PERSISTENCE PAYS

   In medicine sometimes persistence pays. We see things and with previous experience we think we know the diagnosis  and then the tests are carried out and the diagnosis is not obtained . So sometimes the persistence pays. In past it has also happened that we think that there is cancer or some other diagnosis  and then the tests show something different. But one has to go by what we think  and continue the work up. This brings me to the story for today. 

  I had seen this patient in office for the shortness of breath. She had been smoker in past  and had quit many years ago and she was getting short of breath and so the primary care doctor sent her to me .I knew that she must have COPD the disease that happens when people smoke and over period of time it must have gotten worse. So I did the work up . She had o chest X- ray in long time . I did the chest X- ray and breathing test and AAT a genetic test to see if she had lack of certain enzyme that can cause emphysema in smokers. The chest X-ray came showing some abnormality and so I did CT scan. The CT csna showed 2 masses  and she had it quite close to center of left lung. I did PET scan and in Pet scan  glucose is used and that is picked up by every cell in the  body and the concentration of the  glucose pick up is measured. .Higher the pick up more likely to be due to cancer. So the PET scan is 80% accurate in picking the diagnosis of cancer. So there are cancer where the metabolic activity of the cells is not much higher than normal cells and so the pick up is not that high. This is seen in very slow growing cancers. And there are infections that will be positive on PET scan . So it is not 100% . Her Pet scan was positive and so I was sure that she had cancer of the lungs . I did bronchoscopy and I did see narrowing of the bronchus and I was sure that the biopsy will be positive for cancer, but it did not. So, I did ask radiologist to  do needle biopsy. . That also did not show cancer. I had told family that most likely based on our tests , she had cancer. But we did not get the tissue diagnosis. 

    I sent her to a chest surgeon   to consider open biopsy . I thought that was the only 100% test to get the diagnosis of cancer. I was sure that she had cancer. The surgeon called me Her lung function was not that great  and so he wanted to redo needle biopsy with larger needle - so called CORE Biopsy.She had the core biopsy  and that showed the CANCER!

    So the persistence paid.

LESSIONS TO LEARN

     The medicine is fluid. Everyday we get new information and new tests and new drugs and treatments . Sometimes what we learned in past may be partly true or may not be true at all. The classic example that I can give is frontal lobotomy where frontal lobe of brain was removed as a treatment and I think he got Noble Prize for that. But now we know that that is not correct and no one does Frontal Lobotomy any more .But certain principle still guide us They are almost eternal in that sense. The work up of anemia is one of them. But I often see patients who have anemia or low blood count get iron as treatment and many a times that may not be the problem. This brings me to the patient for today. 

     I saw this patient in my office . She was one of my patient's wife and had been diagnosed to have CIOD  as she was smoker . So she had bad lungs - damaged from smoking and she must have been so bad or advanced that she was on oxygen all the time . She had no recent work up and so I decided to do new work up. But then she felt more short of breath and so went to ER and was admitted . She was found to have anemia - her hemoglobin which is normally 14 grams,  was less than half at 6 grams . So the hospital doctor ordered gastroenterologist to see her . No anemia work up as to the cause of anemia was done . Th gastroenterologist saw her and told that she does not need any work up in hospital  and she should be worked up for anemia as she had normal stools and there was no evidence of blood loss . I was notified of her hospitalization 3 days down the road . I saw her and realized that her worsening of shortness of breath was due to anemia rather than COPD . But she also had wheezing and she was not started on any bronchodilators which she used to have at home . I started her on her usual inhalers and did anemia work up. She also had some other problems . 

     Her condition improved and her shortness of breath was better as she was started on medicines and she had a blood transfusion. But the anemia work up showed that she had abnormal protein. Just to give an idea we have raw material that is needed to make hemoglobin - like B12 , Iron, Folic Acid  and vitamin C and some other  and then there is factory - which is bone marrow. We tend to lose blood  in conditions like stomach ulcers or diverticular disease or polyps in colon  and colon cancer  and in younger ladies menstrual blood loss. So one has to find out if anemia - low count is due to poor or lack of raw material iron being one of them or if factory - the bone marrow is defective or if we have blood loss. In this patient the work up showed that she had problem with bone marrow . The abnormal protein which is produced by overgrowth of certain cells in marrow leads to reduction in production of red cells which carry hemoglobin

     So her shortness of breath was made worse by low hemoglobin and that was due to somewhat unusual cause of abnormal growth of certain cells in marrow and iron will not work 

      LESSION LEATNED !.