Multidimensional Challenges in a suspicious case of Lung malignancy and patients uncertainty: What's the solution?

Disclaimer:-

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here February 2017 after collecting informed patient consent (form downloadable Click Here)  by BMJ Elective Student. 

The journey of a patient which is raising multidimensional issues of both diagnostic challenge, therapeutic challenge & patients uncertainty:  

⇒ A 66 years-old-female presented to the emergency department with the complaints of left-sided chest pain for last 3 months which radiates to arm & shoulder and increases with cough. She also complaints of cough & pain in the abdomen & hoarseness of voice. 

⇒ She was admitted in the hospital with the same complaints 6 months back. Her past medical history is significant for hypertension (diagnosed 1 & 1/2 years back), osteoporosis D6, vocal cord palsy.

On examination: 

⇒ On admission, patient was investigated for 

       - Chest X-Ray (P/A & Lateral view), 

       - ECG, '

       - CBC, Urea, Creatinine & Na+, K+.  

Lab investigations results: 

Chest X-Ray (P/A View & Lateral view): 

 

ECG Report:

CECT scan of Thorax:

OLD Reports are: 

2 days after admission :
Mantoux Test & UG guided- diagnostic pleural fluid was aspirated where the reports are as follows:

Fluid for Malignancy:

# Lights criteria met based on the reports which were suggestive of the Exudative nature of the Pleural fluid. Mantoux test didn't show positive results and pleural fluid AFB stain also showed no growth for AFB.

⇒ Then Broncoscopy guided biopsy was scheduled BUT unfortunately biopsy sample couldn't be obtained and report is as follows:

⇒ On discussion with radiologist, they advised that FNAC can be done if  pleural fluid is tapped (USG Guided therapeutic + diagnostic pleural fluid tap) which would decrease the compression on the lung and thus CT guided FNAC/ biopsy from the lung mass can be obtained from the appropriate site.

⇒During the pleural tapping only 180 ml fluid was tapped while patient coughed and procedure was stopped and again tapping couldn't be done and also the CT guided FNAC.

⇒ Whole case was discussed with the patients son and on shared discussion patients son wanted to give a therapeutic trial of antituberculer treatment inspite of understanding that this is a case of suspicious malignancy and planned the discharge as follows:

In the whole scenario, it is seen that with repetitive attempt  for making the diagnosis confirmatory it couldn't be confirmed which raises the multidimensional issues of both diagnostic challenge, therapeutic challenge & patients uncertainty:  

1. What could be the other way for approaching to diagnosis in spite of trying different available modalities?

2. How the problem could be solved for doing FNAC in this case where sample was out of reach?

3. How could we overcome the therapeutic challenge that occurred because diagnosis couldn't be made?

4. How evidence based it is to give therapeutic trial of Anti-tuberculous drug (on patients demand) in an undiagnosed case of suspicious malignancy?

5. What is the effect of the whole challenges to patients uncertainty due to these challenges?