MALINGERING OR REAL

      In medical practice sometimes we see patients that have symptoms but we cannot find the reason for that and then we do the work up and no etiology is found . Sometimes the cause is obvious but may not be easy to be acceptable for the patient. e.g. shortness of breath in someone who is obese and has not done any exercise in several tears . I used to do a pulmonary stress tests that actually had a diagnosis of 'deconditioning'. But sometimes the symptoms are unusual and can be missed as the presentation is not typical. But I often say a YOUR EYES CAN'T SEE WHAT YOUR MIND DOES NNOT THINK.' That brings to my story for today. 

     I was asked to see a patient who was a nurse .  She had some episodes of dizziness and some vertigo . I am not sure exactly what was it but while working she had to sit down and then she would get better in short time . She worked in ICU. One episode was rather severe and she was admitted in ICU itself . The neurologist and cardiologist saw her and did tests and the CT scan of the brain was ok The cardiac work up was also normal. So there was no cause for her symptom found out. This story is from may be 25 years ago.The admitting physician called me to see her . I am not sure why me as I am a lung specialist and there was no lung problem as such. The day that she was to be discharged she had an episode of severe vertigo and so the discharge was held and I was called .I was going to see her and I got a call from the Medical director of her insurance. He was ex oncologist and he knew me . He called me and stated that 'See what you can do - I don't think anything is going on, Get her out quickly.'

     I went to see her in ICU. She was 44 years old female who had no major medical issues . She had some childhood trauma - mistreatment  by her father. She had been diagnosed to have mild high blood pressure and was on medications and all the readings were normal. I talked to the nurse taking care of her . When I went in the ICU , the nurse told me that that morning she was fine and then she had the 'attack' where she was having severe vertigo and felt dizzy and was in bed and did not want to move even in bed as it made her symptoms worse .I went in her room and she was calm and lying in bed comfortably. I looked at the monitor. Her heart rate was 55 and her blood pressure was normal . What struck was her respiratory rate was 4. Normal heart rate is 70 to 100. But I have seen heart rate of 55 in normal people . But normal respiratory rate is 12 and her rate was 4 . THIS WAS VERY UNUSUAL . I have known people who can go in mediation and drop heart rate but never seen low respiratory rate. Due to stimulation of respiratory  centers by lack of oxygen and build up of carbon dioxide one can not reduce respiratory rate. I spoke to her and there was nothing new and her examination was normal. I did not know what to make of her low respiratory rate . She did have some headaches. AND IT STRUCK ME. Could she have something to do with centers for respiration-like what used to be called VERTEBRO BASILER MIGRAIN -now called Migraine with brainstem aura. The neurologist had seen her and  told her that there was nothing he can do. I decided to call Mayo Clinic. I got the number from  case manager  and called Mayo clinic neurology department. I am not sure how this can happen but I got to speak to head of the neurology. I explained him the presentation and my thought process. He agreed with my thought process and told me to do new EEG.I started her on vasodilator and her symptoms improved and she was discharged home . Her vertigo and dizziness had gone down to almost zero. 

I AM LOST

    I AM LOST !I have been in medical practice for many years and I often see things that rea not that common and sometimes I am surprised . But sometimes we have a patient that defies all odds . When it happens to be a patient who has say inoperable - wide spread cancer ,that we think will not make 6 months mark with or without treatment, and then something happens and  patient is cured , we are happy. Though in that case we also have surprise - uncommon - unusual outcome. But since the 'ending' is happy' we are happy and no one questions success. Then we have patient in whom the pendulum swings on the other side, when we expect patient to either not have a cancer or cancer that looks like can be cured  and then either it turns out to be cancer or shows spread etc, then we are more stunned. That brings me to the story for today. As always 

