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A drooping eyelid and shoulder pain in a smoker
A 63-year-old man with a 45-pack-year smoking history has three months of right shoulder pain spreading down the inner arm to the little finger. His right hand has become weak and thin.
Step 1 of 4
His right upper eyelid droops, the right pupil is small, and the right side of his face doesn't sweat.
What is this eye-and-face finding called?
Correct answer: D
Ptosis, miosis and anhidrosis on one side is Horner syndrome, from interruption of the sympathetic supply to the head. A third nerve palsy causes ptosis with a dilated pupil.
Show answer
D
Ptosis, miosis and anhidrosis on one side is Horner syndrome, from interruption of the sympathetic supply to the head. A third nerve palsy causes ptosis with a dilated pupil.
Step 2 of 4
Which part of the brachial plexus explains the hand weakness and inner-arm pain?
Correct answer: A
The inferior trunk (C8–T1) supplies the intrinsic hand muscles and carries sensation from the medial forearm and hand. Superior trunk lesions (Erb palsy) affect the shoulder and elbow instead (see brachial plexus).
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A
The inferior trunk (C8–T1) supplies the intrinsic hand muscles and carries sensation from the medial forearm and hand. Superior trunk lesions (Erb palsy) affect the shoulder and elbow instead (see brachial plexus).
Step 3 of 4
Which structure, damaged at the lung apex, explains the Horner syndrome?
Correct answer: D
A tumor at the apex invades the cervical sympathetic chain/stellate ganglion as well as the inferior trunk. A T1 root avulsion can also interrupt the sympathetic fibers to the head.
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D
A tumor at the apex invades the cervical sympathetic chain/stellate ganglion as well as the inferior trunk. A T1 root avulsion can also interrupt the sympathetic fibers to the head.
Step 4 of 4
What is the most likely underlying diagnosis?
Correct answer: A
Apical lung mass + Horner syndrome + ulnar-side arm pain and hand wasting in a smoker = Pancoast (superior sulcus) tumor. Erb palsy involves the upper trunk (C5–C6) and spares the hand.
Show answer
A
Apical lung mass + Horner syndrome + ulnar-side arm pain and hand wasting in a smoker = Pancoast (superior sulcus) tumor. Erb palsy involves the upper trunk (C5–C6) and spares the hand.
Key points
- Ptosis + miosis + anhidrosis → Horner syndrome.
- Hand wasting + medial arm pain + Horner in a smoker → Pancoast tumor (C8–T1 + sympathetic chain).
Study: Brachial plexus, Lungs, Ulnar nerve