MEDICAL DILEMMA

       In medical practice, we see different types of patients . Some that want medicines and others who are reluctant to take medicine. Some want every test in the world and others don't want any tests - including ones that could help diagnose and treat the element. One of the problem that I face is that if the medicines are not taken at right time then the disease could progress. But we do  not have clear cut understanding as who will will get worse and who will be OK. Certainly high blood pressure , diabetes and cancer are exception and I am sure there are many others conditions including  infection. But one infection is such that we have some variation. That brings me to story for today. 

    The MAC or Atypical Mycobacterial Infection ,also called Mycobacterial Avium is one such. I have seen many patients and some are old and some are young. This is  a chronic infection and may present as cough , abnormal CT scan of chest or may have additional complaints .Recently came across few patients , that taught me that we have a CLINICAL CHOICE . 

    I have seen 2 patients both over 80 years of age now who had MAC. One had it more than 5-7 years ago and we treated it . The treatment is for 18 months with 3 drugs and many do  not like it. This lady continued to have problem and we treated her. Then a new medicine came in and we added that and she was cured. She had no new pulmonary complaints and she seems to be doing OK But after a gap of no treatment for more than a year she had some more cough and so I did do CT scan and then sputum check and she had recurrence of the MAC. I talked to her and started her on medicines. But within a month or two , she called me and told me that she has decided to stop it and just want to see what happens . We have talked to her on dangers of not taking medicines , and then continued to do follow up. In next 18 months , she had no problem and continues to have no worsening of CT scan and no positive sputum cultures. The same thing has happened to one of my other patient . She had MAC and abnormal CT scan and we did try treatment and she could not take medicines as she felt miserable .So after 8 months of treatment she stopped it. We have followed her for 2 plus years  and initially the Ct scan was worse , but in spite of no treatment, the CT scan was stable or may be little better. She has stable weight and we have not done any treatment. 

  The contrast to that we have a young lady who had abnormal CT scan and then diagnosed as MAC and treated her. After 3-4 months she had  positive sputum and so we added 4th drug and she did well and we could stop medicines after 18-20 months of treatment and she did good for 1 year . She had low weight and new scan showed worsening  and so we wanted  to start medicines and she did not want. So after 6 months of observation , we did testing and she agreed to start medicines.

   So in the older patients no medicines has worked so far , but in some other younger patients it has not .

VITAL SIGNS

     In medicine we  have something called vital signs . These include pulse rate ,blood pressure ,temperature and respiratory rate. These are recorded in every patient - in out patient settings and also in ER and in patients setting  or hospitalized patients . The reason these are called Vital Signs , as they tell us about any  disease that needs immediate  treatment. If the Blood Pressure is high or low , it needs treatment and same with temperature - fever or hypothermia  and so on. In an average day in office - clinic , we do not have major issues with anything that needs emergency treatment related to Vital Sings abnormality. Certainly if Blood Pressure is very high we treat it and of someone has fever we treat it . This brings me to the story of this patient for today.

    I had seen this patient few times . He had abnormal CT scan of the chest and after doing the work up , we had done bronchoscopy , PET scan and breathing test and determined that he needed surgery and he had under gone surgery to take out part of the lung that had the growth. It was not a cancer . But we had done follow up CT scan as he was ex-smoker .This time he came to me and had a CT scan that was good , no abnormality was seen. But when I checked his pulse and oxygen saturation , the pulse was 33pwe min. This is very low heart rate - pulse rate . The Blood Pressure was normal , He had no shortness of breath or chest pain . He was not feeling dizzy He felt 'fine'. I checked hos pulse and heart rate to make sure that it was low. I tried to call his cardiologist and could not get anyone to call me . So I called his primary care and told him to see him ASAP. I was concerned that he would need to be admitted or may need pacemaker. 

   The patient and his wife were not very happy as 'he is fine '. I insisted that he goes to his primary doctor NOW . I also called him and he agreed to see him. He was seen and had HEART BLOCK , which means his electric circuit in heart was broken. He was sent to ER and he needed pacemaker . He was ot very happy and initially refused to have pacemaker ,but I called his wife and then he agreed  to have pacemaker. 

      The Vital signs are recorder thousands of time in office and this is one of those rare examples where they proved to be VITAL  and save life .  

WRONG TEST BUT RIGHT ANSWER

        I have seen in medicine, a test is done and then something that we did not anticipate comes out and then we don't know what to do. I remember ,when I was doing internship, I had done a cardiac test and that came back abnormal and I asked my attending cardiologist as to how to explain the result, he answered 'I would not have done the test and so I don't have to give explanation. But this time it was different. That brings me to my story for the patient.

    I have known this patient for few years . He had sleep apnea and he has been on CPAP and had done well. He had some weight loss but nothing major. He also had some other issues but they were stable. He had no major medical problems and so many a times out talks used to be things other than medical problems. He needed new primary doctor and I had suggested a name and he went to him and was very happy. He had seen me and I had told him to get routine chest x- ray as I like chest x- ray once a year . He had quit smoking may be 25years ago. He had some asthma and I had treated him for bronchitis in past and so I had told him to do x- ray.

