Dizzy, falling Chinese man.

Dizziness, room 16

I picked up the chart. This is the last one before lunch, I thought to myself. Maybe I'll get time for lunch today since things are going so smoothly this morning, a great relief from last Saturday's craziness.

It's a charming couple, Han, and his wife Phan, with the sparkling eyes. About 40 years old, he is from China and she from Cambodia. He's in for dizziness. Now I remember, last Friday he called me after falling in his front driveway. I must have tripped, he says. He had been feeling weak and dizzy for a couple of days, like he was drunk. His wife had kept him home because of not feeling well. I could see the small cut on his nose, and some bruising around the eyes. At the time I suggested he rest over the weekend and come into see me today.

I started his exam. Looking over his head and neck, I see mild bruising around the eyes, but none behind the ears to suggest a subdural hemorrage. His neck is flexible and has no pain with movement, good. Cardiac exam shows no evidence of an rhythm problem that could have caused him to faint. Skin is rather yellow. Is it just his Asian features? I compare him to his wife and to my own skin. Definitely yellow. This is worrisome given his history.

It was five years ago that Han came in with his wife worried. He was bleeding from the rectum. I had taken him into our surgical suite and performed an immediate unpreped sigmoidoscopy. A long flexible tube was inserted into his rectum, and by use of fiberoptics, it was immediately obvious - a huge necrotic tumor obstructing his rectum. I was so thankful that my colorectal surgery colleage, Dr. K. agreed to see him that same afternoon. He biopsied that tumor and it proved to be a rather advanced rectal cancer. Later Han underwent surgery and had the tumor removed, the colon temporarily re-routed to a pouch, and then on a second surgery, reconnected to the rectum and reconstructed. The chemotherapy was not pleasant either. But he's been back to a fairly normal life since then.

But now, with jaundice, I am worried about a tumor recurring in the liver. The colon, like almost all the digestive organs, have their own blood return circulation to the heart, through the liver. The liver cells filter and process all the substances coming in through the gut. But they also take the brunt of any cancer cells flipping off from a tumor, so they lodge in the liver and start growing a second tumor, a metastasis.

I can't dwell on the jaundice. I turn to Han's rectal exam. It's clear, and there is no blood. Atleast that's normal.

Now to the neurologic exam. Starting with the cranial nerves, I check his vision for double vision. Holding one finger up, I ask him to follow my finger in all directions. His eyes seem to track well most of the time. Are you seeing one or two fingers?, I ask. One and a half he replies. I crack up laughing and so does his wife. What does that mean? I mean I can see one finger, he corrects. I've heard of diplopia, seeing two fingers instead of one, which is caused by the eyes not tracking coordinately, but one and a half? That's new. Back to more serious stuff, I track his cerebellar function -- coordination and balance. When trying to move a finger back and forth from his nose to my finger, his movement is slow, but accurate. When holding his hands straight out in front of him, there is no unusual shaking -- asterixis-- to indicate liver failure.

His exam concluded, I sit down to talk things over. I'm concerned about how your brain is functioning and also your yellow skin color. Han says that Dr. K told him that if his cancer comes back, it will be in his liver. I'm going to check your liver and blood tests, and at the same time get a CAT scan of your abdomen to get a better look at your liver. I don't want you to go to work or to drive by yourself right now as your balance and reaction time is not normal. If we can't find anything in your abdomen to explain your symptoms, we may need to scan your brain also. It's a tense moment. Phan holds her husband close. We all know Han's life hangs in the balance.