Skin dermatology history and exam general(draft)

[comment memo="Common Conditions: Acne vulgaris, atopic eczema, psoriasis vulgaris, actinic keratosis, seborrheic keratosis, basal cell carcinoma, androgenic alopecia,
vitiligo, melasma"]

[comment memo="High Mortality Morbidity: Melanoma, Stevens-Johnson syndrome, toxic epidermal necrolysis, necrotizing fasciitis, pemphigus vulgaris"]

[text size=5] years old [select value="male|female"] patient with previous history of [text size=100]

[text default="Allergy NKA" size=100]
SUBJECTIVE:
Pt complains skin [select value="lesion|rash"] on [text size=10]  past [text size=10].  
It is [checkbox name="variable_6" value=" asymptomatic| pruritic |painful "]. It [checkbox name="cb1" value="spreads|does not spread"]. [conditional field="cb1" condition="(cb1).is('spreads')"] It started on [text size=30] and spreaded to [text size=10][/conditional]
The individual lesions [checkbox name="cb2" value="changed|stay the same"]. [text size=10]    
Provocative factors_ [checkbox name="variable_1" value=" none| heat |cold |sun| exercise |drug |injestion|pregnancy| season"]
Red flags evaluation:
Systemic sx_ [checkbox name="variable_2" value="none| malaise| flu-like sx |difficulty swallowing |difficulty breathing"]
Signs of Melanoma (ABCDE)_[checkbox name="variable_3" value=" none|Asymmetrical skin lesion| Border irregularity| Color variation| Diameter (new lesion >6mm)| Evolution (changes in size, color or bleeding)"] 
Signs of Stevens-Johnson syndrome/toxic epidermal necrolysis_[checkbox name="variable_4" value=" none| positive Nikolsky's sign (light lateral pressure causes the skin to form a bullae or slough off)| painful rash with mucosal involvement "] 
Sx of necrotizing fasciitis_[checkbox name="variable_5" value=" none| pain out of proportion to physical exam findings "]  
PMHx: [checkbox name="variable_7" value="none relevant| skin cancers |shingles |psoriasis | thyroid disorder |DM| atopy"] [comment memo="Atopy: atopic dermatitis, allergies, allergic rhinitis"] [text size=50]
PO&GHx: [checkbox name="variable_8" value="none relevant| STIs |pregnancy |sexual activity | HIV "] [text size=50]
Meds: [textarea name="variable_1" default="reviewed, none relevant to skin condition"]
FamHx: [checkbox name="variable_9" value="none relevant| psoriasis |atopy |skin cancer | genodermatoses (e.g.,tuberous sclerosis, neurofibromatosis)"] [comment memo="Atopy: atopic dermatitis, allergies, allergic rhinitis"] [text size=50]
SocialHx: [checkbox name="variable_10" value="none relevant| sun exposure | chemical exposure| EtOH |IVDU | recent travel | hobbies"] [text size=50]
[comment memo="- Patient with a lesion suspicious for melanoma would require a complete ROS looking for any sign of organ dysfunction suggesting metastases. 
- Myalgia, arthralgia, fever, oral ulcers, Raynaud's phenomenon. 
- Hair and nails eg psoriasis "]
[checkbox name="variable_11" value=" ROS:|General: _No weight change; _No fatigue; _No weakness; _No fevers; _No chills | Integumentary system: _No issues with hair on nails 
| Resp: _No cough; _No dyspnea; _No wheezing; _No asthma; _No bronchitis; _No emphysema; _No pneumonia; _No TB| CV: _No history of high/low BP; _No murmurs; _No orthopnea; _No PND; _No palpitations; _No edema; _No chest pain; _No claudication; _No evidence of vein disease
| MSK: _No joint pain; _ No muscle pain; _No swelling; _No weakness; _No arthritis | Endo: _No thyroid issues; _No diabetes | HEENT: _No vision changes; _No hearing changes; _No nasal or sinus stuffiness; _No ulcers; _No gingival bleeding; _No dysphagia | Neuro: _No headache; _No fainting; _No seizures; _No paresthesias; _No difficulty walking/dizziness/vertigo; _No confusion; _No tremor/coordination issues | Psych: _No mood disorders/depression; _No anxiety; _No suicide attempts | GI: _No changes in appetite; _No nausea/vomiting; _No abdominal pain; _No diarrhea; _No constipation | GU:_No changes in urine output | Genital/sexual:_No STI issues "] [text size=50]

