Deck 2: Assessment and Management of Various Medical Conditions

Question 1

A 45-year-old woman is evaluated because of a palpable 2-cm right axillary lymph node. The lymph node is completely resected, and histologic study shows adenocarcinoma; hormone receptors are negative. Bilateral mammography is negative, as is MRI of the right breast. CT scans of the chest and abdomen are negative for tumor, and no further lymphadenopathy is detected. Results of bone scan and MRI of the head are also unremarkable. The patient had been previously healthy and has never smoked. Which of the following statements about this patients condition is correct?

A)Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated.
B)Lung cancer is the most likely diagnosis, and optimal therapy for lung cancer paradigm should be initiated.
C)All known disease has been resected, and the patient requires careful monitoring for possible future recurrence.
D)Radiation therapy to the right axilla is required with fields encompassing the right breast.

Answer 1

Breast cancer is the most likely diagnosis, and optimal therapy for breast cancer paradigm should be initiated.

Question 2

A 59-year-old man was referred because of a change in bowel habit. He had noticed no alteration in stool calibre, gastrointestinal bleeding or unintended weight loss. There was no family history of colonic polyps or gastrointestinal malignancy. Physical examination was normal. A rectal examination revealed no masses. A sigmoidoscopy revealed a 4-mm polyp in the mid-rectum, which was removed with forceps, and histology revealed a tubular adenoma. What is the most appropriate next step in management?

A)barium enema now
B)colonoscopy in 3 years
C)colonoscopy in 5 years
D)colonoscopy now
E)sigmoidoscopy in 1 year

Answer 2

colonoscopy now

Question 3

A 42-year-old woman is evaluated because she has noticed a thickening in her left breast over the past few weeks. She noticed it a few months ago, but because it seems to come and go, she put off seeking medical attention. She is premenopausal. She had menarche at age 13 years. When she was 35 years, she had one child (whom she breast-fed) after a normal first full-term pregnancy. She took oral contraceptives for 10 years before her pregnancy. She has no known radiation exposure and no family history of breast cancer. On physical examination, there appears to be some asymmetry in breast tissue density in the upper outer quadrant of the left breast compared with the right one, but no discrete mass. There are no palpable lymph nodes. Results of a mammogram are negative. What would be the most appropriate next step in this patients management?

A)Breast ultrasound; consultation with a surgeon experienced in breast diagnosis
B)Reassurance that because her family history is negative and the mammogram is negative, no additional studies or treatment is required
C)MRI of the breast
D)Measurement of circulating tumor markers, including CA15-3 and carcinoembryonic antigen A 68-year-old woman is

Answer 3

Breast ultrasound; consultation with a surgeon experienced in breast diagnosis

Question 4

A 26-year-old man with testicular cancer who is receiving chemotherapy is evaluated in the emergency department. His temperature is 38.9 °C (102 °F), and he complains of feeling flushed and tired. He has an indwelling central venous port, but there are no localizing symptoms to suggest a source of infection. Chest radiograph shows no abnormalities. The patients hemoglobin is 8.9 gIdL; the absolute neutrophil count is 165/?L and the platelet count is 56,000/?L. Results of other laboratory studies and urinalysis are within normal limits. Blood samples are obtained from a peripheral vein and through the port and sent for culture; a urine culture is also ordered. The patient is hospitalized and intravenous ceftazidime is initiated. Three days later, the patient"s temperature is 37.8 °C (100 °F) and absolute neutrophil count is 4504/?L; his clinical condition is otherwise stable. Results of blood and urine cultures are negative. A repeat chest radiograph is normal, and blood and urine speci

A)Continue the current antibiotic regimen
B)Add vancomycin
C)Switch to oral ciprofloxacin and amoxicillin-clavulanic acid
D)Add granulocyte colony-stimulating factor
E)Remove the central venous port

Question 5

Four years ago, a 67-year-old man had a serum prostate-specific antigen (PSA) level of 16 ng/mL. Biopsy specimen showed adenocarcinoma of the prostate gland. His Gleason score was 7. He was treated with external-beam radiation therapy. One month ago, the patient noted fatigue and rib pain. His PSA was found to be 87 ng/mL, and bone scan revealed diffuse metastatic disease. What is the best treatment for this patient?

