Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 11th Episode 114: clinicalproblemsolving.com/morning-report…
W / @Anu08877649 Joshua Morris & @Rafameed
Teaching points illustration by @sukritibanthiya

Let’s start with an initial problem representation:

A 55 y/o M w/ no known PMH except a 30 pack-year history of tobacco abuse presents with recurrent syncope (lightheaded prodrome) over last 2 mon along w/ R shoulder pain, 15 lb weight loss for 3 months, and an occasional cough

An initial evaluation of syncope should involve ruling out mimickers like Sz or TIA

The fact that he was lying down during the episode is concerning for cardiogenic cause like an arrhythmia

Also, an autonomic given the lightheadedness while lying in bed

clinicalproblemsolving.com/dx-schema-sync…

Is the shoulder pain referred pain?

I wonder about a possible SVC syndrome or mass around carotid causing unilateral carotid compression

never forget cardiac shunts and Eisenmenger syndrome even in adults

What about pulm HTN as cause of syncope w/ liver congestion⏩shoulder pain?

Is referred shoulder pain td to palpation? Seems to point to tissue. Maybe an abscess or mets to scapula

Could also think of Subclavian Steal syndrome ⏩syncope

Any B symptoms?? other than weight loss

He did have recent travel to Vietnam:

Seems like the timing of all symptoms started after returning from Vietnam, but if they have a mechanical cause of syncope like malignancy you’d expect that to have been developing for longer and unrelated to the travel. Signal vs noise?

Shoulder pain, weightloss, syncope - worried about lung cancer or TB

His vitals show no fever, a normal BP but he has bradycardia at 51 bpm

bradycardia > infiltrative dz > heart block

His physical exam shows R scapula td w/ normal lung and heart sounds, no lymphadenopathy

His labs show a nml WBC of 10, Hgb 13, Plt 400

Chemistry panel WNL (nml calcium)

Nml Alk phos (was interesting in seeing if this was elevated 2/2 bony mets)

Nml albumin:

How much does Albumin correlate with weight loss?

Serum albumin levels may not correlate with weight status in severe anorexia nervosa

pubmed.ncbi.nlm.nih.gov/19548148/

What about pre-albumin?

Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation.

medpharm.tandfonline.com/doi/full/10.10…

Here’s another:
pubmed.ncbi.nlm.nih.gov/25912205/ Albumin is a good negative acute phase reactant, but not great for nutritional status

The "markers" failed to identify subjects with severe protein-calorie malnutrition until extreme starvation.

Chest xray is interesting and likely the pivot point showing a LUL mass

Weird that lung mass is in L upper lobe, but having R shoulder pain

Hmmm, we need more imaging. How about a CT scan

CT chest showing a large left lung mass, lymphadenopathy (none palpable) along with a lytic lesion in the right scapula

Man that CT is better than our exam but that is not unusual

Maybe this mass is compressing the vagus nerve

Also note that recurrent laryngeal nerve is more medial than vagus (if we remember correctly so if it's impinging RLN then likely also compressing vagal nerve

Biopsy of scapula showed squamous cell carcinoma

PET showed a LUL hypermetabolic lesion w/ vagus nerve impingement, mediastinal mass w/ RLN impingement ⏩ bradycardia & syncope

Recurrent Syncope as Initial Symptom in Apical Intrathoracic Tumor
ncbi.nlm.nih.gov/pmc/articles/P…

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