PUT YOUR THINKING CAPS

      We often are told to 'put thinking caps '. This is so true when we talk about medicine . Unfortunately today thinking is left to the tests that are ordered or the computer for the 'pathway' for the diagnosis. Many a times if there is no test to be ordered then patients are told "everything from -------(cardiac or pulmonary or gastroenterologist etc ) is OK ".Many a times we don't try to find out if there is any reason that can be treated. I do see patients that are out of shape and have what I call 'deconditioning 'i.e. opposite of conditioning. This can happen to many of us as we decrease our activity as we are too busy or we have arthritis or we are too lazy . I don't tell anybody , without doing 'tests' that they are out of shape .This is a story of one of my patients , where 'thinking ' not a new test or a new scan helped .
      I knew this 79 years old male for a long time . He had severe COPD. , from smoking in the past . He had some increase in shortness of the breath .I did the work up and found out that he had a narrowing of the aortic valve .He was seen by a cardiologist and was advised to have surgery. I was concerned about it,as he had very bad , advanced lung problem. I told him that his shortness of will not improve much or dramatically as lungs are not going to improve . I did 'clear' for the heart surgery . He did very well after the surgery and in fact his shortness of breath also improved .
     He continued to do well. But then about 8 or 9 months down the road he started feeling shortness of breath. His lungs were clear and his oxygen was good and when I made him walk for 6 mins , he got short of breath , but oxygen did not drop.I did the breathing test and it was actually little better than before . So I came to dead end . I had sent him to a cardiologist , who told him that " the heart was OK ". I was stuck . So when he came to see me and was still was short of breath , I suggested him to see a different cardiologist .The 1st cardiologist had not done any test and I was concerned about the heart . I talked to this new cardiologist and told him my concerns . He saw the patient , and called me . He told me that he will be doing a echo cardiogram , but did not feel it will show any thing significant . He told me what he thought was the cause of his shortness of the breath .The patient was put on a drug called beta blocker . This can cause lung problem in some patients (which was not the case in this patient ) ,but it can decrease the heart rate .o when this patient was exercising ,beta blocker would not allow his heart rate to go up , which is essential for  providing more blood that is required to avoid shortness of the breath . So when he reduced the dose of the medicine ,his shortness of breath improved . So a minor change ,changed the shortness of the breath .
      So put your thinking caps, whenever you are faced with what looks like a difficult problem .