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Endgames Picture Quiz

A sinister cause of shoulder pain, with numbness and weakness in the ipsilateral hand

BMJ 2012; 345 doi: (Published 24 October 2012) Cite this as: BMJ 2012;345:e6948
  1. Ravi Popat, core surgical trainee year 11,
  2. Josh Derodra, consultant vascular surgeon2,
  3. Stella Vig, consultant general and vascular surgeon2,
  4. Eric Lim, consultant thoracic surgeon3
  1. 1London Deanery, London WC1B 5DN, UK
  2. 2Croydon University Hospital, Croydon Health Services NHS Trust, Croydon, UK
  3. 3Royal Brompton and Harefield NHS Foundation Trust, London
  1. Correspondence to: R Popat, 20 Weston Drive, Stanmore HA7 2EU, UK ravipopat{at}

A 41 year old patient with insulin dependent diabetes presented with a one month history of progressively worsening pain, numbness, and weakness of his right shoulder and arm. His history included peripheral vascular disease, chronic renal failure, and chronic pancreatitis. He was also a smoker with a 60 pack year history.

On general inspection, he appeared cachectic. On closer inspection of the right upper limb, he had wasting of the intrinsic muscles of the hand. Finger abduction and adduction in the right hand was weak, as was flexion of the right ring finger and right little finger. Tone and reflexes were normal; however, sensation along the right little finger and the ulnar aspect of the upper limb on the right side was reduced. On examination, his elbow and shoulder were normal.

He underwent chest radiography (fig 1), followed by computed tomography of his chest and abdomen.

Fig 1 Anteroposterior radiograph of our patient’s chest


  • 1 What are the radiological findings?

  • 2 What condition do these findings probably represent?

  • 3 What further investigations would you request?

  • 4 What are the common presenting symptoms of this condition?

  • 5 How would you manage this condition?


1 What are the radiological findings?

Short answer

The radiograph shows an area of opacification in the right lung apex but is otherwise normal.

Long answer

The chest radiograph shows an area of opacification in the right lung apex but is otherwise normal (fig 2).

Fig 2 Anteroposterior radiograph showing an area …

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