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  #1  
Old 04-24-2012
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Question Breast Cancer then Lower Back Pain?

A 55-year-old female presents for a 1-week history of low back pain. She denies any recent falls or trauma. She is otherwise well but has a history of breast cancer 2 years ago. She denies any weight loss or night sweats. She denies any bowel or bladder incontinence or lower extremity weakness. Vital signs are heart rate 69 beats/min, respiratory rate 18 breaths/min, blood pressure 133/81 mm Hg, and oxygen saturation 95% on room air. Physical examination reveal minimal lumbar spine pain on palpation and accompanying paraspinal muscle spasm. What is the next step in her management?

A. Bone scan
B. Magnetic resonance imaging
C. Mammogram
D. Nonsteroidal antiinflammatory drugs (NSAIDs)
E. X-ray
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Old 04-24-2012
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mmmm nice question she either has osteoporosis secondary to menopuase (eventho she is too young) or she has bone metastases from the primary breast cancer
they dont mention she was treated from the cancer.. jeez i guess an MRI to look for the metastases but i think im wrong
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Old 04-24-2012
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x-ray

Bone scan looks for only mets.. MRI good for soft tissue imaging..
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Old 04-24-2012
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D. Nonsteroidal antiinflammatory drugs (NSAIDs)
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Old 04-24-2012
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D. Nonsteroidal antiinflammatory drugs (NSAIDs)
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Old 04-24-2012
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Answer is E
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Old 04-24-2012
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I wouldn't treat if i don't know what I am treating.
ct could be good option in real life, but Goljan said"on boards think cheap", so I would go with xray
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Old 04-25-2012
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I'll go with X-ray as the next step in management. this is confirm a compression fracture or rule it out ( as the only clue in the examination points to it).

MRI is not the answer since there is no evidence of spinal compression on HPE. (This would have been my answer if the question asked for the next BEST step in management since it will give the most information about her condition)

Bone scan is not the answer since she has a history of Breast Ca and is most likely on Tamoxifen.

Mammogram is not the answer since she must be being followed up for Breast Ca.

NSAIDs are not the answer since we don't know what we are dealing with here.
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Old 04-25-2012
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If she got treated for breast cancer then I think bone scan will be most appropriate. According to her post treatment follow-up.
But be cheap is true too so
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Old 04-25-2012
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Quote:
Originally Posted by koolkiller88 View Post
If she got treated for breast cancer then I think bone scan will be most appropriate. According to her post treatment follow-up.
But be cheap is true too so

Quote:
Metastatic disease to the bone causes severe, progressive pain, and, less commonly, pathological fracture, erythema over the affected bone, and swelling.
According to question stem she is otherwise well ...................She denies any weight loss or night sweats..............
So bony mets are unlikely.
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Old 04-25-2012
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One way or the other wouldn't you want to do at least some basic diagnostic test?
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Quote:
Originally Posted by Teresa View Post
One way or the other wouldn't you want to do at least some basic diagnostic test?
No. I just want to answer the question-What is the next step in her management? ............based on the information provided in the question stem.
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Old 04-25-2012
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Quote:
Originally Posted by Novobiocin View Post
No. I just want to answer the question-What is the next step in her management? ............based on the information provided in the question stem.
So why not nsaid...single dose no harm just symptomatic treatment..will relieve pain a bit and we can perform diagnostic test next as she will be having less pain??
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Quote:
Originally Posted by confident View Post
So why not nsaid...single dose no harm just symptomatic treatment..will relieve pain a bit and we can perform diagnostic test next as she will be having less pain??
Because of this information in the question stem:


