ONE AND MANY

      Sometimes we see things happening to someone , who has bad things happen to him/ her . Then he gets better and comes out and then again an another calamity hits him. I often wonder as to why this happens . But then when you see the 'etiology' or reason for that , we realize that the cause or causes have common thread. This brings me to story for today. 

   I have known this patient 80 years old or so now for many years. He has been smoker and had COPD - the disease related to smoking. He had continued to smoke in spite of diagnosis of lung problem due to smoking. But then he had abnormality on his chest X-ray and so I did the work up . He had cancer of the lung. Fortunately he was a  surgical candidate and so thoracic surgeon did surgery and part of his lung was removed and he did OK. He continued to smoke and I continue to do follow up in office and CT scan . It looked like he had developed some scaring in the area of the surgery, but since the CT scan was abnormal I decided to do bronchoscopy. This time I saw something on his vocal cords - he had cancer . I sent him to ENT physician and then he was sent for radiation treatment . He did OK. He continued to smoke though had reduced. 

     Next few years I continued to see him . He had lost weight and had some exertional shortness of breath. He also needed some oxygen. Then he was hospitalized and the chest x- ray showed large area of pneumonia. I did not see him during that hospitalization . NO CT SCAN WAS DONE - not sure why. He came to me for follow up and so I decided to do further work up. We did bronchoscopy and also PET SCAN as the density was large almost more than 3 inches .I also did bronchoscopy and his vocal cords were normal and there was no cancer in the bronchial tubes. But the PET SCAN was abnormal. There was no activity on vocal cords and the density that was seen on chest x- ray was not there but had a scar in that area and he had some nodules with some activity. BUT there was new mass in a sinus! and that had very high uptake suggesting  a cancer in sinus. I am  not sure on the new nodules in lungs . But this patient who had lung cancer which seems to be cured and had vocal cord cancer and that also seems to be cured -now has new cancer most likely in sinus.SO IT WILL BE 1-2-3!

IT IS NOT POSSIBLE !

      In medicine I never say never. This is due to the uncertainty of medicine. In medicine there are 3 factors  namely Host -Agent and Agent. So depending upon all 3 the response is determine. The agent may be same and it can cause different response in different hosts  and the host may be the same and the agent may be different and the response will be different and the same with reaction between the different agents and different hosts and different environment ,that the response will be different. The example would be mold in home or office and all the people working there have same reaction or may be not the same degree of reaction. Not everybody have same nasal allergies with allergy pollen season. This is known , but then sometimes we have problem with diagnosis as the incidence of allergic reaction is not known, This brings me to story for today.

     This patient came to me for evaluation of possible asthma. He had seen different lung specialist and had severe asthma diagnosed and has been treated with many different medicines and he still had problem. He was offered  additional treatment with biological shots and he did not want it. I tested him for allergies , There is a immune globulin called IgE. which is elevated with allergies and that was markedly elevated and he has several allergies on testing for allergies , but most of them were mild. The option of treatment was limited with allergies and severe asthma needing steroids many times. I also did CT scan of the chest and he had lots of mucous and dilated  bronchi - what we could see in uncontrolled asthma. To see if he had additional fungal infection I did bronchoscopy and tests came back OK

    I talked to him and adjusted meds and offered him biological shots and he wanted to wait. He did do better with my medicines , but the CT scan did not show much improvement . He still had congestion. Then one day he came back for follow up and his lungs were clear and oxygen was normal. He was happy and I was happy. And so I said to him that 'looks like the medicines are working .' Then he said 'But I am not taking medicines .'NONE AT ALL '.He said I stopped all the medicines.

    I was stunned , but thought that there must be something in his home or office or surroundings that was causing his asthma and somehow he must have eliminated it . And I was correct but not in the sense that I thought. HE HAD STOPPED STATINS THAT HE WAS TAKING . I did do new CT scan of the chest . And the lungs were almost clear.

