DIFFERENT STROKES FOR DIFFERENT FOLKS

    We have saying that there are different strokes for different folks What I may like or enjoy others may not like or enjoy. But in medicine the computer generated treatment will not be different for 2 patients but will be different based on patient's and their family's choice. I have realized this long time ago and so the medicine is as much a Science as it is Art .That brings me to the story for today. 

  I had seen 2 different patients in my office . One was a 93 years old female who had abnormal CT scan of the chest . She had a nodule . The spot on the lung is called nodule when the size is less that 2 or 2.5 cm - roughly less than an inch. It was may be half an inch in size . She was otherwise doing OK and we decided to do minimal work up. With that size it was difficult to do biopsy if not impossible and  she has no symptoms from it . I did do the PET scan. It showed that there was some activity but not very high . So we decided to do follow up CT scan . She continued to have no complaints . We did do the new ct scan and then another one . At the end of 8 months or so the nodule had grown by may be 3-5 mm  and so after discussion I did new PET SCAN .The PET SCAN this time showed more activity that before . So I had discussion. It most likely was slow growing cancer . The size increase though minor and the increase in PET scan uptake was suggesting that it was slow growing and so we had discussion. I suggested BOT TO DO BIOPSY or surgery ,but do radiation treatment . For a small nodule we can do what is called stereotactic radiation ,which is 5 sessions of radiation and the success rate is vert high for such a cancer . We will not know what type of a cancer it is and so no chemotherapy or immunotherapy will be offered. She did not want chemo or surgery and so the decision was easy. She did very well. 

   I also saw another patient. He was 90 years old and had some dementia . He had some cough and he had CT scan done by his PCP  and that was abnormal and so he came to me .I looked at him and then found out that he had prostate cancer in past and he had several CT scans in past We could find out 2 old Ct scan  and the nodule had grown over period of one year. By chance the new Ct scan report had not bothered to check old scans and so I had to pull them out . I spoke to patient and family. I suggested doing a PET scan and then consider work up if it had increased uptake. They were reluctant for any work up. I was not sure why did they come to me if they did not want any work up. After I had more explanation the daughter agreed for PET scan ,but she was still not sure if they would go ahead with radiation -short course like I did in other patient . So the similar age patents , similar growth in nodule ,but thought process was different . 

UNENDING LEARNING

      I often say that in life ,one should never stop learning. Certainly learning new skill will help prevent dementia  and may be even improve in some patients. Learning new language or musical instrument or even brushing teeth or shaving or combing with different hand ,will help to develop some new connections and that may help . But sometimes doctors and same hold about other fields, people stop learning and then with  doing same thing over and again , they get burnt out or bored. So one has to do same things most of the time ,but always think out side the box, when things don't add up . 

    That brings me to story for today. I saw this female patient fo abnormal chest x- ray / CT scan chest  and shortness of breath. She was a young  lady who had shortness of breath going on for few months and she saw  PCP .He ordered CT scan of the chest and that showed some abnormality. So she was sent to me . The CT scan showed some density in the middle part of chest , called mediastinum  and the radiologist thought that to be related to  THYMUS. The Thymus is a gland which we have till infancy and then it disappears But sometimes we continue to see the remnant of that and sometimes it can grow  and then some patients may have Myasthenia Gravis  and sometimes it becomes cancerous called thymoma. So she was seen by neurologist and he did all sort of different tests  and they came back as OK and she did not have Myasthenia Gravis . I saw her and  and did breathing test and did new CT scan of chest, There was no difference in the soft tissue that was seen on first CT scan done 3 months ago. The breathing test done showed mild Asthma  and I started her on inhaler for that .She had shortness of breath and so we did walk test and her oxygen saturation dropped and I could not explain that . 

   The neurologist had seen her and done more blood tests and did  not find anything wrong and she continued to have shortness of breath. She was sent to a chest surgeon though the thymic tissue had not changed on another scan. She continued to have shortness of breath. The chest surgeon sent her to ne lung specialist in his own group  and he did same tests that I had done . But she saw a different , new neurologist who also specialized in genetic disorders. He felt she had no major neurological problems ,but did do genetic tastings . I spoke to him and he did not feel she has had any problems. But then I got a call from her new primary care physician .He informed me that she had a disease base on genetic testing - called POMPE'S DISEASE 

   I has heard about it but had b=never seen a patient with that diagnosis nor did PCP or the neurologist who diagnosed it . But at least we know the diagnosis.