Saturday, September 22, 2018

HOW AND WHY IN MEDICINE

       In medicine we often asked the question as to how does someone get cancer and why does this happens . The common diseases like high blood pressure or diabetes , no one asks this question . In pneumonia or Tuberculosis , we know the answer of how , but not why . One can say in case of Diabetes , that the insulin lack causes the diabetes , But we do not have the answer to 'why' . In high blood pressure we do not have any answer as to how and why . In case of cancer  we know NOTHING . We do have bits and pieces on to how cancer develops . We know that chronic irritation or tobacco increases the 'chance ' of getting cancer . But we still don't have the answer as to how and why . But today I am talking about a patient where there is how and why , but in a different way .

      I saw this patient who was 68 years old and had some cough and then the primary care physician did the chest X -rat and then the CT scan , The CT scan showed a nodule . He was a nonsmoker . He had history of prostate cancer and it was treated and 'cured ' He also had tonsillar cancer and it was treated and he was 'cured ' He was not a smoker and he had no other major medical issues . His physical examination was unremarkable . He had clear lungs and the oxygen saturation was good. I did PET scan and also the Bronchoscopy . I also did the breathing test . The breathing test was good and was normal . He underwent bronchoscopy and it was normal . The nodule was too small for me to do any biopsy. The PET scan where glucose is injected and the uptake is majored . The higher the metabolic rte , higher is the glucose uptake and higher is the chance of cancer . The PET scan showed increased uptake though it was not very high . So i saw him in the office and discussed the various options . One option was to do a needle biopsy . The needle biopsy has some risk of collapse of the lung and the sample is small and so not 100 % if it does not show cancer . The other option was to do follow up of the Ct scan . The good part about it is that it may 'save' an unnecessary  surgery , but the disadvantage is that if cancer , 'waiting' may increase the chance of cancer spreading . The first Ct scan and the time that all this happened was almost 6 weeks . I sent him to chest surgeon . The surgeon did a new CT scan and it showed that the Nodule had increased by very small amount . But taking in to account the PET scan finding and the small but definite though small increase in size in short time , we decided to do the open biopsy .
      The surgery went well and he came back for the follow up . The pathology showed that he had MELANOMA which is skin cancer in lung . That meant that the melanoma - a skin cancer has spread to lung , But he had no history of the melanoma ,nor the PET scan had shown no activity or pick up anywhere but lung nodule. So the patient asked me as to how can he have the skin cancer spread to lung when there was no skin cancer in first place. HOW is this possible and WHY did this happen ?I do not have the answer . 

Friday, September 14, 2018

I DON'T KNOW

     In medicine we , physicians do not ever want to sat ,'I don't know.' nor the patients want to get answer from their that they don't know . But truthfully we do have patients where we truly don't have the answer or know what else to do .If the physicians don't  know the diagnosis or have answers , then what kind of hope patient has or what kind of treatment they can expect ?Recently I came across some patients where I had not much to say . My unfortunate problem is that there is no other physician who has answer.

      So I saw this 70 years old patient almost a year ago . He has been a smoker and had some cough . His primary care physician did a chest x- ray and it showed abnormality . So I saw the patient . I did the work up . He had claustrophobia and could not and refused PET scan . I had tried mild sedation , but he could not do it . He did have a CT scan and that showed a mass at the center of the left lung . I did the bronchoscopy and there was narrowing of the bronchial tube going to left lower part of the lung . I did do some biopsy and that came back OK . I did follow up and did new CT scan . He also saw thoracic surgery and it was felt that we will do follow up on the CT scan . The follow up CT scan continued to show the abnormality and it was not any better or worse. I did second bronchoscopy and that showed the same findings and so I again did some biopsy and it did not show any cancer. I sent him back to the surgeon and asked him to do bronchoscopy or any other biopsy that he could do . I was concerned about the cancer . He told me that only 100% way to get the diagnosis was to take out entire lung . The patient was not keen on it and I was not sure if that surgery would be curative in view of the CT scan findings. He did do the Bronchoscopy under anesthesia and he had the same findings and the deeper biopsies were negative for cancer . We did new CT scan and it showed increase in the mass .So I sent him to a different chest surgeon. The new surgeon did get the PET SCAN done and it did show that the mass was metabolically active . This was highly suggestive of  a cancer . There was no other area in the body that showed the uptake , which meant that if this was cancer , there was no spread of the cancer. So he suggested taking out entire left lung . He came to me with family . He agreed and so the surgery was done . The left lung was taken out He did well.
      He came back for the follow up with  his wife. The surgery was done in different hospital and I had not gotten the report . So when he came for the follow up , I git the pathology report. To my surprise the pathology showed that indeed there was cancer . But not like I had suspected . It was not lung cancer . It was SALIVARY GLAND CANCER THAT HAD SPREAD TO THE LUNG !!
He does not have any abnormality in the salivary glands and there is no cancer there. nor the PET SCAN ever showed any abnormal pick up in salivary glands . So when they ask me as to how can he have cancer of the salivary gland spread to lungs , when he does not have cancer in salivary gland , I had to say 'I  DON'T KNOW '.

