Skin examination

{Skin examination} [+] yes, present, positive [-] no, absent, negative [~] equivocal [\] not applicable, not performed [?] unknown, unsure, unavailable { } annotation, comment PRESENTING COMPLAINTS OR ISSUES Reasons for visit: [-] new problem/issue [-] review/follow-up Fitzpatrick skin type: {Based on reaction to sun exposure after the first one hour of sun exposure on previously unexposed skin on the first day of spring.} I [-] Always burns, never tans. II [-] Always burns, minimal tan. III [-] Burns minimally, gradually tans. IV [-] Burns minimally, tans well. V [-] Very rarely burns, tans profusely. VI [-] Never burns, tans deeply. Type: Presenting complaints: [-] lesion [-] eruption [-] xerosis [-] pruritis [-] pigmentary changes Location/s: [-] face [-] neck [-] trunk/torso [-] flexures [-] extensor surfaces [-] acral (distal extremities) [-] palms/soles [-] hair changes [-] nail changes [-] sun-exposed areas only Onset: [-] rapid [-] gradual [-] intermittent [-] fluctuating Aggravating factors/triggers: [-] climate [-] sun exposure [-] seasonal variation [-] food triggers [-] environmental triggers [-] medications Relieving factors: [+] [-] Management to date: [+] [-] History since last contact: [+] [-] PAST MEDICAL HISTORY [-] skin cancer: [-] SCC [-] BCC [-] melanoma [-] other: [-] sunburn [-] number lifetime count -> [-] dermatitis/eczema [-] burns [-] psoriasis [-] atopic disorders (hayfever/asthma) [-] severe sunburn (with blistering) [-] diabetes [-] TB [-] allergies: Details: SOCIAL HISTORY Environmental exposures: [-] solar radiation [-] other radiation [-] chemicals [-] arsenic [-] biological agents (plants, insects, animals, enzymes) [-] topical agents (including cosmetics) FAMILY HISTORY [-] skin cancer [-] melanoma [-] SCC [-] BCC [-] dermatitis/eczema [-] psoriasis MEDICATIONS Current medication (including cosmetics): Systemic: Topical: ALLERGIES AND ADVERSE REACTIONS Allergies: Causative agent: Reaction: Date first experienced: Causative agent: Reaction: Date first experienced: Other adverse reactions: Causative agent: Reaction: Date first experienced: [Examination findings] Physical examination/dermoscopy: 1. Pigmented lesions: Location/s: Dimensions: [-] lentigo [-] naevus [-] melanoma observations: [-] asymmetry [-] border irregularity [-] colour variation [-] diameter >6mm [-] evolving over time specifics: [-] excoriated [-] eroded/ulcerated [-] raised [-] tethered [-] weeping [-] hyperkeratosis/scale [-] crusted [-] visible blood vessels [-] blanches surrounding skin: [-] normal [-] hot [-] oedematous [-] palpable lymph nodes 2. Other lesion/s: [-] solar keratosis/es [-] seborrhoeic keratosis/es 3. Other findings: [-] eruption Wood's light examination: [+] [-] ASSESSMENT Diagnosis/es: [+] [?] [-] Differential diagnosis: [+] [?] [-] Patient's and carer's concerns, expectations and wishes: [+] [-] MANAGEMENT PLAN Procedures performed: - Diagnostic investigations requested: - Referrals: - Information and advice given: - Medication: - FOLLOW-UP Next appointment: - Outstanding issues: -

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External links

• DermNet NZ A service of the New Zealand Dermatological Society to provide information about skin diseases, conditions and treatment for patients and their health professionals.
  • Glossary of dermatological terms
  • Melanoma
• Dermnet Skin Disease Atlas An independent photo dermatology source providing information on a wide variety of skin conditions including articles, photos and video.