It’s been awhile since Covid-19 has seemingly taken over the world as I knew it. I suppose this is the test of the real extravert. How are you feeling right now? What are you thinking about? How is this affecting your mental health?
I fluctuate between feeling really forlorn and hopeless to finding the slivers of hope. That may sound kind of dire, but what I mean is that there is much more going on in my head than just the coronavirus. In fact, more than I ever thought I would worry and brood about just a few years ago when it was more centered on unhappiness in a career.
My husband was shockingly diagnosed with stage 1b clear cell renal carcinoma. He was given a clean bill of health in September 2019. Clear margins. Lots of “whews.” However, the first CT came back a little bit different than he or I ever expected.
| Reason: Renal cell carcinoma of right kidney (CMS/HCC) [C64.1 (ICD-10-CM)]. Comparison: 7/30/2019. Technique:CT chest using 100 cc Omnipaque 300 IV contrast.CT of the abdomen and pelvis without and with IV contrast.Automated dose control was utilized for this exam. Incidental findings:Renal cysts referred to as simple cysts are statistically benign and require no further imaging workup. Adrenal nodules measuring less than 1 cm are statistically benign and require no further imaging workup. Adrenal nodules measuring greater than 1 cm but less than 4 cm and meeting density criteria for adrenal adenoma are statistically benign and require no further imaging workup. FINDINGS:CT chest:Small cluster of reticulonodular densities in the lateral aspect of the left upper lobe (series 8 image 28), unchanged from comparison exam. Fissural nodule along the right minor fissure measures on the order of 3 mm (series 8 image 66), unchanged. There is an accessory fissure in the right lower lobe. There is a nodular density adjacent to the accessory fissure in the right lower lobe measuring 1.0 x 0.7 cm (series 8 image 76), not significantly changed from comparison exam. Cluster of small nodules noted in the posterior aspect of the left upper lobe (series 8 image 59), unchanged. Irregular groundglass density in the superior left upper lobe (series 8 image 38), unchanged. 4 to 5 mm right middle lobe nodule (series 8 image 65), unchanged. No discretely new or enlarging pulmonary nodules identified. No new focal consolidation or pleural effusion. Central airways are patent without evidence of endobronchial abnormality. Mediastinal and hilar lymphadenopathy is similar to comparison. Right hilar lymph node measures 1.9 cm short axis (series 6 image 54). Partially calcified lymph nodes are noted in the bilateral hila. Right paratracheal lymph node measures 11 mm short axis diameter (series 6 image 39). Low paratracheal lymph node measures 1.4 cm (series 6 image 46). Subcarinal lymph node measures 1.2 cm short axis diameter. Mediastinal lymph nodes are prominent in number. No significant change in the size, number, or appearance of mediastinal or hilar lymph nodes from comparison exam. No axillary lymphadenopathy. No focal abnormality identified in the imaged portions of the thyroid gland. Postoperative changes of ORIF in the right clavicle. Multiple remote right-sided rib fractures. CT ABDOMEN:Subcentimeter hypodense lesion along the anterior margin of the left hepatic lobe (series 6 image 116), unchanged from comparison. No new or enlarging liver lesion identified. The gallbladder is contracted. No intrahepatic or extrahepatic biliary ductal dilatation. Postoperative changes of left nephrectomy. The spleen, pancreatic tail, and bowel are transposed into the left nephrectomy bed. Left para-aortic lymph node measures 7 x 10 mm (series 6 image 147 x 10 mm, series 6 image 148), increased from 4 x 6 mm. No discrete adrenal mass. The right kidney enhances normally without hydronephrosis. Subcentimeter hypodense lesion in the inferior spleen is unchanged from comparison, indeterminate. No focal abnormality identified in the pancreas. No evidence of small bowel obstruction. The abdominal aorta is nonaneurysmal. CT PELVIS:Urinary bladder is decompressed. Central prostatic calcifications. Multiple pelvic phleboliths. No free pelvic fluid. Sigmoid colonic diverticulosis. Small left inguinal hernia. No evidence of acute diverticulitis. The appendix is normal. Bilateral L5 spondylolysis. Grade 1 anterolisthesis of L5 on S1. Degenerative changes in the spine are largely on the basis of facet arthropathy. No focal aggressive osseous abnormality identified. IMPRESSION:1. Left para-aortic retroperitoneal lymphadenopathy near the level of the left renal artery origin has increased in size from comparison exam. Nodal metastatic disease at this location is a diagnostic consideration.2. Multiple pulmonary nodules bilaterally, the largest measuring up to 1 cm in the right lower lobe, not significantly changed from comparison exam. Findings may be related to granulomatous disease. Pulmonary metastatic disease is a diagnostic consideration, felt less likely given the relative stability since 7/30/2019.3. Mediastinal and hilar lymphadenopathy is not significantly changed from comparison exam and appears to demonstrate some degree of calcification. Correlate with history of granulomatous disease, i.e. sarcoidosis.4. Additional postoperative, chronic, and ancillary findings as discussed above and on previous exam. |
So, as you can see, lots of words that I don’t EVER want to see in anyone’s CT. Unfortunately rather than the doctor himself calling and taking the time to have a little bit of sympathy, he put it off on an office worker to deliver the possible news of metastatic spread. They told him they needed to order a PET scan.
We received, in the mail, a rejection of said ordered CT from the insurance due to “inability to determine where a primary cancer source would come from…” leading me to believe, as a former healthcare professional and Doctor of Pharmacy, by God, that someone didn’t submit the earlier CT and the pathology report from the radical nephrectomy in September. “We’re going to have to do a peer-to-peer,” said the office worker again to my husband, again on the phone. I would like to add that I would like to blame their lack of true clinical bedside manner on COVID-19; however, it has been going on since the first time I met this urologist and his office. Rumor has it he does about a third of the revenue for Erlanger. Who knows.
Peer-to-peer was denied.
Let me quote the doctor’s office representative who left a VOICEMAIL.
Your insurance denied the peer-to-peer review for the PET scan and Dr. Singh looked at it again and thinks maybe it is just inflammation and not metastatic spread. We’ll just order the CT for September per usual protocol. If you have any questions let us know.
Problem is, I have had 100 questions and have reached out via phone and app. No response. After the radical nephrectomy in September where he wasn’t on a pain pump post-op and was treated as a pain-seeker because why in the heck would you EVER only give 12 oxycodone/apap 5 mg post-op?
I digress. That’s a whole different issue. We kept the first CT on the books.
I realize that some physicians have a true passion for helping others. I believe I am of the same character. I truly want to improve the lives of others, formerly through pharmacy now through finance. But if you are going to be a physician and spend 6am-midnight case after case not even knowing who is next and having patients stacked up in pre-op for hours, maybe it’s time to re-evaluate what you are doing.
This was the fast-food of nephrectomies. He certainly doesn’t want to even ask how are you?
So, I reached out to my PCP. He DOES have a passion for helping others. I can’t say enough good things about him. He recommended a local oncologist to just take over. Sure, Vanderbilt has someone I’d like my husband to see, but right now COVID-19.
My husband had his PET Scan today ordered by the oncologist.
HE GOT IT APPROVED.
Likely it wasn’t too difficult if you just submit the correct paperwork and also discuss with the patient all of the things that could be going on.
So, I’m going back to journaling and didn’t want to use my usual pharmacy blog from years ago or my personal named blog because of what I do for a living. I just don’t want it searchable, but I do want to put my thoughts out there.
veritable faith 