Advanced dermatology jeopardy orientation for family medicine residents (with gameshow in other slides) Identify the most common lesions seen in primary care practice Identify the 4S’s: Serious Skin Signs in Sick Patients Apply metacognitive principles to dermatologic diagnosis System I pattern recognition System II hypothetical-deductive reasoning

1. Dermatology Jeopardy
TUFMR at CHA – R3 Conference 5/2014
Clinton Pong, MD
Tufts/CHA Master Teacher Fellow
Tufts University Family Medicine Residency at
Cambridge Health Alliance

2. Goals and Objectives
Identify the most common lesions seen in primary
care practice
Identify the 4S’s: Serious Skin Signs in Sick
Patients
Apply metacognitive principles to dermatologic
diagnosis
– System I pattern recognition
– System II hypothetical-deductive reasoning
Tufts University Family Medicine Residency at
Cambridge Health Alliance

3. Evidence-Based Resources
• Essential Evidence Plus*
– User name: Tufts2010 Password: EEPlus2010
– Dermatology H&P EBM Calculator
• http://www.essentialevidenceplus.com/content/hp?class=Skin
– Evidence-Based Medical Guidelines:
• https://www.essentialevidenceplus.com/content/ebmg?class=Skin&rpp=50&view=sum&resource=G&sort=title%20asc&page=1
• DynaMed* - www.ebscohost.com/dynamed/
• NICE/BAD – British Association of Dermatologists
– http://www.bad.org.uk/healthcare-professionals/clinical-standards/clinical-guidelines?l=0
Tufts University Family Medicine Residency at
Cambridge Health Alliance

4. Other Guidelines
• American Academy of Dermatology (AAD)
– http://www.aad.org/education/clinical-guidelines
• Primary Care Dermatology Society
– http://www.pcds.org.uk/p/other-guidelines
Tufts University Family Medicine Residency at
Cambridge Health Alliance

5. ?Derm lesions
• Derm Image Expert (EE+)
– https://www.essentialevidenceplus.com/tools/dermExpert/index.cfm
• PCDS Diagnostic table
– http://www.pcds.org.uk/p/diagnostic-tables-how-to-use
Tufts University Family Medicine Residency at
Cambridge Health Alliance

6. Other Recommended Resources
• Journal of Family Practice
– http://www.jfponline.com/
• American Family Physician
– http://www.aafp.org/journals/afp.html?cmpid=_van_188
• DermNet NZ (New Zealand)
– http://www.dermnetnz.org/
• Books
– Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology: 6th Ed
– Symptom to Diagnosis: an Evidence Based Guide: 2nd Ed
– Derm Notes: Dermatology Clinical Pocket Guide (Davis's Notes)
– DeGowin’s Diagnostic Examination: 9th Ed
– JAMA Rational Clinical Examination
– (others in the library)
Tufts University Family Medicine Residency at
Cambridge Health Alliance

7. Decision Support
• Other point of care decision support tools
• Smartphone apps
– Kindle books
– LowestMed
– Fitzpatrick Dermatology Flashcards app
• https://itunes.apple.com/us/book/fitzpatricks-dermatology-flash/id721121826?mt=11
Tufts University Family Medicine Residency at
Cambridge Health Alliance

8. Shared Decision-Making
• Patient education
– NICE/BAD Patient Information Leaflets
• http://www.bad.org.uk/for-the-public
– Primary Care Dermatology Society
• http://www.pcds.org.uk/p/patient-information-leaflets
• Web resources
• Use of the After Visit Summary
Tufts University Family Medicine Residency at
Cambridge Health Alliance

9. Epic Tips
• Diagnosis coding & Use of the problem list
– CC  specific diagnosis
• Smartphrases, other tips
– .cvderm
– (create your own)
Tufts University Family Medicine Residency at
Cambridge Health Alliance

