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Unable to walk with lesions in CT CHEST. CANCER?

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Hi my father had a stroke in january 2014 however he was still moving his arms and legs and talking although mumbling his words due to stroke.  It took the hospital in the uk 2 weeks to diagnose the stroke as it was not obvious with the ct and mri scan and apart from mobility and mublinng his sentences he was fine. 


Within a few days he was discharged and was able to walk with support with a frame. 


However his mobility went poor again in march 2014 and since then he became withdrawn.  They did scans but said there is nothing wrong and discharged him. 


However we noticed he became totally dependant and he was no longer having much communication.  Just a few words like I'm ok. I want to sleep.  I'm hungry.  And calling our names. 


We took him to India in July to sept 14 and over there he spoke a little more. We came back in sept and his mobility was poor and we put that down to tiredness so let him rest for a couple of weeks.  


Then all of a sudden on friday 24th October 14 he seemed confused.  Wasnt saying anything at all. Not even a single word but was still eating if we fed him and drank water if we fed him but he just stared.


Over the weekend he improved whereby he would acknowledge us by not speaking but saying hmm and if we called him turning his head or eyes. 


We took him to hospital and they did scans but said there is no change in his scans since Januarys stroke.  He suddenly spoke yesterday a couple of words but today he stopped again and wasnt even turning around if we called him.  He would still chew and swallow food etc if we fed him but isnt acknowledging us.


The doctor is saying that due to his age and his stroke in January its affecting him.  I said how can he be ok all this time and then suddenly stop but they are saying that its a general deterioration due to age and stroke.  He is 59 years old. 


They go he will have some days where he will briefly talk but others where he its like hes not there. I don't understand how this can be.  How can he go from talking and now like this and they link to his stroke in January. 


It feels like are just dismissing it. They said some people are ok but even though don't have another stroke they can deteriorate and they fluctuate.


Please can you help.


Our gp thought it was depression a while ago when his level of communication reduced in feb but he would still talk a little. 


His date of birth is 30 oct 1952

He has stage 4 renal failure but its steady. Ct and mri didn't show anything new they said. Hes also diabetic.


They are now saying on the day he was about to be discharged that he has two legions on the right side of his chest. It was clear they said on his chest xray they did a week ago.  They want to do a full body ct scan to rule out that the two legions are cancerous or not.  They said this is a seperate issue to how he is now. But that if the legions turn out to be cancerous then they will have to take this into account in deciding whether to treat or not. 


In regards to him not taking suddenly and not a knowledging why could this be?  He is alert and opens his mouth and eats if we feed.  Like I said yesterday he spoke suddenly and today he didn't.


You can call me on 07956516859 for more info. 

Category: Neurologist, Medical

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Category: Pediatric Neurologist
 25 Doctors Online

Hello,
Thank you for posting your query at DoctorSpring.com
I have noted your father's symptoms and I appreciate the detailed description you have provided.
I agree with the initial diagnosis of stroke, however, his deterioration and current problems can not be fully explained by stroke. This is because patients with stroke continue to improve over time, unless a new stroke occurs. Here, it is clear from new MRI scans, that no new stroke has occurred.
One thing I gather from history is that his symptoms fluctuate, from normal to abnormal. In Neurology, this can occur with minor strokes (also called as transient ischemic attacks-TIA) and seizures. However, TIA is unlikely here, as I am sure your father is on blood thinners such as aspirin or clopidogrel to prevent TIAs.
Regarding seizures, there are no obvious seizures as per the description, however, an EEG (electroencephalography) may be required to exclude subtle/minor seizures.
Depression also can cause fluctuating symptoms, however, he seems to be on anti-depressants.
Also, metabolic problems such as renal failure, fluctuations in blood sugar or sodium levels can also cause similar symptoms.
He would also need to have a detailed near-psychological evaluation to exclude early dementia, where similar symptoms can occur.
I hope it helps.
Feel free to discuss further,
Best wishes,
Dr. Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist


