Learning Objectives
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Learn the common causes of chest wall and subcostal pain.
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Learn the common causes of chest wall and subcostal numbness.
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Develop an understanding of the impact of diabetes on the peripheral nerves.
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Develop an understanding of the anatomy of the intercostal and subcostal nerves.
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Develop an understanding of the causes of peripheral neuropathy.
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Develop an understanding of the differential diagnosis of chest wall and subcostal pain.
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Learn the clinical presentation of diabetic truncal neuropathy.
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Learn how to examine the thoracic dermatomes.
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Learn how to use physical examination to identify diabetic truncal neuropathy.
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Develop an understanding of the treatment options for diabetic truncal neuropathy.
Tommy Teller
Tommy “Tank” Teller is a 68-year-old motorcycle mechanic. He begins our visit by saying, “What the hell, Doc? Don’t let anybody tell you that getting old is any fun. It’s been one thing after another, first the cataracts and now this.” I asked him, “What’s the problem, Tank?” Tommy retorts, “Doc, are you blind? Here you are asking me what’s the problem. Are you kidding? And to think, I’m here in my best T-shirt and all.” It was all I could do to keep from laughing. Tommy was never one for sartorial splendor, but today he was looking particularly “tanklike.” Tommy has been a patient of mine for the last few years. He is a really good guy but not a picture of health. I first saw Tommy when his ophthalmologist asked me to clear him for cataract surgery. The whole thing started when he had failed his eye test when trying to renew his driver’s license. I remember that as I was introducing myself to Tommy, he shook my hand and said, “Doc, fat, stupid, and blind is no way to go through life. But at least we can fix one of them.” Other than cataract surgery a couple of years ago, Tommy said he hadn’t seen a doctor since he had to get his hand stitched up about 10 years ago. As I quickly figured out, fat, stupid, and blind were just the beginning of Tommy’s list. We had to add hypertension and poorly controlled type 2 diabetes. I had done my best to get Tommy tuned up for his surgery, and we got him through it without too much drama. As I got to know Tommy, I realized that the “good old boy” persona was just an act. He was actually a pretty interesting guy. He knew something about most anything I mentioned. Tommy’s problem lies with compliance—and the lack thereof. In spite of my best efforts, his blood pressure and blood sugar were poorly controlled at the best of times. I could hardly wait to see what his current situation involved. As I was thinking about this, Tommy pulled his T-shirt over his head, and I immediately saw the answer.
“Don’t you think I’m getting a little old to be pregnant? I took all the precautions and now this,” said Tommy as he pointed to the large bulge poking out of the right side of his abdomen ( Fig. 10.1 ). “When did that show up?” I asked. Tommy said, “Hank—you know, after Hank Williams—has been there for about a month. Doc, I’ve had a good life. Do you think I have the big C? One of the guys I work with says too much drinking can mess with your liver, but he didn’t say it would get you pregnant! What the hell, Doc? I would be lying if I said I wasn’t scared.”
I asked Tommy how his blood sugars had been doing, and he give me a sheepish grin and said that he had been meaning to get by the drugstore to get some test strips, but he had been awfully busy of late. I responded, “So I take that to mean that you haven’t been checking your sugars. What about your high blood pressure pills?” Tommy said that he took them when he remembered, but added, “They mess with my willy so if I have plans , I don’t take them.” I shook my head and thought, “This guy is going to kill himself if he keeps on.” I asked Tommy to describe any numbness associated with his “pregnancy,” and he said that he had “weird needles and pins sensation over the baby bump” that drove him crazy and kept him up at night.
I asked Tommy about any fever, chills, or other constitutional symptoms such as weight loss, jaundice, night sweats, etc., and he shook his head no. He denied any recent trauma to the abdominal wall or anything else that might account for his symptoms.
I asked Tommy to point with one finger to show me where the pins and needles were, and he pointed to the right subcostal area and said, “Right here, over Hank.” Tommy went on to say that he knew it was a boy and gave out a short laugh, but I could tell that he was really scared and was kidding around to cover it up.
