CT scan principles and interpretation — MCQs

10 questions

A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

A 72-year-old female is brought to the emergency department after being found unresponsive in her garage with an open bottle of unmarked fluid. She is confused and is unable to answer questions on arrival. Her medical history is significant for Alzheimer disease, but her family says she has no medical comorbidities. Serum analysis of this patient's blood shows a pH of 7.28 with a high anion gap. The electrolyte that is most likely significantly decreased in this patient follows which of the following concentration curves across the proximal tubule of the kidney?

A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

A novel PET radiotracer is being evaluated for its ability to aid in the diagnosis of Alzheimer’s disease (AD). The study decides to use a sample size of 1,000 patients, and half of the patients enrolled have AD. In the group of patients with AD, 400 are found positive on the novel type of PET imaging examination. In the control group, 50 are found positive. What is the PPV of this novel exam?

A 64-year-old man presents to the office for an annual physical examination. He has no complaints at this visit. His chart states that he has a history of hypertension, chronic obstructive pulmonary disease (emphysema), Raynaud’s disease, and glaucoma. He is a 30 pack-year smoker. His medications included lisinopril, tiotropium, albuterol, nifedipine, and latanoprost. The blood pressure is 139/96 mm Hg, the pulse is 86/min, the respiration rate is 16/min, and the temperature is 37.2°C (99.1°F). On physical examination, his pupils are equal, round, and reactive to light. The cardiac auscultation reveals an S4 gallop without murmur, and the lungs are clear to auscultation bilaterally. However, the inspection of the chest wall shows an enlarged anterior to posterior diameter. Which of the following is the most appropriate screening test for this patient?

A 45-year-old man with a 15-pack-year smoking history is referred for pulmonary function testing. On physical exam, he appears barrel-chested and mildly overweight, but breathes normally. Which of the following tests will most accurately measure his total lung capacity?

A 45-year-old man presents for a follow-up visit as part of his immigration requirements into the United States. Earlier this week, he was administered the Mantoux tuberculin skin test (TST). Today’s reading, 3 days after being administered the test, he shows an induration of 10 mm. Given his recent immigration from a country with a high prevalence of tuberculosis, he is requested to obtain a radiograph of the chest, which is shown in the image. Which of the following is true regarding this patient’s chest radiograph (CXR)?

Following passage of a calcium oxalate stone, a 55-year-old male visits his physician to learn about nephrolithiasis prevention. Which of the following changes affecting urine composition within the bladder are most likely to protect against crystal precipitation?

A 27-year-old man presents to the emergency department with back pain. The patient states that he has back pain that has been steadily worsening over the past month. He states that his pain is worse in the morning but feels better after he finishes at work for the day. He rates his current pain as a 7/10 and says that he feels short of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. On physical exam, you note a young man who does not appear to be in any distress. Cardiac exam is within normal limits. Pulmonary exam is notable only for a minor decrease in air movement bilaterally at the lung bases. Musculoskeletal exam reveals a decrease in mobility of the back in all four directions. Which of the following is the best initial step in management of this patient?

Q10

A 52-year-old man is brought to the emergency department with a 2-hour history of severe, sudden-onset generalized headache. He has since developed nausea and has had one episode of vomiting. The symptoms began while he was at home watching television. Six days ago, he experienced a severe headache that resolved without treatment. He has hypertension and hyperlipidemia. The patient has smoked two packs of cigarettes daily for 30 years. His current medications include lisinopril-hydrochlorothiazide and simvastatin. His temperature is 38.1°C (100.6°F), pulse is 82/min, respirations are 16/min, and blood pressure is 162/98 mm Hg. The pupils are equal, round, and reactive to light. Fundoscopic examination shows no swelling of the optic discs. Cranial nerves II–XII are intact. He has no focal motor or sensory deficits. Finger-to-nose and heel-to-shin testing are normal. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate next step in management?

