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 !!

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