Quote:
Physical examination reveal minimal lumbar spine pain on palpation and accompanying paraspinal muscle spasm.
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Old 04-25-2012
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I disagree, but it is obviously only my opinion because none of us really know what the answer is.
I believe that the reason she comes to the doctor is not to get painkillers, that she had probably taken already.
Considering her history she would be worried why she has the symptoms and the next step in management would be to diagnose, especially if the pain is minimal.
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Old 04-25-2012
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Quote:
Originally Posted by Teresa View Post
I disagree, but it is obviously only my opinion because none of us really know what the answer is.
I believe that the reason she comes to the doctor is not to get painkillers, that she had probably taken already.
Considering her history she would be worried why she has the symptoms and the next step in management would be to diagnose, especially if the pain is minimal.
i think its bone scan. because it is most sensitive to diagnose any mets. so a negative bone scan will rule out my main concern...metz to spine...
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Old 04-25-2012
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I think that even if there is a compression fracture, we would have to do nuclear bone scan to rule out metastasis as the underlying cause, so I'm with tyagee on this one - A. Bone scan.

Novobiocin has a good point about the wording of "minimal pain" ruling out nsaids as the answer. X-ray (lateral film of thoracic and lumbar spine) is the first step in diagnosing a vertebral compression fracture (if there were a recent trauma, it would be CT, I think). However, even if a VCF were diagnosed on the x-ray and characterized on the MRI (usually with STIR sequence in order to see if it is old or acute, I just learned in a grand rounds lecture today), we'd still want to rule out metastases given the history of breast cancer.
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Old 04-25-2012
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Quote:
Originally Posted by tyagee View Post
i think its bone scan. because it is most sensitive to diagnose any mets. so a negative bone scan will rule out my main concern...metz to spine...
Just curious...you have these questions with no attached explanation to them? what is your source?
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Old 04-26-2012
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Quote:
Originally Posted by Mondoshawan View Post
I think that even if there is a compression fracture, we would have to do nuclear bone scan to rule out metastasis as the underlying cause, so I'm with tyagee on this one - A. Bone scan.
Bone scan is NOT a good test to detect Bone Mets. Since it cannot detect lytic bone lesions. Bone scan can only detect a lesion where active bone remodeling is going on. That's why it is of no use in Multiple Myeloma.
Since Breast Ca mets are mostly lytic lesions. Bone Scan is NOT a good test for detecting Breast Ca mets.

Quote:
However, a nuclear bone scan is a functional test, which means it measures an aspect of bone metabolism or Bone remodeling, which most other imaging techniques cannot.
Also, since according to the question stem, it could be some other cause for her back pain leading to a positive bone scan but we will still not know what is causing it. So, X-ray as the initial test ( MRI as the best test) is the best choice.

Quote:
Areas of active bone changes appear as "hot spots" on the skeleton because they attract the radioactivity. These areas may suggest the presence of cancer, but other bone diseases can also cause the same pattern. To know exactly what is causing the hot spots, other imaging tests such as plain x-rays or MRI scans, or even a bone biopsy might be needed.
References:

http://www.ajronline.org/content/185/4/1082.full

http://www.learningradiology.com/arc...etscorrect.htm

http://en.wikipedia.org/wiki/Bone_scintigraphy
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Old 04-26-2012
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Quote:
Originally Posted by tyagee View Post
i think its bone scan. because it is most sensitive to diagnose any mets. so a negative bone scan will rule out my main concern...metz to spine...
That is not correct. Read my post as above.
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Old 04-26-2012
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So in this case the best step in management is Xray but the best step is MRI? whats the conclusion tyagee? also which qbank are you using?
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Old 04-26-2012
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Quote:
Originally Posted by usmledee View Post
Just curious...you have these questions with no attached explanation to them? what is your source?
source is u consult.
i got the expln....here it is....problem is i m not convinced with expln .
also, novobiocin says bone scan is not good option in this q .i know lytic lesions are not seen by bone scan.but breast cancer is mainly lytic and not absolutely lytic. i may be wrong. can u tell the source for that please?

Explanation
Option C (Bone scan) is correct. A bone scan helps determine if this is a new or old fracture. She has severe osteoporosis, and it is difficult to tell if this is new by plain radiograph.

