Fragile Life

I had a patient admitted to my service a few days ago that has been weighing on my mind. This has been an interesting and tragic case. This is a 53 year old male who presented last a few months ago with painless jaundice which is very often a sign of pancreatic cancer. However at the time the patient did not have other symptoms and his cancer work up was negative. He was found to have a gallstone which had been pressing on his pancreas which had caused pancreatitis and ultimately shut the pancreas down. As a result of the pancreatitis the patient developed pancreatic insufficiency diabetes and had to be put on pancreatic enzyme replacement therapy. 

He was followed in clinic throughout the fall. However he has not been well enough to return to his high profile executive job or to drive his car. His wife and older children have been supportive and concerned for his health. Then earlier this week while climbing some stairs he experienced shortness of breath and did not feel well. He knew something was not right. His wife brought him to the ER where he was worked up and admitted as my patient. I am in charge of his day to day work up and care, thankfully I have a deep team of support to help me and more importantly watch my management of the patient to make sure that I am not missing anything or doing something incorrectly. I have my Intern, senior resident, teaching attending physician and the patient's primary care doctor all looking over my shoulder. I also consulted GI, surgery and interventional radiology on the case. I kind of work as the main point of contact with the patient and the family and I keep all the physicians on the case informed.

This case has taken everyone by surprise. The patient has no past medical issues and really no risk factors. He does not smoke, drink or use drugs. He is health conscious and was not over weight. He exercised and ate very well. His case is serious and he has been decompensating over the last week. He continues to have pancreatitis and his mental status has declined and other organ systems are starting to become affected. If he continues at this rate he will die within 7 to 10 days. We are trying to figure out what exactly is going on. We know that his pancreas has failed but his other symptoms are atypical. He has a pseudocyst in his pancreas which will need to be either drained or surgically removed. We should have this addressed by tomorrow. This case has been like an episode of House (the tv show). Right now we are stumped.

My main theory now is that he must have pancreatic cancer that has metastasized and the cancer must have been in the very beginning stages and not detectable in August when he was first seen Tomorrow we are going to work him up again for cancer and see if we can find anything. Hopefully it is not cancer but we can find a less ominous illness. If in fact he does have pancreatic cancer his prognosis will be terminal. 

In July this was a healthy successful father, husband and friend and today he is hanging on for his life. There has been a large number of people that this has impacted. HIs children, his wife, friends are all devastated. Everyone is still hopeful but I think the outlook is grim.