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5212 Medicine

A 73-year-old woman presents with increasing weakness, most noticeable in the legs. She has noticed some cramping and weakness in the upper extremities as well. She has more difficulty removing the lids from jars than before. She has noticed some stiffness in the neck but denies back pain or injury. There is no bowel or bladder incontinence. She takes naproxen for osteoarthritis and is on alendronate for osteoporosis. She smokes one pack of cigarettes daily. The general physical examination reveals decreased range of motion in the cervical spine. On neurological examination, the patient has 4/5 strength in the hands with mild atrophy of the interosseous muscles. She also has 4/5 strength in the feet; the weakness is more prominent in the distal musculature. She has difficulty with both heel walking and toe walking. Reflexes are hyperactive in the lower extremities. Sustained clonus is demonstrated at the ankles. What is the best next step in her management?

AObtain MRI scan of the head
BBegin riluzole
CObtain MRI scan of the cervical spine
DCheck muscle enzymes including creatine kinase and aldolase
Medicine
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