EXPECT UNEXPECTED

     In medicine we like  and wish certain things  and the medical judgments are accurate in most patients . But sometimes we know what to expect and wish it is not so  and so the disappointment happens when we get what we expected but were wishing something simpler or something less toxic
Then there are cases where we think of something and get some other thing  and that was unexpected  and may be nicer or may be worse than what we thought it would be . I have seen sometimes patients who come for what looks like simple pneumonia  and then further work up shows that there is wide spread cancer which was not suspected at all.That brings me to to the story of a patient that happened sometimes ago.

     This was a 78 years old male who had smoked for many years  and he had COPD - emphysema  and he was short of breath all the time but used to travel from up north to Florida .He was on oxygen  and he did use it with sleep  and did not like to use it when he walked , though he needed it . When he came to Florida , a bladder cancer was diagnosed  and he had treatment for it  and he was doing good . He has some chest x- ray abnormality in past  and I had done CT scan  and the CT scan was stable. The problem sometimes with these kinds of patients is that due to severely impaired pulmonary status , they are not good candidate for invasive work up. So this time I did regular chest X- ray  and he had some abnormality and so I di CT SCAN of the chest . That showed some problem in the middle part or the lobe on the left and some also on right side . The possibility that a cancer could block a bronchus  and cause the collapse was there . So I decided to do bronchoscopy . I had actually expected a cancer  and did not want to see the cancer as he was not a candidate for surgery and even chemo may not be the best thing . So I did the bronchoscopy and I noticed a growth on his Vocal cords . It looked like cancer . I did not expect that . When I looked inside the bronchial tubes I did not see any obstructing cancer  and so I did some brushings  and washings  and expected that it will be OK .So I did not expect the vocal  cord cancer and he had one  and i expected the cancer in lung and he did not have it . So in a way I was happy  and I told them that we will do new CT scan  and hope that nothing new would pop up. So in 2 weeks or 3 weeks I found out that the lab called me  and he was growing an unusual bacteria on the culture. This was not expected . It was called Nocardia  and needs treatment for 6 months to 1 year with antibiotics  and the usual antibiotic is a combination of sulfa drug - simple one .But he was allergist to sulfa  and so that was added problem . So he had unexpected throat cancer  and no cancer in lungs that I though he had  and he had Nocardia that I did not expect .
      The story has happy ending , his throat cancer was treated with radiation  and he has done well. He has no lung cancer  and his Nocardia seems to to be responding very well  and his bladder cancer is also in remission. 

TALE OF TWO PATIENTS

 
     I have written about the old patients  add the 'Age Old Problem'. But we can not avoid this problem and each one needs different approach . My problem is that in modern day medicine , the hospital doctors  and even many primary care physicians do not have the time .So it it ends up to some of the consultants who tend to spend more time to do things that is sometimes their specialty. I have seen this time  and again and the problems are not same though similar.
    I recently saw 2 different patients Both have passed their 90th birthday . Both had some dementia  and limited mobility and one of them had not gone out of the house for 2 years or so. one of then had some cardiac issues  and also had cardiac issues. He had some lung issues  and had seen lung specialist  and then no new tests were planned . He had heart rate problem and so the cardiologist decided that he needed a pacemaker . So he had a pacemaker inserted  and things went well  But then he had problems with breathing . His oxygen dropped  and he had to be started on oxygen and then he continued to have more and more need for oxygen . So I was called in . Withing a very short time after they called me for consult, lot of things happen . The patient was DNR,not to be put on respirator or had CPR done. But then the family decided to change their mind  and so they put him on  a machine that delivers oxygen with pressure  and he had new chest X- ray and also was given some medications. I had not seen patient and I was called again in less than 15 minutes that the patient did not want the pressurized mask  and the family decided that he will be again DNR  and no machines . But now the problem was that once you resend the DNR  and start the 'life prolonging machine', we can not just stop it. We need to do what is called 'withdrawal of life support.'So we need family / patient to agree  and sign forms  and we need 2 physicians to sign the forms . I came in and saw the patients  and discussed the case with nurse  and cardiologist and also to several family members  and also to patine. They all agreed  and I signed the forms  and changed him to a special oxygen delivery systems.
      So we went back and forth and he was DNR, and then i started him on some medicines . I thought that he had some chronic lung problems  and he may have aspirated - fluid or food going wrong way in to lungs - and we do see that in elderly patients not uncommonly,  and so we started treatments. To make the long story short he continued to do better  and he did recover to his base line level.
     I will talk about the other patient in my next blog.

