SHOULDER. SHOULDER OSTEOLOGY ANATOMY:MUSCLES ANATOMY:CAPSULAR ELEMENTS.
Right shoulder and chest pain Kate Rubey November 2013.
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Transcript of Right shoulder and chest pain Kate Rubey November 2013.
Right shoulder and chest pain
Kate Rubey
November 2013
• Patient is a 70 year old male with PMH of HTN and hyperlipidemia who presents with constant substernal chest pain for 2 weeks and new onset R shoulder pain
• Patient has history of similar substernal chest pain, most recently in February when he had a negative NM cardiac stress test
• Notes cough exacerbates shoulder pain• Patient denied abdominal pain at presentation
Clinical History
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Vitals
BP: 141/84
Pulse: 80
Temp: 98.1 °F
Resp: 22
SpO2: 98 %
Exam
Unremarkable with exception of RUQ tenderness to palpation
Physical Exam
3
• Concern for pulmonary embolism vs. ACS vs. gallbladder pathology
• Wells PE criteria low risk, so D-dimer indicated before chest CT
• How should we evaluate the gallbladder?
Work-up
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ACR Appropriateness Criteria
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Normal Liver
Ultrasound long
Abdomen - Liver
Ultrasound long
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• Liver ultrasound revealed multiple large hypoechoic, but not cystic, mass lesions seen throughout the liver, measuring up to 7.6-cm., with very little normal intervening liver parenchyma.
• Differential includes:– hepatic hemangiomas: usually hyperechoic lesions– idiopathic noncirrhotic portal hypertension: generally
isoechoic and poorly visualized on ultrasound – hepatocellular carcinoma: usually with poorly-defined
margins and coarse, irregular internal echoes– metastatic disease: variable appearance, almost always
multiple lesions, may be hypoechoic
Differential
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• Liver metastases are concerning for GI, GU, and lung cancer
• Patient had colonoscopy 4/13 without evidence of GI malignancy
• Patient had CT of the chest, abdomen, and pelvis to look for primary malignancy and characterize liver lesions– For lesions found on US highly suspicious for
malignancy: CT abdomen with contrast is rated an 8 (usually appropriate)
Suspected Liver Metastases
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Abdomen
CT – axial, 5 minutes post contrast
Abdomen – Liver hemangioma
Contrast CT – axial
Abdomen – Hepatocellular carcinoma
Contrast CT – axial
Abdomen – Liver metastases
Contrast CT – axial
Abdomen
CT - axial
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Abdomen
CT - axial
Abdomen
CT – axial
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• CT chest showed a R hilar mass associated with subcarinal and paratracheal lymph nodes, concerning for neoplasm
• Patient underwent ultrasound guided biopsy of one of the liver lesions by IR
• Results of the biopsy showed “Poorly differentiated carcinoma. Immunophenotype (CK7+ and TTF-1+) is consistent with lung primary.”
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