©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWSD1 ;ALB/CMM SKIN DISEASES (Other Than Scars) WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Onset of disease and course - intermittent, constant.
;;
;;
;; 2. Current treatment - include side effects.
;;
;;
;; 3. Symptoms - pruritus, pain, etc.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Extent of disease - specify what exposed areas are involved
;; and how large they are.
;;
;;
;; 2. Ulceration, exfoliation, or crusting.
;;
;;
;; 3. Associated systemic or nervous manifestations.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;;
;; 1. Biopsy, scrapings if indicated.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; 1. Take COLOR PHOTOGRAPHS if disfigurement or disfiguring scars
;; are present.
;;
;;
;;Signature: Date:
;;END