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Author [[PageAuthor::Ahmed Zaghw, M.D. [1]]]
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Head and Neck, Neurology, Neurology, Respiratory
Prompt A 65 year old man comes to the clinic with a weakness and not feeling well. He has been in a bad mood since he lost his best friend who died of cancer. Since then, he has been worried a lot about his health. He noticed that he has difficulty raising his right eyelid for the last 6 weeks. His medical history is significant for an ischemic brain stroke 5 years ago, with no residual motor or sensory deficits. He drinks a two glass of red wine every night after the dinner. He has been smoking 1 pack per day for the last 30 years. He is treated for COPD by formeterol and tiotropium. The physical examination shows a ptosis of right eye lid, however the extraocular muscles movement is intact. The full neurological examination does not reveal any abnormality. What would be the best next step in management?
Answer A Order a I131 thyroid scan
Answer A Explanation Incorrect.- Thyroid scan by I131 is used to detect the activity of thyroid masses, like differentiating the hot nodules from cold nodules. It is used in diagnostic evaluation for the thyroid masses, especially when there is associated clinical hypothyroidism or hyperthyroidism. There is no role of thyroid scan in this case.
Answer B Order a chest X-ray
Answer B Explanation Correct.-Chest X-ray is the best first step to evaluate the lung tissue for the lung cancer in high risk patients.
Answer C Order a chest CT
Answer C Explanation Incorrect.- Chest CT is highly sensitive in detecting lung masses, but it is not the first step in the evaluation. It is done as second step after chest Xray. The randomized controlled trials have demonstrated that annual low-dose CT (LDCT) screening in patients with a 30 pack-year history of smoking, including those who quit smoking in the preceding 15 years, demonstrated a decrease in lung cancer and all-cause mortality.
Answer D Order a MRI for brain and orbit
Answer D Explanation Incorrect.- MRI is highly sensitive detecting masses and fluid especially in soft tissues.It has highly sensitive in orbital lesions and brain however according to the clinical history it is not needed to be done in that case.
Answer E Order a fasting blood sugar
Answer E Explanation Incorrect.- Fasting Sugar is the initial test when Diabetes Mellitus is highly suspected.
Right Answer B
Explanation [[Explanation::Educational Objective:Evaluation of the high risk group for lung cancer should start with Chest X-ray, but CT is mandatory second step as it is more sensitive.

References: The 2013 systematic review for the US Preventive Services Task Force (USPSTF),Ann Intern Med. 2013;159(6):411.

Educational Objective:
References: ]]

Approved No
Keyword Lung cancer screening
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