A)Chemotherapy with docetaxel
B)Chemotherapy with mitoxantrone and prednisone
C)Androgen ablation (medical or surgical)
D)Radiation therapy with strontium-89

Question 6

A 68-year-old woman is evaluated because of rectal bleeding that began recently and a sense of fullness in the rectum. Flexible sigmoidoscopy shows a mass 11 cm from the anus, and biopsy reveals adenocarcinoma. The patient is referred to a colorectal surgeon, and a low anterior resection is performed. The primary tumor, a 4-cm moderately differentiated adenocarcinoma, penetrates the bowel wall. No lymph nodes are involved. What is the most appropriate next step in this patient"s management?

A)No chemotherapy or radiation therapy; annual flexible sigmoidoscopy
B)Postoperative adjuvant chemotherapy and pelvic radiation therapy
C)Postoperative pelvic radiation therapy
D)Complete colonoscopy within the first year, repeated every 3 to 5 years

Question 7

A 58-year-old postmenopausal woman has been taking hormone replacement therapy with combined estrogen and progestin for the past 4 years because she was told it would decrease her risk for heart disease. Her father died at age 65 years of heart disease, and she is concerned that she is also at risk. Recently, her sister has been diagnosed with breast cancer. Her mother died of breast cancer. Three years ago, the patient had a breast biopsy that showed atypical hyperplasia. She has not had a hysterectomy. The patient is considering chemoprevention for breast cancer, but is nonetheless concerned about heart disease. Her calculated risk of breast cancer is 10.4% over the next 5 years. Which of the following options is reasonable to consider for this patient?

A)Continue hormone replacement therapy alone for primary prevention of heart disease
B)Continue hormone replacement therapy and add tamoxifen
C)Discontinue hormone replacement therapy and start tamoxifen
D)Change her hormone replacement therapy to estrogen alone and add tamoxifen

Question 8

A 68-year-old man with locally advanced non-small-cell lung cancer is evaluated because of the new onset of low back pain over the past 2 weeks. It is relieved with ibuprofen, and his only other symptom is mild fatigue. The patient completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiograph of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable. What is the most appropriate next step in the management of this patient?

A)Gallium scan
B)Re-evaluation if the symptoms get worse
C)CT scan of the chest and abdomen with bone windows of the spine
D)MRI of the spine
E)Intravenous dexamethasone and MRI of the spine

Question 9

A 72-year-old man is evaluated because of constipation, abdominal pain, and distention that have worsened over the past week. Two years ago, he was diagnosed with stage III rectal cancer (primary tumor and renal involvement) and underwent low anterior resection. Chemotherapy with 5-fluorouracil and leucovorin followed, and pelvic radiation was given with concurrent infusion of 5-fluorouracil. He has been having regular bowel movements, and results of his most recent colonoscopy (1 year ago) were unremarkable. On physical examination, his pulse rate is 100/min. He has orthostatic hypotension, a slightly distended abdomen with hyperactive bowel sounds, and some guarding to deep palpation in the left lower quadrant. Plain radiograph of the abdomen shows distended loops of small bowel, with no stool in the distal colon or rectum. The patient is hospitalized for bowel rest and intravenous hydration. What is the next step in this patient"s management?

A)Complete colonoscopy
B)Upper gastrointestinal series with small-bowel follow-through
C)Positron emission tomography scan of the abdomen
D)Measurement of serum carcinoembryonic antigen
E)CT scan of the abdomen with oral and intravenous contrast

Question 10

A 60-year-old postmenopausal woman at elevated risk for breast cancer is taking tamoxifen to reduce her risk. She has not had a hysterectomy. Which of the following surveillance strategies for the detection of endometrial cancer is most important to incorporate into this patient"s care?

