Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, April 17, 2007

Clinical Case (Part 1)

There is a principle in writing known as "Show; don't tell." I offer this case as an example of that principle, though the context probably won't be clear until after the discussion in Part 2, in which the answer will be given.

A very active 67-year-old woman came to me several times complaining of mid-right-sided back pain that occasionally radiated around her right side to her abdomen. This had been going on for about one month before she first consulted me. She played a lot of tennis (right-handed) and was under the impression that she had pulled something, although she didn't recall any specific trauma. The pain seemed to be exacerbated by certain motions, though she was unable to be more specific about what kinds of movements. Sometimes it had a "boring" quality. It sometimes woke her at night. Occasionally when it came around to her abdomen it had the quality of "hunger pains" though there seemed to be no relation between the pain and eating (ie, neither exacerbated nor relieved by food, nor consistently recurring before or after eating.) OTC pain relievers taken intermittently provided inconsistent relief.

Other than that she felt fine. The pain didn't radiate anywhere else. There was no nausea, vomiting, anorexia, weight loss, black/tarry stools, melena or bright red rectal bleeding. There were no urinary symptoms. Past history was unrevealing. Her blood pressure was a little elevated, but we were just starting to keep an eye on it. She had never smoked and consumed very little caffeine or alcohol.

Physical exam was basically normal. She had full range of motion of her spine. Perhaps there was some tenderness in the right lower thoracic region, but while in the office she would usually say, "It's not hurting right now." There was no costovertebral angle tenderness. Her abdomen revealed normally active bowel sounds, and was soft. There were no masses or organomegaly, and there was no tenderness or guarding anywhere. There were no skin rashes or lesions. Lab tests were all within normal limits including urinalysis, liver function tests and hemoglobin/hematocrit.

My initial impression (shared by the patient) was musculoskeletal back pain, so she was treated conservatively with heat, massage and OTC acetaminophen. She returned several times, giving a story of increasing pain unresponsive to treatment. She felt very strongly that something was wrong with her back, so when I suggested it was time for some imaging studies, she readily agreed to spinal x-rays. I tried to explain to her my concern that an intra-abdominal process might be causing her pain, so she reluctantly agreed to an ultrasound (although she only went for the x-rays.)

Finally, she called one evening telling me that the pain was now "excruciating," so I sent her to the ER where the diagnosis was made.

Post your thoughts in the Comments.
(Hint/disclaimer: listen to the hoofbeats. No zebras here.)

39 Comments:

At Tue Apr 17, 04:57:00 PM, Anonymous Jimmy said...

I had a lady a few months ago with an almost identical presentation(aside from the tennis playing). The final diagnosis was renal carcinoma. It was removed and she is doing great now and the pain is resolved.

 
At Tue Apr 17, 06:43:00 PM, Blogger Dr. Smak said...

Shingles.

I saw a lady admitted for a rule out MI with classic rash on her back. Labs, stress, CT chest. No one ever looked.

 
At Tue Apr 17, 06:46:00 PM, Blogger Dr. Deb said...

Gall Bladder. Only because she demonstrated similar symptoms as did I. Not that I have any substantial medical training.

 
At Tue Apr 17, 08:32:00 PM, Anonymous Anonymous said...

Abdominal aortic aneurysm

 
At Tue Apr 17, 09:23:00 PM, Blogger A Kipp said...

I'd say hydronephrosis from a kidney stone

 
At Tue Apr 17, 09:44:00 PM, Anonymous Anonymous said...

I agree with zoster.
Sometimes the rash doesn't appear or shows up later.

Thoracic radiculopathy is rare but can present with similar symptoms.

Also since I just had a kidney stone this can't be excluded.

AAA is probably the most life threatening and should be excluded- but less likely.

 
At Tue Apr 17, 10:32:00 PM, Anonymous difficultpt said...

I'm just a difficult patient, but when I read this, I thought it sounded exactly like the symptoms my mother had when she had shingles. So, make that 3 votes for shingles . . .

 
At Tue Apr 17, 10:40:00 PM, Blogger The Hatchling said...

Until the last paragraph I was going to say gallbladder or kidney stones. It fits the presentation but WOULD be diagnosed with ultrasound.

Spinal x-rays would show a compression fracture or if you got lucky a herniated disk compressing the spinal cord/nerve.

 
At Tue Apr 17, 11:44:00 PM, Blogger A Kipp said...

hatchling,

pay attention to the last paragraph though. She agreed to the U/S, but in actuality, only got the X-rays

plus, I seem to remember hearing that ultrasounds don't pick up EVERY kidney stone (I'm a 2nd year med student), but I may be wrong on that one

 
At Wed Apr 18, 01:01:00 AM, Blogger Judy said...

