Clinical Pearls-Cases We Can All Learn From: Referred Pain

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78-year-old female with a past medical history of hypertension, stress-induced cardiomyopathy and Crohn’s disease p/w bilateral shoulder pain. Patient reports that she had 4 episodes of non-bloody diarrhea the night before. She sat up in bed in order to make herself more comfortable as she felt her stomach gurgling too much while lying flat. She took Immodium and since the medication has not had any diarrhea. Since she sat up in bed she has noticed her shoulders hurting. It hurts a great deal when she moves her arms, especially her right shoulder. She denies any shortness of breath, decreased exercise tolerance or concomitant chest or back pain. Her last stress test was normal and she had a completely clean catheterization 3 years ago. She denies any nausea or vomiting. She denies any leg swelling, recent hospitalization or travel, DVT or pulmonary embolus history. She reports that her EKG has an abnormality in it and that you should call her Cardiologist to verify.
Her medications include: Metoprolol, Steroids
Physical exam shows normal vital signs. Her exam is significant for the following:
CHEST: Regular rate, normal rhythm, no murmurs, rubs or gallops
LUNGS: normal air entry, slight crackles to right base, otherwise no wheezes or rhonchi
ABDOMEN: soft, nontender, normal bowel sounds
EXT: point tenderness to R shoulder, full range of motion but difficult due to pain

What do you do now? Run the scenario through your head as to what you would do….
Pain medicine and discharge? Cardiac work-up? Shoulder x-ray? Etc.?
The decision is made to run some basic labs including a troponin, EKG and chest x-ray as shoulder pain is atraumatic. Labs return only significant for a WBC of 17 (although she has been recently started on stress-dose steroids for her Crohn’s), a negative troponin and CPK of 30. EKG shows a TWI in V1-V3 which you have verified with her cardiologist is old. What do you do now? Admit the patient for cardiac workup? Give pain medicine for musculoskeletal shoulder pain/torticollis? You have talked with her primary care and already organized an appointment for follow up in the morning (8 hours from now).
Your chest x-ray returns and is found below:

As you will notice in the chest x-ray there is a subtle double line along the diaphragm on the right. The patient is actually experiencing referred pain from the diaphragmatic irritation to her shoulders. If you were to only look at the lung fields and focus on the shoulder area itself, you will miss the diagnosis. On final diagnosis, the patient has a perforated diverticulum and has accumulated a large amount of free air under her diaphragm. Her abdominal exam is benign due to the fact that she is on steroids. So 3 pearls offered by this case.
1. DO NOT trust a benign belly exam on somebody who is on steroids
2. DO NOT restrict your differential for shoulder pain to musculoskeletal
3. DO read your xrays in the same systematic way every single time.
Please leave your thoughts and comments.

Reference:
Image from:
http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/cxr/atlas/diaphragm1.htm

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