“I hate to leave you with such an unfinished workup”, my senior colleague, Dr. Wilford Brown, said three Thursdays ago. He was going on vacation and Norman Sprague had just been in to see him with a one day history of a strange pain near his right shoulder blade.
Mr. Sprague is a 68 year old retired accountant with rheumatism and diabetes. Dr. Brown ordered some bloodwork and a chest X-ray and told the patient to stay in touch with me about his symptoms.
“I wonder if it’s early shingles”, Dr. Brown told me.
The next day I got the negative wet read of the chest X-ray and a bunch of normal blood tests and a phone message from Mr. Sprague that he was getting some nausea. I told Autumn to have him come in to get reexamined.
Norman didn’t have a fever, and he didn’t have a rash or any alteration of skin sensation on his torso. His lymph nodes and breath sounds were normal and his abdomen was soft. But if I pressed hard enough over his gallbladder, he did hurt – that was obvious from his facial expression. He told me the pain was also I the lower front of his chest now, to the right of his sternum just by his lowest rib. It was relentlessly steady and unaffected by movements or deep breathing. He denied any shortness of breath. He told me was nauseous but still able to eat a little, and he had not vomited. His ribs weren’t tender. His bowels were normal and his urine had normal color.
I ordered a gallbladder ultrasound. There were no gallstones, but the radiologist said there was a suggestion of sludge in the gallbladder and the common bile duct was at the upper limit of normal size.
I called one of our local surgeons. He suggested doing a plain HIDA scan. Because of the national shortage of cholecystokinine, that is the only type of biliary scan we can get right now. The test showed that the gallbladder filled normally, but the tracer was slow to travel down the bile ducts and into the duodenum.
Last Monday, Norman met with the surgeon, who called and said he was pretty sure the pain was biliary, but also told me that over the weekend before the consultation, Norman had developed shortness of breath and dizzines. I asked him to send Norman over so I could reassess him.
He was not all that short of breath and did not have a cough, but his breathing had changed since I saw him last. He admitted that he had had some difficulty shopping at Walmart since last winter because he felt “out of shape” pushing a cart up and down the aisles. He also described his right-sided chest pain as more severe, but still unrelated to movement and breathing.
He had dizziness and a hint of nystagmus only when turning his head to the left in a supine position with an otherwise normal ENT and neuro exam, so I was comfortable ascribing his dizziness to Benign Positional Vertigo.
His oxygen saturation was normal and his EKG was unchanged from three years ago.
I ordered a PE protocol contrast chest CT, which did not show any pulmonary emboli, but it did show mildly enlarged mediastinal lymph nodes and three nodules peripherally in the right lung, the largest one just over an inch. I had also ordered an abdominal CT, which was perfectly normal. The nuclear stress test I also ordered that day came back normal. By that time I had called Cityside Pulmonary Associates. They promised to look over the images and get back to us with an appointment.
Norman Sprague called back two days later. He had received a call from the pulmonary office, telling him he was on a cancellation list, but only had a firm appointment for the first week in October.
I called the thoracic surgery group at Cityside and got to talk with Dan Grossman. He looked at the images and when I asked him if a video assisted thoracoscopy was an option for getting a tissue diagnosis, he said, yes, but bronchoscopy would be better. I told him about the long want to see a pulmonologist.
“Either we or they will see him sooner”, Dan said. I’ll get back to you. Twenty minutes later he called me back. “It’s all set, Roger White will see him on Friday and do a scope then.”
Norman had his bronchoscopy. The needle aspirates were benign and the washings and cultures negative. Dr. White’s note listed sarcoidosis and methotrexate related lung disease as the top differential diagnoses, and he thought a PET CT would be the next step, and maybe a percutaneous needle biopsy of the distal lesions.
Today I met with Norman and his wife to go over the results that had come in after the bronchoscopy. As I reexamined his abdomen, he was more tender in the right upper quadrant than before, and when I lifted up the back of his shirt there was a red spot with a small, raised center, not a blister but more of a papule.
“Ouch, that’s sore”, he said.
And so I leave Norman Sprague in the competent hands of Dr. Brown, who returns from his vacation tomorrow. Norman’s lung nodules and lymphadenopathy still remain to be diagnosed, and he still may have gallbladder disease, but he also, again, has the original working diagnosis of herpes zoster, the great imposter.
A Country Doctor Writes: 