Option A (Biochemical markers for bone turnover) is incorrect. These markers are more important in patient management than in acute diagnosis. Bone markers may help determine and monitor the rate of bone turnover. They also help monitor the effectiveness of treatment but are not used in the diagnosis of acute vertebral fracture.

Option B (Biochemical screening for hyperparathyroid disease) is incorrect. This screening is important in management and determination of the suspected osteoporosis of the patient but not in acute diagnosis of a fracture. This test would be part of an extensive osteoporosis evaluation in a patient who develops a compression fracture from coughing.

Option D (Dual-energy x-ray absorptiometry (DEXA) scan) is incorrect. A DEXA scan is important in management of the patient but not acutely. An osteoporosis evaluation is warranted for a patient who develops a compression fracture with a mild stress such as a cough.

Option E (Magnetic resonance imaging of the back) is incorrect. Magnetic resonance imaging (MRI) is not helpful in determining the acuity of the patientís vertebral fracture. The MRI may show compression and some associated inflammation, but it does not help determine if there is active bone disease.
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Old 04-26-2012
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Bone scan is only for blastic lesion..so we use mostly in osteoporosis..

what are other indication for bone scan???

Breast ca can cause both blastic and lytic i think??
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Quote:
Originally Posted by Novobiocin View Post
I'll go with X-ray as the next step in management. this is confirm a compression fracture or rule it out ( as the only clue in the examination points to it).

MRI is not the answer since there is no evidence of spinal compression on HPE. (This would have been my answer if the question asked for the next BEST step in management since it will give the most information about her condition)

Bone scan is not the answer since she has a history of Breast Ca and is most likely on Tamoxifen.

Mammogram is not the answer since she must be being followed up for Breast Ca.

NSAIDs are not the answer since we don't know what we are dealing with here.


So if q ask about best next step its MRI

Next step is xray

what we have to choose if q ask what is MOST APPROPRIATE NEXT STEP?? and why??
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Quote:
Originally Posted by confident View Post
Bone scan is only for blastic lesion..so we use mostly in osteoporosis..

what are other indication for bone scan???

Breast ca can cause both blastic and lytic i think??
I remembered this by using b for l and l for b mnemonic..

breast carcinoma = lytic lesion
lung carcinoma = both (lytic and blastic)

also, we know, prostate carcinoma = blastic
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Old 04-26-2012
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Quote:
Originally Posted by confident View Post
Bone scan is only for blastic lesion..so we use mostly in osteoporosis..

what are other indication for bone scan???

Breast ca can cause both blastic and lytic i think??
You are confusing Bone scan with DEXA scan which are different.
Bone scan is useful for any bone lesion except the purely lytic bone lesions (e.g. Multiple myeloma, early Breast Mets). I agree that Breast mets my not be purely lytic at a later stage but the point I was trying to make was that the Bone Scan (nuclear scan) will "light up" in ANY condition causing bone remodelling (osteobastic activity). Therefore it will not help much in the this scenerio since it could be any condition causing vertebral compression fracture.
You are right that Breast mets can cause both lytic & blastic lesions but they are mostly lytic in the early stages.
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Quote:
Originally Posted by confident View Post
So if q ask about best next step its MRI

Next step is xray

what we have to choose if q ask what is MOST APPROPRIATE NEXT STEP?? and why??
An X ray as the next step in management will tell us which will be the next best step in management.
For example_ If the x ray shows a compression fracture the DEXA scan will be the next best step.
If the x ray suggests mets then the MRI will be the most useful since it will show any impending spinal compression and you can operate BEFORE the spinal compression actually occurs.
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Quote:
Originally Posted by Novobiocin View Post
An X ray as the next step in management will tell us which will be the next best step in management.
For example_ If the x ray shows a compression fracture the DEXA scan will be the next best step.
If the x ray suggests mets then the MRI will be the most useful since it will show any impending spinal compression and you can operate BEFORE the spinal compression actually occurs.
i have posted the expln still you are up with xray. for refrence, kaplan surgery mentions bone scan as next step and not xray. may i know why not bone scan? btw, bone scan can see breast cancer metz to spine.
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Quote:
Originally Posted by tyagee View Post
i have posted the expln still you are up with xray. for refrence, kaplan surgery mentions bone scan as next step and not xray. may i know why not bone scan? btw, bone scan can see breast cancer metz to spine.
Because your question and the explanation don't add up. You seems to have posted the explanation for some other question.