A)Annual transvaginal ultrasound
B)Annual transabdominal pelvic ultrasound
C)Annual endometrial aspiration sampling
D)Biennial dilatation and curettage
E)Annual routine bimanual pelvic examination

Question 11

An 82-year-old woman who has never smoked is evaluated because of a persistent cough. Chest radiograph shows several lung nodules and infiltrates. There are no significant findings on physical examination. The patient reports no weight loss. Blood studies show no abnormalities. CT scans confirm pulmonary involvement only, and results of bone scan and CT scan of the head are normal. The patient most likely has which of the following histologic types of lung cancer?

A)Bronchoalveolar cell carcinoma
B)Small-cell lung cancer
C)Large-cell carcinoma
D)Squamous cell carcinoma
E)Carcinoid tumor

Question 12

A 45-year-old woman has recently undergone lumpectomy and radiation therapy for a stage II breast cancer. She received chemotherapy for 6 months. Her periods ceased while she was receiving chemotherapy, and she remains amenorrheic. Her tumor was rich in estrogen receptor, and she is taking tamoxifen. Her hair is growing back, her energy is returning, and she has no specific complaints, but she is worried about recurrence. In addition to routine follow-up, what is the most appropriate management of this patient?

A)Positron emission tomography now and annually
B)No further management
C)Routine tumor marker evaluation every 3 to 4 months (serum CAl 5-3, carcinoembryonic antigen)
D)Bone scan and annual CT of the chest, abdomen, and pelvis
E)Estrogen replacement therapy

Question 13

A 66-year-old black woman diagnosed with stage III colon cancer underwent definitive resection of the primary tumor 3 years ago. After surgery, she received adjuvant chemotherapy with 5-fluorouracil and leucovorin. Approximately 20 months later, she developed metastatic disease in the liver (five lesions in right and left lobe) and lungs (one lesion in the right and left lobe). She was treated with irinotecan, 5-fluorouracil, and leucovorin, and had a partial response to therapy. One month ago, disease progression was documented on restaging CT scans. The patient"s laboratory studies show relatively normal organ function. She has fatigue, decreased appetite, and has noticed a 2.3-kg (5-Ib) weight loss over the past 3 months. She has stopped participating in weekend bike trips with a cycling club, but remains involved in church and family activities and states that she wants to be as aggressive as possible in fighting the cancer. What is the most reasonable recommendation for this patie

A)Metastatectomy
B)Hepatic arterial infusion
C)Second-line chemotherapy regimen with leucovorin and oxaliplatin
D)High-dose chemotherapy with autologous peripheral stem cell transplantation

Question 14

A 65-year-old woman has a modified radical mastectomy for a 1.0-cm, well-differentiated breast cancer. The tumor is positive for estrogen and progesterone receptors and negative for HER2. Sentinel node mapping and excision show that none of the three lymph nodes removed is positive for metastasis. She is otherwise healthy. What is the best treatment for this patient at this time?

A)Chest wall radiation therapy and tamoxifen for 5 years
B)Chest wall radiation therapy and anastrozole for 5 years
C)Tamoxifen for 5 years
D)Tamoxifen and anastrozole for 5 years

Question 15

A 59-year-old woman with an 80-pack-year smoking history is evaluated because of weight loss and severe pain in the upper part of her left leg. She has lost 11.3 kg (25 Ib) from baseline weight of 59 kg (130 Ib). A large lytic lesion is noted on the left femur, with erosion into the cortex. Bone scan shows multiple lesions, and CT scan of the chest shows a large left hilar mass and med iastinal lymphadenopathy. Bronchoscopic biopsy specimen shows poorly differentiated adenocarcinoma. Radiation therapy to the left femur is initiated. Which of the following findings would preclude use of palliative chemotherapy for this patient?