Friday, August 31, 2018

LUCK

      I was reading an article from one of the Indian magazine . It was about the statistical probability and the prayers. But the question that arose in my mind is can you change the destiny with efforts or prayers? There is  story of a king in Mahabharata , where the king knew that he was going to die of snake bit .So he gets out of his Kingdom and becomes easy  pray for the snake . This brings me to my today;s story .

    I have known this patient for several years . He had bad lungs and had sleep apnea .He was obese and had cardiac issues . He had open heart surgery too . he was doing OK . But he had multiple problems . One day he was hospitalized for pneumonia and then he had pus collection in the pneumonia -what is called lung abscess . He needed antibiotics for long time . He improved , but the chest X- ray and the CT scan continued to show the abnormality I continued to do follow up for several years . I had also done Bronchoscopy and all the work up was negative for cancer . This  continued for 5 years . Then he had back problem and went for surgery . He had major problem and was in and out of hospital and needed antibiotic . He did improve . The a year down the road he was in hospital for heart problem . I did  see him and did CT scan of the chest . It showed the same abnormality , which was due to old abscess may be 4-5 years ago . But there was a new nodule . So we decided to do some work up . He was ot in the best shape , but we did follow up CT scan and then the PET scan . The nodule increased in size and so I did send him to Radiation doctor . . We decided to do the biopsy . The needle biopsy was done and it showed the lung cancer . It was very small and so we did radiation treatment called steriotactic radiation. He did well and the repeat CT scan and then the pet scan did not show any cancer . He did OK for next 5 months . Then one day he had nausea and vomiting and felt weak and could not do much walking and so he came to hospital.
I saw him and then the work up was done . He had no sign of the cancer where he had biopsy confirmed cancer , but the other nodule - which has been stable for few years was minimally enlarged . But he had nodules in Liver . We did additional work up and he has cancer in spine and liver and lung . The biopsy was done and it was confirmed that he had what looked like lung cancer , but the type of cancer that he had this time was different than the first one that we treated 6 months ago .

     He was seen by radiation doctor and cancer specialist . Next 2 weeks down the road his condition deteriorated to a point that we decided to put him on Hospice .

    So we watched the nodule and it was stable and we treated the cancer that we diagnosed , but we could not  'change' the outcome or may be destiny  or LUCK !!! 

Friday, August 3, 2018

COMPUTERS AND MEDICINE

      Recently I came to know about the old IBM building new IBM computer for medical diagnosis. The thought process of making a diagnosis is like computer . The history is like data fed in to computer and so is the physical examination and then the computer will make some 'Differential Diagnosis 'or the various possibilities , based on the data fed . The possibilities in Differential Diagnosis are listed in order of probability. So the number one would be most likely and the last one on the list would be least likely. So the precess is similar when we do not use computer and use the Human Brain as the computer.. We do not us the computer in day to day medical life and we do not need one and  it may be time consuming and may be even confusing . I was told that the new IBM computer is more accurate than the best of best clinicians . My issue with this process is the problem of the Data that is fed . The computer gives the diagnosis based on information that is given to the computer. The human brain is same . If we as physicians do not put in or get accurate information , the diagnosis can not be accurate. This brings to my my today's story.

      I was called in on a consult for this patient who was 38 years old . He was diagnosed to have pneumonia by hospital doctor . When I saw him , his mother was bedside . He was a nonsmoker and did  not consume alcohol He was working in a office and had no dust exposure. He was sick for almost 6 or 8 months . He had gone to walk in clinic and was told to have bronchitis . He was given antibiotics and sent home . he continued to have problem and so he went to see family doctor . He was given cough syrup and some more antibiotics . The chest x- ray was ordered . He continued to feel poorly and now was short of breath . He went back to family doctor and was given an inhaler. He was told to do CT scan . His copay was too high and he did  not do it . The shortness of breath got worse and so he came to ER and was admitted . In ER the CT scan is done and he was told to have pneumonia. I saw the patient . He had some congestion on the back side of the lungs. He was on oxygen . When I saw the CT scan I was more concerned . The CT scan had extensive congestion ,in both lungs . It was not like typical pneumonia . So I was not sure  as to the cause . He did not have much fever .
    I ordered the blood oxygen and when it came back with low oxygen , I decided to transfer him to ICU. He was also anemic and he told me that he knew that and was told to take iron . ( I was not sure why a young male would get iron deficiency anemia  ) I ordered number of tests and antibiotics . I also called the infection disease consultant . They ordered more and ordered HIV or blood test for AIDS . So I talked to them . While taking history , I had asked him as to the sexual history as the thought of AIDS causing the anemia and the chronic sickness and atypical pneumonia had crossed my mind . He had told me that he did not use any drugs and he had not had any sexual exposure in last 20 years . So I was shocked when the test for the AIDS came positive .Thai solved all the mystery. The anemia and the chronic sickness, and the atypical pneumonia etc were all related to HIV .

      So the Brain computer of mine did not get the data of some risk factors was not 'entered ' . But the Infectious Disease doctor , did not pay any attention to that information and just went with 'instinct' . The instinct was correct ! 

