Surgery,Carlos Pestana

USMLE Step 2 — Lesson 1 Surgery Highlights for USMLE Step 2 Carlos Pestana, MD Trauma Cases Case #1: A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20 minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks for a blanket and water. Initial survey confirms the presence of an entry wound in the midepigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.

Diagnosis: Hemorrhagic shock •

Most common shock post trauma: hypovolemic (hemorrhagic)

•

If trauma to the chest occurs: must also consider pericardial tamponade and tension pneumothorax. Look for elevated CVP and distended neck veins.

Management: •

If possible, control bleeding first and then fill up vascular tree

•

Immediate laparotomy preceded by big bore IV lines, Foley catheter and IV antibiotics

•

Once bleeders clamped, rapid infusion of Ringers lactate and packed RBC’s

Case #2: A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and there is a barely perceptible pulse at a rate of 115 per min.

Diagnosis: Hemorrhagic shock •

Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to

the chest. Must r/o pericardial tamponade and tension pneumothorax. •

Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely diagnosis.

Management: •

Remember ABC’s. Source of bleeding unknown; can’t use the “stop bleeding first, replace volume later approach”

•

Two large peripheral IV lines with a couple of liters of Ringer’s lactate (no sugar) infused over 20-30 minutes

Management: •

Prompt and lasting stabilization of vital signs in response to fluid bolus would suggest bleeding has spontaneously ceased Prompt and lasting stabilization of vital signs in response to fluid bolus would suggest bleeding has spontaneously ceased

•

If shock not reversed with volume replacement, more aggressive blood replacement and surgery likely required

Case #3: An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest hospital is at least an hour away.

Diagnosis: Hemorrhagic shock Management: •

Infuse Ringer’s lactate while in transit to the hospital

Case #4: An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral breath sounds and is breathing well, but he has large distended veins in his neck and forehead. His blood pressure is 65/45, and his pulse rate is 150.

Diagnosis: Cardiogenic shock due to pericardial tamponade •

Can r/o tension pneumothorax because he has normal breath sounds and is breathing well

•

By exclusion, correct diagnosis is pericardial tamponade

Management: •

Pericardial tamponade is a clinical diagnosis; do not need further diagnostic studies

•

CXR and EKG NOT merited; in an unclear case, would order sonogram

Management: •

Must evacuate blood from pericardial sac

•

Give patient blood or IV fluids despite high venous pressure as elevated pressure due to mechanical impediment to ventricular filling, not ventricular failure

Case #5: A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest. Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead. He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea

shows it to be deviated toward the left.

Diagnosis: Tension pneumothorax Management: •

Clinical diagnosis of a life-threatening emergency: getting a CXR or waiting for ABG results would be a deadly mistake

•

Large bore needle or IV catheter into 2nd intercostal space

•

Chest tube to follow

Case #6: During a round of golf, a business executive is hit on the right side of his head with a golf ball. He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1 hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and he has contralateral hemiparesis.

Diagnosis: Epidural hematoma •

Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil and

contralateral

hemiparesis

suggests

acute

intracranial

hematoma

with

displacement of the midline structures.

Diagnosis: Epidural hematoma •

Epidural vs. subdural: subdural requires a much bigger trauma and presents with a sicker patient.

•

Blow to side of head where middle meningeal artery lies, as well as the very lucid “lucid interval” suggests acute epidural bleed.

•

In 90% of cases dilated pupil on same side as hematoma.

Management: •

CT scan of head to confirm location (right vs. left; epidural vs. subdural)

•

Biconcave epidural hematoma on the right; deviation of midline structures to the left

•

Cranionotomy and decompression

Case #7: The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he has signs of contralateral hemiparesis with decerebrate posture.

Diagnosis: Acute subdural hematoma •

Severity of trauma and profound neurological deficits suggest acute subdural hematoma, probably on the right side.

Management: •

Head CT

•

Semilunar, crescent-shaped hematoma on the right; deviation of the midline structures to the left

•

Deviation provides rationale for surgery; without displacement more conservative approach with ICP management

•

With major blunt trauma to the head, remember to check the C-spine

Case #8: An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap wine. While doing so, he bumps his head against the counter, but suffers no apparent injury. Over the next week, however, he gradually loses his mental capacities, and becomes obtunded and disoriented.

Diagnosis: Chronic subdural hematoma •

Shrinkage of brain (but not skull) in old people and alcoholics

•

Torn venous sinuses with slow venous bleeding

Management: •

CT scan of the head

•

Evacuation of clot

Case #9: A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but his other vital signs are stable. Physical examination reveals an absence of breath sounds in the right hemithorax, which sounds hyperresonant to percussion.

Diagnosis: Pneumothorax Management: •

Not life-and-death; time to confirm with studies

•

CXR will confirm diagnosis and show extent of pneumothorax and whether there is blood in the pleural space

•

Chest tube

Case #10: A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his other vital signs are stable. Physical exam reveals no breath sounds at the right base, and faint, distant breath sounds at the right apex. Right side of his chest is dull to percussion. A CXR shows blood in the right pleural space, and a chest tube is placed at the right pleural base. The tube initially recovers 270 cc of blood, drains another 35 cc in the next hour, and 12 cc in the second hour.

Diagnosis: Hemothorax •

Bleeding from penetrating chest injuries most often from lung

Management: •

While bleeding will stop by itself, expectant therapy not advisable because contaminated blood in the pleural space may produce empyema

Management: •

Evacuation of blood is imperative

•

One or more chest tubes placed and not removed until no blood draining

•

Surgery seldomly required

Case #11: A 19-year-old male is stabbed in the right chest. On arrival at the ER he is short of breath, pale, with a pulse rate of 95 and a blood pressure of 90/70. His right hemithorax has no breath sounds and is dull to percussion. CXR shows the entire pleural space to be filled with blood. When a chest tube is inserted, 1600 cc of blood are recovered.

Diagnosis and Management: •

Hemothorax with systemic vessel bleeding (usually intercostals)

•

Emergency thoracotomy to control bleeding

•

Vigorous fluid and blood replacement

Case #12: A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey shows multiple bruises and minor lacerations, but the most impressive finding is the presence of at least 8 rib fractures on the right side of her chest, and a very peculiar physical finding: there is an area of the chest wall on the right that caves in whenever she inspires and bulges out on expiration.

