Never Stop Learning

Hello everyone.  I know I'm looking forward to only a three-day week this week and the food-coma that will be induced Thursday. I always look forward to Thanksgiving. I'm fortunate to have a huge family, who are local for the most part, equipped with two grandmothers who are incredible cooks, and one uncle who's a chef. Not to toot our own horns or anything, but we do turkey-day right. 

Today I'd like to share with you, probably, one of my last case presentations that walked into the clinic last Friday. This patient presented with strange neck and upper shoulder pain that began 4-5 days prior. The patient could not pinpoint a certain action, or mechanism of injury; he had not lifted anything heavy nor sustained any trauma. As the patient was sitting and telling me his story I could notice he was struggling with some nasal congestion. I then began to ask the patient if he had been feeling sick as of late, to which he answered that he had been fighting off some nasal congestion and a sore throat for about a week. Ding, ding, ding! So now we have a patient with some weird neck and upper shoulder pain: that is worse with laying down for extended periods of time and while on his drive to work; that feels better with massage during a warm shower; who has been fighting off what sounds like an upper respiratory infection. What's the next step? If you guessed a physical exam to rule out any life-threatening conditions, you are correct.

The patient was informed of the risks of a physical exam, he consented, and off we went. Through the physical exam we ruled out a disc issue and facet involvement. In fact, the only instigating exam finding was pinpoint tenderness at a nodule at the right suboccipital area (base of the skull), and the same in the area of the left sternocliedomastoid muscle area (left side of the neck). As soon as I palpated over these nodules, the patient would note that was his pain generator. One should not jump to the conclusion of muscle spasm just because palpating over a muscle is tender. What caused that "knot" to form? This is where listening to the patient is key, but not allowing the patient to give you a diagnosis; that's why you are the doctor and they are the patients. 

Remember, that pesky sore throat? I did. I decided to take a look down the patient's throat, and what did I find? His throat was fiery red on the right side. Can you see where I'm heading from here? Now here is where I only give myself an 80% (very generously, if Dr. Maola has anything to say about it). I honed in on a throat infection that was causing inflammation of lymph nodes beneath the suboccipital and sternocliedomastoid muscles leading to neck and upper shoulder pain. This made sense with the red throat, stuffy nose, and alleviation of pain when the lymphatic chains were manually drained by massage in a hot shower. Seems pretty sealed up, right? Wrong.

Dr. Chad Maola, our dean of academic assessment and mentor of mine, saw a very big flaw in my diagnosis. He asked me to take a look inside the patient's ears. Sure as I'm writing this right now, that poor patient's right ear was red as could be; an ear infection was the root of all the pain! The ear infection was causing the lymph nodes to swell, and the infection was draining down the eustation tube (tube that connects the middle ear to the throat for drainage) to the back of the patient's throat causing a sore throat.

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Image from Northwestern University

Now, I could have managed the patient for a throat infection and manually drained the lymphatic chains and offered the patient some relief, but what would have happened if I didn't notice the ear infection. With an ear infection in adults, ear pain is an end-stage symptom, right before tympanic membrane rupture. In real life, if this patient came to me, paid me $80 or so for a diagnosis, then had to turn around and head to an urgent care clinic to spend another $80 for them to tell him that he in fact had an ear infection rather than a primary throat infection, he wouldn't be very happy.

I adjusted the patient's cervical spine which resulted in an instant sensation of ear drainage and sent him on his way with some instructions on dripping in some warm garlic olive oil into his ear, continue to massage out his lymphatic chains in the shower, and to seek a physician for antibiotic therapy to clear up the infection. Sure enough, the patient felt ear pain that night, found relief from the garlic olive oil, and after visiting his general practitioner received an antibiotic prescription to resolve the infection. The patient was happy, and I learned yet another valuable lesson from Dr. Maola and my patient.

I hope today's entry helps someone down the line. Assess every option and always allow the patient to tell you what their signs and symptoms are, and then you diagnose them. I hope everyone has a quick short week and a terrific Thanksgiving!

Gobble Gobble,
Dex