Saturday, June 11, 2016


   In medicine we talk about the standard of cars . What may be standard of care in one area may not be standard of care in another area. To give an example referring to a cardiologist may be a standard of care in one area where there may be 10 cardiologist, but in another area there may be none in 100 miles area so to manage on own by a family doctor is OK . Standard of care is what a medical community would do under given circumstances in a particular area or under given situation.So if some one has chest pain , we do work up to rule out heart problem. So today I am telling a story of a patient where we followed the so called standard of care and had more problems .
     I saw this 65 years old female who had some cough. The routine work up was done and her cough got better. but then due to the scare of cancer , she wanted a CR scan of the chest . I have seen patients with normal chest X-ray and abnormal CT scan showing cancer . So I did agree  to do the CT scan.The CT scan was done and it showed some some tiny nodules. The size of the nodule was so small that the usual tests that we do would be not effective in getting diagnosis. The usual test are Bronchoscopy , needle biopsy, PET scan or open biopsy .. With the size of the nodule less than 10 mm we can't do much . Now a days we are doing so many CT scans -almost 1000% more -that we are seeing these nodules and we are stuck with the follow up . I often tell patients that doing a chest X-ray is like looking at the sky at night and say looking at MARS. Doing a CT scan is like seeing the same MARS through powerful telescope. One is bound to see more details.So what is not seen on plain chest X-ray , will be seen on CT scan . So now I have to do follow up CT scan . The criteria which are established -the so called standard of care is to do follow up CT scan based on the size of the nodule . If it is 8 mm , then do CT scan in 3 months , if the nodule is 5 to 8 mm then do in 4 months and if the nodule is less than 5 ,mm then do the CT scan in 6 months . So I continued to do CT scans . Every time I did new CT scan it would show a new nodule and some old would either disappear or would be stable. (This sometimes can occur due to sectioning variation. I must have done follow up for more than 2 years and unfortunately due to new ones , I had to continue doing more CT scan . Again none of them were bi enough to do other tests .
     And then one day I did CT scan and this time it showed lymph node enlargement. So now I was not sure if she had a cancer of the lymph nodes or it was part some disease that was causing the nodules and now the enlarged nodes.I had to call her for discussion and she also came with number of family members . Had no choice but to recommend the biopsy . I did not want the needle biopsy as the sampling size is small and if we do not get 100% diagnosis , we will be stuck again . So I sent her to a chest surgeon .
       The happy ending is there . The biopsy showed SARCOIDOSIS. This is a benign disease and no disease !! 

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