MKSAP: 66-year-old man with vague abdominal pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 66-year-old man is evaluated for vague abdominal pain of several months’ duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. On physical examination, vital signs are normal. No lymphadenopathy is noted. Cardiopulmonary examination is normal. He has a slightly distended abdomen with vague left-sided upper abdominal fullness but without tenderness, rebound, or guarding. The rectal examination is normal, and the fecal occult blood test is guaiac-negative. Laboratory studies indicate a hemoglobin level of 11.4 g/dL (114 g/L) and a mean corpuscular volume of 81 fL. Urinalysis reveals microscopic hematuria. A CT scan of the abdomen demonstrates a 15-cm left upper kidney mass with 3-cm perirenal lymph node enlargement and multiple 1-cm pulmonary nodules on the lowest cuts of the chest portion of the scan. A thoracic CT confirms pulmonary nodules consistent with metastatic disease. A bone scan is negative. Which of the following is the most appropriate initial management of this patient? A: CT-guided lung biopsy B: CT-guided kidney biopsy C: Cytotoxic chemotherapy D: Left nephrectomy Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Cancer Source Type: blogs