The morning with Dr. Chen was spent
rounding on patients and the afternoon was spent seeing outpatients. We are learning a lot from Dr. Chen and I
will do my best to record notable cases and things I learned.
Some interesting cases:
Case 1: 36 year old female with ascending colon cancer
and retroperitoneal tumor. Initially,
the physicians only thought she had colon cancer. After PET scan, it was discovered that she
had a tumor in her retroperitoneal cavity that could not be resected or accessed. She opted to not tell her husband or family
this (who were present at the outpatient consultation with us). Dr. Chen put her on chemotherapy and after
just 2 rounds, her cancer was gone. Dr.
Chen said that she could have just had a very good response to treatment, or
their initial diagnosis were off.
Case 2: 41 year old male with
squamous cell carcinoma of the skin over his left humorus. He went to a dermatologist without consulting
Dr. Chen. The dermatologist decided to
do cryotherapy. This ended up making the
tumor much worse. Because of this, the
tumor had to be resected and he is now undergoing adjuvant therapy. I was thinking about a possible MOA of this
happening. Maybe the cryotherapy killed
off the weaker cancer cells and left the more aggressive more malignant cells
to proliferate.
Case 3: 69 year old female who
has anemia. Dr. Chen initially thought
that it could have been MPD; however after checking her Rheumatoid Factor
(elevated), it turned out to be an anemia of chronic disease/inflammation.
From the many cases today, some
of the clinical things I learned:
·
Petechiae in the extremities means that the
platelet count is still likely 20-50k.
When patechiae are found, we must check the oral mucosa for signs of
bleeding. If we find purpura or
patechiae in the oral mucosa, than the platelet count is likely around the 10k
range and blood transfusion must be done immediately.
·
Bleeding from a tumor is under very high
pressure. Dr. Chen told us that during a
procedure, a nurse just touched the tumor with her hand and it started
bleeding. Within minutes the whole
abdominal cavity was filled with blood.
·
Distinguishing Tumor Fever vs Infection Fever
o
First, there must be a neoplasm for tumor fever
to be present.
o
Second, NSAIDS will lower tumor fever for
periods of days from just one dose, while NSAIDS will have to be re
administered multiple times in a day to keep the temperature low from fever due
to an infection.
·
There was a middle aged to old male who was
diagnosed with iron deficiency anemia.
In recent bloodwork, his Hb has dropped so we must re-evaluate for GI
bleeding.
·
COPD can sometime look like malignancy on CT
(Dr. Chen sometimes gets referrals from other doctors because of this).
Some of the medical system things I learned:
·
We had several patients who needed to get CXRs
done. Expecting to see them on next
consultation or at least in an hour or so, we were amazed to see them come back
in 5-10 minutes right after we finished with just one consultation.
·
Some patients come from out of the country like
mainland China. Because they are paying
out of pocket, they expect better service.
We had a patient who implied this to Dr. Chen. What they don’t know is that the doctor does
not see this money. The hospital does.
·
The national health insurance here seems to not cover many things until patients
need them. For example, a lot of the
anti-nausea medications that chemotherapy patients would highly benefit from
are not covered by the health insurance until after they experience symptoms and it is objectively verified.
One of the first moral discussions that we
had today was regarding end of life care.
There is an elderly inpatient with terminal cancer who currently has CO2
retention. The patient has been on BPAP
but it has been unsuccessful. Dr. Chen
asked us whether we would continue use of BPAP in this case as the family
signed a DNR. Both Student Doctor Heidi
Pang and I said that we would; however, Dr. Chen said that he probably would
not.
If you recall from my last blog, there was
a terminal esophageal cancer patient who was refusing treatment. I just wanted to update and say that Dr. Chen
discussed the facts with him and his family.
He is refusing treatment and will be discharged tomorrow.
Dr. Chen also discussed with us the
difficulties of discussing death with the patients’ families.
Lastly, it is interesting to note how
different the patients respond emotionally to their conditions. We see some patients that are motivated and
ready to fight the cancer despite how scary the road may be. On the other side of the spectrum are
patients who have given up already. I
can tell that Dr. Chen cares a lot about his patients. I am excited to learn more tomorrow.
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