Sunday, August 27, 2017


   In physics there is uncertainty principle. But I think it applies to medicine more . We expect certain things and at the end of work we get something else . I recently saw some patients and in each of them I was surprised after I did the work up. We always know that when we start working up a patient with certain complaints or problem, we have some idea as to what may be the final diagnosis or the outcome . If we did not have the idea as to what is the likely diagnosis , then we would not have the direction in which to do the work up.This is called the differential diagnosis. In other science it is called hypothesis. But sometimes the out come is so different that even the physician who ordered the tests is surprised.

      This brings me to my first patient . I saw this 70 some years old male patient who moved in from other state. He was told to have pulmonary fibrosis or scars in the lungs . He had some chronic cough and so he was seen by a family doctor and then when the cough persisted , he was sent to a lung specialist. He did the CT scan and then he was told that he had pulmonary fibrosis . He was followed for may be 3 years and then he moved here . He had new family doctor and so with the diagnosis of the fibrosis , he was sent to me . He was fairly stable . He had some cough , but it was not worse and he had some shortness of the breath,but that was stable too. His lungs had some crackles ,which are typical of fibrosis . So they sound like the sound that one would hear when one rubs the hair in 2 fingers . When I asked him on the last CT scan , he was not sure , but certainly it was not done in at least1 year .  Same was about the lung functions. To assess the extent of the fibrosis and it's effect on the lung functions ,I ordered the CT scan and the breathing test.
      The CT scan report came and I was surprised . IT showed the fibrosis , but it also showed a mass in one of the segments of the lung . IT was about the size of a Quarter coin . I called him up and told him about the possibility of the cancer and ordered the PET scan . When the PET SCAN report came I was more surprised . The PET scan showed the lung mass to pick up glucose , suggesting that it most likely was cancer , but it also showed a mass and the pick up in colon. So now we had a question , Is it colon cancer which has spread to lung , or Does he have two separate cancers,one in lung and one in colon . My problem was that he had such a bad lungs due to scar tissues , that doing a needle biopsy would certainly cause collapse of the lung . And in patients with scars , it might not be well tolerated or if tolerated , it might take long time to heal the lung .
      So he is having colonoscopy and bronchoscopy . Then I will decide , based on breathing test as to the treatment options. Should we do resection of colon cancer and the lung cancer , if he has two cancers . Should we do resection of colon cancer and treat the lung cancer with radiation , or should we treat both conservatively  i.e. lung with radiation and colon with laser or something like that where the risk of surgery is avoided .

    The jury is still out .
     But to make my point , when I saw the patient , I did not anticipate all these problems that I was  or he was going to face . I thought I was doing routine work up for patient who had established diagnosis of pulmonary fibrosis. 

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