Skin (Integumentary System)

#Skin (Integumentary System)

S: Subjective

Presenting Complaint/s:
(-) lesion/s 
(-) eruption
(-) xerosis
(-) pruritis
(-) pigmentary changes
(-) other/s ->

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
(-) Other ->

Relieving factors:

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.

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: 
?

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

Social History:
- Smoking: 
- Alcohol use:

Current Medication (Including Cosmetics):
- Systemic: 
- Topical:

Medication Reactions/Allergies:

O: Objective

Pigmented lesion/s: 
(-) Dermoscopy 
(-) lentigo
(-) naevus 
(-) asymmetry
(-) border irregularity
(-) colour variation
(-) diameter >6mm
(-) evolving over time

Other lesion/s: 
(-) solar keratosis/es 
(-) seborrhoeic keratosis/es

Specifics: 
(-) excoriated, (-) eroded/ulcerated, (-) raised, (-) tethered, (-) weeping, (-) hyperkeratosis/scale, (-) crusted, (-) visible blood vessels, (-) blanches.

Other findings:

Surrounding skin: 
(-) normal, (-) hot, (-) oedematous, (-) palpable lymph nodes.

Wood's light examination:

A: Assessment

Clinical Summary:

Diagnosis / DDx:

P: Plan

Investigations:

Treatment:

Referrals:

Patient Education / Home Care Advice:

Review:

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