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Synthesis of History in Dermatology

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BIO-DATA

  • Name
  • Age
  • Sex
  • Occupation
  • Tribe/race
  • Address
  • LMP
  • LC

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Presenting Complaints

Rash or a lump

  1. Site…face…sun exposed parts
  2. Onset……days,weeks,months
  3. Associated symptoms….pain, pruritus, bleeding
  4. Change in appearance…..recent growth, colour change
  5. Exposures….sun

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Presenting complaints

Pruritus (Itch)

  1. Site…face, scalp, extensor/flexor
  2. Onset……days,weeks,months
  3. Associated symptoms….pain, rash, bleeding,fever
  4. Change in appearance…..recent growth, colour change
  5. Exposures….sunlight, creams,medications, detargents, cosmetics
  6. Timing….duration, frequency, constant/intermittent
  7. Alleviating factors…eg cream

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Presenting complaints

Pain (SOCRATEAS)

Site….Localised/Generalised; Unilateral/bilateral

Onset….Sudden, gradual, situation, following trauma

Character….burning,sharp,dull

Radiation….To the other site

Associated Symptoms…..redness, swelling, lump,fever

Timing….duration,frequency,constant,fluctuate

Exposures….Medications, cosmetics,detergents,sunlight

Alleviating Factors….eg cream

Severity ….On scale 1-10 with 10 being the worst

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Presenting complaints

  • Alopecia

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Presenting complaints

  • Bleeding

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Presenting complaints

  • Discharge

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Presenting complaints

  • Systemic symptoms….fever,rigor,malaise

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Past Medical History

  • Past Medical Issues

Diabetes, inflammatory bowel disease

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Past Medical History

  • Skin Conditions

Diagnosis, severity, management

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Past Medical History

  • Atopy

Asthma, allergies, atopic dermatitis

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Past Medical History

  • Skin Cancers…When, type, management

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Past Medical History

  • Current Medications

Indication, when started, side effects

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Past Medical History

  • Topical Agents

Drugs, creams, ointments

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Past Medical History

  • Allergies

Allergen, reaction, severity

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Past Medical History

  • Relationship with the Sun

Tans / burns, amount of exposure, sunscreen

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Family History

  • Skin Conditions

Atopic eczema, psoriasis, ichthyosis, keratoderma

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Family History

  • Skin Cancers

BCC, SCC, melanoma

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Social History

  • Living Situation

Where, who they live with, cleanliness

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Social History

  • Social Supports

Family, friends

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Social History

  • Infected Contacts

E.g. with chickenpox, scabies

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Social History

  • Pets

New pets, pet allergies

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Social History

  • Recent Travel

When, where, sun exposure

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Social History

  • Occupation

Exposure to toxins

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Social History

  • Hobbies

E.g. gardening

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Substance History

  • Alcohol

Average per day / week, CAGE

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Substance History

  • Smoking

Pack-years, years since quitting

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Substance History

Recreational drugs, Especially IV drug us

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Systems Review

  • General

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Systems Review

  • Cardio-respiratory

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Systems Review

  • Gastrointestinal

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Systems Review

  • Neurological

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Systems Review

  • Genitourinary

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Systems Review

  • Musculoskeletal