 

VICIOUS CIRCLE

    I have often used this term and many other use it too. The vicious circle could be in any form. When one likes a particular food - say ice cream, we eat it  and we like it and we love it . So there is an impression after eating ice cream  and then when we are hungry or even when I am nor hungry, but see ice cream, we want to eat it and that leads to action and that again leads to impression  and hat again leads to action.This is vicious circle . But the one that I am talking about today is different one  and we do see it sometimes in medical life. We have seen patients that get in trouble with certain actions  and then get in trouble  and then get better  and get better and they do the same action and then the circle continues.
       This brings me to today's patient. I have known this patient for many years . She has been smoker and she was a nurse . She had diagnosis of COPD  and she continued to smoke . She also had arthritis and she was on pain medications. She had stopped working and she was in hospital few times I saw her few times  and she was treated  and discharged . She was not regular in doing office follow up, but she was in hospital in between and so I continued to do the follow up. She continued to smoke.
      One time she was admitted  and she had pneumonia  and she had significant cough and bronchospasm and she was not getting better and she could not cough up the secretions well. So I did the bronchoscopy . I saw something in the bronchial tubes  and thought that she may have aspirated part of her bridge form partial dentures. But trying to take out was difficult as she had problem with oxygen saturation and also she had significant bronchospasm. I called a surgeon and he did do bronchoscopy with anesthesia, so the respiration could be supported  and he found out that she had beckon pieces on lung. She got better and I did swallow study and she ha some problem and she had some arthritis in neck and that may have caused the problem . The speech therapist told her to see ENT doctor  and then she was discharged .Next few years she continued to smoke  and was readmitted several times and was treated . I had a suspicion that she was having problems due to her continuation of smoking and also respiratory infection and may be aspiration. I did few swallow studies  and she had some abnormality  and the speech therapist and they felt that she had abnormality and not bad to do much . My feeling was that she may do OK and then when she would aspirate that would cause chemical bronchitis.That would cause problem with COPD  and with recurrent problem she had more secretions  and then needed more medications . This caused more damage .But she would not follow up in office  and would not do nay precautions for aspiration .
     Then she was admitted  again  and she did better  and was to be discharged  and she did not have a place to go  and so she was waiting in hospital. And then she had worsening of COPD.  and so I was called  and i knew what had happened She had aspirated !! I did the treatment and also the CT scan and that did confirm that she had aspirated  and developed pneumonia when she was in hospital and the new swallow study did show aspiration. She was told by speech therapist to do certain precautions - not to drink liquids . She did not follow them . I used to see soda in her room  and soft drink cans  and she was drinking them . NO PRECAUTIONS . She improved  and went to rehab . But I am quite sure that she will be back in hospital as she continues to smoke  and has aspiration and does not follow precautions. This is the vicious circle that I was talking about . 

MEDICINE ART OR SCIENCE

   When one goes to college we have various degrees that we get based on the subjects that we learn . So when the subjects are classified as art related we have different teachers  and different degree . So some colleges are art colleges  and some are science colleges  and some are engineering colleges  and some are medical colleges. History or language study are not science  and the Engineering is not a Art . But medicine is Art and Science. Many a times it is science  and may not look like art at all . But most of the time it is both and when we make decisions , we are using ART Part of it  and think based on Science part of the knowledge. Recently I came across some patients  and I had to fall back on art and not much help from science part of medicine.
     I saw this patient in my office who had been seen by me for several years . She has COPD  and she is on oxygen and also has sleep apnea  and some other problems . She was out of town  and then she had some worsening of the shortness of breath. She was short of breath in past and then we had checked the need for oxygen and she needed it  and then when she got better and was feeling good we did another test and she was better and so the oxygen was discontinued .She did have oxygen but she had stopped using it  and when she started feeling bad, she came to me  and we did another test and she was short of breath with walking for 6 minutes.Her oxygen did drop and so she needed the oxygen. In medicine we have to do 6 minute walk test where patient walks for 6 minutes and we monitor oxygen and if the saturation goes down to 88% then patient needs oxygen , So we arranged for new oxygen . We also did additional work up and so I did CT scan of the chest  and it showed some abnormality , there was a nodules or the spot. It was not very solid but , it was there . So I did additional work up. We did new breathing test  and also the bronchoscopy and also a PET SCAN .
     These tests were suppose to make our decision making life easier. The science part of medicine. But it added more questions  and problems . The PET scan picks up cancer in may be 80 % of the cases. The bronchoscopy did not show any tumor  and the tests that I did did not show cancer cells , but the nodule was small and it was much deeper . But the PET scan showed some lymph nodes in chest and also in armpit. Based on these findings , I decided to do couple of things .I sent her to chest surgeon  and My concern was that she may have cancer  and with her COPD  and shortness of breath and need for Oxygen made her difficult patient to cut out part of the lung containing the nodule.I also asked her to see breast surgeon and radiologist to do biopsy of the lymph node in arm pit.
   She did see the chest surgeon and he wanted to do the biopsy and then consider resection of the spot. But then the reports of my bronchoscopy came back , the TB culture can take up to 6 weeks  to be final. She had atypical TB called MAC.In patient with this infection patient can have some uptake on PET scan.. To add to the problem, the lymph node biopsy from armpit did not show much - certainly no cancer. So now we have to make a decision We have patient with COPD  and has limited lung capacity and need for oxygen  and has PET positive spot and also some nodes enlargement and also has MAC . So I have to make decision based on art of medicine  and the science part of medicine - the CT scan the PET SCAN , the bronchoscopy and the biopsy of node etc have not helped yet .
    I am collecting more sputum for TB cultures  and also we have surgeon will do biopsy of the chest lymph nodes  and then decide. 

