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skin lesion

Practice targeted AMC-style multiple-choice questions on skin lesion.

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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents to his general practitioner with a lesion on his nose that has been present for approximately 3 months. He initially thought it was a persistent pimple but it has not resolved and seems to be slowly growing. He denies pain, itching, or bleeding from the lesion. He has no significant past medical history and takes no regular medications. He works outdoors but reports using sunscreen inconsistently. On examination, vital signs are stable. The lesion is as shown in the image. There are no other skin lesions noted elsewhere. Regional lymph nodes are not palpable. Based on the appearance of the lesion shown, what is the most appropriate next step in the management of this patient?

A. Advise observation for a further 3 months to assess for changes
B. Order a full blood count and inflammatory markers
C. Perform cryotherapy in the clinic
D. Referral to a dermatologist for assessment and biopsy
E. Prescribe a course of topical antibiotic cream
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old male presents to his GP with a lesion on his nose that has been slowly enlarging over the past six months. He reports no pain, itching, or bleeding. He has no significant past medical history and takes no regular medications. On examination, vital signs are stable. The image shows the appearance of the lesion. Given the clinical presentation and morphology, what is the most appropriate initial step in management?

A. Punch biopsy of the lesion
B. Reassure the patient and arrange review in 12 months
C. Prescribe topical antibiotic cream
D. Prescribe high-potency topical corticosteroid cream
E. Arrange immediate wide surgical excision
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents to his general practitioner complaining of a persistent, asymptomatic lesion on his nose that has been present for approximately 6 months. He denies any trauma to the area. He reports no other skin issues or systemic symptoms. Physical examination reveals the lesion shown. The patient is concerned about cosmetic appearance and potential for malignancy. What is the MOST appropriate initial management step?

A. Topical imiquimod
B. Referral to a dermatologist for biopsy and potential excision
C. Reassurance and observation
D. Cryotherapy
E. Topical corticosteroids
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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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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents with a painless lesion on his nose that has been present for several months. He denies any trauma or recent illness. Examination reveals the image shown. What is the most appropriate initial management?

A. Topical corticosteroids
B. Topical retinoids
C. Excisional biopsy
D. Oral antibiotics
E. Cryotherapy
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 62-year-old man presents with a lesion on his nose that has been slowly enlarging over the past 8 months. He reports occasional tenderness but no bleeding. He has a significant history of outdoor work and multiple previous sunburns. His medical history is otherwise clear. On examination, vital signs are stable. The lesion appears as shown in the image. Regional lymph nodes are not palpable. Considering the clinical presentation and the appearance of the lesion, which of the following is the most appropriate initial step in the management of this patient?

A. Arrange for cryotherapy of the lesion.
B. Perform a punch biopsy of the lesion.
C. Refer immediately for wide local excision.
D. Apply topical imiquimod cream daily.
E. Schedule a follow-up appointment in 3 months to monitor for changes.
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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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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 40-year-old man presents with a painless, slowly growing lesion on his nose for the past 8 months. He denies any trauma or previous skin conditions. Examination reveals the pictured lesion. What is the MOST appropriate next step in management?

A. Cryotherapy
B. Observation with serial photography
C. Referral for Mohs micrographic surgery
D. Punch biopsy for histological diagnosis
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 72-year-old woman presents with a 6-month history of a non-healing rash on her chest wall at the site of a previous mastectomy performed 10 years prior for invasive ductal carcinoma. She completed adjuvant chemotherapy and radiation. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Skin biopsy of the affected area
B. Empiric antibiotic therapy
C. Reassurance and observation
D. Referral for wide local excision
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 with a persistent rash on her chest wall at the site of a previous mastectomy performed 8 years ago. She denies pain or itching. What is the MOST appropriate next step in management?

