Thursday, August 22, 2013


     As a lung specialist I often see patients with the complains of shortness of the breath . I have mentioned  many common causes of the shortness of the breath . I saw a patient recently saw a patient which had one more not very common cause .
     I saw this 67 years old female , who was referred to me by a cardiologist . She had shortness of the breath and some difficulty swallowing . She was seen by her primary care physician and had X -ray done . She had history of high blood pressure and was little obese . She also had hypothyroidism , low function thyroid , which I see in may be 30-40 % of the females that I see . She was referred to a cardiologist and he did the work up . She had echocardiogram , and a stress test and both were normal . The cardiac cause for the shortness of the breath was ruled out . So with her other complaints , he decided to referred to me and a gastroenterologist . So I saw her . There was not much in her history . I was sure that her lung would be 'clear ' as if there were some findings , they would have been picked up by these 2 physician . So I was thinking about doing the breathing  tests and some other work up .I had not examined her yet .
    So when I started examining her . I put my hand on her neck . I normally check for the lymph nodes and the thyroid . I was surprised . I felt a  Hugh thyroid , some what firm . It was extending way out of it's normal position . I knew why she was short of breath and may be why she had some difficulty swallowing . I asked her if she knew about her thyroid . She told me that she had a condition called Hashimoto's thyroiditis . This is a condition where patients get inflammation of thyroid and it enlarges . It may be tender . This is a condition , where there are antibodies against the thyroid and then they attack the thyroid and then over period of time , patient gets low functioning thyroid as the thyroid is damaged . So the history of low functioning thyroid was true , but the cause for it was not common . When thyroid has this problem and then it is under functioning , it becomes big . In case of this patient it was HUGH . I told her about her about my diagnosis . I was worried about the enlarged thyroid pressing on the trachea , the wind pipe and causing the shortness of the breath .I ordered the CT scan of the neck and the chest , as I was worried that the enlarged thyroid might be inside the chest . I got the CT scan reports . Both the suspicions were correct . There was big thyroid and it had deviated the trachea and it was so big that it was extending to the chest .
    I called a thyroid surgeon for the surgery .This is one of these unusual causes of the shortness of the breath where there is a mechanical cause out side the lungs and lungs themselves are OK .

Sunday, August 11, 2013


    Many of us know that when we breath the Helium , our voice changes . We have tried this when we were kids , and it was funny to talk in a different voice , may like a duck . The reason is that the helium is less dense than the room air . This has been made use of in treating asthma . When we breath the 'lighter'  gas , then the resistance to the air flow is reduced . In case of asthmatic attack , the bronchial tubes are in spasm . So the  person who is in attack , has shortness of the breath . This feels like breathing through a straw . So when the patient is given the lighter gas , like Helium , the resistance to air flow ( or the gas flow ) is reduced and the shortness of breath is improved . This is a short term solution . As the treatment improves the narrowed airway, then helium is discontinued .But today the story that I am going to tell is very different .
     I had known this patient , we will call him John . He was diagnosed to have advanced COPD . This was due to his  smoking in the past . He was on oxygen all the time . He was diagnosed to have got a lung cancer about 3 years and since he was not a surgical candidate , to re sect the tumor , he got radiation treatment and that seems to have 'cured ' him . Recently he was having some more trouble . He had a respiratory infection , and he continued to feel poorly and more short of breath . We gave him an antibiotic and a another , added several courses of steroid and he was still not his 'usual' . I continued him on the steroid for long time and gave an appointment in 6 weeks or so . So when I saw him in office in less than 2 weeks , I was surprised . I asked him as to why he came so soon . His wife started telling me the reason . But she did not have to describe his problem , as when he started talking , I knew why he was in my office soon . His voice had changed . Now many a timed when patients have a lung cancer and the voice changes , we suspect an involvement of the nerve going to the vocal cord . The nerve that goes to the left vocal cord has a long route , It goes down in the chest , then winds around the left main bronchus and then goes back to the neck and goes to the vocal cord . So during the long course of the nerve , especially in the chest, it can get caught in the cancer process -spread and then the voice changes . But his voice change was not like that , but was more like the one that we have with the helium inhalation . They both had noticed it and so though he was not more short of breath , he decided to come to office . I listened to his lungs and they were clear and there was good air movement.  His oxygen level was OK too . But when I felt in the neck , I could feel the air in the soft tissues of the neck .
     THIS WAS THE CAUSE OF HIS CHANGE OF VOICE . He had ruptured  one of  the air sacks and the air had leaked  in to the neck . Some how it was causing the voice change . I am not sure how the voice change ocures, but I have seen it . So I decided to get him in the hospital . for the observation . Fortunately his lung had not collapsed , and he did not need much intervention. We did the CT scan of the chest and the CT scan of the neck , and it confirmed the diagnosis . He was released in 2 days , and is doing fine .The cancer that he had , had nothing to do with his voice change (thank God ).

