Susan and I have been rewatching the Buffy the Vampire Slayer series this past month. We have all seven seasons on DVD. We watch one episode nightly; right now, we are on Season Five. A recent episode was titled The Shadow referring to an abnormality in Buffy’s mother’s head CT. The Spanish word for shadow is sombra.
After the episode, I remembered Do̱a Lupita Рa seventy-something matriarch who had come across the Southern border to visit her 50-something daughter and grandchildren. The daughter had taken the opportunity of this visit to arrange for her mother to see me Рone of a handful of Austin physicians fluent in Spanish at that time.
It seems that Do̱a Lupita had been losing weight gradually for a few months; her appetite was off. There were no other remarkable symptoms. Her history was remarkable only for smoking a pack of cigarettes daily since her teenage years Рsomething that we shared in common. She had no remarkable occupational exposures. She was mother to three daughters, two of whom lived in the US, and grandmother to seven children. She spoke a few words of English, and her Spanish was fluent.
Her examination was unremarkable except for a localized wheeze audible in her right mid-back. Wheezing is high-pitched noise that typically arises from one or more larger airways that are narrowed by mucus or swelling or external compression. Wheezing is audible during exhalation.
Wheezing is common during a bout of uncontrolled asthma when it is usually diffuse – audible anywhere on the chest that one places the stethoscope. It is also common during exacerbations of chronic bronchitis where the wheezes are audible in scattered areas of the chest. Discrete, localized wheezing that is confined to a small area of the chest is almost always a bad sign. It could be caused by an intra-bronchial obstruction such as a peanut aspirated into a young child’s airway or, in this case, a malignant mass obstructing or compressing an airway.
My practice in those days was located in an aging medical park that had been home to several private practices, a small pharmacy, and a satellite of Austin Radiological Associates. The radiology facility was adjacent to my office. I sent Doña Lupita there for a chest x-ray with instructions for her to return to my office after her brief visit to the radiologist.
When she returned to my office, my assistant escorted her and her daughter back to the exam room, and I stepped out of the office to visit my friendly radiologist. Once there, I viewed the film with him. Doña Lupita had mild changes of chronic obstructive lung disease, and a large mass compressing her right lower lobe bronchus. Sigh.
I returned to my office to visit with Doña Lupita and her daughter. I explained that her chest x-ray showed “una sombra” in her right lung. I recommended a surgical consultation and a visit to an oncologist. The family took it surprisingly well. They thanked me and left.
Doña Lupita most likely had small-cell lung cancer which had a dismal prognosis in the 1980s. Since she was a Mexican national, she had no US health insurance. I never heard from her again, and I can only imagine that she returned to Mexico to seek care from the physicians in the Mexican Social Security healthcare system.
I don’t think that I ever again encountered a patient with a localized wheeze. It’s one of those physical finding that we all learn in medical school or perhaps during a pulmonary medicine rotation, but which most of encounter rarely.