nyu medical grand rounds clinical vignette
DESCRIPTION
NYU Medical Grand Rounds Clinical Vignette. Josie Ni, PGY-3 9/13/11. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 63 year old man presents with urinary frequency and nocturia for 3 months. - PowerPoint PPT PresentationTRANSCRIPT
NYU Medical Grand Rounds Clinical Vignette
Josie Ni, PGY-3
9/13/11
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 63 year old man presents with urinary frequency and nocturia for 3 months.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Patient had his first screening prostate specific antigen (PSA) in 2007 at age 59. The level was 0.6 (normal).
• He was asymptomatic until early 2010, when he began to develop urinary frequency and nocturia.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Additional History
•Past Medical History:•GERD•Left inguinal hernia
•Past Surgical History:•Vasectomy•Melanoma excision•Hemorrhoidectomy
•Social History:•Lives with famiy, works as a tutor for Kaplan•No alcohol, tobacco, or drugs
•Family History:•No family history of prostate cancer
•Allergies: •No known drug allergies
•Medications:•Prilosec 20mg by mouth daily•Nasonex 1 spray intranasally twice daily•Vitamin B complex 1 tablespoon by mouth daily
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination
•General: awake alert and oriented, well-nourished man in no acute distress.
•Vital Signs: list T:98.7 BP:125/75 HR:70 RR:12 and O2 sat:100%RA
•Digital rectal exam with small firm nodule, prostate size approximately 45 grams.
•Remainder of physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Laboratory Findings
•CBC: 6.5/15.2/253 (all values within normal limits) •Basic Metabolic panel: creatinine 0.9
•Remainder of basic was within normal limits
•Hepatic panel: all values within normal limits•PSA 3.6 (normal is less than 4)
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Other Studies
•ECG: normal sinus rhythm
•Chest X-Ray: no infiltrate
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Prostate cancer
Or
• Benign Prostatic Hyperplasia
Working or Differential Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Transurethral ultrasound guided biopsy was performed (12 core), and a single focus of gleason 6 was detected.
• Because of low volume and concerns regarding erectile dysfunction the patient chose active surveillance.
• MRI performed 3 months later showed a 5mm highly suspicious lesion
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
MRI
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• A repeat 20 core biopsy showed 2/10 positive for Gleason 8 (high grade) cancer on the right and 1/10 positive for Gleason 6 on the left.
• Patient was no longer a candidate for active surveillance.
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Pelvic lymph node dissection and bilateral nerve sparing radical prostatectomy was performed in 7/2010.
• Surgical margins were negative.
• First PSA after resection was undetectable.
• However, 3 and 6 months later repeat PSAs were 0.24 and 0.84.
Hospital Course
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• Adenocarcinoma, gleason 8 without extracapsular extension.
• Also with presumed occult metastases.
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS