When my kids were growing, there used to be a puzzle where the kids have to find out abnormal thing in the picture like a bird with one wing or a flower is missing a petal etc. Sometimes in medicine I feel the same way . Thre are so many things that are wrong that we have to go through them . In medicine we used to have dictum that symptoms are most of the time explained by one diagnosis or condition and one need not try to get to 2 or 3 different conditions that could explain them. That brings me to the story for today.
I saw this years old male for pulmonary problems . He was nonsmoker and had been diagnosed to have asthma . He was admitted to a hospital and had treatment done for the asthma and then discharged. As usual he did not come with any old records .So I looked at the hospital records and realized that he had CT scan done and that had shown a nodule. So I asked him if any additional work up was done like special scan or biopsy etc. . and the answer was no. It looked like he had severe asthma and he needed steroids all the time . He had a nodule and he was wheezing . So I ordered a PET scan and scheduled him for the biopsy /bronchoscopy. The PET scan was done and that showed that the nodule had high pick up of glucose on PET scan and so the nodule was likely to be cancerous or at least needed further work up. 2 days before the bronchoscopy ,I was informed by my office that his insurance denied doing the biopsy and the procedure at the hospital where I had scheduled it . This was the same hospital where he was admitted and had CT scan done , but they told us that it was emergency. He had missed doing the breathing test and he also did the blood tests for allergies , but he had continued taking steroids and so they would not be accurate. I saw him in office again. We decided to start him on some biological agents for control of asthma and did the forms. At the same time I called a interventional pulmonologist to do the biopsy who was affiliated with the hospital system where the insurance would allow the procedure .You might think that story would end here ,but no. The pulmonologist called me telling me that they made several phone calls and he did not answer even when they left messages .He also had severe back pain and so he was seeing spine surgeon. I again called him and made sure that he comes for the breathing test and also made appointment for him to see this new pulmonologist.
So like the picture where we had to found odd or abnormal things , we have several things here . He has more than 1 problem - asthma , back pain and pulmonary nodule . He was admitted and and they did find the nodule but no additional test were ordered or done or follow up set - may be he did not want or do it -I don't know . Then the insurance covered the hospital for the admission and work up but would not cover out patient procedure . He did not show up for breathing test .He did blood tests while taking steroids - making the tests invalid. He did not respond to new pulmonologist for the biopsy.
Hope we can get new medicines for his asthma and he will keep appointment with new pulmonary doctor and also get the biopsy done.