Diagnosis:

•

Consider: severe trauma to the chest, deceleration injury

•

Think of obvious injuries as well as hidden ones

•

Broken ribs and flail chest are obvious

•

Consider possibility of traumatic rupture of aorta

•

Manage the obvious, uncover the hidden

Management: •

Deal with broken ribs first: local nerve blocks

•

Flail chest: contused lung exquisitely sensitive to fluid overload; limit fluid infusion and use colloids rather than crystalloids; maybe add diuretics

•

Monitor blood gases for respiratory failure

Monitor blood gases for respiratory failure •

If she requires a respirator, must also insert prophylactic chest tubes

•

Check CXR for aortic transection; wide mediastinum leads to aortogram. If mediastinum not widened, spiral CT or transesophageal echo

Case #13: A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely tender at a point in the sternum, where palpation elicits a gritty feeling of bone grating on bone.

Diagnosis: Sternal fracture •

Probable myocardial contusion

•

Fracture of hard-to-break bones (sternum, scapula, first rib) suggest major trauma

•

Sudden deceleration chest trauma- possibility of aortic rupture

Management: •

CXR will reveal sternal fracture and can check for widened mediastinum

•

Diagnosis and management of myocardial contusion similar to MI; EKG more reliable than enzymes

Case #14: Two airplanes collide on runway and there are multiple casualties. One of the survivors is found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he is taken to the hospital, where a CXR shows a wide mediastinum and a fractured left first rib.

Diagnosis: Traumatic rupture of aorta •

Intima and media may have cracked and be asymptomatic until adventitia gives way

Management: •

Aortogram

•

Widened mediastinum on CXR not sufficient to rush to surgery; could be mediastinal hematoma from other causes

USMLE Step 2 — Lesson 2 Case #15: A 22-year-old man has been shot in the abdomen with a 38 caliber revolver. He is hemodynamically stable, but has moderate abdominal tenderness. There is an entrance wound to the left of the umbilicus, and x-rays show the bullet lodged in the right paraspinal muscles.

Management: •

Management of abdominal trauma straight forward in gun shot wounds and any trauma that results in acute abdomen: exploratory laparotomy!

•

Prep includes bladder catheter, big bore IV lines, broad-spectrum antibiotics

•

Stab wounds more controversial

Case #16: A 27-year-old man hits his abdomen against the steering wheel when his car collides with another at an intersection. On arrival at the ER, his blood pressure is 95/75 and his pulse is 98. His abdomen is distended, tender in all four quadrants, with muscle guarding and rebound tenderness.

Management: •

Presence of “acute abdomen” makes exploratory laparotomy mandatory

Case #17: A 32-year-old woman has been involved in an automobile accident. She has facial lacerations, a broken arm, and bruises over her chest and abdomen. CXR is normal. Shortly after arrival at the ER, she becomes progressively hypotensive, tachycardic and diaphoretic. Her hematocrit is dropping and her central venous pressure is low.

Diagnosis and Management: •

Shock with normal CXR and low CVP: she’s bleeding somewhere

•

Start infusion with Ringer’s lactate and follow with packed red cells

Where is the bleed? •

Head: No. Would have developed neuro signs . Hypovolemic shock can’t happen from intracranial bleed.

•

Chest: No. Pericardial sac not a possibility (low CVP in this patient); pleural spaces could fill with blood but would have seen on CXR.

Where is the bleed? •

Pelvis or thighs: large enough spaces to hold that much blood, but vignette doesn’t suggest these possibilities.

•

Most likely: Abdomen

Diagnosis and Management: •

Abdominal CT: will show the blood and source and will give idea of magnitude.

•

Note: abdominal CT requires that patient be hemodynamically stable!

Diagnosis and Management: •

When patient “crashing,” – diagnostic peritoneal lavage (DPL); alternatively, newer option is sonogram done in the ER. DPL and sonogram provide less info that CT- just yes or no on bleeding, not source or magnitude

•

If indeed there is bleeding in the abdomen – emergency laparotomy

Case #18: An 18-year-old college freshman is involved in a motorcycle accident. Among numerous other injuries, he has a pelvic fracture. At the initial survey it is noted that he has blood at the penile meatus, as well as a scrotal hematoma. He says that he feels the need to void, but can not do it. Rectal exam reveals a “high-riding” prostate.

Diagnosis: Urethral injury •

Hallmark of urological injuries is hematuria after trauma

•

High abdominal or flank trauma can lead to bleeding from kidney (lower rib fractures)

•

Pelvic fracture- bleeding from bladder or urethra in males; blood at the meatus suggests urethral injury

Management:

•

Don’t attempt to pass a Foley!

•

Retrograde urethrogram: anterior injuries repaired at the time; posterior ones delayed

•

If urethrogram negative, pass a Foley and perform a cystogram. Look at post void film

Case #19: A 55-year-old woman sustains multiple injuries in a car accident including fractures of the lower ribs on both sides. There is no pelvic fracture. When a Foley catheter is inserted, gross blood is recovered.

Diagnosis: Kidney injury •

Urethral injury rare in women

•

Absence of pelvic fracture makes bladder unlikely; r/o with cystogram

•

Confirm with CT of kidneys

Management: •

Most penetrating renal injuries need surgery; most blunt ones do not

•

Avulsion of renal pedicle example of exception

Case #20: A 26-year-old man is shot in the leg with a 22-caliber gun. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is lower down in the posterolateral aspect of the thigh. He has normal distal pulses in that leg, and a small, non-expanding hematoma under the entrance wound. The bone is intact.

Management: •

Wound cleansing; tetanus prophylaxis

•

Surgical challenge in reference to possible vascular injury

•

Think about the anatomy: Femoral vessels at risk in this case

Management: •

Arteriogram (would skip this step if pulses absent or hematoma expanding)

•

Repair dilemma of vascular injury PLUS bone injury

Case #21: A 14-year-old boy complains of pain in his right knee. His family notices that he has been limping. He is sitting on the examination table with both feet dangling, and the right foot is rotated towards the left. Physical examination is completely normal for the knee, but it shows limited hip motion. When the hip is flexed, the leg goes into external rotation and it can not be internally rotated.

