IT IS ELEMENTARY

      I often say that the  'base ' of any thing should be solid . If the base is not perfect then further knowledge will be difficult to understand and one may forget it . This so true of every subject , but more so when one is practicing medicine . I was fortunate enough to have some of the great teachers and that helps me even today . I practice pulmonary medicine , but I still come across the other medical issues that need general medical knowledge and invariably I come out to of help in getting to the bottom of the problem . The story that I am going to tell is one such incidence.
    I was taught by an endocrinologist  named Hyneman . I still remember what he said 30 years ago . He had told me that do not let urologist touch your patient with kidney stone,unless it is obstructing the urine flow .
    I saw this 37 years old male who had myopathy --progressive muscle weakness which had led him to be  a wheelchair bound .I saw him and talked to him about some help for his breathing on long term , with a machine and Tristam in future . He was not ready for either. The next time I saw him was in the hospital , when he was admitted  due an abscess. The surgeon wanted to drain it and needed respiratory help . I saw him and did some respiratory treatments and he did fine with surgery. At that time I came to know him and his wife more . We talked about his condition and why was he  ' suffering ' . She was somewhat familial with eastern philosophy and the 'law of  Karma '. She had accepted the situation , but enjoyed talking to me . He was musician in past and so we also talked about Indian classical music and how it is composed.
     After discharge from the hospital they did come for a follow up . It was routine follow up . He was found to have a kidney stone . The urologist was consulted and he was going to have 'blassting of the stone ' called lithotrypsy. From lungs standpoint I had nothing to add . But when I heard about the stone I could not keep quiet . I told him that the stones occur due to a " cause " and if we don't find the cause and treat it , the stone will recur. I also told him that in his case , due to immobility , the calcium from his bones could be taken out , which can increase the blood level of calcium and that could lead to kidney stones ,which will be calcium stones . So it was  important to analyse the stone and find out if he had calcium stone and if he did we could treat and prevent  it.
      I did not see them for a while . But then he came for the follow up . There was no new lung issue . But then the wife told me how they had followed my advice and gotten the stone analysed . It was a calcium stone . Further work up revealed that he had a parathyroid tumour. (The parathyroid glands are located next to the thyroid gland in the neck and are responsible for the calcium metabolism . A benign tumour called adenoma could lead to excessive secretion of the parathyroid hormone called PTH and this will increase the level of the blood calcium and can cause the kidney stone . ) He was referred to a local doctor who saw him and felt that he was too high risk to be operated . He was referred to a university centre . He was operated by a surgeon under local anesthesia and did great . The parathyroid adenoma was removed and the calcium was normal. The great part of the story was that I had not forgotten the teaching and when I told them about the possibility , they acted upon it and in spite of his disability , he had the surgery and had the ' cure ; of the  kidney stones .
     THEY HAD SIMPLY HAD COME TO TELL ME THE SUCCESS STORY .
     AND I WAS HAPPY THAT I HAD GREAT TEACHER IN DR. HYNEMAN.
     IT IS ELEMENTARY AS SHERLOCK HOMES SAID