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pruritus

Practice targeted AMC-style multiple-choice questions on pruritus.

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breast cancerdermatologyelderly patientoncologyskin lesionrashskin biopsybiopsyitchymiddle-aged woman

A 45-year-old woman presents with a 3-month history of an intensely itchy rash on her wrists and ankles. On examination, you note violaceous, flat-topped papules. What is the most likely diagnosis?

A. Tinea corporis
B. Contact dermatitis
C. Psoriasis
D. Lichen planus
E. Atopic dermatitis
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino — CC BY-SA 2.0 · Source

A 68-year-old woman presents with a persistent, pruritic rash on her chest wall at the site of a previous mastectomy performed 8 years ago for invasive ductal carcinoma. She completed adjuvant chemotherapy and radiation. Examination reveals the area shown. What is the MOST appropriate next step in management?

A. Initiation of systemic chemotherapy
B. Reassurance and observation
C. Referral for wide local excision
D. Skin biopsy of the affected area
E. Topical corticosteroid application
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino — CC BY-SA 2.0 · Source

A 70-year-old woman, post-mastectomy, presents with a chronic, pruritic lesion. What is the MOST likely underlying pathophysiology?

A. Contact dermatitis
B. Intraepithelial adenocarcinoma
C. Granulomatous inflammation
D. Dermal melanocytosis
E. Superficial fungal infection
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino — CC BY-SA 2.0 · Source

A 68-year-old woman presents to her GP with a 3-month history of a persistent, mildly pruritic skin lesion on her left chest wall. She had a left simple mastectomy for invasive ductal carcinoma 10 years ago, followed by adjuvant therapy. She denies fever, weight loss, or other systemic symptoms. Physical examination reveals the appearance shown. What is the most appropriate initial diagnostic investigation?

A. Prescribe a course of topical antifungal cream
B. Punch biopsy of the lesion
C. Order a PET-CT scan for staging
D. Arrange a follow-up appointment in 3 months to monitor the lesion
E. Perform a shave biopsy of the lesion
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino — CC BY-SA 2.0 · Source

A 68-year-old woman presents to her general practitioner with a persistent, pruritic rash on her chest wall. She reports a history of left mastectomy for invasive ductal carcinoma 8 years ago, followed by adjuvant chemotherapy and radiation therapy. She denies any recent trauma or changes in soaps or detergents. Physical examination reveals the findings shown. A punch biopsy is performed. Which of the following immunohistochemical stains would most likely be positive in this patient's biopsy sample, supporting the suspected diagnosis?

A. Vimentin
B. Cytokeratin 7 (CK7)
C. Smooth muscle actin (SMA)
D. S-100
E. Human epidermal growth factor receptor 2 (HER2)
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino — CC BY-SA 2.0 · Source

A 62-year-old woman presents for a routine follow-up appointment several years after undergoing a simple mastectomy for pT1N0M0 invasive ductal carcinoma of the left breast. She completed adjuvant endocrine therapy and has been well since, reporting no new systemic symptoms such as unexplained weight loss, fatigue, or bone pain. Her last mammogram of the contralateral breast and clinical examination at her previous visit six months ago were unremarkable. During the current consultation, she mentions that she has noticed a persistent area of skin change on her left chest wall, near the mastectomy scar, over the past few months. She describes it as occasionally itchy and slightly raised, but denies pain, discharge, or significant discomfort. Her vital signs are stable (BP 130/80 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C). Physical examination reveals no palpable axillary or supraclavicular lymphadenopathy. The appearance of the affected area is shown in the image. Considering the patient's history, the duration and nature of the symptoms, and the clinical presentation, what is the most appropriate initial diagnostic step to investigate this new finding?

A. Prescribe a course of topical antifungal cream and review in two weeks.
B. Perform a punch biopsy of the affected skin area.
C. Arrange for a repeat mammogram of the contralateral breast and ultrasound of the axilla.
D. Order a CT scan of the chest, abdomen, and pelvis to rule out metastatic disease.
E. Reassure the patient that this is likely a benign inflammatory reaction related to the scar and monitor clinically.
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