Saturday, November 23, 2013


   We now a days have many specialists . In past , we had family doctor and he took care of everything . If he refereed a patient to a specialist , and the specialist advised a test , the patient would go back to the family MD to make sure that the test that was ordered by the specialist was needed and should be done . That kind of trust is gone , but those family physicians are also gone .Even when the specialist saw the patient , he looked at the entire medical history of the patient . Now a days this has not remain so .It remind me of my residency training days . We had a radiologist who taught us the reading of X-rays . He used to put a chest X-ray on the screen or viewing box , and one of us had to go in front of the class and read it . You are already nervous and not sure about your ability to read a X-ray . I was asked to read one . I saw the X-ray . Did not see anything wrong or abnormal in lungs or heart or any other area .  Then he pointed out to the entire class that the X-ray abnormality . Even though it was a chest X-ray , and there was nothing wrong in the lungs or heart , the X-ray did show the fracture of both humerus . Obviously trying to concentrate on lungs I had missed the 'out side ' bone abnormality, which was as clear as bright Sun . Since then I have tried to see patient in it's entirety, rather than sticking to my speciality .
     The story that I am going to tell is one such story , where I spend more time trying to figure out as to what was happening with the patient , which other consultants had not .
      I saw this 61 years old patient in my office , sent by a cancer doctor . The patient had back pain and was to undergo a back surgery . The routine blood test showed that his white cell count was very high . So he was sent to the blood /cancer doctor . He did CT scans of chest belly , brain and some blood tests . The CT scan of chest showed a nodule and so he was sent to me . Patient had also seen a gastroenterologist for difficulty swallowing . He did the upper and lower endoscopies and told the patient , that nothing was wrong . Did not try to find out as to why he could not swallow . The endoscopy did not show any blockage or tumour , so his job was done . I had noticed some bulge in lower part of the neck . So I mentioned it to patient that we may need to have him see Ear Nose, Throat specialist . He told me he had seen one , who had told him that he 'scraped' his vocal cords and they were OK . He was smoker . He had lost 30 -40 lbs . He was unable to eat , swallow and had some shortness of the breath . His examination was positive for what I originally thought was a mass in the lower right neck . But on further examination , it appeared that the mass was deeper and it was pushing the what could be the right side of the thyroid upward . So the mass that I was seeing was the pushed up thyroid . The lungs were clear . The Ct scan also showed that there was a mass on the right side and it was pushing the thyroid . This mass was about 5 Cm in size and the nodule was 1.5 Cm . The mass was next to the 'hard ware ' that was put in when he had neck surgery . I called several doctors . The first one was the radiologist . He looked at the CT scan and told me the details of the findings , which gave me some idea as to how to proceed and why he was having the swallowing difficulties . Then I called the surgeon who had done the surgery and the gastrienterologist , who had done the endoscopy . He told me that there was no explanation for  his problem . I also called the ENT MD and discussed with him the CT scan finding . I decided to do the PET scan and the bronchoscopy . My thinking was that this smoker may have a small lung cancer , which had spread to the lymph nodes that were so big that they pressed his esophagus or the food pipe and so he could not swallow . I was not sure if it had anything to do with the neck surgery . The PET scan ,which picks up cancer in 85% of the cases . It was positive . The bronchoscopy was OK . So I had radiologist do the biopsy of the neck mass and it showed the cancer .
     I called the radiation oncologist , called the oncologist and the gasroenterologist . He will start radiation , chemotherapy and will need feeding tube to avoid worsening of his swallowing problem in the initial course of the therapy with the radiation therapy .     

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