ONE TWO AND THREE ?

   In medicine we have saying that usually we do not have 2 diagnosis . This  does not mean that a patient has only one diagnosis . It means that when a patient presents with a symptom or complaints , we may start with differential diagnosis - what different diseases could explain the problem ,but at the end of work up we have one Final Diagnosis. But sometimes we have exception to the rule. That brings me to patient for the today. 

    I was asked to see this patient who was doing fine . He had seen his  PCP and has had done follow up regularly as I  understand. But had cough and shortness of breath and so he came to ER and then had work up. He was found to have quite extensive pneumonia. He had pneumonia on both sides. The right was much more affected than left side. He had not been smoker and had no previous history of lung problems. He was admitted and the hospital physician started him on antibiotics. He was found to be anemic and  so the work up was done and he had iron deficiency . So he was given iron. 

    I saw him and was some what surprised that he had extensive pneumonia on both sides as he was not a smoker and his only other medical problem was chronic back problem and he ha shad some kind of surgery for that .I asked him questions as to what had happened . He had history of narrowing of the esophagus and he has had dilatation done in past -last one was 7-8 months ago . He had vomited and then started having problem and he had called PCP and then was told to come to ER The vomiting episode was only once and so neither the ER physician or the Hospital physician who admitted had asked or mentioned in their notes .So we did the work up. I did swallow study and X- ray of the esophagus  and sure enough he had severe narrowing of the lower part of the esophagus  and he also had severe reflux . So now we have 2 different problems or may be 3 . He had pneumonia which was caused by aspiration when he vomited  and he also had vomiting due to narrowed esophagus. The anemia may be due to severe reflux with oozing of blood from there . But it also could be due to problem with absorption of iron. Iron deficiency is uncommon in men unless they have loss of blood from peptic ulcer or colon polyps or cancer . 

    But the problem list did not end . We did CT scan of the abdomen and that showed a renal mass - mass in the kidney which was potentially cancerous . So we had initial diagnosis of pneumonia  and then the narrowing of the esophagus  and anemia and renal tumor..