Diagnosis: Slipped capital femoral epiphysis Management: •

Orthopedic emergency

•

After AP and lateral x-rays confirm diagnosis, femoral head will be pinned in place

Hip pathology: •

Can show up as knee pain

•

Age is important clue:

Hip pathology: By age group In newborns: think developmental dysplasia (order sonogram; not CXRs); treat with Pavlik harness Painful hip in toddler after a febrile illness: think septic hip. Diagnosis established by aspiration under general anesthesia. Emergency drainage required.

Hip pathology: By age group Hip pain at age 6: think avascular necrosis of femoral head Hip pain in early teens (boys): think slipped capital femoral epiphysis

Case #22: A child complains of persistent, severe pain in his arm. He has a very tender area to palpation at a very specific point in his radius, but he has no history of trauma to that area. For the past several days he has had a febrile illness, for which he has received no treatment.

Diagnosis: Acute hematogenous osteomyelitis •

A febrile illness in a toddler, followed by refusal to move the hip is a septic hip (an emergency).

•

A febrile illness in a child, followed by bone pain is osteomyelitis.

Management: •

Do a bone scan and treat with antibiotics.

•

Do not order x-rays in this setting: they will not show anything for two weeks. Go with the scan.

Case#23: A 55-year-old homeless man comes to the ER complaining of extremely severe pain in his right forearm. He has no history of trauma to that area, and relates that he was very drunk, slept on a park bench, the next morning, the arm was numb, and began to hurt shortly thereafter. The muscles in his forearm are very firm and tender to palpation . He has excruciating pain when they are subjected to passive extension. Pulses at the wrist are normal.

Diagnosis: Compartment syndrome •

Prolonged ischemia, followed by reperfusion, is the usual setting for the development

of compartment syndrome. •

Forearm and the lower leg are the two most common sites.

•

Excruciating pain with passive extension is a classical finding.

•

Presence of normal pulses does not rule out compartment syndrome.

Management: •

Emergency fasciotomy

•

Permanent disability will ensue, if not promptly decompressed.

Case #24: A 46-year-old man develops sudden excruciating pain, when attempting to lift heavy object,“like an electrical shock,” in his lower back and down the posterior aspect of his right leg. He suffered from very mild back pain for several months, which he attributed to “muscle spasms.” At this time he is unable to ambulate, he keeps the right leg flexed, and says that the pain becomes unbearable when he sneezes, coughs, or strains. Straight leg raising elicits excruciating pain.

Diagnosis: Lumbar disk herniation •

The peak age incidence is 45-46.

•

Discogenic pain precedes the neurogenic pain.

•

The most common locations are L4-L5 or L5-S1.

•

If the pain does not get worse with sneezing, coughing and straining, it is not a herniated disc.

Management: •

MRI for diagnosis. Bed rest for several weeks, unless he develops progressive neurological deterioration, or has sphincteric deficits.

•

MRI is the best way to look at the cord and roots.

•

Bed rest takes care of most herniated discs. Surgery is rarely needed.

Management: •

The cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia) is a surgical emergency.

Case #25: A 54-year-old, obese lady has a laparoscopic cholecystectomy that has to be converted to an open procedure. The following morning she has a fever of 102.

Diagnosis: Atelectasis •

The most likely sources of fever in the surgical patient are:

•

If over 104-105: o

Shortly after anesthetic induction: Malignant hyperthermia

o

Shortly after instrumentation: Bacteremia

Diagnosis: Atelectasis •

“More standard fever” (101-102), by post-op: Day 1: atelectasis Day 3: urinary tract infection Day 5: thrombophlebitis Day 7: wound infection Day 10-15: deep abscess (subphrenic, pelvic)

Management: Rule out other causes of fever by checking the wound, IV sites, and her urine; Document extent of atelectasis with chest x-ray, improve ventilation with deep breathing and coughing,

postural drainage, incentive spirometry.

Case #26: On the seventh post-operative day after pinning of a broken hip, a 72-year-old lady develops sudden, sever chest pain and shortness of breath. The pain is accentuated by deep breathing. She is anxious, diaphoretic and tachycardic, and she has prominent, visibly distended veins in her neck and forehead.

Diagnosis: Pulmonary embolus •

•

Timing of post-op chest pain gives the first clue: o

MI occurs on day one or two

o

PE occurs after 5 to 7 days

Doubt the diagnosis of PE if CVP is low, or blood gases do not show hypocapnia

Management: •

Confirm the diagnosis with blood gases (that will show hypoxemia and hypocapnia), and ventilation-perfusion scan.

•

Although pulmonary angio is the “gold standard,” ventilation-perfusion scan is more commonly done.

•

If PE’s recur while properly anticoagulated, place a Greenfield vena cava filter.

Case #27: 12 days after surgery for multiple gunshot wounds, a 27-year-old man becomes progressively disoriented

and

unresponsive.

He’s

had

multiple

complications,

including

several

intraabdominal abscesses that have been percutaneously drained. He has bilateral pulmonary infiltrates, and a PO2 of 65 while breathing 40% oxygen. Meticulous attention has been paid to his fluid balance, and there is no evidence that he is in congestive heart failure.

Diagnosis: ARDS Management:

•

PEEP allowing enough hypercapnia to minimize pulmonary barotrauma. Continue the search for other intraabdominal collections that may need to be drained.

Postoperative Disorientation and Coma Relevant Points : a. Always check blood gases first. b.On post-op day 2 in an alcoholic, think DTs. c. Check serum sodium, both hyponatremia or hypernatremia can do it.

Postoperative Disorientation and Coma Relevant Points : d. In the diabetic, or those on TPN, think blood sugar. e. In a cirrhotic, ammonium is the culprit. f. No obvious explanation? Look at the medication chart, we may be doing it.

Case #28: Several hours after completion of surgery for multiple gunshot wounds to the abdomen, a 70 Kg., 52-year-old man is reported to have hourly urinary outputs of 17cc, 13cc, and 21cc, in three consecutive hours. His blood pressure has hovered around 95 to 125 systolic during that time.

