# What's going on with this pt?



## Voodoo1 (Nov 3, 2010)

64 year old woman, lung cancer pt (renal clear cell carcinoma that has spread to lungs), Hypertensive-takes Valsarten HCT @ 160mg daily. Chief complaint is pain in her right arm that radiates to scapula. Has been to the hospital and ECG showed a anterior left fasticular block. She says the doctors didn't do anything for her at all except giver her perc's which she won't take. Her family doctor prescribed Voltarin, she had an adverse reaction to it and stopped taking it. Pain has been going on for approx. 3 weeks. Now her right arm is almost paralyzed, no other paralysis CVA or TIA signs or symptoms, no altered LOC, no headaches, no N/V. When asked if she can remember the onset of her pain, she said she bumped her arm, but nothing too hard. BP in affected arm is 160/90, BP in left arm is 130/80. I don't have any other info right now, but will update.


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## Aidey (Nov 3, 2010)

Is it that she can't move it, or won't because it hurts? What was the adverse reaction? Does she still have the symph nodes on that side?


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## EMSLaw (Nov 3, 2010)

Blood clot, possibly?  Or maybe some sort of nerve issue, even perhaps methathesis of the cancer to somewhere in the arm/shoulder or to a nerve that would cause refered pain to that area.  Since there was a truama, I might consider fracture, but the presentation so far doesn't make it seem likely.  Is there any point tenderness in the arm?  Any remarkable physical findings?  Pulse/Motor/Sensory findings?  Range of motion?  

In pure EMS terms, what's going on with her is merely interesting, unless there's some sign of fracture.  It's not anything we can fix in the field, nor is there anything immediately life threating that requires intervention.  So, I'd probably go with position of comfort, monitor and transport.


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## Voodoo1 (Nov 3, 2010)

She has all lymph nodes on her right side. She can't move it at all, and there is tenderness in her shoulder. I noticed that the veins on her right hand are REALLY sitcking out.


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## Aidey (Nov 3, 2010)

What was the adverse reaction?


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## Voodoo1 (Nov 3, 2010)

Aidey said:


> What was the adverse reaction?



To the voltarin? She said she was experiencing rectal bleeding. Bright red blood, and runny stool. It stopped when she stopped taking the med.


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## ejd372 (Nov 8, 2010)

Could be upper extremity DVT. It would explain the paralysis, distended veins, pain and differentiated BPs. She would already be at risk because of the HTN, and can I assume from the lung cancer that she was a chronic smoker? Is the PT sedentary/in bed rest?


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## Voodoo1 (Nov 9, 2010)

ejd372 said:


> Could be upper extremity DVT. It would explain the paralysis, distended veins, pain and differentiated BPs. She would already be at risk because of the HTN, and can I assume from the lung cancer that she was a chronic smoker? Is the PT sedentary/in bed rest?



The lung cancer is from renal cell carcinoma which has spred to her lungs. I was thinking DVT as a possiblity too. She's getting an ultrasound in a few days and she said she would let me know what they found (if anything).


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## abckidsmom (Nov 9, 2010)

Has she been having radiation to her chest?  Depending on the location of the tumor, radiation can cause thinning and decreased elasticity to tissues and I'd wonder about the patency of the blood vessels serving that arm.  Maybe an aneurysm or dissection of a subclavian vessel?  

DVT is definitely on the list too, though.


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## EMSLaw (Nov 9, 2010)

Upper extremity DVT is reasonably rare.  I think we're all thinking along the same lines here, though.  Veinous engorgement would be a tick in favor of DVT, but I'd be curious to know if there was redness, swelling, heat, etc.  

I'm curious to know the answer, whenever it comes up.


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## Veneficus (Nov 9, 2010)

http://en.wikipedia.org/wiki/Inferior_vena_cava_syndrome

http://en.wikipedia.org/wiki/Superior_vena_cava_syndrome


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## abckidsmom (Nov 9, 2010)

Veneficus said:


> http://en.wikipedia.org/wiki/Inferior_vena_cava_syndrome
> 
> http://en.wikipedia.org/wiki/Superior_vena_cava_syndrome



Smarty pants.    Thanks.


