NR 511 Week 7 Case Study, Shoulder Pain and Ptosis Example

Case Study Analysis: Six Weeks of Right Shoulder Pain Treated as a Rotator Cuff Problem, Then a Drooping Eyelid, and Why the Second Problem Reorders Everything Decided About the First

Student Name

College of Nursing, Chamberlain University

NR 511: Differential Diagnosis and Primary Care Practicum

Instructor Name

Month Day, Year

Case Study Analysis: Six Weeks of Right Shoulder Pain Treated as a Rotator Cuff Problem, Then a Drooping Eyelid, and Why the Second Problem Reorders Everything Decided About the First

Where the Reasoning Stood

Mr. A. B. is a 59-year-old retired roofer who first came in six weeks ago with a dull ache in the top of his right shoulder, present for about a month, worse at night and not clearly linked to overhead movement. His smoking history is 40 pack-years, ending six years ago when he quit. At that visit, strength and range of motion in the shoulder were near normal, with mild pain on resisted abduction, and the neck examination and reflexes were unremarkable. The working diagnosis was rotator cuff tendinopathy, with cervical radiculopathy as the alternative. He was given naproxen and referred to physical therapy, and a return visit was booked if the pain did not improve.

That reasoning was reasonable with what was known. The night pain and the weak link to movement were noted but not weighed heavily, since many people with cuff tendinopathy also ache at night. Whether he had ever been screened for lung cancer was not asked.

The Second Problem

He returns today. The shoulder pain is worse despite six physical therapy sessions and now runs down the inside of his right arm into the ring and little fingers. He has dropped his coffee mug twice. Last weekend his wife noticed that his right eyelid droops. He has no headache, no recent neck injury or sudden neck pain, no cough, no blood in his sputum, and no fever; he thinks he has lost about 8 pounds but blamed that on less appetite from the pain.

On examination, the right upper eyelid sits about 2 mm lower than the left, and the right pupil is smaller than the left, a difference more obvious in dim light. His face sweats normally on the left, and he says the right side of his forehead has been drier. Grip and finger abduction are weaker on the right, and there is early wasting of the small muscles between the thumb and index finger. Sensation to pinprick is reduced along the inner forearm and the ring and little fingers. The right supraclavicular fossa is fuller than the left, with a firm, nontender fullness but no discrete node. The lungs sound clear.

One Explanation or Two

The first question is whether one condition explains both problems. The combination of shoulder and arm pain in the C8 and T1 distribution, weakness and wasting of the intrinsic hand muscles, and an ipsilateral Horner syndrome (ptosis, miosis and reduced sweating) is the classic presentation of a tumor at the apex of the lung, the superior sulcus, invading the lower brachial plexus and the sympathetic chain. This combination is known as Pancoast syndrome (Huehnergarth & Lipsky, 2004). In a 59-year-old with 40 pack-years of smoking, weight loss and a fuller supraclavicular fossa, a single explanation covering everything becomes the leading candidate.

The second question is whether the problems are in fact related, because arriving together is not evidence of a link. Two separate conditions have to be given a fair weighing. The shoulder pain could still be rotator cuff disease, with an unrelated Horner syndrome from another cause. The most important unrelated cause is dissection of the internal carotid artery, which can produce a painful Horner syndrome and a stroke. Against it: he has no headache or sudden neck pain, no recent trauma, and his Horner syndrome comes with arm and hand signs that dissection does not explain. Cluster headache can cause a transient Horner syndrome but not arm weakness, and he has no headaches. A cervical disc at C7 to T1 could explain the arm signs but not the eyelid and pupil.

So the test is this: two separate explanations would each have to be true and would still leave the hand wasting and the supraclavicular fullness unexplained. One apical process explains all of it.

The Revised Ranking, With Reasons for Each Move

1. Superior sulcus (Pancoast) tumor of the right lung apex. Moves from absent to first. Reason: it alone accounts for the pain pattern, the hand weakness and wasting, the Horner syndrome, the weight loss and the supraclavicular fullness, in a patient with a heavy smoking history.

2. Other apical or neck masses involving the plexus, such as lymphoma, metastatic disease to supraclavicular nodes or, rarely, an infection at the lung apex. New on the list. Reason: they produce the same anatomy of injury; they are separated from the first candidate by imaging and tissue.

3. Carotid artery dissection with an unrelated shoulder problem. New on the list and ranked high by danger. Reason: without treatment it can lead to stroke; it is weakened by the absence of head or neck pain and by the arm findings.

4. Cervical radiculopathy at C8. Moves down from second. Reason: it could explain the arm but not the Horner syndrome or the supraclavicular fullness.

5. Rotator cuff tendinopathy. Moves from first to last. Reason: it explains none of the new findings, and the failure of six weeks of treatment now counts against it rather than being a matter of patience.

The Plan, Rebuilt

The earlier plan, physical therapy and an anti-inflammatory, is stopped rather than extended. Continuing therapy on a shoulder that may be the site of referred tumor pain adds nothing and delays diagnosis.

Imaging. A computed tomography scan of the chest with contrast is ordered for today or tomorrow. A plain chest radiograph was considered and rejected as the first test, because tumors at the lung apex can hide behind the overlying bones on a plain film. Because carotid dissection is serious if missed and the history does not fully exclude it, the radiology team was asked to extend the study to include a CT angiogram of the neck vessels; this covers the dangerous candidate under either reading in a single visit. Magnetic resonance imaging of the brachial plexus will likely follow if a mass is found, since it defines how far the tumor has spread into the nerves and spine, which decides surgical options.

Referral. An urgent referral to the lung cancer rapid-access clinic, with a pulmonologist and thoracic surgeon, is placed now rather than after the scan, so the appointment is not waiting on the report.

Pain and function. Naproxen is continued for pain, with a short supply of an opioid for night pain and a bowel regimen. Occupational therapy advice on protecting the weak hand.

Screening. By age and history he was eligible for yearly low-dose CT screening under the United States Preventive Services Task Force recommendation, which apply between the ages of 50 and 80 to people with a history of 20 or more pack-years who are current smokers or quit within 15 years (Krist et al., 2021). He had never been offered it. This is recorded as a missed opportunity and raised with the clinic's quality team, since the value of screening is to find disease before symptoms.

Safety net. He is to go to the emergency department for sudden weakness of the face, arm or leg, trouble speaking, sudden severe headache or neck pain, coughing up blood, or new weakness in his legs or problems with his bladder, since an apical tumor can extend toward the spinal canal.

Communication. The possibility of a lung tumor was discussed with him and his wife in plain terms, including that the scan may show something else. He asked whether the six weeks of therapy had caused harm. He was told honestly that the new findings changed the picture and that the next step is to find out quickly.

References

Huehnergarth, K. V., & Lipsky, B. A. (2004). Superior pulmonary sulcus tumor with Pancoast syndrome. Mayo Clinic Proceedings, 79(10), 1268. https://doi.org/10.4065/79.10.1268

Krist, A. H., Davidson, K. W., Mangione, C. M., Barry, M. J., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Kubik, M., Landefeld, C. S., Li, L., Ogedegbe, G., Owens, D. K., Pbert, L., Silverstein, M., Stevermer, J., Tseng, C.-W., & Wong, J. B. (2021). Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA, 325(10), 962-970. https://doi.org/10.1001/jama.2021.1117