A. Reassurance and observation
B. Topical corticosteroid application
C. Skin biopsy
D. Referral to dermatology for cryotherapy
E. Excisional biopsy with wide margins
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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 65-year-old woman presents with a chronic, non-healing lesion at the site of her mastectomy scar, performed 7 years ago. She denies pain but reports occasional itching. What is the MOST appropriate next investigation?

A. Mammogram of the contralateral breast
B. Fungal culture
C. Topical corticosteroid application
D. Excisional biopsy with wide margins
E. Skin biopsy
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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 70-year-old woman presents with a lesion on her chest wall at the site of a mastectomy performed 10 years prior. She reports it started as a small area of redness and has slowly enlarged. What is the MOST likely diagnosis?

A. Eczema
B. Radiation dermatitis
C. Paget's disease of the breast
D. Invasive ductal carcinoma
E. Herpes zoster
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 40-year-old man presents with a solitary, asymptomatic nodule on his nose. Biopsy reveals perivascular eosinophilic infiltrate. What is the MOST likely diagnosis?

A. Keratoacanthoma
B. Angiofibroma
C. Spitz nevus
D. Eosinophilic granuloma
E. Basal cell carcinoma
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old man presents with a painless lesion on his nose, present for 6 months. Examination reveals the image shown. What is the MOST likely diagnosis?

A. Angioma
B. Squamous cell carcinoma
C. Melanoma
D. Basal cell carcinoma
E. Eosinophilic granuloma
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A 65-year-old lady weighing 70 kg has an enlarging papule on her right neck, measuring 8 mm, raised with a keratotic horn. A keratinocytic tumor is suspected. What is the maximum safe dose of 1% lidocaine with adrenaline for local anesthesia in this patient?

A. 490 mg
B. e/ 1000 mg
C. 140 mg
D. 70 mg
E. 210 mg
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 72-year-old female on warfarin for chronic atrial fibrillation presents with a 2-day history of increasing pain and a developing lesion on her right lower leg. She denies trauma. Her INR is therapeutic at 2.5. Vitals are stable. Considering the clinical presentation and the image provided, what is the most appropriate immediate management?

A. Continue warfarin at a reduced dose and monitor the lesion closely.
B. Switch anticoagulation to a direct oral anticoagulant (DOAC).
C. Discontinue warfarin, administer vitamin K, and initiate heparin.
D. Initiate broad-spectrum antibiotics and arrange surgical debridement.
E. Apply topical corticosteroids and compression bandaging.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old man presents to his general practitioner reporting a lesion on his nose that he first noticed approximately three months ago. He describes it as initially resembling a persistent pimple, but notes it has not resolved and appears to be slowly increasing in size. He denies any associated pain, itching, or bleeding from the site. His past medical history is unremarkable, and he is not currently taking any regular medications. He works outdoors in a role involving significant sun exposure but admits to inconsistent use of sun protection measures. On physical examination, his vital signs are within normal limits. The lesion in question is located on his nose and has the appearance shown in the accompanying image. No other suspicious skin lesions are identified elsewhere on his body, and regional lymph nodes are not palpable. Considering the clinical presentation and the appearance of the lesion depicted, what is the most appropriate initial step in the management of this patient?

A. Perform a punch biopsy of the lesion for histological examination.
B. Arrange an urgent ultrasound scan of the nose and regional lymph nodes to assess for depth and spread.
C. Prescribe a course of topical antibiotic cream and review in two weeks.
D. Advise the patient to monitor the lesion for further changes and return in three months if it persists or grows.
E. Initiate treatment with a high-potency topical corticosteroid cream twice daily.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents to his general practitioner with a lesion on his nose that has been present for approximately 3 months. He initially thought it was a persistent pimple but it has not resolved and seems to be slowly growing. He denies pain, itching, or bleeding from the lesion. He has no significant past medical history and takes no regular medications. He works outdoors but reports using sunscreen inconsistently. On examination, vital signs are stable. The lesion is as shown in the image. There are no other skin lesions noted elsewhere. Regional lymph nodes are not palpable. Based on the appearance of the lesion shown, what is the most appropriate next step in the management of this patient?

