Sunday, January 22, 2023

ONE OR TWO OR THREE?

    In Medicine we had a rule. When we see patient, and there are number of symptoms, try to explain all the findings with one diagnosis, rather than explaining different findings with different diagnosis. That does not mean 2 different diseases cannot be there in the same patient. But that is not common. We have seen atypical TB and cancer in the same patient . But that is not a common occurrence. But then in medicine one can never say never. That brings me to the story for today.

   I saw this patient . He was 66 years old patient and had a ulcer or a wound on his legs . He was working and has been doing a full time job and also has been followed by a physician as out patient. He had seen surgeon in past for the wound and was treated. He started having pain  in the leg and he called PCP but could not get appointment for a month or 6 weeks. ,So he decided to come. I was called in as he had abnormal chest x- ray and then the CT SCAN of the chest. I saw the patient . He as obese  and had lot of edema in legs and had a big ulcer that looked infected . But he also had abnormal CT scan of chest and the radiologist had not compared that with old one . He had severe pneumonia few years ago and was on ventilator  and he had that in right lungs as he could tell me . The scan from almost 2 years ago showed same findings of scar tissue in the same area . He also had some lymph nodes enlarged and they also looked to be about the same. But what also caught my eyes was that he had some changes in liver  and that suggested early cirrhosis. I had asked the radiologist to check old CT scan and all that he did was mention the scars in lungs and did not bothered to  tell about the lymph nodes  and also nothing about the liver. He had new CT scan of abdomen and that showed that he had a stone in ureter and that was blocking the kidney and so we called urologist . He was also anemic and so the work up was done . This is a patient who came for the ulcer and a nonhealing wound on leg  and we found out abnormal chest CT  and anemia and some liver abnormality and also renal stone . 

    The work up was done  and he has anemia due to bone marrow not working properly . The bone marrow makes the white cells and red cells and platelets ,so when it is not making these cells then the blood counts drop. He seems to have the problem . He may have contribution from the liver not being normal  and also the infection - the wound. I don't think that the lymph nodes enlargement is due to that but it also may be due to that. So we have a patient who comes for wound which was there for few months  and now had anemia due to bone marrow not working  and kidney stone  and also some odes enlarged and liver issues . None of these were know to him or were diagnosed even though he has been followed by a physician regularly !!

Sunday, December 11, 2022

WHY DO WE DIE

     We often see people that have lived for ever. I have recently seen at least 3 patients on same day who were 90 years plus old  and were good in health and then I see patients who are mid forties and have multiple elements and are not in great health and don't do well and die at early age. Some die young and some old  and some are retaining their faculties even at advanced age and Others don't have it at  at younger age . What determines the TIME OF DEATH .That brings me to story for today. 

   I have known this patient for many years may be 10 years .He had smoked in past and had COPD . Over the years of my follow up he got older and also had some worsening of he disease. He could not do much physical activity and needed oxygen . And in spite of using oxygen he was short of breath. But he was stable from my stand point. One day he had some trouble eating  and as per his story it was less than a week  and so he was admitted to hospital  and he ha d work up and he had canner of the food pipe or esophagus. I saw him in the hospital. I had extensive discussion with him  and his son and daughter who were out of state . His wife had dies 3 years ago. The hospitalist had admitted him and had not known him and had not started his usual medications for COPD nd so he was quite short of breath. He was seen by oncologist and then they had called a surgeon for possible surgery. I saw him and i knew him well from medical stand point . He was not a candidate for surgery as he had severe COPD  and would not have survived the major surgery to cut out esophageal cancer. I told hi that and also to his family . They had known that.as they had seen the father walking and using oxygen etc. The oncologist also called radiation oncologist and the plan was to do both- radiation and chemotherapy. I had told him that the chemotherapy may be too much  and the side effects may be worse and with his COPD he may not do well and there won't be quality. I had suggested Radiation and told him that that will get him some time . The other physicians convinced him that if he does both he has a 'chance 'of cure , which I knew was remote. Who does not like the thought of being CURED of cancer. So he and the family agreed.

     He was discharged and the plan was to star the treatment in a week or so. But he was readmitted with pneumonia . The esophageal cancer had blocked his food pipe  and he had stent, but he had vomiting and then that went in his lungs  and he had shortness of breath and he needed to be admitted . After 2 weeks of treatment it looked like he was getting better . No treatment for cancer was possible at this time . It looked like that will have to wait till he gets stronger  and infection to be gone. But one day he became worse and I called family and told them to come back and in next 36 hours he died. 

    My question is what decided that he would die in less than a month after diagnosis of cancer and could not get any treatment. I have some thoughts. The short answer is that the KARMA WHICH WERE GOING TO COME TO FRUITION had come to fruition and this physical body had done it's job  and so it was time to go. 

    You may check out my You tube video under JUST A TALK . 


