Cellulitis history taking

1. Introduce and establish the presenting complaint

• Confirm the patient’s name, age, and preferred name.
• Ask an open question:
  “Can you tell me about the redness/swelling and how it started?”
• Clarify the affected site: leg, arm, face, hand, around the eye, etc.

2. History of presenting illness

Onset and progression

• When did it begin?
• Was onset sudden or gradual?
• Is the redness, swelling, warmth, or pain spreading? How quickly?
• Has this happened before? How frequently?

Local symptoms

• Pain or tenderness, including pain out of proportion to the visible skin change
• Redness, heat, swelling, tightness
• Itch, which may suggest dermatitis or an insect-bite reaction rather than cellulitis
• Skin break, crack, ulcer, blister, wound, abrasion, puncture, burn, eczema, or surgical incision
• Discharge or pus, fluctuance, boil, abscess, foul smell
• Red streaking toward the groin or axilla, suggesting lymphangitis
• Numbness, altered sensation, skin discoloration, blisters, black areas, or reduced movement

Systemic symptoms

• Fever, chills, rigors
• Malaise, fatigue, myalgia
• Nausea, vomiting, poor oral intake
• Dizziness, confusion, reduced urine output

3. Identify the portal of entry and specific exposures

• Any recent trauma, cut, shaving injury, injection, tattoo, piercing, or surgery?
• Any ulcer, athlete’s foot, toe-web maceration, fissures, eczema, psoriasis, or insect bite?
• Animal or human bite?
• Freshwater, brackish-water, seawater, aquarium, or fish exposure?
• Soil or gardening exposure?
• Recent travel, tick bite, or outdoor exposure?
• Recent hospital admission or antibiotic use?
• Injection drug use?

4. Screen for complications and urgent differentials

• Is pain rapidly worsening or disproportionate?
• Is there rapidly spreading redness, skin necrosis, bullae, purple/black discoloration, or a crackling sensation under the skin?
• Any weakness, numbness, inability to bear weight, or restricted movement?
• Is a joint involved, with severe pain on movement or inability to move it?
• Is the limb markedly swollen, or is there calf pain, chest pain, or shortness of breath?

5. Risk factors and past medical history

• Diabetes and glycaemic control
• Peripheral vascular disease, venous insufficiency, chronic leg oedema, lymphoedema
• Obesity
• Neuropathy
• Eczema or chronic skin disease
• Immunosuppression: HIV, cancer, chemotherapy, transplant, long-term steroids, biologics
• Kidney or liver disease
• Previous MRSA infection/colonisation or recurrent cellulitis
• Previous episodes and any prophylactic antibiotics

6. Drug, allergy, and treatment history

• What treatment has been tried already: antibiotics, analgesia, elevation, dressings?
• Which antibiotic, dose, duration, and adherence?
• Has it improved, stayed the same, or worsened?
• Any prior culture results?
• Drug allergies, especially penicillin or cephalosporin allergy.
• Regular medicines, especially immunosuppressants, steroids, anticoagulants, and diabetic treatment.

7. Social history

• Smoking and alcohol
• Occupation and impact on mobility/work
• Housing, ability to rest/elevate the limb, wound-care support
• Recent travel
• Injection drug use where clinically appropriate

8. Focused systems review

• Respiratory symptoms, especially if systemic sepsis or pulmonary embolism is a concern
• Joint symptoms for septic arthritis or gout
• Symptoms of venous disease or DVT
• Neuropathic symptoms and diabetic foot symptoms

Concise OSCE summary

“This is a patient with acute, progressive, unilateral painful erythema, warmth and swelling of the [site], with/without systemic symptoms. I would establish duration and progression, look for a skin portal of entry and relevant exposures, assess risk factors such as diabetes, oedema, venous disease and immunosuppression, ask about previous episodes and antibiotics, and actively exclude abscess, DVT, septic arthritis and necrotizing soft-tissue infection.”

Red flags requiring urgent senior review

• Pain out of proportion or rapidly escalating pain
• Rapid progression over hours
• Bullae, dusky/purple or necrotic skin, crepitus
• Hypotension, confusion, rigors, marked systemic toxicity
• Immunocompromised patient
• Facial or periorbital involvement
• Suspected septic arthritis, abscess, or necrotizing infection

• No obvious free air beneath the diaphragm, so there is no clear radiographic evidence of perforated hollow viscus on this image.
• I do not see convincing multiple dilated small-bowel loops or multiple air-fluid levels to support a typical acute small-bowel obstruction.
• The bowel gas pattern appears relatively paucigas/nonspecific, which can occur with several conditions and can also reflect technique or a non-obstructive state.