Dermatology — General Consultation Template

Consultation Information

Date: [Date]
Visit type: New patient / Established / Consultation
Referring provider: [Name, if applicable]
Reason for referral: [Chief complaint]

Chief Complaint

[Primary skin/hair/nail concern]
Duration: [X] days/weeks/months/years
Location(s): [Body site(s)]
Current status: Improving / Stable / Worsening / Fluctuating

History of Present Illness

Lesion/Condition History

Onset: [Date of first appearance]
Initial presentation: [How it looked when first noticed]
Evolution: [How it has changed]
Growth: Stable / Slow / Rapid
Color change: No / [Description]
Shape change: No / [Description]

Associated Symptoms

Pruritus: None / Mild / Moderate / Severe — Interference with sleep: Yes / No
Pain: None / [X]/10 — Character: Burning / Stinging / Sharp / Aching
Bleeding: None / Spontaneous / With trauma
Drainage: None / [Clear, purulent, etc.]
Scaling: None / Mild / Moderate / Severe
Crusting: None / Present

Aggravating/Relieving Factors

Worse with: [Sun, heat, cold, friction, sweating, stress, foods, etc.]
Better with: [Treatment, avoidance, etc.]
Seasonal variation: None / Worse in [season]
Relationship to activities: [Exercise, occupation, hobbies]

Prior Treatment

Self-treatment:

• OTC products: [Products tried, duration, response]
• Home remedies: [If any]

Previous prescription treatments:

• Topicals: [Medications, duration, response]
• Systemic: [Medications, duration, response]
• Procedures: [Biopsies, surgeries, dates, results]
• Phototherapy: [If applicable]

Dermatological History

Similar previous episodes: None / [Description, timing]
History of skin cancer: None / [Types, dates, locations, treatments]
History of melanoma: Personal: Yes / No — Family: Yes / No
Atopic history: Eczema / Asthma / Allergies / None
Psoriasis history: None / [Duration, treatments, severity]
Autoimmune conditions: None / [List]
Sun exposure history:

• Occupation: Indoor / Outdoor
• Recreational: [Activities]
• Tanning beds: Never / Former / Current
• History of sunburns: [Number of blistering sunburns]

Skin type (Fitzpatrick): I / II / III / IV / V / VI

Past Medical History

[Relevant medical conditions]
Immunocompromised: No / Yes — [Reason: transplant, HIV, medications]
Diabetes: No / Yes — [Control status]
Hepatitis/liver disease: No / Yes

Medications

[Current medications - especially immunosuppressants, anticoagulants, photosensitizing drugs]
Recent medication changes: None / [Changes]

Allergies

Drug allergies: [Medications and reactions]
Topical sensitivities: [Products, preservatives, fragrances]
Contact allergies: [Known allergens - nickel, latex, etc.]

Family History

Skin cancer: [Type, relationship]
Melanoma: [Relationship]
Psoriasis: Yes / No
Atopic conditions: Yes / No
Autoimmune conditions: Yes / No

Social History

Occupation: [Type, exposures]
Hobbies: [Relevant exposures]
Tobacco: Current / Former / Never
Alcohol: [Use]
Sun protection habits: [Sunscreen use, protective clothing, avoidance]

Review of Systems

Constitutional: [ ] Fever [ ] Weight loss [ ] Fatigue [ ] Night sweats
Mucosal: [ ] Oral lesions [ ] Genital lesions
Joints: [ ] Arthralgia [ ] Joint swelling
Nails: [ ] Pitting [ ] Discoloration [ ] Dystrophy
Hair: [ ] Hair loss [ ] Texture change
Other: [Relevant systems based on differential]

Physical Examination

General

Appearance: Well-appearing / Ill-appearing
Fitzpatrick skin type: I / II / III / IV / V / VI

Skin Examination

Primary Lesion(s):

Location: [Anatomic site(s)]
Distribution: Localized / Regional / Generalized / Symmetric / Asymmetric

• Pattern: [Dermatomal, follicular, acral, photoexposed, intertriginous, etc.]