Patient replied :

Hi yes in January he had multiple minor clots in his brain but he was still talking a lot with full conversations after it. Then gradually but in the space of a month he started taking less. Then in late February early march we took him back to hospital with poor mobility and not being fully alert. They said not a Stoke after ct scans etc and treated him for chest infection and discharged him. But he seemed more withdrawn. He mobility was poor but built up again. But his conversation level was not the same. The doctor prescribed him anti depressants a very low level due to kidneys but he never took as each time he would get an infection etc the doc would say don't start yet till it goes.
He would still walk with a frame etc if we helped him but no longer took part in conversations. He would just stare at the floor with his head down or into nothingness.
We would need to ask him something several times before he responded.
But he didn't really talk part in any conversations apart from saying I'm hungry. I'm tired. I want to sleep. Or our names.
In January one of the junior doctors did say he has lots of fluid in between his brain and sulk in the water ducts but that this has not changed since before his stroke and when compared to scans 1 year ago. They never looked into or diagnosed dementia though. But we as a family as he became withdrawn did think that.
We took him to India in end of July till sept but although he spoke a little more so instead of just them words listed above he would say when people kept saying do you know who this is or who that person is he would say their name or say I'm not stupid you know. But that would be it. He would also constantly call our names in India and be scared he was going to fall off the bed. He would say I'm going to fall and even if we would say your not 5 mins later he would wake up and call us and say it again.
But if someone went somewhere and I would say where have they gone he would say.
Anyway in sept we brought him back and his mobility was poor again and he still just seemed to stare same like India but he just said the few words but less. We thought maybe tiredness from the journey. We noticed his muscles stiffining up. But as he hadn't walked but been in effect bedbound for a week coming back from India maybe that's why. I tried walking him and he could do a little before his legs would give way. But his arms and hands remain clenched to his chest.
Then all of a sudden on Friday he stopped taking completely. Not even our names. A week leading to that if we called him he would turn his head. Or if I say are you ok he would say I'm ok. But he stopped saying our names etc or any other form of words. But then Friday he stopped that too and although he would havevhis eyes open and when we fed him he would chew and eat his food etc and when we give his water and medication he would have. He didn't respond like he wasn't there. Just kept staring into nothing.
But then on Sunday he would turn his eyes and head if we called him. If I asked him a question he would speak but would acknowledge with hmm. And if I said close your eyes he would do it. But we couldn't understand why he was no longer talking.
We took him to hospital. They said his blood results were fine and no sign of infection. They did ct scan and said there is no change from him December ct scan and you can see small remberenace of his january stroke but there are no new strokes or new changes. I said to the doctor we was thinking dementia and the fluid etc but he said his ct scan didn't show anything new or changes from jan scan. So I wasnt sure why he wasn't talking then and gradually going worse. He didn't know. They moved him to stroke unit due to mobility. But the stroke unit said he hasnt had another stroke. He had a chest xray in January, in between and even when admitted but it came back clear. However sudden a few days later in recent xray before they discharged they said they spotted 2 legions on right side of chest. The radiology department want to do a full body ct scan. The stroke doctor said this is seperate to him not taking and that this is something new. The radiology dept want to rule out cancerous legions and he said the full body ct scan will determine if these legions anywhere else and also will 95 percent confirm if these lesions are cancerous or not. He said if they are cancerous due to his frailness and his other conditions they will have to have a meeting to see if worth treating or not but at this point they just want to rule it out. He said if nothing then can take him home.
I said yes but why is he not taking or responding. Because the day before whilst in hospital he suddenly started saying a couple of words and spoke very small sentences to my mother and sister. But then today he never responded at all and just staring into nothing but still eats his food etc when feed him. Its like automatic reaction. Opens mouth and takes spoon into mouth if we put to mouth and chews etc. But no other response.
The doctor goes its not a new stroke but that they think its his January Stoke having an impact now due to him getting older. I don't see how from getting better he can gradually decline then suddenly stop talking and that be blamed to his age and January stroke when he was good then.
The stroke doctor said he will fluctuate on a day to day basis and that some days he will be alert and others not. I don't agree and think there is something else that is causing.
In regards to medication he is on. .. Clopidogrel teva 75mg Furosemide 40mg Adcal d3 1500mg Omeprazole 20mg Amlodipine 10mg Senokot 5ml Ferrous fumate 322mg one teo times day Humilin m3 20 in the morning.
His kidney function was stage 3 but after his stroke it fluctuated up and down and then in march it was 13 percent. But in India and since back its been 15 percent so the doc said its improved and his bloods are good. Since last year well before his stroke his hemoglobin levels kept dropping to 7 and 5 so they said he is anaemic due to his kidneys. Early last year they were going to do epo injections but they started him on iron tablets and his hemoglobin levels moved up so they didn't do the epo. They did think maybe cancer then but did camera checks through bottom and mouth but came back with nothing.
This year however in march it dropped again and the doctor increased his iron dosage to 322mg which brought it back up whilst in India. Since then its been steady at 10. But our gp instead this time from last week said lets increase dosage to 644mg of iron. So he was on double dosage of iron and also ceflexin as he had a slight infection which cleared on Friday when he stopped taking.
Ive asked the hospital that the neurological team needs to see him but they are saying there is no new change in ct brain scan so its not that.
The renal team in sept did a vitamin deficiency blood test but they said that was fine. But he was saying limited words then.
They do daily blood tests on him at the hospital and I'm assuming it would have picked up b12? I will ask.
What do you think is wrong? Or possible causes. The hospital are saying if full body ct scan comes clear they will discharge.
Its only been since January but his mental abilities and engagement has been declining so quick. Don't get it as he spoke lots after stroke. And they said the reason why they never picked up his January stroke from mri and ct scans initially as it was a subtle stroke with minor clots on brain. But he was still speaking lots even after.
What do you suspect it could be or we need to get the hospital to check for.
I know there is a lot of questions. I'm sorry. We just feel like the hospital isn't looking into the cause.