Saturday, July 21, 2018

HISTORY-PHYSICAL-LAB

       In medicine that I learned we had to do first history then physical examination and then do or order tests. Now a days the process is reversed . I still remember when one of the functions that my wife was attending, some one had transient blackout .. some one called 911. The lady was fine , but she was taken to hospital ER . I was in the hospital and my wife called me . So I went t Emergency Room . When I went to ER she was being brought to ER . So I was there from the very beginning . As the patient was brought in the ER , she was taken to one of the room right away. The nurse came in and she  gave her the gown , She checked the blood pressure and the oxygen and started the IV line . Then the tech came in and drew blood . Then the cardiogram was done , Then she was taken to radiology and chest X-ray was done and then the CT scan of the chest was done . I was there all the time . All the time this was done , there was no physician seen or she had seen him/her.
   Since I have access to the medical records, I checked them and the blood tests and the CT scan and the chest X- ray - all were OK . So I told them that the tests were OK . Then came the ER physician .
He asked not more than 2 questions , told me and the family that all the tests were OK and ideally he would put her in for 'observation' for a day . The patient did not want to stay and so she was discharged . No history was taken to see why she had blacked out . The process of HISTORY- PHYSICAL-TESTS - was reversed . The tests were ORDERED based on what was told by ambulance paramedics , then the doctors came in and hardly did the history or physical examination.
     This brings me to the today's story. I saw this patient who was 66 years old female. The reason for the office consult that we were told was abnormal CT scan of the chest . She was a current smoker
and she had CT scan done and it was 'abnormal' So she was sent to me . I asked her as to why was the CT scan done . She had lost 30-35 lbs of weight , So the PCP did CT scan of chest and ABDOMEN- belly and Pelvis. The CT scan of the belly and pelvis was OK . But the CT scan of the chest showed 2 tiny nodules , 2mm and 4 mm . 25 mm make an inch , so they were very very small . So Small that hardly any test would tell us the diagnosis. . So I asked her as to why she has lost weight - is she not eating or she has no appetite or she has problem with swallowing  etc . She told me that she has good appetite , but she throws up every time she eats and she feels that food gets stuck and then when she vomits she gets the relief . . I did further inquiry and then examined her and then told her that I was not concerned about the nodules , but I was concerned about the HISTORY OF vomiting and food getting stuck . I was worried that she may have esophageal cancer .
      I ordered the tests to check the esophageal and told her that she needs to see gastroenterologist ASAP. I told her that the nodules were so small that Bronchoscopy , or PET scan or needle biopsy or open biopsy  were of no use in getting the diagnosis and so we will have to repeat the CT scan in 4-6 months . She had very strong family HISTORY of cancer and Lung cancer and so she wanted me to d beonchscopy .So I ordered it , but also did the X- ray of the esophagus .
    The bronchoscopy was K nd the X- ray of the esophagus showed that it was narrowed at the end and it was not having any contractions . So the food was not MOVING down . So she will need the gastroenetologist to check it out to see what could be done .
      So it was HISTORY that made me ORDER A TEST  and not the other way around . 

Friday, June 15, 2018

SEEING THE TREE AND NOT THE FOREST

    Many a times we all do it .We are so focused on something that some other things which is in front of our eyes , we don't see. But I often feel that in medical practice to day has become so fragmented that we all have OUR OWN specialty and we have the blinders. So we do not see the patient , but we see the disease . What used to be done by good Family doctor in past is not done by today's PCP and the the specialist of today are only Specialist . In addition to that we have patients that have sometimes selective hearing . This brings me to today's story.

     I saw this older patient . She had lot cough and some shortness of breath , She had routine tests done and she was treated with medicines . She was told about pneumonia and was treated with antibiotics in past . She was in hospital and she was also seen by different specialists . She was seen by a lung specialist . He had done bronchoscopy and no specific etiology was found out and she was still having the cough and the congestion , so she was brought to me by her family. I reviewed the data and saw patient , She had usual problems like high blood pressure and some leg problems and neuropathy . She had not been smoker and the chest X-ray and the old CT scan did show the pneumonia.. We decided to do breathing test as some times asthma can cause recurrant  respiratory  infections. . We decided to do new CT scan and the decided to do new bronchoscopy . She had lost some weight and atypical infection like MAC can also cause such symptoms.. All the work up was OK , but I had done swallow study too . She had aspiration . Whenever she swallowed , the liquid went in lungs .So this causes chemical injury to bronchial tubes and lungs and that causes inflammation and that leads to infection . She also had very small diverticulum , which may have added to the aspiration problem . When I did the CT scan I had also noticed that her esophagus was dilated and so I had ordered functional test to see how it works , motility study . As I suspected , her esophagus was not contracting properly and so the squeezing of the food that happens to get food down towards stomach.So the reason for the recurrent pneumonia and the cough was aspiration. I told the family that this is going to recurring problem and only 100 % way to help this is to have feeding tube put in . Thew were not ready . They were stuck on the diverticulum and wanted to get it fixed and then the problem would go away. She was readmitted and then had another episode of aspiration . I called in a gastroenterologist and he decided to do endoscopy - I am not sure why . The family wanted  a surgeon to fix the diverticulum . I knew  this would not change , but had no choice and a surgeon was willing to 'fix'it .

