Lack of Focus

03/22/2015 at 8:29 AM Leave a comment

This man in his late 50’s came in the other day for two small problems. Both of them rather trivial; not so trivial that they did not require attention but trivial compared to what I discovered.

During the visit I noticed a lump/mass/tumor in his neck below and slightly anterior to the ear. “Oh yes, that has been there for months! But it is nothing, see I can push and poke on it and it doesn’t hurt”

“Oh my” how do i tell him that lack of pain is a bad sign not a good one, and that three months is not a good sign either.

He goes further, “and the other reason I don’t worry about it is because it is not just a little lump but actually I can feel it way back here below the ear and all the way to the jaw bone.”

“double Oh my” another bad sign.

The sense of touch is amazing, we can detect the slightest contour, the slightest subtlety in hardness. there are clinical words for these things. If you have a ‘bad’ lymph node the term you don’t want to hear is ‘rubbery’, another word you don’t want to hear is hard, irregular, fixed in place. His was definitely rubbery, irregular and fixed in place. The other thing you don’t want to hear is large and his was large.

So now i have a late middle age, smoker, who is full denial of the seriousness of his problem. All through the visit he kept trying to steer me to the reasons he came in (actually I forget what they were for my focus became rather narrowly focused at the time)

On careful palpation I noticed that the tumor was pulsating. Clearly it was near the carotid artery and it could just be that it was transmitting the normal pulses but it was more than that, it was inseparable from the carotid as if it had enveloped it. For a second i worried (hoped?) he might have an aneurism or something serious but non malignant . However the mass was hard not the soft feel of a large vessel, even a calcified one.

It took some effort to keep the patient focused on this issue. I first of all had to deal with his two minor issues, then insist that he get a soft tissue CT of his neck right away. I consulted with a surgeon to discuss the best approach to diagnosing this mass and depending on what the initial test shows we will either go directly for the biopsy by either a surgeon or interventionist Radiologist, or get a contrast MRI. Without tissue we cannot make a definitive diagnosis and therefore cannot give a prognosis. Although there remains the possibility that it is an odd, non malignant growth it is not likely and  but even then it would cause interference problems. Another worry is that the tumor could erode the wall of the carotid artery, which to say the least, is not a good thing.

Now we just have to check up on him to make sure he gets the test. Then somehow break through his lack of focus regarding the seriousness of this problem.

Ideally i would simply call a family member to guide him through the process, but the only legal way to do that is to have him come in with someone and discuss it together. I cannot reveal his information without his permission stated or implied. (which, by the way, is the way it should be–IMHO)

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Learning from the young night of anxiety

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