Aches and shoulder weakness
Author and Disclosure Information [Show]

Karl J. D'Silva, MD, Clinical Assistant Professor, Department of Medicine, Tufts University School of Medicine, Boston; Medical Director, Department of Oncology and Hematology, Lahey Hospital and Medical Center, Peabody, Massachusetts

Karl J. D'Silva, MD, has disclosed no relevant financial relationships

Question 1 of 3

A 63-year-old man presents to his primary care physician with increasing fatigue; general achiness; and unrelenting pain, numbness, and weakness in his right shoulder that radiates down the middle of his arm. He has been experiencing these symptoms for the past two months. The patient has a 40-year smoking history and, other than hypertension that is successfully controlled pharmacologically, has an unremarkable history.

Physical exam reveals slight hepatomegaly and a tender spot on the cervical spine. Further exam of arm weakness and numbness are suggestive of possible brachial plexus impingement. Radiography shows a soft tissue opacity in the apex of the lung. MRI confirms presence of superior sulcus tumor with brachial plexus involvement and shows multiple supraclavicular lymph node lesions and distal bone metastases. The complete blood cell count shows an elevated white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels are elevated.

What would be an appropriate next step in diagnosis?



Needle biopsy

Mediastinoscopy with biopsy

This quiz is not accredited for CME.

More from Case in Point: Non Small Cell Lung Cancer


Appetite loss and persistent cough
Fatigue, cough, and dyspnea
Man with coughing and bloody sputum
Man with dyspnea and chest pain