Saturday, March 8, 2014


   I have often said that the critical thinking is very important in medicine . Again treating cold or respiratory infection ,like bronchitis or pneumonia or sour throat etc does not need much critical thinking .Even computer with enough data can do it . But when the problem is recurrent or more serious , then the critical thinking becomes very important . I often see patients where computer generated medicine is used. (not that doctors use computer to make decision) But our thinking becomes limited as is that of computer.Heart rate is up/more give medicine to reduce it , without trying to find out why is the heart rate is up , and then treat it.The story that I am going to tell today is one such .
    I had seen this patient . She was a smoker and had persistent cough.The usual treatment for the cough did not help. So the doctor ordered the X-ray and it was abnormal . The CT scan was ordered .The patient was referred to me . The CT scan had shown that patient had multiple nodules , almost more than 100. With her history of smoking , I thought that this was most likely a lung cancer, that has spread.. I did a PET scan . As I expected it was positive in lungs . But there was also an uptake in colon. She underwent both a bronchoscopy and a colonoscopy . There was a tumor in her colon and biopsy from that was positive for cancer. The lung biopsy also showed that the cancer in the lung was a spread from the colon cancer .So she had a colon cancer which had spread to lung and there was no lung cancer .
    She was referred to an oncologist and was started on chemotherapy.Within next few months she was admitted to hospital on number of occasions .Sometimes it was due to shortness of breath, sometimes it was due to cough. Due to significant part of her lug being replaced by the cancer she was always short of breath and we could never get rid of her cough. In an attempt to treat it she was put on steroids and was on steroid most of the time . I was trying to reduce the steroids to zero and she would get admitted again. Her last 4 or 5 hospitalization she would come in with cough ,shortness of breath and fever . She wold be started on 3 different antibiotic as she was considered compromised host due to underlying cancer and being on chemotherapy.With repeated use of antibiotics , she developed what is called CDT colitis . The infectious disease consultant was seeing her . So I could not stop the antibiotics. But every time all the cultures were negative. We would reduce the steroids and then discharge her on oral steroids and antibiotics. In the hospital she would have no fever , but always had fever at home .
    I realized as to what was happening.The fever was not due to any infection , but it was due to cancer . So when we stopped the steroids , the fever came back and she was in the hospital. We would give her steroids and it would suppress the fever.The recurrent CDT , colon infection was due to recurrent use of antibiotics , and we could never clear it up as she was obstructed due to colon cancer. I decided to stop all antibiotics except for one for colon infection. and decided to continue steroids at low dose , but not to stop it .This has worked out so far .
    So the knee jerk reaction is give antibiotics whenever there is fever .But critical thinking was to find out if we really needed antibiotics and how can we avoid recurrent colon infection in patient with partial obstruction . 

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