EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for James’s skin lesion?

• Prompt: How do you differentiate between benign and malignant lesions?
• Prompt: What red flag features would raise suspicion of malignancy?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors would you assess?
• Prompt: When would you consider performing a biopsy?

Q3. How would you explain the diagnosis and next steps to James?

• Prompt: How do you communicate the likelihood of a benign lesion while ensuring appropriate follow-up?
• Prompt: How do you address his concerns about skin cancer?

Q4. Outline your management plan for James’s skin lesion.

• Prompt: What are the treatment options for benign neoplasms?
• Prompt: When would you consider referral to a dermatologist?

Q5. What preventive strategies should James follow to reduce his skin cancer risk?

• Prompt: What sun protection measures should be discussed?
• Prompt: How often should he undergo skin checks?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for James’s skin lesion?

A structured differential diagnosis is essential to differentiate benign vs malignant skin neoplasms.

• Benign Skin Lesions (Most Likely):
  • Seborrhoeic keratosis – “Stuck-on” appearance, rough texture, well-demarcated, slow-growing, often pigmented.
  • Solar lentigo – Flat, brown, sun-exposed areas, common with cumulative UV exposure.
  • Dermatofibroma – Firm, mobile, hyperpigmented nodule, often dimples when pinched.
  • Lipoma – Soft, mobile, subcutaneous, no epidermal changes.
• Malignant or Premalignant Lesions (Must Exclude):
  • Basal cell carcinoma (BCC) – Pearly, rolled edges, telangiectasia, may ulcerate.
  • Squamous cell carcinoma (SCC) – Scaly, crusted, indurated nodule, rapid growth.
  • Melanoma – Asymmetry, irregular borders, colour variation, diameter >6mm, evolving.
  • Actinic keratosis (pre-malignant) – Rough, scaly patches on sun-damaged skin.

A competent candidate prioritises benign lesions but ensures red flag features are ruled out.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Lesion characteristics: Onset, growth rate, symptoms (itching, pain, bleeding).
  • UV exposure history: Occupational and recreational sun exposure.
  • Personal history: Previous skin cancers, blistering sunburns.
  • Family history: Melanoma, BCC, SCC.
  • Immunosuppression: Organ transplant, immunosuppressive medications.
• Investigations:
  • Dermatoscopy – Evaluates pigment patterns, vascular structures.
  • Biopsy (if suspicious features present):
    • Shave biopsy (superficial lesions).
    • Punch biopsy (deeper lesions).
    • Excisional biopsy (if melanoma suspected).

A competent candidate uses history and dermatoscopy first, reserving biopsy for suspicious lesions.

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Q3: How would you explain the diagnosis and next steps to James?

1. Acknowledge concerns:
   • “I understand you’re concerned about skin cancer, especially given your sun exposure.”
2. Explain likely diagnosis:
   • “From my examination, this lesion appears to be a seborrhoeic keratosis, a benign, slow-growing skin growth.”
3. Reassure but ensure vigilance:
   • “It is not cancerous and does not require treatment unless bothersome.”
   • “However, we always monitor skin changes carefully.”
4. Discuss follow-up and safety netting:
   • “If the lesion changes—becomes darker, bleeds, or grows rapidly—we should reassess.”
   • “Given your sun exposure, I recommend regular skin checks.”

A competent candidate balances reassurance with the need for ongoing skin surveillance.

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Q4: Outline your management plan for James’s skin lesion.

1. Observation (if benign features confirmed):
   • Reassurance that no treatment is needed unless symptomatic.
   • Education on monitoring for changes.
2. Treatment (if symptomatic or cosmetic concern):
   • Cryotherapy – Quick, effective for seborrhoeic keratosis.
   • Curettage and cautery – Used if lesion is thickened.
   • Excision – If malignancy suspected or patient prefers removal.
3. Referral (if malignant features present):
   • Dermatology referral if atypical dermatoscopic features.
   • Urgent referral for suspected melanoma or high-risk SCC/BCC.
4. Follow-up:
   • Routine skin check every 12 months, earlier if high risk.

A competent candidate ensures appropriate lesion management and follow-up recommendations.

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Q5: What preventive strategies should James follow to reduce his skin cancer risk?

1. Sun Protection (Slip, Slop, Slap, Seek, Slide):
   • Wear protective clothing and a broad-brimmed hat.
   • Use SPF 50+ sunscreen daily, reapplying every 2 hours.
   • Seek shade during peak UV hours (10 am – 4 pm).
   • Wear sunglasses to protect against UV exposure.
2. Regular Skin Surveillance:
   • Self-check every 3 months – Look for new or changing lesions.
   • Annual skin check by GP or dermatologist (sooner if new suspicious lesions).
3. Lifestyle Factors:
   • Avoid tanning beds.
   • Ensure adequate vitamin D through diet and monitored sun exposure.

A competent candidate reinforces the importance of sun protection and early detection.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates between benign and malignant skin lesions, recognising red flag features.
• Takes a structured history, assessing UV exposure, family history, and lesion characteristics.
• Uses dermatoscopy as a first-line investigation, reserving biopsy for suspicious lesions.
• Communicates clearly and empathetically, addressing patient concerns about skin cancer.
• Provides appropriate management, including observation, treatment, or referral if needed.
• Implements preventive strategies, focusing on sun protection and regular skin checks.

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PITFALLS

• Failing to consider malignancy, assuming all lesions are benign.
• Over-investigating benign lesions, leading to unnecessary biopsies and patient anxiety.
• Not addressing sun protection, missing an opportunity for preventive education.
• Inadequate safety netting, not advising when to seek medical review for changing lesions.
• Delaying referral for a suspicious lesion, potentially missing an early melanoma diagnosis.

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REFERENCES

• RACGP – RACGP Guidelines on Skin Cancer Assessment
• GP Exams – Neoplasm skin, benign/unspecified

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an appropriate management plan.
4.3 Provides patient-centred management.

5. Preventive and Population Health

5.1 Applies preventive care strategies relevant to the patient’s condition.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD