For the last couple months he'd had difficulty swallowing solids, and he'd lost about 15 pounds. Otherwise, he had no complaints. He did not normally see doctors, but his daughter insisted. We went through the rest of our review of systems, moving head to toe inquiring about other symptoms. "Perfecto," he repeated pleasantly, between translations by his daughter. Nothing else seemed wrong. He was active; he liked to stay busy. He'd even quit smoking a few months ago.
The physical exam showed similar results, moving methodically through organ systems. Head and neck exams were benign, just a few teeth missing from his smile. Heart sounds were normal: one-two, one-two. The lung exam, however, was different - almost no breath sounds on the left. It was also dull to percussion, not hollow-sounding like a lung should be. Based on these concerning findings we got a chest x-ray which confirmed our suspicions: There was a large pleural effusion - fluid around the lung. It was so large he was essentially breathing with one lung.
Yet every morning I came to see him during his stay, the refrain was the same: enthusiastic handshake, warm smile, "perfecto."
Pleural effusions develop for a variety of reasons, perhaps the scariest being cancer, and his chest x-ray also showed something in the center of the chest. A subsequent CT scan revealed a 10 centimeter mass, displacing the heart and constricting the esophagus, the tube which carries food from the mouth to the stomach. This mass no doubt explained his difficulty swallowing solids and likely the pleural effusion as well. And for this long-time smoker, lung cancer was at the top of the list of potential culprits.
We explained the findings and their implications. The diagnosis would not be definitive without a biopsy, but we were concerned. They were anxious but understanding, and grateful for our help. As a part of the work up we also wanted to take a sample of the fluid from around his lung - a diagnostic thoracentesis. "Perfecto," he agreed.
We gathered the necessary equipment and went through the procedure step by step. We positioned the patient, identified our landmarks, cleaned the area (not twice but three times), donned our sterile gloves and numbed the site. The needle went in. It hit the top part of the rib a couple times, but the give as it entered the pleural space was unmistakable. As I drew back on the plunger the syringe filled with fluid. It was bloody, another sign of cancer. After only a couple of milliliters it jammed up and ceased to draw. We tried again with a fresh needle and syringe - another give, more fluid.
It jammed again.
At this point he began feeling light-headed and sweating badly. We didn't have an adequate sample but we stopped, bandaged the site and check his vitals. Before long, he felt fine, "Perfecto, perfecto," he told us.
But in a perfect world the lung would have drained completely, the fluid would have flowed as if from a faucet, its cell count and cytology would prove innocent and time would quickly heal all things. At least in our perfect world, the one he was asking us to put aside, at least for now. His perfect happens to be perfecto. The least we can do is take him at his word.
Jeffrey Sturek is a University Medical Scientist Training Program student. He can be reached at jms3hk@virginia.edu.
Read More
U.Va. students and physicians team up for another year of free kidney screenings
By Merrill Hart | November 5, 2024Saturday’s screening marked the first by KDSAP at Portico Church, near IX Art Park.
U.Va. Health sees a spike in COVID-19 cases
By Emily Horn | September 4, 2023U.Va. Health ended their vaccination requirements in August, and masks were made optional in most hospital areas in early April.
U.Va. Cancer Center harnesses $12 million grant to support opportunities for undergraduates, ongoing research and new center
By Ellen Wu | January 12, 2023The grant provides an opportunity to establish the Center for Systems Analysis of Stress-Adapted Cancer Organelles, which seeks to find the cause of cancer in individual organelles.
