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"Upper Left Quadrant" symptoms in 27y/o M *updated some info*

Exit forum ID Forum Discussion "Upper Left Quadrant" symptoms in 27y/o M *updated some info*

This topic contains 2 replies, has 2 voices, and was last updated by   Doc Nina September 15, 2019 at 10:18 am.

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    Doc Nina

      1st order Hx:
      27 y/o M
      “Upper left quadrant”
      Specific symptom locations + quality (there were several):
      – Left anterior shoulder and pec = Ache, stab/sharp
      – Left Superior shoulder = ache
      – Left posterior aspect of scapula = ache
      – Left arm and forearm mostly medial but indicated it travels into the thumb = numb/tingle and ache
      – Left axillary region = throbbing, stabbing/sharp and swelling that comes and goes.
      Pain is 2 at rest, but not constant, and 7 at worst with P+
      P+ = “Excessive physical activity” specifically heavy lifting, pushing, and jerks. Wakes up in pain or with numbness and did indicate he sleeps on the left shoulder.
      P- = stretching sometimes, ice or Advil. Better as day goes on.

      2nd order Hx:
      Patient reports a “stinger” in 2017 playing flag football where he made SH to SH contact with another player and his arm went numb for 5 minutes, and was achy the next day.
      NON contrast, NON arthrogram MRI of left shoulder from 10/2018 suggests a posterior inferior tear of the left labrum. No arthrogram has been done to follow up.

      Patient says that his increased soreness with activity always starts in his axilla, and there will be a palpable and visible swelling that occurs. He also said “the source of my pain is from under my arm”

      Ultrasound of axilla was reported as normal.

      Patient has undergone EXTENSIVE testing including testing for autoimmune diseases like Lyme disease (was negative) has some all over the place blood labs as well which are borderline abnormal in every case nothing wildly off.

      My thoughts:
      Pt should probably get the SH arthrogram in order to confirm the suspected labrum tear and grade it.
      Traction injury/neuritis? Even if the mechanism was more of a jamming type force? Symptoms still after 2 years?
      Axillary swelling.. that comes and goes could this be a chronic myositis? Related to his injury? Remember US was normal.. so not likely to be lymphnodes or anything right?


      Keith Puri, DC

        Great job collecting the 1st and 2nd order history info. It sounds like he has a lot going on. With multiple symptoms, it’s helpful to determine priority by collecting how often he has each symptom, what each symptom grade is and if they occur in isolation or in combination.

        Do you have any exam findings and FAST map results? It’s very difficult to establish a Dx list without them. While it sounds like he has a local shoulder and brachial plexus component, the consult provides us with the necessary info to build our examination, not a dx. I would start with the exam first before jumping on the MRI arthrogram.


        Doc Nina

          Great news for this patient is he certainly is loaded with adhesion. SA was 40% function bilaterally. The remaining outlier is the swelling in the axilla, which he was able to point out where for me, seems to be the pec minor making its way across the anterior superior roof of the axilla. I have seen muscle hernias through fascia before, and in-fact I have one of the anterior tibialas muscle in my leg personally in which the “swelling” will sort of come and go dependent on how much I am loading it. They are generally really easy to assess with ultrasound examination, but easily missed if the Doc delivering or reading the US is not trained in MSK ultrasound, or if the DDX of a muscle hernia isn’t on the radar of potential pathologies to rule in or out. Thanks for letting me go through my thought process! Any insight would be welcome!

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