Sunday, November 29, 2020


   We sometimes say 2 steps forward and 1 step backward . But sometimes we have a different situation. We can't seem to go anywhere in life or the situation and we continue to depend upon FEELING rather than the fact. In medicine we often go by statistics or feeling and we do not want to accept it and feel that we are making scientific decision. But if we look at our usual decision in case of any patient's treatment is based on science as much as our feelings. Suppose I see a patient who is smoker  and has cough and blood in sputum and has no fever and has lost some weight, and has chest C- ray showing some spot, we consider cancer as highest possibility  and if that was in India and a nonsmoker  patient and same complaints , we will consider TB as the possible diagnosis as the first one. So we depend upon our experience  and past experience. But sometimes we have patients that has nothing typical and we struggle to decide  and we do tests to get to the bottom of the problem and then after work up are left with same ot more questions than when we started . This is one of those stories. 

   So I saw this 58 years old female who had a cough and the primary care physician had treated with antibiotics  and cough meds  and the cough continued and so she was sent to me , He had done chest X-ray and that had shown some congestion. She had CT scan ordered . The CT scan showed  multiple areas of congestion and she had no fever  and she had some bronchospasm  and some shortness of breath. I did further work up and did treat her with medicines for asthma  and did blood tests to find out the reason for the CT scan abnormality. We did allergy blood tests and also tests for autoimmune disorders like rheumatoid arthritis  and lupus  and also some blood tests for what is called hypersensitivity pneumonia -pneumonia due to allergies  and not infection. We also did breathing tests  and also did follow up CT scan . The scan did not improve  and so I did bronchoscopy and biopsy and that just showed inflammation and not much diagnosis of specific reason for it. So I did try steroids as treatment . I wanted to have her do open lung biopsy. She did see a chest surgeon but did not do the biopsy. After gap of 6 months or more she had COVID infection  and she was hospitalized. She did OK but needed oxygen and then when I saw her in office she had done well. . But the problem continued .So I sent her to the surgeon for the biopsy and she had the biopsy. She called me 7 days after the biopsy asking for my advice as to what to do now . I had not received the report as it was done in a hospital where I don't go. I checked the biopsy report in the computer  and could not make any decision as the pathologist had not given me any specific diagnosis. I called the pathologist  and spoke to him. He told me that it could be any number of things - that has caused the problem and I thought to m myself - I KNEW THAT EVEN BEFORE THE BIOPSY was done. He told me that he has sent the biopsy to Mayo clinic for second opinion  and it should be ready in 3-5 days . 

    I called the patient and told her to see me in 1 week in my office and discuss the diagnosis  and treatment. She came with her daughter . In the mean time I did get the Mayo clinic notes and opinion  and to my disappointment they had about the same opinion as I had before the biopsy was done .' It could be this or that or may be that and that also is possible'- was the report.    


   This is what I called 2 steps forward and 2 steps backward.. Now I have to make CLINICAL DECISION.

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