Sandy Brown, MD


November 24, 2009

It was a busy morning, with every 15-minute slot taken from 9:00 to 12:00, when Felicia stumbled in assisted by her husband Nigel. I could see them coming through my waiting room window. Felicia was holding onto Nigel for support with one hand while grasping onto my building’s side rail with the other. She was visibly ataxic and ecchymotic around her eyes; the aftermath of a fall the previous day. As Felicia also suffered with ongoing poorly controlled diabetes, this was clearly not a case I had the time or facility to work up in the office. I sent them to the emergency room for evaluation.

Almost 3 hours later, I got a call from Buz, the hospitalist. "Bad news," Buz said. "Your patient has a cerebellar mass, probably metastatic. Her chest x-ray is suspicious for a primary. She also has a probable cutaneous metastasis on her scalp the size of a large marble. I can admit her, start her on some Decadron for her cerebral edema, and arrange for specialty consultation." "Thanks," I said. "I’m at fourth down with long yardage here. I’ll come by and see here as soon as I finish my consultations."

I reviewed Felicia’s chart. I had seen her only 4 months earlier for her annual exam. She had complained about a small lump behind her ear, approximately the size of a pea, which I had written off as either a lymph node or a sebaceous cyst. I had recommended that she call back if it increased in size; she never did.

The next day, Ken, a surgical colleague, removed the scalp lesion. The frozen section report characterized the mass as a carcinoma rather than lymphoma and hinted that it might even be a clear cell tumor. An abdominal computed tomography (CT) confirmed a large mass by her left kidney, whereas a chest CT disclosed that the abnormal chest x-ray was probably an infiltrate and not a malignancy. Further bad news revealed that there were numerous metastases to her abdominal wall. A renal primary with metastases to her brain and abdomen was the final diagnosis.

With some consolation, I realized that by the time Felicia came to me with the lump on her scalp, the horse was already out of the barn. I always do a urinalysis on my annual exams and proceed with a work-up if there is any detected hematuria. Her urinalysis was negative for blood. I looked at her urinalysis from the preceding year, and it too was negative. In the hospital, she had told me that she had never had grossly bloody urine either. I told myself that it was not my fault, and I should not beat myself up over this one. Yet, part of me was feeling guilty that I had missed something that would prove fatal to my patient. It never ceases to amaze me how much responsibility we physicians take for things that are beyond our control. I could imagine how badly I would have felt if Felicia had presented with blood in her urine several years before, and I had failed to work it up. But what more could I have done? Would my patient blame me for a missed diagnosis? How much time did she have left? Thoughts squirreled around and around in my head until I resolved that this was a case of bad luck and unfair to boot. People with urogenital cancers are supposed to bleed. How else can we find them?


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