     She had the surgery and 2 weeks down the road she had another episode of aspiration . I explained again to them . This time a different gastroenetologist was consulted . He decided to do endoscopy again ! I am not sure . She is doing better and was d/c and I am sure she will get another episode and will be back .
     Not the hospital doctor or the 2 different gastroenetologist told them what I told them and I am not sure what information we got from the endoscopes . The family is seeing TREE and can not see the Forest -and so do some others !

Friday, May 25, 2018

DO THE RIGHT THING

        I enjoy medicine -otherwise with today's demand on medical practitioner for non medical things and things that do not help patients , I would have stopped doing medicine..I also watch news and the political commentaries. In my life time I have never seen such a divide.It almost reminds me of OJ court trial. The conclusion drawn are diagonally opposite. I wonder if they were watching same proceeding or not . But I often get the same feeling when I see patient. This is not new .In past it has happened to me that I was asked to 'clear' a patient for surgery and I thought that the patient was terminal. He was thought to have incarcerated hernia and needed surgery . He was seen by hospital MD , surgeon and cardiologist and kidney specialist . When I saw the patient , his hernia was reducible and nor incarcerated , his heart was pumping at 10 % and he had kidney failure and he had water in lungs .Not only he DID NOT need surgery , he could not have SURVIVED THE surgery. So when I told this to the daughter , she was surprised as OTHER doctors had cleared him . I went see her again and showed her the labs and the heart reports and the chest X- ray .We made him DNR and he dies in 24 hours . This brings me to today/s story . 
       When I was passing in the hallway of the hospital , I came across an Indian male , who mistook me for some one else . His wife was admitted and so I hello to them . I came to know minimal things about her medical problems . I told them that I will let the physician -that they knew , and from behind mistook me for him -know that she is admitted. After about 3 days or so I got a call from hospital . The nurse told my secretary that I was to see a new consult . My office took the information . I was busy with office patient and then I got 2 text message to call the nurse . So I called . The same lady that I had seen socially 3 days ago , was the new patine. She was short of breath and they wanted me to see her . She was so bad that the nurse called me on my cell phone twice. I had no call from any other doctor -not even the Hospitalist MD. The nurse had called Rapid response team twice. I spoke to the nurse and got brief history and gave orders . I told her to do chest X- ray and a blood test to check on congestive heart failure and give couple of medicines and call me is she was not better in 1 hour . I also told her that I will see her at 5 pm , which was 2 hours from the call.

    I went see her at 5 pm I looked at the chart to see as to what was happening . I saw the chest X- ray. and I saw the blood reports and then went to see the patient. There were family members and the nurse . She was little better . I told them that I felt that in my opinion she had episode of congestive heart failure and with new medicines she should improve in next 4-6 hours . I ordered medicines for the congestive heart failure and also for wheezing that she had . I did not get any call from the nurse after that . I went to see her next day and she was like new person . I readjusted her medicines . I reviewed the chart . She was seen by cardiologist , Infection specialist , blood doctor and hospital doctor . I did not see any mention of the things that happened yesterday in any of the notes other than hospital MD and the infection specialist , who had called me personally after he saw the patient .
If one would look at the cardiologist note only ,he would not know that she went in congestive heart failure.  There was no mention of the problem that she had , that was related to HEART .So 2 people seeing same patient , have very different view of the patient . 

Saturday, May 5, 2018

KARMA AND LUCK

      I came across a book that had discussion on KARMA .I liked some of the discussion that was done and some I did not agree . But overall it is a good book. I have talked about the Karma and the principles governing the Law of Karma. in the past . But I will summarize them before I talk about some new points. There is no patient story in this blog.
        The Karma is ACTION. To understand this one must realize that sometimes the INACTION can be ACTION. Sometimes the Action may not be obvious as it is MENTAL or not DIRECT. .So let me explain . If i am walking see someone in an accident and I walk away without helping . That not doing anything -inaction - is ACTION . This is simple to understand. Now the Mantle Action. I am think harm or lustful for someone once , because we had fight , it is not an Action .But if I continue with the same thought everyday it will become Action . (according to the book's author this is not action ). And lastly Indirect action is also Action . The claim that I do not kill chicken or pig and so I am not doing the Action of Killing is not right thinking . It is an Action .
        The action or the Karma that we do is called KRIYAMAN Karma .Some of it will have effect in this life and rest is stored as SANCHIT KARMA or 'Stored Actions'. So with several lives , we collect or store millions of Karma and not all can come to fruition or have effect in present life . So the Karma that are to come to fruition in this life -that happened in past lives -, is called PRARBDHA. This determines the 'outline' of our present life . In Hindu religion 4 actions or PURUSHARTH are described ,namely ARTHA-MONEY ,KAMA-DESIRES ,DHARMA-RELIGION AND MOKSHA-ETERNITY OR NIRVANA . The first 2 namely ARTH or money that we can make and KAMA or desires that we get fulfilled in this life are to some extent predetermined  and the to follow DHARMA or do our duties and try to achieve MOKSHA or eternity is in our hands . But we continue work for Money and Fulfillment of our desires.
           This does not mean that we can not WE can not CHANGE any outcome in our present life, But it is like swimming against the current and so our efforts must not only Match the force of the past Karma -PRARABDHA , but outperform it. If we do not try in this life ,thinking that our future is predetermined , we are CREATING new Karmas that will determine our next or future lives . So we must try and that may change some of the weak effects or the reaction to our previous life's  ACTION .So this effects of past life Karma determines our LUCK to major extent and some is determined by our present life Actions. 

