1. Physical Exam as the Hallmark for Medical Diagnosis: A case of metastatic uterine sarcoma presenting with neurologic complaints
Amelia Bowman, MSIV1; Maria G Frank, MD1,2 1University of Colorado, School of Medicine, 2Denver Health Hospital Authority
Introduction
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Discussion
The Choosing Wisely Campaign, Do not Harm Project and many other initiatives reinforce the importance of doing the right test to the right patient, and avoiding unnecessary and potentially harmful tests.
We present a case of an unnecessary test with an incidental abnormal result leading to a diagnosis.
In the past, history taking and physical examination have been referred to as “responsible for over 80% of diagnosis.”
Current particulars of medical education and practice (i.e. time constraints, easy access to multiple complementary testing modalities) have led these historical pillars of medical diagnosis to be set aside.
This case demonstrates the importance of chief complaint, history taking and physical exam findings in guiding additional studies.
Our patient’s chief complaint was “inability to move right upper extremity.”
Careful physical exam of this patient localized a lesion to the C5-C7 dermatomes and myotomes, temperature deficits suggested a more anterior location on the right side of the spinal cord.
This localization almost precisely matches the actual lesion found on the MRI of the c-spine. A C D 43 B
Case Presentation
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58 year-old female presented to the emergency department with a progressive inability to move her right upper extremity (RUE) over one month. Did not improve with naproxen or shoulder exercises. Denied history of trauma, and endorsed mild shoulder “soreness,” but no other pain. CTPE obtained in ED for tachycardia incidentally revealed 2 right pulmonary masses and was admitted for further work up.
Pertinent Complementary Testing
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X-Ray: Right shoulder and C-spine were non-contributory.
MRI: Brain and C-spineC demonstrated a soft tissue mass encasing neural foramina of C4-5, C5-6 and C6-7.
CTPEA,B: incidentally demonstrating 2 right pulmonary masses (arrowsA).
CT abdomen/pelvis: revealed masses in liver and adrenal gland, as well as an enlarged uterusD.
Conclusions
Relevant Physical Exam
Physical exam alone could have led to imaging of the c-spine soft-tissue, with a reasonable expectation of visualizing a lesion.
This diagnosis would have been reached if initial imaging had been based on history and exam.
This case reinforces the importance of physical exam and history as the basis of diagnosis, and the role of imaging studies to confirm, rather than identify the presence of pathology.
Vital signs: Significant for tachycardia.
RUE Neurologic Exam:
Hypoesthesia C5-C7 dermatome.
Intact sensation C8-T1 dermatome.
Non-specific thermal dysesthesia.
DTRs 1+ at biceps and triceps.
Decreased strength in C5-C7 myotomes.
Muscle mass and tone of RUE normal . Passive ROM intact, without step offs.
Ultimately patient was found to have metastatic disease, thought to be secondary to a uterine sarcoma (by history, exam, complementary tests).
Patient refused further work up (biopsy) or treatment, and was discharged home with palliative medicine follow up.
Hospital Course