Sunday, September 29, 2013


   In last blog I wrote about the new tests that are now available for us to diagnose the diseases and extent of the cancer .But these tests cost money and how we order them and how often we order and what information comes out of them that is useful for the treatment or telling the prognosis of the disease is very important . All of us know how we value the money . If I am spending 'my ; money for myself , I am very careful . If I am spending 'my ' money for someone else (say buying gift for a friend ) then I am careful , but not as much as I would be if I was spending for myself . And lastly when I spend someone else  money for a third party I care least . This last one is the politicians spending our money for some cause that will bring them more votes . I think in medicine I should add one more . When we spend somebody else's money for some other person and make money for our-self , then I am more likely to be more liberal than any other time . The case that I am going to tell is one such case , though I can't say for sure if it was the 3rd or 4th cause for  ordering of the test .
   I saw this 74 years old male with the diagnosis of pneumonia . He had cough , shortness of breath and had fever . He was congested and the X-ray did show pneumonia . He also had a history of laryngeal cancer and it was treated few years ago with radiation . He had follow up with the cancer doctor 2 or 3 months ago and no tests were ordered . He had not seen the throat doctor (ENT MD ) in last 12 months . He also had history of the Parkinson's disease . I did start him treatment and did a CT scan . The scan showed a "mass like density-consolidation right lower lobe of the lung ". The clinical picture was that of infection . But with his history of cancer , smoking in the past , and the CT scan finding , I had to rule out cancer . So I did the bronchoscopy . The bronchoscopy was negative for any tumor and all the biopsy , cultures came back OK . I spoke to him and his wife and told them that I was happy withe the findings. Due to the size of the abnormality seen on the CT scan , 6 cms ,I wanted to do follow up CT scan . If it was pneumonia , then it should get better and if it did not then I would worry about cancer and do a scan called PET  scan .
     He was discharged and I saw him in office for a follow up . I forgot  to mention that I had also a swallow study and he was not normal . The thin liquids were going down to lungs instead of the esophagus . So the cause of the pneumonia was the aspiration .He was doing good . Had no fever. Had minimal cough. I ordered the follow up CT scan in 2 months . He was suppose to see me after the follow up CT scan .
     He was admitted to the hospital with fever of 102 f and I saw him again . He had the follow up CT scan and the consolidation , which was 6 cms , was only 2 cms . "Significant improvement " was the report of the radiologist . I had seen it , but patient ended up in the hospital with fever . I did the new swallow study and it did confirm that he was aspirating . But patient and the wife did not want feeding tube and the speech therapist felt that we could change the consistency of the food and give one more try . He had fever due to aspiration and that caused the pneumonia . He responded to the antibiotics .When I looked in the computer  I noticed that the oncologist had done a PET scan , one week before the CT scan that I had ordered . The  PET scan had shown some uptake in the area of concern and the radiologist felt that the uptake was consistent with the pneumonia .I was not aware of the fact that he had seen the oncologist and they had ordered the PET scan . I wish that the PET scan was not ordered without doing the CT scan . The cancer does not go down in size from 6 cms to 2 cms . So if the oncologist or their nurse practitioner would have checked with the patient on the CT scan that was ordered , and waited for the results of the CT scan , then they would have seen that there was no need for PET scan and we would have not 'wasted ' $3000 for the PET scan .
     I am not sure if the PET scan was ordered by the doctor or their assistant. I am also not sure if the PET was ordered , due to lack of information or it was due to some other reason . But one thing for sure , it was done and  we wasted the money .

No comments:

Post a Comment