    I saw this young lady, who had abnormal CT chest . She was nonsmoker and had h/o positive skin test for TB , Positive test means she was exposed to TB and so the body reacts and has positive skin test . It does not mean one has TB now. She had never smoked and she had minimal cough and no other complaints. The Ct scan did show a small  nodule -less than an inch. She had no old CT scan to know if this was new or old .Since she had exposure to TB, it could have been related to TB . But I did the work up. I did order PET scan , In PET scan glucose uptake is measured and in cancers the uptake is high , as the metabolic activity of the cancer cells is higher that normal cells. The PET scan showed minimal activity. I also did bronchoscopy and that showed no TB or mold. The nodule was too small for me to do any biopsy and I did do brushing and washings and that came back no cancer but showed chronic inflammatory cells. I  decided to do follow up on CT scan in 6 months. The CT scan was done and showed no change in the nodule. But I decided to send her to interventional lung specialist . Since there was no change in nodule they decided to do a new scan. The new one was done in 2 months . It showed no change in 8 months. Normally the cancer will grow and her we have a patient who has never smoked and has history of exposure to TB and bronchoscopy showing inflammatory cell .I do not know the reasoning behind doing a navigational bronchoscopy where a computer helps getting to the nodule . But it was done by the interventional lung specialist . The biopsy showed SHE HAS LUNG CANCER . 

      So a nonsmoker patient , who has no change in nodule in 8 months , no uptake on PET scan and inflammatory cells on first bronchoscopy - defies all odds of being BENIGN and has cancer . That is heart breaking. 

SOMETHING NEW EVERYDAY

     I am in medical practice for many years and feel that 'i have seen this movie before,' many a times . But every now and then , we come across a case where something new is seen and that stuns me..

   I saw this patient who had cough and some fever . He had not smoked for many years but had been admitted to hospital with pneumonia more than  6 months ago. I had no old records, but when he saw me his Primary care doctor had done chest x- ray and that had shown pneumonia and so he was treated with antibiotics and was sent to me. I looked at old reports and hospital records. He was admitted with cough , fever and then was admitted and then the chest x- ray had shown pneumonia - in the same place as it was seen now - upper part of the lung. I looked at the old CT scan chest done few months ago. He had pneumonia and looked like he had obstruction of the bronchus going to that lobe - segment of the lung - the same upper lobe , that he had pneumonia now. I was now worried and may be convinced that he had a tumor in the upper lobe bronchus , and that had blocked the bronchus , and that had caused recurrent infection and HE MAY HAVE CANCER. 

    I explained him  as to what I was concerned about. We ordered new scans and also the PET scan . As I have stated in many blogs , the Pet scan is done to see glucose uptake in abnormal areas and usually the uptake of the glucose is high when there is cancer or infection. I also decided to do Bronchoscopy. The Pet scan was done and that showed only mild uptake . So it may have been a blocked bronchus with only pneumonia. 

     The bronchoscopy was done and I saw a blocking mass that was occluding the opening of the bronchus. As I looked at that carefully to consider biopsy, I realized that it was very hard . There was no way I could biopsy as it was not a soft - friable cancer, but was a STONE -HARD STONE that was blocking the bronchus. It was a broncholith or a stone in the bronchus. There was no way I could biopsy it or remove it as it was embedded  deep. 

   I sent him to a chest surgeon , but he did ot want surgery. . 

CAN ONE SLEEP ON IT ?

      I have not done much on sleep medicine stories. I do practice sleep medicine - mainly sleep   apnea. Bot some times we get different problems associated with sleep. To sleep on -is used when one wants to postpone making decision. But I m using it differently. We se patients that has certain characteristics of someone who has sleep apneas . Apneas means one stops breathing and Hypopnea means the breath is smaller and is associated with oxygen saturation drop. On an average we have these episodes less than 5 per hour. When they occur more than 30 per hour of sleep it is considered severe . And I have seen as high as 90 per hour. These episodes are counted as -episodes per HOUR OF SLEEP and not hour of recording. This brings me to story for today. 

