A 64-Year-Old Man Unable to Lift His Arm or Walk

A 64-Year-Old Man Unable to Lift His Arm or Walk

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Winston Tan, MD; Nicole Ganon, PA; Ashton Ritter, MMS

May 21, 2019

Editor’s Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

A 64-year-old right-handed man presents to the emergency department with left-sided arm and leg weakness. He reports that over the past 4 weeks, he has had episodes of feeling “off balance” when walking but denies any falls or syncopal episodes. Over the past week, he has developed weakness and numbness in his left side, with increased difficulty when walking. The weakness worsened to the point where he could not comfortably walk or lift his left arm.

He does not report headaches, visual changes, confusion, facial weakness, or incontinence. He denies any falls or loss of consciousness. He has no pain. He has no recent history of fever, immunocompromised state, or neck stiffness. He has no history of convulsions or seizures. His history does not include stroke, myocardial infarction, or blood clots. He does not take any blood thinners but is on aspirin (81 mg by mouth daily). His past medical history includes well-controlled hypertension, sleep apnea, migraine, and depression. He is a current smoker, with a 30–pack-year history.

He has a history of stage I non-small cell lung adenocarcinoma diagnosed 5 years ago, for which he had a right upper lung lobectomy. The tumor was EGFR negative, anaplastic lymphoma kinase (ALK) negative, ROS1 negative, and PD-L1 positive. He did not have any chemotherapy or radiation adjuvantly and has been following up with PET and CT annually, with no evidence of disease on the most recent PET scan 5 months before evaluation.

Medscape © 2019 WebMD, LLC

Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Winston Tan, Nicole Ganon, Ashton Ritter. A 64-Year-Old Man Unable to Lift His Arm or Walk – Medscape – May 21, 2019.

Consultant, Hematology/Oncology, Mayo Clinic, Jacksonville, Florida

Disclosure: Winston Tan, MD, has disclosed no relevant financial relationships.

Hematology/Oncology, Mayo Clinic, Jacksonville, Florida

Disclosure: Nicole Ganon, PA, has disclosed no relevant financial relationships.

Physician Assistant, Hematology/Oncology, Mayo Clinic, Jacksonville, Florida

Disclosure: Ashton Ritter, MMS, has disclosed no relevant financial relationships.

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A 64-Year-Old Man Unable to Lift His Arm or Walk

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A Visual Guide to Lung Cancer

A Visual Guide to Lung Cancer

Lung cancer is the top cause of cancer deaths in both men and women. But this wasn’t always the case. Prior to the widespread use of mechanical cigarette rollers, lung cancer was rare. Today, smoking causes nearly 9 out of 10 lung cancer deaths, while radon gas, pollution, and other things play a smaller role. Newly developed drugs provide new hope for those diagnosed today.

Cigarettes are packed with cancer-causing chemicals. They also disarm the lungs’ natural defense system. The airways are lined with tiny hairs called cilia. To protect the lungs, they sweep out toxins, bacteria, and viruses. Tobacco smoke stops the cilia from doing their job. This lets the cancer-causing chemicals build up.

Lung cancer begins quietly. There are usually no symptoms or warning signs in the early stages. As it gets worse, you may notice:

A type of scan called spiral CT may pick up early lung cancers in some people, but it’s not clear whether it finds them early enough to save lives. 

The U.S. Preventive Services Task Force recommends that heavy smokers ages 55-80 get a CT scan every year. The same goes for those who used to smoke a lot and quit less than 15 years ago.  

If your doctor thinks you might have lung cancer — for instance, because you have a long-lasting cough or wheezing — you’ll get a chest X-ray or other imaging tests. You may also need to cough up phlegm for a sputum test. If either of these tests suggest that you could have cancer, you’ll probably need to get a biopsy.

Your doctor will take a small sample of the suspicious growth, usually with a needle, for examination under a microscope. By studying the sample, a pathologist can determine whether the tumor is lung cancer, and if so, what kind.

Small-cell lung cancer is more aggressive, meaning it can spread quickly to other parts of the body early in the disease. It is strongly tied to cigarette use and is rare in nonsmokers. Non-small-cell lung cancer grows more slowly and is more common. It’s responsible for almost 85% of all lung cancers.

Staging describes how far someone’s cancer has spread. Small-cell lung cancer is divided into two stages: “Limited” means the cancer is confined to one lung and maybe nearby lymph nodes. “Extensive” means the cancer has spread to the other lung or beyond. Non-small-cell lung cancer is assigned a stage of I through IV, depending on how far it has spread.

When doctors find non-small-cell lung cancer before it spreads beyond one lung, an operation can sometimes help. The surgeon may remove the part of the lung that has the tumor, or if necessary, the entire lung. Some people get radiation or chemotherapy afterward to kill any remaining cancer cells. Surgery usually doesn’t help with small-cell lung cancer because it probably has already spread before diagnosis.

