Student cases

Occam’s Razor cuts deep

After a bit of a hiatus, we re-start up the Med Student Case of the Week!

Our patient is a man in his 60’s who presents to the ED with a chief complaint of shoulder pain for a few months.  He does not report having injured or strained it, but has been increasingly experiencing pain in his thoracic back and right shoulder.   Despite over-the-counter NSAID’s, the pain has been getting more intense.  He’s had intermittent numbness of the R arm over a similar period of time.  Over the last few days he’s been feeling weak overall and increasingly short of breath.  What finally brought him to the ED after years of not seeing doctors was that he spit up some blood and passed some blood in his stool over the weekend.

Let’s analyze where we are so far.  We have on one hand a man presenting with symptoms that have been present for months.  Almost any EP would feel a bit of his or her soul dribble out their ears as they pick up that chart.  But keeping an open mind and sticking with the history some other concerning findings start cropping up.  He doesn’t see doctors.  The presence of neuro symptoms is always concerning though a lot of times numbness is a difficult one to get a handle upon.  The presence of the blood is quite interesting.  A lot of times it can be difficult to determine whether blood is of respiratory or GI origin.  

It’s always nice to come up with one unifying diagnosis.  Where does the Venn Diagram of Chronic Back pain and Hemoptysis/hematemesis intersect?  I can think of three fairly straightforward answers.  PE probably has to be on the differential given hemoptysis, pain, and shortness of breath.  It would be odd for it to cause pain for months though so let’s look at some other options.  If the blood is of a GI source how would that connect with the back?  Referred shoulder pain from a splenic problem is a common board question; I don’t know that I’ve ever heard of an ulcer directly causing shoulder pain however.  It could certainly be two related processes; the scenario that we probably encounter most often would be a patient over-using NSAID’s in an attempt to treat the pain and ending up with an ulcer.  There’s a third solution however.  Malignancy could easily account for hemoptysis and bony mets could explain the neuro symptoms.  

In my mind the difference between a 3rd year student and a 4th year student is that the 3rd year is merely a reporter of symptoms whereas the 4th year is learning to analyze what the patient reports.  What are some additional questions (and exam findings!) that would help support our various theories?

With regards to PE, our patient denies pleurisy or Lower Extremity swelling.  Obviously you can have a PE without those symptoms but perhaps we’ll move that down for now.  The patient has no epigastric tenderness so let’s move an NSAID-induced ulcer down too.  When asked about weight loss however the patient agrees that his pants are fitting more loosely than they did previously.  He is a lifelong smoker.

The team ordered labs and a chest x-ray.  The CBC showed a WBC count of 15 and a Hgb of 10.  The Basic Metabolic Panel was significant for a Sodium of 124.  BUN:Cr are normal.

So we have a hyponatremic anemic patient with a leukocytosis.  Where are we now?  In real life, hyponatremia is usually caused by HCTZ or a spurious result in the setting of extreme hyperglycemia.  On an EM Board exam hyponatremia is caused by brain or lung pathology.  Shall we look at the chest X-ray?

Picture1

Sigh.  Not good.  It’s unusual for pneumonia to cause upper lobe infiltrates in the absence of a mass to obstruct a bronchus.  Always consider an large upper lobe infiltrate to be concerning for a tumor.  

A CT was obtained.

Picture2

Unfortunately it’s all tumor.  The radiology read felt that it was likely a primary malignancy and was eroding into the T2 and T3 vertebral bodies and corresponding ribs.

Can we make a classic presentation even more classic?  What can tumors at the apex of the lung cause?  Would you believe it if I told you the patient later asked the nurse on his way up to the floor if this could be the cause of only half his face sweating (Anhidrosis) for the last month or so?  Do you remember the rest of Horner’s Triad? 

Miosis (a constricted pupil) and Ptosis (droop of the upper lid) are the other two signs (another common EM board question).

SO.  What take-homes are there from this case?

  • Chronic complaints WILL sometimes have an answer; keep an open mind!
  • Many of our patients lack access to health care and so can present with advanced disease.
  • Similar to the idea that the most commonly missed fracture is the second one, here we have a lung cancer causing hyponatremia.  Having caused one problem a person has to ask what other complications could be present.  In this case the penalty for missing the Horner’s Syndrome isn’t severe; the diagnosis is already known.  However, that may not be the case on the next patient you see.

Thanks to Emily Franckowiak for presenting this case.

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