Fearing the Worst

Seeing George Hess last Friday, I almost gasped as I registered his dramatic weight loss over the last four months. His complexion was pasty, his cheekbones protruding and his eyes sunken, yet intense with an expression of anguish, framed by dark circles.

He seemed tired and not himself. He barely spoke at first. Harriet, his wife, listed all the symptoms George had developed since I last saw him: severe, unrelenting back pain at first, followed by steady abdominal pain, loss of appetite and later intense nausea with vomiting with most attempts at eating.

George was always thin, but now he looked cachectic after losing more than twenty pounds. His eyes showed no jaundice and his urine and bowels had normal color. His back wasn’t tender, but his abdomen was tender just about everywhere, yet soft. I couldn’t feel his liver, spleen or any tumors.

“You’ve got to help me”, he said in a quiet voice. “I can’t go on like this”. Even when he was quite ill last year with diverticulitis, he had not looked or acted like this.

“We need some bloodwork right away and then some x-rays. We should know by Monday or Tuesday what this is”, I said. In my mind I wondered if this was yet another case of pancreas cancer. I have seen several in the past five or six years. My wife, in her entire career, has never seen one.

I prescribed some pain medication and something for nausea and sent George to the lab. I needed to know if his kidneys could tolerate the CT scan contrast and I wondered if he was anemic and what his liver and pancreas chemistries would show.

By the close of business his blood test results were back – all normal, except nearly borderline kidney function for using contrast. We couldn’t get a CT scheduled until late Monday. I worried over the weekend what was the matter with George. I even described the clinical scenario to my wife over dinner as I reviewed in my mind what I knew so far about George’s case. She thought for a moment, then asked if the patient still had his gallbladder and wondered if I had considered ordering a gallbladder ultrasound before thinking pancreas cancer and CT scan.

“He just looked too sick, and his eyes had that intense, terrified stare all my other pancreatic cancer patients have had”, I explained.

Yesterday the radiologist called me and said he wasn’t comfortable using contrast. By his calculation, George was just under the creatinine clearance limit.

“Do it without contrast then”, I said. “You’ve got him there, and maybe we’ll see something.”

The rest of the afternoon went by and I didn’t hear anything from the x-ray department.

Mid-morning today the report came in. The CT scan showed no evidence of any tumors or fluid in his abdomen. It did show that in comparison with last year’s scan, George’s gallbladder was significantly larger, but no gallstones were visible. The radiologist suggested an ultrasound to better assess for gallstones.

I guess my wife was right in reminding me of one of my own favorite expressions: Common things are common.

1 Response to “Fearing the Worst”

  1. 1 Nicki October 10, 2010 at 12:00 am

    But hooves do sometimes belong to zebras! Like you, our GP thinks ‘beyond the box’ and it was only this that enabled the early diagnosis of my husband’s pancreatic cancer. Although it was locally advanced and inoperable this early diagnosis has given us many more months together than would otherwise have been the case.

    I’ve known of other pancreatic cancer patients who went through a whole battery of gallstone/IBS testing before their doctors even considered pancreatic cancer resulting in them having little time for their loved ones to come to terms with this terrible disease and its (almost) inevitable outcome. In one case, diagnosis was just a week or two before death.

    Bless you.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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