Global Dermatology Grand Rounds
Research Form
A signed Photographic Consent Form is required for study enrollment

The Internet Dermatology Society is committed to the application of advanced telecommunication technologies to dermatologic education and practice. Global Dermatology Grand Rounds represents an application area of great potential importance. Formalization of the process of case submission is the first stage in a careful study of the effectiveness of Global Dermatology Grand Rounds as both a distance learning and telemedicine application. After presentation of your case in this format, you may be asked to participate in a survey regarding this format. Presentation of your case in no way binds you to completing this survey, however.

We invite you to submit your cases and welcome any comments regarding the submission format. Following presentation of your case on Global Dermatology Grand Rounds, you will be asked for clinical follow-up information regarding your case.

Referring Physician(s):

Patient's Date of Birth (Month/Day/Year):

Sex:

Cline:

REASON FOR SUBMISSION OF CASE TO GRAND ROUNDS
Stating the purpose of your submission of this Global Dermatology Grand Rounds case will allow more detailed analysis as to whether your goals were met by presenting your case in this format. Possible reasons might include:

  • Presentation of unusual clinical manifestations of a common disease process for educational purpose
  • Presentation of a classic case of a rare clinical entity for educational purpose
  • Presentation of an clinical unknown for diagnostic assistance
  • Presentation of a case for therepeutic assistance

CHIEF COMPLAINT Please enter only the initial presenting complaint of the patient's below.

HISTORY OF PRESENT ILLNESSPlease describe in detail the patient's clinical course. After presentation of this case on Global Dermatology Grand Rounds, we welcome any follow-up information regarding diagnosis or therapeutics.

PAST MEDICAL AND SURGICAL HISTORYPlease list the patient's other medical and surgical conditions that are known

CURRENT MEDICATIONSPlease list all current medications below, with the generic (chemical) names and dosages

ALLERGIESLeave the section below blank if there are no known allergies.

FAMILY HISTORY

SOCIAL HISTORYPlease list below any occupational history or habits that may be relevant to diagnosis or therapy

PHYSICAL EXAMINATIONPlease describe the current physical findings in detail. Please include a description even of the findings that are shown in the images you are providing. Some users of Global Dermatology Grand Rounds may access this information with text-based browsers.

HISTOPATHOLOGYPlease record below the date and findings of any pathologic examinations
Date
Findings

Date
Findings

Date
Findings


 

OTHER LABORATORY EXAMINATIONS

Please record below the findings of any additional laboratory examinations. Provide the units of measurement and normal ranges.

Date

Exam

Value

Normal Range

THE DIFFERENTIAL DIAGNOSISPlease list below your differential diagnosis, from most likely to least likely diagnosis.










IMAGES OF DISEASEPlease submit any clinical images appropriate for this case presentation. Photographic consent forms are required. Information regarding methods of image submission is available. Please enter the mode of submission you have chosen. If your images are already located on a WWW server, please record below the exact URL (Uniform Resource Locator) of all images that you would like to have included in this case presentation. If you plan to send images through another route, LEAVE THIS SECTION EMPTY.




















This document is a resource
from the Internet Dermatology Society
Send your comments to:
Rhett Drugge, M.D.
Last update: January 7, 1996