What to do when the doctors shrug their shoulders?

July 12, 2007 11:34 AM

Diagnosis Filter: Looking for opinions of what might be wrong with my mom. (more inside - long)

My mom (76 years old) just spent four days in the hospital, after my brother took her to the ER. Her symptoms were a burning sort of pain under the skin in her back, which radiated to the front and in her upper arms. Sometimes the pain was so intense her eyes involuntarily teared up (that is, she wasn't actively crying). She has a history of some heart artery blockage, and has a stent in one artery. She also has a history of pancreatitis.

She was admitted to the hospital and given a battery of tests, mainly related to her heart and also checking for blood clots (she'd developed blood clots on her lungs about 12 years ago after gall bladder surgery). All those tests turned up negative. They gave her Morphine for the pain, and blood thinning IVs just to be safe. Many tests later, and she was discharged last night with both her cardiac specialist and her GP saying whatever it was, it wasn't her heart.

She just phone me and said she's still getting bouts of that same type of pain - it feels like a hot burning pain underneath the skin. It starts in her back, across her shoulders, then radiates to the chest and arms, and now is also going down the backs of her legs. When I spoke with her, she sounded as if she was breathing heavily, and she said that that happens when the pain hits. Her other complaints when it happens are a feeling of pressure in her ears, and a tightness in her jaw, as if she's clenching her teeth (even though she isn't). Her stomach feels slightly upset, but she's not experiencing any nausea.

She's obviously going to have to pursue this with further doctors and tests, but I don't know where to start, what type of specialist (if any), etc. Any ideas out there as to what might be wrong?

posted by Oriole Adams to health (12 comments total)

If it were my mom, I'd insist she go back in to the hospital for observation.
posted by thinkpiece at 11:42 AM on July 12, 2007

Does she have any marks around her diaphraghm/just under her breastbone. Rash anything near the area of pain

Did they check for Shingles? The burning is often mentioned with this. Otherwise possibly nerve inflammation that may settle with non-steriodals if she can take them.

Her family doctor needs to conduct a few more tests and take a more detailed history. Are you sure she characterised the pain as burning when admitted? Sometimes older patients in pain are difficult to hear, but this is one of the basic questions they ask about pain in that area so I can't imagine a situation where they wouldn't rule out Shingles as the differential diagnosis.
posted by Wilder at 11:45 AM on July 12, 2007

When I hear about burning pain in the back, my first thought is "kidney stones." I haven't heard of kidney stone pain radiating down the arms, though I have heard of it radiating to the legs, but just because I haven't heard of it doesn't mean it's impossible.

As for the other symptoms, it's possible that the pain is bad enough to be causing them. I had kidney stones about twenty years ago, and I woke up from a dead sleep, bolt upright in bed, and (honestly!) nearly looked behind me to see if someone was stabbing me in the back, it hurt so much. I've known women who've had kidney stones and given birth, and they've told me that the kidney stones hurt worse than labor pains.
posted by cerebus19 at 11:48 AM on July 12, 2007

Obviously you'll want to investigate immediately acute diagnoses like kidney stones or anything else matching her symptom profile, but if that doesn't get you anywhere fast, you should probably do a thorough review of all her current medications, including vitamins and other over-the-counter substances. (If she's 76 and has some health problems, I assume she's taking something or other). Even if she's been taking a particular medication for years with no ill effects, it's possible that it has only recently begun to affect her adversely. Presumably the doctors who've examined her have already considered this possibility, but I can't count the number of times I've had the docs tell me that my meds couldn't possibly be causing my problem, then have it disappear when I stop taking them. See if her docs can prescribe alternative meds long enough to determine whether this is the case with your mother.
posted by Clay201 at 12:45 PM on July 12, 2007

I was going to say shingles too - but it seems like the kind of thing they'd test for, so it's probably not that. Good luck, and hopefully it's nothing too serious - and she'll be pain free again soon.
posted by backwards guitar at 1:03 PM on July 12, 2007

I was going to third shingles, but this would *not* be bilateral. There's no test for it, just a clinical diagnosis.

