Friday, June 15, 2018


    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 !