Derma Guide

Brought to you by JI Francis Castell

For Chief Complaint, write only the primary lesion (see below). Example: Papules

For HPI, only the pertinent Dermatological history, including meds and consult. Remember to write whether (+) or (-) for pruritus. If considering viral, (+) or (-) for fever.

For Previous Treatment, include the medications & procedures listed in the HPI, plus soap, shampoo, facial wash, and other dermatological products the patient used (especially Chinese ointments). Example: (+) Loratadine 10mg/tab, OD in the AM x 3 days (+) Katialis prn x 1 week (+) Safeguard soap

For Past Med Hx and Family Med Hx, include HPN, BA, DM, Allergy. Example: (+) HPN (-) DM (-) BA (+) Allergy to seafoods

For Physical Examination, include the following: 1. Number & distribution few, multiple (>5) or solitary; localized or diffuse, generalized 2. Shape (optional) annular, guttate, etc 3. Border well defined or ill-defined 4. Colorhypopigmented, hyperpigmented, depigmented, skin-colored, erythematous 5. Primary lesion a. Macules variously sized, circumscribed solid changes in color, without elevation or depression (aka small, flat spots) b. Patches a large macule, 1 cm or more c. Papules circumscribed solid elevations with no visible fluid, varying in size from pinhead to pea d. Plaques a broad papule (or confluence of papules), 1 cm or more e. Noduleslarger and deeper papule, arising in dermis f. Tumorssoft or firm, freely movable or fixed masses g. Wheals (Hives)evanescent, edematous, flat elevations of various sized, almost always with itching h. Vesicles (Blisters)circumscribed epidermal elevations, 1-10mm with a clear fluid i. Bullae rounded or irregularly shaped blister containing serous or seropurulent fluid, larger than 1 cm

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Pustules (Pimples)small elevations containing pus, usually with inflammatory areola

6. Secondary lesion a. Scales (exfoliations)dry/greasy laminated masses of keratin b. Excoriations (abrasions, scratch marks)punctuate or linear abrasions produced by mechanical means such as scratching, usually involving only the epidermis c. Fissures (Cracks, Cleft)linear cleft through the epidermis, rarely into the dermis. Occur mostly when the skin is thickened & inelastic from inflammation & dryness d. Crusts (Scabs)dried serum, pus or blood, usually mixed with epithelial debris e. Erosionsloss of all or portions of the epidermis alone f. Ulcersloss of both dermis & epidermis g. Scarsnew formations of connective tissue that replace loss of substances in the dermis or deeper parts. 7. Measurement (in centimeters) 8. Location

Example: Multiple well defined erythematous to skin-colored papules and plaques with excoriations measuring 0.1 x 0.2 cm to 2.5 x 3.5 cm on the lateral aspect of the left leg.