Sunday, April 28, 2019


     In medicine one does see number patients at the same time  and in sub specialty practice we see similar patient all the time  as there are limited number of common diseases . But even though the diseases are common each patient is different. But there are some differences in the disease process and differently the behavior  and the reaction of each patient.I see this everyday  and sometimes the contrast is so glaring that I have to  write it.
      So I saw this patient several years ago , She was 84 years old  and had severe COPD - damage to lungs due to smoking.She continued to smoke  and then was more short of breath. Then she needed to be on oxygen.Her chest X- ray changed  and she had a nodule  She did not want to do CT scan and was not interested in CT scan . She did not want o quit smoking . She became irregular in follow up and then would miss follow up . We did follow up and she finally agreed to do CT scan and she did have a nodule. She did not want work up and she was not a candidate for open Biopsy or even needle biopsy. She did not want any work up anyway. Over period of time I did not see her and then when I saw her the nodule had grown and she was also older and she had started to be in wheel chair.
She did not want to do CT scan and then when we did it the nodule had become a mass - bigger . Her daughter came in picture  and we had a a talk and we did not do much work up . Then she was admitted to hospital with pneumonia , She was sick and needed more oxygen and she was quite short of breath. and she was worse She had CT scan done  and had pneumonia  and had increase in mass .By now she was 90 years old .  She was very sick and no biopsy could be done as she could not have tolerated even bronchoscopy. She was seen by cancer specialist and they agreed that she was not candidate for much work up and also for much treatment given her dementia , oxygen dependent COPD.
     She was discharged home . We had discussion and she was seen by oncologist  and no further work up was done . She lost some weight and had more dementia . She did not come to see me . The daughter came to me to talk without any formal appointment. When I could not justify signing form to continue oxygen and other medications without seeing in office, she did come . She was cachectic  and she was followed by a group of oncologist and the daughter had taken her to different oncologist and radiation doctors in hope that they would offer her something NEW. They all wanted biopsy as chemotherapy could not be done without knowing exact nature of the cancer-tissue type The oncologist did not offer her any or she did not want any. The daughter walked in my office one day and had CD of CT scan that was done by different group of oncologist and they wanted to do biopsy. So she wanted  my opinion. I told her that I could take CT scan to radiation doctor as the mass was 11 cm now. She wanted to see what I would suggest. The radiation doctor called me and saw her and told her that the biopsy was needed. She was admitted for congestion and we went through the same discussion . She was 92 years , on oxygen all the time , had dementia  and could not walk even 20 feet . The 2 daughters were bedside  and I had my discussion including calling Hospice . One daughter wanted that but the other one that came to my office did not want to make her DNR or hospice  and wanted the biopsy . The biopsy was done  and the pathologist called me.She had CANCER . I talked to the daughter  and she was extremely surprised "Oh NO " she shouted . Now I was surprised . All the doctors she had seen in last 2 years had all told her that she has cancer .So why was the surprised and not willing to accept the inevitable?
       I saw this 73 years old female  and she had CT scan and she had a nodule . 9 mm She was non smoker and so we decided to do follow up on the CT scan. so in 1 year or more it went to 11 mm -increase by 2 mm . Sometimes this kind of variation may be due to sectioning . So I decided to do follow up. She was followed up by PCP  and did not come to me ,But then was admitted to hospital for pneumonia .I saw her ,. She had pneumonia in the same area  as the nodule and so it was difficult to assess  any change in the nodule. She was treated  and discharged. She came to me  and I did chest X- ray and it was improved . I ordered the CT scan and then the follow up. She did not do the CT scan and missed the follow up. The PCP called me  and wanted to to know if I wanted the CT scan or plain chest X- ray and I did CT scan . The Ct scan showed that the pneumonia that she had 6 months ago was gone and the nodule now was 15mm. So I called her and saw her in office . I told her that in roughly 3 years the nodule has grown from 9 mm to 15 mm and it could be very slow growing cancer and we need to do the work up. So I wanted to do PET scan  and Biopsy. I asked her how much active she is .She was working for 4 days a week and on average she was walking 10 miles a day .She had no cough , shortness of breath or weight loss or any complaints.But then she surprised me by saying that 'I am too old - how long I am going to live , is it worth doing all this work up etc'
          So this is 73 years old patient, who is working 4 days a week  and has no shortness of breath and is walking 10 miles a day  and has 15 mm nodule who does not want to do the work up. And the other lady is 92 years old is on oxygen all the time  and has dementia  and has mass of 11 cm  and her daughter wants her to do everything and not even consider DNR status . WHAT MORE PARADOX CAN YOU SEE . 

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