Diagnosis: •

A urinary output of zero represents a mechanical problem, not a biological one.

•

Normal hourly urinary output approx. 1cc (0.5 to 2) per Kg. of body weight, per hour.

Diagnosis: •

Oliguria occurs during shock.

•

In the presence of adequate perfusing pressure, oliguria is either from dehydration or from renal failure.

Diagnosis/Management: •

Look at his urinary sodium. It will be low (under 10 or 20 mEq/L) in the dehydrated patient (give him more fluid), while it will exceed 40 in the case of renal failure (restrict fluid).

Surgery Highlights for USMLE Step 2 Carlos Pestana, MD GI/Abdomen Cases

USMLE Step 2 — Lesson 3 Case #29: A 62-year-old African-American man reports progressive dysphagia that started three months ago with difficulty swallowing meat, and progressed to inability to swallow other solid foods, then soft foods and now liquids. He has lost over 25 lbs. during that time. He has a history of heavy smoking and drinking.

Diagnosis: Cancer of the esophagus •

Probably squamous cell

•

Had the history been one of long standing reflux, adenocarcinoma would have been a better bet.

Management: •

Barium swallow first, then endoscopy and biopsies, eventually CT scan to determine operability. Treatment will probably be palliative only.

•

Although endoscopy and biopsy provides the diagnosis, the fear of perforation prevents their use without a previous “road map” (provided by the barium swallow).

Management:

•

Other esophageal tests, and when to do them: o

Questionable symptoms of reflux: pH monitoring

o

Long standing clear picture of reflux: endoscopy and biopsies

o

Dysphagia that is worse for liquids: manometry studies

o

Hematemesis after prolonged vomiting: endoscopy

Case #30: A 32-year-old man presents with a history of several days of protracted vomiting, progressive abdominal distention, and colicky abdominal pain. He has not passed gas for the past 2 days. On physical exam he’s found to have a distended, tympanitic abdomen with high pitched bowel sounds that correspond to the colicky pain. X-rays show distended loops of small bowel, with air-fluid levels, and no gas in the colon. 5 years ago he had an exploratory laparotomy for a gunshot wound.

Diagnosis: Mechanical intestinal obstruction •

Mechanical intestinal obstruction in someone with a previous laparotomy is due to adhesions.

•

In the absence of prior abdominal surgery, look for a hernia to be causing the obstruction.

Diagnosis: Mechanical intestinal obstruction •

When obstruction happens in the postoperative period the differential diagnosis is with paralytic ileus. A barium tag may help differentiate them.

Management: •

Start conservative treatment expecting spontaneous resolution.

•

NPO, NG suction, IV fluid, and watchful waiting. Surgery if no improvement within 24 hours, or if he develops fever, leukocytosis or a tender abdomen.

•

Wait no more than 24 hours in complete obstruction (no gas in the colon, passing no

gas at all). Wait several days in partial obstruction. Watch for signs of strangulation.

Management: •

Surgery is indicated for unresolving obstruction or strangulated obstruction, but it can only “save the bowel,” it can not get rid of the adhesions (they’ll form again).

•

Always operate in obstruction due to hernias, because we can fix the hernia. Will do it emergently if strangulation is suspected, electively if not.

Case #31: An 18-year-old college student develops anorexia, followed by vague periumilical pain, that a few hours later localizes to the right lower quadrant and becomes sharp and consistent. On physical exam he has tenderness to deep palpation, muscle guarding and rebound tenderness, all of them localized to the right lower quadrant of the abdomen. His temperature is 100.5 and his WBC is 13,000 with a shift to the left.

Diagnosis: Acute appendicitis •

What makes it typical? The sequence: 1. Anorexia 2. Vague periumbilical pain 3. Sharp RLQ pain; plus the physical signs located rather than all over the belly

Management: •

Emergency appendectomy

•

For typical acute appendicitis, the management is still emergency appendectomy (rather than a lot of diagnostic studies).

•

In doubtful cases, the standard approach is Sonogram or CT scan. Sonogram is

cheaper but it is operator-dependent.

Case #32: A 62-year-old man seeks medical attention at the insistence of his family, who have noticed that he looks extremely pale. He admits to being tired and occasionally having fainting spells. He is found to have a hemoglobin of 5, and 4+ occult blood in the stools.

Diagnosis: Cancer of the right side of the colon •

98% of colorectal cancers are adenocarcinomas.

•

Large lumen and liquid content make obstructive symptoms very unlikely in the cecum. Likewise, blood loss is not obvious. Thus, main presentation is anemia.

•

In the left colon, change in bowel habits and blood coating the stools are the predominant presentation.

Management: •

Colonoscopy and biopsies, eventually blood transfusions and right hemicolectomy.

Case #33: A 34-year-old man has been passing large bloody bowel movements for the past 12 hours. While in the office waiting to be seen, he has another very large evacuation of dark red blood. On examination he looks pale and diaphoretic, has a blood pressure of 98 over 69, and a pulse rate of 104.

Diagnosis: Probably upper GI bleeding •

Three out of every four GI bleeders are bleeding from the upper GI

•

Lower GI bleeding happens mostly to old people (polyps, cancer, diverticulosis or angiodysplasia)

Diagnosis: Probably upper GI bleeding •

If patient is vomiting blood, the source is upper GI. If not vomiting (but presumed to be actively bleeding at the time), the same information can be obtained by recovering blood by NG tube.

Management: •

Start volume replacement. Pass nasogastric tube and aspirate. If blood is found in the stomach, do upper GI endoscopy.

•

The best diagnostic modality for upper GI bleeding is endoscopy (it allows treatment also).

Management: •

If bleeding is not from the upper GI, and it exceeds 2 cc per minute (one unit of blood every 4 hours), best diagnostic modality is emergency angiogram. Before you do it, look for bleeding hemorrhoids!

Management: •

Colonoscopy at the time of profuse lower GI bleeding is useless (anoscopy is OK).

•

Best diagnostic modality for slow lower GI bleeding (less than 0.5 cc per minute) is either tagged red cell study, or waiting for bleeding to cease and do colonoscopy then.