Based on her age ONLY -- and the fact that a former co-worker had very similar symptoms -- I'm guessing that her pain was cardiac in origin. Co-worker had very similar symptoms shortly before her first bypass surgery (co-worker was 20 years younger, but was a smoker).

 
At Wed Apr 18, 05:56:00 AM, Blogger #1 Dinosaur said...

Hints (since no one's close):

This went on for 2-3 months with no rash erupting.

Never smoked/female; AAA very unlikely.

Right-sided, non-exertional. Even with the caveat of women and atypical cardiac presentations, heart is way out there.

Go back to horses, and not even thoroughbreds. (As you'll see in the "answer", this exercise is as much to display my failure to diagnose something I should have as it is a clinical game.)

 
At Wed Apr 18, 08:33:00 AM, Blogger Voter Mom said...

appendicitis.
Hey, what do I know? :)

 
At Wed Apr 18, 09:16:00 AM, Anonymous Anonymous said...

ovarian cyst?

 
At Wed Apr 18, 09:17:00 AM, Blogger Sid Schwab said...

I'd take out her gallbladder. If she didn't get better, I'd do a workup. It's called the organ-elimination approach to diagnosis.

 
At Wed Apr 18, 09:20:00 AM, Anonymous ndenunz said...

After the hint I would say gall bladder but I thought it was an AAA before the hints.

 
At Wed Apr 18, 10:11:00 AM, Blogger Dr Tom F. Dork said...

From the presentation, I'd primarily exclude renal pathology. Hepatobiliary would be #2 on the differential.

Tom

 
At Wed Apr 18, 11:35:00 AM, Anonymous Anonymous said...

cholecystitis/biliary colic?

 
At Wed Apr 18, 11:37:00 AM, Blogger A Kipp said...

After conferring with a colleague of mine (hi jarrad), we would like to add the following to the differential:

cracked rib

She's a woman, probably somewhat osteopenic/porotic, and VERY active, so she may have had some minor trauma that she can't remember. And perhaps it was a minor fracture that took a little while to get loose and cause lots of problems.

 
At Wed Apr 18, 12:53:00 PM, Blogger MedStudentGod (MSG) said...

Pancreatic CA.

 
At Wed Apr 18, 01:13:00 PM, Blogger R. W. Donnell said...

Pancreatic Ca is a thought. Since the first 9 or 10 commenters apparently missed the boat, what else is left? Colon, musculoskeletal or chest disease of some sort? I'm wondering what her chest xray looked like.

 
At Wed Apr 18, 01:52:00 PM, Anonymous Anonymous said...

A sport bra that's too tight? What's a 67 y/o grandma doing playing tennis?

 
At Wed Apr 18, 02:17:00 PM, Anonymous Anonymous said...

OK, intermittent right flank pain radiating anteriorly. Let's try the systemic approach..

No association with food - less likely to be biliary colic

U/A negative - no blood, less likely to be renal colic

No rash - less likely to be shingles, although she could have chronic herpetic neuralgia

Blood pressure slightly elevated on first visit...dissection? Nah

No pain on palpation during exam - less likely to be rib fracture or musculoskeletal.

Pulmonary? No mentioning of respiratory symptoms so less likely to be PE, etc...

Cardiovascular? Less likely in healthy active person.

GI? abd. exam unremarkable, no association with food, labs negative, less likely....

Renal - nope as already hinted

Urologic - Nah U/A negative

Neuro - nah

Derm - nah

Gyn - oh my, not grandma!

HEENT - hehehe, no pain above the neck.

Autoimmune? - nah

Neoplastic? nah

The answer is likely to be something so simple that it was overlooked...I agree with the ill-fitting bra theory because during the exam, she probably didn't have the bra on! Hehehe.

 
At Wed Apr 18, 04:05:00 PM, Anonymous N=1 said...

Hmmm....Show - don't tell.

The ED doc had her demo her tennis swing? Did she have a limited ROM of the spine? She gave a history of intermittent symptom flares.

Ankylosing spondylitis?

 
At Wed Apr 18, 04:58:00 PM, Anonymous Anonymous said...

Too acrobatic during sex.
Recommendation: no more little pills for her partner.
:-)

 
At Wed Apr 18, 05:08:00 PM, Anonymous Anonymous said...

An ill-fitting bra would cause discomfort on both sides of body. And, believe me as a bra-wearer of 30+ years, it is a no-brainer to tell if a bra is causing discomfort.