            So the verse in BHAGAWAT GEETA , which is often coated from Chapter 2 , verse 47-or misquoted . The verse states that one has Right to Action but not to the fruits-EFFECT- of the ACTIONS. The usual interpretation is that just because one tries does not mean he will get success . This is true , but the other meaning or the one which I like is that whenever there is Action or Karma , there is going to the fruit or reaction or effect of it . One can not say that I will not accept this or that fruit or effect . SO EVERY ACTION HAS REACTION -ONE CAN NEVER BE WITHOUT ACTION AS ONE CAN NOT STOP THINKING EVEN IF HE CAN STOP PHYSICAL ACTION. 

Saturday, April 14, 2018

NEEDED TOOTH FERRY !

     I am against the price control in many situations . Th feeling that  'whatever market bears 'is the price was my opinion . But more I look at life , I think some regulations are required to avoid exploitation. I had a dog many years ago . One day when I returned home from going to beach on Friday and Saturday, he could not walk . I had to do something . So I called a veterinary doctor that I knew . He has seen me and come to my house and I have gone to his place may be once a year.at that time . He agreed to see my dog . He did X-ray and did give him a steroid shot ( which I thought was only thing that was needed ) , He also did Give me some shampoo and some steroids pills . My bill was $467. I was shocked as I knew the cost of the medicines and the cost of X- ray . I did not say anything nor did I ever took my dog to him again. He did tell me that people are willing to spend lot of money on their pets than on their kids . When in next year or so my dog needed back surgery , I had another shock . This time I was told as to how much each test would cost .Again my shock was that the doctor charged me for disposing of the needle too ! Having a pet is by 'choice and so may be if one does not want to spend money, he should not have pet . But that brings me to my today's story.

       I saw this 63 years old male . He had some cough and had bad bronchitis . He was in hospital and I saw him and treated him and as 'usual' he had CT scan in ER. It showed a nodule as small as 9 mm or so . He had quit smoking more than 20 years ago , so for the practical purpose he was non smoker -after 14 years of quitting smoking, the incidence of lung cancer is same in  ex smoker as in nonsmoker . Taking in to account the age and the size of the nodule I decided to do the follow up n the CT scan . The new CT scan showed increase in the nodule -almost double. So I did a PET SCAN .
    The PET scan did show uptake in the nodule suggesting that it was likely to be cancer . I did do a bronch and then saw in office . The bronchoscopy did not show any lesion and the cytology -pap smear of the lung was negative . But the size of the nodule was so small that I had not expected it to be positive . So now I talked to him and the wife . He had good lung capacity and he would have tolerated the resection of the nodule .So my first choice was to send him to a surgeon and then have do the surgery. Now a days robotic surgery is done , which has very small incision and the recovery is very quick. The other choice was to do needle biopsy and then if positive consider either resection by surgeon or do Steriotactic Radiation. This relatively new technique. This is used for nodules -- cancerous nodules that are less than 2.5 cm or inch . The radiation is given in higher than usual dose and it is more precise and only 5 treatments ts or sessions are needed . Some times this can be done in patients who are very high risk for open biopsy or resection due to poor lung capacity or age or other conditions like heart problem etc . The good news is that this treatment is almost as effective as resection . Some times we can do this without having  definite diagnosis of cancer . 

    I spoke to him and his wife and wanted to send him to surgeon . So I was shocked when he told me he would prefer either doing nothing and watching it --which I was against or seeing radiation doctor.. I was talking to him and he told me that 'Doc I have spent $46000 for getting new teeth and I want to use them !'So this 83 years old patine had to spent that much money more than an average cost of new car - to get new teeth.

       IS THERE ANY DENTIST WHO CAN JUSTIFY SUCH A COST - 20 TIMES MORE THAN WHAT HEART SURGEON MAKES FOR DOING BYPASS ???

    

Saturday, March 17, 2018

THE ATTACHMENT

        We have number of  attachments in life.Some have attachment to smoking and some to alcohol, some to drugs and some for some other. Many patients tell me that the smoking is very difficult to quit . so there are lots of attachments and we have difficult time quitting them . But the attachment to the BODY is the one that is the worst and none can not leave it till end. Even the best and learned one can not get detachment from it. I have seen this all the time . I am no better , but most of us want to LIVE and not LEAVE the body no matter how disease reddened it may be . That brings me to the today's story.