Case #34: A 63-year-old woman began to feel discomfort in the left lower quadrant of her abdomen about 12 hrs. ago. The pain gradually built up in intensity and is now constant and moderately severe. She has a vaguely palpable mass in her left lower quadrant, is tender to deep palpation, w/mild muscle guarding and no rebound. She has fever and leukocytosis and previously had 3 similar episodes requiring hospitalization.

Diagnosis: Acute diverticulitis •

Acute abdominal pain can result from inflammatory processes, obstructive phenomena, or perforation.

•

Inflammatory processes have gradual build up, constant pain, signs of peritoneal irritation in the area, and systemic signs (fever and leukocutosis).

•

The “anatomical approach” is used to make the list of suspects.

Management: •

CT scan will confirm the diagnosis. NPO, antibiotics and IV fluids should “cool it down.” With three prior episodes, elective sigmoid resection should be considered.

Case #35: A 47-year-old man develops extremely severe, colicky right flank pain of sudden onset, that radiates to his inner thigh and scrotum. He also has mild nausea and some dysuria. When seen in the ER, he is thrashing around on the stretcher, looking for a position of comfort. He has microscopic hematuria.

Diagnosis: Ureteral colic •

Abdominal pain from obstructive processes has sudden onset, is colicky , has specific location and radiation patterns, and makes the patient move around seeking relief.

•

Location and radiation patterns: o

Ureter: Flank, to inner thigh and scrotum or labia

o

Biliary tract: RUQ, to back (as a belt) and right shoulder

o

Pancreas: Epigastic, straight through to the back

Management: •

Start urological work up with sonogram, or plain film of the abdomen to be followed by IVP.

Case #36: A 57-year-old man is brought to the ER in the middle of the night. About one hr. before, he had sudden onset of extremely severe abdominal pain, described as constant and involving his entire abdomen. He lies motionless on the stretcher, guarding his abdomen with his hands, perspiring, and obviously in great pain. His abdomen is rigid, very tender to palpation, with muscle guarding and rebound in all quadrants.

Diagnosis: Acute abdomen from perforated viscus •

Abdominal pain from perforations has sudden onset, is constant and generalized, and makes the patient lie still.

Management: •

Emergency exploratory laparatomy

•

The clear-cut diagnosis of an acute abdomen is sufficient indication for exploratory laparatomy. Work up only needs to exclude myocardial ischemia (EKG), lower lobe pneumonia (chest x-ray), and pancreatitis (amylase).

Additional Diagnostic Hints in Abdominal Pain: •

Fat, fecund female in her forties: biliary tract

•

Alcoholic: pancreatitis

•

Patient with chronic ascites: primary peritonitis

•

Very old: sigmoid volvulus or mesenteric ischemia

•

Atrial fibrillation: mesenteric embolus

Case #37: A 62-year-old man presents with progressive jaundice that began six weeks ago. For the past two weeks he has had severe pruritus, and he also describes choluria and acholic stools. He has total bilirubin of 24, with 14 direct (conjugated) and 10 indirect (unconjugated). His SGOT (transaminase) is only mildly elevated, while his alkaline phosphatase is ten times the upper

limit of normal.

Diagnosis: Obstructive jaundice •

Hemolytic jaundice has elevation of unconjugated bilirubin only, without bile in the urine.

•

Hepatocellular jaundice shows high levels of SGOT.

•

Obstructive jaundice shows high levels of Alkaline phosphatase.

Management: •

Start with sonogram. It should confirm dilated ducts. If it shows gallstones as well, continue with ERCP. If is shows thin walled, dilated gallbladder without stones, continue with CT.

•

A dilated gallbladder in a jaundiced patient suggests malignancy (Courvoisier-Terrier sign).

Case #38: A white, fat female, age 40 and mother of 5 children, has severe right upper quadrant pain that began six weeks ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. The past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant, a temperature of 101 and WBC of 12,000. Liver function tests show a bilirubin of 2.5, and normal alkaline phosphatase.

Diagnosis: Acute cholecystitis •

The spectrum of gallstone-related disease includes:

a. Asymptomatic gallstones: No treatment needed

b.

Biliary

colic:

Colicky

pain,

no

inflammatory

process.

Elective

cholecystectomy indicated

Diagnosis: •

The spectrum of gallstone-related disease includes:

c. Acute cholecystitis: Constant pain, inflammatory process, mild fever, normal or near normal liver function tests. Medical management first, cholecystectomy soon thereafter.

d. Acute ascending cholangitis: Constant pain, inflammatory process, sick patient, spiking fever with chills, king-size elevation of the alkaline phosphatase. Emergency ERCP needed.

Management: •

Start with sonogram. It should show gallstones, thick walled gallbladder and pericholecystic fluid. NPO and antibiotics should “cool down” the process. Cholecystectomy will be eventually needed.

USMLE Step 2 — Lesson 4 Surgery Highlights for USMLE Step 2 Carlos Pestana, MD Breast Disease Case #39: A 42-year-old lady has a 2cm. firm mass in her right breast, which has been present for three months, and is steadily growing.

Diagnosis: •

Breast cancer has to be ruled out.

•

The probability of a breast mass being cancer is directly related to the patient’s age.

Typical patterns of breast disease: •

18 year-old, rubbery mass: Fibroadenoma

•

20-40, multiple lumps, tender, related to cycle: Fibrocystic disease

•

Bloody nipple discharge: Intraductal papilloma

•

Breast abscess: Found only during lactation

Typical patterns of breast disease: •

Older lady, hard mass, skin dimpling: Cancer

•

Older lady, eczematoid lesion of areola: Cancer

Management: •

Start with mammogram to identify other lesions if present. Then, core biopsies.

•

Mammogram should precede biopsies in women over 35, but it is done to identify other potential lesions, not as a substitute for the biopsy (only the pathologist can make the diagnosis).

Management: •

Do not order mammograms below age 20 (breast too dense – use sonogram if needed) or in lactating women (will only see milk).

•

Depending on the probability of cancer, a spectrum of progressively more aggressive Tissue sampling is done: FNA, core biopsy, mammotome, ABBI, incisional biopsy or excisional biopsy.

