A 63-year-old woman presents to your clinic with complaints of general malaise, weakness, and occasional cough—symptoms that started a couple of days ago. Also, her left shoulder has been hurting her “more than usual.”

She denies any fever, chills, nausea, or vomiting. She admits to smoking two packs of cigarettes per day and having hypertension. Otherwise, her medical history is unremarkable.

During the physical exam, you observe that the patient is an older female in no obvious distress. She is afebrile, and the rest of her vital signs, including pulse oximetry, are normal. 

Her breath sounds demonstrate scattered rhonchi but overall are clear. She does have localized tenderness over her left shoulder, with decreased range of motion in that arm secondary to the pain and stiffness in it. 

You send a blood sample to the lab to check her complete blood count and obtain a chest radiograph, which is shown. What is your impression?

ANSWER
The radiograph demonstrates a slightly elevated left hemidiaphragm, which is nonspecific, as well as normal to slightly increased lung markings. There is no definite infiltrate or consolidation noted. 

Of note, there is a displaced fracture of the mid-distal left clavicle, which may be partially healed. There appears to be a focal lytic lesion within that area. The surrounding bone is extremely osteopenic as well. 

These findings, especially in the absence of injury or trauma, raise the question of a pathologic fracture, and further workup is warranted. Subsequent workup on this patient demonstrated a large renal mass, which was felt to be, most likely, a metastatic lesion.