Friday, March 27, 2020


      I have talked about the aging population in past. We in medicine  and also in society seeing the older or aging patients. I have at one time seen 3 patients in the hospital who were over 90 years old. So my last one was on over 90 patient. This one is similar to that one , but little more complicated and not as clear cut in some  cases. This is going to be an issue in future  and we will have think deeply.
   I saw this patient almost 93 years old . He had persistent cough and also has been treated with medications like antibiotics  and cough medications . He continued to have cough and he came to me sent by one of my other 89 years old patient. He was nonsmoker and had no fever and no shortness of breath. He had not lost any weight and the cough was there for more than 4-6 weeks. He was comfortable  and came to my office with his girl friend . He came walking in my office  and  he looked much younger than his stated age. He had no memory problem and no major issues other than some circulation problem that he had few years ago . He was on very minimal medications. He had good appetite  and he had no other problems. So I talked to him on common causes of chronic cough in nonsmoker . These are asthma . allergies and re flux of acid from stomach to esophagus.  I ordered a blood test for allergies  and also a chest x- ray  and breathing test to see if he had asthma . I gave him a sample of an inhaler  and then do follow up in 4 weeks .
     He  had blood test  and also the chest x- ray . The X- ray caught me with surprise . It showed that there was a blockage of bronchus  and his lower lobe on one side was collapsed. I did not know what to do - I knew what to do but was stunned due to the possibility in this older nonsmoker patient. I called him and ordered a CT scan  and then bronchoscopy. I was concerned about doing any biopsies if there was amss or a tumor in the bronchial tube blocking it. So I called help from anesthesiologist . The CT scan confirmed that he had a tumor blocking the bronchus. So we did the bronchoscopy with anesthesia . This was the precaution. The bronchoscopy did show the he indeed have a tumor  and that was blocking the main bronchus going to right lung. The appearance was quite smooth and this may be a tumor called CARCINOID . Some people say that carcinoid is benign tumor which sometimes spread  and some say it is cancer that very rarely spreads . In any case this tumor tens to bleed on biopsy  and i did not want to take that chance in this patient . So I did some lavage  and then talked to patient and family .
     The problem is that he has blockage and that will not go away . That is causing cough. If we need to do surgery , we will need to take out entire lung . We may not have enough bronchial tube stump to cut out the entire lung. We do not have the diagnosis.So what can we do in this 93 years old who otherwise is in good health  and looks much younger.
  I have talked to chest surgeon and radiation doctor  and also to patient and done PET scan . We will have to make a decision and it will not be easy. 

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