Case #40: A 32-year-old lady has a solitary, 2cm., firm mass in the right lobe of her thyroid gland. The mass has been present for at least three years, and is growing very slowly. Her thyroid function tests are normal.

Diagnosis: •

Probably benign, but have to rule out cancer.

•

Thyroid cancers can occur in young people, they grow very slowly and they do not affect the thyroid function.

•

Highest probability of cancer is in young male with single, solid, cold nodule and history of radiation to the neck.

Management: •

DO FNA. Leave alone if reported benign. Operate if reported indeterminate of malignant. Even with good case selection, most resected thyroid nodules are benign. Highest yield of malignancy when selected by FNA.

Case #41: A 42-year-old lady has had hypertension for three years, and is not responding well to therapy with blockers. She has a potassium of 2.5. She has not been on diuretics.

Diagnosis: Hyperaldosteronism •

Either adenoma or hyperplasia

•

Key finding to initiate work-up is low serum potassium not accounted for by diuretics.

Other surgically correctable causes of hypertension: •

thin, hyperactive lady with episodes of pounding headache, palpitations, pallor, and

perspiration: pheochromocytoma. •

Young person with high pressure in the arms, low pressure in the legs: coarctation of the aorta.

•

Either young woman or old arteriosclerotic man, with faint upper abdominal or flank bruit: renovascular hypertension.

Management: •

Confirm diagnosis by finding high levels of aldosterone and low levels of renin. Verify adenoma versus hyperplasia with lack of response to postural changes. Locate the adenoma with MRI or CT.

Case # 42: An 8-hr-old baby in the newborn nursery is noted to have “excessive salivation.” A small, soft nasogastric tube is placed, and the baby is taken to x-ray to have a “babygram.” The film shows the tube to be coiled back upon itself in the upper chest. There is normal gas pattern in the abdomen.

Diagnosis: Esophageal atresia with tracheoesophageal fistula •

The most common type of TE fistula has a blind end of esophagus at the top, and a fistula between the distal esophagus and the trachea (that is how air gets into the GI tract).

•

First rule out the other components of the VACTERL syndrome: look for an imperforate anus by physical exam, look for vertebral or radial anomalies in the x-ray, do sonogram for renal anomalies, do echocardiogram to rule out congenital cardiac defects.

•

Have a primary repair of the fistula, or if other problems delay it, a gastrostomy.

Case #43: Half an hour after the first feed, a newborn baby vomits greenish fluid. X-ray shows a “doublebubble,” i.e., a large air fluid level in the stomach, and a smaller air fluid level to the right of it, originating from the first portion of the duodenum.

Diagnosis: Either duodenal atresia, annular pancreas or malrotation. •

Green vomiting in the newborn period has ominous significance.

Management: •

Although surgical correction will eventually be needed for either of the above, malrotation represents a more dire emergency. Look for it with contrast enema, or upper GI study.

•

The main risk in malrotation is torsion of the mesenteric vessels with ischemic necrosis of the entire small bowel.

Case #44: A 3-wk-old baby boy has been vomiting repeatedly for 3 days. The vomiting is projectile, has no bile, and follows each feeding. After vomiting, the baby seems hungry and eager to eat. He looks somewhat dehydrated, and has a scaphoid upper abdomen with visible gastric persitaltic waves. A small, olive-sized mass is palpable in the right upper quadrant.

Diagnosis: Hypertrophic pyloric stenosis •

The main problem in congenital diaphragmatic hernia is the hypoplastic lung.

•

Feeding problems in the premature, think necrotizing enterocolitis. Dropping platelet count signifies sepsis.

Diagnosis: •

Abdominal problems plus cystic fibrosis equals meconium ileus (do gastrographic enema).

•

Progressive jaundice at age 8 weeks, think biliary atresia. Rule out hepatitis, do HIDA scan after one week on Phenobarbital.

Management: •

First correct the dehydration and the hypochloremic, hypokalemic metabolic alkalosis likely to be present. Then do Ramsted Pyloromyotomy.

Case #45: A well-fed, healthy-looking 9-month-old boy has experienced brief episodes of colicky abdominal pain that make him double up, squat, and cry vigorously. They seldom last more than one min., and once gone, the boy is happy. Examination done during an episode showed an “empty” right lower quadrant,and a vague mass above it, along the right gutter. The mother has reported the baby’s stool has been blood-tinged during these episodes.

Diagnosis: Intussusception •

For some reason everyone who describes a child with intussusception calls the bloodtinged stools “currant jelly stools.” If you see that description in the exam question, they have given you the diagnosis on a silver platter.

Management: •

Barium enema will show the pathology and reduce the intussusception. Surgery may be needed to prevent recurrences.

Case #46: A 15-month-old child is brought in with second degree burns on both buttocks. The stepfather relates that the child is beginning to walk all around the house, and that he got into the kitchen where he tipped a pot of boiling water.

Diagnosis: Child abuse •

All scaldings in babies should make you think of child abuse, but the pattern in both buttocks is classic: the baby was held by arms and legs, and dipped into boiling water.

•

Other classical presentations for child abuse:

Child abuse classic presentations: •

Subdural hematoma and retinal hemorrhages (shaken baby)

•

Multiple fractures at different stages of healing

Management: •

Silvadene cream for the burned areas, reporting to the proper authorities to protect the child.

USMLE Step 2 — Lesson 5 Case #47: A 52-year-old chronic smoker gets a pre-operative CXR in preparation for bilateral, laparoscopic repair of inguinal hernias. A 2cm. “coin lesion” is found in the upper lobe of the left lung.

Diagnosis: Probably cancer of the lung •

After age 50, coin lesions have an 80% chance of being malignant. History of smoking makes it more likely.

Management: •

Start by locating an older CXR if available. If the lesion was present and has remained unchanged for a year or two, not cancer.

Management if this is a new lesion: •

Start with sputum cytology and CT scan (including upper abdomen to see liver).

•

2/3 of patients already inoperable when first seen. Thus the value of trying to establish the diagnosis and extent in a non-invasive way (sputum cytology and CT scan).

Management: •

Next steps to establish diagnosis (if needed): Biopsy via bronchoscopy for central lesions, percutaneous for peripheral.

