What the ACD IMG oral assessment is testing
The Australasian College of Dermatologists IMG Assessment is typically a structured interview-style assessment. Questions often use clinical scenarios and ask you to reason aloud rather than recite a list of dermatology facts.
A useful answer must show more than recognition of a rash. You need to demonstrate that you can:
- identify the immediate problem and its urgency;
- distinguish common diagnoses from dangerous alternatives;
- select investigations that will change management;
- propose a safe initial and longer-term plan;
- explain when and how you would escalate;
- communicate with the patient and check consent, capacity and understanding; and
- work within Australian or New Zealand referral and health-system practice.
Do not treat every vignette as a request for a definitive diagnosis. In an oral station, the examiner is often listening for how you manage uncertainty. Say what you think is most likely, what you must not miss, what information would change your view, and what you would do while obtaining it.
A reliable opening is:
“I would first establish whether this patient is clinically unstable or has a time-critical dermatological condition. I would then summarise the problem, assess severity, look for red flags, and develop a focused differential. My investigations and management would be guided by those risks.”
This gives the examiner a structure before you enter the detail.
The six-part answer structure
For most clinical scenarios, use these headings in order:
- Problem representation and triage: age, time course, morphology or symptoms, relevant exposure, and immediate stability.
- Focused history and examination: ask only for information that changes risk, diagnosis or treatment.
- Differentials and red flags: state the leading diagnosis, serious alternatives and the findings that separate them.
- Investigations or biopsy plan: explain what you would test, why, and how the result would alter management.
- Management: cover immediate treatment, definitive treatment, complications and specialist input.
- Follow-up, safety-netting and communication: explain the plan, document it, arrange review and tell the patient when to seek urgent help.
The order matters. A technically correct answer that starts with a long differential before addressing instability can sound unsafe.
ACD IMG is not a test of a single memorised script. The exact referral route, local service availability and prescribing details may depend on the health service in which you are working. For a real application, check current information from the official College and the relevant Australian or New Zealand health authority. In practice questions, state the appropriate level of escalation clearly rather than inventing a local pathway.
MySummaries' examiner setup for this type of practice can be configured around the following areas:
Build stations that force prioritisation
Do not practise only with diagnosis cards such as “What is this rash?” A useful station has a patient, a time course, a decision and a risk. It should force you to decide whether the patient needs routine review, urgent specialist assessment, emergency care or admission.
A good practice set should include:
- a changing pigmented lesion where melanoma must be considered;
- a widespread painful eruption with mucosal involvement where a severe drug reaction is possible;
- a chronic inflammatory condition where severity, comorbidity and longer-term management matter;
- an immunosuppressed patient with an ulcer, nodule or infection risk; and
- a professionalism or systems problem involving consent, documentation, escalation or referral.
For each station, write the opening question before you start. The first 30 seconds should test your structure, not your memory. Then add follow-up questions that expose weak reasoning: “What would make this an emergency?”, “Would you biopsy it?”, “What would you tell the patient today?” and “Who would you contact?”
Here is a useful five-station set for one revision board:
The practice score is less useful than the missing action. After each answer, write one sentence under each heading: what you noticed, what you missed, and what you would say next time. If you repeatedly omit escalation or safety-netting, create a separate prompt for that skill.
Station 1: a changing pigmented lesion
The opening task is not to announce “melanoma”. It is to show that you can assess a potentially malignant lesion without delaying diagnosis.
Start by clarifying the change: duration, enlargement, change in colour or shape, new bleeding, ulceration, itch or pain. Ask about previous skin cancers, melanoma in the patient or family, sun exposure, immunosuppression and whether the patient has noticed other lesions. Check whether the patient is otherwise well.
Examine the lesion systematically. Describe site, size, symmetry, border, colour variation, evolution, surface change and palpability. Examine the regional lymph nodes and perform a skin examination for additional suspicious lesions if clinically appropriate. Record a baseline photograph according to local policy and consent.
Your differential should include melanoma, a benign melanocytic naevus and seborrhoeic keratosis, while remaining alert to other pigmented tumours. Features such as marked asymmetry, irregular borders, multiple colours, evolution, ulceration, bleeding or a firm palpable component increase concern. A normal dermatoscopic impression does not override a convincing clinical history.
