A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola. What should you advise her?
Answer(s): C
Any new palpable breast lesion in females (or males) of any age necessitates a mammographic evaluation and biopsy. Delay is inadvisable. Serum tumor markers, such as CA-27/29 (or even less specifically CEA), are useful to follow tumor response to therapy; however tumor markers are not reliable as diagnostic tools in breast cancer because of a relatively low sensitivity. Lobular carcinomas are frequently not visualized on mammogram, particularly standard mammograms; ultrasound however detects these tumors and should be ordered when a palpable lesion is not detected on a mammogram.
A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola.Amammogram is performed; however, the mammogram demonstrates no abnormality involving either breast. What next should be done?
Answer(s): D
A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged. What next should be ordered?
Answer(s): B
Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.
A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged.The patient has the follow-up test that you recommend. It shows a 5-cm mass compressing the left upper lobe bronchus with consolidation of the left upper lobe. Two 1 cm peribronchial lymph nodes near the left main stem bronchus and several 1.52.0 cm mediastinal lymph nodes are seen. The hilar nodes do not appear enlarged. There are no enlarged lymph nodes visualized in the right chest. There are no lesions seen in the right lung. There are emphysematous changes involving both lungs.A biopsy of the lung mass shows a small cell carcinoma. What should be done next?
Answer(s): A
A 45-year-old female develops fever, dysuria, and back pain and is admitted to the hospital after evaluation in the ER discloses pyelonephritis. The patient is placed on broad-spectrum antibiotics and has a good improvement in her symptoms. On hospital day 4, the patient develops a new fever, leukocytosis, and profuse watery diarrhea. A colonoscopy is performed and the following finding is seenWhat is the first-line therapy for treating this disorder?
The colonoscopy image demonstrates the pseudomembranes classically seen in pseudomembranous colitis, also known as Clostridium difficile colitis. C. difficile colitis is commonly encountered in patients on broadspectrum antibiotics, although almost any antibiotic can predispose a patient to this illness. The disease is toxin mediated, and is frequently seen when antibiotics disrupt the normal balance of gut flora, allowing C. difficile to more widely colonize the bowel than it would normally. Crohn colitis and ulcerative colitis would have different patterns of ulceration of the mucosa, which is not seen here. Ischemic colitis would appear as an area or areas of blanched, edematous, or frankly necrotic mucosa due to an interruption of vascular flow. Microscopic colitis, which can cause a chronic form of watery diarrhea, typically has a normal appearance at colonoscopy. The first-line therapy for patients diagnosed with pseudomembranous colitis is typically a course of oral metronidazole. Patients can also receive oral vancomycin, although this is usually reserved for persistent or recurrent infection. Oral vancomycin also carries a much higher cost than metronidazole. Oral or topical= steroids would be contraindicated in the setting of an infection, although these medications are frequently used in patients with IBD such as ulcerative colitis or Crohn colitis. Sulfasalazineis a topical anti-inflammatory agent that is also sed for patients with IBD.
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