10. .CVDERM
SUBJECTIVE:
@NAME@ is a @AGE@ @SEX@ @CC@@PROBX@
HPI: Onset/ Duration:/ Location:/ Spread and Evolution:/ Radiation to:
Aggravated by:
Heat: Cold: Sun: Exercise:
Associated with:
Itch: Pain: Weeping/oozing / Blisters / Odor:
Alleviated by:
Topical: Systemic:
Prior episodes:
Recent Travel:
Recent Medication/OTC/Supplements:
?atopic history (asthma, hay fever, eczema)
?drug allergies
?Family medical history (of psoriasis, atopy, melanoma, xanthomas,
tuberous sclerosis, atypical mole/melanoma, icthyosis, bullous disorders)
?Social history (hobbies, exposures, travel, injecting drug use)
Ethnicity:
Occupation:
?Sexual history: history of risk factors of HIV: blood transfusions, IV drugs,
sexually active, multiple partners, sexually transmitted disease?
ROS:
?headaches, chills, feverishness, weakness
?fatigue, weakness, anorexia, weight loss, malaise
?arthralgias, myalgias, joint swelling
?cold/blue fingers/toes/Raynaud
?dry mouth/dry eyes
(rheumatic complaints, myalgias, Raynaud, sicca sx)
OBJECTIVE:
@VS@
GA:
Skin:
Macule, papule, nodule, pustule, plaque, ulcer, vesicle, bulla
Color: Pink, red, purple, white, tan, brown, black, blue, grey, yellow.
Uniform/variegated.
Margination: Well defined, ill defined.
Shape: Round, oval, polygonal, polycyclic, annular (ring-shaped), iris, serpiginous
(snakelike), umbilicated.
Palpation:
(1) consistency (soft, firm, hard, fluctuant, boardlike);
(2) deviation in temperature (hot, cold);
(3) mobility.
(4) tenderness
(5) depth estimation (i.e., dermal or subcutaneous).
Arrangement:
(1) grouped: herpetiform, arciform, annular, reticulated (net-shaped), linear,
serpiginous (snakelike);
(2) disseminated: scattered discrete lesions.
Confluence: Yes or no.
Distribution:
(1) extent: isolated (single lesions), localized, regional, generalized, universal,
(2) pattern: symmetric, exposed areas, sites of pressure, intertriginous area,
follicular localization, random, following dermatomes or Blaschko lines.
DDX:
Solitary: macule (portwine stain, fixed drug eruption, erythema migrans), papule/nodule (dermal
nevus, BCC, nodular melanoma), plaque (lichen simplex chronicus, Bowen disease, superficial
spreading melanoma), ulcer (BCC, diabetic ulcer, primary syphilitic chancre)
Multiple:
Localized: Macular (solar lentigines, fixed drug eruption), papular (condylomata accuminata,
syringomas, lichen planus), plaque (psoriasis, mycosis fungoides), nodular (metastasis),
vesicular/bullous (herpes zoster, herpes simplex), pustular (folliculitis barbae, herpes zoster,
impetigo)
Generalized: macular (viral exanthem, drug eruption), papular (psoriasis, lichen planus,
secondary syphilis, neurofibromatosis), vesicular/bullous (varicella, bullous pemphigoid),
pustular (pustular psoriasis, smallpox), nodular (metastasis, lipoma)

11. Diagnostic Hints: What to Do
When You’re Uncertain
Did you consider:
1. Drug eruption?
2. Factitial?
3. Lupus erythematosus?
4. Mycosis fungoides?
5. Occupational or
hobbies?
6. Sarcoidosis?
7. Scabies?
8. Syphilis?
9. Systemic illness?
Did you think of
these broad
categories?
1. Infectious
2. Neoplastic
3. Inflammatory/
autoimmune
4. Allergic
5. Drug reaction
6. Metabolic
7. Genetic
Tufts University Family Medicine Residency at
Cambridge Health Alliance
Did you examine for
or enquire about:
1. Focus of
infection?
2. Foreign travel?
3. Mucosal clues?
4. Nail clues?
5. OTC, herbals?
6. Pets?
7. Scalp clues?
8. Tinea pedis?
9. Tumor?

12. Diagnostic Hints: What to Do
When You’re Uncertain
Did you:
1. Biopsy?
2. Culture?
3. Envision the lesion at another site?
4. Order blood studies?
5. Order imaging studies?
6. Patch test?
7. Perform a KOH?
8. Really listen to the patient?
Tufts University Family Medicine Residency at
Cambridge Health Alliance

13. Jeopardy Rules
• (Optional) Answer in the form of a question
– It’s okay if you give the answer without adding a “?”
at the end
• Open Book
– 10 second countdown after
the first buzzer
– Answer MUST be written on paper
– All correct answers receive full points
• Partial credit/Point negotiations
• Other
Tufts University Family Medicine Residency at
Cambridge Health Alliance

14. Break
• Teams of 2 (or 3 if there is someone left
over)
• Create a team name
• Use a silly team buzzer
Tufts University Family Medicine Residency at
Cambridge Health Alliance

15. Goals and Objectives
Identify the most common lesions seen in primary
care practice
Identify the 4S’s: Serious Skin Signs in Sick
Patients
Apply metacognitive principles to dermatologic
diagnosis
– System I pattern recognition
– System II hypothetical-deductive reasoning
Tufts University Family Medicine Residency at
Cambridge Health Alliance

16. Fill out Eval/Feedback Forms!
1. What was the most important thing
you learned today?
2. What question remains uppermost in
your mind afterward?
3. What is the muddiest point in today's
Tufts University Family Medicine Residency at
Cambridge Health Alliance
quiz show?