Heme/Onc: Downtown Clinic

During Tumor Board yesterday, one of the oncologists put me on the spot by describing a patient with a history of pancytopenia with an 8:14 translocation, now presenting with fever, diarrhea, and new-onset HTN, and asking me to give a differential diagnosis. Fortunately I remembered that 8:14 = Burkitt's lymphoma (if you recall the trick we learned during path review for Step 1), so my differentials were Burkitt's lymphoma, carcinoid (primary DDx), and pheochromocytoma. More than one oncologist later told me I'd done well, so I'm glad I didn't come off as a total idiot.

When Dr. RP isn't around (he has admin duties when we're downtown) I get bounced around amongst the other attendings, though I'm usually with NP Sandy and Drs BR and LM. A patient we saw last week with a combined lung cancer and mantle cell lymphoma (both very bad cancers to have) also returned with his wife and son; the pathology slides from his previous hospital had not arrived yet. His son (whom Dr. BR described as extremely passive aggressive) then wondered if we should go ahead and redo the biopsy if the slides never arrive. "I mean, maybe they made a mistake. Maybe if you check again, you'll see that there isn't cancer there," he said. We knew he was grasping at any shred of hope that his father didn't have a 1-year death sentence looming over his head, but if we were to rebiopsy his swollen lymph node, we might as well do another thoracentesis to see if he really had lung cancer.

I was with Sandy when I saw a really sad case of a man with small cell lung cancer with "destructive" bony mets to the ribs and pelvis. His wife reported that he hadn't been able to keep anything down for 9 days. 2 weeks ago he was 152 points, but now he weighed only 132. Pretty frightening. Then, right in front of us, he threw up a lime-green puddle on the ground; looked like scrambled eggs and Gatorade. Sandy made arrangements for them to go upstairs and get a fluid infusion, but privately she said that at this stage, the patient would be better off in hospice care. She later talked to the couple about it, and they agreed. *sigh* Really, really sad. Later on I got to interview a new patient with a finding of "elevated platelets" and presented to Dr. LM, one of the hematologists. He said I did a good HPI and said he thinks I'm well prepared for intern year =) Sure hope so; it's always good to be thorough. Dr. LM also likes to pimp so I need to brush up on my anemia workup knowledge.