A. Reassure the patient and arrange for review in 3 months.
B. Prescribe a course of topical corticosteroid cream.
C. Initiate a course of oral antibiotics.
D. Arrange for cryotherapy to the lesion.
E. Perform a biopsy of the lesion for histological examination.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 55-year-old man presents to his GP with a lesion on his nose that he first noticed about 6 months ago. It has gradually increased in size but is not painful or itchy. He has no significant past medical history and takes no regular medications. On examination, vital signs are stable. The image shows the lesion. Based on the appearance of this lesion, what is the most appropriate next step in management?

A. Advise observation and review in 6 months.
B. Perform an excisional biopsy for histological examination.
C. Refer urgently to a dermatologist for Mohs surgery.
D. Prescribe a course of topical antibiotic cream.
E. Arrange for cryotherapy in the clinic.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 55-year-old man presents with a slowly growing lesion on his nose that he first noticed about 6 months ago. He reports occasional mild discomfort but no bleeding. He has a history of significant sun exposure due to his occupation. His medical history is otherwise unremarkable. On examination, vital signs are normal. The lesion appears as shown in the image. Regional lymph nodes are not enlarged. Considering the patient's history, risk factors, and the appearance of the lesion, what is the most appropriate initial step in the management of this patient?

A. Apply a high-potency topical corticosteroid cream
B. Excisional or incisional biopsy of the lesion
C. Observe the lesion for a further 3 months and review
D. Order a CT scan of the facial bones and sinuses
E. Refer directly to a plastic surgeon for cosmetic removal
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 65-year-old patient recently started on warfarin for deep vein thrombosis presents with a painful, expanding skin lesion on their leg. They report the lesion appeared suddenly and has worsened over the past 24 hours. INR is 2.8. Considering the clinical presentation and the appearance of the lesion, what is the most appropriate immediate management step?

A. Apply topical corticosteroids and compression bandaging.
B. Administer broad-spectrum antibiotics and debride the lesion.
C. Obtain a tissue biopsy for histopathology and culture.
D. Stop warfarin and initiate heparin and vitamin K.
E. Increase the warfarin dose and monitor INR closely.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old man presents to his GP with a lesion on his nose that has been present for several months and seems to be slowly enlarging. He denies pain, itching, or bleeding. He works outdoors but reports using sunscreen inconsistently. His past medical history is unremarkable, and he takes no regular medications. On examination, vital signs are stable. Regional lymph nodes are not palpable. The lesion is as shown in the image. Considering the clinical presentation, risk factors, and the appearance of the lesion, which of the following represents the most appropriate initial step in establishing a definitive diagnosis and guiding management?

A. Referral for cryotherapy
B. Application of topical corticosteroid cream twice daily
C. Punch biopsy for bacterial culture and sensitivity
D. Excisional or incisional biopsy for histological examination
E. Reassurance and review in three months
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 55-year-old man presents to his GP with a persistent lesion on his nose that has been present for several months and has not changed significantly in size or appearance. He reports it is occasionally itchy but otherwise asymptomatic. His medical history is unremarkable, and vital signs are within normal limits. On examination, you observe the lesion shown in the image. Considering the appearance of this lesion, what is the most appropriate initial step in the management of this patient?

A. Perform a punch or shave biopsy of the lesion.
B. Advise watchful waiting and review in 6 months if it changes.
C. Prescribe a 7-day course of oral flucloxacillin.
D. Initiate treatment with topical hydrocortisone 1%.
E. Refer for Mohs micrographic surgery.
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 68-year-old woman recently started on warfarin for a pulmonary embolism presents with a painful, rapidly expanding purpuric lesion on her thigh, which developed two days ago. Her INR is 2.5. She has no history of trauma to the area. Considering the clinical presentation and the appearance of the lesion, what is the most likely underlying pathophysiological process?