LOOK AND YOU WILL SEE

    When my children were young and could not find out their books or note books or a shirt or something, my wife would go and find it in less than a minute. Her comment would be 'If you look for it you will find it . But I think it is same thing when I am looking for something in kitchen cabinets. If I can not find it , she can find it in seconds. Again the statement is if you look for it you will see it. I have seen this medicine and I have used a line (borrowed from someone),Your eyes don't see what your mind does not see.But sometimes I wonder if it is 'Not thinking ' or 'not looking'.This brings me to today's story.
     I saw this patient for shortness of breath. She was 77 years old female who had some shortness of breath and it was not bad . But the further work up was done by cardiologist and she had not seen lung specialist . She was told to have aortic valve problem and so she was sent to cardiac surgeon and she had surgery . She had chest x- ray and ultrasound of the heart and cardiac catheterization to make sure that she did not have any blockage in coronary arteries. She had new technique for the surgery.She did very well. In this type of surgery the chest is not opened  and it is minimally invasive  and so she did well. She had some shortness of breath and she saw primary care MD  and then she felt she will recover in some time and she did . She was better.
   In next to few months , she again started having some shortness of breath. She was seeing the cardiologist who told her that her heart was OK.She was tried on some inhalers for possible asthma.She felt little better  and this was continued . But she still did not feel that she was cured.So the Primary care MD sent her to me . She had chest X- ray and that was clear and we did new breathing test .That was almost normal but one could make  a case for mild asthma based on certain numbers or values on it .So I started her on  different inhaler which had 2 drugs  and also a nebuliser
treatment at home . She came to see me couple of more times . I was trying to get some information from cardiologist  and the only ultrasound -or echo cardiogram I could find was one that was done before the surgery for aortic valve.I talked to her  and she saw the cardiologist on follow up and she was again told that she was fine as far as her heart was concerned . I was not much convinced that she had bad asthma, as the cause of her breathing problem.I was concerned about cardiac etiology of her.But with cardiologist doing the follow up I had to do lung work up. But when I could not find any 'cardiac tests' from cardiologist , I decided to do new cardiac  tests. I did call the cardiologist and ordered new echo cardiogram. It showed that she had  different valve which was leaky and the pressure in the lung blood vessels was increased- may be related to the leaky valve . Her old test had shown the pressure was elevated. So the problem was the HEART and the elevated pressure in lung circuit.
    I started her on some treatment and told her to have cardiologist do new cardiac cathetarization. we can treat the pressure with different medications but they would need actual pressure from heart catheterization  . 

ONE AND MANY

   In medicine we were taught that when you see a patient, try to have ONE diagnosis to explain the problem or the symptoms.So we were allowed to develop differential diagnosis.So each one should be in position to explain as many symptoms as possible with each diagnosis. That does not mean that there is only one condition but this habit tends to make thought process such that one tends to know as many symptoms as possible.of each disease. This brings me to the patient that I was going to tell you about .
     I saw this patient as semi emergency. She was admitted with some nausea and she had no fever . she has not sob but she had some vague chest pain with exertion . so she was worked up . The chest X- ray was normal.She had history of high blood pressure and had coronary artery disease  and so she had work up done too. She was thought to have coronary artery disease, She also had some diagnosis of scleroderma.She had cardiac cauterization   and she had blockage  and so she had stent done The cardiologist called me as her oxygen level was low when he started the procedure  and it continued to be low .