 
At Wed Apr 18, 09:15:00 PM, Anonymous Anonymous said...

A 67 year old would be more likely to have spinal stenosis rather than a herniated disc.

My vote is for stenosis, pancreatic involvement, or a foreign object within her body (maybe she went hunting with Dick Cheney at some point in her life).

 
At Wed Apr 18, 09:18:00 PM, Anonymous Anonymous said...

What about Dr. Dino's fifth law? Perhaps she had an US in the ER which showed she's the oldest pregnant woman alive.

 
At Wed Apr 18, 11:02:00 PM, Anonymous red rabbit said...

Hm. I think it's peptic ulcer. Or else pancreatic ca.

I *hope* it's an ulcer.

 
At Thu Apr 19, 02:13:00 AM, Blogger Dr. K said...

I am late to join in on this fun and I have to admit that, after reading all of the ddxs and #1 Dino's response to initial guesses, I am stumped.

#1 Dino: I can only suppose that there are details in this patient's history that made you realise (post-diagnosis) that there are no zebras here.

 
At Thu Apr 19, 07:57:00 AM, Blogger stlcoptony said...

Gallbladder or Nephrolithiasis (but I'm just a pharmacy student)

 
At Thu Apr 19, 03:46:00 PM, Blogger TheTundraPA said...

Jumping in late here, but what a fun comment-fest! How about staghorn calculus in the right kidney?

 
At Thu Apr 19, 04:26:00 PM, Anonymous Anonymous said...

she got "jumped" by the 2 elusive dudes and had a chronic hemo-pneumothorax?

Just kidding. How 'bout another hint, ya old dinosaur? Does one actually have to order any tests or studies to make the diagnosis or is it simple as an ill-fitting bra?

 
At Thu Apr 19, 05:01:00 PM, Blogger RM said...

it's possible someone's gotten it right since the hint, but I'll guess ddx's anyway (though I'm not remotely a doctor)...

I thought it ultimately might have been a perforated ulcer after all (NSAID-related) despite the initial lack of GI bleed/eating-related symptoms. Could be something like "slipping rib" syndrome, although your last bit seemed to indicate the problem wasn't a musculoskeletal issue. Were there any other bowel symptoms? maybe Crohn's disease/colitis...there also could be a somatizing/anxiety element, of course.

In the realm of 'out there,' it's possible that long ago your patient had an IUD implanted and never had it removed, and it's migrated out of the uterus.

look forward to Part 2!

 
At Thu Apr 19, 05:24:00 PM, Anonymous RJS said...

I know it's not Crohn's. Probably not colitis, either.

What's the answer doc??? Inquiring minds want to know. :P

 
At Thu Apr 19, 08:01:00 PM, Blogger Judy said...

Your long list of what there wasn't eliminates a great many things. Or at least appears to.

I'm sticking with age-related statistics. Would diverticulosis show up on an xray without contrast?

In the ER, I suppose they either did a US or CT which showed the real problem.

 
At Thu Apr 19, 10:36:00 PM, Blogger The Bug Lady said...

How much does she drink?
I'll put my money on pancreatitis.

 
At Fri Apr 20, 01:29:00 AM, Blogger SeaSpray said...

You ruled out renal involvement, but being one who has a chronic hydronephrosis, I know that the blood work and urine can be normal for that. It is true that ultrasounds don't always pick up kidney stones and a CT would be better. Can she drink without discomfort?
The pain from hydronephrosis isn't only flank - it can radiate arounf to the RUQ. All a moot point because ruled out.

Interesting post. Can't wait to hear the answer. :)

 
At Sun May 25, 05:06:00 PM, Blogger Jonathan said...

I am almost 26 and I have the exact same problem as this lady and the doctors are doing and saying the same things and they cant figure it out I would appreciate it if you could save me a couple of thousand dollars and possible my life by saying what it is. It has been going on for 6 months!

 
At Mon May 26, 03:35:00 AM, Blogger Jonathan said...

Yep went to the doctor and they told me that it was shingles and I had to pay for Acyclovir and I even know that it isn't going to help b/c that is not the problem, i have never even had chicken pox and No I have not been exposed to it either, and I had to explain to her 5 times that I don't drink! What gives my blood work and my ua all say im fine but I have the same problem as she. It really bothers me, give me a break I do know, it has been months and it is getting worse and hydrocodone which they give me every time I go to the doctor is only covering up the pain and not doing anything to help it and now it really doesn't get rid of the pain either! HELP PLEASE!!!!!!!!!!!
I thank you ahead of time for your concern!

 

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