A. Allergic vasculitis secondary to warfarin
B. Protein C deficiency leading to paradoxical thrombosis
C. Vitamin K deficiency exacerbating bleeding
D. Direct toxic effect of warfarin on dermal capillaries
E. Heparin-induced thrombocytopenia causing microthrombi
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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 65-year-old woman presents with a several-month history of a slowly enlarging, mildly pruritic skin lesion on her left chest wall. She underwent a simple mastectomy on the left side for invasive ductal carcinoma 8 years ago. She denies systemic symptoms. Physical examination reveals the appearance shown. What is the most appropriate next step in management?

A. Punch biopsy of the lesion
B. Arrange a CT scan of the chest, abdomen, and pelvis
C. Order a mammogram of the right breast
D. Reassure the patient and review in 6 months
E. Prescribe a high-potency topical steroid cream
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 62-year-old man presents with a painless lesion on his nose, present for 8 months. He denies trauma or fever. Examination reveals the image shown. Histopathology is MOST likely to show which of the following?

A. Nodular basaloid cells with peripheral palisading
B. Granulomatous inflammation with eosinophils
C. Keratin pearls and intercellular bridges
D. Atypical melanocytes with pagetoid spread
E. Spindle cells arranged in a storiform pattern
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old man presents with a painless lesion on his nose that has been present for several months. He denies any trauma or recent illness. Examination reveals the image shown. What is the most appropriate initial management?

A. Oral antibiotics
B. Cryotherapy
C. Topical antifungals
D. Excisional biopsy
E. Topical corticosteroids
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 45-year-old man presents with the finding shown. He denies pain but is concerned about its appearance. What is the MOST appropriate initial step?

A. Surgical referral for elective repair
B. Referral for physiotherapy
C. Reassurance and observation
D. Prescription for a scrotal support
E. CT scan of the abdomen and pelvis
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 50-year-old man presents with a slowly growing, asymptomatic nasal lesion. He reports no trauma or fever. Examination reveals the image shown. What is the MOST likely long-term outcome if left untreated?

A. Transformation to squamous cell carcinoma
B. Local tissue destruction
C. Metastatic spread
D. Spontaneous resolution
E. Development of systemic lupus erythematosus
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 40-year-old patient presents with a persistent, slightly raised lesion on their nose that has been present for several months. It is asymptomatic except for occasional mild itching. There is no history of trauma or recent changes in size or colour. The patient is otherwise healthy. Considering the appearance of the lesion shown and the clinical presentation, which of the following represents the most appropriate initial approach?

A. Reassure the patient that it is likely benign and requires no further action.
B. Obtain a biopsy of the lesion for histological examination.
C. Prescribe a course of topical antibiotic cream.
D. Advise the patient to apply over-the-counter hydrocortisone cream.
E. Arrange urgent referral to a plastic surgeon for wide local excision.
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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. During the 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 systemic symptoms such as weight loss or fever. Her vital signs are stable, and 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 and the clinical presentation, what is the most appropriate initial diagnostic step?

A. Arrange for a PET-CT scan to assess for metastatic disease
B. Perform fine needle aspiration cytology of the lesion
C. Prescribe a course of topical antifungal cream and review in two weeks
D. Excisional or incisional biopsy of the lesion
E. Reassure the patient that this is likely post-surgical scarring and review in six months
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 55-year-old man presents to his GP with a lesion on his nose that has been slowly enlarging over the past 4 months. He reports no associated pain, itching, or bleeding. He is otherwise well, with no significant past medical history. On examination, vital signs are within normal limits. The lesion is as shown in the image. Considering the clinical presentation and the appearance of the lesion, what is the most appropriate initial step in the management of this patient?

A. Refer the patient directly for Mohs micrographic surgery.
B. Arrange for cryotherapy to the lesion.
C. Prescribe a course of oral antibiotics.
D. Excisional or incisional biopsy of the lesion.
E. Prescribe a high-potency topical corticosteroid cream.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 50-year-old man presents with a slowly growing nasal lesion. Examination reveals the image shown. What is the MOST appropriate initial management?