      She looked OK from his standpoint and the procedure went well  and she had no complications.But since  her oxygen was low he called me . I talked to nurse  and then I saw her few hours after the procedure.She looked comfortable  and did not feel short of breath.But she had rales or congestion in the lungs on physical examination. I had ordered the Chest X-ray and that had shown congestion and that was not there in the chest X- ray that was done 2 days ago. I had also ordered the blood test for the congestive heart failure  and that was quite high, Normal is 800 and hers was 15000.She had denied  any problem with swallowing. She had echocardiolgram- ultra sound of the heart  and that had shown to be normal . So I was not sure why would she had congestive heart failure . But when I heard that she also had scleroderma , I also thought about the abnormality in esophagus that can cause aspiration. As I mentioned we try to or we should try to have ONE diagnosis as the explanation. But she was on lot of oxygen  and I had to treat her . So I decided to treat for BOTH the congestive heart failure and aspiration I started her on water pill to treat water in lungs and also antibiotics  and steroids for possible aspiration pneumonia .
      I saw her next day and I had done new chest X- ray . She was doing much better  and her oxygen need was much lower  and the X- ray was not clear but was better. So she had both-Aspiration  and Congestive heart failure .
       By the way no one had mentioned scleroderma in their notes! .                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

BACK TO THE SQUARE ONE

      The phrase of 'back to the square one' is very commonly used when we do something as a plan  and that does not work . This probably came from one of the board games  may be chutes  and ladder  when we are going to the higher squares  and suddenly we find our-self going down due to chute. The same things happen when someone is trying to solve the criminal case and the clues lead us to dead end  and then we are back to original level. The same thing happens in medicine , but not often. This brings me to the present story.
      I saw this lady for shortness of the breath. She had smoked  and had diagnosis of COPD  and in past she had lung cancer diagnosed  and she had treatment for it She also had breast cancer  and she had surgery and she was cured. I saw her  and did  act scan  and also breathing test and started her on oxygen. She was started on medicines for the COPD  and then the CT scan showed tiny nodule. I told her that we will need to do the follow up fort the nodule  and it was too small for the further work up to know the diagnosis. Doing bronchoscopy , or doing needle biopsy or doing PET  scan or asking surgeon open biopsy were not options as they would not have given the diagnosis. So we decided to do the follow up . I continued to see her for next year and we did couple of CT scans  and they did not show any any change or growth . She did not come to me for follow up a year. Then she  had shortness of breath and she was hospitalized.I was asked to see her . She was very sick and she had to be in ICU for short time  and even after getting out of ICU. She had new CT scan done  and that was abnormal . The nodule that we had seen was same but she had new 'mass' in rt middle part . She was not in very good shape for biopsy and so we did PET scan  and that did show that the mass was likely to be cancerous -had increased uptake of the glucose.She was never a candidate for the resection  as she had advanced COPD and the location was such that she could not have had resection or entire lung and then also she would not have been cured. I did do bronchoscopy  and I had to get help from anesthesiologist and she did OK . I did see narrowing of the middle part of the right lung and i though that she may have external pressure from cancer or it may be narrowed due to cancer itself. I did do the biopsy and other things  and they came back with 'atypical cells but not conclusive for cancer.
      She was getting better  and i told her that we need new biopsy but she needs to be better  and so after 2 weeks i had do EBUS - biopsy with help of ultrasound , This was done and they came showing no cancer . I knew the CT scan , I knew the PET SCAN  and i also knew her history. She had 2 different cancers  and she also had OXYGEN dependent COPD.So now what I can I do to get to the diagnosis? As you can see every time we did a test thinking that we will get the diagnosis we were back to the square one.
     So I had a surgeon to review her scans  and he called me stating that the situation was very difficult, but he felt that he could do some biopsies  and get the diagnosis. He saw her and did a procedure called Mediastinoscopy  and biopsies came back showing no cancer. So he did see her again and did biopsies through chest  and they also came OK. So she came back to me  and she was hurting from the surgery and we had no diagnosis. I asked radiation doctor to see her and see if they can do radiation WITHOUT the tissue diagnosis of cancer. They were not very happy to do such a treatment without the proof for cancer . This is not like giving antibiotics.
     So I decided to do new CT scan in 3 mo this The month before she was to have new CT scan done she was in hospital  and I saw her . She had developed fluid collection around the lung - same side as was the mass. I did new CT scan  and that did show the fluid  and also that the mass has increased. So there was no question that she had cancer . But we had no proof. So I called the same surgeon  and told him the situation . I was concerned that she had fluid due to cancer and just taking it out once may not be enough.She was also on blood thinner . So I asked the surgeon to do the  catheter insertion to drain the fluid  and do some additional biopsies.
    He did do the catheter and did  not do he biopsies .The fluid was sent for cancer cells  and they came back as No cancer . So we were back to square one - same place that we started after  5 procedures to get the answer. So now I  again called the radiation doctor and asked if they could do radiation without the diagnosis OF CANCER..
   This time they agreed  and she got the radiation therapy without tissue diagnose of the CANCER .