DR PARKER: Mrs L is a
44-year-old woman admitted to a Boston, Mass, teaching hospital with
terminal cancer complicated by severe pain. She lives in the greater
Boston area with her husband and has managed care insurance.
Mrs L experienced a flaccid left arm for 5 days prior to admission—the
first manifestation of metastatic lung cancer. She also noted some mild
weakness in the left leg accompanied by slurred speech and some
drooling. There was no associated headache, change in vision, fever, or
weight loss. She complained of mild shortness of breath and back pain.
Her medical history is complex and notable for a seizure disorder since
age 16 years, polycythemia vera, hemiplegic migraine, carcinoid,
colitis, pseudotumor cerebri, and distal pancreatectomy for islet cell