ONE OR TWO OR THREE?

    In Medicine we had a rule. When we see patient, and there are number of symptoms, try to explain all the findings with one diagnosis, rather than explaining different findings with different diagnosis. That does not mean 2 different diseases cannot be there in the same patient. But that is not common. We have seen atypical TB and cancer in the same patient . But that is not a common occurrence. But then in medicine one can never say never. That brings me to the story for today.

   I saw this patient . He was 66 years old patient and had a ulcer or a wound on his legs . He was working and has been doing a full time job and also has been followed by a physician as out patient. He had seen surgeon in past for the wound and was treated. He started having pain  in the leg and he called PCP but could not get appointment for a month or 6 weeks. ,So he decided to come. I was called in as he had abnormal chest x- ray and then the CT SCAN of the chest. I saw the patient . He as obese  and had lot of edema in legs and had a big ulcer that looked infected . But he also had abnormal CT scan of chest and the radiologist had not compared that with old one . He had severe pneumonia few years ago and was on ventilator  and he had that in right lungs as he could tell me . The scan from almost 2 years ago showed same findings of scar tissue in the same area . He also had some lymph nodes enlarged and they also looked to be about the same. But what also caught my eyes was that he had some changes in liver  and that suggested early cirrhosis. I had asked the radiologist to check old CT scan and all that he did was mention the scars in lungs and did not bothered to  tell about the lymph nodes  and also nothing about the liver. He had new CT scan of abdomen and that showed that he had a stone in ureter and that was blocking the kidney and so we called urologist . He was also anemic and so the work up was done . This is a patient who came for the ulcer and a nonhealing wound on leg  and we found out abnormal chest CT  and anemia and some liver abnormality and also renal stone . 

    The work up was done  and he has anemia due to bone marrow not working properly . The bone marrow makes the white cells and red cells and platelets ,so when it is not making these cells then the blood counts drop. He seems to have the problem . He may have contribution from the liver not being normal  and also the infection - the wound. I don't think that the lymph nodes enlargement is due to that but it also may be due to that. So we have a patient who comes for wound which was there for few months  and now had anemia due to bone marrow not working  and kidney stone  and also some nodes enlarged and liver issues . None of these were know to him or were diagnosed even though he has been followed by a physician regularly !!