CT scan principles and interpretation US Medical PG Practice Questions and MCQs

Question 1: A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

A. AP and lateral radiographs of hips
B. Lateral radiograph (x-ray) of hips
C. Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area
D. Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area
E. Computed tomography (CT) scan of cervical spine, hips, and lumbar area (Correct Answer)

Explanation: ***Computed tomography (CT) scan of cervical spine, hips, and lumbar area*** - In **high-energy trauma** (fall from height), a CT scan is the **gold standard** for evaluating the **spine and pelvis**, providing detailed cross-sectional images superior to plain radiographs. - Since the **cervical exam was not performed**, cervical spine imaging is **mandatory** per ATLS (Advanced Trauma Life Support) protocols. High-energy falls carry significant risk of **cervical spine injury** even without obvious neurological symptoms. - CT allows comprehensive assessment of **hip fractures, pelvic injuries, and the entire spine** (cervical, thoracic, lumbar), identifying both obvious and **subtle fractures** that may be missed on plain films. - This approach provides the most **efficient and thorough evaluation** in the acute trauma setting, allowing for appropriate surgical planning and ruling out life-threatening spinal instability. *AP and lateral radiographs of hips* - Plain radiographs provide **limited detail** and may **miss subtle fractures**, particularly in complex areas like the pelvis and acetabulum. - This option **fails to address cervical spine clearance**, which is essential in all high-energy trauma patients, especially when cervical exam has not been performed. - Radiographs are insufficient for **comprehensive trauma evaluation** after a fall from height. *Lateral radiograph (x-ray) of hips* - A single lateral view is **grossly insufficient** for evaluating hip and pelvic fractures, providing only a **two-dimensional perspective** that can miss significant injuries. - This option **completely neglects spinal evaluation**, which is dangerous in an uncleared trauma patient with a high-energy mechanism. *Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area* - While MRI excels at evaluating **soft tissues, ligaments, and bone marrow**, it is **not the initial imaging modality** for acute bony trauma due to longer scan times and lower sensitivity for acute fractures compared to CT. - MRI is **time-consuming and impractical** in the emergency setting for initial fracture assessment, potentially delaying definitive treatment. - CT is superior for evaluating **acute skeletal injuries** in the trauma bay. *Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area* - Multiple plain radiographs have **limited sensitivity** for complex or non-displaced fractures, particularly in the **spine and pelvis**, making them inadequate for high-energy trauma evaluation. - Obtaining multiple radiographic views requires **numerous patient repositionings**, which risks further injury if **spinal instability** is present. - Plain films provide significantly **less diagnostic information** than CT scanning for trauma assessment.

Question 2: A 72-year-old female is brought to the emergency department after being found unresponsive in her garage with an open bottle of unmarked fluid. She is confused and is unable to answer questions on arrival. Her medical history is significant for Alzheimer disease, but her family says she has no medical comorbidities. Serum analysis of this patient's blood shows a pH of 7.28 with a high anion gap. The electrolyte that is most likely significantly decreased in this patient follows which of the following concentration curves across the proximal tubule of the kidney?

