Saturday, May 27, 2017


         In my last blog I talked about the guidelines that are given by the medical society and the insurance companies and the Medicare. but then I realize that even when one follows the guidelines , there is no guaranty  that we can succeed . I have seen this in many cases and the today's story is one of the similar one.
          I saw this 80 years old patient with cough .He had the cough for few months and so the usual tests were done by the family doctor. The chest X- ray was OK and the antibiotics and the other medicines did not help. So he came to me. I was treating his wife for several years and so I knew the patient though not as patient., He was not a smoker and the lungs sounded clear. He had normal chest X-ray and the lungs sounded clear.I ordered the pulmonary function tests  and it was OK There was minor abnormality that could go for the mild asthma.So I tried the medicines for the asthma. It did not help.. He gave me the history that the cough was getting worse with the eating and drinking water. So I suspected aspiration , which means that the liquids or the solids would be going in the lungs rather than the food pipe. So this causes chemical irritation. and that leads to the chronic cough. So I did the swallow study and it did confirm the aspiration . But the speech therapist gave him some instructions.

      The cough was better but was not gone. He had  follow up chest X-ray and it was OK. I had done the CT scan before and it was OK. He continued to me for next couple of months and then stop coming as he  was OK.
        I did not see him for just over a year. He was followed by the family doctor. But then he started loosing the weight. His appetite was down and he had lost weight. So the family doctor did the work up. He had CAT scan of the belly. The CT scan did not show any abnormality in the belly. But it showed mass in the lung .So he came to me . I did the CT scan and then the PET scan as the CT scan showed mass in the lung. The CT scan showed 8 cm size mass. I did the bronchoscopy and it showed lung cancer blocking the left lower bronchus.

    He was referred to radiation doctor for the treatment .
    So the mass that was not seen 14 months ago was now 8 cm .So even if he had chest X- ray done in a years , the cancer would have been diagnosed 2 months ago. But certainly not soon enough to be small enough for resection. (With his age and other issues , he was not surgical candidate. But he was younger still it might have been not the earliest stage .So following  the guidelines of doing X-ray would not have been enough.

Saturday, May 6, 2017


       When ever I read the Guide lines on work up or the treatment of a symptom or the disease, I often wonder as to what about people that fall out side the NORMS, or 'usual'. So a particular symptom is seen in say 90 % of the patient with a diagnosis, what about the 10 %. So I know that the working for rare causes may be expensive and time consuming. But what about the standard things that are not 'required' , but is a good idea.  But in the modern day practice of the medicine , we are more controlled by the insurance companies, and hospitals, and medical associations and the government rather than by what is good f fro the patient. So sometimes when I see some patients ,I often question as to the 'cook book medicine'. This brings me to the today's story.

        I saw this male patient in my office. He was a 70 years old male , who had smokes for several years . he has some chronic cough and also had some weight loss. He had worsening of the cough and was treated with usual medicines . I asked him if he got short of breath with activity. This is to assess the lung capacity as he was smoker. He told me that since his arthritis got worse in last 3 or 4 months , he has not been walking. He had hip pain and was treated for the arthritis.  He did not get much better and so then had chest X-ray done . The chest X-ray was abnormal and so then he was ordered to have chest CT scan and then he was referred to me.
       The CT scan showed what looked like a lung cancer . So he came to me . I had chat with him and the family. I told them that we have to answer 3 questions , Is it cancer , Has it spread and What can be done IE what is the treatment choice. I ordered the PET scan and decided to do the bronchoscopy. The PET scan showed that he had positive pick up in the lung mass , but it also showed that there was pick up in adrenal and bones, especially in the pelvic bone and the hip bone , where he was having severe pain .
     So this man had chronic cough and he was smoker and has had no chest X-ray done in last 5 years. I am not saying that the chest X-ray would have Dx lung cancer earlier. But one thing for sure , I tend to do chest X- ray in every smoker and ex smoker every year. This I have done before the new 'Guidelines' came out to do low dose radiation CT scan of chest for high risk patients. But it is not a requirement for the HMO,Quality of care . So most the patients get cholesterol and blood sugar check up and the mammograms done , but not chest X- ray. So hopefully we will be doing the chest X-ray if not CT scans.
    Guidelines are good but when we do only COOK BOOK MEDICINE , we don't do as well !!