CONFIRMING DIAGNOSIS Unexplained postmenopausal bleeding and an abnormal Papanicolaou smear (suspicious or positive in up to 50% of all cases) suggest fallopian tube cancer, but laparotomy is usually necessary to confirm this diagnosis.
When fallopian tube cancer involves both the ovary and fallopian tube, the primary site is difficult to identify. The preoperative workup includes:
❑ultrasound or plain film of the abdomen to help delineate tumor mass
❑ excretory urography to assess renal function and show urinary tract anomalies and ureteral obstruction
❑ chest X-ray to rule out metastasis
❑ barium enema to rule out intestinal obstruction
❑ computed tomography of the abdomen and pelvis
❑ routine blood studies
❑electrocardiogram.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Gallbladder and bile duct cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
No test or procedure, by itself, can diagnose gallbladder cancer. However, the following laboratory tests support the diagnosis when they suggest hepatic dysfunction and extrahepatic biliary obstruction:
❑baseline studies — complete blood count, routine urinalysis, electrolyte studies, enzymes
❑ liver function tests — typically reveal elevated serum bilirubin, urine bile and bilirubin, and urobilinogen levels in more than 50% of patients as well as consistently elevated serum alkaline phosphatase levels
❑ occult blood in stools — linked to the associated anemia
❑ cholecystography — may show calculi or calcification
❑ cholangiography — may locate the site of common duct obstruction
❑ magnetic resonance imaging — detects tumors.
The following tests help compile data that confirm extrahepatic bile duct cancer:
❑ liver function studies — indicate biliary obstruction: elevated levels of bilirubin [5 to 30 mg/dl], alkaline phosphatase, and blood cholesterol as well as prolonged prothrombin time
❑ endoscopic retrograde cannulization of the pancreas — identifies the tumor site and allows access for obtaining a biopsy specimen.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Gastric cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis depends primarily on reinvestigations of any persistent or recurring GI changes and complaints. To rule out other conditions producing similar symptoms, diagnostic evaluation must include the testing of blood, stools, and stomach fluid samples.
Diagnosis of gastric cancer generally requires these studies:
❑Barium X-rays of the GI tract with fluoroscopy show changes (tumor or filling defect in the outline of the stomach, loss of flexibility and distensibility, and abnormal gastric mucosa with or without ulceration).
❑ Gastroscopy with fiber-optic endoscopy helps rule out other diffuse gastric mucosal abnormalities by allowing direct visualization and gastroscopic biopsy to evaluate gastric mucosal lesions.
❑ Photography with fiber-optic endoscope provides a permanent record of gastric lesions that can later be used to determine disease progression and effect of treatment.
Certain other studies may rule out specific organ metastasis: computed tomography scans, chest X-rays, liver and bone scans, and liver biopsy. (See Staging gastric cancer, page 84.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Scrotal swelling:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Scrotal Pain/Swelling:
Differential Overview
(Field Guide to Bedside Diagnosis)
Pain Predominant
❑ Epididymitis
❑ Testicular torsion
❑ Prostatitis
❑ Referred pain
❑ Trauma
❑ Orchitis
❑ Torsion of the appendix testis
❑ Inguinal hernia/incarcerated
Swelling Predominant
❑ Varicocele
❑ Inguinal hernia
❑ Hydrocele
❑ Spermatocele
❑ Sebaceous cyst
❑ Testicular cancer
Diagnostic Approach
Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.
Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.
Referred pain can be differentiated from scrotal pathology by a normal testicular examination.
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Source: Field Guide to Bedside Diagnosis, 2007
Testicular cancer:
Diagnosis
(Handbook of Diseases)
❑ Two effective means of detecting a testicular tumor are regular self-examinations and testicular palpation during a routine physical examination.
❑ Transillumination can distinguish between a tumor (which doesn’t transilluminate) and a hydrocele or spermatocele (which does). Follow-up measures should include an examination for gynecomastia and abdominal masses.
❑ Diagnostic tests include excretory urography to detect ureteral deviation resulting from para-aortic node involvement, urinary or serum luteinizing hormone levels, ultrasound, and abdominal computed tomography scan.
Serum alpha-fetoprotein and beta-human chorionic gonadotropin levels, indicators of testicular tumor activity, provide a baseline for measuring response to therapy and determining the prognosis.
❑ Surgical excision and biopsy of the tumor and testis permits histologic verification of the tumor cell type — essential for effective treatment. Inguinal exploration determines the extent of nodal involvement.
