CASE REPORT

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AN 80-YEAR-OLD WOMAN WITH LEFT SHOULDER PAIN

SB Khoo FRACGP,Penang Medical College

Address for correspondence: Dr Khoo Siew Beng, Senior Lecturer & Family Physician, Penang Medical College, No 4, Sepoy Lines Road, 10450 Penang, Malaysia. Tel: 604-2263 459, Email: siewbeng@gmail.com

CASE HISTORY

Madam YN was an 80-year-old Chinese lady who presented with pain in her left shoulder for two months since the end of year 2007. Her daughter took her to see private general practitioners (GPs) who prescribed her some painkillers with the reassurance that it was “rheumatism due to old age” that should improve with rest.

At the initial stage, the pain was confined to the inferolateral aspect of the left scapula. Her pain became worse and gradually extended down her left arm and forearm at the medial ulnar aspects. She described the pain as continuous “deep, drilling and gnawing” at the shoulder and excruciating, episodic “cutting, lancinating and lightning type of pain” down the left arm. Intensity of the pain was variable. Initially there was temporary relief with massages, topical salicylate ointment and oral painkillers but towards the end the pain became unbearable. During the period between the onset of pain at the end of year 2007 and August 2008, she had consulted more than ten different private GPs and hospital specialists with overall 20-30 consultations including a GP pain specialist who advised her to go for acupuncture. Medications prescribed for her ranged from oral paracetamol to non-steroidal anti-inflammatory drugs (NSAID), tramadol and DF 118 (mild opioids) to transdermal ketoprofen. X-rays were done twice in a private hospital A; there was no fracture detected and YN was referred for physiotherapy. YN requested for hospital admission in August 2008 because she could no longer tolerate the pain but she was told that this was due to old age, that there was no specific treatment for it to warrant hospitalization.

Madam YN’s medical history was unremarkable except for diabetes mellitus that was well controlled with oral gliclazide and metformin. Other than moderate bilateral hearing impairment, she was generally well physically and mentally, was independent and with good assessment scores for activities of daily living.

In May 2008, YN noticed her left eye had become smaller and there was drooping of the upper eyelid on the same eye. She consulted an ophthalmologist who screened her for diabetic retinopathy and informed her there was nothing to worry about.

In November 2008, YN’s daughter decided to take her to see a neuro surgeon “friend” in a private hospital B who did another left shoulder X-ray. Incidentally, he discovered a mass at the apex of the left lung. CT scan of the thorax confirmed the presence of a tumour at the apex of the left lung, about 5 cm in diameter with irregular borders. YN was referred to a general physician as there was no chest physician in that private hospital. A review of the previous X-ray done three months earlier at private hospital A showed that the mass was already there. It was slightly smaller than the current size. It was missed by the radiologist who reported as “No fracture or dislocation seen”. In view of YN’s age the physician advised that YN should not be subjected to further biopsy tests in pursuit of curative treatment but only to relieve her pain with low dose palliative radiotherapy.

YN’s children requested that their mother must not be told of the diagnosis; she would not be able to take it.
 
YN was entitled to free treatment at the General Hospital (GH) as her children were in the government service. She was referred to Oncology Clinic of a Public General Hospital. Needle biopsy of the tumour mass conducted under ultrasound guidance was attempted twice, but no malignant cells were seen on both occasions. In view of the negative results, GH oncologist could not prescribe radiotherapy treatment but prescribed aqueous morphine 10 mg tds. for her pain instead.

After taking two doses of 10 mg morphine for the first time, YN became drowsy, nauseated and slept the whole day. She developed delirium. She was talking incoherently, could not recognise her children, refused to eat, and was seeing visual images of relatives who had passed away years ago. Her blood pressure increased to 180/100 mm Hg and glucometer recorded a random blood sugar of 3.5 mmol/L. Frantically her daughter took her back to private hospital B for admission. Head CT scan done did not show any brain metastases, MRI of spine did not show vertebral infiltration of malignant cells or spinal cord compression and her serum calcium was normal. After two days of showing no improvement, YN’s daughter requested for her mother to be transferred to a private Oncology hospital C where radiotherapy facilities were available.

Low dose palliative radiotherapy (DXT) was delivered with the intention to just control the pain. However after delivering five fractions of DXT, the tumour mass was found to have shrunk considerably. The radiotherapist decided to carry on with DXT treatment to a total course of 25 fractions. YN’s delirium did not seem to improve but she was more comfortable where pain was concerned.

YN’s delirium cleared the day after coming home. Her family decided not to let her go back for hospital readmission. She continued her radiotherapy treatment as a day care patient till completion of the full course.
 
YN never recovered from her inability to walk. She gradually developed loss of sensation, paralysis and wasting of muscles of left hand, pleural effusion, progressive hoarseness and loss of voice. Pain was under control but she continued to lose weight, became more anaemic and anorexic and her general condition progressively deteriorated. She was going in and out of hospitals B and C for symptom management and was confined to bed till the end. She was admitted into private hospital B for five days before she passed away in the same hospital at the end of September 2009.

Acknowledgement

Sincere thanks to YN’s family for their consent in sharing with us this case history and for providing us with the relevant X-ray films.

DISCUSSION

This case history illustrates the dilemma of an elderly woman with left shoulder pain, in her search for a correct diagnosis, appropriate investigations, specific treatment and palliative care. Key features for discussion in this case are determined by the events encountered by the patient. Table 1 gives a summary of these encounters under appropriate headings with related topics for discussion.

Table 1

Key features for discussion
Encounters		Related topics for discussion
Difficulties in diagnosing Pancoast tumour
a.	Why did it take so long to diagnosis Pancoast tumour in spite of YN’s consultations with so many GPs, public and private hospital specialists?	Non typical presentation of Pancoast tumour. Inadequate pain assessment. “Doctor hopping and shopping”.
b.	Why was YN’s request for hospitalization turned down at private Hospital A? Why did the ophthalmologist miss the diagnosis of Horner’s syndrome? Why did the radiologist miss the tumour mass in the apex of the left lung in August 2009? Why were YN’s pain and eye problem not detected by the endocrinologist at her three monthly review for diabetes?	Healthy aging process. Chronological age versus functional age. Missing cues. Premature convergence of hypothesis. Practice of “compartmental medicine”.
Pain management
a.	Why must YN endure the pain for so long?	Inadequate pain management. Collusion of anonymity.
b.	Was it ethical to call off all painkillers and focused on control of hypertension and diabetes?	Prioritization for pain control in palliative care.
Ethical issues and limited treatment plan
a.	Was it ethical to forego further investigations and curative treatment based alone on patient’s age?	Curative versus palliative radiotherapy. Limited treatment plan/patient autonomy.
b.	Was it ethical to subject YN to radiotherapy treatment if there was no positive HPE report of malignancy?	Risk versus benefits of low dose palliative radiotherapy for pain control without HPE results.
c.	Was it ethical in hiding the truth from YN?	Disadvantages of conspiracy of silence.
Palliative care
a.	Why did YN behave abnormally after taking the morphine?	Contributing factors to patient’s delirium.
b.	Were total bed confinement, IV infusion, Ryle’s tube feeding and catheterization in-situ necessary?	Acute hospital care versus home palliative care for end-of-life cases. Definition of a good death.