The safest diagnostic plan for a suspicious, clinically localised lesion is timely complete excision for histopathological diagnosis where feasible, with the specimen oriented and the clinical details provided. If complete excision is not practical because of size, location or functional risk, discuss an appropriately planned biopsy with a clinician experienced in skin cancer management rather than performing an inadequate sample. Do not destroy a suspicious lesion with cryotherapy or assume that a partial sample answers the whole question.
The report may provide Breslow thickness, ulceration and other prognostic information that affects subsequent management. I would not promise a particular margin, staging test or treatment before the pathology and clinical assessment are available. I would arrange prompt review of the result and explain that further treatment may be required.
A concise answer could be marked like this:
Examiner
A 45-year-old patient reports a 9 mm pigmented lesion on the upper back that has enlarged and developed colour variation over two months. It is asymmetric with an irregular border and a small area of surface crust. Talk me through your assessment and plan.
The answer identifies an evolving, asymmetric pigmented lesion as potentially malignant and gives it prompt rather than routine attention.
ImproveState explicitly whether the patient has systemic symptoms, bleeding or palpable nodes, and what would require same-day escalation.
Melanoma is prioritised and benign mimics are acknowledged; evolution, asymmetry, colour variation and crust are used as red flags.
ImproveExplain which examination findings would increase concern for nodal or locally advanced disease.
The plan is a timely complete excision for histology and avoids destructive treatment of an undiagnosed lesion.
ImproveMention the clinical information that should accompany the specimen and that pathology guides further staging and management.
The answer arranges review, avoids premature treatment promises and includes further management after pathology.
ImproveGive the patient a clear interim instruction to return promptly for bleeding, rapid change, pain or new lesions.
Consent, baseline photography and a calm explanation of possible further treatment are addressed.
ImproveCheck the patient's understanding and preferences, particularly if the lesion is in a functionally important site.
The answer recognises the need for prompt review and experienced biopsy planning.
ImproveState how you would document the lesion, photograph, examination of nodes and the follow-up owner.
A strong answerProblem summary and triage: This is an evolving, asymmetric, multicoloured pigmented lesion with surface change, so melanoma must be excluded promptly. Assessment: I would ask about bleeding, ulceration, pain, previous skin cancer, immunosuppression and other lesions, then examine the lesion with dermoscopy, the rest of the skin and regional nodes. Diagnosis: My leading concern is melanoma, with a benign naevus or seborrhoeic keratosis as alternatives. Investigation: I would arrange a timely complete excision for histopathology if feasible, or discuss the safest diagnostic biopsy if not. Follow-up: I would document the findings, explain the uncertainty, arrange responsibility for the result and advise the patient to return urgently for rapid change, bleeding or new symptoms.
That is a MySummaries station, filled with ACD IMG material. Yours is written from your own notes. Start free
Station 2: a painful drug eruption
This scenario tests whether you recognise a time-critical dermatological presentation and act before every investigation is complete.
The key features are fever, skin pain, dusky or atypical lesions, blistering or epidermal detachment, and involvement of mucosal, ocular or genital surfaces. A recent medicine is central to the history. Ask when each medicine was started, including prescribed drugs, over-the-counter products and supplements. Ask about swallowing, urination, eye pain or visual change, breathing, fluid intake and reduced urine output.
Assess airway, breathing, circulation, mental state, hydration, temperature and pain. Estimate the extent and distribution of skin involvement and look for tenderness, blistering, detachment and mucosal disease. Check eyes early. Look for features suggesting sepsis or organ involvement.
With fever, skin pain and mucosal erosions three weeks after lamotrigine, severe cutaneous adverse drug reaction, particularly Stevens–Johnson syndrome or toxic epidermal necrolysis, must be considered. Other differentials include erythema multiforme, staphylococcal scalded skin syndrome in the appropriate patient, severe infection and autoimmune blistering disease. The diagnosis is clinical and needs urgent specialist assessment; a biopsy may support it but must not delay escalation.
I would stop the suspected culprit medicine urgently after checking the indication and discussing the immediate risk with the treating team. I would arrange emergency hospital assessment or admission, involve dermatology and the relevant acute-care team, and seek ophthalmology input when there is ocular involvement. Management includes supportive care, analgesia, fluid and electrolyte assessment, wound care, temperature control, nutrition and infection assessment. I would avoid casually prescribing additional medicines with a risk of worsening the reaction.
