Tufts University Family Medicine Residency at Cambridge Health Alliance

Dermatology JeopardyTUFMR at CHA – R3 Conference

5/2014Clinton Pong, MD

Tufts/CHA Master Teacher Fellow

Tufts University Family Medicine Residency at Cambridge Health Alliance

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

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

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

?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

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

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

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

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

.CVDERMSUBJECTIVE:@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, bullaColor: 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)

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?

Tufts University Family Medicine Residency at Cambridge Health Alliance

Did you think of these broad categories?1. Infectious2. Neoplastic3. Inflammatory/

autoimmune4. Allergic5. Drug reaction 6. Metabolic7. Genetic

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?

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

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

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

Tufts University Family Medicine Residency at Cambridge Health Alliance

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

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