      I have seen this patient for last 10 years. He has been smoker in past and when I saw him he had breathing difficulties. Hr had diagnosis of COPD -smoking related lung problem . He was quite sick when I saw him  and he needed to be put on oxygen . He had severely reduced lung function and over period of the time he got worse and in one of the hospitalizations , he had to be put on respirator. . I was concerned as to how to wean him and if we could wean him off the respirator. But we did it . He was OK but needed to be on the oxygen all the time . He also had very limited walking ability . AS the time went on , he was in hospital few more times . The function of the lungs is to get in oxygen and get rid of carbon dioxide . When the lungs fail first thing is the oxygen drops . When the disease progresses , the carbon dioxide can not be washed out and patients start retaining it . So he started having that problem . That leads to sleepiness and fatigue and lack of energy. He started having that . So I talked to him and his wife . He was started on  breathing machine which can deliver breath and oxygen and it is done with a tight fitting mask . This helps the function of the lungs . We started him on that for the night . The machine helps the lings and the muscles of the breathing . So during day time they do not get fatigued and patient feels better . He did get better . He was on it for more than 3 years and was doing OK . He did need the machine to be adjusted due to carbon dioxide retention. Slowly his ability to walk was reduced and the lungs were failing . So he had to use the machine had to be used during day time too . So now he was on it during night and then may be 6 hrs during day time -not continuous but total 6 hrs during day time.

     There was not much I could change . We treated him for his respiratory infections and gave him steroids off and on and he did OK . He did ask me one day ''Am I going drown the drain slowly?"I could not answer yes , but I did tell him that not much can be changed .
     I do yearly chest X-ray and most of the time breathing test . His lung function was so poor that I did not do it again. The chest X- ray was done and it shows a mass . This was highly suggestive of cancer . It was not very small . So I called him and his wife . Our options of treatment or for that matter work up to get diagnosis . Even doing the bronchoscopy was very risky as he may end up having more problem. The needle biopsy was impossible and open biopsy was out of question. . So only thing we can do was to do PET SCAN . The PET scan id about 85% accurate in predicting cancer if the PET is positive.
     I talked to them several times about the limited or not much options and suggested consider radiation evaluation and HOSPICE . He did not know what to do and I have not completed any additional tests as he did not want it and did not want to consider HOSPICE YET !!

     THAT IS THE ATTACHMENT TO THE BODY !!!

Saturday, March 3, 2018

EXCEPTION TO THE RULE

      In medicine we were told that when we see patients , and the patient has multiple complaints , try to find out one diagnosis . In most of the patients , one diagnosis explains all or most of the symptoms. Try not to have more than one diagnosis. Again this did not apply to the things that patients had it like hypertension and diabetes and the heart attack history. So if one comes in with shortness of breath and headache and fever  and say chest pain , try to find out one diagnosis to explain all the symptoms . Once one is in medicine for many years , he finds out that there is always exception to the rule. So the story of my patient that I am going to tell one such story .
         I saw this patient for abnormal chest CT scan  He had cough and had chest X - ray and it showed some nodule and so the PCP did chest CT scan and then the CT scan was abnormal and so he was sent to me . He was 70 years old male and had history of heart attack and had some high blood pressure. He had cough and some white sputum . He had not lost any weight and has no fever and no weight loss. He had cough for may be 3 months . He was not smoker . The CT scan showed multiple nodules . All of them were very small. they were like dots and some may be like small pea. The PET scan , which picks up cancer in 85 % of the cases of the cancer , has limit on the size and so these were too small to be picked up . The PET scan needs size of at least 8 mm, preferably 10 mm. The nodules were 3-4 mm . The needle biopsy of then nodules was impossible as they were too small. The open biopsy could be done , but which nodule and with the given size and the lack of any symptoms , we decided to d the bronchoscopy to rule out atypical TB called MAC.

    The bronchoscopy was negative for cancer and the other tests on the lavage and the bushings were also negative for cancer and the TB or any mold .So we decided to do the follow up on the CT scan . I followed him for year and half and the CT scans .Some of the nodules disappear and some got smaller.. His cough was better and he had no other problem . He came for the follow up. I did Ct scan after 2 years  and it showed that one of the remaining nodule has grown . So I did PET SCAN . The PET scan did show activity in that nodule . He also had some other smaller nodules and they did not get picked up on PET scan..I did do new bronchoscopy and the work up was negative for cancer . But I was concerned and so We did needle biopsy of the nodule that had grown . It was cancer - type of  a cancer that is treated with chemo.But at the same time I got the report on the bronchial lavage , it showed MAC - atypical TB .

     So we had 2 different diagnosis. -both of them will need treatment at the same time.   

Sunday, February 4, 2018

UNUSUAL CASE

     In my practice I have seen unusual cases . Some patients came for the complaints that are related to mu field -pulmonary medicines and the diagnosis was non pulmonary. Some came for pulmonary complaints and the diagnosis was not what was normal or usual . But some times I see patients , that have no pulmonary complaints and still they are referred to me  and then it becomes a challenge. The patient that I saw recently , was one such patient .

