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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Clerking Note - Leprosy

HISTORY

Case

Method Of Case Detection

Contact Case

YesNo

History Of Present Complaint

Past Medical History

Nil

Diabetes Mellitus (DM)

Dyslipidaemia

Hypertension (HPT)

Ischaemic Heart Disease

Asthma

Tuberculosis (TB)

Chronic Obstructive Airway Disease(COPD)

Stroke

Epilepsy

Chronic Kidney Disease (CKD)

Atopic Eczema

Allergic Rhinitis

Hyperthyroidism

Hypothyroidism

Inflammatory bowel disease

Cancer

Others, specify

Past Surgical History

Past Sti

Obstetric / Menstrual History / Gynae History

Drug History

Drug History

ALLERGIES AND ALERT

Allergies And Alert

Social History

Marital Status

Children

Occupation

Comments

Smoker

Alcohol Consumption

Other Relevant History (Shall Include High Risk Behaviour)

Family History

GENERAL EXAMINATION

Vital Signs

General Description

Skin

Nerve

Eye

Visual Acuity

Please Update Method

Hands

Visible deformity or damage present

Others, specify

Feet

Visible deformity or damage present

Others, specify

Cardiovascular System

Respiratory System

Abdomen

Nervous System

Locomotor

Others, Specify

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

Leprosy

Type Of Leprosy

WHO Classification

PBMB

Slit Skin Smear (SSS)

Date

Mi

Bi

Deformity

Eye

Hand

Feet

Reactions

MANAGEMENT

Orders

Sss (Slit Skin Smear)

Biopsy

Mouse Foot Culture

Others, Specify

Choice Of Treatment

Treatment Plan

Contact Tracing

Notification Done

YesNo

Referral

Outgoing Referrals

Comments

Plan

SIGNATURES

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