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NYU Medical Grand Rounds Clinical Vignette

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.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Josie Ni, PGY-3 9/13/11 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 63 year old man presents with urinary frequency and nocturia for 3 months.

  3. History of Present Illness 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.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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)

  7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: normal sinus rhythm • Chest X-Ray: no infiltrate

  8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Prostate cancer Or • Benign Prostatic Hyperplasia

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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

  10. MRI UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Adenocarcinoma, gleason 8 without extracapsular extension. • Also with presumed occult metastases.

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