ACCIDENTAL DICOVERY

     In medicine we do tests  and sometimes we do tests that we expect to be negative. It is like calling someone expecting him to be not home and then leaving message , and taking credit that we did call. When someone has clot in lungs, we try to find out why . So we do the work up. The clot in lungs come from some other source - usually from leg veins  and then a small portion of the clot gets detached and then goes to lungs where it blocks the circulation and that causes the shortness of breath and other symptoms. There are reasons why a clot may form in leg veins - so called DEEP VEIN THROMBOSIS. Usually it happens due to inactivity - long distance travelblog injury  or surgery and also other causes. Immobility leads to stagnation of the circulation and that leads to clot and so this is called PROVOKED.  Then there are clots which form when we cannot see the cause. This is called UNPROVOKED clot. That brings me to the today's patient. 

    I was called to see this patient . He was 70 years old and had some cough and no shortness of breath, He had 3-4 episodes of so called Pneumonia in last few months. He had some chest pain and so he went to walk in clinic and had CT scan done and that showed a clot in the lungs  and so he was admitted. But it also showed a density in the lungs and so there was a concern as what that was. I saw him and he was also seen by hematologist. They had ordered some blood tests - this is to know if there is 'tendency to form clot' so called Hypercoagulation status . For some reason related to abnormality in blood itself which makes forming clot easier. But they also ordered CT scan of abdomen and pelvis . Now I have seen this being done many times as OCULT CANCER can present as Unprovoked Clot. I have not seen any new discovery in past many years when CT scan is done . But in this case it showed  a mass in stomach, Normally the stomach is a hollow cavity or a bag and mass in it is nit obvious on CT scan. But this time it did  and so we have him do a biopsy and that showed a type of a tumor not very common called GIST -gastro-intestinal stromal tumor. 

   So, we have a patient who had pneumonia  and CT scan showed a clot  and also a clot in leg - which is common scenario, but now we also have other abnormality in lung which could be a tumor or pneumonia or clot related  infarcted lung . But he also has a tumor in stomach. 

   We will do  follow up CT scan of lung and also PET scan and then he will need surgery to remove the stomach mass . If the lung abnormality does not clear , he will need biopsy of that too. But for now with clot and need for blood thinner we have not done any surgery or additional biopsies. 

ONE TWO AND THREE ?

   In medicine we have saying that usually we do not have 2 diagnosis . This  does not mean that a patient has only one diagnosis . It means that when a patient presents with a symptom or complaints , we may start with differential diagnosis - what different diseases could explain the problem ,but at the end of work up we have one Final Diagnosis. But sometimes we have exception to the rule. That brings me to patient for the today. 

    I was asked to see this patient who was doing fine . He had seen his  PCP and has had done follow up regularly as I  understand. But had cough and shortness of breath and so he came to ER and then had work up. He was found to have quite extensive pneumonia. He had pneumonia on both sides. The right was much more affected than left side. He had not been smoker and had no previous history of lung problems. He was admitted and the hospital physician started him on antibiotics. He was found to be anemic and  so the work up was done and he had iron deficiency . So he was given iron. 

    I saw him and was some what surprised that he had extensive pneumonia on both sides as he was not a smoker and his only other medical problem was chronic back problem and he ha shad some kind of surgery for that .I asked him questions as to what had happened . He had history of narrowing of the esophagus and he has had dilatation done in past -last one was 7-8 months ago . He had vomited and then started having problem and he had called PCP and then was told to come to ER The vomiting episode was only once and so neither the ER physician or the Hospital physician who admitted had asked or mentioned in their notes .So we did the work up. I did swallow study and X- ray of the esophagus  and sure enough he had severe narrowing of the lower part of the esophagus  and he also had severe reflux . So now we have 2 different problems or may be 3 . He had pneumonia which was caused by aspiration when he vomited  and he also had vomiting due to narrowed esophagus. The anemia may be due to severe reflux with oozing of blood from there . But it also could be due to problem with absorption of iron. Iron deficiency is uncommon in men unless they have loss of blood from peptic ulcer or colon polyps or cancer . 

    But the problem list did not end . We did CT scan of the abdomen and that showed a renal mass - mass in the kidney which was potentially cancerous . So we had initial diagnosis of pneumonia  and then the narrowing of the esophagus  and anemia and renal tumor..   

CHANGING FACE OF MEDICINE

     I have written in past about medicine has changed in last 10 years or so what we never thought was possible has been done routinely. But I also remember when Obamacare came in there was a talk od so called Death squad '. How do you handle he aging population . Do we older members of our society same as younger members or treat them same? I have always maintain that every case should be treated based on INDIVIDUAL and as a GROUP . and I feel the same. But problem is becoming more frequent. That brings me to the talk for today. 

  I have seen at least 3-4 patients who were older than 89 years of age . The  good part was hat though they were old they all were in fairly good health  and had some issues but not depilating. But they were old. The second part was that 2 of 3 were also menially clear and one had fair amount of memory loss. The common factor was that all 3 had a pulmonary nodule that was PET positive . So I saw 2 of them who had a nodule  and that had grown in time . I had seen them and decided to do follow up CT scan and the nodule grew and so we did do PET scan and then showed that the nodule had uptake suggesting that it was cancerous . The growth and the positive PET SCAN was almost 100% suggesting that it was cancer. Now a days we have techniques like Navigational bronchoscopy ,which gives us diagnostic yield much higher than what we could have gotten in past with simple bronchoscopy. We also have better technique of needle biopsy. But we decided not do it as they were not interested in getting chemotherapy. So there was no need for tissue type - what kind of cancer it is as chemotherapy is based on type of cancer. We did radiation therapy - a short one 5 sessions in all 3  and that is suppose to give cure in many - may be 80% in these small cancers . 

    Then I saw this 4th patient, who has weak heart and had fluid around the lung and then when I treated it with diuretics the fluid is gone but now he has a nodule which is growing. So he is 95 years old who has heart problem and has increasing nodule - how do you handle it -stay tuned .