A. Curve C
B. Curve E
C. Curve B
D. Curve A
E. Curve D (Correct Answer)

Explanation: ***Curve D*** - The patient presents with **high anion gap metabolic acidosis**, which, in the context of an unknown fluid ingestion, is highly suggestive of **methanol** or **ethylene glycol poisoning**. These toxins are metabolized into toxic acids (**formic acid** from methanol; **glycolic acid, oxalic acid** from ethylene glycol). - These toxic acid anions displace **bicarbonate** (HCO3-) in the blood to maintain electroneutrality, leading to a **decreased bicarbonate level**. Curve D represents bicarbonate, which is largely reabsorbed in the proximal tubule but significantly reduced in this scenario. *Curve C* - This curve likely represents a substance like **phosphate** or **urea**, which is partially reabsorbed and partially excreted. - While phosphate levels can be affected in various metabolic derangements, it's not the primary electrolyte significantly decreased in **high anion gap metabolic acidosis** from toxic alcohol ingestion. *Curve E* - This curve typically represents a substance that is **filtered and then minimally reabsorbed** or even secreted, such as **creatinine** or **potassium** when excess is being excreted. - **Potassium** levels can be variable in acidosis but are not typically the most significantly decreased electrolyte in this poisoning scenario. *Curve B* - This curve would normally represent an electrolyte that is **highly reabsorbed** in the proximal tubule, with very little remaining. - This might represent substances like **glucose** (under normal conditions) or **amino acids**, which are not the primary electrolyte affected in this case. *Curve A* - This curve represents a substance that is **freely filtered** and then **neither reabsorbed nor secreted** significantly in the proximal tubule, such as **inulin**. - This pattern does not correspond to an electrolyte whose level would be significantly decreased due to high anion gap metabolic acidosis.

Question 3: A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

A. Doppler ultrasound of the carotids
B. CT head with intravenous contrast
C. MRI head without intravenous contrast
D. CT head without intravenous contrast (Correct Answer)
E. MRI head with intravenous contrast

Explanation: ***CT head without intravenous contrast*** - The sudden onset of severe headache, visual disturbances, and neurological deficits (inability to move extremities), coupled with uncontrolled severe hypertension despite initial treatment, is highly suggestive of an **intracranial pathology**, most likely a **hemorrhagic stroke**. - A **non-contrast CT scan of the head** is the **gold standard** for rapidly identifying acute intracranial hemorrhage, as it can be performed quickly and is readily available in emergency settings. *Doppler ultrasound of the carotids* - This test is primarily used to evaluate **carotid artery stenosis** due to atherosclerosis, which can lead to ischemic stroke. - While the patient has risk factors for atherosclerosis, his acute presentation with severe central neurological symptoms points more towards an acute intracranial event rather than carotid disease. *CT head with intravenous contrast* - While a contrast CT can be useful for identifying tumors, abscesses, or vascular malformations, it is **contraindicated in the initial assessment of acute stroke** if an intracranial hemorrhage is suspected. - Contrast can sometimes obscure subtle bleeds or complicate the interpretation of acute hemorrhage, and it also carries a risk of **contrast-induced nephropathy**, especially in a patient with diabetes. *MRI head without intravenous contrast* - An MRI provides superior soft tissue resolution compared to CT and is excellent for detecting ischemic strokes in later stages, as well as subtle hemorrhages, tumors, and other conditions. - However, it is **less available, takes longer to perform**, and is often not the first choice in an acute neurological emergency where time is critical, particularly when differentiating between ischemic and hemorrhagic stroke. *MRI head with intravenous contrast* - Similar to a contrast CT, an MRI with contrast is generally **not the initial imaging choice for acute stroke** due to time constraints and the need to quickly rule out hemorrhage before considering contrast administration. - Contrast agents for MRI, such as gadolinium, have their own risks, including **nephrogenic systemic fibrosis** in patients with renal impairment, which is a concern in a diabetic patient.

Question 4: A novel PET radiotracer is being evaluated for its ability to aid in the diagnosis of Alzheimer’s disease (AD). The study decides to use a sample size of 1,000 patients, and half of the patients enrolled have AD. In the group of patients with AD, 400 are found positive on the novel type of PET imaging examination. In the control group, 50 are found positive. What is the PPV of this novel exam?

