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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Clerking Note - Skin Cancer

HISTORY

Chief Complaint

History Of Presenting Complaint

Duration Of Lesion Before Presentation

Date Of First Presentation

Date Of Diagnosis

Previous History Of Malignancy

YesNo

Risk Factors

Excessive Ultraviolet Exposure

Fair Skin Type

Family history of Cutaneous Malignancy

Immunosuppression

Post-transplant

Chronic Scar

Exposure to Arsenic/Chemical Agents

Exposure to Ionizing Radiation/X-ray

Gorlin's syndrome (Basal Cell Naevus Syndrome)

Xeroderma Pigmentosum

Others, specify

Systemic Review

Fever

YesNo

Weight Loss

No

Loss Of Appetite

No

Cardiovascular System (CVS)

NormalAbnormal

Respiratory

NormalAbnormal

Gastrointestinal

NormalAbnormal

Genitourinary

NormalAbnormal

Central Nervous System

NormalAbnormal

Others, Specify

Past Medical History

Nil

Diabetes Mellitus

Dyslipidaemia

Hypertension

Ischaemic Heart Disease

Asthma

Tuberculosis

Chronic Obstructive Pulmonary Disease

Stroke

Epilepsy

Chronic Kidney Disease (CKD)

Atopic Eczema

Allergic Rhinitis

Hyperthyroidism

Others, specify

Past Surgical History

Drug History

Drug History

Allergies And Alert

Social History

Family History

EXAMINATION

Skin

Location Of Lesions

Face

Scalp

Neck

Lip

Abdomen

Back

Buttock

Arms

Hand

Leg

Foot

Genitalia/perineum

Whole body (erythrodermic)

Others, specify

Type Of Lesion

Macule

Patch

Papule

Nodule

Plaque

Tumour

Ulcer

Others, specify

Colour Of Lesion

Erythematous

Hypopigmented

Hyperpigmented

Purpuric

Poikiloderma

Others, specify

Lymph Node

Hepatomegaly

YesNo

Splenomegaly

YesNo

Remote Metastasis

YesNo

Cardiovascular System

Respiratory System

Abdomen / Genitourinary System

Nervous System

Others, Specify

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

Final Skin Cancer Diagnosis

Basis Of Diagnosis

Clinical

Clinical investigation

Specific tumour markers

Cytology

Histology of metastasis

Histology of primary tumour

Unknown

Investigations

Skin Biopsy

Cxr

Ct Scan

Bone Marrow Aspiration

Hpe

Liver Function Test (Lft)

Lactate Dehydrogenas (LDH)

Renal Profile (RP)

Full Blood Count

Other blood tests

Tnm Staging

t

n

M

b

Comments

Nmsc Staging

Comments

Melanoma Clarks Level

Melanoma Breslow's Depth

Melanoma Ajcc Staging 2001

Comments

Mycosis fungoides/Sezary Syndrome ISCL/EORTC staging

Treatment

Topical

Corticosteroid

5-Fluorouracil

Imiquimod

Others, specify

Cryotherapy

Curretage

Surgery (specify)

Radiotherapy

Electron beam

X-Ray irradiation

Chemotherapy

Phototherapy

NBUVB

Oral PUVA

Bath PUVA

Others, specify

Systemic steroids

Retinoid

Methotrexate

S/C Interferon

Extracorporeal photophoresis

Photodynamic Therapy

Others, specify

Outcome

Plan

SIGNATURES

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