Ruling out heart disease, my list includes: gastroesophageal reflux disease, aortic dissection, or a muscle spasm. This is a case for a good primary care physician.
posted by Slarty Bartfast at 1:38 PM on July 12, 2007

hot burning pain in the spinal column = neurologist.
probably NOT shingles unless skin lesions are present
Pressure in the ears and chest - cardiologist

This is NOT repeat NOT kidney stones. Get her to an ER NOW.
Could be medication conflict/allergy or panic attack
posted by Carnage Asada at 3:11 PM on July 12, 2007

Shingles can present without a skin lesion although uncommon. Burning pain should rule out things such as kidney stone (as pointed out earlier). I would also look for local signs of redness and swelling (?cellulitis). A good physical and routine exam including neuro should be illuminating.
posted by london302 at 4:22 PM on July 12, 2007

Look to the lower cervical spinal cord. That's the spot I'd be concerned about on based on what you've said. This is neither shingles, nor kidney stones.
posted by drpynchon at 6:26 PM on July 12, 2007

Okay, what this hospital has communicated is that (a) they've hit the limits of their diagnostic knowledge/resources and (b) have no problem washing their hands of a patient in pain without so much as a followup referral. There's nothing to gain by sending her back there. Get her to a large teaching hospital or tertiary care medical center. If she's near you, University of Michigan Hospital comes to mind.
posted by nakedcodemonkey at 7:09 PM on July 12, 2007

Thanks for the input. U of M is about an hour away, so that's an option. I also thought a neuro might be the place to start, but wasn't sure.
posted by Oriole Adams at 7:14 PM on July 12, 2007

I know of a woman 10 years younger than your mother, who had almost all of your mother's symptoms, right down to the sciatica and up to the feeling of pressure in the ears (I have no information about the jaw) and who had been diagnosed with Thoracic outlet syndrome. The real underlying problem in her case was apparently a leak in her cerebro-spinal fluid (CSF) right up at the top where the containment is thinnest-- in her sinuses. She had an annoying, perpetual post-nasal drip which turned out to be CSF. The only time she got complete relief from the pressure in her ears was when she was on an airplane, though she did usually feel a little better when the weather was stormy.

I knew personally another woman in her 40s who had some of your mother's symptoms, the sciatica and the burning pains in her torso (as well as blinding headaches) who had had a lumbar puncture spinal tap which had not healed properly. She was also leaking CSF.

The explanation for all these problems in these two cases is that the pressure in the CSF was too low because of the leaks, which caused the spine to deflate and the nerves coming out of the spine to impinge upon the openings they pass through, producing burning sensations of pain, and in the first case, numbness and pins and needles in her arms and her torso.

CSF leaks are not common, as far as I know, and I would speculate that these same symptoms could occur when CSF pressure was on the low side for other reasons, perhaps including low thyroid, though I haven't been able to find the kind of definitive statement about low thyroid and low CSF pressure I would like to be able to point you to. If your mother's CSF pressure is too low, it seems to me the sensation of pressure in her ears should get worse if she holds her nose and blows until her ears pop, and better if she holds her nose and sucks in until, well until as in my case, her ears crackle.

When I was putting together the links for this answer, I ran into something interesting in the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (NINDS-NIH) page about Thoracic outlet syndrome (TOS):

Disputed TOS, also called common or non-specific TOS, is a highly controversial disorder. Some doctors do not believe it exists while others say it is very common. Because of this controversy, the disorder is referred to as "disputed TOS." Many scientists believe disputed TOS is caused by injury to the nerves in the brachial plexus. The most prominent symptom of the disorder is pain. Other symptoms include weakness and fatigue.


It wouldn't surprise me, if it turns out your mother does not have a frank CSF leak, if she were to fall into this disputed TOS category, and if the fatigue they refer to is generally the result of low thyroid.
posted by jamjam at 8:49 PM on July 12, 2007