Saturday, October 22, 2016


     In medicine like in many things in life or other sciences we have rules and they do apply in many cases or under many circumstances . But we also talk about exception to the rule. In medicine we have the same thing . When we see a patient and try to diagnose the disease that may be causing the symptoms. So when we see some one with high blood pressure we  don't try to work every patient for etiology for the elevated blood pressure . Again if we see very young patient with elevated blood pressure we WILL DO tests to find any cause of the elevated blood pressure -so called secondary hypertension.In medicine we are often told that the cause of symptoms is more likely to be due to ONE diagnosis , rather than 2 or 3. So this is one of the stories where there was a exception to this rule .
      I saw this patient who was seen by number of physicians before me . He came to see me referred by a family doctor. When I went the room in my office to see him , he was lying down on the examination table. In my practise this is very unusual as most of my patients are sitting in a chair ,waiting to be seen . So this was a 65 years old male who was referred to me for the evaluation of abnormal CT scan of the chest . He was admitted to the hospital in recent past his first primary doctor with chest pain . He was seen by a cardiologist and the had heart catheterization  and it showed the blockage and so a stent was put in. He was discharged in spite of him complaining that he still had chest pain . So in less than on week he went back to the ER with chest pain and he was readmitted. Again the cardiologist saw him and told him that his heart was OK and no further work up was needed. He was discharged and the primary care physician saw him in office . The pain was still there and so he did a CT chest . The CT chest showed number of small nodules and some abnormality in bones including spine. He was sent to a lung specialist . As I understand he was told that he needed to do follow up on CT scan in future. He still had lot of pain and so he decided to change physician . The new MD sent him to a orthopedic doctor who ordered MRI of spine . It showed abnormality in vertebra. But no further action was done. He was now referred to me . He was not sitting in a chair as he was hurting badly and there were no additional tests ordered. I saw the CT scan report and it clearly specified that patient had bony abnormality in ribs and spine that was 'consistent with metastasis '. Patient was smoker had quit smoking NOW . So most likely he had some kind of CANCER that had spread to the bones and it was causing the chest pain .
     I decided to admit him . My worry was two fold . One is the pain control and other was the abnormality seen in first thoracic vertebra . If something would happen to this vertebra , he may be paralyzed . So I talked to radiation oncologist . I did further work work up in the hospital . The CT scan of the abdomen and the pelvis did not show any source of the cancer. The bone scan confirmed the spread of the cancer to several bones . I also got the old history that he had prostate cancer 5 years ago and had surgery and radiation treatment. But the PET scan showed increased up tale in several lymph nodes. It also showed some uptake in colon .So I consulted a chest surgeon who did the biopsy of the lymph nodes in the lung and it showed the LUNG CANCER . So we had the diagnosis . But the question was does he have second or even third cancer ? Remember the rule in medicine is not to look for more than one diagnosis . So here we had diagnosis of lung cancer , which could explain the entire picture . was elevated PSA -a blood test that indicates possibility of prostate cancer . We had done bone biopsy and it was OK But it was not done from the exact place where the bone scan was showing abnormality . So I decided to ask radiologist to redo it , but this time with help of CT scan . So the biopsy was from possible metastatic lesion . It showed prostate cancer . So he had 2 different cancers . The pain was not from the lung cancer ,but was from the prostate cancer spreading to bones .I am not sure if he has third cancer colon We have not done colonoscopy yet .


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