Hello,
Thank you for the follow up. I understand how this may seem overwhelming.
There are 4 things I would like to address:
(1) The appearence of 2 lesions on the right chest of chest will are being evaluated with a whole body CT scan. It is important to determine the exact nature of these lesions because cancer, especially when it spreads tends to cause some of the symtoms you have decsribed.
(2) In addition to the stroke, you mentioned that your father is in Stage 4 renal failure. When our kidneys fail to function, it can result in electrolytes and other toxins which are normally flushed out to build up. Electrolyte imbalance can affect our body and personality in many ways and therefore I would appreciate if in your next reply, if you can include the report of the whole body CT scan (when it becomes available) as well as the most recent copy of renal function tests and serum electrolytes which would bring more clarity to the status of his kidney function. The anemia (low hemoglobin) can also result in a person feeling extremely tired and slow them down.
(3) You mentioned that he was prescribed low dose anti-depressants in early March, but have never been able to give them; also I did not see them in the list of medications that he is currently on. It probably means the doctor who prescribed these medications noted signs of depression which have a fluctuating nature. From your description, it is possible that your father is going through an episode of depression currently.
(4) As I mentioned in my previous email it would be helpful to get a detailed near-psychological evaluation to exclude early dementia.
I hope that this helps you understand that there are many things to consider when trying to understand the decline in your father's health and personality. It is probably why one singular cause cannot be used to explain his condition.
Regards


Dr. Sudhir Kumar
Category: Pediatric Neurologist
Experience: 
Senior Residency, Fellowship: DM, Neurology, CMC, Vellore, 2001
Junior Residency: MD, Internal Medicine, CMC, Vellore, 1998
Medical School: MBBS, Christian Medical College, Vellore, 1995
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