Two Red Herrings

Rodney Grussman is a mild-mannered, unassuming seventy-year-old man with diabetes, emphysema and valvular heart disease. I see him every three months to monitor his bloodwork and his symptoms. He sees his pulmonologist about twice a year and has a couple of nodules in his right lung Dr. Welch is following.

At his last three-month-visit everything seemed fine, except he was at the tail end of a cold, which seemed to have left him slightly short of breath. His exam was normal, his oxygen saturation hovered around his baseline, and we agreed that he would let me know if he didn’t bounce back over the next week or so.

Almost two months later, Rodney came back to see me.

“Doctor, I am so winded. I have lost my stamina since I had that cold.”

His exam was unchanged. I wondered if he could have had a silent heart attack or if something was going on with his lungs. His EKG was unchanged, but his chest x-ray suggested a couple of new, very small nodules in his left upper lobe.

I ordered an echocardiogram because of his leaky valve and referred him back to Dr. Welch for his opinion.

The echo showed no deterioration of Rodney’s pump function; his ejection fraction was still 40%, just like three years ago. That is a little lower than the 55% considered normal. His valves looked about the same as two years ago.

I waited for Jerry Welch’s report, but didn’t hear anything for a while. Then I found out that he was trying to get insurance approval for a PET-scan because the new nodules in Rodney’s left lung looked suspicious on a non-contrast CT scan. Due to his compromised kidney function, Rodney can’t have intravenous contrast dye with his CT scans.

The PET-scan finally came back normal. Rodney came back to see me. His pulmonology report focused on the new lung nodules much more than Rodney’s shortness of breath.

As I listened to Rodney’s story again, it struck me: His heart was still decent, his lungs no worse than before, but what about the oxygen carrying capacity of his blood? A simple blood count showed he was quite anemic, and his stool test was positive for blood. He’s getting his upper and lower endoscopy next week.

I hadn’t considered all my ABC’s from my emergency training – A for Airway, B for Bleeding and C for Circulation, although for more chronic conditions, perhaps it should be A for Anemia, B for Breathing and C for Circulation.

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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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