In medicine we have to make decisions . We have to decide what should be or would be next stage in work up. We may know what is the most likely cause or the explanation or the diagnosis, but we have to make sure that the serious diagnosis is not there. And then we do the work up. That brings me to the story for today.
I saw this lady who was a smoker . She had some cough and also clear sputum. She had chest x- ray done and that was abnormal. She them had CT scan of the chest and so she saw me. I saw her and advised her to quit smoking and did additional work up including PET SCAN and breathing test. As expected she had some reduction in lung capacity. She was not born in US and had some history of TB and I thought that the abnormality was most likely due to old TB . But with her smoking I did do the bronchoscopy and that came back OK .She continued to smoke. My plan was to do follow up on CT scan as smoker can develop cancer and sometimes scar cancer can develop in scars . She was lost for follow up.I tried to call her and then sent a letter . She told me that she had lot of copay and so she did not want new scans
But she did come back and then agreed for the follow up on CT scan. 6 months had passed since last CT scan and I was worried as she had continued to smoke . I ordered the scan and she did it and it was abnormal. Now I wanted to do PET scan and she told me she will do it but did not do it for 2-3 months . She was also no show for the follow up. I called and she told me the problem was very copay and promised me that she will do it . She did do the new PET SCAN and that showed some abnormality in the lymph nodes that was not clear cut for old Tb. I was concerned about cancer , though I thought that it was due to old TB . But with the new abnormality seen on PET scan I had to make sure . We did have interventional pulmonary specialist .
The biopsy was done and there was o cancer and it was due to inflammation . I was sure or may be 90 % sure that the abnormality was due to old infection and inflammation, but had to do the biopsy to confirm as she was smoker and the abnormality was little worse.
