A 24-year-old man comes to the office due to nonproductive cough for the past 2 months. He has used over-the-counter cough syrups without improvement. The patient has no fever, chest pain, or dyspnea but recently began having dull back pain. He has no chronic medical issues and takes no other medications. Vital signs are within normal limits. Pulmonary auscultation reveals normal breath sounds. Back examination shows no deformity or tenderness, and a straight leg raise does not elicit pain. Bilateral lower extremity motor strength and sensations are equal, symmetric, and normal. Imaging studies reveal several pulmonary nodules and retroperitoneal lymphadenopathy. Which of the following would most likely establish the primary source of this patient's current findings?

Question

A 24-year-old man comes to the office due to nonproductive cough for the past 2 months.  He has used over-the-counter cough syrups without improvement.  The patient has no fever, chest pain, or dyspnea but recently began having dull back pain.  He has no chronic medical issues and takes no other medications.  Vital signs are within normal limits.  Pulmonary auscultation reveals normal breath sounds.  Back examination shows no deformity or tenderness, and a straight leg raise does not elicit pain.  Bilateral lower extremity motor strength and sensations are equal, symmetric, and normal.  Imaging studies reveal several pulmonary nodules and retroperitoneal lymphadenopathy.  Which of the following would most likely establish the primary source of this patient's current findings?

Quizplus · Accepted Answer

11ec25c8_d290_1f56_bc81_1313a57edc03_MD0003_00 This young patient with 2 months of cough has evidence of pulmonary nodules and retroperitoneal lymphadenopathy, raising concern for a neoplastic process. Malignancies are rare in young men; most are caused by testicular cancer, lymphoma, or leukemia. Patients with testicular cancer usually seek medical care after incidentally finding a painless testicular mass; however, a minority present with symptoms of metastatic disease. Because testicular cancer spreads primarily through regional lymphatics, the retroperitoneal lymph nodes are often initially affected. Bulky retroperitoneal lymphadenopathy may compress adjacent structures (nerve roots, psoas muscle) and lead to lumbar back pain. Solid organ metastatic disease to the lungs and liver are also common. Lung metastases (nodules) may result in cough or dyspnea. This patient requires a testicular examination to evaluate for a mass. If a mass is present, scrotal ultrasound and tumor markers should be performed without delay. (Choice A) Leukemia may be diagnosed with bone marrow biopsy. Symptoms usually arise due to cell line abnormalities such as thrombocytopenia (bruising, bleeding), neutropenia (infections), or anemia (dyspnea, fatigue). Leukemia is not typically associated with bilateral lung nodules or isolated retroperitoneal lymphadenopathy. (Choice B) Colorectal cancer may spread to regional lymph nodes and the lungs; however, this malignancy is uncommon in individuals age <40 in the absence of hereditary colorectal cancer syndromes (eg, familial adenomatous polyposis, Lynch syndrome) or ulcerative colitis. In addition, most patients with metastatic colorectal cancer have liver lesions (due to portal venous drainage). (Choice C) Esophagogastroduodenoscopy can help identify intraluminal abnormalities in the upper digestive system. Esophageal, gastric, and duodenal tumors are quite uncommon in young individuals. (Choice D) Renal cell carcinoma may spread hematogenously to the lungs. The classic symptom triad is hematuria, flank pain, and a palpable abdominal mass. This malignancy is rare in young adults. Educational objective: Testicular germ cell tumors are common in young men and manifest primarily with a painless testicular mass. However, a minority of patients may have symptoms of metastatic disease, including low back pain (retroperitoneal lymphadenopathy) and dyspnea/cough (pulmonary nodules). Testicular examination showing a firm, ovoid testicular nodule should prompt a scrotal ultrasound and tumor markers to support the diagnosis.

A 24-Year-Old Man Comes to the Office Due to Nonproductive