Cytologically Yours: CoW: 20131111

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Contents

Clinical Summary

The patient is an 80 year old male who presented to the Emergency Department with a chief complaint of right flank pain. He described the pain as a 10/10 pain in his right flank. He denied any associated symptoms with this pain. He denied constipation, cough, shortness of breath, fever, dysuria, hematuria, nausea, or diarrhea. He could not identify anything that made the pain worse or better. He did take 5mg of acetaminophen-hydrocodone and did not have any relief. He had just taken his evening medications when the pain began, and he can not identify any activity that may have caused the pain.

Past Medical History

  • Chronic obstructive pulmonary disease
  • Allergic rhinitis
  • Hypertension
  • Hyperlipidemia
  • Diverticulosis
  • Coronary artery disease
  • Diabetes mellitus type 2

Past Surgical History

  • 1993 Disk arthroplasty
  • 2002 Coronary artery bypass with grafting
  • 2009 arthroplasty
  • Cholecystectomy year unknown

Medications

  • Acetominophen-hydrocodone
  • Acetaminophen-oxycodone
  • Albuterol
  • Aspirin
  • Gabapentin
  • Losartan
  • Meloxicam
  • Metoprolol
  • Nitroglycerin

Clinical Plan

Differential diagnosis for flank pain includes: kidney stone, vertebral compression fracture,and infection. The suspicion for kidney stone was highest on the list. A urine culture, abdominal CT, and POC urine were ordered.

Radiology

CT scan revealed multiple lytic and sclerotic lesions within the thoracolumbar spine and sacrum. These were thought to be suspicious of metastatic disease. Wall thickening in the descending colon was seen and was thought to possibly represent a primary colon cancer. The prostate was enlarged.

The clinicians decided to perform a CT guided biopsy and a touch prep was made for rapid interpretation by the Cytology team.

CT

Pathology

Touch Preparation

Resident Questions


Biopsy

Immunohistochemistry

Resident Questions
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Final Diagnosis

Cytology

  • Positive for malignancy.

Biopsy

  • Metastatic prostatic adenocarcinoma.

Case Discussion

This is a classic case of prostatic adenocarcinoma, metastatic to the spine.