Friday, November 23, 2012


    I have often said that treat patient as a patient , not only from your speciality stand point , but as a patient , who has medical problem . We all sub specialist are physicians first and specialist or sub specialist latter .We all do medical training , first as Internal Medicine ,so we should be in position to diagnose , if not treat everything in an expert way . We may not know be in position to know all the details of the treatments of all the diseases , but we should be in position to help diagnose . The case that I am about to tell is one such case .
    I had known this 70 years old patient for few years . I had diagnose him to have a lung cancer . Fortunately for him he was operable . We were in position to operate and resect the cancer . I did continue to see him for a while . He continued to do well and was followed by Cancer doctor , an oncologist .
    When I saw him after a gap of 2 years , it was because he was short of breath . It had started suddenly and his oxygen was low . I saw him and did CT scan . It surprisingly showed a metallic object in right bronchus . He had lost 2 lobes out of three  lobes . So he was left with only one lobe , which was blocked by something and so he was short of breath and oxygen was low . I did a bronchoscopy    and saw the obstruction . IT WAS A PILL .I tried to take it out , but was unable to do so with his oxygen dropping . Finally we had to do it under anesthesia . .He did well and was discharged . I saw him once in my office . He did not see me for almost more than year and a half . He came to office as the oncologist had done a CT scan and it showed fluid around the lung . He was mildly short or breath. On examination the lungs sounded clear . There was mild reduction of air going in the right lung . The CT scan had shown a pocket of fluid on the top part and 2 other pockets on the lower part .When I started to check his blood pressure , I noticed that his arm was swollen on left side . I asked him about it . He noticed a week ago and it got gradually worse . He had kidney issues and his kidney function was quite compromised .So when he saw the kidney doctor , he called the cancer doctor and he had test (called Doppler ) to rule out phlebitis or a clot in the arm , that could explain the swelling . It was normal . So then CT scan was done and it showed the fluid and he was asked to see me to take out fluid . I asked him on the cause of the swollen arm , and he did not know . I asked him if any other test was ordered , to find out the cause of it ,he said no . I was surprised.I was not sure what was the cause of the swelling, but suspected that there must be a blockage to the blood flow return deeper that what was tested . But I was not sure why  there was no swelling of the right arm as the deeper structure called SVC , drains all the blood back from both upper extremities and head . So if it is blocked , why there was no swelling of right arm ?
    I called a vascular surgeon , but when my secretary called the office , they got appointment after 3 weeks . I called a cardiologist , who does vascular studies , but he was out of town . So I called his associate and he agreed to see the patient . He saw the patient and did the Doppler of the same left arm and did echo cardiogram . He told him that his heart was OK and the swelling was not due to heart and may be due to kidney problem . I was not happy . I called a radiologist who also does lot of vascular interventions . He was very helpful . I told him that I was suspecting the blockage of the SVC .He looked at the CT scan that was done earlier and told me that my hunch  was most likely correct .. Unfortunately he could not do the study and treatment on Friday . I decided to admit the patient on Sunday and he agreed to do the procedure .
   I am glad to tell that the test was done and there was blockage of the SVC and he did stent it and the swelling got resolved in 3 days .
   I had said it in the past , " your eyes can't see what your mind can't think ."Otherwise I am not sure why it took so long and 4 doctors to solve the problem .

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