06-30-2007, 03:35 PM
A 59-year-old man who is a heavy smoker presents with cough, shortness of breath, and a sensation of head fullness. Physical examination is notable for facial cyanosis and edema. A chest radiograph shows a widened superior mediastinum.
Which of the following is most likely present?
( A ) Aortic dissection
( B ) Chronic constrictive pericarditis
( C ) Pulmonary embolism
( D ) Superior vena cava syndrome
A 72-year-old man comes to the emergency department with severe mid-back pain, radiating around to the front of the chest, of 3 days' duration that did not respond to treatment with a nonsteroidal anti-inflammatory drug. He survived an uncomplicated inferior myocardial infarction 2 years ago. His medications include metoprolol, simvastatin, aspirin, and ramipril.
On physical examination, blood pressure is 160/70 mm Hg and heart rate is 66/min, with occasional extra systoles. An apical impulse is noted 1 cm lateral to the midclavicular line. An S4 is present. The remainder of the physical examination, including measurement of the peripheral pulses, is unremarkable.
The troponin I level is less than 0.3 µg/L, blood urea nitrogen level is 22 mg/dL, and creatinine level is 1.1 mg/dL. Electrocardiogram shows sinus rhythm and inferior Q-wave progression, consistent with a previous inferior myocardial infarction. This finding is unchanged from the one obtained 1 year earlier. Chest radiograph shows a midline retrocardiac density.
Which of the following is the most appropriate initial diagnostic study?
( A ) Cardiac catheterization
( B ) Dipyridamole myocardial perfusion scan
( C ) Helical chest computed tomography scan with contrast
( D ) Lumbar spine magnetic resonance imaging scan
( E ) Lumbar spine x-ray
A 67-year-old woman is evaluated because of intermittent lower back pain of 4 weeks' duration. The pain is dull, nonradiating, and nonpositional, and is unrelated to meals or exertion.
On physical examination, blood pressure is 145/85 mm Hg, and heart rate is 86/min and regular. Abdominal examination shows a midline pulsatile mass. No spinal or costovertebral angle tenderness is noted. Distal pulses are normal.
Abdominal ultrasound shows a 4.8-cm abdominal aortic aneurysm that originates from the celiac trunk and extends below the renal arteries.
Which of the following is the most appropriate next step?
( A ) Follow-up ultrasound in 6 months
( B ) Follow-up ultrasound in 12 months
( C ) Hospitalization and vascular surgery
( D ) Lumbar spine magnetic resonance imaging
( E ) Simvastatin
A 68-year-old man with locally advanced non-small cell lung cancer is evaluated because of the new onset of low-back pain over the past 2 weeks. It is relieved with ibuprofen, and he has no other symptoms. He completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiographs of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable.
Which of the following is the most appropriate next step?
( A ) Computed tomography scan of the spine
( B ) Gallium bone scan
( C ) Magnetic resonance imaging scan of the spine
( D ) Reevaluation in 2 weeks
A 57-year-old man with a long history of intermittent back pain related to his work is evaluated because of severe back pain radiating down his left leg that began 2 days ago. He says that his left leg feels weak.
On physical examination, left straight-leg-raising causes pain at 45 degrees, great toe dorsiflexion is weak, and ankle jerk is diminished. Anal wink is present, the prostate gland is enlarged, and sphincter tone is normal. No sensory level is detectable. Lumbosacral spine films are normal, and the erythrocyte sedimentation rate is 10 mm/h.
In addition to analgesics, which of the following is the best management at this time?
( A ) Bed rest, with activity as tolerated
( B ) Chiropractic therapy
( C ) Lumbosacral traction
( D ) Physical therapy and exercise program
( E ) Referral to an orthopedic surgeon
A previously healthy 30-year-old man is evaluated because of a 1-year history of right-sided low-back pain. The pain is present when he awakens, and worsens throughout the day. It radiates down his right posterolateral thigh, to the midcalf, and is somewhat worse with cough, sneezing, and heavy lifting. The pain has been progressive and poorly responsive to high doses of acetaminophen or ibuprofen.
The patient has a 7-month history of a persistent, erythematous, scaly rash on his elbows and knees, and has noticed pitting of his fingernails. He has no conjunctivitis, urethritis, oral or genital lesions, or joint pain.
Physical examination reveals normal painless flexion of the lumbosacral spine; flexion, abduction, and external rotation of the right hip do not provoke pain. The straight-leg-raising sign is negative. Neurologic examination reveals no abnormalities.
A papulosquamous, erythematous rash is evident on the extensor surfaces of the elbows and knees. A number of the fingernails and toenails are pitted. Laboratory studies, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein levels, are normal.
Which of the following is the most likely diagnosis?
( A ) Herniated disk, with minimal nerve root compression
( B ) Osteoarthritis of the lumbar spine
( C ) Sacroiliitis
( D ) Vertebral compression fracture
Which of the following is most likely present?