Explain to the patient that this may be a serious medicine reaction, that the suspected drug should not be restarted without specialist advice, and that the reaction must be recorded clearly. The patient needs a written medicine plan and safety advice for future prescribing.
Examiner
A 29-year-old develops fever, marked skin pain, dusky lesions on the trunk and lips that are crusted and eroded. Lamotrigine was started three weeks ago. They report sore eyes and difficulty drinking. What are your immediate actions?
The answer recognises a potentially life-threatening severe drug eruption with mucosal, ocular and hydration concerns and treats it as an emergency.
ImproveState an immediate airway and circulation assessment before moving to dermatological detail.
Stevens–Johnson syndrome or toxic epidermal necrolysis is prioritised, with skin pain, fever, mucosal disease and recent lamotrigine identified as red flags.
ImproveBriefly distinguish the main alternatives using the patient's age, distribution and mucosal findings.
The answer supports urgent clinical assessment and recognises that biopsy can help without delaying treatment.
ImproveName baseline blood tests and assessment for organ involvement while avoiding an unfocused test list.
The suspected drug is stopped, emergency admission and specialist input are arranged, and supportive care and ocular review are included.
ImproveSay who would lead the immediate escalation and how deterioration would be monitored during transfer.
The answer explains seriousness, avoids rechallenge and provides a future medicine warning.
ImproveCheck the patient's ability to drink, understanding of the risk and whether a support person or interpreter is needed.
Dermatology, acute care and ophthalmology are involved and the adverse drug reaction is documented.
ImproveMention communication with the general practitioner and the hospital medicines team so the culprit is not inadvertently re-prescribed.
A strong answerTriage: This patient may have Stevens–Johnson syndrome or toxic epidermal necrolysis, a time-critical severe drug reaction, and needs emergency assessment now. Immediate actions: I would assess airway, breathing, circulation, hydration, pain, skin detachment and mucosal sites, stop lamotrigine after discussing it with the treating team, and arrange hospital admission with urgent dermatology and acute-care involvement. Investigations: I would obtain baseline blood tests and assess renal, hepatic and respiratory involvement; a skin biopsy may support the diagnosis but must not delay transfer. Supportive care: The patient needs fluid and electrolyte management, analgesia, wound care, nutrition and infection assessment, with urgent ophthalmology review for sore eyes. Communication and follow-up: I would document the suspected reaction clearly, provide a future drug warning, contact the primary care team and explain the plan to the patient and their support person.
The common weak answer here is a long list of tests followed by “refer to dermatology”. That reverses the priority. Say what you will do in the next few minutes, who must be involved, and what harm you are trying to prevent.
Station 3: recurrent axillary nodules
A 32-year-old with recurrent painful nodules and draining sinuses in both axillae may have hidradenitis suppurativa, but the station is about severity, consequences and a realistic care plan.
Clarify onset, frequency, duration of flares, scarring, discharge, fever, pain, mobility and impact on work, sleep and relationships. Ask about lesions in the groin, inframammary area or buttocks. Ask about smoking, weight, menstrual or hormonal associations, inflammatory bowel symptoms, arthritis and mood. Ask what treatments have already been tried and whether the patient could follow them.
Examine all relevant areas with consent. Record nodules, abscesses, draining tunnels, scarring and the extent of active disease. Consider whether there is an acute abscess requiring procedural assessment, cellulitis, systemic infection or an alternative diagnosis such as recurrent furunculosis or Crohn disease involving the skin.
Do not make the plan a weight-loss lecture. Discuss modifiable factors non-judgementally, but address pain, wound care, smoking if relevant, mental health and the patient's goals. Routine swabs are not automatically useful for diagnosing hidradenitis; consider microbiology when infection is clinically suspected or the result will change management.
Initial management may include analgesia, dressings and treatment of an acute abscess where indicated. Longer-term management should be staged according to severity and response, with dermatology referral for recurrent tunnels, scarring or inadequate control. Surgical options may be relevant for persistent localised disease. Check for anaemia, psychological distress and functional effects when clinically indicated. Agree a review point and explain what symptoms require urgent attention.
