Sunday, September 4, 2016


     We in medicine have algorithm and diagnostic tree to make decision in case of simple or complicated cases and diseases . So some people are doing 'tele medicine ' . But my problem is that the computer can not diagnoses it nor treat it. The problem that I have is there is more to medicine than just knowing the diagnosis. One needs to know the patient and the family and the other factors. So I am writing this story to tell.
      I saw this 90 years male patient for abnormal chest x-ray. He had quit smoking 54 years ago and had no major problems other than high blood pressure. He was in good health and did not have any shortness of breath. He did have some vague chest pain and so the chest X-ray was done and then it showed abnormality . So the CT scan was ordered and he was sent to me .He was OLD but was completely oriented to and fully with the program. He came with his wife who was in wheel chair. She was also quite well as far as understanding is concerned. The CT scan showed a mass in the right lower lobe of the lung. So I told them the routine 3 questions, Is it Cancer , and has it spread and lastly the treatment options . So I also told them that we will need to do the PET scan to know the 'extent' of the disease , i.e. spread, and will need bronchoscopy and may be needle biopsy to 'know' the tissue type which would help in determining the treatment options . So the surgery was mentioned and I myself was not sure that this 90 years old would be a surgical candidate. But I had to mention it.Both of them of the opinion that he would not be considering the surgery as option of treatment. Then we talked about the chemotherapy and the radiation treatment as other options . We left is at that without making any final decision. I told them on the need for biopsy . At that time the wife asked me if there was an option of 'doing nothing' . Before I could answer the patient turned to her and said , 'why , why would I consider no treatment?No I want to get treatment. 'So we did the bronchoscopy and I did see the tumor. It was blocking the right lower lobe and the middle lobe was also seem to be involved in the tumor process. I did do the biopsy and he had some bleeding though I could control it with epinephrine and saline.  I was reluctant to do more biopsy. The PET scan that was done came back with bad news . He had PET scan that showed the pick up not only in the lung tumor , but also in the lymph nodes in the lungs and in the RIBS and in the bones of pelvis /hip. So essentially not only he was inoperable , but also had 'wide spread ' cancer and the prognosis was not very good.
      The biopsy came as 'possible cancer' but could not state as to exactly where did it come from and overall it was iffy at best. So I called them in the office to discuss as to the further work up ans /or treatment . The options of radiation treatment and or chemotherapy was discussed . For chemo to be given we would have needed more definite tissue diagnosis . So we will have to do a needle biopsy.After telling them the PET scan findings, it was decided that we will go for radiation treatment and do no further biopsies. I made arrangements to see the radiation doctor.
      2 days down the road I got a call from the ER physician that he was in ER with shortness of the breath and the chest X-ray showed a large fluid collection around the right lung. He did have small fluid on PET scan done may be 10 days ago . He was quite bad and I had to do a procedure to take out the fluid that same evening at 6-7pm. When I talked to him about the overall disease and the plan of the treatment ,since he now had one more problem to deal with. He told me to cancel the radiation treatment consult , which was to take place next day. He also wanted to be DNR and was considering HOSPICE.
    All the things that happened in this patient and how the decision was changed on number of occasions can not be done by computer. We might get options of treatment choices but not the definite decision without a physician explaining the options and choices made by patient and the family with the input by doctors.

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