A)A solitary liver metastasis with normal serum bilirubin level
B)Multiple liver metastases with a serum bilirubin level of 3.0 mg/dL
C)A cytologically positive pleural effusion
D)Hypercalcemia
E)Poor performance status

Question 16

A 57-year-old man has tried to stop smoking unsuccessfully for the past year. He has tried smoking cessation counseling and use of nicotine gum. Although he has no new symptoms, the „smokers cough" that he has had for years is a constant reminder that he is at risk of dying of lung cancer. He wants to know what measures he can take that have been shown to reduce that risk. In addition to a smoking cessation program, what is the best recommendation for this patient?

A)Daily dietary supplementation with the antioxidantl3-carotene
B)Daily isotretinoin, titrated to limit skin toxicity
C)Daily bupropion
D)An annual low-dose spiral CT scan of the chest
E)Sputum cytology every4 months

Question 17

A 71-year-old man with mild chronic obstructive pulmonary disease and mild hypertension is evaluated during an annual routine visit. Review of systems is notable for intermittent cough, increasing dyspnea on exertion, a 2.3-kg (5 Ib) weight loss, and fatigue. The patient takes aspirin, 81 mg/d, and hydrochlorothiazide, 50 mg/d orally. He smoked one pack of cigarettes per day for 49 years but quit smoking 2 years ago. On physical examination, distant breath sounds are audible in both lungs and there are scattered rhonchi. Chest radiograph shows a perihilar mass. Abnormal laboratory results include hemoglobin of 12.5 g/dL and a serum sodium of 127 meq/L. Endobronchial biopsy reveals small-cell lung cancer. Further staging studies suggest that the disease is limited-stage. What is the most appropriate treatment for this patient"s hyponatremia?

A)Fluid restriction to 1 L/d
B)Fluid restriction to 1 L/d and demeclocycline therapy
C)Discontinuation of hydrochiorothiazide
D)Combination chemotherapy for the small-cell lung cancer

Question 18

A 23-year-old man is evaluated because of a painless right-sided scrotal mass. Ciprofloxacin, 500 mg every 12 hours, is administered for 10 days, but he notes little improvement in the swelling. His serum ?-fetoprotein level is elevated at 100 ng/mL, and his 13-human chorionic gonadotropin level is 64 m/UImL. Testicular ultrasound examination reveals a hypoechoic mass. Which of the following would be the most appropriate next step in his treatment?

A)Retroperitoneal lymph node dissection
B)Combination chemotherapy with bleomycin, etoposide, and cisplatin
C)Radiation to the pelvis
D)Inguinal orchiectomy

Question 19

A 40-year-old woman has a routine gynecologic examination. At the age of 32 years, she gave birth to twins after receiving fertility drugs. She has just seen a television program on ovarian cancer, and is concerned because previous use of fertility drugs and a family history of ovarian cancer were mentioned as possible risk factors. Her mother developed endometrial cancer at 56 years, and a paternal uncle was diagnosed with a type of lymphoma at 60 years. She has one older sister with hypertension and one younger brother who is healthy. Results of her pelvic examination are unremarkable, but she asks what additional tests she should have to look for ovarian cancer in the early stages that cannot be detected by physical examination. What is the most appropriate management for this patient?

A)Blood test for CA-125
B)Rectovaginal pelvic examination in 1 year
C)Transvaginal ultrasound
D)Screening test for BRCA-1 and BRCA-2

Question 20

A 44-year-old woman has a lumpectomy and radiation therapy for stage II breast cancer. She receives 6 months of chemotherapy. Her periods cease while she is receiving chemotherapy, and she remains amenorrheic. Her tumor was found to be rich in estrogen receptor, and she is taking tamoxifen. Her hair is growing back and her energy is returning, but she is having severe hot flushes that keep her awake at night. She is so tired during the day that she is unable to perform her job in a satisfactory manner. She also relates that she and her husband have been unable to have satisfying sexual relations because intercourse is painful for her. What would be the most appropriate treatment for this patient?