Sunday, November 27, 2022

PERSISTENCE PAYS

   In medicine sometimes persistence pays. We see things and with previous experience we think we know the diagnosis  and then the tests are carried out and the diagnosis is not obtained . So sometimes the persistence pays. In past it has also happened that we think that there is cancer or some other diagnosis  and then the tests show something different. But one has to go by what we think  and continue the work up. This brings me to the story for today. 

  I had seen this patient in office for the shortness of breath. She had been smoker in past  and had quit many years ago and she was getting short of breath and so the primary care doctor sent her to me .I knew that she must have COPD the disease that happens when people smoke and over period of time it must have gotten worse. So I did the work up . She had o chest X- ray in long time . I did the chest X- ray and breathing test and AAT a genetic test to see if she had lack of certain enzyme that can cause emphysema in smokers. The chest X-ray came showing some abnormality and so I did CT scan. The CT csna showed 2 masses  and she had it quite close to center of left lung. I did PET scan and in Pet scan  glucose is used and that is picked up by every cell in the  body and the concentration of the  glucose pick up is measured. .Higher the pick up more likely to be due to cancer. So the PET scan is 80% accurate in picking the diagnosis of cancer. So there are cancer where the metabolic activity of the cells is not much higher than normal cells and so the pick up is not that high. This is seen in very slow growing cancers. And there are infections that will be positive on PET scan . So it is not 100% . Her Pet scan was positive and so I was sure that she had cancer of the lungs . I did bronchoscopy and I did see narrowing of the bronchus and I was sure that the biopsy will be positive for cancer, but it did not. So, I did ask radiologist to  do needle biopsy. . That also did not show cancer. I had told family that most likely based on our tests , she had cancer. But we did not get the tissue diagnosis. 

    I sent her to a chest surgeon   to consider open biopsy . I thought that was the only 100% test to get the diagnosis of cancer. I was sure that she had cancer. The surgeon called me Her lung function was not that great  and so he wanted to redo needle biopsy with larger needle - so called CORE Biopsy.She had the core biopsy  and that showed the CANCER!

    So the persistence paid.

Saturday, November 12, 2022

LESSIONS TO LEARN

     The medicine is fluid. Everyday we get new information and new tests and new drugs and treatments . Sometimes what we learned in past may be partly true or may not be true at all. The classic example that I can give is frontal lobotomy where frontal lobe of brain was removed as a treatment and I think he got Noble Prize for that. But now we know that that is not correct and no one does Frontal Lobotomy any more .But certain principle still guide us They are almost eternal in that sense. The work up of anemia is one of them. But I often see patients who have anemia or low blood count get iron as treatment and many a times that may not be the problem. This brings me to the patient for today. 

     I saw this patient in my office . She was one of my patient's wife and had been diagnosed to have CIOD  as she was smoker . So she had bad lungs - damaged from smoking and she must have been so bad or advanced that she was on oxygen all the time . She had no recent work up and so I decided to do new work up. But then she felt more short of breath and so went to ER and was admitted . She was found to have anemia - her hemoglobin which is normally 14 grams,  was less than half at 6 grams . So the hospital doctor ordered gastroenterologist to see her . No anemia work up as to the cause of anemia was done . Th gastroenterologist saw her and told that she does not need any work up in hospital  and she should be worked up for anemia as she had normal stools and there was no evidence of blood loss . I was notified of her hospitalization 3 days down the road . I saw her and realized that her worsening of shortness of breath was due to anemia rather than COPD . But she also had wheezing and she was not started on any bronchodilators which she used to have at home . I started her on her usual inhalers and did anemia work up. She also had some other problems . 

     Her condition improved and her shortness of breath was better as she was started on medicines and she had a blood transfusion. But the anemia work up showed that she had abnormal protein. Just to give an idea we have raw material that is needed to make hemoglobin - like B12 , Iron, Folic Acid  and vitamin C and some other  and then there is factory - which is bone marrow. We tend to lose blood  in conditions like stomach ulcers or diverticular disease or polyps in colon  and colon cancer  and in younger ladies menstrual blood loss. So one has to find out if anemia - low count is due to poor or lack of raw material iron being one of them or if factory - the bone marrow is defective or if we have blood loss. In this patient the work up showed that she had problem with bone marrow . The abnormal protein which is produced by overgrowth of certain cells in marrow leads to reduction in production of red cells which carry hemoglobin

     So her shortness of breath was made worse by low hemoglobin and that was due to somewhat unusual cause of abnormal growth of certain cells in marrow and iron will not work 

      LESSION LEATNED !. 

Sunday, September 18, 2022

DO WE NEED 'TESTS' FOR DIAGNOSIS

      We in medicine have seen pendulum swinging from one end to other in many aspects of medicine. We have seen popularity of different tests or treatments . With time we may have n=better tests or the tests becomes less reliable with more tests being done. CT scan or PET scans can be considered belonging to this category. When the PET SCAN came in we thought that it was going to be 100%  accurate in getting diagnosis of cancer. But as more and more tests were done and we gained more understanding in to the tests, we realized that the accuracy of getting diagnosis of cancer , was reduced and not closer to 100%.But now we know that it's close to 85% . But sometimes things that we assume based on history and physical examination, are not 100% and we need additional information . Sometimes we order tests to confirm our suspicion  and then we are surprised. That brings me to story for today.

