Case Study #2

[VA Hopeful Dr]

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Another case study from practice. A few thoughts before I dive in:

First, if you have been out of residency for over 1 year don't respond immediately - give everyone else a good 24 hours before you add anything.

Second, I actually screwed this one up somewhat so I'm hoping y'all learn from this and do better than I did.

Third, I've seen this patient 3 times so far so I'll present it in a per-visit way.

HPI: 30 y/o male with 3 month h/o RUE pain. Localized on posterior upper arm. Worse with exertion. OTC tylenol doesn't help. Occasional tingling of the right hand on the dorsal surface, no pattern noticed as to when that happens. No weakness or trouble with grip even when that happens. No known injury. Does have a fairly physical job - cable installer. No history of anything like this before, never seen a doctor about this previously. Stays fairly constant over the 3M period.

PMH: Childhood asthma, no problems in over 10 years, ulcerative colitis untreated with no flares for 5 years, gastric ulcer at age 25 with no treatment or problems in 3 years.

PSH: Smokes 1ppd, 4 cups of coffee per day

PE: Normal vitals except a BMI of 36
Normal UE strength, sensation, reflexes. No pain with passive ROM. Pain is worse with active lateral elevation and resisted extension at the elbow. No bony tenderness, no swelling or skin changes, very mild TTP at triceps tendon.

Differential, additional testing, plan?

 

[mabinante]

I would start out with anti-inflammatory. Spurlung test then possible Cspine Xray. Rheum basic work up (esr, crp, RF, ANA)

 

[SqEdSaint]

extraintestinal manifestation of UC, seronegative arthritis? Check HLA B27 and get x ray of the right shoulder, elbow, and sacroiliac joint??? May I ask what TTP stands for?

 

[VA Hopeful Dr]

extraintestinal manifestation of UC, seronegative arthritis? Check HLA B27 and get x ray of the right shoulder, elbow, and sacroiliac joint??? May I ask what TTP stands for?

Tender to palpation

 

[TableMD]

Hi

Ddx
Impingement (2/2 pain with lat elevation), can eval with Hawkins, Neers, tx with high dose NSAID and PT (gentle range of motion exercises)

Tricep tendonitis/calcification (2/2 pain with elbow extension, pain Location in hx, and tendon is TTP, can start with RICE, NSAIDs, if refractory, then MSK ultrasound

C7, C8impingement (2/2 dermatome distribution of tingling on post hand) eval with Spurling

Lateral epicondylitis - less likely, but pain is somewhat near elbow and patient may have hurt himself with repetitive screwdriver use, can eval with Cozens test.


Ought to consider rotator cuff, labrum path, perform tests for those if not done on physical

Id want to see how patient does with NSAIDS and Ice for 3 - 4 weeks (wishful thinking in my DMV resident clinic)

 

[VA Hopeful Dr]

Some pretty good thoughts on this. I'm hoping the full anti-inflammatory work up suggested is merely because I'm posting this as an interesting case and not what you'd actually do for patients at first visit without more extensive joint involvement.

So my thought at the time was tricep tendonitis. Impingment seemed less likely as pain was worse with elevation and relieved with bringing the arm back down. Epicondylitis is possible, but pain just wasn't in the right spot for it and no real tenderness to bony structures. Nerve issue seemed less likely as it was sporadic and resolved itself fairly well. Plus, the pain didn't match with the dermatome very well.

Tried 3 weeks of meloxicam and ICE.

Patient returns with no improvement. Also has noticed when working that prolonged elevation of the right arm leads to worsening pain and oh by the way I have some posterior arm swelling when that happens as well.

Exam shows mild edema to most of the posterior upper arm, worse around mid-humerous. Holding his arm up definitely makes the pain worse after about 60 seconds, but doesn't seem to increase swelling.

Where do I go from here?

 

[deleted87716]

X-ray.

 

[cabinbuilder]

xray then proceed to MRI. Could be sarcoma or some other muscle pathology. Had a patient in Alaska with similar presentation ending up having a malignant tumor in the UE that was resected followed by chemo.

 

[JustPlainBill]

any signs of vascular involvement? had DVT of UE present one night at a UC facility -- US --

 

[VA Hopeful Dr]

The worsening when arm was kept elevated worried me for Thoracic Outlet Obstruction, and the swelling component suggested a venous obstruction (with or without nerve involvement) so the patient went for a doppler (why not r/o DVT at the same time).

The doppler showed big axillary lymph nodes. The recommended CT scan showed axillary and supraclavicular nodes with a significanly enlarged spleen.

Patient has a lymph node biopsy scheduled next week to see what kind of lymphoma he has.

 

[deleted87716]

The worsening when arm was kept elevated worried me for Thoracic Outlet Obstruction, and the swelling component suggested a venous obstruction (with or without nerve involvement) so the patient went for a doppler (why not r/o DVT at the same time).

The doppler showed big axillary lymph nodes. The recommended CT scan showed axillary and supraclavicular nodes with a significanly enlarged spleen.

Patient has a lymph node biopsy scheduled next week to see what kind of lymphoma he has.

Interesting. So, the nodes weren't palpable?

 

[VA Hopeful Dr]

Interesting. So, the nodes weren't palpable?

That's the part I screwed up - it never occurred to me to look. I got a little too focused on the extremity exam and didn't go up quite far enough, which is really a pisser because normally I always hit the supraclavicular fossa on exams.

Thankfully from first visit to biopsy is only 6 weeks as is, so I would have shaved off 2 weeks tops had I been as thorough as I usually am.

 

[JustPlainBill]

That's the part I screwed up - it never occurred to me to look. I got a little too focused on the extremity exam and didn't go up quite far enough, which is really a pisser because normally I always hit the supraclavicular fossa on exams.

Thankfully from first visit to biopsy is only 6 weeks as is, so I would have shaved off 2 weeks tops had I been as thorough as I usually am.

don't beat yourself up -- great case;

 

[pulmoblast]

This is a great case. Exactly why I think that primary care docs need to be the best and brightest. It's probably the hardest "specialty" around

Please post more such cases...I miss being a generalist