QUESTION: 81

A26-year-old man presents with a hard, painless testicular mass. At operation, frozen section reveals testicular cancer. Which of the following is a risk factor?

What serum marker can be used to monitor therapy?

carcinoembryonic antigen (CEA)
human chorionic gonadotropin (hCG)
sedimentation rate
lactic dehydrogenase (LDH)
prostate-specific antigen (PSA)

Answer(s): B

Explanation:

Testicular cancer is the most common cancer in men between the ages of 20 and 40. Predisposing factors include cryptorchidism, hernias, and testicular atrophy. Abdominal testes are at higher risk than inguinal cryptorchid testes. Family history of testicular or prostate cancer, radiation exposure, or maternal DES seems to play no role. Testicular cancers are divided into nonseminoma and seminoma subtypes.
Seminoma represents about 50% of all tumors and generally follows a more indolent course. The primary tumor is treated by inguinal orchiectomy regardless of cell type. Pure seminomas do not require retroperitoneal lymph node dissection, because radiation is usually adequate therapy. Nonseminomatous testicular tumors (embryonal cell, teratocarcinoma, choriocarcinoma, endodermal sinus) are usually treated by retroperitoneal dissection. Serum alpha-fetoprotein (AFP) and hCG levels are markers that are important for diagnosis and as prognostic indicators and are used to monitor therapy. Serum LDH level is often elevated with bulky tumors but is not as specific as either AFP or hCG. CEA is a nonspecific marker elaborated by many adenocarcinomas. PSA is a marker associated with prostate cancer

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QUESTION: 82

A55-year-old man with a 50 pack-year history of smoking presents with hemoptysis. CXR shows a left upper lobe mass and laboratory evaluation reveals hypercalcemia. Which of the following is the most likely diagnosis?

small cell lung cancer
tuberculosis
squamous cell lung cancer
adenocarcinoma of the lung
metastatic testicular cancer

Answer(s): C

Explanation:

Although 515% of patients with lung cancer are identified while they are asymptomatic, most patients present with signs and symptoms including cough, hemoptysis, wheeze, stridor, shortness of breath, and postobstructive pneumonia. Paraneoplastic syndromes are common among patients with lung cancer.
Endocrine paraneoplastic syndromes are seen in 12% of patients. Hypercalcemia may result from ectopic production of PTH or PTH-related peptides by squamous cell carcinomas. Small cell cancers may secrete ACTH or excessive amounts of ADH leading to hyponatremia and SIADH. Other nonendocrine paraneoplastic manifestations may include anorexia, cachexia, weight loss, fever, suppressed immunity.
peripheral neuropathy, and the myasthenic Eaton-Lambert syndrome.

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QUESTION: 83

A 25-year-old man has the sudden onset of chest pain on the right side and dyspnea. On CXR, his trachea is deviated to the left. Which of the following should be anticipated on examination?

rales on the left
rales on the right
hyperresonance on the left
distant breath sounds on the right
pleural friction rub on the left

Answer(s): D

Explanation:

In the patient described in the question, the movement of the trachea to the left suggests a difference between right and left pleural pressures, either a reduction in pressure on the left or a rise in pressure on the right. The acute onset of right-sided chest pain in an otherwise healthy young man suggests a pneumothorax. On the side of the pneumothorax, we would expect increased resonance and distant or absent breath sounds because of the air trapped in the pleural space between the lung and chest wall and possible compression of the normal lung. No rales or rhonchi would be expected. Apleural friction rub suggests an inflammatory process involving the left chest, a finding not likely on the basis of the patient's presentation.

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QUESTION: 84

A 65-year-old woman with a long history of uncontrolled hypertension and valvular heart disease presents for evaluation. She is fatigued and complains of swelling in her legs and shortness of breath. Which of the following is the distinguishing feature of left ventricular failure?

elevated liver enzymes
pulmonary edema
ascites
peripheral edema
jugular venous distention

Answer(s): B

Explanation:

Physical findings are often helpful in distinguishing left-sided from right-sided heart failure. When the left ventricle is either overloaded or weakened, patients develop dyspnea and orthopnea as a result of pulmonary congestion. When the underlying abnormality is primarily right ventricular failure symptoms related to pulmonary congestion are uncommon and patients experience edema, venous distention, and hepatic congestion. Liver enzymes may be elevated secondary to hepatic congestion

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QUESTION: 81

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QUESTION: 83

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QUESTION: 84

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