   I have seen this patient for last few years. He was quite obese and had sleep apneas and that was treated with pressurized mask called CPAP-CONTIUOUS POSITIVE AIRWAY PRESSURE. This keeps airways open and the that prevents the apneas and hypopneas. He was doing good . Then he had some other medical problems - liver related and also has some personal problems that caused stress. He lost weight and was not sleeping well. he attributed that to old machine and  wanted new machine. I needed new sleep study to justify new machine as he had done the sleep study many years ago and he had new health insurance and they would not approve new machine without new sleep study. So we decided to do new sleep study. The sleep study was done  and he did not sleep well and the study came back showing he has NO SLEEP APNEA. He did not believe that and wanted second sleep study . the first was done in sleep lab and he felt that he could not sleep there in unusual surroundings. He felt that if we do the study AT HOME then he will be in his own bed and bedroom and he will sleep better.   The home sleep studies are not as good as one done in sleep lab , but his thinking was correct. People may not fall asleep in lab, as they are in unfamiliar surroundings. So I ordered Home sleep study . That also came back as having no sleep apneas. Now we both are stuck . He does not sleep well - in lab study he slept less than 10 % of the time. He definitely has Insomnia and when one does not sleep well during night , he will have drowsiness and fatigue and lack of energy during day time  and also will feel sleepy - all the signs and symptoms of sleep apneas. He wants me to get new machine and he wants me to increase the pressure settings on his current machine. No one will give him new machine unless he has diagnosis of sleep apneas and I cannot increase pressure when he does not have diagnosis of apneas . It is quite possible that he has NO APNES  and all the problems are related to Insomnia or it is also possible that he did ot sleep well when sleep study was done and so we did not get apneas. But there is not much we can do . I did order new sleep study with sleeping pill . But his insurance company REFUED THAT stating that he had already 2 sleep studies . 

  AND WE CANNOT SLEEP ON IT !!!

THE OLD DICTUM IS NOT ALWAYS CORRECT

     When we were in medical school , we were told that one does not  need of try to explain the symptoms with 2 different diagnosis . When a patient  is having some complaints , we should not have 2 different diagnosis to explain the problem . And that is true in many conditions and also in most patients .But sometimes we have 2 different diagnosis and then it becomes difficult to 'work up ' for 2 different diseases. This brings me to the story for today. 

    I had seen this male patient may be 3-4 years ago . He was admitted with pneumonia - 6 or more months ago and was seen by lung specialist .He was a smoker and had abnormal chest x- ray and then CT scan chest . He was treated with antibiotics and also  had bronchoscopy. He was discharged and was told that looks like he had cancer  and no diagnosis was done . He and his family were not happy and so they came to me. I reviewed the scans and the reports and realized that he had bronchoscopy and the samples - which take 6-7 weeks to finalized - was positive for atypical TB called MAC. I explained him the reports and started him of 3 different antibiotics  that needs to be continued for 18 months. I did tell them that he had abnormal CT scan and that needs to be followed as he could still have cancer. He was a smoker and had COPD. He did not have good lung capacity - reserve to do open lung biopsy.

    We followed him and did new CT scan several times and that continued to show improvement and the nodules that we were concerned had become smaller. We di complete the MAC medicines and then did CT scan and it continued to show improvement. Then last one was a problem . He had no new complaints and he had done sputum for TB - MAC and that was OK and the Ct scan showed that one of the nodules ,which was very small , like 4-5 mm or 1/5th of an inch , had doubled in size- still less than 10 mm or less than half an inch. I was concerned and I had interventional lung specialist do biopsy. This is relatively new procedure - may be 4-5 years old where computer guides to do biopsy in right segment and so the yield is high. This is more effective and when patient is not a good candidate for open lung biopsy due to poor lung capacity , we can get diagnosis. So the biopsy was done and HE HAD CANCER . So he did have MAC and he did respond to treatment - and he DID NOT have cancer 3-4 years ago - but now he has cancer . 

ALL THAT GLITTER IS NOT ----

      In medicine we often come across things that still brings in an element of surprise. We have known the disease but not always expect the diagnosis as it is not the common one and so when we see that then we are surprised . The story that I am going to tell is one such story .