    I continued to do follow up and for last 2 years he has not had much problem and he has not taken asthma medicines on daily basis. He still needs inhaler PRN. - as needed especially when he has resp infecetion. But otherwise he has no problem . 

   So, it seems like he had allergies to STATIN THAT CAUSED THE LUNG INFILTRATES AND AGRAVATED HIS MILD ASTHMA . I have not know this allergy . So my statement that ANYTHING UNDER SUN INCLUDING THE SUN CAN CAUSE ALLERGIES is true 

REFERRED PAIN

           In Medicine we talk of REFERRED PAIN. This means there is pain at one place and the origin of the pain is not near by organ ,but somewhere  farther out. Sometimes there may be pain in upperpart of the belly on right side and that could be from liver of gall bladder .But then there could be right shoulder pain or shoulder blade and that could be from not from shoulder problem but could be from gall bladder. The nerve supply to gall bladder and right shoulder is common and so one could have right shoulder pain and have no shoulder problem ,but have gall bladder problem. Again this is when someone has gall bladder attack.  This not ordinary shoulder pain, but intense pain. That brings me to story for today. 

       I saw this new patient in the office. She was mid 70ies and was sent to me by a psychiatrist. She had moved here from a town 250 miles away from our place. She had complaints of breast pain or as she described -' my breasts are hurting - tender.' The primary care had done the work up and had chest x- ray and EKG and had found nothing. When the pain continued and there was no etiology found for that , he sent her to a psychiatrist. He evaluated her and found no depression and no psychiatric cause . So then he sent her to me. I got her old records from primary care physician and also x- ray report , which was normal. When I asked her about the pain, she said there is pain as if there is a band of chest tightness. and she held her hands on both sides of the breasts. There was nothing in her physical examination. Her blood pressure was normal and her lungs were clear. And the oxygen saturation was ok . I reviewed her primary care records. I also had records from previous physician. I realized that she has been complaining about this pain for more that 6 months . The previous physician had asked a chest surgeon to evaluate and he had done a procedure called MEDIASTINOSCOPY. In this procedure under anesthesia a scope is introduced through incision above sternum and then biopsies are done . They found nothing. But she continued to have pain/ pressure. One thing that I noticed that she had lost weight . In last 8 months she had lost 60 lbs. The weight recorded from previous physician and 2-3 visits by local PCP showed that she was gradually losing weight. 

     I decided to order a new CT scan. I knew something was wrong and there was a problem in her chest . I the CT scan did confirm my suspicion. She had a mass in the posterior part of the mediastinum and the tumor was invading and pinching nerve . This was causing the 'Band like pain'. The tumor was causing the pain and was also causing the weight loss. The mediastinoscopy cannot reach back side structures -near spine , where that was causing the pressure on nerves and causing pain .So we did the biopsy of that mass . We started treatment with radiation and the pain was resolved .

    This pain on the chest wall and breasts is called referred pain as it was due to pressure on nerves from tumor which was farther from the breasts or chest wall.  

CAN YOU PREDICT DEATH ?

      This is very interesting question. I am not talking about someone sick in ICU and is on respirator and falling blood pressure. I am talking about can we predict death in a regular walking -talking patient ,who has no cancer. But recently I came across a form that I had to complete where the first question was 'Is patient likely to die in one year?' This is recent and it was a patient who was to undergo minimally invasive cardiac surgery. As a lung specialist, I often get forms to ;CLEAR' the patients for various procedures or surgeries - endoscopies to cataract surgery to colon resection and so on. The risk of any surgery is increased when the patients have lung problems and the lung capacity is compromised. This brings me to the story for today.

     I have known this patient for many years . He was  70 years old patient, who had chronic cough . I had done the work up and that included breathing test and Chest x-ray . We even did the CT scan of chest . He had mild to moderate asthma or obstruction on his breathing test. The x- ray was ok and so I gave him inhalers to treat the asthma. He used it and came back and told me he does not know when to use as he did not find any change in cough. So he would  not use it. I also did swallow study to see if he was aspirating-food or liquid going wrong way -instead of going in food pipe , esophagus ,it would go in wind pipe or trachea. This would then trigger the cough reflex. He did have aspiration. But then again he did not feel he had any problem with swallowing. So he did not do anything . I continued to follow him for more than 5 years  and he did well with no hospital admission or major pneumonia. 

