Saturday, July 21, 2018


       In medicine that I learned we had to do first history then physical examination and then do or order tests. Now a days the process is reversed . I still remember when one of the functions that my wife was attending, some one had transient blackout .. some one called 911. The lady was fine , but she was taken to hospital ER . I was in the hospital and my wife called me . So I went t Emergency Room . When I went to ER she was being brought to ER . So I was there from the very beginning . As the patient was brought in the ER , she was taken to one of the room right away. The nurse came in and she  gave her the gown , She checked the blood pressure and the oxygen and started the IV line . Then the tech came in and drew blood . Then the cardiogram was done , Then she was taken to radiology and chest X-ray was done and then the CT scan of the chest was done . I was there all the time . All the time this was done , there was no physician seen or she had seen him/her.
   Since I have access to the medical records, I checked them and the blood tests and the CT scan and the chest X- ray - all were OK . So I told them that the tests were OK . Then came the ER physician .
He asked not more than 2 questions , told me and the family that all the tests were OK and ideally he would put her in for 'observation' for a day . The patient did not want to stay and so she was discharged . No history was taken to see why she had blacked out . The process of HISTORY- PHYSICAL-TESTS - was reversed . The tests were ORDERED based on what was told by ambulance paramedics , then the doctors came in and hardly did the history or physical examination.
     This brings me to the today's story. I saw this patient who was 66 years old female. The reason for the office consult that we were told was abnormal CT scan of the chest . She was a current smoker
and she had CT scan done and it was 'abnormal' So she was sent to me . I asked her as to why was the CT scan done . She had lost 30-35 lbs of weight , So the PCP did CT scan of chest and ABDOMEN- belly and Pelvis. The CT scan of the belly and pelvis was OK . But the CT scan of the chest showed 2 tiny nodules , 2mm and 4 mm . 25 mm make an inch , so they were very very small . So Small that hardly any test would tell us the diagnosis. . So I asked her as to why she has lost weight - is she not eating or she has no appetite or she has problem with swallowing  etc . She told me that she has good appetite , but she throws up every time she eats and she feels that food gets stuck and then when she vomits she gets the relief . . I did further inquiry and then examined her and then told her that I was not concerned about the nodules , but I was concerned about the HISTORY OF vomiting and food getting stuck . I was worried that she may have esophageal cancer .
      I ordered the tests to check the esophageal and told her that she needs to see gastroenterologist ASAP. I told her that the nodules were so small that Bronchoscopy , or PET scan or needle biopsy or open biopsy  were of no use in getting the diagnosis and so we will have to repeat the CT scan in 4-6 months . She had very strong family HISTORY of cancer and Lung cancer and so she wanted me to d beonchscopy .So I ordered it , but also did the X- ray of the esophagus .
    The bronchoscopy was K nd the X- ray of the esophagus showed that it was narrowed at the end and it was not having any contractions . So the food was not MOVING down . So she will need the gastroenetologist to check it out to see what could be done .
      So it was HISTORY that made me ORDER A TEST  and not the other way around .