Saturday, August 6, 2016


   I love stories that have mystery , I also love movies where one can not predict the end .But the problem with these stories is that once we know the end , we can not read it again . There is no fun in reading such story , when we know what is going to happen . The same is true of the movies. In medicine when some one says patient is interesting , it is because we did not know the diagnosis. But sometimes finding the diagnosis is not the end of story. And we don't know what to do .Today I am talking about a mix of these 2 problems .
     I was asked to see a patient for abnormal chest CT scan . I saw this 48 years old patient who came for not feeling good and having black stools. He was a homeless person. He was a smoker 2 packs a day and 18 cans of Beer a day alcoholic . In spite of all this he came because he was not feeling good. The work up was done . It included CT scan of the chest .It showed couple of nodules . So I was called in to see patient . He looked cachectic and so I asked him as to if he had lost weight .Again it would be easy to understand if a homeless person had lost weight. But some one who can smoke 2packs per day and drink 18 cans of beer should not loos weight due to lack of food. He had lost 40lbs of weight. Weight loss is an indicator of cancer in many cases , at least in many patients . So I asked him if he was not eating well. He told me that he could not swallow. The food sticks in throat  was his answer. So I ordered the swallow study and CT scan of the neck. The swallow study showed no problem with the food pipe or esophagus. Son at least he did not have cancer of the esophagus. But the CT scan of the neck was abnormal.
     We called the throat doctor-ENT specialist .I had also decided to look inside the lung -bronchoscopy. He had lung nodules and so I also ordered the PET scan . In PET scan tagged glucose is injected and whole body is scanned to see the uptake of the glucose . The glucose is picked up by every cell in the body and the 'pick up' is higher in cancer cells and inflammation . So it helps the diagnosis of cancer.When I did the bronchoscopy, I saw A MASS INVOLVING THE RIGHT VOCAL CORD AND extending above it . I did not do biopsy as I felt it was too risky to do it with mild sedation. The PET scan did not show any 'pick up' in lung nodules but did show the pick up in throat mass. So I called the ENT surgeon .
    With the vocal cord cancer , radiation treatment can be done . But due to Location of the cancer ,patients usually can not swallow well with radiation, so they need FEEDING TUBE . He would have also needed food like Ensure or BOOST to feed through the feeding tube . He would also need daily transportation to get radiation. So now we are faced as to how to manage this in a homeless man . To add to our trouble the surgeon could not do the biopsy for next 10 days. So if we discharge him we don't know if if he would show up for the follow up and the biopsy.
    So this takes me to my original point . NOW we KNOW the diagnosis , but WHAT NEXT? 

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