A 57-Year-Old Man Comes to the Office Due to Constant

A 57-year-old man comes to the office due to constant middle and low thoracic back pain.  The pain started 4 weeks ago and has progressively worsened.  It is greatest at night, particularly when he lies down.  The patient has had no trauma to the back and has no bowel or bladder symptoms.  Review of systems is positive for a 4.5 kg (10 lb) weight loss and fatigue.  He has no chronic medical conditions and takes no medications other than a multivitamin.  The patient has smoked cigarettes since high school and occasionally drinks beer on weekends.  Temperature is 37 C (98.6 F) , blood pressure is 110/70 mm Hg, pulse is 80/min, and respirations are 16/min.  BMI is 28 kg/m².  Examination of the spine shows no focal tenderness, and spinal range of motion is normal.  Straight leg raise testing does not elicit pain.  Muscle strength and sensation are intact in the lower extremities.  Deep tendon reflexes are 2+ bilaterally.  Babinski sign is absent.  X-ray of the spine shows no abnormalities.  Complete blood count and serum creatinine are within normal limits.  Which of the following is the most appropriate next step in management?

A) Blood culture
B) Bone marrow biopsy
C) CT scan of the abdomen
D) Physical therapy
E) Sacroiliac joint x-ray
F) Upper gastrointestinal endoscopy

Correct Answer:

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