What is the best approach to manage a patient with back pain, right arm numbness and pain, vomiting, dysuria, dizziness, and fatigue, with a history of T2DM and breast cancer in remission?

Immediate Diagnostic Workup Required to Rule Out Metastatic Disease

This patient with breast cancer history presenting with new-onset back pain, vomiting, near-syncope, and constitutional symptoms requires urgent evaluation for metastatic disease, particularly spinal metastases with potential cord compression, before attributing symptoms to benign causes. 1

Critical Red Flags Present

This clinical presentation contains multiple concerning features that mandate immediate investigation:

• Back pain between shoulder blades in a breast cancer patient is metastatic disease until proven otherwise, even though currently resolved 1
• Near-collapse episode with bending suggests possible neurological compromise or vertebral instability 1
• Constitutional symptoms (vomiting, dizziness, fatigue) in combination with back pain raise concern for systemic disease progression 2
• Breast cancer is the most common malignancy to metastasize to bone, with spine being a frequent site 1, 2

Immediate Investigations Required

Urgent Imaging

• MRI of the entire spine is mandatory to evaluate for vertebral metastases and cord compression, even with resolved pain 1
• Plain radiographs are insufficient and should not delay MRI 1

Laboratory Assessment

• Complete blood count (anemia may contribute to fatigue and near-syncope) 3
• Comprehensive metabolic panel including calcium (hypercalcemia from bone metastases) 3
• Liver function tests (hepatic metastases) 2
• Urine culture (to confirm or exclude UTI as contributing factor) 3

Cardiac Evaluation

• ECG should be performed immediately given near-syncope, dizziness, and diabetes 3
• Consider cardiac dysfunction as cause of symptoms, particularly given chemotherapy history 3

Symptom-Specific Management While Awaiting Workup

Pain Management

• Acetaminophen or NSAIDs for musculoskeletal pain if no contraindications 3
• If neuropathic component suspected (arm numbness/pain), consider duloxetine 30 mg daily for one week, then 60 mg daily 3, 4
• Avoid attributing arm symptoms solely to nerve impingement without excluding brachial plexus involvement from metastatic disease 2

Neuropathy Assessment

• Assess for chemotherapy-induced peripheral neuropathy (CIPN) given taxane/platinum exposure history 4
• CIPN occurs in 30-40% of patients after taxane chemotherapy and may persist long-term 4
• Physical activity programs (moderate-intensity walking, resistance exercise) reduce CIPN symptoms 4
• Duloxetine provides 30-50% reduction in neuropathic pain 3, 4

Fatigue Management

• Rule out treatable causes first: anemia, thyroid dysfunction, cardiac dysfunction 3
• Assess for depression and anxiety using validated screening tools, as these commonly coexist with fatigue 3
• Cancer-related fatigue is multidimensional and requires assessment before implementing interventions 3
• Exercise programs (Level I evidence) are first-line non-pharmacological intervention 3
• Consider pharmacological interventions only after non-pharmacological approaches 3

Dysuria Management

• Urine dipstick and culture to confirm recurrent UTI 3
• Given history of E. coli UTI in June 2025, empiric antibiotics may be appropriate pending culture if dipstick positive 3
• Consider diabetes as predisposing factor for recurrent UTIs 3

Vomiting and Dizziness

• Rule out medication side effects, particularly from diabetes medications (Jardiance, Galvus, Glibenclamide) 3
• Consider hypoglycemia as cause given triple diabetes therapy 3
• Evaluate for vestibular causes if symptoms persist 3
• Rule out increased intracranial pressure from brain metastases if vomiting persists 3, 2

Diabetes Management Considerations

• Monitor glucose closely given vomiting and decreased oral intake 3
• Triple oral therapy (SGLT2 inhibitor + DPP-4 inhibitor + sulfonylurea) carries hypoglycemia risk, particularly with glibenclamide 3
• Consider holding glibenclamide temporarily if oral intake poor 3

Hormonal Therapy Considerations

• Continue hormonal therapy unless contraindicated by acute illness 3
• Hot flushes are expected side effect; offer SSRIs, SNRIs, or gabapentin for vasomotor symptoms 3
• Fatigue may be partially attributable to hormonal therapy and premature menopause 3

Urgent Oncology Consultation Indications

Contact oncology immediately if:

• MRI reveals spinal metastases or cord compression (requires emergency neurosurgical evaluation) 1
• Symptoms progress or new neurological deficits develop 1
• Constitutional symptoms worsen despite supportive care 2

Physical Therapy Referral

• Refer for physical therapy for upper back/shoulder blade pain and arm symptoms once metastatic disease excluded 3, 5
• Physical therapy with stretching and strengthening exercises effective for musculoskeletal symptoms 3, 5
• Acupuncture may be offered as adjunct for pain management 3, 5

Common Pitfall to Avoid

The most critical error would be attributing back pain to muscular strain without imaging in a breast cancer patient. Metastatic breast disease commonly presents as back pain, and delayed diagnosis of spinal metastases can result in irreversible neurological damage from cord compression 1. The fact that pain temporarily improved with massage does not exclude serious pathology 1.