overcautious?

[Guest guest]

Like to have the groups input on a case… 75 year old man, presented with right mid back pain of 2 years duration, 10/10 VAS, 75% on Oswestry. He denies any precipitating event. He told me, “doctors have doneevery test and there’s nothing wrong with me. But I still have pain.” He also noted that the mid back pain is worse when he is lying down and the pain increases with breathing. He admitted to a chronic cough, which really increases the pain. He is a non-smoker. He worked for many years as a scuba diver in the navy; then for 20+ years in the ship yards exposed to asbestos. The only other pertinent history is an untreated hiatalhernia. The only significant exam findings were severe spasm in the thoracic paraspinals, rib and thoracic subluxations and severe limited aROM in the thoracic spine. I took AP and Lat Thoracic films. There was an inch and a half deviation to the right of the tracheal shadow and a very dense radiopacity which appeared to be causingthis deviation. This opacity appeared to be the aortic arch only larger and more dense. My initial concern was aneurism of the aortic arch or lung cancer so I sent him to the ER with a quick referral note and the films. I was hoping maybe the deviation wascaused by scar tissue from years of diving. Apparently the ER doc implied that I was over cautious and this amount of deviation to the tracheal shadow was within normal limits. (16years in practice and I’ve neverseen anything close to half that much deviation) The patient also reported, “that white shadow ain’t nothing but my heart and its normal.” (side note – it may have been the aortic arch but it surely wasn’t his heart) I’d love to hear from the group…. Over cautious? Or prudent clinic decision making? BTW after implying I was over cautious, the ER doc not only repeated the thoracic films but did a thoracic MRI, CBC, full chem. screen and cardiac enzymes. I feel likecalling the ER doc and asking, “If I was ‘over cautious’ your additional tests imply either A) you are more ‘over cautious’ or you were just running up the bill?” Glenn Sykes, DC Gresham Town Fair Chiropractic ClinicPhone: (503) 667-6744Fax: (503) 661-7896WWW.GRESHAMCHIROPRACTOR.NET __________ Information from ESET NOD32 Antivirus, version of virus signature database 6568 (20111023) __________The message was checked by ESET NOD32 Antivirus.http://www.eset.com