Saturday, November 13, 2010

A Twisted Case of Constipation


(Warning....for non medical readers, you will have to google a lot on this post as it has a lot of medical jargon)



I had a 83 year old male present with constipation and a "knot" to his neck. He was in good shape and health for being 83 years old.

Anyways, his belly felt a little more distended and tympanic than I was expecting for constipation, but he looked really well. Every part of me wanted to just give him an enema, make him poop, and send him home. But because of the mild distension I decided to get an abdominal series (a series of X Rays of the abdomen and chest).

What did I find in the X Ray?? The abdomen looked OK, but his chest X Ray showed a huge lung mass. I then did a full workup, and a cat scan showed diffuse metastasis to the liver, intestines, and bones. That "knot" to the neck was a cancerous lymph node

Next I reviewed his medical history. 6 months ago he was seen in the ER for chest pain and shortness of breath. A X Ray at that time showed a nodule in the lung, and a cat scan was recommended by the radiologist. The patient was admitted to the hospital by the ER Doc. For some reason, the hospitalist decided to a pulmonary embolism work up. His creatinine was a little high so he didn't get a cat scan but a worthless V/Q scan. The V/Q scan was negative and the patient was discharged.

The patient's doctor was never notified about the abnormal chest X Ray. The PATIENT was never notified about the X Ray. And now the patient has horrible cancer. Lots of things went wrong. The hospitalist had 1 diagnosis in mind and chased it....and was wrong. The patient couldn't get the cat scan with contrast, but he could have had a regular cat scan to evaluate the nodule. Even if the hospitalist didn't do the cat scan during admission, he should have informed the patient and the patient's doctor.

I hate to place blame on other doctors. I am sure this was multifactorial. If the ER doctor would not have admitted the patient, it would have been his job to inform the patient's primary doctor about the nodule....but that wasn't the case. The facts in this case are clear. And the prognosis = death.

-ER Doc

11 comments:

rnraquel said...

What a freaking mess. It was amazing how often in the ER we discovered cancer. But the patient was always told! What a lame hospitalist too.

SuFu said...

Sad. Who knows how diffuse it was at original imaging, but a simple wedge resection could have made such a huge difference. Hopefully he has EGFR mutated NSCLC and erlotinib will give him a few extra months.

Crazed Nitwit said...

Dang. I hate when this kind of thing happens! Poor guy. Poor you but excellent catch!!!!

Arzt4Empfaenger said...

Oh fuck. Good on you for doing your workup thoroughly, but that poor patient! You simply can't weigh up the damage the previous doctors let happen.

(Two years ago in bedside teaching class, they introduced us to a patient that was similarly screwed up by his doctors until it was too late; he'd repeatedly been dismissed and diagnosed offhandedly with stinky nose (by his local ear/nose doc), and by the time he went to the large hospital on his own, months later, the tumor had undermined nearly his whole skull base in the nasal region, leaving palliative care the only option.)

Even if they don't do anything, they should at least communicate the findings they have to the GP and optionally the patient, if it's relevant and understandable for him.
This is such a sad story.

shash said...

Lack of communication is the downfall of of most things everywhere.

How terribly sad.

Anonymous said...

this story makes me angry all over again..

When I had persistent abnormal bleeding, TWO gynaes (one a gynae oncologist) brushed off my concern as pre menopausal symptoms not to worry as its common for women my age (45 above). By the time I really bled alot, they decide to do D&C, then say not to worry & less than 1 week later, I was told to QUICKLY go for Total Hysterectomy. I have this suspicion that they are in cohort so that I develop cancer & they benefit by all the expensive follow up treatment for ca patients!

ERP said...

Was the doctor Happy Hospitalist?

Anonymous said...

Blah. That's shitty to say the least. Good catch for sure on your part... I feel absolutely terrible for this patient.
It's so heart breaking when stuff is missed. We had a patient admitted once for 'SOB - NYD'. Then, they started querying TB due to his chest xray. He had been seen by many, many (did I say many?) doctors for months, each telling him a different thing. Finally he was admitted to us. With the TB workup, they chose to do an HIV workup. Outcome? Full blown AIDS. Didn't even see that one coming... The saddest part was how fast he went down hill after being admitted. He was with us for 2 weeks, then coded and went to ICU. He died less than a week after being transferred there. He was 29 years old...

Ninjamedic said...

I wondered the same thing, ERP. This has Happy written all over it.

SerenityNowHospital said...

It was grumpys cousin

ER doc

Anonymous said...

Sad. But it doesn't really sound like any one persons fault. But horrible non the less.

Poor guy.