The patient’s symptoms defied explanation. He wasn’t sleeping, felt as if breathing was a chore, and had persistent pain in his abdomen that wrapped around into his back. He had been suffering for weeks and was at the end of both his physical and emotional ropes. Multiple physicians had already been consulted, dozens of lab tests had been ordered, and a stomach specialist had even put a camera down his throat to check out his stomach and esophagus. No answer could be found.
I was not hopeful. His symptoms were unusual individually, together they were beyond confusing. As intense as the symptoms were, they did not fit any diagnosis with which I was familiar. After hearing his story and performing a brief exam I sat quietly and thought, completely dumbfounded. Other doctors, similarly perplexed, had told him that he was having anxiety. While this was a possible explanation (and an easy one at that), it didn’t make sense to me. I had seen hundreds of anxious patients over the years, many with physical symptoms, but none whose complaints matched his.
I went over his labs again, looking to see if anything had been missed. His potassium had been off, and I remembered that abnormalities of cortisol production were often associated with changes in potassium levels. It was a diagnosis I had seen only once, and that was over 20 years ago, but I went ahead and ordered the test.
That night I sat at my computer and searched for other possible causes. I read about rare conditions I had never seen before and vaguely remembered from medical school. Nothing fit. I decided that if the cortisol was normal I would blindly look everywhere I could. I knew I would probably not find an answer, but I was determined to be thorough in my search.
The cortisol test was normal, so I decided to order imaging tests. Deciding which tests to order was also a challenge. His symptoms were nonspecific so I was not sure where to start, what body part to image first. Frustrated and uncertain, I decided to order CT scan images from his neck to his waist. I doubted I would find anything but I could at least tell the patient I had tried.
He went in for the scans the next day. The phone call from the radiologist came the day after. “I am not sure why you decided to include the abdomen in your order, but it is good you did,” he said, “he has a 5 centimeter mass on his right kidney.”
I felt the color drain for my face. “Oh crap,” the words came out of my mouth involuntarily. 5 centimeter kidney masses are always cancer. I did not know whether it was dumb luck or divine intervention, but I realized that my decision to take pictures of everything may have just saved his life. Importantly, the scans showed no signs of spread, suggesting we may have caught the cancer in time. I could not explain how or if the cancer was related to his symptoms, but I had found it!
I spent the next few days reflecting on the near miss, on how easy it would have been to not order the tests, to refer him elsewhere or blame anxiety. I realized that I had found the cancer not because I knew what I was looking for or because I understood his presenting symptoms. I found the cancer because a patient was worried that something was wrong and I believed him.
My reflections included memories of times when I did not believe worried patients as I should have, of concerns I may have dismissed and diagnoses I may have missed. I promised myself to be better in the future. I cannot always know, but I can always listen and I can always care.
- Bart