The preventable risk factor common to all skin cancers is sun exposure. Recommend to your at-risk patients limiting exposure to sunlight in the middle of the day, wearing appropriate protective clothing, and using sun screen.
Contrary to popular belief, the use of tanning beds is also a risk factor for skin cancer.
There is no such thing as a "healthy tan."
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Pierson JC. Pigmented skin lesions (nevi and melanoma). Best Practice of medicine. November 2001. Available at: http://merck.micromedex.com/index.asp?page= bpm_brief&artic le_id=B PM01DE07.
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Saraiya M, Glanz.K. Briss P. et al. Preventing skin cancer: findings of the task force on community preventative services on reducing exposure to ultraviolet light. MMWR _ October 17, 2003:52(RR15);1-12_.
Stulberg DL. Crandell B, Fawcett RS. Diagnosis and treatment of basal cell and squamous cell carcinomas. Am Fam Physician 2004;70:1481-1488.
A 40-year-old male with no past medical history presents to the clinic to establish care. He reports that he had a prior urinalysis that revealed blood as an incidental finding. The urinalysis was done as a standard screening test by his former employer. He denies ever seeing any blood in his urine and denies any voiding difficulties, dysuria, sexual dysfunction, or any history or risk factors for sexually transmitted diseases. His review of systems is otherwise negative. He has smoked a half-pack of cigarettes per day for the past 10 years and exercises by jogging 15 minutes and light weight training daily. On examination, his vital signs are normal and the entire physical examination is unremarkable. A complete blood count (CBC) and a chemistry panel (electrolytes, blood urea nitrogen, and creatinine) are normal. The results of a urinalysis done in your office are: specific gravity, 1.015; pH 5.5; leukocyte esterase, negative; nitrites, negative; white blood cell count (WBC). 0; red blood cell count (RBC), 4-5 per high-power field (HPF).
^ What is your diagnosis?
♦ How would you approach this patient?
^ What is the work-up and plan for this patient?
^ What are the concerns and how would you counsel the patient?
ANSWERS TO CASE 14: Hematuria
Summary: A 40-year-old male smoker is found incidentally to have red blood cells in his urine sample on a urinalysis.
^ Current diagnosis: Asymptomatic microscopic hematuria
^ Initial approach to this patient: Repeat the urinalysis, assess for risk factors, image the upper and lower urinary tract.
^ Work-up and plan: Rule out infection by performing a urine culture; evaluate for malignancy by imaging of the upper urinary tract, cystoscopy, and voided cytology.
^ Concerns and counseling for the patient: The primary concern is to rule out malignancy, including renal cell carcinoma and transitional cell carcinoma. Counsel the patient on the importance of an appropriate work-up. but reassure the patient about the low prevalence of the condition.
1. Learn about the significance of microscopic hematuria.
2. Learn an evidence-based approach to work-up asymptomatic microscopic hematuria.
3. Be familiar with recommendations for follow-up on patients with hematuria after a negative work-up.
Gross hematuria: The presence of enough blood in a urine sample to be visible to the naked eye. Lower urinary tract: The urinary bladder and urethra. Microscopic hematuria: The presence of 3 or more red blood cells per
HPF on 2 or more properly collected urinalyses. Upper urinary tract: The kidneys and ureters.
This patient has asymptomatic microscopic hematuria, as opposed to gross hematuria. Although he is asymptomatic, this patient deserves a thorough workup in order to determine an etiology, if possible, and to rule out malignancy.
The patient's history should be reviewed with specific questions to determine any risks for sexually transmitted diseases (STDs), occupational exposures to chemicals, strenuous exercise, drugs, medications, and herbal/nutritional supplements. The work-up should begin with a repeat urinalysis. If the condition persists, the patient should have imaging studies of both the upper and lower urinary tract. The upper tract can be imaged by either an intravenous pyel-ogram (IVP) or computed tomography (CT) scan. The lower tract is most commonly evaluated by cystoscopy, an endoscopic procedure. Urine should also be sent for cytology and culture. Urologic consultation should be requested if the work-up reveals an abnormality that cannot be treated in a primary care office or if the condition persists. Inform the patient that a complete work-up is necessary to evaluate for the presence of conditions such as infections or tumors, but he should be reassured that the incidence of cancer presenting as asymptomatic microscopic hematuria is low.
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