     When I see new patients I do things differently than what many do or what we were told to do . In medical school , we are told to start with chief complaints and then history of present illness and then past medical history, family history and personal history and the review of systems and then examination . I start with past history etc and then before examination I ask as to why they are in my office . So I saw this 67 years old patient . He had no significant past history except high blood pressure. H e was not  a smoker and did not drink alcohol  much . He  was otherwise healthy. So when I asked him as to why did he come to me , he answered that his primary care doctor told him that if anyone can help , it would be me. This followed by him telling me that so far he has seen 12 different doctors. So I asked as to what was the problem , he answered that HE HAS HICCUPS ALL THE TIME .! I was not sure as to how this was lung or pulmonary problem.. Granted  that the hiccup is spasm of the Diaphragm.and the Diaphragm is part of respiratory system . But this connection is too remote . Any way he had seen several primary care physicians as he had moved from Tampa. He had seen more than one ENT doctors and Gastroenterology  physicians. No treatment was successful . The hiccups were worse at night though they did occur during day time too. I asked him if he had any swallowing difficulties and he had none . But then he told me that he had some  doctor in Tampa do a study for it . Interesting enough and good for a change - he had the report. Normally I have to be detective in finding as to what kind of test was done and where was it done in most cases. I would say 70 % of the time . It is so time consuming that now a days my office checks couple of computer data on all new patients . Any way the answer was right there .

    He had what is called Esophageal Motility Study .In this test a probe is put in to food pipe or esophagus and the contraction of the esophageal muscles is recorded. The esophagus is like a sleeve and it has circular muscles and the wave of contraction of these muscles squeezes the food down . I have seen many patients that have the problem with this function of the esophagus. Typically we see this in disease called Scleroderma.. When I looked at the report , HE HAD NO CONTRACTIONS . This was the answer of his problem . The test was done the result was abnormal , but no treatment or co relation with his complaints were made. So when he ate solid food , it did not get pushed down and got stuck in food pipe or the esophagus . To dislodge it the diaphragm went in spasm and that is why he had hiccups. During day time he may not have been eating much or as much as dinner time as he was still working . Also he was upright and the gravity helped the food to go down. But after the evening meals, at 8 pm or so , he was going to bed at 9-30 or 10 pm and he was supine and then he got food stuck and so had more hiccups. At least this is my explanation. I explained him my thought and told him that he has to see a Gastroenterologist and there was no real treatment for this . There are some surgeons who do a surgery and it may be effective . I told him to go on liquid diet for 10 days and not have any food or even liquids after 6 pm . My thought was that if there was no solid food , then it will not get stuck and then the spasms of the diaphragms will not be there . But he was not very receptive to my idea and agreed to do it for may be 2-3 days .

       The jury is still out as he did not see Gastroenterologist for a month and I am not sure if he can offer any medical treatment .  

Friday, February 2, 2018

MEDICAL MYSTERY

     In medicine we have patients that do not behave as we expect --may be they have not read the medical text books! But after being in practice for long time ,I have realized that whenever there is 'interesting case ' , it is bad for the patient . In past I have seen patients that I thought had cancer and they did not have it -good for the patient and then when sometimes I thought it could not be cancer , it turned out to be cancer-bad for the patient. The case that I am about to tell is one where there is no diagnosis -at least for now .
     I saw this patient in office for some cough and shortness of the  breath . As usual we do some tests and he did have some asthma . The pulmonary function test confirmed it . The chest x- ray was OK and so I put him on medicines for the asthma and he did well . He came back for follow up and he was again having problem . So I saw him . He had some more cough and some sputum and had no fever. His lungs did not sound bad . But he was having problems and so i added some medicines and also gave  short course of the steroids . He called me to tell me that it had helped .

      He came back earlier. The steroids helped , but when he completed the course , he started having problem . He had no fever and not much cough . But he was short of breath and has some cough . The oxygen was little low . The lungs did not have any wheezing. I was concerned. I wanted to get him in hospital . He was reluctant and wanted to try steroids again . I  told him that I  wanted to do CT scan of the chest to make sure that he did not have the blood clots . He agreed . I ordered the CT scan stat. I got a call at 4 pm that he had larger fluid around the left lung and had some mass in pancreas. I called him and told him to come to ER ASAP. We admitted and then started work up . He had PET scan scheduled and I did tap the chest and took out 1200 ml fluid . He had biopsy of the pancreas and the blood tests done for the pancreatic cancer . The blood test came back normal and the fluid that I had drained out , did not show any cancer cells . The biopsy also did not show cancer .

   So now we have no diagnosis . He had larger fluid collection and we don't know the diagnosis . He had pancreatic mass and in spite of the biopsy we don't have the diagnosis . The next step would be to do 'open biopsy' either of pancreas or if the fluid collects , biopsy from inside lungs . The mystery of the medicine continues.   

Sunday, January 28, 2018

AGE OLD PROBLEM

      I have been in practice for many years and I have noticed the aging population. Now a days it is not uncommon to see patients in their eighties.It is very easy to say that everybody should be treated according to the disease and not according to their age. Some older patients are well preserved and have sharp mind . But the body is like house . So often we see  30-40 years old house and it looks good and has no problems . But when one looks at it , the windows are old and not according to the new standard, or the roof may need to be fixed and the plumbing is old .Many a times when I see older patients who are accompanied by their younger relatives , they are not demented, but when one starts asking questions , we realizes that memory is not as sharp and sometimes the understanding capacity is less than what might have been at younger age. But the family members are not aware if this as they see them everyday. When one does the same routine everyday , early dementia is not obvious. -going to the same place to eat or do shopping or doing same thing like goinfg to same friends or relatives . But when one is given little complex and not the routine task or direction , then the ability to follow the instruction is not as good as younger people.But my main concern is aging body. That brings me to today's patient .

