A young boy came to AIIMS, New Delhi with complaints of fever and abdominal pain. On investigation, he was found to have multiple enlarged lymph nodes in the abdomen.
For Non-Medicos: Lymph nodes are tiny bean-shaped organs found throughout the body. They may be 500 to 600 in number. They filter the lymph flowing in the body and are an important part of the body’s immune (defense) system against various germs.
The lymph nodes are generally few mm in size with the largest being lymph nodes lying in the inguinal (groin) region where size up to 1 cm (10 mm) may be normal. They may become enlarged (increased) in size in a variety of disorders such as viral or bacterial infections, e.g. infectious mononucleosis, tuberculosis, skin infections, and even cancer.
He got admitted in the surgery department and a laparotomy, (opening the abdomen by making a surgical incision (cut) and examining the internal organs usually done under general anesthesia in the major operation theatre, and biopsy of enlarged lymph nodes was planned. This was the days before the spread of laparoscopic surgery.
For Non-Medicos: Lymph node biopsy is a surgical procedure where single or multiple lymph nodes are removed by operation and sent to the pathology department for histo-pathological examination to find if they are having any disease.
On routine check-up the junior resident found that he had minimally enlarged lymph nodes in the left inguinal (groin) region. This finding was discussed on the ward clinical round, and as tiny lymph nodes in the groin region are very common even in a normal person and the biopsy of these inguinal lymph nodes usually is not diagnostic, the original plan of laparotomy was followed.
On opening the abdomen the lymph nodes were found to be adherent to each other and to large blood vessels and covered with fibrous tissue. A small piece was taken for biopsy due to fear of causing any complications due to injury to the large blood vessel stuck to the lymph nodes mass.
The pathology report came back after a week. It was inconclusive, i.e. no clear opinion was possible and the pathologist advised to repeat the biopsy with a bigger piece.
The patient and his parents were upset when they learned that the patient will once again have to undergo the major laparotomy operation to get a fresh tissue sample for repeat pathological examination.
The junior resident looking after the patient noticed that those left groin lymph nodes which were initially tiny on admission had now grown to significant size since the patient had got admitted to the ward. This was discussed in the clinical ward round. Although biopsy from the groin lymph nodes are usually inconclusive, but after considering the risk-reward ratio, it was decided to do lymph node biopsy from the groin and wait for the result before doing a repeat abdominal operation.
The patient underwent the relatively minor operation of the lymph node biopsy from the groin region under local anesthesia in the minor operation theatre.
One week later the biopsy report came and there was the unequivocal diagnosis of lymphoma, a cancer of the lymphatic system. With the diagnosis made, the repeat laparotomy was canceled and the patient was referred to the oncology (cancer) department for further treatment such as chemotherapy.
During an ongoing treatment of a patient, a project, a journey, etc. the situation may change. As in this patient, there were only tiny lymph nodes on admission but they increased to a significant size during the hospital stay. Keep on continuously monitoring the situation and if something new occurs then you may change your plan accordingly.
Do not disregard the observation and suggestion of any member of the team, no matter how low in the hierarchy he/she is. This is especially true if the team member is closely involved in the day to day care/function of the patient/project. For example, the junior resident is junior most in a medical college unit, yet due to his keen observation, the patient was saved from undergoing another major surgery.
In real life, sometimes there may be an exception to general rules or guidelines, such as in this case. Biopsy from the groin lymph nodes is not usually done but in this patient, biopsy turned out to be diagnostic from the groin region. So be open to making exceptions to rules and guidelines according to the actual situation.
(Based on an allegedly true incident)
— ND
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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost.
DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.