     I saw this patient at the request of primary care physician. It is not very common that a primary care physician calls me 'personify'.  We do get request to a patient ASAP or STAT. But on rare occasions the physician calls and want to talk to me . This time I had a message that he wanted to talk to me ASAP. He had seen a patient who had cough. He was a 66 years old patient, who had not smoked for 30 years. He had cough and so he saw PCP  and was treated with usual medicines - cough syrup, an antibiotic and when that did not work an Inhaler - bronchodilator inhaler. He continued to have cough and and so the PCP did a CT scan of the chest . The CT scan showed a growth in the one of the bronchus and so he was sent to me. I saw the patient and he was little obese male. He had high blood pressure and had no other medical history. He had quit smoking many years ago and he had cough for 6-8 weeks . He had some rattling in the chest and when I asked he did have at one or 2 times blood tinged sputum. The medicines that the PCP had given had not helped much . The CT scan did show a growth in the bronchus and that did noit look like mucous plug The lung segment distant to the growth was collapsed . There was no question that he had a mass in the bronchus and that was blocking the entry of the air going tn the middle part and to some extent lower part of the lung. The mass was irritating the bronchus and to get that out the body was reacting by having bad coughing spells. 

      I explained the patient that I am concerned about cancer and we will do the work up . He was scheduled for the PET scan - which picks up concentration of the glucose and that tells us the chance of malignancy and if the cancer had spread to other organs . We also ordered breathing test - to know if in case we decide to cut part of the lung that has cancer , he has enough breathing capacity to tolerate the surgery. I also decided to do bronchoscopy  and see if we can do the biopsy of the mass. I am not sure why but I also told him that there is a possibility that this Growth could be BENIGN and not a cancer. .I did  the bronchoscopy and I saw a shinning smooth surface mass obstructing middle and lower lobe bronchus. The look was that of a benign growth called CARCINOID. The lung cancer has appearance of chewed meat - very irregular friable and not smooth surface mass . The cancers have more blood supply and so they bleed easily. THIS MASS did not have that appearance. The carcinoid tumors are considered  benign growth that SOMETIMES CAN SPREAD or the other way to say it is that CARCINOID is a malignant tumor that RARELY SPREADS. In any case the treatment is to do surgery. The carcinoid tumors also bleed when biopsied . So the best option is to have surgeon cut the part of the lung that has carcinoid. 

      So all that glitter is not GOLD and not a likely to be cancer but is or may be CARCINOID. 

    

HEALTH CARE COST AND MEDICARE

    Several years ago I saw a study that showed that when people reached Medicare Age , the suddenly health care expenses went up. Is it a surprise ?Do we really need a study to KNOW that and FIND CAUSE for it ? The answer is obvious. When people are getting OLDER there are health issues and that increases the cost . When we have Health Insurance ,then we tend to USE IT. Certain things are recommended after certain age - vaccines - preventive tests like  colonoscopy -mammograms . I know some of them are to be done at an earlier age than 65 years , but still with HIGH DEDUCTIBLE Health insurance , people tend to POSTPONE them. That brings me to my today's patient.

    I saw this 67 years old patient in office. He has been smoker and has continued to smoke . He had NO HEATK insurance till he got Medicare . Once he had that , he had colonoscopy and had some polyps removed . He had routine blood tests done and he had elevated cholesterols - lipid and so he was started on statins - medications  and since he was a smoker he had routine LOW DOSE RADIATION SCREENING CT SCAN OF THE CHEST. Now a days for last few years. Low dose Radiation CT scan of chest is covered by Medicare and other Health insurances in patients who are over 50 years of age and are current smoker or ex smoker for 14 years . One has to take in to account the smoking pack history and also the age that we do screening is also being reduced. The idea was that we DETECT AND TREAT cancer Early, by doing the scan .But the problem is to ACT WHEN WE DO THE TESTS 

  He had Ct scan done in October and that showed a nodule in lung . Then then a PET SCAN was done and that was also abnormal and so he was old to see lung specialist and cancer specialist . He did not do anything and continued to smoke . Noe that he comes to me , I have to repeat the CT scan and also PET SCAN and certainly do additional work up like breathing tests and biopsy and may be even surgery . And if the cancer has grown or has spread then chemotherapy . That all will increase the COST . So to have insurance is good and that certainly increases the USE of tests , but then acting in time will reduce the cost of health care .If he needed statin 5 or more years ago then using them would reduce the cost of cardiac and vascular problems that elevated lipid would cause. So one needs to have health insurance - do proper tests  and ACT ON IT and that will reduce the health care cost on long run.