When lung cancer spreads too far to be cured, treatments may still help people live longer and have a better quality of life. Radiation and chemotherapy can shrink tumors and help control symptoms, such as bone pain or blocked airways. Chemotherapy is usually the main treatment for small-cell lung cancer.

Targeted therapy plus chemotherapy may help, if other approaches don’t work. One type prevents the growth of new blood vessels that feed cancer cells. Others interrupt the signals that prompt lung cancer cells to multiply, as shown in the image here.

Immunotherapy works with your immune system to fight advanced cases of non-small-cell lung cancer. It doesn’t work for everyone, but when it does, the results look strong. You’d also get chemotherapy.

Clinical trials help doctors explore promising new treatments for lung cancer. Ask your doctor if there’s one that you could join, what to consider, and how to sign up.

Being diagnosed with lung cancer can be a shock. If you smoke, or used to, it’s not too late to make healthy changes. Research shows that people who quit smoking after learning they have lung cancer do better than those who keep smoking.

While smoking is the top cause of lung cancer, it is not the only risk factor. Breathing in secondhand smoke at home or at work also appears to raise your risk. People who are married to someone who smokes are 20% to 30% more likely to get lung cancer than the spouses of nonsmokers.

Some jobs make lung cancer more likely. People who work with uranium, arsenic, and other chemicals should try to limit their exposure. Asbestos, which was once widely used in insulation, is a known cause of lung cancer. It’s rarely used now, but workers who were exposed years ago are still at risk.

This natural radioactive gas is found at higher than normal levels in certain parts of the U.S. The gas can build up inside homes and raise the risk of lung cancer, especially in people who smoke. It is the second leading cause of lung cancer in the U.S. You can’t smell or see it, but you can use a simple test kit to find it.

It causes far fewer cases than smoking, but air pollution is still something to avoid. Experts think that pollution from cars, factories, and power plants may affect the lungs like secondhand smoke does.

Lung cancer does happen to people with no well-known risk factors — including those who’ve never smoked. Researchers don’t know why. It seems to happen to women more than men. And one type, adenocarcinoma, is more common in nonsmokers than smokers.

Lung cancer is the leading cause of cancer deaths for men and women. But if you don’t smoke and you avoid other people’s smoke, that will greatly lower your odds of getting it. If you smoke, do whatever it takes to quit. It often takes several tries to kick the habit, so keep trying. It’s worth it, and will benefit your whole body.


Medically Reviewed on 5/28/2018

Reviewed by Carol

DerSarkissian on May 28, 2018


1)         3D4Medical.com
2)         Louisa Howard / Photo Researchers, Inc
3)         Echo/Cultura
4)         James Cavallini / Photo Researchers, Inc
5)         Du Cane Medical Imaging Ltd. / Photo Researchers, Inc
6)         Shannon Fagan/Riser
7)         Michael Abbey / Photo Researchers, Inc
8)         Brian Evans / Photo Researchers, Inc.
9)         Barry Slaven/The Medical File
10)       Peter Widmann/Imagebroker.net
11)       SPL / Photo Researchers, Inc.
12)       Mason Morfit/The Medical File
13)       Nacho Muro/Age Fotostock
14)       Hitoshi Nishimura/Taxi Japan
15)       Alain Le Bot/Photononstop
16)       Steve Cole/Photodisc
17)       Nello Giambi/Stone
18)       Jacobo Zanella/Flickr
19)       Stone Images/Age Fotostock


American Cancer Society web site.
University of Texas M.D. Anderson Center web site.
National Cancer Institute web site.
Toxilogical Sciences, November 2001.
Wakelee, H. Journal of Clinical Oncology, Feb. 10, 2007.
World Health Organization web site.
U.S. Preventive Services Task Force web site.
Memorial Sloan Kettering Cancer Center: “Why a New Immunotherapy for Lung Cancer Only Works for Some People.”
Hopkins Medicine: “Former Smokers: What’s Your Risk for Lung Cancer?”

Reviewed by Carol

DerSarkissian on May 28, 2018

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A Visual Guide to Lung Cancer

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Lung Cancer Health Center

Lung Cancer Health Center

From diagnosis to treatment.

13 of the best tips.

Seeing the big picture.

Lung cancer and smoking often, but not always, go hand in hand. As lung cancer stages advance, lung cancer symptoms include coughing, wheezing, shortness of breath, and bloody mucus. Treatment includes surgery, chemotherapy, and/or radiation.

Lung Cancer Screening’ Risks Not Discussed Enough

Lung cancer screening is recommended for high-risk current and former smokers. But the U.S. Preventive Services Task Force and other organizations say that doctors need to explain the risks as well as the benefits. Those risks include a high rate of false positives, which can lead to unnecessary follow-up procedures.

Read Full Article

Do you know the myths from the facts?

Tips to managing them.

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WebMD does not provide medical advice, diagnosis or treatment.

See additional information.

Lung Cancer Health Center

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