Hello my fellow medics,

Dermatology is something that can be easily tested in the Clinical Skills Exam- it might involve showing a photo of a lesion and being asked to describe it and how you would manage it.

I am going to concentrate on a skin lesion i.e. a changing mole. This is an important station as skin cancers are on the rise, and so recognition and educating patients about this is essential.

So without further ado, let’s get on with concepts to consider, questions to ask and how to pass this station (and more importantly, to be a competent doctor!)

Below I use the A to D system to make sure all questions are asked and all red flags symptoms and signs are considered to rule out a melanoma. Before we get started, lets have a think about some concepts in a dermatology station.

Some key tips for OSCE (and real life!)

• Ask the patient about the lesion before you look. Some candidates/doctors once confronted with “doctor I have a lesion I am worried about” want to jump straight to examination. You get far more vital information asking the patient the necessary questions before examining rather than during the examination. Multi tasking can be difficult as well as not building on rapport.

• Respect the patient. They may need to uncover a part of their body to show you a lesion, so respect that fact. Ask them to uncover when needed and then once you finish the examination, ask them to cover up again. This links with my point above, you don’t want to have a patient exposed unnecessarily as you ask all the questions.

• Be systematic in your approach in asking the questions and examination. This will reduce chances of missing vital facts. Use A-D for both history and examination.

• Don’t guess the size, measure it with a tape measure/ruler (if in the exam the photo of a lesion has a scale- please don’t ignore!)

• Asking about change is so important. So with the A-D questions below, you want to ask about: change to colour, size and shape etc.

• “How did you first notice this lesion” - this will tell you if it was painful, itchy, just by chance or a loved one was worried and commented on it. They may have had it for years and now coming for a check up, or it is a new and they are petrified.

• Give a Patient Information Leaflet for what to look out for (there is a lot of information to remember) - a good one is on bad.org.uk

A- Asymmetry

Is the lesion symmetrical, meaning the two halves of the lesion are the same.

“How would you describe the shape? is it symmetrical?”

“Are both halves the same?”

B- Border

What is the border of the lesion like, is it blurred, irregular?

“Is the lesions/mole border blurred? Is it regular?”

“What does the edge of the mole look like?”

C- Colour

What is the colour of the lesion, has the colour changed (this is usually the main presenting complaint). If it has changed, find out more about change i.e. Is it darker, lighter?

The colour may be uneven. In a melanoma, the colours may be black, brown or even pink.

“How would you describe the colour of the mole? What colour was it, and what colour is it now?”

D- Diameter

Most melanomas are 6mm or more in diameter. You ask the patient about this before you examine to get their ideas on the size.

“What size is it roughly?”

“Has it grown in size?”

You would then measure it with a ruler.

Additional questions :

“Is the lesion itchy? does it bleed?”

I hope you found this information useful and simple. As I have stated before, my aim is not to teach a topic (you guys are intelligent and resourceful for this) but to give some concepts, ideas and ways of asking the question. This is to get you thinking and practising.

Enjoy your weekend, stay safe and focused :)