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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.

A Red Herring

When Joel Mulholland fell off his garage roof last winter he must have hit every bone in his upper body. The muscular, tattoo-armed, motorcycle-riding fifty-five-year old, who had never complained of pain or even taken a sick day before, became almost unable to work.

His x-rays at the emergency room showed no fractures and his blood tests during our office follow-ups showed no evidence of any inflammatory disease. Our local rheumatologist, Norm Fahler, saw him several times and made a diagnosis of cervical myofascial syndrome. I followed Joel for his cholesterol medication. The blood tests showed no sign of muscle damage from the medication. I even asked him not to take the pills for a month to make sure they weren’t causing his muscle and joint pain.

The muscle relaxant and nonsteroidal medications offered him some relief, but the physical therapy did not. Joel was discouraged. He had a brand new Harley-Davidson motorcycle sitting in his new garage, and he told me he was beginning to wonder if he would be able to ride it when spring came.

Joel’s neck seemed to get slowly better. He had full range of motion and not as much tenderness as before, but his shoulders were in constant pain and his range of motion was not improving.

He had some heartburn, so I gave him an acid blocker, concerned that his arthritis medication might be putting him at risk for an ulcer. That took care of his indigestion, but soon thereafter Joel’s appetite started to dwindle. We did some blood tests again and I made a follow-up appointment for the following week.

The day after our appointment Joel’s wife called. This was unusual; he never let anyone else speak for him. She reported that he was nauseous and had vomited twice that morning. I called in some nausea medication and advised Sandy to bring him to the hospital if the vomiting wasn’t controlled with the medication.

That weekend felt like the first day of spring. The sun was bright, the roads were dry, and there were motorcycles in town and on the County road. I kept thinking of Joel and his new Harley-Davidson. What was wrong with him?

Monday morning’s faxes from the hospital brought the answer: Joel was admitted for intractable vomiting. His blood tests were normal, except for some signs of dehydration. His scans showed a normal looking liver, pancreas and gallbladder, but there was a little fluid at the bottom of his right lung and in the upper lobe there was a large tumor that had not been visible on plain x-rays.

I copied the hospital reports to the rheumatologist, who called me right back. Joel’s muscle and joint symptoms, in retrospect, were part of a paraneoplastic syndrome. “We were fooled”, Dr. Fahler said. “The fall from the roof was a red herring. It was cancer pain all along.”

Joel did get to ride his Harley-Davidson just a few times during the two short months of therapy he had before his cancer got the upper hand again.

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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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