A. 400 / (400+50) (Correct Answer)
B. 450 / (450 + 100)
C. 400 / (400+100)
D. 450 / (450 + 50)
E. 400 / (400 + 150)

Explanation: ***400 / (400+50)*** - The **Positive Predictive Value (PPV)** is the probability that subjects with a positive test result actually have the disease. It's calculated as **True Positives / (True Positives + False Positives)**. - In this scenario, **True Positives** are 400 (patients with AD who tested positive), and **False Positives** are 50 (control patients without AD who tested positive). *450 / (450 + 100)* - This calculation incorrectly includes **False Negatives** (450, total AD patients - true positives) in the numerator or denominator for PPV, and misidentifies other components. - The formula for PPV specifically focuses on positive test results and the proportion of those that are truly disease-positive. *400 / (400+100)* - This option correctly identifies **True Positives** as 400 but incorrectly assumes **False Positives** are 100. - The problem states that 50 control patients (without AD) tested positive, which are the false positives. *450 / (450 + 50)* - This formula incorrectly uses **450** as the number of **True Positives**, which represents the total number of patients with AD testing positive and negative (400 TP + 100 FN). - PPV only considers those who tested positive in its numerator. *400 / (400 + 150)* - While 400 is correctly identified as **True Positives**, the **False Positives** are incorrectly stated as 150. - The problem explicitly states that 50 control patients were found positive, making 50 the correct number for false positives.

Question 5: A 64-year-old man presents to the office for an annual physical examination. He has no complaints at this visit. His chart states that he has a history of hypertension, chronic obstructive pulmonary disease (emphysema), Raynaud’s disease, and glaucoma. He is a 30 pack-year smoker. His medications included lisinopril, tiotropium, albuterol, nifedipine, and latanoprost. The blood pressure is 139/96 mm Hg, the pulse is 86/min, the respiration rate is 16/min, and the temperature is 37.2°C (99.1°F). On physical examination, his pupils are equal, round, and reactive to light. The cardiac auscultation reveals an S4 gallop without murmur, and the lungs are clear to auscultation bilaterally. However, the inspection of the chest wall shows an enlarged anterior to posterior diameter. Which of the following is the most appropriate screening test for this patient?

A. Low-dose CT (Correct Answer)
B. Bronchoalveolar lavage with cytology
C. Magnetic resonance imaging
D. Pulmonary function tests
E. Chest radiograph

Explanation: ***Low-dose CT*** - This patient, a 64-year-old with a 30 pack-year smoking history and current emphysema (COPD), falls precisely within the **high-risk criteria** for lung cancer screening. - The **USPSTF guidelines** recommend annual **low-dose computed tomography (LDCT)** for individuals aged 50-80 years with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. *Bronchoalveolar lavage with cytology* - This is an **invasive diagnostic procedure** used to collect cells and fluid directly from the airways, typically performed when there is already suspicion of a lung malignancy or infection. - It is not a recommended **screening test** for asymptomatic individuals due to its invasiveness and the absence of clear evidence of benefit as a primary screening tool. *Magnetic resonance imaging* - **MRI** is primarily used for evaluating soft tissue structures, defining tumor extent, and assessing metastatic disease, but it is **not the preferred imaging modality for lung cancer screening** due to its lower spatial resolution for pulmonary nodules compared to CT and higher cost. - It involves longer scan times and is not routinely used for primary lung screening. *Pulmonary function tests* - **PFTs** are used to assess lung function, diagnose and monitor respiratory conditions like COPD, and evaluate the severity of airflow obstruction. - While important for managing his **emphysema**, PFTs do not directly screen for **lung cancer**; they measure how well the lungs work. *Chest radiograph* - A **chest X-ray** is less sensitive than LDCT for detecting small lung nodules and early-stage lung cancer due to its two-dimensional nature and potential for superimposition of structures. - While readily available and less expensive, it is **not recommended for lung cancer screening** as it has not shown a mortality benefit in randomized controlled trials compared to no screening.

Question 6: A 45-year-old man with a 15-pack-year smoking history is referred for pulmonary function testing. On physical exam, he appears barrel-chested and mildly overweight, but breathes normally. Which of the following tests will most accurately measure his total lung capacity?

