A 63-year-old man comes to the office due to a month of right shoulder pain. The pain is nagging, extends down his medial right arm, and is especially bothersome at night. Over the past week, the patient has also felt a tingling numbness in his right fourth and fifth fingers. He does not know what caused the pain but recalls chopping wood a month ago. The patient also notes weight loss but cannot quantify the amount. He went to an urgent care clinic 2 weeks ago due to the shoulder pain and was prescribed naproxen, which has provided no significant relief. He believes he needs something "stronger" to cope with the pain.
Other medical problems include hypertension, chronic low back pain, and degenerative arthritis in the knees. He has a distant history of opioid abuse and completed a methadone program. The patient has a 40-pack-year smoking history and drinks 2 or 3 beers most weekends.
Vital signs are within normal limits. There is no lymphadenopathy or thyromegaly. The chest is clear to auscultation, and heart sounds are normal. Active and passive range of motion of the right shoulder is normal and elicits no pain. There is no shoulder deformity or right upper extremity muscle weakness or atrophy. Sensation to light touch is diminished in the right fourth and fifth fingers compared with the left.
Which of the following is the most appropriate next step in management of this patient?

Question

A 63-year-old man comes to the office due to a month of right shoulder pain.  The pain is nagging, extends down his medial right arm, and is especially bothersome at night.  Over the past week, the patient has also felt a tingling numbness in his right fourth and fifth fingers.  He does not know what caused the pain but recalls chopping wood a month ago.  The patient also notes weight loss but cannot quantify the amount.  He went to an urgent care clinic 2 weeks ago due to the shoulder pain and was prescribed naproxen, which has provided no significant relief.  He believes he needs something "stronger" to cope with the pain.
Other medical problems include hypertension, chronic low back pain, and degenerative arthritis in the knees.  He has a distant history of opioid abuse and completed a methadone program.  The patient has a 40-pack-year smoking history and drinks 2 or 3 beers most weekends.
Vital signs are within normal limits.  There is no lymphadenopathy or thyromegaly.  The chest is clear to auscultation, and heart sounds are normal.  Active and passive range of motion of the right shoulder is normal and elicits no pain.  There is no shoulder deformity or right upper extremity muscle weakness or atrophy.  Sensation to light touch is diminished in the right fourth and fifth fingers compared with the left.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9828_c932_853d_3faed0a8da3f_MD0002_00 This patient with a 40-pack-year smoking history has right shoulder pain, weight loss, and paresthesias in the right fourth and fifth digits, raising suspicion for a superior pulmonary sulcus (Pancoast) tumor. This tumor arises in the apical pleuropulmonary groove adjacent to the subclavian vessels, brachial plexus, and C8-T2 nerve roots. Manifestations include: apical pleuropulmonary groove Shoulder pain due to invasion of the brachial plexus or adjacent bone, fascia, or pleura. Shoulder pain is the most common initial symptom and is often incorrectly attributed to a benign cause (eg, bursitis, osteoarthritis), which may delay diagnosis by weeks or months.Horner syndrome due to invasion of the paravertebral sympathetic chain or inferior cervical ganglion. Horner syndrome is marked by ipsilateral ptosis, miosis, enophthalmos, and anhidrosis.Upper extremity neurological complications due to C8-T2 nerve root invasion. Common neurologic complications include hand atrophy and pain/paresthesia in the fourth and fifth digits. Shoulder pain due to invasion of the brachial plexus or adjacent bone, fascia, or pleura. Shoulder pain is the most common initial symptom and is often incorrectly attributed to a benign cause (eg, bursitis, osteoarthritis), which may delay diagnosis by weeks or months. Shoulder pain due to invasion of the brachial plexus or adjacent bone, fascia, or pleura. Shoulder pain is the most common initial symptom and is often incorrectly attributed to a benign cause (eg, bursitis, osteoarthritis), which may delay diagnosis by weeks or months. Horner syndrome due to invasion of the paravertebral sympathetic chain or inferior cervical ganglion. Horner syndrome is marked by ipsilateral ptosis, miosis, enophthalmos, and anhidrosis. Horner syndrome due to invasion of the paravertebral sympathetic chain or inferior cervical ganglion. Horner syndrome is marked by ipsilateral ptosis, miosis, enophthalmos, and anhidrosis. ipsilateral ptosis Upper extremity neurological complications due to C8-T2 nerve root invasion. Common neurologic complications include hand atrophy and pain/paresthesia in the fourth and fifth digits. Upper extremity neurological complications due to C8-T2 nerve root invasion. Common neurologic complications include hand atrophy and pain/paresthesia in the fourth and fifth digits. Patients with suspected Pancoast tumor usually undergo a chest x-ray to evaluate for an enlarged apical cap and/or bone destruction. Additional chest imaging (eg, CT scan, MRI) and core needle biopsy are then typically required. Most Pancoast tumors are non-small cell lung cancer. enlarged apical cap CT scan (Choice B) MRI of the shoulder can determine if a patient has a rotator cuff injury with impingement syndrome. This usually manifests with shoulder pain that worsens with overhead reaching and atrophy of the surrounding muscles (if long-standing). This patient with a normal physical examination, extensive smoking history, and paresthesias in the fourth and fifth digits is more likely to have Pancoast tumor and requires a chest x-ray. (Choice C) Nerve conduction studies could diagnose nerve root compression but would not determine the underlying etiology. (Choices D and E) Physical therapy can help improve many types of shoulder pain (eg, osteoarthritis, bursitis), and pain management can be used for refractory cases. However, given this patient's smoking history, paresthesias, and weight loss, he should first undergo a diagnostic work-up starting with chest x-ray. Educational objective: Superior pulmonary sulcus (Pancoast) tumors arise in the apical pleuropulmonary groove and typically present with shoulder pain (most common), Horner syndrome, and/or C8-T2 neurological findings (eg, paresthesias in the fourth and fifth digits). Chest x-ray is usually the first diagnostic step; additional chest imaging (eg, CT scan, MRI) and core needle biopsy are then typically required. __________ References: Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units. (http://www.ncbi.nlm.nih.gov/pubmed/10645168) Cervicobrachialgia and Pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/15553951)

A 63-Year-Old Man Comes to the Office Due to a Month