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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Clerking Note - Psoriasis

HISTORY

Chief Complaint

History Of Present Complaint

Age When Psoriasis Started

Age When Psoriasis Diagnosed

Aggravating factors

Infection

Drugs

Topical treatment

Trauma

Pregnancy

Stress

Smoking

Alcohol

Sunburn

Hypocalcaemia

Others, specify

Joint Pain

YesNo

Pain Score

Disease Burden In The Past 6 Months

No of days of work/school due to psoriasis

No of hospital admissions due to psoriasis

Past Medical History

Nil

Diabetes Mellitus (DM)

Dyslipidaemia

Hypertension (HPT)

Ischaemic Heart Disease

Cerebrovascualar disease

Asthma

Tuberculosis (TB)

Chronic Obstructive Pulmonary Disease(COAD)

Stroke

Epilepsy

Chronic Kidney Disease (CKD)

Atopic Eczema

Allergic Rhinitis

Hyperthyroidism

Inflammatory bowel disease

Cancer

Hyperlipidaemia

Others, specify

Past Surgical History

Obstetric / Menstrual History

Pregnancy

YesNo

Gestation

Drug History

Drug History

Allergies And Alert

Social History

Smoking

When stopped

Alcohol

YesNo

Number of Unit Consumed Per Week

Family History

Family History Of Psoriasis

YesNo

No Of Family Members Affected

GENERAL EXAMINATION

Vital Signs

General Description

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

Type Of Psoriasis

Plaque

Guttate

Erythrodermic

Inverse

Pustular

Generalised

Localised

Palmoplantar

Others, specify

Others, specify

Severity Of Psoriasis

Body Surface Area(BSA)

Body Part

Scalp

Face And Neck

Trunk

Upper Limbs

Lower Limbs

Pasi Score

Nail Disease

YesNo

Pitting

Discoloration

Onycholysis

Subungual hyperkeratosis

Total dystrophy

Others, specify

Joint Disease

YesNo

Type

Oligo/monoarthropathy

Distal hand joint disease

Symmetrical polyarthropathy

Spondylitis/Sacroilitis

Arthritis mutilans

Eye Disease

YesNo

Impression/Assessment

Trigger KPI

MANAGEMENT

Orders

Others, Specify

Treatment For Psoriasis

Topical

Tar preparation

Topical steroids

Vitamin D analogues

Vitamin D analogues with topical steroids

Dithranol

Keratolytics

Emollients

Others, specify

Phototherapy

BB-UVB

NB-UVB

Topical PUVA

Oral PUVA

Bath PUVA

Excimer laser

Others, specify

Systemic

Methotrexate

Acitretin

Sulfasalazine

Cyclosporine

Hydroxyurea

Systemic steroids

Biologics

Others, specify

Referral

Outgoing Referrals

Comments

Plan

Counselling

Individual

Group

Pharmacist

SIGNATURES

Notes Component

HISTORY
GENERAL EXAMINATION
PROBLEM LIST
DIAGNOSIS
MANAGEMENT
SIGNATURES

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