On physical examination, Tommy was afebrile. His respirations were 16, his pulse was 72 and regular, and his blood pressure was 168/90. In his T-shirt and underwear, Tommy weighed 268 pounds, up 10 pounds from his last visit. His fundoscopic examination was a mess. He had most everything wrong you could see on a patient’s retina ( Fig. 10.2 ). “So, Tank, when is the last time you saw the eye doctor?” “You remember, Doc! It’s when I got my cataracts fixed—must be about 2 years ago.” I shook my head and continued to examine the patient. The rest of his head, eyes, ears, nose, throat (HEENT) exam was normal. Because Tommy was one of those guys who liked to chew on a cigar while he was working, I took extra care when I examined his oral mucosa, but things looked pretty good. Other than the hypertension, his cardiac examination was normal. His lungs were clear, and his thyroid was normal. His abdominal examination revealed a large bulge in the subcostal area. It was soft, and there was no abnormal mass or organomegaly. I asked Tommy to suck in his gut, and there was obvious weakness of the abdominal wall muscles on the right. His eyes weren’t the only thing that the diabetes got, I thought, as I completed my exam. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema, and his peripheral pulses were 1+. A careful examination of his feet revealed no diabetic ulcers, and his nail care was good. His low back examination was unremarkable. Visual inspection of the skin over his right subcostal region revealed no evidence of current or past herpes zoster infection, and the skin was otherwise unremarkable. There was no rubor or color. There was no obvious abdominal wall hernia. A careful neurologic examination of the upper extremities revealed a symmetric decrease in sensation distally in all four extremities, consistent with diabetic neuropathy. “Tank, I think that the diabetes has got your nerves. You may want to change Hank’s name to Sugar, because if you don’t get your blood sugars and your blood pressure under control, Hank is going to be the least of your problems.” He replied, “I hear you, Doc… I hear you, Doc.” I shook my head and wondered if Tank ever heard anything I said. Oh well, my job was to keep trying, and I knew that I would.
Key Clinical Points—What’s Important and What’s Not
The History
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History of onset of painless bulging of the abdominal wall in the absence of antecedent trauma
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History of poorly controlled diabetes
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History of obesity
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History of poorly controlled hypertension
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History of onset of right chest wall and subcostal pain with associated paresthesias
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No fever or chills
The Physical Examination
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Patient is afebrile
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Obvious weakness of the right abdominal wall
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Decreased sensation in the distribution of the subcostal nerve
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Grossly abnormal fundoscopic examination
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Findings consistent with symmetric diabetic polyneuropathy
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No evidence of infection
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No evidence of herpes zoster
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Hypertension
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Obesity
Other Findings of Note
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Otherwise normal HEENT examination
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Normal cardiac examination
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Normal pulmonary examination
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No abdominal wall hernia
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No organomegaly
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No peripheral edema
What Tests Would You Like to Order?
The following tests were ordered:
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Electromyography (EMG) and nerve conduction velocity testing of the lower thoracic dermatomes and extremities
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Complete chemistry profile
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Hemoglobin A1c (HbA1c) determination
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Urinalysis
Test Results
EMG and nerve conduction velocity testing revealed a subacute-chronic neurogenic pattern, characterized by complex and long-duration motor unit potentials and increased percentage of polyphasic potentials. Evidence of spontaneous activity, including positive sharp waves, was noted, as well as an associated mixed sensory-motor polyneuropathy in all four extremities.
Tests showed an abnormal complete chemistry profile, including a blood sugar of 282 and an elevated creatinine at 1.5.
There was an elevated HbA1c determination of 10.8.
Abnormal urinalysis showed 1+ proteinuria.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Diabetic truncal neuropathy
The Science Behind the Diagnosis
Anatomy
The precise mechanisms responsible for diabetic neuropathy continue to be elucidated, with the current concepts as to the evolution of diabetic neuropathy adopting a multifactorial pathologic approach ( Fig. 10.3 ). Maladaption and dysfunction of the nervous and vascular systems provide the basis for the angiopathy and neural damage that lead to diabetic polyneuropathy. Concurrent inflammatory and immune responses combined with mitrochondrial dysfunction and schwannopathy appear to also play a role in the pathogenesis of diabetic polyneuropathy.
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Doug Montgomery: A 38-Year-Old Male With Anterior Chest Wall Pain Made Worse by Bending
Chuck Connors: A 72-Year-Old Male With Persistent Pain Following a Thoracotomy for Lung Cancer
Brian Nguyen: A 23 Year-Old With Severe Testicular Pain and Hematuria
Lydia Lutz: A 24-Year-Old Bartender With the Acute Onset of Severe Abdominal Pain That Radiates Through to Her Back
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