Configuration: Discrete / Grouped / Linear / Annular / Arcuate / Reticular / Targetoid / Serpiginous
Morphology:

• Type: Macule / Patch / Papule / Plaque / Nodule / Tumor / Vesicle / Bulla / Pustule / Cyst / Wheal / Comedone
• Size: [X] mm/cm (or range if multiple)
• Shape: Round / Oval / Irregular / Polygonal
• Border: Well-defined / Ill-defined / Raised / Flat
• Color: [Erythematous, hyperpigmented, hypopigmented, violaceous, brown, black, flesh-colored, etc.]
• Surface: Smooth / Rough / Verrucous / Scaly / Crusted / Ulcerated / Excoriated
• Texture: Soft / Firm / Hard / Fluctuant

Secondary Changes:

Scale: None / Fine / Thick / Silvery / Greasy / Adherent
Crust: None / Serous / Hemorrhagic / Honey-colored
Erosion: None / Present
Ulceration: None / Present — Base: [Clean, necrotic, granulating]
Excoriation: None / Present
Lichenification: None / Present
Atrophy: None / Epidermal / Dermal
Scarring: None / [Type]

Quantification:

Number of lesions: [X] / Innumerable / Confluent
Percent BSA involved: [X]%

Dermoscopy (if performed)

Global pattern: [Reticular, globular, homogeneous, starburst, multicomponent, nonspecific]
Pigment network: None / Regular / Irregular / Atypical
Dots/globules: None / Regular / Irregular
Streaks: None / Regular / Irregular / Pseudopods
Blue-white structures: None / Present
Vascular pattern: [Comma vessels, hairpin vessels, polymorphous, etc.]
Regression structures: None / Peppering / Scar-like
Other features: [Milia-like cysts, comedo-like openings, leaf-like structures, etc.]

Hair Examination (if applicable)

Scalp: [Findings]
Hair density: Normal / Decreased [pattern]
Hair caliber: Normal / Fine / Varied
Pull test: Negative / Positive — [Location, number]
Exclamation point hairs: Absent / Present
Broken hairs: Absent / Present

Nail Examination (if applicable)

Nails affected: [Which nails]
Nail plate: Normal / [Findings: pitting, ridging, dystrophy, discoloration]
Nail bed: Normal / [Findings: onycholysis, oil spots, subungual debris]
Periungual: Normal / [Findings: paronychia, pterygium]

Lymph Node Examination (if indicated)

Regional lymphadenopathy: Absent / Present — [Location, characteristics]

Mucosal Examination (if indicated)

Oral: Normal / [Findings]
Genital: Normal / [Findings]

Photography

Clinical photos taken: Yes / No

• Views: [List]

Dermoscopic images taken: Yes / No

Diagnostic Studies

In-Office Tests

KOH prep: Not performed / Negative / Positive for [Hyphae, budding yeast, pseudohyphae]
Tzanck smear: Not performed / Negative / Positive for [Multinucleated giant cells]
Wood's lamp: Not performed / [Findings]
Diascopy: [Results if performed]
Patch testing: Not performed / [Results]

Laboratory

[ ] CBC
[ ] CMP
[ ] ANA
[ ] RF
[ ] ESR/CRP
[ ] Skin culture: Bacterial / Fungal / Viral
[ ] Other: [Specify]

Pathology

Biopsy performed: Yes / No

• Type: Shave / Punch / Excisional / Incisional
• Location: [Site]
• Clinical indication: [Reason for biopsy]
• Sent for: H&E / DIF / Special stains / Culture
• Pending / Results: [If available]

Assessment

1) [Primary diagnosis] — [Severity: mild, moderate, severe]
[Location, distribution]
2) [Differential diagnoses]

• [Alternative 1]
• [Alternative 2]
• [Alternative 3]

Plan

Diagnostic Workup

• [ ] Biopsy: [Type, location] — Indicated for: [Reason]
• [ ] Laboratory: [Tests ordered]
• [ ] Imaging: [If indicated]
• [ ] Patch testing: [If indicated]
• [ ] Referral: [Specialty, reason]

Treatment

Topical Therapy:

• [Medication] [Strength] [Vehicle] — Apply [frequency] to [location] for [duration]
• Quantity: [X] grams
• Refills: [X]

Systemic Therapy:

• [Medication] [Dose] [Route] [Frequency] for [Duration]
• Monitoring: [Labs, clinical]
• Precautions: [Specific warnings]

Procedural:

• [Procedure planned, date]

Phototherapy:

• [Type: NB-UVB, PUVA, etc.] — [Frequency]

Patient Education

• Diagnosis explanation
• Treatment expectations and timeline
• Proper medication application technique
• Sun protection recommendations
• Skin self-examination instruction (if applicable)
• Warning signs to watch for

Follow-up

Return: [X] weeks for [Reason: treatment response, biopsy results, etc.]
Sooner if: [Specific warning signs]