Archives of The Cheerful Oncologist, Volume 2

“Doctors perform physical examinations in order to diagnose illness or injury,” said The Cheerful Oncologist as he leaned against a wooden desk placed strategically in the front of the hall.

Thank you for stating the obvious. Perhaps you would like to proffer an opinion as to why bears wander off into the woods each morning after finishing their eggs and bacon.

“Pay no attention to any wisecracks you may hear from the rear of the hall,” he replied. “Today’s lesson is entitled Examining the Cancer Patient: The Key Findings.”

Oh, brother - good thing I brought this morning’s New York Times crossword puzzle.

“Let’s face it - as your careers progress, or for some of you court jesters sitting in the back - drag on, you will find yourself forced to abbreviate the physical examination in order to satisfy the constraints of time. Obviously patients suffering from disruptions of specific organ systems like the heart or lungs will require particular attention to these areas. But what of the patient diagnosed with cancer? How can we ensure that our exam has been accurate and complete enough to uncover clues as to where the tumor started, where it is now, and what complications has it released upon our patient?

“As an example let’s present a patient with the chief complaint of four weeks of cough - with no other symptoms. A chest radiograph reveals multiple small pulmonary nodules throughout all lung fields. The odds are that this tumor did not start in the lung - especially if the patient is a non-smoker, as in this case. Because of the paucity of findings on the x-ray, if we examine this patient’s lungs with the intention of solving the mystery we are likely to come up as empty-handed as Grandma playing a game of three card monte. ”

What? Did he just say three card monte? Hmm….need a five letter word for “Steppenwolf” author….

“Therefore, in addition to taking a careful history, we must examine the patient while simultaneously formulating a differential diagnosis for the cause of his multiple lung nodules. This patient will serve as a model for what we should concentrate on when examining the cancer patient during a busy clinic afternoon, when efficiency is of the essence.”

Why didn’t I stop off for coffee on my (yawn) way here? Okay - a six letter word meaning ‘nauseating‘…

“The crucial areas one must concentrate on during this exam are as follows:

Skin - think melanoma! Look for blatant melanomas, atypical moles, old scars from earlier mole removal - plus subcutaneous nodules, skin cancers, nicotine stains on the fingers (always a clue that the smoking history was incorrectly reported by the patient).

HEENT - think head and neck cancer, or lymphoma! Look for primaries in the nasopharynx, oral cavity and hypopharynx; check carefully for lymphadenopathy as well as thyromegaly; look for scleral icterus, too.

Breasts - do not neglect this exam in both men and women, although the incidence in men is as rare as hen’s teeth.”

Hen’s teeth? Hey, could that be the answer to “Rarity found on ground after poultry fight“?

“Abdomen - think masses and -megaly! If the liver is enlarged the primary may be from there or from the G.I. tract or pancreas; splenomegaly again raises the question of Hodgkin disease or non-Hodgkin lymphoma - and don’t forget to look for renal enlargement, or omental caking which is seen in ovarian and colorectal cancer, or a suprapubic mass suggesting endometrial cancer, or even bladder cancer.

G.U. and rectal exam - testicular cancer is high up on the list of possibilities for a non-smoking man with lung nodules, and of course we must always rule out a rectal mass plus check for occult gastrointestinal bleeding.

Legs - are they swollen? Could the patient have a deep vein thrombus, or even Trousseau’s syndrome which raises the spectre of G.I. or pancreatic cancer?

“There are scores of other parts to a complete physical, but for the busy clinician these tips are at least a basic template which will hopefully maximize the chance to actually find the patient’s primary site before shuffling him or her off to the CT scanner.”

Okay, just three more to go and I’m done…let’s see - a six letter word for “Gentleman’s gentleman likely found in Totleigh Towers, Market Snodsbury, Rowster Abbey, Brinkley Court and Steeple Bumpleigh…

(At this moment our back-bencher puzzle master looked up to see the unsmiling visage of his lecturer, who uttered, using a tone suggesting a judge sending a pack of pusillanimous pickpockets to the penitentiary, the following word:

“Jeeves.”)