Dermatology Clinical Case Proforma

For Ward Presentation — Department of Dermatology

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply (patients often present with more than one). Fill site, side and duration for each selected.

✓	Chief Complaint	Side	Site	Duration (since)
	Itching (pruritus)
	Skin rash
	Hair loss
	Acne
	Pigmentation changes
	Non-healing skin ulcer
	Nail changes
	Blisters
	Dry skin / scaling
	Excessive sweating
	Other:

3. History of Present Illness

Mode of Onset

Acute onset Gradual / progressive onset Following drug intake Following sun exposure Recurrent / seasonal Following contact with an agent (soap/cosmetic/plant/metal) Other:

Character of Pain / Key Symptom — SOCRATES

To be filled whenever pain/burning is associated with the skin lesion.

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Past, Personal, Family & Treatment History

5. General Physical Examination

Build

Nutrition

Consciousness

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. Cutaneous Examination

A. Lesion Description

Site & distribution
Primary lesion type
Size & shape
Colour
Margin
Surface
Arrangement
Number

B. Palpation

Texture / Consistency
Tenderness / Local temperature
Mobility / fixity

C. Mucosa, Hair & Nails

Mucosal involvement
Hair
Nails

D. Special Clinical Signs

7. Systemic Examination

8. Investigations

✓	Investigation	Findings
	Skin biopsy (histopathology)
	KOH mount
	Wood’s lamp examination
	Patch testing
	Tzanck smear
	Gram stain / culture of discharge
	Hb / TLC / ESR
	Serum IgE
	Other:

9. Diagnosis

Provisional Diagnosis

Differential Diagnosis

10. Treatment Plan

Topical medication Systemic medication Phototherapy planned Biopsy / procedure planned Avoidance of identified trigger/allergen Counselling given Follow-up plan

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

Dermatology Clinical Case Proforma — for teaching purpose · not a legal medical record

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

System	Normal	Abnormal	Details
Cardiovascular System
Respiratory System
Joints