( A ) Aortic dissection
( B ) Chronic constrictive pericarditis
( C ) Pulmonary embolism
( D ) Superior vena cava syndrome
A 72-year-old man comes to the emergency department with severe mid-back pain, radiating around to the front of the chest, of 3 days' duration that did not respond to treatment with a nonsteroidal anti-inflammatory drug. He survived an uncomplicated inferior myocardial infarction 2 years ago. His medications include metoprolol, simvastatin, aspirin, and ramipril.
On physical examination, blood pressure is 160/70 mm Hg and heart rate is 66/min, with occasional extra systoles. An apical impulse is noted 1 cm lateral to the midclavicular line. An S4 is present. The remainder of the physical examination, including measurement of the peripheral pulses, is unremarkable.
The troponin I level is less than 0.3 µg/L, blood urea nitrogen level is 22 mg/dL, and creatinine level is 1.1 mg/dL. Electrocardiogram shows sinus rhythm and inferior Q-wave progression, consistent with a previous inferior myocardial infarction. This finding is unchanged from the one obtained 1 year earlier. Chest radiograph shows a midline retrocardiac density.
Which of the following is the most appropriate initial diagnostic study?
( A ) Cardiac catheterization
( B ) Dipyridamole myocardial perfusion scan
( C ) Helical chest computed tomography scan with contrast
( D ) Lumbar spine magnetic resonance imaging scan
( E ) Lumbar spine x-ray
A 67-year-old woman is evaluated because of intermittent lower back pain of 4 weeks' duration. The pain is dull, nonradiating, and nonpositional, and is unrelated to meals or exertion.
On physical examination, blood pressure is 145/85 mm Hg, and heart rate is 86/min and regular. Abdominal examination shows a midline pulsatile mass. No spinal or costovertebral angle tenderness is noted. Distal pulses are normal.
Abdominal ultrasound shows a 4.8-cm abdominal aortic aneurysm that originates from the celiac trunk and extends below the renal arteries.
Which of the following is the most appropriate next step?
( A ) Follow-up ultrasound in 6 months
( B ) Follow-up ultrasound in 12 months
( C ) Hospitalization and vascular surgery
( D ) Lumbar spine magnetic resonance imaging
( E ) Simvastatin
A 68-year-old man with locally advanced non-small cell lung cancer is evaluated because of the new onset of low-back pain over the past 2 weeks. It is relieved with ibuprofen, and he has no other symptoms. He completed combined chemotherapy and radiation therapy 6 months ago, and restaging scans afterward showed marked shrinkage of the right perihilar mass. He has no muscle weakness. Plain radiographs of the thoracic and lumbar spine shows no abnormalities other than signs of mild osteoarthritis. Neurologic examination is unremarkable.
Which of the following is the most appropriate next step?
( A ) Computed tomography scan of the spine
( B ) Gallium bone scan
( C ) Magnetic resonance imaging scan of the spine
( D ) Reevaluation in 2 weeks
A 57-year-old man with a long history of intermittent back pain related to his work is evaluated because of severe back pain radiating down his left leg that began 2 days ago. He says that his left leg feels weak.
On physical examination, left straight-leg-raising causes pain at 45 degrees, great toe dorsiflexion is weak, and ankle jerk is diminished. Anal wink is present, the prostate gland is enlarged, and sphincter tone is normal. No sensory level is detectable. Lumbosacral spine films are normal, and the erythrocyte sedimentation rate is 10 mm/h.
In addition to analgesics, which of the following is the best management at this time?
( A ) Bed rest, with activity as tolerated
( B ) Chiropractic therapy
( C ) Lumbosacral traction
( D ) Physical therapy and exercise program
( E ) Referral to an orthopedic surgeon
A previously healthy 30-year-old man is evaluated because of a 1-year history of right-sided low-back pain. The pain is present when he awakens, and worsens throughout the day. It radiates down his right posterolateral thigh, to the midcalf, and is somewhat worse with cough, sneezing, and heavy lifting. The pain has been progressive and poorly responsive to high doses of acetaminophen or ibuprofen.
The patient has a 7-month history of a persistent, erythematous, scaly rash on his elbows and knees, and has noticed pitting of his fingernails. He has no conjunctivitis, urethritis, oral or genital lesions, or joint pain.
Physical examination reveals normal painless flexion of the lumbosacral spine; flexion, abduction, and external rotation of the right hip do not provoke pain. The straight-leg-raising sign is negative. Neurologic examination reveals no abnormalities.
A papulosquamous, erythematous rash is evident on the extensor surfaces of the elbows and knees. A number of the fingernails and toenails are pitted. Laboratory studies, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein levels, are normal.
Which of the following is the most likely diagnosis?
( A ) Herniated disk, with minimal nerve root compression
( B ) Osteoarthritis of the lumbar spine
( C ) Sacroiliitis
( D ) Vertebral compression fracture