    I have known this patient for last 1 or 15 years , Now she is 91 years old . She lives by herself and her daughter and the grand kids help her. She has heart problems and has been under care of cardiologist . She had fluid around the lungs 7 or 8 years ago and I took it out . It came back and so after doing the procedure 3 times , I had called surgeon and had a catheter called PLEUREX inserted . It can stay for months to year and one can drain the fluid as needed by attaching it to bottle with vacuum bottle  . Her fluid was gone and the drainage was not much and so the catheter was removed . She did fine for may be 3 years . Then she had some fluid and she was OK , Her shortness of the breath was not bad as her activity level is limited . I watched the fluid with periodic chest X- ray and it did not see to be any worse or for that matter any better. As long as she was fine I did not do the drainage with needle..
    She then had fluid around her heart and had elevated pressure in lungs called pulmonary hypertension . The cardiologist 'watched' the fluid around the heart and it did get better. So the she has some shortness of the breath and she was again in the hospital , So the cardiologist felt that I should 'drain' the fluid -same one who did not want to drain the fluid around the heart. She was on blood thinner and I had to hold it and then do the procedure . She did well but had small amount of air around the lung after the procedure . I was worried as if that gets worse then she would need insertion of tube to sick out the air . But my thinking was that her lower part of the lung is chronically collapsed and so it can not expand and so the gap was filled by the air . I did new chest X- ray in 4 hours and the fluid was back and the air was gone. Since then she is in hospital 3 times . We 'adjust' the meds and sent her home and she does OK and is back again . She does not look any different or is not in any distress, but she feels short of breath . The fluid is also same as was 2 months ago.. But again the cardiologist and the family feels we need to treat the fluid . In my estimates she has multiple , chronic problems and they will not be fixed at age 91. But everyone sees the fluid and that they feel can be 'fixed' .So now I have to treat it .
    She is 91 years old and has multiple problems and she will probably have similar issues  and doing more procedures is risky. Thia is what I call AGE OLE OR OLD AGE PROBLEM . .  

Monday, January 1, 2018

COINCIDENCE

     When we say that it is a coincidence,it means we did not expect it or the chance of the thing happening was too low and so when that happens , we call it a coincidence .It is not uncommon to have the family members to go to same family doctor as that is what the family doctor is or was suppose to be , -treat the family . But to see same specialist for the similar condition is less likely. But again the high blood pressure or the diabetes are so common and do depend sometimes on common environmental factors , such as diet , exercise or life style, that the husband and the wife can get similar condition and then go to same specialist . In my specialty COPD could be one such condition as it is related to smoking and many couples do or did smoke together . So that is not a coincidence . But today I am going to tell you about a patient that is rather unusual and so it is a coincidence.

       Many years ago I saw this fire fighter , who was about 50 years old . He had retired earlier and had some cough . He was short of breath and had no chest pain or weight loss . In fact he was obese. He had no fever and had no other problems . We did the routine work up and it turned out that he had some scars in the lungs . We did the further work up  and did the breathing test and also did some blood work up . He had reduced lung capacity and also had reduced ability to transfer the oxygen , which is  seen in patients with scar tissues or fibrosis. He was young and so we decided to do the open lung biopsy.His blood tests were not very specific for any particular condition like lupus or rheumatoid arthritis.The open biopsy was done and it confirmed the diagnosis of the fibrosis . But we had done the biopsy to find out the reason for the fibrosis and so the biopsy was difficult one to get the diagnosis . So it was sent out to Mayo Clinic . The report came as 'fibrosis and the inflammation most likely due to connective tissue disorder , may be scleroderma'.The blood tests were not very specific for the connective tissue disorders. So I did call a specialist for the same , rheumatologist.
      He decided to start him on some drugs . The patient did not like the doctor , but did do follow up with him . But unfortunately he had pancreatic inflammation related to the drug that was used . He decided that he did not want to see anybody else , but me . I did try to send him to other university centers , but he refused. So I had no choice to give him steroids . This did help him to some extent , but he gained some weight and then had sleep apnea .  He continued to get worse over period of next 5 or more years and needed oxygen 24/7. He was young patient and so I wanted to send him for transplant evaluation , but he told me hr was too old and he feels that the transplants are for young adults and he did not want to take them away from some kid who would benefit from this better than he.To make the long story short , he dies about 6 or 7 years after I started seeing him .

      Fast forward to 2016. I saw this lady in my office for the chronic cough and her last name was same as this patient . The name is German  and I had difficult time pronouncing it . So I remembered it quite well . I had seen her when he was sick , but most of the follow up he had come alone as they had mentally challenged son. So when I saw her I knew that she must be his wife , even though there was a gap of 4 years or so . So I did work up on her and she had fibrosis . She also had scleroderma and she had classical finding of the scleroderma .She had circulation issues , she had very bad esophagues and had some aspiration and many other things that are seen in scleroderma. I sent her to a different rheumatologist and she is very happy with her , She has not progressed as far as her fibrosis is concerned and she is stable.

           So this is what I call coincidence. The husband and the wife , who are not genetically related had similar or same diagnosis, which is other than diet or smoking related and has nothing to do environment.