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## rescue99 (Nov 9, 2010)

Voodoo1 said:


> 64 year old woman, lung cancer pt (renal clear cell carcinoma that has spread to lungs), Hypertensive-takes Valsarten HCT @ 160mg daily. Chief complaint is pain in her right arm that radiates to scapula. Has been to the hospital and ECG showed a anterior left fasticular block. She says the doctors didn't do anything for her at all except giver her perc's which she won't take. Her family doctor prescribed Voltarin, she had an adverse reaction to it and stopped taking it. Pain has been going on for approx. 3 weeks. Now her right arm is almost paralyzed, no other paralysis CVA or TIA signs or symptoms, no altered LOC, no headaches, no N/V. When asked if she can remember the onset of her pain, she said she bumped her arm, but nothing too hard. BP in affected arm is 160/90, BP in left arm is 130/80. I don't have any other info right now, but will update.



Pain out proportion to an injury, decreased power, decreased sensation...How about a compartment syndrome? Exept for the veins.


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## Voodoo1 (Nov 10, 2010)

rescue99 said:


> Pain out proportion to an injury, decreased power, decreased sensation...How about a compartment syndrome? Exept for the veins.



It could be a possiblity. Her cap. refill time is still within normal limits on the afected arm, and there is a higher pressure not a lower one in the arm. This one has got me really scratching my head.


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## Voodoo1 (Nov 10, 2010)

Veneficus said:


> http://en.wikipedia.org/wiki/Inferior_vena_cava_syndrome
> 
> http://en.wikipedia.org/wiki/Superior_vena_cava_syndrome



Would Vena Cava Syndrome show up on an ECG?


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## Aidey (Nov 10, 2010)

I'm 99.999% confident in saying the left anterior fascicular block has NOTHING to do with her arm. A LAFB is a type of conduction delay in the heart. The path the electricity travels through the heart is abnormal. It is one of those things that can mean anything. Some people are born with it, some people develop it randomly, and other people develop it as the result of heart disease or an MI. Unless it is occurring along with another heart problem, people are almost always asymptomatic, and some don't even know they have it. It usually doesn't need treatment, although if the block progresses intervention may be necessary later. 

My concern in this case is cancer spread, specifically a tumor affecting nerve conduction and blood flow. If you look at the path of the lymph system, a tumor in the right spot could easily affect the right arm.


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## Veneficus (Nov 10, 2010)

Voodoo1 said:


> Would Vena Cava Syndrome show up on an ECG?



usually seen as JVD when the pt head is elevated 30 degrees from supine.


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## Veneficus (Nov 10, 2010)

Both Renal and lung can spread via heme or lymph pathways. 

A bronchocellular CA or met. is a common culprit. 

I am guessing if it is creating a venous block the usual palliative therapy with focal radiation to releive symptoms and opioids for pain. 

Depending on the amount and location of mets, (TNM score) she is not likely a surgical/radiation candidate, is she still on chemo? If so, what?


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## Voodoo1 (Nov 10, 2010)

If her bone scan shows that the cancer has spread into her shoulder, the plan of attack is focused radiation. She's thinking of trying Sutent. I'll post an update as soon as I hear of the results.


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## Veneficus (Nov 11, 2010)

Voodoo1 said:


> If her bone scan shows that the cancer has spread into her shoulder, the plan of attack is focused radiation. She's thinking of trying Sutent. I'll post an update as soon as I hear of the results.



If it is spreading through the vessles already, I am going to venture that the radiation therapy will be palliative for sure.

By bone scan do you mean a PET scan?

That should basically light up all mets of any significant size.


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## Voodoo1 (Nov 11, 2010)

Veneficus said:


> If it is spreading through the vessles already, I am going to venture that the radiation therapy will be palliative for sure.
> 
> By bone scan do you mean a PET scan?
> 
> That should basically light up all mets of any significant size.



She had a CT scan done. Yes, this is palliative therapy. The ultrasound tech had let it slip that there was a torn muscle in her shoulder. We'll see what the CT shows, hopefully there is no cancer spread to her bones.


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