Looking for a cyst

Claudia is back and the pain is worse. She’s done everything I’ve asked but the problem is getting worse.

It was about a week ago when she showed up with her son, Christopher, complaining of pain under the left breast. I checked there area and it was a bit perplexing. There was tenderness, but I could not feel anything abnormal – no telltale bogginess to suggest a fluid collection. Yet my suspicion remained – there could be an abscess or cyst under there. But I don’t want to go in there with a scalpel without knowing what I’m going to find.

So I sent her to ultrasound. I was pleased to get a personal call from Dr. V., letting me know that there was a fluid collection, and that it was likely a sebaceous cyst. It was only 1 centimeter in size, so not extensive in size.

Now back in the exam room, I had Claudia get back on the exam table. Once again I felt for any telltale localizing signs to help me know where to cut. There was not much there to guide me. I got out the syringe with anesthetic and begain to inject a little of it. But this was destroying what little telltale signs there were. Then the area was cleansed with iodine, making ever larger circles with the brown colored swabs until the are was painted about 6 inches across. With scalpel in hand, I chose and area and began to cut into the skin. It did not feel like the right spot. The skin was too firm, too normal. I felt the skin again with my gloved hand, trying to detect the telltale flexibility in the skin. There, just a centimeter to the left, it was a little different. Again I took the scalpel and cut in, looking at her face to detect whether the anesthetic was working. No pus or liquid was detected. I cut alonger incision, now 1 -2 cm long and gradually began to dissect the skin to the side. Suddenly, the telltale white, cheesy liquid bubbled to the surface. I was in the cyst. Paydirt! ‘

Opening the incision a little more I began to explore the cyst cavity. Large amounts of purulent smelly marterial bagan to extrude and trickle down her left side. I pushed the curved hemostat into the wound, exploring it’s limits. The cyst extended along the muscular chest wall about 1 inch in each direction, forming a large flat cystic structure.

Then, taking the syringe, I injected saline solution to cleanse the wound until fragments of the cheesy material stopped rising to the surface. I then pushed a long piece of gauze into the wound, taking care to fill all the empty spaces. I trimmed it close to the opening of the wound.

Claudia looked exhausted and painful, but relieved. I gave her a prescription for an antibiotic, and asked her to return in a few days. Her husband will withdraw the drain little by little until I see her.

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.

Jan's chest pain

I was working the morning urgent care clinic, rather annoyed at how tightly things had been scheduled. But there is nothing I can do about being 1-1/2 hours behind. I'm just going to have to deal with it.

In room 18, Jan, age 52, is sitting on the exam table. Her husband Evan sits attentively in the chair next to her. She is here because of chest pain. I'm on my guard knowing chest pain can present a number of traps for the primary care physician. A host of serious conditions can masquerade as commonplace muscular strains or joint problems. Now she has my full attention and any distraction I had about the overscheduling is gone.

Jan first noticed chest pain about 2 weeks ago. It's located just to the left of the breastbone and goes through to her shoulder blade. She thinks it's related to some painting and yard work she was doing a few months ago. In fact her husband, taking charge at this point, assures me that it is a very muscular kind of pain, and he is sure she does not have heart pain. Jan does have a history of heart disease, having received a stent two years ago. Just 6 months ago she was examined by Dr Q, the cardiologist, and found to have pristine arteries on cardiac catheterization. Evan makes clear, their son is arriving within the hour from basic training, and they are intent on seeing him.

There's not much remarkable on Jan's exam. Her chest wall is not tender anywhere. The shoulder exam doesn't reproduce the pain. The heart and lung exams are normal. The right leg shows some varicose veins, but I can't reproduce any tenderness with pressure over the calf. The only slight abnormality -- oxygen saturation at 95% -- a little low for a non smoker.

Every physician has been lectured about this type of patient-- it's engraved in our memories with the admonition, "do not miss a pulmonary embolism", a blood clot that has arisen from the legs and lodged in the arteries to the lungs from the heart. The story is perfect -- leg pain, chest pain, a little short of breath.

Jan, I think you need to go to the hospital, I say. Turning to her husband, who looks a little uncomfortable. I can see their plans melting away and hours of emergency room evaluation looming ahead. I know it's difficult to interrupt your plans, I explain, but a blood clot to the lungs would be extremely dangerous. It can result in sudden death. I can't agree with you going home or giving it time. Anything other than going directly to the hospital would be like playing Russian roulette. I don't like to pull out the "death" card frequently. It's the atom bomb of medical advice.

Jan accepted my recommendation, and the couple headed down to the hospital. I called report into the hospital, waiting to hear what would be found.

About 3 hours later, I received the call. You were right, Jan has multible pulmonary emboli. 3 in the right lung and 2 in the left lung. She is being admitted for treatment and monitoring. I'm thankful that my annoyance at the scheduling snafus did not result in a superficial encounter and a missed diagnosis.