       I saw this 60 years old male who came to me for shortness of breath. This was going on for years  and he has seen new PCP and he had sent him to cardiologist .He was nonsmoker  and had history of high blood pressure and mild diabetes. The cardiologist di the work up and the work up did  not reveal any cardiac problem and he came to me. He had shortness of breath for long time. His physical examination was unremarkable. His lungs were clear and he had good oxygen saturation. He was obese  and may have had sleep apnea, but that was not related to his current problem or complaints. I thought that he had increased BMI  and overweight had caused decreased activity and exercise  and so he was DECONDITIONED . So the shortness of breath was due to that, especially as cardiac problems were ruled out . But I was going to do the work up . My presumption was that the work up will be good  and then I can tell him on weight and lack of exercise and shortness of breath. 

    I did do the pulmonary function studies  and to my surprise he had moderate obstruction - indicating ASTHMA . So even though he had shortness of breath for long time and the lungs were clear  and oxygen was fine - he had asthma .So sometimes we need TESTS to diagnose !!

Saturday, August 27, 2022

IS THERE END TO IT?

        I have often seen patients that have medical problems  and the treatment is started  and patients  and the physicians look for the completion of therapy. Certainly this is not true for high blood pressure or diabetes, in many cases the treatment is life long . But say someone has lung cancer  and we decide to have surgery  and so when the surgery is done  and that is successful, the so called treatment is over-complete. Pneumonia would be other condition . Do antibiotics  and the treatment is done with. But in some patients we end up having one thing leading to other. This is such a story.

    I saw this patient in my office who was seen by other lung specialist in past. She had abnormal CT scan of chest  and the physician had done bronchscopy  and she had MAC -the atypical TB called mycobacterial intracellular and so she was started on medications but somehow he did not do much follow up and so she came to me. She came to me . We did the follow up on CT scan and also did new sputum for TB bacteria  and then continued to do the follow up. She was doing OK  and at the end of almost 1 year of treatment we did new CT scan . The treatment for this disease is usually for 18 months , Or 6 months after the sputum is negative. This is done as the chance of recurrence is high if treated for shorter duration. The CT scan showed some worsening of the findings  and so I did do new bronchoscopy  and that showed that she still had MAC. So I added 4th medicine . So now she was on 4 drugs  and we had already exceeded 18 months . But then i did do new sputum check in 3 months  and that was negative . The scan was OK and she had no complaints. So we were happy  and we had plan to stop the medication in short time. But we did new sputum check  and IT SHOWED A DIFFERENT MYCOBACTERIUM.  

    So now we are stuck with treating her with NEW DRUG  and for HOW LONG ?

   But I know there is a light at the end of tunnel. 

    

Saturday, July 30, 2022

NON SMOKER AND LUNG MASS

     We often talk about the smoking and the lung cancer. The incidence of lung cancer is high or 20 times that of nonsmoker. So when we see a spot on the lung it is easy to make decision . But even though the incidence of cancer is low in nonsmoker, it is not zero. So the decision making is difficult. The general public has a belief that the incidence is zero. That brings me to  the story of today. 

    I saw this new patient 55 years old male who had abnormal scan. He had no major complaints  related to lungs, but in 2019 he had car accident and he had been to er and had work up. He had a CT scan of chest and that had shown a spot on the lung , size of dime. He was told to do new , follow up scans .He did not do any scan till now in 2022. It may have been due to the belief that the non smoker do ont get cancer or may be that it was pandemic and since he had no symptoms , he thought he was OK .Any way he did not do new scan till 2022. The scan showed that the spot had increased in 3 years and it was now of a size of quarter  the coin. His primary care physician send him to me. He had been non smoker and has no cough , fever , chest pain or weight loss. He had no shortness of breath.

   His physical examination was unremarkable . He was not on any medications. I saw the scan . The mass had increased  and so i had discussion with him  . I told him that we have to do work up and then decide if we can do surgery to take it out. The usual things that I tell patients is that we need to answer 3 questions , namely is is cancer , has it spread  and what is the treatment . So I have ordered  PET SCAN , a breathing test and bronchoscopy. There is a tumor called carcinoid which some people call a cancer which rarely spread or benign tumor which can spread . I thing it may be carcinoid and only 100% way to know is to take it out. When we tried to schedule the tests , he wanted to postpone them . 

    So there are 2 points , one is that if he was a smoker he would not have waited for 3 years to do new scan or see lung specialist  and now that we know THAT IT HAS GROWN he was not in hurry to take steps to take it out . This comfort comes from the feeling that nonsmokers are immune to getting cancer. He may have cancer or carcinoid , the slow growth rate suggests that this may be carcinoid , but one cannot be 100% sure till surgery is done.