Chief Complaint: "My skin is all yellow."
I sighed, and pulled back the curtain. 2 am isn't exactly when my peak diagnostic skills are kicking in. To be honest, I think I almost dropped my clipboard when I first saw her. Icteric eyes blinked back at me. There in the stretcher was probably the most jaundiced woman I have ever seen. She was fluorescent yellow, including her scalp.
As we chatted about her medical complaint and history, it was clear that there wasn't going to be a happy outcome- progressive jaundice, abdominal pain, unintentional weight loss. This was all adding up to cancer.
The patient related that she had been seen initially in an urgent care and what started with x-rays led to a referral for a CT scan as an outpatient. She had no private physician-- "I'm healthy." She said that she was told that she had a hiatal hernia and was put on an antacid, but it wasn't helping. In fact, she thought the medicine was making her more yellow and now was giving her itchy skin, so she quit taking it.
I asked her if she had the report, and she handed it over. Sure enough, in tiny print, it mentioned a hiatal hernia. However, just below that, there were several more lines about the existence of multiple masses in the liver, abdomen, pelvis, and spine. I asked her if she was told about the tumors, and she said no, but an appointment had been set up with a local specialist at the end of the month.
I reviewed our labs with her and told her that it didn't look good. I called the hospitalist for admission and ordered a contrast study. I went back to the patient and told her we needed more images to define the tumors better, but it looked like she had widespread cancer and that it was likely too advanced to be treated. I'm not sure where her cancer originated from, but at this point, she will probably just be put on palliative care, or referred to home hospice.
The way that the woman presented herself from the beginning was kind of bizarre. I feel certain that she must have been told about the tumors, and she had a copy of the report in her hand. I think that she was just in denial, and hoping that her symptoms could be blamed on anything else. She did thank me for letting her know what was going on, I just think that the diagnosis was probably too much for her to process the first time she heard it.