Wednesday, January 1, 2020


   When one goes to college we have various degrees that we get based on the subjects that we learn . So when the subjects are classified as art related we have different teachers  and different degree . So some colleges are art colleges  and some are science colleges  and some are engineering colleges  and some are medical colleges. History or language study are not science  and the Engineering is not a Art . But medicine is Art and Science. Many a times it is science  and may not look like art at all . But most of the time it is both and when we make decisions , we are using ART Part of it  and think based on Science part of the knowledge. Recently I came across some patients  and I had to fall back on art and not much help from science part of medicine.
     I saw this patient in my office who had been seen by me for several years . She has COPD  and she is on oxygen and also has sleep apnea  and some other problems . She was out of town  and then she had some worsening of the shortness of breath. She was short of breath in past and then we had checked the need for oxygen and she needed it  and then when she got better and was feeling good we did another test and she was better and so the oxygen was discontinued .She did have oxygen but she had stopped using it  and when she started feeling bad, she came to me  and we did another test and she was short of breath with walking for 6 minutes.Her oxygen did drop and so she needed the oxygen. In medicine we have to do 6 minute walk test where patient walks for 6 minutes and we monitor oxygen and if the saturation goes down to 88% then patient needs oxygen , So we arranged for new oxygen . We also did additional work up and so I did CT scan of the chest  and it showed some abnormality , there was a nodules or the spot. It was not very solid but , it was there . So I did additional work up. We did new breathing test  and also the bronchoscopy and also a PET SCAN .
     These tests were suppose to make our decision making life easier. The science part of medicine. But it added more questions  and problems . The PET scan picks up cancer in may be 80 % of the cases. The bronchoscopy did not show any tumor  and the tests that I did did not show cancer cells , but the nodule was small and it was much deeper . But the PET scan showed some lymph nodes in chest and also in armpit. Based on these findings , I decided to do couple of things .I sent her to chest surgeon  and My concern was that she may have cancer  and with her COPD  and shortness of breath and need for Oxygen made her difficult patient to cut out part of the lung containing the nodule.I also asked her to see breast surgeon and radiologist to do biopsy of the lymph node in arm pit.
   She did see the chest surgeon and he wanted to do the biopsy and then consider resection of the spot. But then the reports of my bronchoscopy came back , the TB culture can take up to 6 weeks  to be final. She had atypical TB called MAC.In patient with this infection patient can have some uptake on PET scan.. To add to the problem, the lymph node biopsy from armpit did not show much - certainly no cancer. So now we have to make a decision We have patient with COPD  and has limited lung capacity and need for oxygen  and has PET positive spot and also some nodes enlargement and also has MAC . So I have to make decision based on art of medicine  and the science part of medicine - the CT scan the PET SCAN , the bronchoscopy and the biopsy of node etc have not helped yet .
    I am collecting more sputum for TB cultures  and also we have surgeon will do biopsy of the chest lymph nodes  and then decide. 

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