Another Long Day

What a long day yesterday was - for Phil I mean.  I actually faired well up until the end of the evening which I'll get into later.  Mostly I kept Phil company while we waited to hear the results of the tests he went through.  With the fever he had in the night the initial work up included the obligatory urine and blood cultures, a chest x-ray, and an MRI of the sinuses and brain.  About midway through the day Dr. Mayer (Infectious Disease) came in for a bedside consult and Dr. Mansfield (Oncology ENT) had us wheel on over (literally) to his office across the street so he could look in Phil's sinuses with his sophisticated equipment.


During morning rounds with Dr. Kossman Phil mentioned that he'd started having a cough and a pain in the middle of his chest when he took a deep breath.  It was sharp and very painful.  Dr. Kossman didn't hear anything in the lung fields and wanted to see the chest xray results.  He thought it could be an irritation to the pleura (lining of the lung) from the methotrexate and wanted to keep an eye on it through the day.


By 5 p.m. everything was looking fantastic and we'd confirmed that there was nothing growing in any of his cultures, his chest x-ray was totally clear, his MRI was awesome - no signs of any active processes and the Mucor and previous infections were completely resolved.  Dr. Mansfield had taken a look at the sinuses and down Phil's throat and declared everything there to look great with no signs of active infection.  So, while this was all really great news, we still had no culprit for the source of the fever.  


During the consults with both Dr's. Mayer and Mansfield Phil mentioned the chest pain.  While neither heard any abnormal lung sounds, both were concerned about the pain as well and the need to rule out a more significant cause like a pulmonary embolism (a blood clot in the lung - potentially life threatening).  As we got back to Phil's room he was suddenly in so much pain he couldn't sit still and starting to have difficulty breathing deeply.  He called for morphine and finally settled down.  At this point the phone rang and it was Dr. Kossman, ordering a spiral CT scan to rule out the pulmonary embolism.  Now Phil has azotemia (a type of decreased kidney function) and the CT scan requires a dye which is excreted by the kidneys.  To make a long story short, there is risk to his kidneys of further worsening function so he'll be getting a LOT of fluids through the night to flush them to minimize this risk.  Between the pain and the fluids the poor guy may not be sleeping much tonight if you know what I mean...


Fortunately spiral CT scans only take about 10 minutes to do and we had the results quickly.  There was no pulmonary embolism and we were able to learn that the 13 cm mass of lymphoma tissue that was initially in his chest at diagnosis is gone; it is now <1cm of scarred tissue.  In other words, Dr. Kossman says it is "essentially nothing".  Well that was worth the risk to find out I'd say!  So, again, we're back to thinking that Phil probably has a viral respiratory infection or a pleuritic irritation from the chemotherapy.  Morphine is the treatment, to keep him comfortable until there are signs pointing to another diagnosis or way to manage it.


I said I did well until the evening.  When I was getting ready to go for the night Phil started to have more chest pain and was really hurting.  We called the nurse and got him the morphine but it took so long for him to get comfortable.  There was nothing I could do to make it better.  I just had to wait it out with him until the relief came.  And it took at least 20 minutes.  That was a long time.  Finally he felt comfortable enough that I felt comfortable enough to go home to the kids.  What a bugger.