Thursday, August 1, 2013


      I was reading the chapter 18 of the Bhagawat  Geeta , and I was stunned by the shloka 66. In this shloka the Lord Krishna states that "let go all other Dharmas, and remember me alone .I(If you do that ), I will free you from all sins .Do not grieve . "
      I am not sure why  all the scriptures are written in symbolic way, as anyone can interpret it as he or she wishes . Does this not sound like any other religion ?The christens believe that Christ is the only God and the savior , the Muslims believe that the Allah is the only God and Christ is 'messenger ' and every other religion believes that their religion is the only  one and their God is the only God to be worshiped , For me there is one more problem . When the Lord states that if you surrender to the God , then all the sins will be forgiven, then what happened to the Law of Karma . Does this not sound like the God father , if you surrender to Him , then he will 'take care ' of every thing . Is He claiming that the Hinduism is the ONE that everyone should follow and not worry about any other religion? From what I know about the Hinduism , it can not be the correct meaning.
      If my understanding of the real religion is correct , than this does not sound correct . Every one must pay the price for the action either in this life or next or next . If you read the life of Lord Krishna , , he had to repay all the debt , before he died .( as he was born as a human being). We also believe that everyone has a choice . We can follow different paths , and all the paths will meet the same goal of reaching Him . We can follow the path of knowledge , or devotion , or action , and we will achieve the same goal .So then how can one God be better or stronger or forgiving etc?\
      Let me try to explain . There are many meanings of Dharma . One of the meaning is the religion . But we also use it in other ways . When I say that the wood floats on the water as it is it's dharma or Gunadharma . The Snake will bite , even if you do not harm or threaten it as 'it is his Gunadharma ' , the character  or  nature . We also talk about the Dharma in other sense . I have a dharma to be a good father  or good husband or good son or good neighbor and a good citizen etc . So I have various duties , which sometimes are referred as Dharma . I have to follow these all different duties , as otherwise I am committing sin . One may say that in the same connection that for me to be a good husband or son or a family man , I must make money , have sex , 'collect' thing etc So these are our different Dharmas . The lord id telling us that ultimately one has to forget all these things , then and than only we can achieve Him . Does this mean we should not do any of the duties ? No . It means that we should do all the duties , but not get attached or involved or may be at one or other time 'give it up ' .We get attached to all these Dharmas ,and believe that it is our true nature . The LORD is telling us to forget it all and think about HIM and only HIM .Then all our sins that may occur when we don't do our duties , will be wiped out. Again he is not advising us to forget our duties . He wants us to consider our only 'real' duty to be one with Him .We mistakenly think that our body is our soul and so we feel that we must full feel it's desires etc . 
     The law of Karma will apply , but if we do things , act without the attachment , then the law of karma does not affect us . So if we continue to do our daily duties , without the attachments , we will not have committed  any sin I can describe this time of behavior in one line --one of the old song of Raj Kapoor , MUD MUD KE NA DEKH . . Enjoy the  good food , good music good beauty , but don't get attached , or turn around and think about it and get attached .