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

2

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

4

ACR Appropriateness Criteria

5

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

8

• 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

9

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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