A. Excisional biopsy
B. Topical corticosteroids
C. Observation
D. Imiquimod cream
E. Cryotherapy
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents with a painless lesion on his nose that has been present for several months. He denies any trauma or previous skin conditions. Examination reveals the image shown. What is the MOST appropriate initial management step?

A. Topical antifungal cream
B. Topical corticosteroid application
C. Biopsy of the lesion
D. Cryotherapy
E. Observation with regular follow-up
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old male presents with a painless lesion on his nose that has been present for 6 months. He denies any trauma or previous skin conditions. Examination reveals the lesion seen in the image. What is the MOST appropriate next step in management?

A. Referral for Mohs micrographic surgery
B. Topical corticosteroid application
C. Observation with serial photography
D. Biopsy for histopathological examination
E. Cryotherapy
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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 72-year-old woman presents with a persistent, slowly expanding skin lesion on her right chest wall, present for several months. She underwent a right mastectomy for invasive ductal carcinoma 12 years ago. She denies pain, discharge, or systemic symptoms. Physical examination reveals the appearance shown. Considering the patient's history and the clinical finding, which of the following investigations is most appropriate to assess for potential underlying malignancy or systemic involvement?

A. Bone scan
B. Serum tumour markers (CA 15-3, CEA)
C. Mammography of the contralateral breast
D. CT scan of chest, abdomen, and pelvis
E. PET scan
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old male presents with a painless lesion on his nose that has been present for several months. He denies any trauma or recent illness. Examination reveals the image shown. What is the MOST appropriate initial management?

A. Observation with serial photography
B. Topical antifungal cream
C. Topical corticosteroid application
D. Biopsy for histopathological examination
E. Cryotherapy
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

An 82-year-old woman with a history of paroxysmal atrial fibrillation was recently discharged from hospital following treatment for community-acquired pneumonia. Five days ago, she was commenced on warfarin 5mg daily for stroke prevention. She presents to the emergency department today complaining of severe, rapidly worsening pain and a dark, blistering lesion on her right lower leg that developed over the past 48 hours. She denies any recent trauma to the leg. Her vital signs are stable: blood pressure 132/82 mmHg, heart rate 76 bpm, respiratory rate 18/min, temperature 37.0°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Laboratory results show an INR of 4.8, haemoglobin 125 g/L, white cell count 8.5 x 10^9/L, and platelets 250 x 10^9/L. She has no known personal or family history of thrombophilia. Considering the clinical presentation, recent medication changes, and the appearance depicted, which of the following is the most appropriate immediate management strategy?

A. Discontinue warfarin, administer Vitamin K, and initiate therapeutic dose low molecular weight heparin.
B. Reduce the dose of warfarin and monitor the INR closely.
C. Discontinue warfarin and administer Vitamin K only.
D. Initiate broad-spectrum intravenous antibiotics and arrange urgent surgical review for debridement.
E. Continue warfarin at the current dose and administer fresh frozen plasma to correct the INR.
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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 at that time. Examination reveals the area shown. What is the MOST appropriate next step in management?

A. Topical corticosteroid application
B. Referral for excisional re-resection
C. Mammogram of the contralateral breast
D. Empiric antifungal treatment
E. Skin biopsy of the affected area
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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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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 presents with a persistent, slowly enlarging skin lesion on her left chest wall, which she first noticed several months ago. She underwent a left simple mastectomy for invasive ductal carcinoma 12 years prior. Physical examination reveals the findings depicted. A recent biopsy of the lesion confirmed the presence of Paget cells. She has no other new symptoms. Her vital signs are stable. Considering the patient's history and the biopsy findings, which of the following investigations is the most appropriate next step in her management?