Secondly the reference you posted is for patients not for doctors. Please feel free to click on the references I posted from reputable medical sources.

Thirdly, I have explained that a nuclear bone scan is not a good test to detect Breast ca mets to bone as the early mets are mostly lytic and the nuclear bone scan will not be able to detect them in majority of the patients. Therefore, it is not a good test to detect bony mets in Ca Breast.

Quote:
Originally Posted by tyagee View Post
A 55-year-old female presents for a 1-week history of low back pain. She denies any recent falls or trauma. She is otherwise well but has a history of breast cancer 2 years ago. She denies any weight loss or night sweats. She denies any bowel or bladder incontinence or lower extremity weakness. Vital signs are heart rate 69 beats/min, respiratory rate 18 breaths/min, blood pressure 133/81 mm Hg, and oxygen saturation 95% on room air. Physical examination reveal minimal lumbar spine pain on palpation and accompanying paraspinal muscle spasm. What is the next step in her management?

A. Bone scan
B. Magnetic resonance imaging
C. Mammogram
D. Nonsteroidal antiinflammatory drugs (NSAIDs)
E. X-ray

Quote:
Originally Posted by tyagee View Post
source is u consult.

Explanation
Option C (Bone scan) is correct. A bone scan helps determine if this is a new or old fracture. She has severe osteoporosis, and it is difficult to tell if this is new by plain radiograph.

Option A (Biochemical markers for bone turnover) is incorrect. These markers are more important in patient management than in acute diagnosis. Bone markers may help determine and monitor the rate of bone turnover. They also help monitor the effectiveness of treatment but are not used in the diagnosis of acute vertebral fracture.

Option B (Biochemical screening for hyperparathyroid disease) is incorrect. This screening is important in management and determination of the suspected osteoporosis of the patient but not in acute diagnosis of a fracture. This test would be part of an extensive osteoporosis evaluation in a patient who develops a compression fracture from coughing.

Option D (Dual-energy x-ray absorptiometry (DEXA) scan) is incorrect. A DEXA scan is important in management of the patient but not acutely. An osteoporosis evaluation is warranted for a patient who develops a compression fracture with a mild stress such as a cough.

Option E (Magnetic resonance imaging of the back) is incorrect. Magnetic resonance imaging (MRI) is not helpful in determining the acuity of the patientís vertebral fracture. The MRI may show compression and some associated inflammation, but it does not help determine if there is active bone disease.
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Old 04-26-2012
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Bone metastases may be osteolytic, sclerotic, or mixed on radiographs (see the first image below). Lesions usually appear in the medullary cavity, spread to destroy the medullary bone, and then involve the cortex. Osteolytic metastases are encountered most frequently, especially in breast and lung carcinomas (see the second image below).[29, 30, 31, 32] The specific appearance of bone metastases is often useful in suggesting the nature of the underlying primary malignancy.
Radiography remains the best method for characterizing bone metastases.

