FOLLOWING THE GUIDELINES

         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.