•

Further diagnostic steps depends on potential for cure and ability to tolerate pulmonary resection. Cure is not possible if there are mets at carinal nodes. Resection is not possible if the residual FEV1 would be less than 800.

Management: •

Resectability is not an issue for small cell CA, which is treated with chemotherapy and radiation.

Case #48: A 72-year-old man is found on physical exam to have a 6cm. pulsatile mass in the abdomen, located between the xiphoid and the umbilicus. The mass is not tender, and the patient is otherwise completely asymptomatic.

Diagnosis: Abdominal aortic aneurysm Management: •

Size is the key-determining factor of the probability of rupture, and thus the need for elective repair.

•

Verify precise measurements with sonogram or CT scan. If indeed the aneurysm is 6 cm. in diameter, do elective surgical repair.

Management: •

Under 4 cm., watchful waiting is appropriate.

•

Over 6 cm., repair should be done.

•

Aneurysm tender to palpation is going to rupture within 1 to 2 days. Repair immediately.

Management: •

Excruciating back pain in a patient with an abdominal aortic aneurysm means the aneurysm is already rupturing (leaking retroperitoneally, and about to blow up into the peritoneal cavity). Surgery has to be done as a super-emergency.

Case #49: A 63-year-old car salesman is having difficulty doing his job. He works at a large, suburban used-car lot which is about 3 blocks long. When he walks about 1/2 a block, he gets severe cramping pain in his right calf, and must stop and rest for the pain to go away. As soon as he has walked another 1/2 block, pain recurs. He is the sole supporter of his family and he is about to be fired. He does not smoke.

Diagnosis: Intermittent claudication, from vascular disease. Management: •

Surgery for intermittent claudiaction is palliative. If symptoms do not interfere with lifestyle, surgery is not indicated.

•

The natural history of intermittent claudiacation is unpredictable; thus there is no role for “prophylactic surgery.” Tobacco use however, leads to predictable progression. Cessation of smoking is imperative.

•

Start with Doppler studies looking for a pressure gradient. If there is one, do arteriograms, and provide the appropriate vascular reconstruction.

Management: •

Revasculariztion options include: angioplasty and stenting (for short segments), saphenous vein bypass (for obstructions below the common femoral) and prosthetic grafts (when the aorta has to be the proximal vessel).

•

If there is no pressure gradient by Doppler studies, the disease is in the small vessels, and not amenable to surgery.

Case #50: A blond, blue-eyed, 71-year-old West Texan farmer of Scandinavian ancestry, has a nonhealing, indolent, punched-out, 2 cm. ulcer in the skin over his left temple, which has been slowly growing over the past 3 years. He has no palpable lymph nodes in the head and neck, but his skin has a “weather- beaten” appearance, with multiple areas of actinic keratosis.

Diagnosis: Skin cancer, probably basal cell carcinoma. •

Skin cancer (basal cell, squamous cell, and melanoma) occur mostly in light-skinned individuals with a lot of sun exposure.

•

Most basal cell carcinomas are above a line drawn across the mouth, while most squamous cell carcinomas are below that line.

Diagnosis: Skin cancer •

Melanomas occur in pigmented lesions that either have the ABCD mnemonic (ASYMETRIC, irregular BORDERS, various different COLORS, and a DIAMETER over 0.5 cm.); or else pigmented lesions that have recently changed (in any way).

Management: •

Full thickness biopsy at the edge of the lesion, including the bed of the ulcer and the normal skin next to it. Resection with appropriate margins.

Case #51: A 12-year-old boy has a round, 1 cm. cystic mass in the midline of his neck, at about the level of the hyoid bone. The mass retracts when the tongue is pulled forward. Although the mass has been present for at least 8 years, it had not bothered the patient until it got infected and drained some pus a few weeks ago.

Diagnosis: Thyroglossal duct cyst •

Congenital masses in the neck are seen in young people, they typically have been noticed for several years, but medical help is not sought until they become symptomatic.

Common congenital masses in the neck: 1. Midline, at the level of the hyoid: Thyroglossal duct cyst 2. Up and down the anterior edge of the sternomastoid: Branchial cleft cysts 3. Mushy, at the base of the neck, supraclavicular: Cystic hygroma

Management: •

Elective surgical resection, removing the mass, the middle segment of the hyoid bone and a core of muscle from the tongue all the way back to the foramen cecum.

Case #52: 3 months ago, an 18-year-old woman noticed the presence of a 2 cm., firm, non-tender node located in the left jugular chain, at the level of the hyoid bone. She thinks it is larger now than when it first came to her attention. For the past 3 weeks she has had low grade fever and night sweats. Physical exam confirms the presence of the node, and also shows 2 other smaller nodes on that side of the neck, as well as enlarged nodes in both axillas.

Diagnosis: Probably lymphoma

•

The timetable of inflammatory neck nodes is measure in weeks, while that of neoplastic nodes is typically of months.

Best diagnostic bets neoplastic neck nodes •

Young person, multiple nodes: Lymphoma

•

Supraclavicular node: Primary below the clavicles (not head and neck)

•

Old man who smokes and drinks and has rotten teeth: Metastatic squamous cell carcinoma from the mucosae of the head and neck.

Management: •

Start with FNA of the most accessible, largest node. Excisional biopsy will probably be needed to establish specific tumor type.

•

When dealing with a node that has just been discovered, a delay of a few weeks (two or three) is appropriate before doing invasive, expensive studies. If the node was inflammatory, it may go away during that time.

Case #53: A 72-year-old man seeks help for a 4 cm., fixed, hard mass in the left jugular chain, at the level of the upper edge of the thyroid cartilage. Patient says that he found it a week ago, but his wife claims that it has been present for at least 6 months. The patient has a long-standing history of alcohol and tobacco abuse, and he has terrible oral hygiene.

Diagnosis: Metastatic squamous cell carcinoma, from a primary in the head and neck mucosa. Other potential presentations: •

Persistent unilateral ear ache with serous otitis media

•

Persistent hoarseness

•

Unhealing ulcer in the mouth

Management: •

Do not biopsy the mass! (FNA is OK, but do not take a piece of it.) Best way to establish the diagnosis is with panedoscopy (“triple endoscopy”) looking for and doing biopsy of the primary (or primaries). Then CT scan for determine operability. Platinumbased chemotherapy and radiation therapy have central role in therapy.