Quote:
Indications for bone scintiscanning include staging in asymptomatic patients, evaluating persistent pain in the presence of equivocal or negative radiographic findings, determining the extent of bone metastases in patients with positive radiograph findings, differentiating metastatic from traumatic fractures by assessing the pattern of involvement, and determining the therapeutic response to metastases.
Nuclear Imaging

Quote:
Results from a recent retrospective study conducted by Memorial Sloan-Kettering Cancer Center investigators suggest that PET/CT scanning might offer the most efficient and effective detection of newly diagnosed breast cancer that has spread to the bone. The new findings may mean less stress and more timely therapy for patients, and could make the longtime use of radionuclide bone scans for breast cancer obsolete in this setting.
http://www.mskcc.org/news/announceme...ast-metastases

Last edited by Novobiocin; 04-26-2012 at 04:43 PM.
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Old 04-26-2012
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http://cancer.swedish.org/types-of-cancer/bone-cancer/
Mentions that's the initial test of choice should be an X-ray.

X-ray When a patient experiences pain that is suspected to be a result of bone cancer, the first step in diagnosis is usually to X-ray the area near the pain. When enough of the healthy bone in any area is worn away by metastatic lesions, the damaged area will show up as a dark spot on the X-ray that look like holes in the bones.
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Old 04-26-2012
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wow. now i m totally confused...

xray as initial option is okay if negative xray prompts bone scan.
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Old 04-26-2012
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Quote:
Originally Posted by tyagee View Post
thats the beauty of this qbank. but neverthless, nice for practise.
I totally agree. I don't think any of us will have any problem answering questions regarding bony mets.
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Old 04-26-2012
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Ok...so according to Wiki... It depends on the patients presentation, whether they are symptomatic or asymptomatic.....

In the detection of bone metastases, skeletal scintigraphy (bone scan) is very sensitive and is recommended as the first imaging study in asymptomatic individuals with suspected breast-cancer metastases.[8] X-ray radiography is recommended if there is abnormal radionuclide uptake from the bone scan and in assessing the risk of pathological fractures, and is recommended as the initial imaging study in patients with bone pain.[8] MRI or the combination PET-CT may be considered for cases of abnormal radionuclide uptake on bone scan, when radiography does not give an acceptably-clear result.[8]

http://en.wikipedia.org/wiki/Metasta..._cancer#Workup
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Old 04-26-2012
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Quote:
Originally Posted by Novobiocin View Post
I totally agree. I don't think any of us will have any problem answering questions regarding bony mets.
I feel like I have spent the whole frekin' day thinking about bone metastasis...and I won't be surprised if I don't get a single question on it
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Old 04-26-2012
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So according to Wiki.... X-ray still remains the Dx of choice since the pt in the stem of the question ( yeah her...we forgot about her ) presents with lower back pain, thus symptomatic..therefore ..shoot for an X-ray.
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Old 04-26-2012
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Originally Posted by usmledee View Post
I feel like I have spent the whole frekin' day thinking about bone metastasis...and I won't be surprised if I don't get a single question on it
Welcome to the club ! (of rotten luck)
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Welcome to the club ! (of rotten luck)
High5...
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  #39  
Old 04-26-2012
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Because your question and the explanation don't add up. You seems to have posted the explanation for some other question.
yup . you are correct. i appreciate your concern. on contrary, i am puzzled by my foolishness.

i searched over and found the correct expln.

Option E (X-ray) is correct. A female patient with back pain and a history of cancer needs to have an x-ray prior to discharge. The possibility of a pathologic fracture and metastatic disease must be addressed prior to discharge. Even if the x-rays are negative, close followup is needed.

Option A (Bone scan) is incorrect. A bone scan may be needed at some point in the workup, but a plain film of the lumbar spine is the first step in her workup.

Option B (Magnetic resonance imaging) is incorrect. The patient has no signs or symptoms of cauda equina syndrome, so an urgent magnetic resonance imaging is unnecessary.

Option C (Mammogram) is incorrect. The patient should be getting yearly mammograms but the only urgent imaging needed in this case is a plain x-ray of the spine.

Option D (Nonsteroidal antiinflammatory drugs (NSAIDs)) is incorrect. The patient may be discharged with NSAIDs for pain control, but given her history of cancer an x-ray is indicated.
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  #40  
Old 04-26-2012
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Originally Posted by tyagee View Post
yup . you are correct. i appreciate your concern. on contrary, i am puzzled by my foolishness.

i searched over and found the correct expln.

