Tuesday, April 24, 2012


    Sometimes when we see patients , and they ask about the 'prognosis ', we tend to think that we 'know ' the statistics and give an answer. And may be we are OK or right most of the times. But then sometimes we see patients that are so far from our 'understanding ' of the medicine or the statistics that we are proved wrong, and wonder why someone is so 'lucky ' or 'unlucky'. Then we ( at least me personally) tend to believe in the 'law of the karma ' . So today I am going to tell couple of stories of the patients that 'fit ' in this description.
    I was called to see this one patient who was post op. She was 68 years old and had belly pain .Further work up revealed that she had gall bladder problem and had stone in the duct of the gallbladder. So had the surgery to take the gall bladder, and the gastroeterologist did a procedure to take out the stone . The over all everything went well . But then 3rd day she got short of breath. So I was consulted . I saw her  in less than 15 mins , so no additional tests were done . She was mildly short of breath. She had quit smoking 20 years ago. She was wheezing a little bit and had lot of positive fluid balance. (her fluid 'intake ' was more than her ' output' ) . I ordered for the x-ray, some breathing treatments to help the wheezing and ordered for a 'water pill ' ( to improve urine out put.) I also ordered a blood test called  d-dimer. It is elevated in patients who has 'clotts' . in patients who have been not moving much tend to get clots in the legs and when it travels to lungs , it causes shortness of the breath and drop in oxygenation.The x-ray was normal and she responded to the water pill and felt significantly better in next 2 hours. However the blood test that I ordered came back elevated , meaning that there could be a clot somewhere. Sometimes it may be related to post operative status. But with the given history I could not let it go without any further work up . I almost felt guilty for ordering the test as by now she was off the oxygen and wanted to go home . I was forced to order a ct scan of the chest to rule out 'clot in the lung' As I expected the ct scan did not show any clot , this was 'good ' news , but it showed a mass in the lung . Mind you even when I went back and try to look at the previous x-ray I could not see the 'mass' . This means that she may have Cancer . She wanted to go home , so I discharged her and scheduled her for the further work up , which included a PET scan and a biopsy. She had Cancer and had good lung capacity  to resect it out . She was referred to a chest surgeon and a cardiologist . The cardiologist did a stress test to make sure that she did not have cardiac issues for the lung resection.
     She had the surgery and the cancer was resected , only thing which was not expected was that they had to take out entire lung, No cardiac problem or lung problems during post operative period . She was discharged and was doing well. When she went to the cardiologist, I have no idea why , but he ordered a holter monitor. This one records cardiogram for the 24 hrs period . She had absolutely no complained. To her and her cardiologist's surprise it was abnormal, It showed ventricular tachycardia and even some ventricular fibrillation !!!!THIS IS LIFE THREATENING AND SUDDEN DEATH CAN OCCUR.She had defibrillator put in , and is doing well.
     So now look at the 'Luck ' If I had not ordered the blood test, I would not have done the CT scan and the cancer would not have been detected , (as plain x-ray was 'normal '), and by the time she would have symptoms , it might have been to late.
      Not only that her cancer was detected unexpectedly, but the dangerous and lif threatening  arrhythmia was detected by 'accident ' . (remember that the cardiac stress test was 'normal ' ). So she must have had good or great luck .
     The one with 'bad luck ' next time.

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