A. Exhaled nitric oxide
B. Closed-circuit helium dilution
C. Spirometry
D. Body plethysmography (Correct Answer)
E. Open-circuit nitrogen washout

Explanation: ***Body plethysmography*** - This method accurately measures **total lung capacity (TLC)** by applying **Boyle's Law**, assessing pressure and volume changes within an enclosed chamber. - It is superior to gas dilution methods for patients with **air trapping** or **poor ventilation distribution**, as it measures all gas in the chest, including trapped air. *Exhaled nitric oxide* - This test measures **airway inflammation**, particularly in conditions like asthma, but does not assess lung volumes. - It is useful for monitoring treatment response and disease severity but does not provide information about **Total Lung Capacity (TLC)**. *Closed-circuit helium dilution* - This method estimates **lung volumes** by diluting a known concentration of helium, but it underestimates **TLC** in patients with significant **air trapping** because helium cannot equilibrate with unventilated areas. - Given the patient's **barrel chest** suggestive of air trapping, this method would be less accurate for measuring his true TLC. *Spirometry* - Spirometry measures **forced vital capacity (FVC)** and **forced expiratory volume in one second (FEV1)**, which are dynamic lung volumes reflecting airflow limitation. - It does not directly measure **Total Lung Capacity (TLC)** or **residual volume**, as it cannot measure the air remaining in the lungs after maximal exhalation. *Open-circuit nitrogen washout* - This method estimates **functional residual capacity (FRC)** by washing out nitrogen from the lungs with 100% oxygen, but like helium dilution, it can underestimate volumes in patients with **air trapping**. - It provides an estimate of the gas that communicates with the airways, excluding any **trapped gas**.

Question 7: A 45-year-old man presents for a follow-up visit as part of his immigration requirements into the United States. Earlier this week, he was administered the Mantoux tuberculin skin test (TST). Today’s reading, 3 days after being administered the test, he shows an induration of 10 mm. Given his recent immigration from a country with a high prevalence of tuberculosis, he is requested to obtain a radiograph of the chest, which is shown in the image. Which of the following is true regarding this patient’s chest radiograph (CXR)?

A. Posterior ribs 9 and 10 are visible only in an expiratory film.
B. The right lower boundary of the mediastinal silhouette belongs to the right ventricle.
C. If the spinous process is not in-between the two clavicular heads, the image is repeated. (Correct Answer)
D. The film is taken in a supine position.
E. The view is anteroposterior (AP).

Explanation: ***If the spinous process is not in-between the two clavicular heads, the image is repeated.*** - Proper patient positioning is crucial for an accurate chest X-ray; **rotation of the patient** can distort the appearance of the heart and lungs, simulating pathology or obscuring real findings. - Symmetrical positioning, indicated by the **spinous process being equidistant from the medial ends of the clavicles**, ensures an ideal posteroanterior (PA) view for interpretation. *Posterior ribs 9 and 10 are visible only in an expiratory film.* - In a properly **inspired chest X-ray**, at least 9 or 10 posterior ribs (or 5-6 anterior ribs) should be visible above the diaphragm. - If fewer ribs are visible on a standard PA film, it indicates a **poor inspiratory effort**, which can compress lung fields and mimic pathology. *The right lower boundary of the mediastinal silhouette belongs to the right ventricle.* - The **right lower boundary of the mediastinal silhouette** is formed by the right atrium, not the right ventricle. - The right ventricle forms part of the **anterior cardiac border** and is typically not seen as a distinct border on a standard PA chest X-ray. *The film is taken in a supine position.* - The presence of the **gastric bubble visible below the left hemidiaphragm** confirms an upright position, as gas rises in the stomach. - A supine film would typically result in a **magnified cardiac silhouette** and less prominent gastric air. *The view is anteroposterior (AP).* - In an AP view, the **medial ends of the clavicles overlay the lung apices**, and the scapulae are often within the lung fields; this image shows the scapulae largely clear of the lung fields, consistent with a PA view. - AP films also tend to **magnify the heart shadow** due to the divergent X-ray beam, which is not evident here.