    He called me one day . He had my cell phone number. So he texted me that he had seen Primary care physician and he was complaining of right sided chest pain. He was seen by PCP and they ordered a CT scan of chest pain. The CT scan showed LEFT UPPER LUNG MASS .So the pain was on the right side and the CT scan showed mass on left and that does nit explain the pain . But the liver ,which is in belly and on right side showed masses. Now that would explain the pain on RIGHT SIDE. So the patient was sent to cancer doctor - oncologist. The oncologist is the physician who treats CANCER with chemotherapy. But there must be CONFIRMED DIAGNOSIS OF CANCER to treat with chemotherapy. Without a tissue diagnosis , this doctor cannot do any treatment. The oncologist ordered PET SCAN and wanted radiologist to do biopsy . The patient  called me as the oncologist wanted MRI of the Liver. He was frustrated a little bit and so he called me 

   I got hold of the PET SCAN pictures and took it personally to interventional radiologist. He agreed to do the biopsy ,and did not feel that MRI of liver was needed. The biopsy was done and it showed NOT A LUNG CANCER, but showed COLON cancer , which had spread to liver and lungs . 

     So, the pain that he had MAY HAVE BEEN due to liver metastasis, or could be something else But a CT scan of CHEST was ordered and that showed  Lung masses on RIGHT ,. The discovery of lung masses and liver metastasis was accidental.

     

EVERY GOOD THING HAS TO COME TO END

      I have talked about  many of may patient without  disclosing any identity, Sometimes i have to change their age , sex and other part of the story , keeping intact the core of medical story intact. I also talk about things that have happed in distant past and not current. I have seen patients that have defied the medical odds.. So I am going to tell you couple of stories when the GOOD THING did come to end . 

     I had seen this patient several years ago . After a simple gall bladder surgery, she could not come off respirator. I was called in and I checked her and then consulted a neurologist as I felt that her lungs were fine and the problem was in her respiratory muscles. The neurologist saw her and did not feel there was any neurological cause and told me that it was my problem. I called the surgeon and asked him to do muscle biopsy and the biopsy showed that she had a very rare form of myopathy. She remained on respirator for fo years to come. Over period of time she did get worse and needed feeding tube and became bed bound. Every time I talked to her , she had to write her answer as she had tracheostomy and she would write the number of years that she was seeing me . After 34 plus years , when she was admitted to ICU with pneumonia, she requested me to be disconnected from the respirator. After long discussion, she was she was taken off the respirator and passed away peacefully. ALL GOOD THINGS MUST COME TO END. 

I will tell ypu about couple of my other patients next time. 

RIGHT AND WRONG OR NEITHER

   In medicine we have situations where WE feel most of the time ,things are right or wrong. If I see a patient with blood pressure is elevated, I think it is RIGHT TO TREAT WITH MEDICINES. It is NEVER RIGHT not to treat high blood pressure. The same is true of elevated blood sugars and pneumonia and asthma and so on. But sometimes a good doctor and good patient can make decision which are different, but they both could be right. This brings me to case for today. 

   I had seen this patient 88 years of age , who had quit smoking many years ago . She had no major complaints , but had some cough and so her primary doctor did chest x- ray and then send her to me 

     She had work up and we did CT scan chest and that showed a nodule . The nodule was not the cause of her cough, but I had to do the work up . So we suggested doing a PET scan and a bronchoscopy. The PET scan showed that there was some uptake of the glucose in that nodule , but not very high. So the possibility of cancer was low though not zero. We discussed the situation. We could do a needle biopsy or a navigational bronchoscopy and biopsy or open biopsy - the open biopsy would be 100 % . She did  not want any invasive procedure. So we decided to do new scan in 3 months . 

    She did new scan in 3 months and that showed that the mass was same size .She had refused any additional invasive procedures , and the nodule had not grown, we decided to do new scan in 3-4 months. I did new scan, and she came for the follow up. The nodule had grown Now I had a problem . A slow growing cancer may have low uptake on PET scan as the metabolism of cells is not very high compared to normal cells .The growth means there was most likely a slow growing cancer. So we again had the same discussion- do a needle biopsy . do navigational bronchoscopy or do nothing. This time I had one additional suggestion . The lady and her family did not want any biopsy and so I suggested asking radiation doctor and see if based on the growth and PET SCAN if they could treat it as cancer WITHOUT BIOPSY. 

   So Doing nothing could be RIGHT, Doing biopsy also could be right and doing radiation WITHOUT BIOSY  is also right. 

