OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's skin lesions using the OPQRST/OLD CARTS approach.
Specific histories based on Chief Complaint:

Mole Changes

Change in size, shape or colour (ABCDE screen for melanoma)

  • A: Asymmetry
  • B: Border irregularity
  • C: Colour change
  • D: Diameter > 6mm
  • E: Evolution (change in last 6 months) (can include itch or new bleed, not just size/shape evolution)

Consider blistering sunburn before age 20

Skin changes or lesions

  • Pruritic or painful
  • Bleeding or non-healing
  • Ocular or mucous membrane involvement
  • Provoked by sun? Is it seasonal?
  • Constitutional symptoms:
    • Weight loss
    • Malaise
    • Fever
  • Response to any previous treatments (topical or systemic)
Skin Type Description
I White, very fair, always burns
II White, fair, burns more than tans
III White, tans more than burns
IV Dark brown (e.g. Mediterranean skin), rarely burns, tans with ease
V Dark brown (e.g. Middle Eastern skin), tans easily, very rarely burns
VI Black, never burns, tans easily

Hair changes (scarring or non-scarring)

  • Focal or diffuse
  • Slow or rapid
  • Does the hair break off or fall out at the root
  • Are menstrual periods regular or irregular
  • Acne or hirsutism
  • Shedding or gradual thinning

Nail changes

  • Associated skin findings (e.g. tinea pedis, psoriasis, lichen planus)
  • Number of nails involved
  • Number of hands and feet involved
  • Present from birth
  • Nail polish use
  • Trauma (picking/rubbing cuticles, friction induced ex: runner's toe)
  • Consider anemia

Past Medical History (PMHx)

  • Skin diseases
  • Autoimmune disease (e.g.diabetes, connective tissue disorders)
  • Allergies or atopic diseases
    • Asthma
    • Eczema
    • Allergic rhinitis/hay fever
  • Cancer
  • Any hospitalizations or surgeries
  • Recent viral illness
  • Prior skin biopsies
  • Exposure history
    • Water contamination
    • Toxins
    • Medications and drugs, including
      • Over-the-counter
      • Supplements
      • Herbal products
      • Immunizations
    • Detergents and soaps
    • Skin, hair, nail products
    • Employment, hobbies, chance of home exposure (see social history)

Family History (FmHx)

  • Skin diseases (e.g., psoriasis)
  • Other people itchy in household
  • Autoimmune diseases (e.g. vitiligo, lupus)
  • Allergies or atopic diseases
    • Asthma
    • Eczema
    • Allergic rhinitis/hay fever
  • Cancer (especially melanoma)

Social History (SocHx)

Specifically ask about:

  • Occupation and occupational exposures (e.g. cement workers, florist)
  • Sexual orientation and practice
  • Hobbies (e.g. sun exposure, travel, pets)
  • Travel History
  • Stressors

Substance Use History (SubHx)

Specifically ask about:

Medications

Gather complete list, but specifically ask about:

  • Oral contraceptive pills

Allergies

Allergies

Immunizations

Note immunizations and ensure they are up to date in the patient's record.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. James W, Berger T, Elston, D. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Saunders; 2005.
  3. Hunter JC, Savin J , Dahl M. Clinical Dermatology. 3rd ed. Massachusetts: Wiley-Blackwell; 2002.
  4. Freiman A, Barankin B. Derm notes: Dermatology Clinical Pocket Guide. F. A. Davis Company; 2010.