Wednesday, May 2, 2012


   Sometimes doing nothing is the best approach, But in today's medicine practice, which is 'procedure ' oriented or because it is more to 'do things ', or the primary care physicians expect   consultants  to do things , whatever may be the reason , everybody tends to do  more procedures than do the thinking to see what may be the reason for the problem . This very similer to writing a script than to listen to the patients and do the proper advice.. This is more obvious to me in cases of pleural effusion or the fluid around the lungs . I have seen many patients with the pleural effusion and elected to do nothing or at least not do the procedure to take out the fluid.
    I saw this young lady, about 33 years old , for abnormal x-ray. She was diagnosed to have a 'Lymphoma ' --a malignancy of the lymph nodes , about 2 years and got the chemotherapy. She did very well and was in remission . She felt good and had no fever or cough . Her appetite was good and she had gained some weight since being off the chemotherapy. As a routine she had PET scan and then a chest CT scan. The pet was OK but the CT scan showed pleural effusion , fluid around the lung . She was not much short of breath, but did find some shortness of the breath an exertion. She was referred to me to see  if she needed to take out fluid. The oncologist was concerned about the recurrence of the lymphoma.
    When I saw her I was concerned too, but things did not look like she had lymphoma again. She did not 'look ' sick ', did not have fever, weight loss, her appetite was good and more than this her PET scan was 'good '. Even though PET scans are not 100 % they are quite reliable , may be 90% accurate in picking up malignancies.. But then there was this pleural effusion. I still had no idea , why she had the fluid . I   looked at the CT scan again . And it struck me . She had a port put in for the chemotherapy. When patients need chemotherapy , it causes sclerosis of the veins and even drawing blood is also very difficult. So we put in a semipermenant intravenous line which is called a port, This is put under the  clavicle bone in a vein called subclavian vein . So she did have a port. My thinking was that the port had caused the 'narrowing ' of this vein .  The veins drain back the blood , which goes to various organs by arteries. So if one has partial blockage of the returning fluid or the venous drainage the pressure would go up and the fluid will 'go out ' of the circulation and this could cause the pleural fluid .
    I told her my theory and told her that I  was going to schedule for a test to confirm my theory and then have radiologist put in a 'stent' to open up the blockage . Off course the port has to come out . This will help and 'cure ' the pleural effusion .
   I am glad to let you know that my  hunch was  correct and she had the venogram that confirmed the narrowing of the veins. The radiologist did put in a stent and that solved the proble. The pleural fluid disappeared and she did not need me to drain the pleural fluid .

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