MALINGERING OR REAL

      In medical practice sometimes we see patients that have symptoms but we cannot find the reason for that and then we do the work up and no etiology is found . Sometimes the cause is obvious but may not be easy to be acceptable for the patient. e.g. shortness of breath in someone who is obese and has not done any exercise in several tears . I used to do a pulmonary stress tests that actually had a diagnosis of 'deconditioning'. But sometimes the symptoms are unusual and can be missed as the presentation is not typical. But I often say a YOUR EYES CAN'T SEE WHAT YOUR MIND DOES NNOT THINK.' That brings to my story for today. 

     I was asked to see a patient who was a nurse .  She had some episodes of dizziness and some vertigo . I am not sure exactly what was it but while working she had to sit down and then she would get better in short time . She worked in ICU. One episode was rather severe and she was admitted in ICU itself . The neurologist and cardiologist saw her and did tests and the CT scan of the brain was ok The cardiac work up was also normal. So there was no cause for her symptom found out. This story is from may be 25 years ago.The admitting physician called me to see her . I am not sure why me as I am a lung specialist and there was no lung problem as such. The day that she was to be discharged she had an episode of severe vertigo and so the discharge was held and I was called .I was going to see her and I got a call from the Medical director of her insurance. He was ex oncologist and he knew me . He called me and stated that 'See what you can do - I don't think anything is going on, Get her out quickly.'

     I went to see her in ICU. She was 44 years old female who had no major medical issues . She had some childhood trauma - mistreatment  by her father. She had been diagnosed to have mild high blood pressure and was on medications and all the readings were normal. I talked to the nurse taking care of her . When I went in the ICU , the nurse told me that that morning she was fine and then she had the 'attack' where she was having severe vertigo and felt dizzy and was in bed and did not want to move even in bed as it made her symptoms worse .I went in her room and she was calm and lying in bed comfortably. I looked at the monitor. Her heart rate was 55 and her blood pressure was normal . What struck was her respiratory rate was 4. Normal heart rate is 70 to 100. But I have seen heart rate of 55 in normal people . But normal respiratory rate is 12 and her rate was 4 . THIS WAS VERY UNUSUAL . I have known people who can go in mediation and drop heart rate but never seen low respiratory rate. Due to stimulation of respiratory  centers by lack of oxygen and build up of carbon dioxide one can not reduce respiratory rate. I spoke to her and there was nothing new and her examination was normal. I did not know what to make of her low respiratory rate . She did have some headaches. AND IT STRUCK ME. Could she have something to do with centers for respiration-like what used to be called VERTEBRO BASILER MIGRAIN -now called Migraine with brainstem aura. The neurologist had seen her and  told her that there was nothing he can do. I decided to call Mayo Clinic. I got the number from  case manager  and called Mayo clinic neurology department. I am not sure how this can happen but I got to speak to head of the neurology. I explained him the presentation and my thought process. He agreed with my thought process and told me to do new EEG.I started her on vasodilator and her symptoms improved and she was discharged home . Her vertigo and dizziness had gone down to almost zero. 

I AM LOST

    I AM LOST !I have been in medical practice for many years and I often see things that rea not that common and sometimes I am surprised . But sometimes we have a patient that defies all odds . When it happens to be a patient who has say inoperable - wide spread cancer ,that we think will not make 6 months mark with or without treatment, and then something happens and  patient is cured , we are happy. Though in that case we also have surprise - uncommon - unusual outcome. But since the 'ending' is happy' we are happy and no one questions success. Then we have patient in whom the pendulum swings on the other side, when we expect patient to either not have a cancer or cancer that looks like can be cured  and then either it turns out to be cancer or shows spread etc, then we are more stunned. That brings me to the story for today. As always 

    I saw this young lady, who had abnormal CT chest . She was nonsmoker and had h/o positive skin test for TB , Positive test means she was exposed to TB and so the body reacts and has positive skin test . It does not mean one has TB now. She had never smoked and she had minimal cough and no other complaints. The Ct scan did show a small  nodule -less than an inch. She had no old CT scan to know if this was new or old .Since she had exposure to TB, it could have been related to TB . But I did the work up. I did order PET scan , In PET scan glucose uptake is measured and in cancers the uptake is high , as the metabolic activity of the cancer cells is higher that normal cells. The PET scan showed minimal activity. I also did bronchoscopy and that showed no TB or mold. The nodule was too small for me to do any biopsy and I did do brushing and washings and that came back no cancer but showed chronic inflammatory cells. I  decided to do follow up on CT scan in 6 months. The CT scan was done and showed no change in the nodule. But I decided to send her to interventional lung specialist . Since there was no change in nodule they decided to do a new scan. The new one was done in 2 months . It showed no change in 8 months. Normally the cancer will grow and her we have a patient who has never smoked and has history of exposure to TB and bronchoscopy showing inflammatory cell .I do not know the reasoning behind doing a navigational bronchoscopy where a computer helps getting to the nodule . But it was done by the interventional lung specialist . The biopsy showed SHE HAS LUNG CANCER . 

      So a nonsmoker patient , who has no change in nodule in 8 months , no uptake on PET scan and inflammatory cells on first bronchoscopy - defies all odds of being BENIGN and has cancer . That is heart breaking.