A 58-year-old man had an history of three visits to the hospital in relation to strong pain located over his left shoulder. He was a heavy smoker.
CLINICAL CASE: Five months before he went to the Emergency Department (ED) with a strong pain on his left shoulder and an important limitation for movement. He said that he was working with heavy machinery. No other symptoms were recorded and he was discharged with a presumptive diagnosis of epicondylitis.
CLINICAL EVOLUTION: The patient had two more visits to the ED with alternative diagnosis. No reports from X-ray images were obtained. In one of the visits he referred low back pain. In a new visit an abnormal finding located on the external border of the left scapula was detected and a diagnostic process was properly implemented.
Final Diagnosis: Lung cancer with bone metastases.
CLASSIFICATION OF THE PROBLEM: WRONG DIAGNOSIS AND DIAGNOSTIC DELAY.
There is an aspect of perception in relation to the X-ray evaluation. The general doctor in the ED was probably “focused” on the humerus. Also the x-ray of only half of the thorax made more difficult a comparison between both sides.
.Simple radiology was not informed at the ED. In a situation like this one, important details can be missed.
. Technical aspects of the image are also important to discriminate bone and soft tissue.
. Context in this case is related to idiomatic problems that must be resolved properly.
MEASURES FOR IMPROVEMENT:
. Even if the problem is unilateral, both anatomical sides in a x-ray must be included.
Technical aspects of simple radiology are key to detect important and subtle differences.
. A complete physical examination is mandatory even for localized problems.