Management: •

Another area where open biopsy is a no-no: Tumors of the parotid gland (anything in front of the ear, or behind the angle of the mandible)

Surgery Highlights for USMLE Step 2 Carlos Pestana, MD General Surgery Cases

USMLE Step 2 — Lesson 6 Case #54: A 64-year-old right-handed man has transitory episodes of aphasia and paralysis of his right upper extremity. The episodes occur suddenly without prior warning, are not associated with headache, and last only 10 minutes or so, leaving no neurological sequela. His neurological exam is normal, but he has carotid bruits on both sides of his neck.

Diagnosis: Transient ischemic attack (TIA) •

Neurological problems of vascular nature have sudden onset; without headache if

they are occlusive, with very severe headache if they are hemorrhagic.

Management: •

Duplex scanning of his carotid vessels, looking for stenosis of at least 70%, or ulcerated carotid plaque, on the left. Carotid endarterectomy for either of the above.

•

TIA’s are a predictor of strokes. Elective surgery is indicated if stenosis of at least 70%, or ulcerated plaques at the carotid bifurcation are found.

Case #55: A 32-year-old lady comes to the ER because of an extremely severe headache of sudden onset. She describes it as a “thunderclap,”, different from any other headache she’s had. Neurological exam is completely normal. She is sent home with analgesics. Ten days later she returns with a similar history, but this time she has nuchal rigidity.

Diagnosis: Subarachnoid bleeding from an intracranial aneurysm •

The sequence of an undiagnosed “sentinel bleed,” and a second bleed a few days later is often seen.

•

Prognosis depends on severity or neurological deficit at the time of presentation. Identifying the “sentinel bleed” is crucial, because the next one may be devastating.

Diagnosis: •

Other conditions leading the intracranial bleeding include A-V malformations and uncontrolled hypertension.

Management: •

CT scan to demonstrate the bleeding

•

Angiogram to delineate the aneurysm

•

Eventual clipping of the aneurysm

Case #56: A 42-year-old right-handed man has a history of progressive speech difficulties and right hemiparesis for five months. For the past two months he has had progressively severe headaches, worse in the mornings. At the time of admission he is confused, has projectile vomiting, blurred vision, papilledema and diplopia.

Diagnosis: Brain tumor, on the left side, affecting the motor strip and the speech center, with signs of increased intracranial pressure. •

The timetable of brain tumors is typically measured in months.

•

Progressive headaches, worse in the mornings, are typical of brain tumors.

Diagnosis: •

Location nay not be obvious, if the tumor is pressing on a “silent area” of the brain, but it may be clear if a particular function if affected.

•

Some typical locations: o

Inappropriate behavior, anosmia: base of frontal lobe

o

Bitemporal hemianopsia: optic chiasma, sella

o

Loss of upper gaze: pineal area

o

Ataxia, unstable gait: posterior fossa

Management: •

MRI for diagnosis.

•

Mannitol, hyperventialtion and high dose corticosteroids (dexamethasone) to lower his intracranial pressure, while preparing for surgery.

Case #57: A 13-year-old boy presents with excruciating pain of sudden onset in his right testicle. No fever, pyuria or history of recent mumps. The testis is swollen, very tender, located high in the scrotum, and with its long axis in a horizontal position. Cord above the testis is not tender.

Diagnosis: Testicular torsion •

The differential diagnosis is with epididimitis.

•

Epididimitis happens in sexually active men, there is fever and pyuria, the testis is in the normal position and the cord as well as the testicle are exquisitely tender. Sonogram should be done, just to make sure it is not testicular torsion. Treatment is with antibiotics.

Management: •

A urological emergency. Immediate surgery is indicated, with no time wasted on any diagnostic studies. Once the testis is untwisted and fixed, orchiopexy may also be done on the other side.

Case #58: A 74-year-old man has a 3mm. ureteral stone lodged just above the ureterovesical junction. He is receiving IV fluids and analgesics, with the expectation that the stone will pass. He suddenly develops chills, his temperature shoots up to 104, and he complains of severe flank pain.

Diagnosis: Another urological emergency: the dreaded combination of obstruction plus infection •

Urinary tract obstruction alone is bad

•

Urinary tract infection alone is bad

•

Those two together are horrible (one of the few true urological emergencies)

Diagnosis: Another urological emergency: the dreaded combination of obstruction plus infection. •

Urinary tract infections that are unexpected (i.e. on people who should not get them), have to be worked up for possible unsuspected obstruction. Examples: o

Urinary tract infection in children

o

Urinary tract infections in men

Management: •

Massive doses of IV antibiotics and immediate decompression of the urinary tract above the obstruction. In the presence of infection, manipulating and attempting to extract the stone would be hazardous.

Case #59: A 59-year-old man reports an episode of gross, painless hematuria, without any history of trauma. He has normal renal function.

Diagnosis: Cancer of the kidney, ureter or bladder has to be ruled out. •

Most cases of hematuria are from benign disease, but cancer has to be ruled out on all of them.

Management: •

Start with IVP, follow with cystoscopy

•

IVP is the standard test to look for renal and ureteral tumors. It can not be done if renal function is poor (creatinine above 2). CT scan is an alternative. Neither is very good for bladder cancer, thus cystoscopy is also required.

Case #60:

During a routine physical, a 64-year-old black man is found on digital rectal exam to have a rock-hard, discrete, 1.5 cm. nodule in his prostate.

Diagnosis: Prostatic cancer •

Except for very advanced cases, prostatic cancer is asymptomatic and has to be actively sought.

•

The two complementary screening exams are the digital rectal exam and the prostatic specific antigen (PSA).

•

The classical palpable tumor is a rock-hard discrete nodule.

Diagnosis: Prostatic cancer •

A high PSA without palpable nodule should lead to transrectal sonogram.

•

After age 75, screening is no longer indicated.

Management: •

Transrectal needle biopsy.

•

Resection after determining the extent of the disease.

•

Advanced metastatic disease responds for a few years to androgen ablation (surgical or medical).