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Source: Handbook of Diseases, 2003
Bone tumors, primary malignant:
Diagnosis
(Handbook of Diseases)
A biopsy (by incision or by aspiration) is essential for confirming a primary malignant bone tumor. Bone X-rays and radioisotope bone and computed tomography (CT) scans show tumor size. Serum alkaline phosphatase levels are usually elevated in patients with sarcoma.
Clinical tip Bone X-rays, CT scans, and magnetic resonance imaging are all useful in assessing tumor size. Bone scans and CT scans of the lungs are important in checking for metastatic disease.
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Source: Handbook of Diseases, 2003
Brain tumors, malignant:
Diagnosis
(Handbook of Diseases)
In many cases, a definitive diagnosis follows a tissue biopsy performed by stereotactic surgery. In this procedure, a head ring is affixed to the skull, and an excisional device is guided to the lesion by a computed tomography (CT) scan or magnetic resonance imaging (MRI).
Other diagnostic tools include a patient history, a neurologic assessment, skull X-rays, a brain scan, a CT scan, MRI, and cerebral angiography. Lumbar puncture shows increased pressure and protein levels, decreased glucose levels and, occasionally, tumor cells in cerebrospinal fluid (CSF).
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Source: Handbook of Diseases, 2003
Bladder cancer:
Diagnosis
(Handbook of Diseases)
Only cystoscopy and a biopsy can confirm bladder cancer. Cystoscopy should be performed when hematuria first appears. When it’s performed under anesthesia, a bimanual examination is usually done to determine if the bladder is fixed to the pelvic wall. A thorough history and physical examination may help determine whether the tumor has invaded the prostate or the lymph nodes.
The following tests can provide essential information about the tumor:
❑ Urinalysis can detect blood in the urine and malignant cytology.
❑ Excretory urography can identify a large, early-stage tumor or an infiltrating tumor, delineate functional problems in the upper urinary tract, assess hydronephrosis, and detect rigid deformity of the bladder wall.
❑ Retrograde cystography evaluates bladder structure and integrity. Test results help to confirm the diagnosis.
❑ Pelvic arteriography can reveal tumor invasion into the bladder wall.
❑ Computed tomography scan reveals the thickness of the involved bladder wall and detects enlarged retroperitoneal lymph nodes.
❑ Ultrasonography can detect metastasis beyond the bladder and can distinguish a bladder cyst from a tumor.
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Source: Handbook of Diseases, 2003
Breast cancer:
Diagnosis
(Handbook of Diseases)
Diagnostic measures for breast cancer include the following.
Breast self-examination
Although not proven to lower mortality rates, breast self-examination may detect palpable breast lumps, allowing the woman to contact her physician for early evaluation.
Mammography and biopsies
Other diagnostic measures include mammography, a needle biopsy, and a surgical biopsy. Mammography is indicated for any woman whose physical examination might suggest breast cancer. It should be done as a baseline on women ages 35 to 39, every 1 to 2 years for women ages 40 to 49, and annually for women older than age 50, women who have a family history of breast cancer, and women who have had unilateral breast cancer, to check for new disease. However, the value of mammography is questionable for women younger than age 35 (because of the density of the breasts), except those who are strongly suspected of having breast cancer.
False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a normal mammogram result should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. Ultrasonography, which can distinguish a fluid-filled cyst from a tumor, can also be used instead of an invasive surgical biopsy.
Other tests
Bone scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and a liver biopsy can detect distant metastasis. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen- or progesterone-dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)
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Source: Handbook of Diseases, 2003
Cervical cancer:
Diagnosis
(Handbook of Diseases)
A cytologic examination (Papanicolaou [Pap] test) can be used to detect cervical cancer before symptoms appear. Abnormal cervical cytology generally calls for colposcopy, which can detect the presence and extent of preclinical lesions requiring a biopsy and histologic examination.
Staining with Lugol’s solution (strong iodine) or Schiller’s solution (iodine, potassium iodide, and purified water) may identify areas for a biopsy when the smear shows abnormal cells but there is no obvious lesion. Although the tests are nonspecific and have a high rate of false-positives, they do distinguish between normal and abnormal tissues: Normal tissues absorb the iodine and turn brown; abnormal tissues are devoid of glycogen and don’t change color.
Additional studies — such as cystography, magnetic resonance imaging, computed tomography and bone scans — can be used to detect metastasis.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Colorectal cancer:
Diagnosis
(Handbook of Diseases)
Only a tumor biopsy can verify colorectal cancer, but the following tests help detect it:
❑ Digital examination can help detect almost 15% of colorectal cancers.
❑ Hemoccult test (guaiac) may show blood in the stool.
❑ Proctoscopy or sigmoidoscopy can help detect up to 66% of colorectal cancers.
