A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a history of hypertension and obstructive sleep apnea due to obesity. He is not conscious and no other history is available. An examination shows no focal neurologic findings, but a general examination is limited because of his size. Breath sounds are diminished, and heart sounds are difficult to hear. He has venous insufficiency changes on his lower extremities, with brawny-type edema. Laboratory testing reveals a sodium level of 116 mmol/L (N 135-145), but normal renal and liver functions. A chest radiograph shows mild cardiomegaly. A BNP level is pending, but immediate treatment is felt to be indicated.
Which one of the following is the treatment of choice for this patient?
Correct Answer D:
This patient has severe hyponatremia manifested by confusion and seizures, a life-threatening situation warranting urgent treatment with hypertonic (3%) saline. The serum sodium level should be raised by only 1-2 mmol/L per hour, to prevent serious neurologic complications. Saline should be used only until the seizures stop. Some authorities recommend concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but it should not be used alone. The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures.
A 62-year-old man who is a cigar and pipe smoker develops a circular lesion on the lower lip. See picture:
What is the most likely diagnosis?
Correct Answer B:
Squamous cell carcinoma of the oral cavity occurs mostly in smokers. About 38% of all oral squamous cell carcinomas occur on the lower lip. Fortunately for lower lip lesions, 5 year survival is 90%, and metastases are rare. Surgery and radiation therapy are the treatments of choice.
Basal cell carcinoma most often appears on sun-exposed areas such as the face, scalp, ears, chest, back, and legs. The most common appearance of basal cell cancer is that of a small dome-shaped bump that has a pearly white color. Basal cell cancer can also appear as a pimple-like growth that heals, only to come back again.
A 60-year-old man has an ulcerating carcinoma of the lateral side of the tongue.
Which one of the following features has the most important effect upon his management?
Oral squamous cell carcinoma affects about 30,000 Americans each year. Ninety percent are smokers. Alcohol is also a risk factor. Early, curable lesions are rarely symptomatic; thus, preventing fatal disease requires early detection by screening. Treatment is with surgery, radiation, or both. The overall 5-yr survival rate is 52%. If carcinoma of the tongue is localized (no lymph node involvement), 5-yr survival is about 50%. For localized carcinoma of the floor of the mouth, 5-yr survival is 65%. With lymph node metastasis, the 5-yr survival is 20%. For tongue lesions, radiation therapy is often the treatment of choice because surgery is extensive, disfiguring, and associated with poor quality of life. In addition, patients with cancer of the floor of the mouth are often medically compromised and are not good candidates for surgery.
A 75-year-old white male presents with a nonhealing 2.5-cm ulcer on his neck. A 4-mm punch biopsy reveals a squamous cell carcinoma.
Which one of the following would be most appropriate at this time?
For treatment of squamous cell carcinoma (SCC) greater than or equal to 20 mm, surgical excision with 6-mm margins is the preferred treatment. This will clear 95% or more of these tumors, and provides good cosmetic results.
→ Cryosurgery (choice A) or electrodesiccation (choice B) can be used for tumors < 1 cm.
→ Mohs’ surgery (choice C) would be appropriate if the tumor were high-risk (e.g., if it were in a location associated with a high risk of metastasis.)
→ Radiation therapy (choice E) as primary treatment for cutaneous SCC is typically reserved for patients who are unable to undergo surgical excision.
A man comes to see you. His past medical history includes hypertension. He tells you that he has experienced impotence for the past 6 months with his wife. But he is able to develop an erection in the morning and while reading an adult magazine in the washroom.
What should you do?
Correct Answer E:
Erectile dysfunction (ED) is a common problem among males. It can be caused by medicine side effects. Beta blockers used to treat hypertension are common causes of male ED. However this patients history suggests he has non-organic impotence. Since he is able to achieve an erection. At this time is appropriate to discuss counseling for him and his wife to help treat this partner-specific ED.
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