We were taught in medical school that usually there is only one diagnosis that can explain the patient's symptoms. There are always exception to the rule and this is not a rule anyway.But we sometimes come across situations where there are more than 1 diagnosis and sometimes we have 2 major diagnosis , both of which are serious or bad.The patient that I am going to describe is one such case.
I saw this 68 years old patient , who was referred to me for the evaluation of lung mass . Patient was ex-smoker and had persistent cough and so the primary care physician ordered a x-ray . The x-ray showed a spot and he was referred to me . The primary care physician had ordered CT scan too . I saw him and looked the CT scan and then discussed withe patient . I usually tell patient that we need to answer 3 questions , i.e. Is it cancer , Has it spread and lastly what can we do . Then I tell patient how to do the workup to get to the answers. We do a PET scan , a bronchoscopy and biopsy and breathing tests .If needed we do additional scans based on these tests . When I looked at the CT scan of the chest I thought that he may lymph nodes involved in the Cancer process and we may not be able to do the surgery, which is the best treatment even today. But what bothered me more was mention by the radiologist of some other abnormality in the belly. When we do CT scan of the chest , to include the lower part of the lungs they end up including the upper part of the belly.So we sometimes see part of liver or upper part of kidney etc . Since these are not done to check on belly parts, they are not always conclusive . This was what I thought. But in case of these situations I end up ordering CT scan of the belly .
It was 4-50 pm on the day after the CT scan was done , when I got preliminary report faxed to me . It showed an aortic aneurysm . THE SIZE WAS MORE THAN 15 CMS BY 8 CMS . This is huge . I was stunned . He had lung cancer that may be inoperable, and now has huge aneurysm that had potential for rupture due to shear size being huge .The time was so close to closing time of all the physician's office , that I would be lucky to get them on phone . I put a call to the vascular surgeon and at the same time a call to the primary care physician . When I talked to the vascular surgeon , he was not excited , definitely not as much as myself . He told me to fax him the report and told me that he will see him as planed . I had talked to the patient and told him about the aneurysm . He had no symptoms of pain or any other that would suggest impending rupture , so the surgeon was OK with seeing him in next day or two.I was concerned.Primary care was referring him to a different surgeon , who was not a chest surgeon .
The surgeon saw him in the office and called me . He wanted to do the aneurysm repair first and then do the lung resection . As it turned out , the aneurysm repair was done . It was a long surgery, but the patient did well. He was discharged and the in next 6-7 weeks he had lung resection . The lymph nodes were positive for the cancer spread , but it was only one , and he was started on chemotherapy. . As of today he is off the chemotherapy , had new CT scan and new PET scan and there is no evidence of cancer .
The major problems and he did well. But I would still say , when it rains , it pours.