BLOG: That relentless shoulder pain
Click Here to Manage Email Alerts
The other day, I was rounding with our fellow in one of our teaching hospitals. As we stopped at a nursing station, a physician was sitting at a computer.
He looked at me and said with a big smile.
“Dr. Aldasouqi, it is a pleasure to see you, again!”
I looked at him, and we both seemed to realize that I did not remember him.
He then showed me his badge with his name. The name and his face may have rung a bell, but still I could not place him.
“You taught me in the PBL class when I was a second-year medical student, some years ago.”
PBL, or problem-based learning, was the old curriculum of our medical school. As I wrote in prior posts, we switched to an innovative new curriculum in 2016, utilizing simulated medical education.
The physician said that it was about 10 years ago, that he would always remember me very well and that he would never forget a class about GI disorders. He said we were discussing the case of a patient with abdominal pain. He said he vividly remembered my own story about my relentless shoulder pain.
I wrote about that shoulder pain in a December 27, 2016, blog post https://www.healio.com/news/endocrinology/20200408/blog-the-relentless-shoulder-pain-what-is-the-diagnosis.
I wrote about how in early 2002, I experienced severe abdominal pain that prevented me from sleeping. I thought I had an acute abdomen and was about to go to the emergency department but decided I would wait and have my abdomen imaged. I would also get imaging of my right shoulder, which had been vaguely painful for about 2 years.
In the post, I described what happened with my abdominal pain. In brief, I had recurrent episodes of abdominal pain due to gall stones, and my gall bladder was found to be chronically inflamed. I underwent a cholecystectomy.
And — intriguingly — the shoulder pain never recurred.
That shoulder pain is an example of the so-called referred pain, a pathological condition where a patient will feel pain in an area in the body away from the site of the original pain. This results from cross-neurologic connections. That is when a visceral (inner) organ, such as the heart or an abdominal organ, share neurologic innervation with a dermatome, an area of the skin. When pain occurs in the visceral organ, the heart, for example, the patient will feel additional pain in the skin away from the heart, for example, in the shoulder or the arm.
In my own case, the area of the gall bladder is in the vicinity of the phrenic nerve, which traverses vertically from the neck into the abdominal cavity, passing into the vicinity of the liver and the gall bladder. The phrenic nerve is vital for respiration. It covers the C3-C5 innervations, and this dermatomal regional distribution is the shoulder. Hence, when pathologies occur in the abdominal cavity, gall stones, irritation to the phrenic nerve will trigger pain in the right shoulder.
I was so happy that the medical student, now a consultant in the teaching hospital, whom I taught about 10 years ago, still remembers that educational piece. I then explained to my fellow that in order to have an impactful teaching experience, one has to be creative. Utilizing personal stories, humor, etc., enriches education. Students will not remember the majority of the details of the education they receive from teachers and preceptors, but they will always remember educational pieces that came with personal reflections and other spices.
Collapse