❑ Colonoscopy permits visual inspection (and photographs) of the colon up to the ileocecal valve and gives access for polypectomies and biopsies of suspected lesions.
❑ Computed tomography scan helps detect areas affected by metastasis.
❑ Barium X-ray, using a dual contrast with air, can locate lesions that are undetectable manually or visually. Barium examination should follow endoscopy or excretory urography because the barium sulfate interferes with these tests.
❑ Carcinoembryonic antigen, although not specific or sensitive enough for an early diagnosis, is helpful in monitoring patients before and after treatment to detect metastasis or recurrence.
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Source: Handbook of Diseases, 2003
Esophageal cancer:
Diagnosis
(Handbook of Diseases)
X-rays of the esophagus, with barium swallow and motility studies, reveal structural and filling defects and reduced peristalsis. Endoscopic examination of the esophagus, punch and brush biopsies, and an exfoliative cytologic tests confirm esophageal tumors.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Gallbladder and bile duct cancers:
Diagnosis
(Handbook of Diseases)
No test or procedure is in itself diagnostic of gallbladder cancer. However, the following laboratory tests support this diagnosis when they suggest hepatic dysfunction and extrahepatic biliary obstruction:
❑ baseline studies (complete blood count, routine urinalysis, electrolyte studies, enzymes)
❑ liver function tests (typically reveal elevated serum bilirubin, urine bile and bilirubin, and urobilinogen levels in more than 50% of patients as well as consistently elevated serum alkaline phosphatase levels)
❑ occult blood in stools (linked to the associated anemia)
❑ cholecystography (may show stones or calcification)
❑ cholangiography (may locate the site of common duct obstruction)
❑ magnetic resonance imaging (detects tumors).
The following tests help compile data that confirm extrahepatic bile duct cancer:
❑ liver function tests (indicate biliary obstruction: elevated levels of bilirubin [5 to 30 mg/dl], alkaline phosphatase, and blood cholesterol as well as prolonged prothrombin time)
❑ endoscopic retrograde pancreatography (identifies the tumor site and allows access for obtaining a biopsy specimen).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Gastric cancer:
Diagnosis
(Handbook of Diseases)
Diagnosis depends primarily on reinvestigations of persistent or recurring GI changes and complaints. To rule out other conditions that produce similar symptoms, a diagnostic evaluation must include the testing of blood, stools, and stomach fluid specimens.
Gastric cancer commonly requires the following studies for diagnosis:
❑ Barium X-rays of the GI tract, with fluoroscopy, show changes (a tumor or filling defect in the outline of the stomach, loss of flexibility and distensibility, and abnormal gastric mucosa with or without ulceration).
❑ Gastroscopy with fiber-optic endoscopy helps rule out other diffuse gastric mucosal abnormalities by allowing direct visualization and gastroscopic biopsy to evaluate gastric mucosal lesions.
❑ Endoscopy for biopsy and cytologic washings and photography with fiber-optic endoscopy provide a permanent record of gastric lesions that can later be used to determine the progress of the disease and the effect of treatment.
The following studies may rule out metastasis to specific organs: computed tomography scans, chest X-rays, liver and bone scans, and a liver biopsy.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Kidney cancer:
Diagnosis
(Handbook of Diseases)
Studies to identify kidney cancer usually include computed tomography scans, excretory urography and retrograde pyelography, ultrasound, cystoscopy (to rule out associated bladder cancer), and nephrotomography or renal angiography to distinguish a kidney cyst from a tumor.
Related tests include liver function studies showing increased levels of alkaline phosphatase, bilirubin, alanine aminotransferase, and aspartate aminotransferase as well as prolonged prothrombin time. Such results may point to liver metastasis, but if metastasis hasn’t occurred, these abnormalities reverse after the tumor has been resected.
Routine laboratory findings of hematuria, anemia (unrelated to blood loss), polycythemia, hypercalcemia, and increased erythrocyte sedimentation rate call for more testing to rule out kidney cancer. A bone scan should also be performed to rule out skeletal metastasis.
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Source: Handbook of Diseases, 2003
Laryngeal cancer:
Diagnosis
(Handbook of Diseases)
Any hoarseness that lasts longer than 2 weeks requires visualization of the larynx by laryngoscopy.
A firm diagnosis also requires xeroradiography, a biopsy, laryngeal tomography, computed tomography scan, or laryngography to define the borders of the lesion, and a chest X-ray to detect metastasis.
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Source: Handbook of Diseases, 2003
Liver cancer:
Diagnosis
(Handbook of Diseases)
The confirming test for liver cancer is a needle or open biopsy of the liver. Liver cancer is difficult to diagnose in the presence of cirrhosis, but several tests can help identify it:
❑ Liver function studies (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, lactate dehydrogenase, and bilirubin) show abnormal liver function.
