Dermatology consult guide

Dermatology consult guide

Mar 29, 2020 0
onthephones

Contributor: Glenn Parham

Editors: Melissa Peera

 

  • Is the patient clinically well?
  • Is there a fever +/- an acute rash?
  • Is there mucosal surface involvement? (eyes, mouth, genitals)
  • Is there blistering, erosions or ulcers? (epidermal detachment)
  • Is the patient’s pain out of proportion to the physical exam?
  • Is the dermatological concern an acute or chronic problem?
    • If chronic -> consider outpatient referral.
  • Has the patient been seen by a dermatologist (publicly or privately) previously?
    • If yes -> who, when, why, are there previous investigations and an existing treatment plan for this concern, has the patient been taking the prescribed treatment?
  • Patient demographics
  • Why is the patient in hospital?
  • When and where (anatomically) did the rash start?
    • Is there mucosal surface involvement? (eyes, mouth, genitals)
  • How has the rash evolved?
  • Rash description
  • Skin symptoms?
    • Itch, burning, pain?
  • Systemic symptoms?
    • Fevers, headaches, arthralgias, myalgias, fatigue, weight loss, swollen lymph glands?
    • Treatment to dermatological concern thus far?
  • Drugs
    • Patient’s medications, including topicals, OTC and complimentary medicines and any changes over last 2 months.
    • Medications received whilst inpatient.
  • Allergies & specific reaction (where appropriate):
    • Sick contacts & recent travel (where appropriate).
    • Personal and family history of melanoma +/- non-melanoma skin cancers (where appropriate).
    • Previous/current immunosuppression? (where appropriate)
    • Personal history of malignancy.
  • Skin exam
    • lesion morphology – flat (macule/patch), raised (papule/plaque/nodule), filled (pustule/vesicle/bullae), crust, scale, excoriation, erosions, ulcers, etc.
    • lesion texture – palpable, soft, firm, blanchable, compressible, tender, indurated, atrophied, etc.
    • colour – erythematous, blue, black, brown, etc.
    • configuration – targetoid, linear, dermatomal
    • distribution – flexural surfaces, truncal, acral, symmetrical, sun exposed sites, localised, widespread
    • including mucous membranes, palms and soles
  • Lymph node exam
  • Skin swab for bacterial MCS, viral PCR / NAT (where appropriate)
  • Skin scrapings for mycology (where appropriate)
  • Leukocyte and eosinophil count
  • Completed drug chart (e.g. documentation of all drugs patient has been exposed to over the last 3 to 6 months, particularly noting any antibiotics, anticonvulsants, NSAIDs and sulpha drugs)
  • Patient’s ethnicity
  • Personal and family history of autoimmune diseases
  • Abdominal exam for hepatosplenomegaly
  • Nail involvement
  • Not examining the patient (look, feel).
  • Not ascertaining whether the patient is known to a dermatologist and if there is a current plan in place:
    • including private dermatologists, and liaising with them if this is a chronic problem.
  • Mistaking the causative drug responsible for a drug reaction to be the one started a day or two before the rash onset. Drug reactions typically occur from drugs commenced 10 to 14 days prior to rash onset.
  • Inform dermatology registrar if finding it difficult to describe skin exam with correct terminology, try using simple terminology for what you can see and feel.
  • Not considering outpatient referrals for chronic dermatological concerns.
  • Sending bacterial MCS swabs to investigate for viruses – a tip to remembering swabs, Blue for Bacterial (medium: amies gel), green for viral (medium: VTM bactericidal).

Helpful Resources

 

Tags: #allergy,#consult guide,#dermatologist,#dermatology,#rashes,#referral,#requesting a consult,#skin exam

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