   Then he saw a cardiologist and they diagnosed him with a heart valve problem and they wanted to do minimally invasive heart surgery to fix it. I cleared him for the surgery and he did well. He came back to see me. He was doing good and had uneventful recovery from the heart surgery. He however had urinary retention and he was diagnosed with enlarged prostate and needed surgery to fix that. Just as a rule risk of lung problems is increased when the surgery is close to lungs Say for example amputation of a toe is much less risky that having lung surgery with compromised lungs. Now he needed prostate surgery. I cleared him for the surgery. He did well and then was to be discharged. And then HE ASPIRATED . The aspiration caused major pneumonia and his oxygen dropped . He developed respiratory failure and then was struggling. He and family made decision not to put him on respirator and so then hospice was called and he died . 

    So the patient that survied heart surgery dies after prostate surgery -CAN TOY PREDICT DEATH?  

IT IS SIMPLE FLU -IS IT ?

       We all have heard of Flu and how it is a viral infection and there is vaccine for that. The vaccine are good and prevent diseases. But in case of Flu it is 'hit or miss'. There are seasons when flu vaccine are not that effective and some others where it's effective,  In my last several years of practice I have seen Flu where people get better in 4-7 days and then there are some where the fatigue and cough and malaise continues for weeks.  But then there are some where the diagnosis is done in 1-2 days and then we use antiviral medicines and people get better. And then there are EXCEPTIONS to rule. Which brinhs me to the story for today. 

      I had seen this elderly male who was 82 years old and had a nodule on his chest x- ray. He came to me and had work up done . He had had hypertension and had chest pain and that was worked up and he had CAD coronary artery. He had work up and then had blockage and then had stents. During the work up he was found to have this new spot on the lung and so he came to me 

     We did the work up and then he had breathing test and also PET scan. He had descent lung capacity and the PET scan did show increased uptake suggesting the spot to be cancer. I had options of surgery - radiation treatment. He wanted to have it removed. I sent him to a chest surgeon and he agreed and the patient had the surgery. It was cancer and everything was good and he did not need any additional treatment like radiation or chemotherapy. 

    Over period of next few weeks he developed fluid around his lung and had some cough. He thought it was a set back and was worried - could it be cancer? I treated him with steroids and the fluid went down to minimal. He continued to do well. And then he had flu.

     He went to ER and was treated with antiviral medicines and he did not feel better . He saw primary care and was given steroids and antibiotics . He continued to have sough and could not eat well and lost weight. He was congested and had no energy . He could not do much waking and exercise . He used to go to gym before this Flu infection. He did not have fever and his oxygen saturation was normal . He came to me and he looked 'bad.' As mentioned no fever and no shortness of breath . But he looked mineable. I decided to hospitalize him . The standard rules don't apply as he had no fever - no shortness of breath and no pneumonia . The does not meet the criteria for hospitalization. But when you look at patient , the story was different. HE was old patient who had heart problem and had lost part of the lung with cancer and he was not recovering from this SIMPLE FLU quickly and he needed better care that can be done in hospital . I ADMITTED HIM !

   SIMPLE FLU CAN BE BAD IN CERTAIN HOSTS - PATIENTS. 

IS IT EVER SAFE

     In medicine we have many terms used and one of them is 'cure rate' or recurrence rate. This is tru especially in cancer diagnosis. If we have a patient who has say 1 cm lung nodule  and we  do surgery and it is taken out , and we have no evidence of spread of the cancer at the time of surgery, we call it a success. But is it really a cure ?The answer is yes and no - many will be cured and some will have recurrence of the cancer . We usually do  follow up CT scan for 3 years as the majority will recur in 3 years and if there is no recurrence of cancer in 3 years then we are 'safe' and the chance of recurrence is very little. This brings me to the story for today. 

