Outpatient Clinics

In addition to general dermatology clinics, you will be assigned to various specialty clinics, such as pigmented lesion (melanoma), autoimmune/connective tissue disease clinic, wound clinic, psoriasis clinic, and many others. Don’t be afraid to ask your attending if you may see patient(s) and present (even if this is your first and only visit in a specialty clinic)!

How to prep the night before: Spend 10-20 minutes reviewing the patients that will be seen in clinic on Epic. 

For return patients: Focus on previous dermatology notes, especially current and previous diagnoses and treatments. Read up on diagnoses and management if not familiar. 

For new patients: Jot down relevant major PMH (e.g., s/p organ transplant, immunosuppression, previous outside derm visits)

During clinic: 

  • Level of autonomy will vary from clinic to clinic, ranging from shadowing to seeing patients individually.  Feel free to ask for greater autonomy as you progress in the clerkship.
  • Some clinics will have scribes that may accompany you while seeing patients and help with notes.
  • If shadowing, you can still stay engaged by asking questions, especially between patients!
  • When in the room with an attending, don’t be afraid to get close to the patient during the exam – this shows interest and you will get more exposure to the skin exam.

Physical Exam:

  • In gen derm clinic, you will likely observe many skin checks. It is important to do the full body skin exam the same way each time in order to be thorough and avoid missing areas. Here’s an example by Dr. Susan Burgin.
  • You may see the attending take a closer look at skin lesions using a special tool called a dermatoscope, which gives a magnified view of the lesion of interest. See “Resources” section for 3 helpful links on dermoscopy.
  • There is more information on this in chapter 3 of Lookingbill and Marks’ Principles of Dermatology.

Presentation:

  • One liner, CC
    • If return patient: include date of last visit, who it was with
  • HPI, focused on CC
    • If return patient: summarize last visit and changes since then, including symptoms
    • Remember to get a timeline: progression of disease, changes in lesion
  • Past Derm History: history of skin biopsies? Skin cancers? Indoor tanning or severe sun burns?
  • PMH: Focused, list those relevant to CC, any tx for dermatologic conditions
  • Meds: Focused on relevant treatments that were attempted, otherwise can skip or say “not contributory”
  • Allergies: Only if relevant (e.g., possible drug reaction – in which case describe the allergy and the specific reaction), otherwise can skip or say “not contributory”
  • FH: Again focused but definitely ask about FH of melanoma and non-melanotic skin cancer 
  • SH: Only if relevant, occupation can give you clues about sun exposure, smoking can exacerbate some diseases
  • Exam: Skin type, describe findings (see “Morphology” in Content section), location of lesions
  • A/P: Level of detail really depends on the CC. For annual skin checks, there may be many findings to document but not necessarily a lot of discussion for each. For others, such as rashes, there may be more discussion needed. Sometimes you may want to lump the exam and A/P together, especially for annual skin exams in which there are many benign findings. 
    • Ex: On the left upper back, there is a well circumscribed 1.5 cm tan, waxy stuck on plaque most consistent with seborrheic keratosis. DDx also includes pigmented BCC, melanoma, benign nevus. My overall suspicion for malignancy is low, therefore I favor not biopsying, reassuring the patient that it is benign with no further management needed. 
  • Tips: Derm presentations are generally quick and focused, especially in the outpatient setting. The average presentation is generally about 30 secs, and may include as little as CC, relevant HPI, exam, and A/P.  As you are starting out, it is absolutely not expected that you will always know what it relevant, so when in doubt about a piece of information, always include it or ask the attending. It is also sometimes challenging to get used to describing skin exam findings. A helpful formula for descriptions is location + other descriptors (e.g., color, borders, size) + primary lesion + secondary characteristics (e.g., scale)

Clinic Note:

  • Like the presentation, the dermatology note is focused. Style varies from attending to attending, so it is helpful to look at previous notes that they have written (likely much less detailed than your note). 
  • PE mostly consists of describing lesions/rashes and is a good way to demonstrate and practice descriptions. See “Morphology” in Content section for helpful terms.
  • If possible, try and copy over a previous clinic note or ask your attending or resident if they have a template you can use. Here is a link to a template you may use.