A)A selective serotonin reuptake inhibitor and use of nonhormonal vaginal lubricating preparations
B)Reassurance that these normal physiologic responses to menopause will resolve in time
C)Estrogen replacement therapy with a progesterone supplement
D)Work-up for endometrial cancer because she is taking tamoxifen

Question 21

A 64-year-old white man presents for serum prostate-specific antigen (PSA) screening at his wife"s urging. He is in generally good health, except for mild hypertension. His digital rectal examination reveals a mildly enlarged prostate gland with no discrete nodules. He has no family history of prostate cancer. What is the best advice to give him?

A)There is no evidence that PSA screening leads to the earlier detection of prostate cancer
B)There is insufficient evidence to establish whether PSA screening affects overall mortality rates
C)On the basis of his lack of symptoms it is unlikely that he has an elevated PSA
D)Because a digital rectal examination is more sensitive than a serum PSA test, his normal examination makes it unlikely that he has cancer

Question 22

A 58-year-old woman with a 60-pack-year smoking history is evaluated because of hemoptysis and weight loss. Chest radiograph and CT scan show a right perihilar mass with mediastinal adenopathy. The results of CT scans of the abdomen, bone scan, and MRI of the head are otherwise negative. Examination of a specimen by bronchoscopic biopsy confirms small-cell lung cancer, and the findings suggest limited-stage disease. After the patient completes mediastinal radiation therapy and four cycles of cisplatin and etoposide, repeat CT scans indicate that her disease is in complete remission. What is the best recommendation concerning further therapy?

A)Prophylactic cranial irradiation
B)Four more cycles of chemotherapy, including a taxane
C)Resection of the localized disease
D)No further therapy; follow-up only

Question 23

A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. The patient has been working full time. On physical examination, he has mild hepatomegaly. His hemoglobin is 12.2 g/dL, serum alkaline phosphatase level 280 U/L, and serum aspartate aminotransferase level 65 U/L. CT scan of the abdomen and pelvis shows multiple hepatic lesions ranging in size from 1 cm to 4 cm; mesenteric, para-aortic, and paracaval lymphadenopathy, and a colonic mass at the splenic flexure. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine- needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. What is the most appropriate next step in

A)Resection of the primary tumor followed by systemic chemotherapy
B)Combined regional chemotherapy to the liver and systemic chemotherapy
C)Exploratory laparotomy with resection of the primary tumor and placement of a hepatic arterial infusion pump
D)Systemic chemotherapy
E)Best supportive care

Question 24

A 69-year-old man underwent a radical prostatectomy ii years ago. His serum prostate-specific antigen (PSA) level was 7.1 ng/mL, clinical stage was Tic (clinically organ-confined and detected by screening PSA blood test only), and his Gleason score was 5. His PSA level became detectable 4 years ago. Over the past 3 years, his PSA values have been 1.4 ng/mL, 1 .8 ng/mL, and 2.2 ng/mL. He remains asymptomatic, and a recent bone scan revealed only degenerative disease. The patients risk for rapid metastasis is low for which of the following reasons?

A)He was initially treated by radical prostatectomy.
B)His PSA level became undetectable.
C)He has had a slow, prolonged rise in his PSA.
D)He is almost 70 years old.

Question 25

A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. CT-directed needle biopsy is positive for squamous cell carcinoma. CT scans of the abdomen and pelvis, bone scan, and MRI of the head are negative for metastatic disease. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. The patient undergoes a right upper lobectomy. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. What is the most reasonable adjuvant therapy for this patient?

A)Four cycles of combination chemotherapy including a taxane
B)Four cycles of combination chemotherapy including a taxane, followed by radiation therapy to the draining lymph node sites in the mediastinum
C)Radiation therapy to the draining lymph node sites in the mediastinum
D)Six cycles of combination chemotherapy including a platinum agent
E)No radiation therapy or chemotherapy is required at this time