OBJECTIVE:
[textarea cols=100 rows=10 default="NAD VS normal.No _Jaundice; No _Anemia clinically; No _Cyanosis; No _Clubbing; No _Lymphadenopathy; No _Edema; No _Thyroid palpable "]
DERM:
• Size [text size=30]
• Surface area of lesion [text size=30]
• Color[select name="variable_12" value=" erythematous | hyperpigmentation | hypopigmentation |leukoderma |purpura"] [text name="variable_15" default="purpura as petechiae or ecchymoses"][comment memo="Purpura — bleeding into the skin. This may be as petechiae (small red, purple or brown spots) or ecchymoses (bruises). Purpura does not blanch with pressure (diascopy- glass or plastic cup pressure test to see if blanches). Leukoderma eg viteligo"] [text name="variable_16" default="Telangiectasia — prominent cutaneous blood vessels present."]
• Arrangement [select name="variable_13" value=" linear | annular ringlike configuration | grouped clustered lesions|serpiginous wavy or serpent-like appearance | reticular net-like arrangement | target like a bull's eye | discoid"]
• Lesion primary morphology is [checkbox name="variable_14" value= " Macule: flat,non-palpable lesion, <1cm | Patch: flat,non-palpable lesion. >1cm (e.g., vitiligo,cafe au lait spot) | Papule: palpable lesion, elevated above the skin, <1cm (e.g., molluscum contagiosum, acne vulgaris) |Plaque: palpable lesion, elevated above the skin, >1cm (e.g.. psoriasis) | Vesicle: <1cm blister (e.g.. varicella, contact dermatitis)| Bulla: >1cm blister (e.g., bullous pemphigoid)| Pustule: superficial cavity of the skin that contains a purulent exudate (e.g., folliculitis) | Nodule: <1cm deep palpable solid lesion within the skin (e.g.. lipoma)| Tumor: >1cm nodule |Cyst| Wheal: rounded or flat-topped papule or plaque that is evanescent due to edema of the dermis (e.g., hives,angioedema) | "]
Papule type: 
• Lesion secondary morphology
• Distribution: Diffuse (e.g., viral rashes and drug reactions), extensor (e.g., psoriasis), flexural (e.g.,atopic dermatitis), dermatomal (e.g., shingles)
 • ABCDE of melanoma

Hair and Scalp:
[textarea cols=100 rows=10 default=" texture, scars, thinning, absence (alopecia) or excess (hypertrichosis), infestations (lice), masses (on scalp),plaques,crusting"]
Nails: 
[textarea cols=100 rows=10 default="  clubbing, thickness,pitting (psoriasis),separation from nail bed (onycholysis), yellow discoloration of nail bed
(oil drop sign for psoriasis), other discoloration,periungual erythema, splinter hemorrhages (endocarditis)"]
 [comment memo="Box 3 Secondary lesions:•Scales: excess keratin (e.g„psoriasis) •Crusts: dried serum, scab (e.g., impetigo) • Erosion: loss of epidermis, heal without scarring (e.g., dermatophyte infection) • Ulcer: loss of epidermis and dermis, heal with scarring (e.g., stasis ulcer) • Fissure: linear loss of epidermis and dermis • Atrophy: thinning of epidermis or dermis causingdepression (e.g., morphea) • Scarring: abnormal formation of connective tissue after dermal injury (e.g., keloid) • Special Lesions: • Excoriation: scratch mark: if lesions occur at site of scratchingit is called Koebner's phenomenon • Comedone: hair follicle plugged with sebaceous and keratinous material (e.g., acne) • Petechiae: <0.5 cm deposits of extravased red blood cells (RBC) suggestive of vasculitis • Purpura: >0.5 cm petechiae (e.g., senile traumatic purpura) • Telangiectasias: dilated superficial blood vessels (e.g., rosacea,basal cell carcinoma, CREST syndrome)"]


[comment memo="B/W:• CBC, ESR, CRP; ANA if suspicious of connective tissue disease • TSH, fasting glucose, blood culture; LFT if suspicious of internal pathology, order organ specific blood work • Radiology/Imaging • CXR (heart or lung pathology) • Special Tests • Skin scraping for fungus, Wood’s lamp to accentuate areas of depigmentation • Surgical/Diagnostic Interventions • Skin Bx: shave, punch or excisional biopsy; new lesions usually more useful than old lesions • Bx is indicated in all skin lesions suspected of being neoplastic, in bullous disorders, along with immunofluorescence, and disorders in which diagnosis is not possible by clinical exam alone"]

[comment memo="Tx:
Emergent
• Stop offending agent if drug reaction (e.g., Stevens-Johnson syndrome/toxic epidermal necrolysis)
• Start antimicrobials for infection (e.g., cellulitis) or immunosuppressive agent for immune mediated disease
Treatment Options
• Topical: steroids, antibiotics, antifungals, emollients, retinoids, etc.
• Systemic medications: immunosuppressives (methotrexate), retinoids, ATBx, antimalarials
• Light: narrow band ultraviolet B, ultraviolet A (PUVA), laser therapy
• Surgical: curettage, cryotherapy, electrotherapy, scalpel
Follow-up
• Monitor skin findings over time to evaluate progression, monitor for medication side effects
Referral as indicated"]