A 50-year-old woman comes to the office due to 3 months of progressive right shoulder pain radiating to her forearm. The patient has a history of rheumatoid arthritis and takes methotrexate and naproxen, which have controlled her morning stiffness and joint tenderness. She has smoked a pack of cigarettes daily for 25 years and drinks 1 or 2 cocktails on weekends. Vital signs are within normal limits. Physical examination shows mild drooping of the right upper eyelid and right pupillary constriction. Range of motion over the right shoulder is normal and does not elicit arm pain. There are bilateral hand joint deformities with no swelling and minimal tenderness. Which of the following is the best next step in the management of this patient?

Question

A 50-year-old woman comes to the office due to 3 months of progressive right shoulder pain radiating to her forearm.  The patient has a history of rheumatoid arthritis and takes methotrexate and naproxen, which have controlled her morning stiffness and joint tenderness.  She has smoked a pack of cigarettes daily for 25 years and drinks 1 or 2 cocktails on weekends.  Vital signs are within normal limits.  Physical examination shows mild drooping of the right upper eyelid and right pupillary constriction.  Range of motion over the right shoulder is normal and does not elicit arm pain.  There are bilateral hand joint deformities with no swelling and minimal tenderness.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d948_daab_bc81_7548dc69fd9d_MD0003_00 This patient with well controlled rheumatoid arthritis (eg, no joint swelling/minimal tenderness) has had several months of progressive right shoulder pain radiating to the arm. Although physical examination of the right shoulder is normal, the presence of ipsilateral miosis and ptosis and a long history of smoking raises strong concern for Horner syndrome due to a superior pulmonary sulcus (Pancoast) tumor. Superior pulmonary sulcus tumors usually arise in smokers; most cases are caused by adenocarcinoma or squamous cell carcinoma of the lung. Because the superior sulcus is located in the lung periphery, pulmonary symptoms such as dyspnea, hemoptysis, and cough do not generally occur until late in the disease course. Therefore, most patients come to clinical attention due to symptoms related to invasion of adjacent structures, including: Shoulder pain (most common) due to invasion of the brachial plexus or adjacent bony structures Horner syndrome (miosis, ptosis, anhidrosis) due to invasion of the paravertebral sympathetic chain or cervical ganglion Arm pain/hand weakness in an ulnar distribution (eg, weakness in intrinsic hand muscles) due to invasion of the C8/T1 nerve roots Patients with suspected superior pulmonary sulcus tumors should undergo chest imaging (eg, chest x-ray) followed by staging imaging and biopsy if a lesion is found. chest x-ray (Choice A) Acetylcholine receptor antibody testing is used to diagnose myasthenia gravis, which often presents with ptosis. Although migrating muscle weakness is common, progressive shoulder and arm pain would be atypical. (Choice B) CT scan of the head could reveal a CNS lesion (eg, medullary infarction), which can sometimes cause Horner syndrome. However, this would not account for the patient's progressive arm and shoulder pain. (Choice C) Nerve conduction studies (combined with electromyography) are often performed to help diagnose peripheral nerve disease (eg, neuropathy, nerve entrapment). However, these conditions do not typically cause Horner syndrome. (Choice E) X-ray of the shoulder can evaluate for fracture due to trauma or lytic lesions due to malignancy. However, shoulder pathologies are not typically associated with Horner syndrome. In addition, given this patient's normal shoulder examination, x-ray of the shoulder would not be the best next test. Educational objective: Superior pulmonary sulcus tumors are malignant lung neoplasms that arise in the superior portion of the lung. They most commonly present with shoulder pain, Horner syndrome, arm pain, and/or hand weakness. References: Pancoast tumors: characteristics and preoperative assessment. (http://www.ncbi.nlm.nih.gov/pubmed/24672686)

A 50-Year-Old Woman Comes to the Office Due to 3