A. Observation with regular follow-up
B. PET-CT scan for staging
C. Wide local excision of the lesion
D. Topical corticosteroid cream
E. Repeat biopsy of the lesion
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 45-year-old man presents to his GP with a lesion on his nose that he first noticed about 6 months ago. It has slowly increased in size but is not painful or itchy. He has no significant past medical history and takes no regular medications. On examination, vital signs are stable. The image shows the appearance of the lesion. Considering the clinical presentation and the appearance of the lesion shown, what is the most appropriate initial management step?

A. Reassure the patient and review in 3 months.
B. Excisional biopsy for histological assessment.
C. Prescribe a course of topical corticosteroid cream.
D. Refer immediately for Mohs micrographic surgery.
E. Arrange for cryotherapy in the clinic.
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 68-year-old patient on warfarin for a recent DVT presents with a painful, rapidly expanding skin lesion on their leg that started 48 hours ago. Their INR is 2.9. Given the clinical context and the appearance of the lesion, what is the most appropriate immediate management step?

A. Increase the warfarin dose and monitor INR closely.
B. Switch warfarin to a direct oral anticoagulant (DOAC).
C. Obtain a skin biopsy and continue current management.
D. Apply topical antibiotics and continue warfarin.
E. Stop warfarin, administer Vitamin K, and initiate heparin.
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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. During the 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 systemic symptoms such as weight loss or fever. Her vital signs are stable, and 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 and the clinical presentation, what is the most appropriate initial diagnostic step?

A. Order a whole-body PET-CT scan
B. Reassure the patient and arrange follow-up in 6 months
C. Prescribe a course of topical corticosteroid cream
D. Arrange a mammogram of the contralateral breast
E. Biopsy of the affected skin area
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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 72-year-old woman presents with a 6-month history of a non-healing rash on her chest wall at the site of a previous mastectomy performed 10 years prior for invasive ductal carcinoma. She has completed adjuvant chemotherapy and radiation. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Skin biopsy of the affected area
B. Topical corticosteroid application
C. Referral for wide local excision
D. Empiric antibiotic therapy
E. Fungal culture of the lesion
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 72-year-old woman on warfarin for chronic atrial fibrillation presents with a painful, rapidly expanding lesion on her right lower leg that began two days ago, shortly after her warfarin dose was increased. Her vital signs are stable, and her INR is within the therapeutic range. Considering the clinical presentation and the appearance of the lesion shown, what is the most appropriate immediate management?

A. Administer broad-spectrum antibiotics and arrange urgent surgical debridement.
B. Switch warfarin to a direct oral anticoagulant (DOAC).
C. Discontinue warfarin, administer vitamin K, and initiate heparin.
D. Continue warfarin at the current dose and monitor closely.
E. Reduce the warfarin dose and add aspirin.
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

An 82-year-old woman with a history of paroxysmal atrial fibrillation and a recent hospitalisation for pneumonia was discharged 5 days ago on warfarin 5mg daily. She presents to the emergency department complaining of increasing pain and a rapidly evolving lesion on her right lower leg over the past 48 hours. She denies trauma. Her vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Her INR today is 4.5. She has no known history of protein C or S deficiency. Considering the patient's history, current medication, laboratory result, and the clinical appearance depicted, which of the following represents the most appropriate immediate management strategy?

A. Administer subcutaneous low molecular weight heparin and continue warfarin.
B. Initiate broad-spectrum antibiotics and arrange for surgical debridement.
C. Reduce the dose of warfarin and monitor the lesion closely.
D. Administer fresh frozen plasma to correct the INR and continue warfarin at a lower dose.
E. Stop warfarin, administer intravenous Vitamin K, and initiate therapeutic dose unfractionated heparin.
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 50-year-old man with multiple cutaneous lesions presents with recurrent episodes of abdominal pain and iron deficiency anemia. The provided image was obtained. What is the MOST appropriate next step in management?

A. Colonoscopy with polypectomy
B. Initiation of high-dose corticosteroids
C. Surgical resection of the affected bowel segment
D. Observation with serial abdominal exams
E. Empiric treatment for Helicobacter pylori
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