What is the appropriate diagnostic workup for a 37-year-old male with right shoulder pain, thoracic outlet syndrome, swollen lymph nodes, and radiating pain, who has a history of rib removal and lacks insurance?

Diagnostic Workup for Thoracic Outlet Syndrome with Lymphadenopathy and Radiating Pain

For a 37-year-old male with thoracic outlet syndrome, history of rib removal, and current symptoms of lymphadenopathy with radiating shoulder pain, the initial diagnostic workup should begin with chest radiography followed by ultrasound duplex Doppler of the subclavian vessels, which are cost-effective options for patients without insurance. 1, 2

Initial Evaluation

Imaging Studies

1. Chest Radiography (First Line)

   • Standard views should include anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view 1
   • Can identify:
     • Osseous abnormalities (cervical ribs, first rib anomalies)
     • Previous surgical changes (rib removal)
     • Lung masses that could cause lymphadenopathy 1
   • Should be performed upright as malalignment can be underrepresented on supine radiography 1

2. Ultrasound Duplex Doppler (Second Line)

   • Cost-effective option for patients without insurance
   • Evaluates:
     • Subclavian artery and vein compression
     • Changes in vessel diameter and peak velocity during arm abduction
     • Lymph nodes in the neck and axilla 1, 2
   • Can detect vascular complications of TOS

Laboratory Tests

• Complete blood count (CBC) - to evaluate for infection or malignancy causing lymphadenopathy
• Basic metabolic panel - to assess overall health status
• ESR/CRP - to evaluate for inflammatory conditions

Further Workup Based on Initial Findings

If initial evaluation suggests specific TOS variant or concerning findings:

For Neurogenic TOS (most likely based on symptoms)

• MRI of the chest without contrast - superior for evaluating brachial plexus and cervical spine 1, 2
  • Can identify:
    • Brachial plexus compression
    • Cervical spine pathology
    • Soft tissue masses
  • Particularly useful for evaluating post-surgical changes after rib removal

For Vascular TOS

• CT with IV contrast - if vascular complications are suspected 1
  • More cost-effective than MRA/MRV
  • Can evaluate for thrombosis or stenosis

For Lymphadenopathy Evaluation

• Targeted ultrasound of lymph nodes - to characterize size, morphology, and vascularity
• Consider fine needle aspiration if lymph nodes have concerning features

Cost-Conscious Approach

Given the patient's lack of insurance, a stepwise approach is recommended:

1. Start with chest radiography (~$50-200)
2. Proceed with ultrasound duplex Doppler (~$200-500)
3. Consider MRI only if absolutely necessary and explore charity care options (~$1000-2000)

Management Considerations

• 60-70% of patients with neurogenic TOS respond favorably to conservative management 2
• Physical therapy focusing on postural correction and strengthening exercises should be initiated
• For persistent symptoms, consider ultrasound-guided anterior scalene muscle injection with local anesthetic as both diagnostic and therapeutic intervention 2

Pitfalls to Avoid

• Relying on a single test maneuver for diagnosis - multiple physical examination maneuvers should be performed 2
• Attributing symptoms solely to TOS when lymphadenopathy suggests possible alternative diagnoses
• Pursuing expensive imaging without first exhausting cost-effective options
• Overlooking the possibility of recurrent TOS after previous rib removal, which occurs in a small percentage of cases 3

By following this algorithm, you can provide a thorough yet cost-conscious evaluation for this patient with complex symptoms and limited financial resources.