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ED Case: Neck/Shoulder Pain

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First time at this, but gonna give this a try as an effort to bring back some cases presentations... (so, sorry ahead of time if this doesn't necessarily work out to plan)


This one comes from our Oakland/Alameda County facility:


Chief Complaint. Neck and shoulder pain x12 hours.


History of Present Illness

39 y/o male, previously healthy, BIBA c/o worsening left-sided neck and shoulder pain since this morning. Reports that pain was initially 8/10, but is now 10/10, is localized to his left side of posterior neck, made worse with movement of the neck and upper extremities, not relieved by any interventions, “sharp, dull, burning… everything you just said” in nature, radiating to his upper back and left shoulder, no previous h/o similar symptoms. States that he was completely asymptomatic last night, and hasn’t done anything out his daily routine for the past few weeks. Reports that he woke up this morning with his current pain profile and has been worsening in severity since. Denies any fever/chills, ill contacts, acute episodes or h/o trauma or injury, ingestion of foreign bodies, headache, cough, sore throat, dysphagia, odynophagia, other URI-type symptoms, chest discomfort, SOB, abdominal/urinary complaints, swelling of extremities.


Past Medical History. GSW to right thigh (>10 years ago)


Past Surgical History. None.


Medications. None.


Allergies. NKDA, no environmental allergies.


Family History. No chronic medical illnesses.


Social History. Resident of Oakland, lives with wife and 2 children, unemployed. EtOH: 6 pack q weekend, 15 pack year smoking history, distant h/o IVDU, no other elicit drug use.


Review of Systems

General. Denies fatigue/malaise, weakness, night sweats, unwanted weight loss.

Skin. Denies rash, petichiae.

HEENT. Denies H/A, photophobia, sore throat, changes in voice, swollen neck, goiter.

Cardiac. Denies chest discomfort, SOB, palpitations.

Respiratory. Denies cough, wheeze, sputum, hemoptysis.

Gastrointestinal. Denies n/v/d, bowel changes, hematochezia/melena, BRBPR.

Urinary. Denies hematuria, dysuria, incontinence.

Neurologic. Denies changes in sensation/numbness/tingling, weakness/paralysis, syncope.



I'll leave things at that for now, with more details to come based on the discussion...

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focused exam of area- mass, sites of focal tenderness

cardiopulmonary, abd exam

neurovascular exam

UE, neck ROM




Physical Examination

V/S. BP: 168/92 (RA, seated), P: 106 (regular), RR: 24 unlabored, Tmax (oral): 100.5°F, SpO2: 99% RA. Wt: 210 lbs, Ht: 6’2”, BMI: 27.0

General. Heavy set AA male, A&O x4. NAD, WDWN, appropriately conversing, in mild obvious discomfort walking around gurney not wanting to stay in one place. Of note, constantly using right hand to rub at left neck and trapezius muscle area.

Skin. Warm, dry, no rash or other acute skin lesions.

HEENT. NC/AT. PERRL, EOMI, conjunctivae clear. Oropharynx non-erythematous/non-exudative, no tonsilar inflammation, no airway obstruction. Decreased moisture of mucous membranes. Good dentition without use of dentures. No dental abscesses, caries, signs of trauma.

Neck. When asked to indicate specific location of pain, unable to do so with one finger, pain diffusely localized to area that he has been rubbing. Minimally tender palpable left posterior cervical lymphadenopathy, otherwise no palpable masses of neck and upper extremity. No thyromegaly. No JVD noted @ 30° elevation. No carotid bruits bilaterally. Limited and guarded ROM to flexion/extension/rotation throughout 2/2 pain symptoms. Negative Brudzinski’s sign. No spinous process tenderness.

Cardiac. Tachycardic, normal rhythm, no m/r/g. nl S1/S2.

Lungs. CTAB, no wheeze, rhonchi, rales.

