A 58-Year-Old Man Is Brought to the Emergency Department 30

question 800

Multiple Choice

A 58-year-old man is brought to the emergency department 30 minutes after a generalized tonic-clonic seizure.  His wife witnessed the event and says the patient was watching television, suddenly developed twitching of the left hand, and then lost consciousness and had generalized shaking.  The event lasted approximately 1 minute.  He spontaneously regained consciousness but has been confused.  The patient has no history of seizure, head trauma, or other medical problems, but over the past few months he has had a persistent cough, anorexia, and fatigue and has lost 10 kg (22 lb) .  He has not seen a physician in 20 years and takes no medications.  The patient is a current smoker with a 30-pack-year history and drinks alcohol occasionally.  Temperature is 37.2 C (99 F) , blood pressure is 138/86 mm Hg, and pulse is 94/min and regular.  The patient is somnolent but easily arousable.  Bilateral pupils are equal and briskly reactive to light.  There is no focal weakness, and deep tendon reflexes are 2+ throughout.  Digital clubbing is present and there are several right-sided, enlarged, nonmobile supraclavicular lymph nodes.  Blood cell counts and serum chemistry studies are within normal limits, except for a serum calcium level of 10.6 mg/dL.  MRI of the brain reveals a 1-cm mass in the gray-white junction of the right frontal lobe with mild surrounding edema.  Imaging of the chest and abdomen reveals a 6-cm right lung mass, multiple enlarged hilar and mediastinal lymph nodes, and several liver lesions of 1-3 cm.  Which of the following is the most appropriate next step in establishing the diagnosis in this patient?

• A)CT-guided biopsy of the lung mass
• B)Excisional biopsy of the supraclavicular lymph node
• C)Stereotactic biopsy of the brain lesion
• D)Transbronchial biopsy of hilar lymph node
• E)Ultrasonography-guided biopsy of the liver lesion