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.

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