Sentinal Events

There are only a handful of clinical findings in medicine that send up red flags regarding a serious medical condition. Many patients with new or painful symptoms worry about whether or not they have cancer, and more often than not, they don’t. However when you combine symptoms like new onset radiating back pain, in a “red flag” patient (over age 55 for example) with one of these sentinal findings, it’s hard to disguise your fear that the patient may have a serious illness…cancer.

Yesterday a family of three sisters arrived with a stack of CT films weighing at least 10 pounds. I was afraid this would be one of those cases where a hysterical patient had been doctor shopping for years, arriving in my ED in the hopes that I could fix all of her problems. Well, I was wrong. She had only been having symptoms for three months, then noticed a “lump” in her neck only 5 days ago. Her primary care doctor I’m sure panicked and tried to get her into an oncologist as soon as possible, but that wasn’t soon enough for the patient, who had over a dozen 1st & 2nd degree family members with a variety of cancers.

When I was ready to examine the patient, I asked, “Now where is this lump that you found?” As she pointed to the base of her neck, on the left hand side, I felt a lump growing in my own throat. A Virchow’s node…a sentinal node of probable cancer. It was a hard, firm lump…one that I’ve read about, always feel for on physical exam, but despite having examined a few thousand patients in my short career, I’ve never actually felt a Virchow’s node. This one I could not only feel, but also see. And it had just appeared 5 days ago.

I excused myself from the room and telephoned the oncologist on call. It was an easy admission request…enlarging neck mass, 30 pound weight loss and family history of multiple cancers. The patient and family were thrilled at the quick response, and commented how thourough the oncology team was. “More thorough than me?” I asked jokingly. “You were equally thorough,” they reassured me.

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