A case of abdominal pain that turned out to be………..


When I was preparing for my FCPS exam, I went with my colleague to Civil Hospital medical ward, to prepare for a long case. We were very enthusiastic to make a spot diagnosis by just looking at the patient. My colleague had become very skilled in clinical diagnosis. We asked the RMO to tell us about a complicated case so we could examine that patient suitable for a long case viva. He pointed us to Bed No 1. It was my turn to examine. We handed over the file to the RMO without going through it. The patient was a tall and thin male about 70 years of age. I saw him and caught in a glimpse his marked clubbing of fingers, prominent ribs revealing from his two opened buttons of kurta, being underweight and appeared to be with weight loss. From that appearance I made the diagnosis of lung cancer in my mind and started taking the history. After writing his biodata, I asked about his presenting complaints thinking he would say cough and  breathlessness but to my surprise he said it was abdominal pain and pointed to his right hypochondrium. I looked at my colleague and he was smiling on my dismay. On my further inquiry, he explained since last two months, he was experiencing this pain and it was constant. He told me he felt better if lies still without moving on bed. It was well localized pain and forbidding him to work. 


On my mind I was still firm on some respiratory illness so I started asking closed questions. I asked about breathlessness, hoarseness of voice, , cough, sputum, hemoptysis, weight loss but to my surprise, he nodded to each question! I asked about smoking and he nodded. I still asked if he had ever smoked cigarettes? He admitted eventually that in the past, for twenty years, he used to smoke a pack of cigarettes  a day but stopped smoking 10 years ago. I said to him, “ maybe you are confined to bed so you didn’t notice whether you had a bit of breathlessness?”  With each of his denying answer, my colleague had a joyful face on my dismay. With my all questions, patient had a nod! I started examining him and except for finger clubbing and being underweight (He denied weight loss and said he was always thin!) there was nothing significant on his general physical examination. I checked his pupils in the hope of finding Horner’s syndrome sign but there wasn’t any! His abdominal pain was well localized in the right hypochondrium and I found a pretty tender liver which was enlarged. There was no other positive signs on his systemic examination.


My colleague was laughing and suggested I should come out of my diagnosis of lung cancer and think about some gastrointestinal problem! But I carried out my questioning again in the hope of finding something positive in the history. Patient seemed bored with my persistent questioning. I eventually asked him if his skin color has darkened now? After listening to this question, he suddenly sat up on bed and said impatiently “Yes doctor Yes! I was fair but since last two months I have been blackened and everybody asks me what has happened to my fair color?” Now it was my turn to look at my colleague victoriously. His face looked masked now!! I told him that my diagnosis was small cell lung cancer with inappropriate ACTH secretion causing hyperpigmentation of his skin and liver metastasis resulting in hepatomegaly, liver capsule was stretching so it was giving him abdominal pain!

We ran to catch the file and flipped over the pages. His diagnosis was exactly the same, biopsy proven small cell lung cancer with inappropriate ACTH secretion and liver metastasis!!

My colleague said “Dr. Zeba you are very persistent”! I came home victoriously! 28th January, 2019