Examiner
A 32-year-old has had painful axillary nodules every few weeks for three years. There are bilateral scars, three draining tunnels and no fever today. They have stopped exercising because of pain and embarrassment. How would you assess and manage this patient?
The answer identifies chronic, scarring, tunnel-forming disease without current systemic instability and still checks for an acute abscess or infection.
ImproveState how you would assess whether an individual fluctuant collection needs same-day procedural care.
Hidradenitis suppurativa is prioritised and alternatives, systemic symptoms and associated inflammatory disease are considered.
ImproveLink the bilateral recurrent tunnels and scarring more explicitly to the leading diagnosis.
The answer avoids routine swabs and reserves investigations for infection, comorbidity or an alternative diagnosis.
ImproveState that diagnosis is primarily clinical and explain when an atypical lesion would require biopsy.
Pain, dressings, acute collections, staged treatment and dermatology referral are covered.
ImproveAgree a concrete early review and explain which symptoms, such as fever or rapidly spreading redness, require urgent care.
The response addresses embarrassment, exercise and non-judgemental discussion of modifiable factors.
ImproveAsk permission before examining sensitive sites and offer a chaperone where appropriate.
The answer recognises the need for dermatology input, mental-health assessment and staged care.
ImproveDocument lesion sites, tunnels, scarring, pain and functional impact so response to treatment can be assessed.
A strong answerSummary and severity: This is likely chronic hidradenitis suppurativa with bilateral scarring and draining tunnels, but I would first exclude an acute abscess, cellulitis or systemic infection. Assessment: I would ask about flares, pain, discharge, other sites, smoking, weight, menstrual associations, bowel symptoms, arthritis, mood and previous treatment, then examine with consent and document active lesions and scarring. Management: I would treat pain and wound care needs, arrange procedural assessment for any collection, discuss modifiable factors without blame and refer to dermatology for a staged medical and possible surgical plan. Safety: I would arrange review, explain fever or rapidly spreading redness as urgent warning signs, and involve other services if psychological, inflammatory bowel or functional problems are identified.
Review the words that cost marks
Oral performance often fails through vague language rather than a completely wrong diagnosis. “I would refer” is incomplete. Say how urgently, to whom, for what reason and what happens while the patient waits. “I would investigate” is incomplete. Name the test or biopsy, its purpose and the decision it informs.
Record your answer and review it against five questions:
- Did I identify the immediate danger in the first minute?
- Did I prioritise two or three differentials rather than list ten?
- Did every investigation have a reason?
- Did I give an immediate plan, a definitive plan and a follow-up plan?
- Did I explain consent, understanding, documentation and escalation?
The transcript below shows how a small phrase can hide a major omission:
This is concerning for a severe drug reaction, so I would assess the patient and arrange specialist review. I would send some blood tests and take a biopsy. I would stop the likely medicine and arrange hospital care. I would explain the concern and provide follow-up.
I would assess the patient and arrange specialist review
The phrase does not show emergency triage, the immediate teams required, ocular assessment, or what happens before transfer. The investigation sentence also risks implying that tests come before stabilisation.
Say: Say: I would assess airway, breathing, circulation, hydration and mucosal involvement; stop the suspected culprit medicine; arrange emergency hospital admission with dermatology and acute-care input; seek ophthalmology review if the eyes are involved; and take baseline investigations without delaying transfer.Use a consistent spoken signpost when the examiner interrupts: “I will come back to the differential, but my immediate concern is safety.” This demonstrates that you can retain priorities under pressure.
You can also practise listening to your own answer. A strong answer should sound like a clinician handing over a patient: concise summary, risk, evidence, action, owner and review. It should not sound like a textbook paragraph.
Your answer correctly prioritised emergency transfer before completing the diagnostic work-up; the next improvement is to name the person responsible for follow-up of the pathology result.
How MySummaries helps
MySummaries lets you build a revision board from your own dermatology notes, then practise oral stations against that material. For this task, use one board for ACD IMG assessment, divide it into triage, red flags, investigations, management, communication and systems awareness, and turn every repeated omission into a new station or remediation card. Recorded answers can be reviewed for structure, missing safety actions and clarity rather than diagnosis alone.
Start with MySummaries and build the first board from the guidance and cases you are using this week.