WHEN YOU HAVE ONE YOU MAY GET SECOND

      In medicine we are taught to have one diagnosis and then differential  diagnosis. Which means one is more likely the explanation of the symptoms , but there are alternatives to that also, which is differential diagnosis. But not to have 2 separate  diagnosis for 2 different symptoms. This meant we have to have explanation for 2 different symptoms as one diagnosis not 2. But that is for symptoms at one given time . I want to talk about cancer and want to state that when there is one cancer, then one has higher chance of getting SECOND CANCER. That brings me to the story for today. 

    I saw this lady for abnormal CT scan chest. She was not a smoker and had COVID pneumonia. She was doing better but the pneumonia on the CT scan was not gone. She had no fever and had cough and clear sputum . No chest pain and the weight was stable. She did not have wheezes. I decided to do a follow up CT scan as the x- ray improvement lags behind clinical improvement, which means patient feels better but x- ray take longer time to improve. The new CT scan which was done 6 weeks down the road did show improvement , but the congestion or the abnormality did not improve on one side -right was better but left was still the same. She was feeling better and so I decided to do Bronchoscopy and then if that was OK , do new CT scan. The bronchoscopy did not show much abnormality and the tests that I did did not show any TB , bacteria or fungus or cancer. But this is never 100% and so we did new CT scan in another 5-6 weeks. The left side continued to be abnormal  and right side cleared . So I did PET scan and that showed increased activity in left sided abnormality . The uptake was not very high  and sometimes inflammation and infection can also have mild increased uptake of the glucose. I told her to see chest surgeon. The thoracic surgery did the surgery and that part of the lung was taken out and she had lung cancer . The good part was that there was no spread and she did not need any additional radiation or chemotherapy.

     She saw the oncologist and he did follow up and new CT scan. The CT scan showed new fluid around her left lung where the cancer was taken out. She came to me and had no idea of the new fluid as she had not had any call from oncologist. I decided to treat her with prednisone as sometimes patients get fluid related to the surgery and that is due to inflammation from surgery. If she did not improve , I will have to drain fluid with a catheter. We did follow up in 4 weeks and the fluid was gone.

    I continued to do follow up as she also had sleep apnea and some cough off and on. Overall she was stable for next 2 years . Then one day she had blood in the stool. The work up was done and she had colon cancer. She had surgery and has done well. The point that I want to make is that when someone has one cancer diagnosed , they have higher chance of getting second cancer over period of time -it could be other lung cancer and I have seen that also or it could be another organ cancer. One has to be watchful. 

IS IT JUST LUCK?

      In medicine we act based on what we think or know as facts. But many a times the facts are based on statistics. When we treat someone with  bronchitis- cough with yellow sputum, fever and wheezes= we treat with certain antibiotics and expect it will help and cure the respiratory infection. I believe that treating with antibiotics to cure him his based on FACTS .But in reality it is based on statistics and experience that antibiotics work in certain infection. But it may or may  not. But I often used to say that if one puts one hand in boiling water and other in ice cold water , 'statistically ' he is at comfort. That brings me to the story for today. 

    I saw this 70 years old male who was a smoker for cough and congestion. He had been smoker for 50 plus years and had no desire to quit. He had cough and wheezes and we did work up. he had breathing test and chest x- ray and was started on some bronchodilator. He continued to see me for 2 years and was doing OK .He had COPD and that was mild and he was active and cough improved . Then when I did new chest x- ray , he had abnormality . When I called him and wanted to do CT scan, he wanted to hold off and wanted antibiotics. So I did that and the repeat chest X- ray continued to show the abnormality . We did work up and he had cancer diagnosed . He underwent surgery and cancer was taken out. But he had some lymph nodes positive for cancer spread and so i sent him to oncologist and radiation doctor. He was told that the chance of recurrence in increased when the nodes show spread and he should have chemotherapy and or radiation . He did not want any further treatment. 

     I continued to do follow up and in next year or two, he had ne scan showing new mass . Again we did the work up and he had new cancer. I sent him to thoracic surgery and he did not feel surgery was an option as he had cancer spread to lymph nodes and so we decided to do radiation and suggested chemo and he was not sure . I continued to do follow up and he was doing OK . He had continued to smoke and the breathing test did not show much worsening. He did get radiation and no chemo.

   I continued to do the follow up and did periodic CT scan . 2 years or so after the second cancer. He was doing great and he had continued to smoke and was having no new complaints. He had new CT scan and he had some chest wall pain. The CT scan showed that he had new tumors and the ribs on rt side were also involved  and showed cancer. I sent him to radiation oncologist and medical oncologist . He was started on radiation and immunotherapy. He had some additional medications for pain . Almost 2 years have passed and he has continued to smoke  and has had new scans and breathing test . The breathing test does not show any significant worsening from previous one . He does not need oxygen .He has not been on any cancer medications for more than a year .AND HE IS AGAIN CANCER FREE . 

NOT SURE WHAT SHOULD HAVE HAPPENED TO HIM STATISTICALLY !!

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.