Option E (X-ray) is correct. A female patient with back pain and a history of cancer needs to have an x-ray prior to discharge. The possibility of a pathologic fracture and metastatic disease must be addressed prior to discharge. Even if the x-rays are negative, close followup is needed.

Option A (Bone scan) is incorrect. A bone scan may be needed at some point in the workup, but a plain film of the lumbar spine is the first step in her workup.

Option B (Magnetic resonance imaging) is incorrect. The patient has no signs or symptoms of cauda equina syndrome, so an urgent magnetic resonance imaging is unnecessary.

Option C (Mammogram) is incorrect. The patient should be getting yearly mammograms but the only urgent imaging needed in this case is a plain x-ray of the spine.

Option D (Nonsteroidal antiinflammatory drugs (NSAIDs)) is incorrect. The patient may be discharged with NSAIDs for pain control, but given her history of cancer an x-ray is indicated.
Phew...........I am so relieved............thank you so much for putting this thread to rest.
Don't worry, we all make mistakes...........that's what makes us human....................especially when dealing with a stress like USMLE.
But we learned at lot today in the process............maybe God is trying to help us..............you may never know
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Old 04-26-2012
usmledee's Avatar
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Originally Posted by Novobiocin View Post
Phew...........I am so relieved............thank you so much for putting this thread to rest.
Don't worry, we all make mistakes...........that's what makes us human....................especially when dealing with a stress like USMLE.
But we learned at lot today in the process............maybe God is trying to help us..............you never know
Hold on cowboys...I didn't get your opinion on the Wiki link I posted. See above..do you agree...after this you can rest
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Old 04-26-2012
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Hold on cowboys...I didn't get your opinion on the Wiki link I posted. See above..do you agree...after this you can rest
OK, allow me to do a complete dissection:


A 55-year-old female presents for a 1-week history of low back pain.--Acute onset

She denies any recent falls or trauma. but rules out trauma

She is otherwise well but has a history of breast cancer 2 years ago. unlikely to have advanced metastatic disease

She denies any weight loss or night sweats. unlikely to have advanced metastatic disease or lymphonma/ tuberculosis

She denies any bowel or bladder incontinence or lower extremity weakness. unlikely to have spinal cord compression and therefore MRI is not a good answer.

PE-minimal lumbar spine pain on palpation and paraspinal muscle spasm. whatever is causing the pain is in early stages (also due to short history of pain)

What is the next step in her management?

A. Bone scan--Good first test to detect bony lesions when you don't have a focal point of pathology (as compared to this patient)

B. Magnetic resonance imaging--Good test if there is evidence of spinal cord compression.

C. Mammogram--should be already being done as a follow up to her Breast Ca.

D. Nonsteroidal antiinflammatory drugs (NSAIDs)--Not a good answer choice since you never start empiric painkillers in a patient with a h/o Breast ca

E. X-ray

Bottomline:

X-ray- next step in a symptomatic patient with a h/o Breast Ca

Bone scan--next step in a patient with a h/o Breast Ca where you strongly suspect bony mets due to nonspecific symptoms like wt loss , anorexia etc for a longer duration so that the lesions had the time to mount a response towards bone remodelling (osteoblastic reaction) to occur so that the bone scan has a chance to "light up".

Quote:
X-ray radiography is recommended if there is abnormal radionuclide uptake from the bone scan and in assessing the risk of pathological fractures, and is recommended as the initial imaging study in patients with bone pain.

Last edited by Novobiocin; 04-26-2012 at 05:43 PM.
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Ace3 (04-26-2012), docsasmit (07-05-2013), Mondoshawan (04-26-2012), spacecadet (01-23-2013), usmledee (04-26-2012), usmlestep (04-26-2012)



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