![]() He will be followed upregularly in the oncology clinic. Results of a lungbiopsy reveal metastatic disease.Based on the results of these studies,the disease is classified as stageIII.The patient undergoes radicalinguinal orchiectomy, and chemotherapy(cisplatin, vinblastine, andbleomycin) and radiation therapyare started. An abdominalCT shows a 5.7 x 6.3 x 5.5-cmmass in the spleen. A fine-needle aspiration of the mass demonstratesembryonal nonseminomatousgerm cell carcinoma.A brain CT shows a 7-cm massand surrounding edema in the frontallobe (Figure 3). α-Fetoprotein level is14,073 ng/mL human chorionicgonadotropin (hCG) level is 23IU/mL (normal, less than 5 U/mL).A chest CT shows a solid mass inthe left lung ( Figure 2). Ultrasonographyreveals that the mass measures9.2 x 9.8 x 7.7 cm and is locatedin the upper anterior part ofthe testicle. Examinationconfirms a large, firm mass in theright testis. The findingof a dense lung infiltrate in ayoung man mandates a careful examinationof the testicles, C.Testicular cancers are common inthis age group, and they metastasizerapidly to the lung.Although the patient did notvoluntarily provide a relevant history,the brother who accompaniedhim mentioned having been toldby the patient that his right testiclehad been enlarging during the past3 months ( Figure 1). Rectal examination with stool test for occult blood WHAT'S WRONG:The chest radiograph shows alarge mass in the left lung thatshifts the cardiac silhouette andmediastinum to the right. ![]() Sputum examination for acid-fast bacilli E. In view of the clinical, laboratory, and radiographicfindings, which of the following is the mostappropriate next step? A. Alkalinephosphatase, 116 IU/L lactate dehydrogenase, 825 IU/L HIV test is negative.An ECG reveals sinus tachycardia. Blood urea nitrogen level, 26mg/dL serum creatinine, 1 mg/dL albumin, 3.2 g/dL.Total bilirubin, 1 mg/dL aspartate aminotransferase,26 IU/L alanine aminotransferase, 22 IU/L. Serum sodium, 138 mEq/L potassium, 4 mEq/L. ![]() Urinalysis reveals nored blood cells or casts. White blood cell count,5600/L, with 68% polymorphonuclear leukocytes, 24%lymphocytes, 4% monocytes, and 4% eosinophils hemoglobin,11.8 g/dL platelet count, 186,000/L erythrocytesedimentation rate, 90 mm/h. Abdominal examination reveals noorganomegaly or tenderness. Heart sounds are normal with nomurmur or gallop. Breathsounds are absent over the entire left lung field. Chest examination reveals poor movement ofthe left chest with impaired note on percussion on theleft side trachea is deviated to the right side. There isno evidence of adenopathy, clubbing, cyanosis, or ankleedema. Temperatureis 37.2C (99F) heart rate, 120beats per minute and regular respiration rate, 24breaths per minute blood pressure (right upper limb),130/88 mm Hg weight, 120 lb height, 66 in. This moderatelywell-built and well-nourished youngman is not in acute distress hecoughs intermittently. ![]() Hehas had no sick contacts, is not sexuallyactive, and does not smoke oruse illicit drugs. The patient has lostabout 30 lb in the last 3 months. He deniesfever, rigors, night sweats, hemoptysis,chest pain, palpitations, orthopnea,paroxysmal nocturnal dyspnea,ankle edema, and lymphadenopathy. A 22-year-old man presents to theemergency department with a2-week history of a worsening nonproductive,irritating dry cough andexertional dyspnea. ![]()
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