Question 8: Following passage of a calcium oxalate stone, a 55-year-old male visits his physician to learn about nephrolithiasis prevention. Which of the following changes affecting urine composition within the bladder are most likely to protect against crystal precipitation?

A. Decreased calcium, increased citrate, increased oxalate, increased free water clearance
B. Increased calcium, increased citrate, increased oxalate, increased free water clearance
C. Decreased calcium, increased citrate, decreased oxalate, increased free water clearance (Correct Answer)
D. Decreased calcium, increased citrate, increased oxalate, decreased free water clearance
E. Decreased calcium, decreased citrate, increased oxalate, increased free water clearance

Explanation: ***Decreased calcium, increased citrate, decreased oxalate, increased free water clearance*** - **Decreased urinary calcium** and **oxalate** reduce the availability of precursor ions for calcium oxalate crystal formation - **Increased urinary citrate** acts as a complexing agent with calcium, preventing its binding to oxalate and inhibiting crystal growth - **Increased free water clearance** leads to dilution of all urinary solutes, reducing supersaturation and preventing crystal precipitation - All four factors work synergistically to provide maximum protection against nephrolithiasis *Decreased calcium, increased citrate, increased oxalate, increased free water clearance* - While decreased calcium, increased citrate, and increased free water clearance are protective, **increased oxalate** significantly increases the risk of calcium oxalate stone formation - Oxalate is a primary component of calcium oxalate stones, and its increased concentration would counteract other protective mechanisms *Increased calcium, increased citrate, increased oxalate, increased free water clearance* - **Increased urinary calcium** and **oxalate** are both risk factors for calcium oxalate stone formation, directly promoting supersaturation - Although increased citrate and free water clearance are protective, they are unlikely to fully offset the increased risk posed by high calcium and oxalate levels *Decreased calcium, increased citrate, increased oxalate, decreased free water clearance* - Although decreased calcium and increased citrate are beneficial, **increased oxalate** and **decreased free water clearance** (leading to more concentrated urine) would both increase the likelihood of crystal precipitation - The combination of increased oxalate and reduced dilution would outweigh the protective effects *Decreased calcium, decreased citrate, increased oxalate, increased free water clearance* - **Decreased urinary citrate** reduces its inhibitory effect on calcium oxalate stone formation, while **increased oxalate** directly promotes crystal precipitation - These two risk factors would largely negate the preventative effects of decreased calcium and increased free water clearance

Question 9: A 27-year-old man presents to the emergency department with back pain. The patient states that he has back pain that has been steadily worsening over the past month. He states that his pain is worse in the morning but feels better after he finishes at work for the day. He rates his current pain as a 7/10 and says that he feels short of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. On physical exam, you note a young man who does not appear to be in any distress. Cardiac exam is within normal limits. Pulmonary exam is notable only for a minor decrease in air movement bilaterally at the lung bases. Musculoskeletal exam reveals a decrease in mobility of the back in all four directions. Which of the following is the best initial step in management of this patient?

A. MRI of the sacroiliac joint (Correct Answer)
B. CT scan of the chest
C. Pulmonary function tests
D. Ultrasound
E. Radiography of the lumbosacral spine

