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A 60-Year-Old Man Is Brought to the Office Due to Difficulty

question 262

Multiple Choice

A 60-year-old man is brought to the office due to difficulty walking. He reports being "weak" and describes occasional brief episodes of intense back pain. Review of systems is negative for constitutional, pulmonary, cardiac, genitourinary, or other neurologic symptoms, including memory concerns. He has no known medical problems except for a remote history of treated pulmonary tuberculosis. The patient recently emigrated from China to the United States to live with his daughter after his wife died. His daughter says that he is afraid of doctors and has not been evaluated for many years. He does not use tobacco, alcohol, or recreational drugs.
Blood pressure is 138/64 mm Hg and pulse is 74/min. Lung examination is normal. Cardiac auscultation reveals an early diastolic murmur in the aortic area. The abdomen is soft and nontender. Rectal examination shows an unremarkable prostate and normal rectal tone. Motor strength is normal. Bilateral lower extremity reflexes are diminished, and vibration and position sensation is decreased. The patient's gait is unsteady and broad-based.
Laboratory results are as follows:

ECG shows normal sinus rhythm. Chest x-ray reveals left upper lobe scarring, widened mediastinum, and calcifications of the ascending aorta and aortic arch.
Which of the following is most helpful in establishing the diagnosis?

Definitions:

Customers Pay

refers to the transactions where customers remit payment for goods or services received from a business.

Prepaid Freight

Costs paid by a shipper in advance for shipment of goods, indicating that the sender bears the freight charges.

Cash Discount

A reduction in the invoice price offered to buyers as an incentive for early payment.

Wholesalers

Companies that sell merchandise to other businesses rather than to the public.