
8. Drug & Allergy history
9. Social history
10. Behavioral history
11. Summery of the History

1. Establishing a good relationship with the patient (introduction& Permission)

• Who are you?
• Why you are here for?
• Politely, ask for permission to take history and examination
• Ensure privacy by closing the door or down the curtains
• Sit beside the patient to be on the patient’s eye level
• Don’t be harry
• Address the patient respectfully, use his name or title
• Little chatting about general issues may be helpful to warm up the interview.

2. Personal Data

• Name
• Age
• Gender
• Occupation
• Marital status

3. Chief Complaint/s or Presenting Symptom

• The main complaint causes patient seeking medical care
• Write them in patients word $\to$ don’t use medical terms
• Patient complaint/ duration
• Ask about duration of the complaint
• (chronic $\to$ months or years)(subacute $\to$ weeks or days ) (acute $\to$ days or hours)
• When the last time you were well or free of this complaints?

4. History of present illness (HPI)

• The backbone and guidance for the history
• Utilize most time in this part
• Narrative, time sequenced writing interrupted by open questions
• After the patient takes time to tell story, close this session by asking direct closed questions to fill gaps in the story.
• Try as you can to avoid using the medical terms when you write the story.
• Many patients have their own hypothesis regarding their symptoms and disease, don’t be leaded.

Analysis of the chief complaint/s

• mnemonic SOCRATES
  • S → Site → Ask where the symptom is exactly and whether it is localized or diffuse. Ask the patient to point to the actual site on the body.
  • O → Onset → does the symptom came on rapidly, gradually or instantaneous and how it goes is it continuously or intermittently
  • C → Character → ask the patient what is meant by the symptom. If there is pain, is it sharp, dull, stabbing, boring, burning or cramp-like?
  • R → Radiation (pain or discomfort)
  • A → Alleviating factors
  • T → Timing → duration
  • E → Exacerbating factors
  • S → Severity → you can use scale (0 to 10)
• Complete reviewing of the target system in this part.

5. Review of Systems (ROS)

• Ask direct questions about the main symptoms for each system, except the C/O system:
• CNS: headache, dizziness, blurring of vision, ??
• Musculoskeletal system: joints pain or swelling, muscular pain or atrophy??
• Cardiopulmonary: palpitations, shortness of breathing, cough, chest pain
• GIT: weight loss, loss of appetite, abdominal pain, nausea, vomiting
• Urogenital system: burning micturition, urine retention, incontinence, urethral discharge
• Integumentary system: pruritus, discoloration,

6. Past medical and surgical history

• If he had any past medical problem, analyze it regarding symptoms, treatment
• History of hospitalization, cause and days of stay
• Surgical history, indications, complications

7. Family History

1. Ask about any disease runs in his family
2. Ask about similar disease in the family
3. If yes, what is the degree of relationship

8- Drug & Allergy history

• List of all drugs , topical, systemic , herbals
• Do you allergic to any certain drugs or foods

9. Social History:

• Ask about :

1. Socioeconomic level
2. Housing setting
3. Occupation
4. Travelling history
5. Hobbies

10. Behavioral History

1. Smoking
2. Drinking
3. Drugs (narcotics)
4. Sexual relations

11. Summarization

• Conclude the interview by asking the patient

• Do you have any thing you want to ADD?

• Write down the positives information and the most important negatives information in points formatting.

• Why summarization is important?

1. Consultation
2. Follow-up
3. Examination

Examination Components

A. General Examination

B. Systems Examinations

1. Respiratory system
2. Cardiovascular system
3. Gastrointestinal system
4. Musculoskeletal system
5. Integumentary system
6. Nervous system i. CNS ii. PNS

Dermatological History and Examination

Key questions for a rash

• HPI:

1. When did it start?
2. Does it itch, burn, or hurt?
3. Is this the first episode?
4. Where on the body did it start?
5. How has it spread (pattern of spread)?
6. How have individual lesions changed (evolution)?
7. Provoking/exacerbating factors?
8. Previous treatments and response?

Key questions for a rash

• ROS
  • Any associated symptoms?
• Past medical history
  • Ask about the atopic triad (asthma, allergies, atopic dermatitis)
• Medications
• Travel history
• Environmental exposures

may also yield important information

Key questions for a growth

• How long has the lesion been present?
• Has it changed and, if so, how?

1. Change in size?
2. Shape?
3. Color?
4. Any itch?
5. Bleeding?

Key questions for a growth

• Further questions that may be pertinent:
• PMH:
  • Any history of skin cancer? What type? When?
  • If melanoma, do you remember the tumor depth or mode of treatment?
• Family history:
  • Any family members with skin cancer?
  • Have any family members had melanoma?