Explanation: ***MRI of the sacroiliac joint*** - The patient's symptoms of **worsening back pain**, morning stiffness that improves with activity, and decreased back mobility are highly suggestive of **ankylosing spondylitis**. - **MRI** is the most sensitive imaging modality for detecting early inflammatory changes in the **sacroiliac joints** and spine, which are characteristic of ankylosing spondylitis, even before radiographic changes are visible. *CT scan of the chest* - While the patient reports feeling **short of breath**, his vital signs and oxygen saturation are normal, and he does not appear in acute distress. - A CT scan of the chest would be a more appropriate step if there were clearer signs of acute pulmonary pathology, such as significant hypoxemia, fever, or adventitious lung sounds, which are not present here. *Pulmonary function tests* - **Shortness of breath** could eventually be a complication of severe ankylosing spondylitis due to restricted chest wall expansion. - However, PFTs are generally not the *initial* diagnostic step given the primary presentation of back pain and the need to confirm the underlying rheumatologic condition first. *Ultrasound* - **Ultrasound** is not a primary imaging modality for evaluating the sacroiliac joints or the spine in the context of suspected ankylosing spondylitis. - It could be useful for assessing peripheral joint inflammation in other arthropathies, but not for axial involvement. *Radiography of the lumbosacral spine* - **X-rays of the lumbosacral spine** might show changes in advanced ankylosing spondylitis (e.g., squaring of vertebrae, syndesmophytes), but they are often normal in the early stages of the disease. - **MRI** is superior for detecting early inflammatory changes and is often used to diagnose the condition before radiographic damage is evident.

Question 10: A 52-year-old man is brought to the emergency department with a 2-hour history of severe, sudden-onset generalized headache. He has since developed nausea and has had one episode of vomiting. The symptoms began while he was at home watching television. Six days ago, he experienced a severe headache that resolved without treatment. He has hypertension and hyperlipidemia. The patient has smoked two packs of cigarettes daily for 30 years. His current medications include lisinopril-hydrochlorothiazide and simvastatin. His temperature is 38.1°C (100.6°F), pulse is 82/min, respirations are 16/min, and blood pressure is 162/98 mm Hg. The pupils are equal, round, and reactive to light. Fundoscopic examination shows no swelling of the optic discs. Cranial nerves II–XII are intact. He has no focal motor or sensory deficits. Finger-to-nose and heel-to-shin testing are normal. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Obtain an MRI scan of the head
B. Repeat CT scan in 24 hours
C. Administer 100% oxygen and intranasal sumatriptan
D. Place ventriculoperitoneal shunt
E. Obtain a lumbar puncture (Correct Answer)

Explanation: ***Obtain a lumbar puncture*** - The sudden onset of a "thunderclap" headache, especially if severe and generalized, is highly suspicious for **subarachnoid hemorrhage (SAH)**, even with a normal CT scan. An earlier, resolving headache ( sentinel headache) further supports this. - A **lumbar puncture (LP)** is the gold standard for diagnosing SAH when a CT scan is negative, as it can detect **xanthochromia** (yellowish discoloration of CSF due to bilirubin degradation of red blood cells), indicating prior bleeding. *Obtain an MRI scan of the head* - While an MRI can detect SAH, especially in later stages, it is **less sensitive than LP** for acute SAH, particularly within the first few hours or if the bleed is small. - MRI is generally reserved for situations where a CT scan is normal and LP is equivocal or contraindicated, or to investigate other potential causes of headache like lesions or thrombosis. *Repeat CT scan in 24 hours* - Repeating the CT scan in 24 hours is **not the most appropriate immediate action** as it will delay definitive diagnosis of SAH, which is a medical emergency requiring prompt management. - While a repeat CT might show subtle changes, an LP is a more sensitive and direct method to confirm or rule out SAH in this clinical scenario. *Administer 100% oxygen and intranasal sumatriptan* - This treatment is appropriate for **cluster headaches** or **migraine**, which typically have a different presentation (e.g., specific aura, unilateral pain, autonomic symptoms for cluster headache). - Given the high suspicion for SAH, administering these medications would delay proper diagnosis and management, which could be life-threatening. *Place ventriculoperitoneal shunt* - A ventriculoperitoneal shunt is used to treat **hydrocephalus**, a condition characterized by excessive CSF accumulation in the brain. - There are no clinical signs or symptoms (e.g., papilledema, altered mental status with focal neurological deficits) in this patient to suggest hydrocephalus requiring immediate shunting.

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