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