Sunday, May 31, 2020


    In medicine we are often faced with diagnostic dilemma.We see patients  and many are simple  and routine . But then we come across some of the patients,that trigger our thought process and puts our medical knowledge to test. We do more tests  and also do some explanations  and try to get to the diagnosis . But sometimes I wonder if it really matters in certain cases. I have heard that there a professor in NY that seeks advice from allover world in case of very unusual cases  and then she is able to help get the diagnosis. But I am not talking about that kind of diagnostic problem. I am talking about something else.We may do tests  and find out something that may give us the diagnosis  and there may be no answer as far as treatment is concerned or may not make difference in out come or life.
    This brings me to the today's case. I saw this lady in my office may be 8 months ago. She was a 68 years old female who was smoker  and was admitted with shortness of breath and then was diagnosed to have pneumonia . The work up was done with CT scan and then bronchoscopy and that showed that she had COPD  and also cancer of the lung.. The further work up was done  and she had spread of the lung cancer to bones  and her left hip was affected . She saw me  on office after the discharge . I don't recollect why she came to me  and not do the follow up with the lung specialist who did see her in the hospital. But any way I did not have much to do . She did breathing test in my office  and I started her on some inhaler for COPD.I had extensive discussion with her son and her  and told them that she will need Radiation treatment to the hip for cancer spread as otherwise she might get fracture  and pain . She had been seen by oncologist and she had not seen radiation doctor  and I managed to get that done . So she was treated by oncologist and also radiation  doctor  and she was treated with chemotherapy and radiation to lungs  and also to hip.
   I saw her in office may be 2 more times  and then she was admitted to hospital for pain in the leg and hip . So she was seen by me in the hospital. She had a blood clot in the left leg  and she had further work up by oncologist and she has fracture of hip. Just to mention here the incidence of blood clot is much higher in patient with any kind of cancer. and that is due to blood clotting too quickly in patients with cancer.So she had clot and we started her on treatment for it . During the work up she was found to have mass in kidney. As per report the the mass was there in past and the oncologist was aware of it . But the mass had grown to much larger size in spite of treatment for lung cancer and so the possibility of kidney cancer was there . She had hip fracture  and clot in the same leg . So the oncologist ordered the biopsy of the bone . This was the same area that had shown spread of cancer in previous tests but it was not confirmed by biopsy. It was also the same area where the radiation was given . The biopsy was done  and that came back with 'no diagnosis' .
      So now we have this patient who has lung cancer  and spread to bones  and had treatment with chemo and radiation  and also now has enlarging kidney mass  and fracture of hip due t cancer and clot in leg due to cancer  and immobility and also has new mass in lungs  and has COPD. Due to the previous radiation to hip we are very limited in giving her more radiation to the hip , so she can not do much or any walking  and we still do not have the diagnosis of kidney mass .
    But does it really matter on long term prognosis ? We could do biopsy of kidney though we do not do it normally due to fear of spread of spread with biopsy . She has new lung abnormality and also rest of the problems - and all of this in spite of the treatment with chemo. and radiation . So it appears that the prognosis is poor even if we get diagnosis of second cancer - that of kidney  and or spread of lung cancer  and the quality is poor as she can not walk due to pain and fracture  and our options of treatment of the fracture are very limited due to previous radiation given to the same area.
   DOE IT REALLY MATTER weather we get the diagnosis or not ?

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