Sometimes we have situation where we see things that are more prominent and miss what may be subtle but more important. I f you have gone for murder mystry dinner show , you might have realized this. The obvious suspect is not the correct answer. I remember when we used to have a radiologist who used to teach us how to read chest x- ray. He would show a x-ray and ask one of us to read it. We would read the most prominent findings and then miss the subtle but important findings. He wpild put up x- ray that looks normal as far as lungs and heart are concerned but had fracture of upper arm bone which would be missed by Intern. I have seen this in my life again ' A subtle fracture of shoulder was missed even by radiologist when there were other findings in lungs like fluid .But the story that I am going to tell is similar but little different.
I was asked to see this patient in hospital.. She had presented to hospital ER with back pain . She was a88 years old lady who had back pain for 3 months . Her PCP had done x- ray of the lower back and had treated with some muscle relaxant and pain meds . She continued to suffer and so came to ER , She used to stay in Florida for 4-5 months and then go back to upstate for 6 months or so. She had a physician up state whom she trusted most and she would have been considered snow bird. She had not smoked for 50 years and had been followed by number of physicians at both places .The x- ray of the spine was done and she had some arthritis . The Chest x- ray was done and that showed a mass lke density in upper lobe and so I was asked to see her. I saw her and had discussion with her and her daughter in law . I told them that she may hve a cancer of the Lung and we could do biopsy to confirm or rule it out . She was not very keen on doing any procedure and since she was nonsmoker , I decided to do PET scan as out patient . For now she was being treated for possible pneumonia by hospital doctor and I continued that . Certainly CT scan was ordered by me and then I saw her next day. The Ct scan confirmed the abnormality that was seen on plain x- ray. I talked to her son this time and he had all old reports in a file - not a common things to see. He showed me a report where there was some infiltrates in same area where this time a mass was seen . That report was almost 9 months old. So she had something but no CT scan or any other additional tests. So, I told them that it is possible that she may have a slow growing tumor may be be like carcinoid which can grow over period of many months or even years . She had back pain. and that was not worked up. I ordered CT scan of the spine and that showed abnormality in lumber 3 vertebra. Oncologist was seeing her and had ordered a bone scan. I asked radiologist to the biopsy of the spine . She was agreeable as I had told them that she could have cancer that has spread to bone. The biopsy did confirm cancer.
So, she had most likely lung cancer that spread to spine and that was causing pain for last 3 months. She came with back pain and that was not worked up by hospital physician and they were distracted by lung abnormality and then when we started doing work up for the back pain , the diagnosis of cancer spreading to spine was established . I had called radiation doctor for radiation even before we had the diagnosis of cancer established.
