Hermanus, a 66-year-old retired coal miner, presents with a rash on his chest. It has been present for several months, is intensely itchy and appears to be enlarging. 

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<p>Hermanus, a 66-year-old retired coal miner, presents with a rash on his chest.</p><p>It has been present for several months, is intensely itchy and appears to be enlarging.</p><p>He has seen other GPs who prescribed potent steroid creams, but these have had little effect.</p><p>Over the past month, he reports an unintentional 10kg weight loss and a cough.</p><p>He has a 50-pack year smoking history. His clinical examination and observations are otherwise unremarkable.</p>

Dr Paul Muthiah is medical co-editor at Australian Doctor and a GP on the Central Coast, NSW.