Abdomen. +BS x4. NTND, no rebound, guarding, masses, organmegaly. No CVAT bilaterally.

Extremities. Distal pulses 2+ and intact bilaterally. No tenderness or swelling of extremities. No dependent edema.

Neurologic. Non-focal exam. CN II-XII intact. Normal cerebellar function, normal gait pattern including heel-toe and tandem gait. Negative rhomberg test. Negative pronator drift. UE/LE DTRs 2+ and equal throughout. Strength 5/5 of upper and lower extremities throughout. Sensation grossly intact to light touch throughout.



EKG demonstrates sinus tachycardia, no acute ST elevation/depression, Q wave infarctions.



To be completely honest, I didn't ask about chiropractic manipulation... but, I will definitely do so in the future! I would assume that he hasn't though. No history of chronic neck/back pain.

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Is the IVDU use truly remote?


In the absence of movement, is the trapezius TTP? Does it feel to be in spasm? Can he localize where he has the most pain (cervical vs scapular)?

it's funny that you ask b/c i repeatedly questioned him about that. his response is, "no man, i haven't done that stuff for more than 20 years. i swear i've been clean." he actually denied IVDU altogether when questioned by my preceptor on a separate occasion... so sorry, i couldn't tell you for certain.


trapezius and neck area are diffusely tender to palpation, but again, very poorly localized. trapezius muscle itself doesn't appear to be in spasm. pain symptoms are primarily in the neck and trapezius, and doesn't extend past the superior edge of the scapula.

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....spurling compression test? grib, deltoid, bicep & tracep strenght in comparision with the unaffected UE? sleep pattern night prior? lift wt?

Sorry I didn't mention it initially, but the Spurling test was negative, as well as the Hoffman. All UE strength was 5/5 and equal to the unaffected UE. No fluctuations in sleep patterns. No recent history of weight lifting or rigorous activity.

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Labs? TSH, CBC, smac20, Any axillary adenopathy or other LAD? any contact with animals?

before labs, just curious what you guys have on differential given the history and exam thus far... things potentially get a little easier from here on out i feel like.


but no, just isolated cervical LAD... and sorry, didn't ask about recent animal exposure.


p.s. - congrats again joelseff, PA-C!

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Hmm. Well, if he's malingering for pain meds, he's got a baseline BP/pulse that looks remarkably consistent with a patient in real pain...


Assuming labs were unremarkable, I'd want a plain film to rule out a bone lesion, such as a metastatic tumor from undiagnosed cancer (e.g., lung)



* Cervical disc syndrome (presenting w/o neural deficits? Hmm....)

* Lymphadenopathy

* Tumor


* Meningitis, fracture, thoracic outlet syndrome, and a few other things inconsistent with PE.

* MI inconsistent with ECG findings.

* Trauma, DJD, muscle strain, torticollis, atlantoaxial subluxation, etc. inconsistent with history.

* Seems pretty specific and intense for referred pain, esp. given a normal abd exam.

* Wrong part of neck for thyroiditis pain, no?

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Fever and tachycardia. Can't fake or lie about those. .


but what happens when someone is coming off (detox) opiates or other depressants? tachy, aggitated, c/o pains, pissed off..... addicts will actually inflict pain on themselves to have some verifyable cause of pain to get their meds.


also any IVDA us in past gotta think of blood spread of bacteria and osteo but usually long slow onset of pain


BP in both arms? looking at discection.....



no MRI's in the ER - most ER people don't get when to order an emergent MRI and MIR departments don't want to hold open spots for the occasional acute.....

also can do a neural tension exam on UE to see if worsens pain for HNP



osteo, drug seaking (get a utox!), HNP of neck (classic to see them rubbing trap), spont. pneumo, shingles


my plan -

cbc, lytes, lft's, amy/lipase, CXR, tox screen, ekg (atypical with past coke use), CPk/Trop I, medicate for pain with toradol first then start with ms04 5mg q 15min till better

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