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55 yo male c/o shoulder pain with a h/o some form of injury some 6 weeks ago, he comes now as the pain is worsened over the past 3 days..every movement is painful.no ecchymosis,erythema,swelling.
he also complaints of fatigue..
smoker,alcoholic,multiple sexual partners, works in some factory..
I did many things to manage the shoulder issue but upon follow up his fatigue kept on getting worse.Eventually i did an Xray chest, there is an apical mass!! i order further tests and consult specialists but..THE CASE ENDS IN 5 MINUTES! too late fellas! i guess i lost it..
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I guess this patient had lung cancer with mets or pancoast tumor needing radiation ?
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yeah and I consulted psych. thought he had chronic fatigue syndrome.and right after that step the patients fatigue worsened and the case ended.shockeedddd...How could I send that patient for psych consult .thought the pt.,s going crazy.;] ;] ;]even though did the x ray on initial workup.dint bother bout the MASS...unbelievable..
I passed..so relax.
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congrats How shd we approach this one
NPo
ivacess
Ns
cbc
bmp
pt inr
chest xray
shoulder xray
ekg
morphine
urine
rbs
pulse oxi vitals
after this
CT chest BIOPSY ??
s. calcium
vit d
onco consult
pulmono
PFT
LFT
radio therapy ?? resection of tumor
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He def needed radiation but atleast a shoulder MRI could have told me something!! the moment i saw the mass,it ended.i did consult specialists though in the final orders.. I hope I pass!
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@ lifestyle75:
the patient did so good on Ibuprofen! he graded the pain as 1/10 in just 5 days Rx, i still gave him physical therapy and he was all set for the pain.but his fatigue worsened over the two wasted weeks!
so u just address the simple measures for pain on office basis,send him home on NSAID n Physiotherapy
n in the next visit,when the fatigue is still bad
u shud do
FOBT
Colonoscopy
Chest Xray
Bingo! u see the mass n u can proceed with fancy stuff n u ll even have time to order a CT/MRI/Biopsy/Brinchoscopy/Consult..
thats what i think i should ve done!
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Your clues smoker 55 think cancer focused workup bone mets
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svc syndrome/pancoast tumor there are very occasions you call heam-onc fellow on night because they can give radiation therapy immediately and control enlarging space occupying region but are you sure they have not given you some more data particularly after physical exam.
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there was nothing on the PE in Lungs/chest/CVS/Extremity that could raise a suspicion of a tumor! no sign of a brachial plexus compression or SVC syndrome.. plus all the movements were limited due to pain! no motor/sensory defect. so i was blinded by the pain complaint and neglected the fatigue. I still did TSH/CBC/FOBT for fatigue but missed xray chest.