  I saw this lade few years ago. She was a nonsmoker and had kidney cancer taken out several years ago - 5- 6 years ago. She was followed by a cancer specialist and he did CT scan every so often . One of the CT scan showed some nodule - a tiny density . He told her there is not much and wanted to redo new CT scan . She came to me and I reviewed the scan and really she had very tiny nodules . At the given size not much could be done as diagnostic test. The bronchoscopy, of needle biopsy or open biopsy could not have ben done to get tissues diagnosis. The PET scan is good for cancers that are at least 8 mm in size . Sometimes we do get it positive for little smaller but then most of the time it comes back negative and then radiologist states - too small to be picked up on PET scan- and we have spent money and sometimes patients get wrong impression. So we decided to do follow up on CT scan . 

     I continued to do  new scans for 3 more years , which means the renal cancer now was diagnosed 8 years ago. But the last 2 scans were showing some growth - still less than 8 mm. Then the last one was 11 mm -one of the nodules -the one that was growing . I decided that she will need biopsy  She was having difficult time with appointment  for biopsy and she finally was scheduled for the biopsy. 

     AND THE BIOPSY SHOWED KIDNEY CANCER !

So the cancer took all most 9 years to recur in lungs . That is why we should call not a cure , but 'disease free time '. 

THE MESSAGE AND THE MESSEHGER

     We have a saying that don't kill the messenger. But sometimes the message is bad and not easy to accept, then people kill the messenger. In medicine I have seen it personally. In spite of advances in medical science, we have diseases that are simply bad  and no matter what treatment you offer, it is not enough and certainly no cure. I have had that experience in past and I am sure I will have that in future. This brings me to the story for today. 

    I saw this 70 plus years old male patient ,who had some cough and some shortness of breath. He had moved here from near by place and was seen by lung specialist and followed by them for 2-3 years. He was ex smoker and had not smoked for may be 10 plus years. He had breathing test done and CT scan done in past. He was started on inhalers and he was OK. Then he started coming to me . I saw him and then I felt that he did not have much of COPD or obstructive lung disease which is related to smoking, but had FIBROSIS. I did do new CT scan of chest - called NRCT -HIGH RESOLUTION CT scan and also did breathing test. The Ct scan showed fibrosis and that was significant. I got hold of old CT scan reports and he did have FIBROSIS IN OLDER CT SCANS ALSO. We di assessment for need for oxygen and he needed oxygen. So now he was on oxygen and I discussed with him on the diagnosis of fibrosis and told him that he had it in past and seems like he was getting worse ,and so we needed to start him on medicines for fibrosis. The problem with medicines for fibrosis is 3 fold . Number one is that it DOES NOT CURE OR REVERESE the process. It slows down the decline. I tell patient that the reduction in lung function continues and does not stop , but the rate of decline is reduced - it continues rob dollars but instead of $100 , it now takes only $50 or so. Then second issue is it does not reverse anything. So the damage which is there does not get better , And lastly , it is expensive. My be as much as $25000 per year. So we need forms to be completed and get patient approved and then copay and other things that are associated with these orphan medicines. There are 2 medicines for the fibrosis - now for last 3 months 3 . I ordered one and the insurance denied the coverage. I was not sure why and we appealed and went through circle of calls and transfer and did not come to any conclusion. Then I realized  that they covered other medicine and not one that I had asked for.

    In between there was a drug trial going for the medicine - same one but as nebulizer and not a pill and we got him in it . He continued to have cough and continued oxygen . He did not get worse on his breathing test, but he felt he was NOT GETTING BETTER OR CURED. I had to tell him that he is not going to be cured and the disease will continue to get worse INSPITE of medicines . 

   He was not happy and dropped out of the study and decided to seek second opinion.  

   The message was not good and so he did not like it .