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Old 10-09-2012
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Arrow Gyrus Daily Questions; Internal Medicine #47

A 29-year-old man being treated for lung cancer comes into your office for an acute visit. He has had back-ache for a few weeks that has improved with ibuprofen but has developed right lower abdominal pain and inguinal pain. On physical examination, he has tenderness over the lower thoracic spinous processes and hyperesthesia in the T11 distribution on the right. Strength is normal in the up-per extremities, but he has symmetric weakness in the lower extremities with hyperreflexia. He also has decreased sensation below the T11 distribution symmetrically. What is the next step in the management of this patient?
A. Add gabapentin to his pain regimen.
B. Order a paraneoplastic antibody panel.
C. Start treatment with glucocorticoids.
D. Order thoracic and lumbar radiographs
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Ans--D. Order thoracic and lumbar radiograph
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MM good questions, I have seen several that are similar, some ask for an acute management due presence of neurological symptoms and some for workup.. I will say C, to decompress.
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(C) Deccompression
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Agree with the gentlemen - C, decompress, prevent further damage and then all the rest.

Radiology prolly will not be of a great help anyway...
If its a metastases (as in P.T.Barnum Loves Kids, the malignancies that metastasize to the bone and L is for Lung) I would maybe do a CT or better MRI to confirm the distant spread
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Quote:
Originally Posted by cingulate.gyrus View Post
A 29-year-old man being treated for lung cancer comes into your office for an acute visit. He has had back-ache for a few weeks that has improved with ibuprofen but has developed right lower abdominal pain and inguinal pain. On physical examination, he has tenderness over the lower thoracic spinous processes and hyperesthesia in the T11 distribution on the right. Strength is normal in the up-per extremities, but he has symmetric weakness in the lower extremities with hyperreflexia. He also has decreased sensation below the T11 distribution symmetrically. What is the next step in the management of this patient?
A. Add gabapentin to his pain regimen.
B. Order a paraneoplastic antibody panel.
C. Start treatment with glucocorticoids.
D. Order thoracic and lumbar radiographs
C best initial treatment for cord compression is CS
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Old 10-09-2012
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The answer is
C. Start treatment with glucocorticoids.

Remember most important point in back pain is Spinal tenderness- implies cord compression : Conrad Fisher.

Spinal cord compression from solid tumor metastases usually results from growth of a bony vertebral metastasis into the epidural space.

The most common primary tumors that metastasize to the bone include lung, breast, and prostate.

The thoracic cord is most often involved. Back pain is a prominent symptom in 90% of patients with vertebral metastases and spinal cord compression. Concerning features of this patientís presentation include the symptoms of radicular injury as well as the signs of radicular and spinal cord impingement on physical examination. Once signs of spinal cord compression
develop, they usually progress rapidly and warrant rapid therapy.

Appropriate therapy includes emergent scanning with an MRI as well as immediate glucocorticoids if there are signs of spinal cord impingement.Subsequent management will depend on the extent of involvement and the primary tumor.

Conservative pain management measures are not appropriate
in this patient since he has very concerning neurologic findings for spinal cord
compression and delay will increase the likelihood of irreversible defects. Antibody-mediated paraneoplastic neurologic syndromes are unlikely to cause focal findings such as in this patient.


Radiographs may show bony metastases but will not show spinal cord damage
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C. Start treatment with glucocorticoids.
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