❑ Alpha-fetoprotein level increases above 500 µg/ml.
❑ Chest X-ray may rule out metastasis.
❑ Liver scan may show filling defects.
❑ Arteriography may define large tumors.
❑ Electrolyte studies may indicate increased sodium retention (resulting in functional renal failure) and hypoglycemia, leukocytosis, hypercalcemia, or hypocholesterolemia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Lung cancer:
Diagnosis
(Handbook of Diseases)
Typical signs and symptoms may strongly suggest lung cancer, but a firm diagnosis requires further evidence, including the following:
❑ Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear. It also indicates tumor size and location.
❑ Sputum cytology is marginally helpful in obtaining a diagnosis. It requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.
❑ Computed tomography (CT) scan of the chest may help to delineate the tumor’s size and its relationship to surrounding structures.
❑ Bronchoscopy can locate the tumor site. Bronchoscopic washings provide material for cytologic and histologic examination. The flexible fiber-optic bronchoscope increases the test’s effectiveness.
❑ A needle biopsy of the lungs uses biplane fluoroscopic visual control or CT guidance to detect peripherally located tumors. This allows a firm diagnosis in 80% of patients.
❑ Tissue biopsy of accessible metastatic sites includes supraclavicular and mediastinal node and pleural biopsies.
❑ Thoracentesis allows chemical and cytologic examination of pleural fluid.
Additional studies include preoperative mediastinoscopy or mediastinotomy to rule out involvement of mediastinal lymph nodes (which would preclude curative pulmonary resection).
Other tests to detect metastasis include a bone scan, positron emission tomography scan, bone marrow biopsy (recommended in small cell carcinoma), and a CT scan of the brain or abdomen.
After histologic confirmation, staging determines the extent of the disease and helps in planning treatment and predicting the prognosis. (See Staging lung cancer.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Ovarian cancer:
Diagnosis
(Handbook of Diseases)
With ovarian cancer, diagnosis requires clinical evaluation, a complete patient history, surgical exploration, and histologic studies. Preoperative evaluation includes a complete physical examination, including pelvic examination with Papanicolaou smear (not clinically useful for ovarian cancer but helpful in diagnosing cervical dysplasia, cervical cancer, and some endometrial cancers) and the following special tests:
❑ abdominal ultrasonography, computed tomography scan, or magnetic resonance imaging (may delineate tumor size)
❑ complete blood count and blood chemistries
❑ chest X-ray for distant metastasis and pleural effusions
❑ barium enema (especially in patients with GI symptoms) to reveal obstruction and size of tumor
❑ mammography to rule out primary breast cancer
❑ liver function studies or a liver scan in patients with ascites
❑ laboratory tumor marker studies, such as CA-125, carcinoembryonic antigen, and human chorionic gonadotropin (the last two are mainly for suspected germ cell tumors).
Despite extensive testing, accurate diagnosis and staging are impossible without exploratory laparotomy, including lymph node evaluation and tumor resection.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Scrotal swelling:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the patient isn’t in distress, obtain his medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is he sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does the patient have a history of prostate surgery or prolonged catheterization? Is the swelling affected by changing his body position or level of activity?
Physical examination
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Scrotal swelling:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient isn’t in distress, proceed with the medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
CULTURAL CUE:Patients of certain cultural backgrounds, such as Mexican-Americans, may need to establish a trusting relationship before discussing matters of a personal nature.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Scrotal swelling:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient's vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in a supine position and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles'position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can't be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
TESTICULAR ATROPHY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of testicular atrophy may require a chromatin analysis,
serum testosterone, follicle-stimulating hormone (FSH) and luteinizing
hormone (LH) levels, and biopsy, but referral to an endocrinologist is the
best way to get this accomplished with accuracy.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
TESTICULAR MASS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Testicular masses may be differentiated by transillumination
(hydroceles and spermatoceles transilluminate, whereas hernias and tumors do
not). Hernias may also be differentiated by reducing them (some will not
reduce, however, if they are incarcerated), and auscultation may reveal
bowel sounds. In noncommunicating hydroceles and testicular tumors, one may
get above the swelling, whereas in torsion and hernias one cannot. In
torsion, the tenderness is increased by elevation of the testicle, whereas
in orchitis the tenderness is relieved if elevation is done for an hour or
more. Serum alpha-fetoprotein beta-human chorionic gonadotropin (HCG) or
lactic dehydrogenase (LDH) will be elevated in testicular
tumors. Surgery may be the only way to differentiate the cause of the mass.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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