Saturday, July 26, 2008

Those Two Ugly Words

A 47 year old female patient came into the office to establish with a history of hyperlipids, Diabetes, and seasonal allergies. The usual kind of patient that I see on a daily basis. Taking her history, asking her the review of systems, and getting a medication list are all the normal routines.
"Any cancer history in you or any of your family members?"

"I had cervical cancer and had some treatments. They said they got it all.", she said.


"Are you up to date with your Paps and Mammograms?"

"No. I haven't had any way to get back and forth to the doctor that I was seeing and just never got around to it.", she said.

"Okay. We will schedule for a Pap, Mammogram, baseline colonoscopy, etc. and get you back on track. How are your blood sugars doing in the mornings?"

"I'm not really sure because I don't check them that often. I think they are usually around 170?", she said.

Big sigh to self. Uncontrolled diabetes, obesity, and poor circulation in lower extremities. Thank goodness the blood pressure is controlled. No small favor.

"Are you taking your medication properly?"

"I'm supposed to take XYZ pills but there were too many so I don't take them all."

"ARGH! Non-compliance issues.

"Any other things bothering you lately?"

"Not really. I have allergy symptoms and a cough that won't seem to go away. No fevers or anything. I haven't had much of an appetite lately. No nausea, stomach pain, reflux, diarrhea or constipation.

Physical exam completed. No abnormal lung sounds. Heart sounds normal. No abdominal pain on palpation. No edema. Note to self. Get her medical records from previous providers. Look for any previous chest xrays, labs etc.

"Okay. I want you to do some things for me. #1. Check your blood sugars twice a day and keep a log. #2. Take your medicine exactly how I prescribe it to you. #3. Get the labs done that I'm ordering today. #4. Come and see me in two weeks for a follow up appt."

Off she went. No showed for next appt. Nurse call to remind. Letter sent. She shows up the office one month later with report of continued cough (this time productive but with no fever.) No sugar log but states blood sugars are better and down to 130 daily.

"How have you been doing with your appetite?" Noted weight loss of about 15 pounds.
"Are you making better choices or are you not eating well? Any diarrhea, constipation, heartburn, anorexia, or bulemia?"

"I've been trying to eat with better choices but I just have to make myself eat. I don't feel like eating. No troubles going to the bathroom."

Note to self. Weight loss-unintentional with cancer history. Recurrent cough. Time for a chest xray. Lung sounds not bad but slightly diminished lower R and slight wheeze upper lobe. Rx given for Z-pack just to make sure.

No showed for follow up appt. Letter sent. No xray report showed up. Here we go...

Fast forward to 1 month later. In she comes with her daughter in tow with a sullen look on her face. Mom has dragged her into the office and seems aggravated that she has to drive her mother anywhere at all.

"How's things going? Appetite any better? How's the cough?" I glance down at the flow chart and notice another 15 pounds down. Bells are ringing. Warning! Warning! Something's NOT right here. Why didn't she come back sooner!!!!

"I finally had that chest xray done that you wanted. Sorry it took me so long. Glance over to pissy looking daughter who has been fidgetting the entire time looking so bored.

A knock at the door and my nurse hands me the stat report on the xray. Not good at all.

"There looks like there might be something in the lower lobes of your lungs and I need to get a stat CT scan of your chest. With a look at the daughter for emphasis, You will need to get this done either today or tomorrow at the latest."

CT scan completed two days later with the stat report showing multiple masses throughout lung fields. Call goes out to pt to bring daughter with her to the office TODAY. This is going to be really bad.

They come into the room and sit down. "This is not the result I had hoped for.", I told her.

"Are you telling me that I have lung cancer? I thought they got it all."

I explained that cancer is only in remission and one can never say that they got it all.
I go over the report with a measuring tape in hand to show the sizing of the masses. We go over the game plan of referral for a biopsy to stage and determine treatment options.

"How long do I have?", she asked. I explained that only God knew the answer to and that the test results and consultation with the oncologist would give us a ball park figure.

I will never forget the look of utter despair in her face and as I filled out the encounter form... I found myself unable to write those two ugly words.

Lung cancer.

She noticed that I hesitated and I sighed...

"Am I your first?"


My first cancer diagnosis as a FNP.

Why did I choose this as a profession? Why would anyone want to deal with the agony of having to tell someone that they have cancer? Because I love helping patients take care of themselves even though some are not as compliant as we would like. For every patient that I have to give bad news to, there are many more that get the good news and get to keep coming back. I live for those visits because they get me through to the next bad one.

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