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 . 

  

THE GOOD AND THE BAD NEWS

      In medicine we often say there is a good news and a bad news. Many a times when I see patient who has abnormal CT scan and then we do the work to get diagnosis, and then the biopsy shows cancer, i sometimes say that there is a good news and a bad news . The bad news is that he has cancer but the good news is that it has not spread anywhere and we can do surgery. But sometimes the situation is different. That brings me to the story for today. 

    I saw this patient who has been a smoker in past and had chronic lung disease, COPD. She was doing good. She had routine Chest x- ray and that was abnormal and so we did do a CT scan of the chest done and that showed a mass . We did usual work up . She had PET SCAN and had  breathing test and also Biopsy. The PET scan showed activity in the central mass on right side and also some in thyroid . We did do the biopsy of the lung mass and that was lung cancer . The thyroid biopsy was also positive for cancer. The tumor in the lung was such that it had spread to nodes in the center of the lung  and so there was no way we could do the surgery. So we decided to do radiation and chemotherapy. The tumor was blocking the bronchial tube and so I we asked for radiation treatment . She had both and did well . 

    The new scan showed that the mass was smaller  and uptake was also reduced . So she was doing good , but she had cough and that was bothering her. She was treated with steroids and she felt better but still had cough. So, I decided to do bronchoscopy  and that was to see if she still had tumor.. What I saw was a significant narrowing of the bronchus which was blocked by tumor. The opening was so much narrowed that I could not see beyond it . It was inflamed  and that probably was the cause of her cough , So, the cancer was not there but the radiation had  killed caner , but also caused narrowing  and so she had cough . 

    There was no medical treatment for such mechanical blockage. I am not sure if we could dilate  it and open it.

 SO THE GOOD NEWS WAS THAT THERE WAS NO CANCER , BAD NEWS WAS R=THAT SHE HAD POST RADAIATION NARROWING WHICH MAY NOT BE IN POSITION TO OPEN UP.

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.