Kaplan USMLE Step 3: 72-year-old man complains of fever, pain in limbs

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

A 72-year-old man comes to the clinic complaining of fever. He tells you that for the past three months he has been suffering from intermittent fevers, chills and night sweats, and he has lost more than 10 lbs. He says he cannot move around much because his “limbs are hurting all the time.” He also states that he had an episode of painless red coloration to his urine recently. His past medical history is remarkable for benign prostatic hyperplasia and hypertension, well controlled with a thiazide diuretic. Physical examination reveals a pale and cachectic elderly man. He has tenderness when moderate pressure is applied to pelvis. CT scan is done and shows a 5-cm right-sided complex cyst involving the renal pelvis and parenchyma. His hematocrit is 55% and platelet count is 625,000/mm³. Which of the following is the most appropriate management of this patient's condition?

A. Empiric chemotherapy and radiation

B. Percutaneous needle biopsy of the mass

C. Radical nephrectomy

D. Chest x-ray and bone scan

E. Ultrasonography of the kidney

The correct answer is D.

This patient most likely has renal cell carcinoma. Chest x-ray and bone scan need to be done in order to rule out pulmonary and bone metastasis. When localized, it is surgically respectable with radical nephrectomy (Choice C). If there is metastasis, the preferred treatment is chemotherapy with vinblastine combined with cytoreductive nephrectomy. The tumor can present in almost any fashion, has a variety of associated paraneoplastic syndromes, and may be picked up incidentally on CT scan. Hematuria is present in approximately 40% of patients, and approximately 5% have erythrocytosis caused by inappropriate erythropoietin production. However, severe anemia is more common. Fever, cachexia, and myalgias are common.

Choice A. Empiric chemotherapy and radiation are not indicated without documented metastasis.