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The available tests for prostate cancer (PSA and DRE) will sometimes indicate cancer when there is none (false positives) and will sometimes fail to detect cancer when it is present (false negatives) C buy 250mg famvir with amex. A positive result on PSA or DRE will suggest that he should undergo invasive testing generic famvir 250 mg fast delivery, such as transrectal ultrasound and prostate biopsy D. Should he be found to have prostate cancer, he will want to consider aggressive therapy, and there is a small but finite risk of early death and a significant risk of chronic illness, particularly with regard to sex- ual and urinary function E. All of the above Key Concept/Objective: To understand the uncertainty surrounding screening for prostate cancer, and be able to communicate that uncertainty intelligibly to patients There is disagreement as to whether men should be screened for prostate cancer. It is important to understand that it is not yet known whether screening for prostate cancer will help men live longer and that significant morbidity and mortality have been associ- ated with the diagnostic and therapeutic procedures involved in screening. These facts should be conveyed to the patient to help him make an informed decision. A 65-year-old man who is otherwise in excellent health comes to you for a second opinion regarding therapy for his recently diagnosed prostate cancer. His records show that his cancer was diagnosed on the basis of a screening PSA level of 5. Transrectal ultrasound revealed no apparent tumor, but four of six random biopsy specimens tested positive for cancer. Low, because his clinical tumor stage is T1c and his PSA level is less than 10 C. Intermediate, because his clinical tumor stage is T2b D. High, because a Gleason score of 7 indicates a high-grade tumor Key Concept/Objective: To understand the clinical staging of prostate cancer Clinical staging is based on the means of diagnosis and the size and location of the tumor. This case highlights the point that the tumors of 12 ONCOLOGY 25 patients whose Gleason scores are greater than 6 should be considered high grade. From your assessment of risk for the patient in Question 41, what is the best advice that you can give him about treatment? It is highly likely that his tumor is confined to the prostate, so radical prostatectomy, external-beam radiation, brachytherapy, and watchful waiting are all reasonable options B. There is about a 50% chance of recurrence in 5 years, so radical prosta- tectomy is of no benefit C. There is about a 50% chance of recurrence in 5 years, and radical prostatectomy is curative in 50% of patients with his profile D. There is conclusive evidence that external-beam radiation is superior to radical prostatectomy in patients with his profile E. Although this means that 50% of men with cancer of this stage will have clinically silent metastases, rad- ical prostatectomy is curative in 50% of men in this risk group who undergo that proce- dure. There are as yet no data to suggest that prostatectomy or radiation therapy is of ben- efit with regard to mortality, and patients should be educated about the risks and benefits of both. The patient in Question 41 elects to undergo external-beam radiation. For 3 years, his PSA result is neg- ative, then it rises to 2. Which of the following treatment regimens has the best data to support it? Salvage radical prostatectomy and either surgical castration or chemi- cal castration with LHRH agonists C. Repeated external-beam radiation and either surgical castration or chemical castration with LHRH agonists D. Antiandrogens, such as flutamide, bicalutamide, and nilutamide, and either surgical castration or chemical castration with LHRH agonists E. Neither would further radiation treatment be of benefit. From the available data, the best therapy would be to combine lowering of testos- terone levels (which can be effected either surgically or through hormonal manipulation wih LHRH analogues) and treatment with antiandrogens, such as flutamide, bicalutamide, or nilutamide. A 67-year-old nulliparous white woman presents to the clinic for evaluation of increasing abdominal girth and bloating; these symptoms have been occurring for several months and are associated with some abdominal discomfort. She previously underwent upper GI evaluation, the results of which were negative. She has not had a gynecologic examination for several years, but she denies having any vagi- nal bleeding or discharge. She also denies having any other relevant medical history, but her sister and her mother have breast cancer.

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In such cases famvir 250 mg generic, illic- it drug use should be considered as a potential contributing factor buy cheap famvir 250mg on-line, but in this case, it is essentially ruled out by the lack of confirmatory history or urinary drug screen. A vasculi- tis, perhaps secondary to a systemic process such as SLE, should be considered. This patient’s sedimentation rate is normal, and her ANA is nonspecific and low. However, the absence of any illness preceding the onset of her symptoms decreases the probability of a systemic inflammatory process. Visual evoked potentials and CSF analysis would be rec- ommended if multiple sclerosis were a serious possibility. This patient has a single CNS lesion in the distribution of a major cerebral vessel (middle cerebral artery) and no other findings on her imaging study that suggest multiple independent CNS lesions. In young 11 NEUROLOGY 13 adults, carotid artery dissection needs to be considered in the differential diagnosis of CVA. Dissection may be diagnosed noninvasively with ultrasonography. A 49-year-old man presents to the emergency department with acute onset of severe headache, photo- phobia, and decreased level of consciousness. His mother had a subarachnoid hemorrhage at 54 years of age. He has no personal history of hypertension, vascular disease, or elevated cholesterol levels. His examination reveals a blood pressure of 148/84 mm Hg and mild nuchal rigidity. A CT scan of the head fails to reveal an abnormality. What is the best step to take next in the management of this patient? Carotid Doppler examination Key Concept/Objective: To understand that CT scanning of the brain is not 100% sensitive in excluding subarachnoid hemorrhage (SAH) This patient presents with many of the classic findings of acute subarachnoid hemorrhage, including the sudden onset of a severe headache, diminished level of consciousness, and nuchal rigidity. Family history of aneurysm is present in about 4% of patients with SAH. Establishing the diagnosis early is necessary to improve long-term morbidity and mortal- ity. It is important to note that CT scanning of the head is not 100% sensitive in exclud- ing this “high-stakes” entity. In the presence of clinical suspicion and a negative imaging study, a lumbar puncture is necessary to look for the presence of xanthochromia and RBCs. A 55-year-old man presents to the emergency department with sudden onset of tachycardia and light- headedness. He has had no previous episodes of similar symptoms. He has a history of hypertension con- trolled with amlodipine. His examination reveals a blood pressure of 132/82 mm Hg and an irregular heart rate of 120 beats/min. His lung examination is normal, and his cardiac exam- ination reveals an irregular rhythm, with no obvious murmur or extra sounds and S1 having variable intensity. An ECG reveals atrial fibrillation and left axis deviation. An echocar- diogram reveals normal left ventricular systolic and diastolic function and no thrombus or valvular abnormalities. Which of the following drugs would you give this patient to minimize the long-term risk of throm- boembolism? Low-molecular-weight heparin Key Concept/Objective: To understand that patients younger than 65 years who are without risk factors are at low risk for thromboembolism from atrial fibrillation Risk factors such as hypertension, diabetes, previous CVA/TIA, and poor LV function, along with older age (> 65 years), are associated with a yearly risk of thromboembolism from atri- al fibrillation of approximately 5%. This risk can be decreased to approximately 1% with warfarin and 2% to 3% with aspirin. The risk of thromboembolism is 1% without therapy in patients without risk factors and younger than 65 years. This patient has a history of controlled hypertension and has a normal echocardiogram, which decreases the probabil- ity that his hypertension has caused end-organ complications. He has no other risk factors 14 BOARD REVIEW for thromboembolism caused by his atrial fibrillation and likely has “lone atrial fibrilla- tion.

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