Saturday, March 9, 2019


    In  past I have always stated that there is a limitation in medicine. I was taught to do physical examination before ordering tests . But even before one could put his hand on patient to examine , we were suppose to take history.Now a days then things have changed  and most of the physicians that I see and meet  do reverse way . They sit at the computer and see the X- ray and the labs  and the 'other notes' and then go to see the patients. Some times there is not much of history or even physical examination . They depend upon  nurse practitioners or ER physicians who in tern depend upon their nurse practitioners .I am still old timer and do my OWN history and physical Examination. But I have realized that the history and physical examinations also has limitations  ans sometimes we get diagnosis with TESTS rather than history or examination .This brings me to today's patient

    I was asked to see this new patient in the hospital . She was 72 years old patient who was having dry cough and so she saw her PCP . he gave her some medicines  and then did chest X- ray and then told her that she has allergies  and she should take some over the counter medicines for allergies . She continued to feel poorly and did see PCP and there was no change in treatment . Then she saw cardiologist as she was  also having some swelling of the feet and shortness of the breath. He gave her some medicines  and was going to do some more tests . But then when she was checking out at front desk , she was noticed to have significant shortness of breath . So she was admitted and I was called in . She had some lung scan done to rule out clots  and that was OK. But she has some fluid around the right lung. So the CT scan was ordered.
   When I saw her she was having dry cough . This was going on for last 2 months . She was getting short of breath for 3-4 weeks . She had worsening edema in legs . She had never smoked  and she had lost some weight , When I asked her about that she told me that she feels 'full'  and so could not eat more . On examination she had reduced air entry on lower part of right lung and she had edema . When I examined her belly , it was obese  and I felt it was 'tight' or firm . I could not feel much  and I did note that in my note . The CT scan showed 2 spots on lungs one on each side  and fair amount of fluid on right side. I told her the possibility of cancer and decided to do the procedure where upon I take out fluid . I took out more than 1000ml of fluid  and I ordered PET scan . The PET SCAN picks up cancer in body . It is about 88 to may be 90 % . The PET scan is done where glucose is injected  and the glucose pick up by cells is recorder . The cancers have higher metabolic rate  and so the cancer cells pick up glucose at much higher rate than the background . Since it is metabolic or biological scan we do not see the structure or the anatomy . So it is accompanied by CT scan . The lung Marses were positive suggestive of cancer. But to my surprise there was big tumour in pelvis  and it was 14 cm  and it was positive . She also had some fluid in belly. She had told me that she had hysterectomy and her ovaries were taken out partially . So it was a shock to me that she had cancer in pelvis . The fluid came back positive for ovarian cancer,

      So in spite of taking adequate history and examination, I did not anticipate the diagnosis . So sometimes one needs to get diagnosis which was not suspected . 

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