Sunday, September 29, 2013


   In last blog I wrote about the new tests that are now available for us to diagnose the diseases and extent of the cancer .But these tests cost money and how we order them and how often we order and what information comes out of them that is useful for the treatment or telling the prognosis of the disease is very important . All of us know how we value the money . If I am spending 'my ; money for myself , I am very careful . If I am spending 'my ' money for someone else (say buying gift for a friend ) then I am careful , but not as much as I would be if I was spending for myself . And lastly when I spend someone else  money for a third party I care least . This last one is the politicians spending our money for some cause that will bring them more votes . I think in medicine I should add one more . When we spend somebody else's money for some other person and make money for our-self , then I am more likely to be more liberal than any other time . The case that I am going to tell is one such case , though I can't say for sure if it was the 3rd or 4th cause for  ordering of the test .
   I saw this 74 years old male with the diagnosis of pneumonia . He had cough , shortness of breath and had fever . He was congested and the X-ray did show pneumonia . He also had a history of laryngeal cancer and it was treated few years ago with radiation . He had follow up with the cancer doctor 2 or 3 months ago and no tests were ordered . He had not seen the throat doctor (ENT MD ) in last 12 months . He also had history of the Parkinson's disease . I did start him treatment and did a CT scan . The scan showed a "mass like density-consolidation right lower lobe of the lung ". The clinical picture was that of infection . But with his history of cancer , smoking in the past , and the CT scan finding , I had to rule out cancer . So I did the bronchoscopy . The bronchoscopy was negative for any tumor and all the biopsy , cultures came back OK . I spoke to him and his wife and told them that I was happy withe the findings. Due to the size of the abnormality seen on the CT scan , 6 cms ,I wanted to do follow up CT scan . If it was pneumonia , then it should get better and if it did not then I would worry about cancer and do a scan called PET  scan .
     He was discharged and I saw him in office for a follow up . I forgot  to mention that I had also a swallow study and he was not normal . The thin liquids were going down to lungs instead of the esophagus . So the cause of the pneumonia was the aspiration .He was doing good . Had no fever. Had minimal cough. I ordered the follow up CT scan in 2 months . He was suppose to see me after the follow up CT scan .
     He was admitted to the hospital with fever of 102 f and I saw him again . He had the follow up CT scan and the consolidation , which was 6 cms , was only 2 cms . "Significant improvement " was the report of the radiologist . I had seen it , but patient ended up in the hospital with fever . I did the new swallow study and it did confirm that he was aspirating . But patient and the wife did not want feeding tube and the speech therapist felt that we could change the consistency of the food and give one more try . He had fever due to aspiration and that caused the pneumonia . He responded to the antibiotics .When I looked in the computer  I noticed that the oncologist had done a PET scan , one week before the CT scan that I had ordered . The  PET scan had shown some uptake in the area of concern and the radiologist felt that the uptake was consistent with the pneumonia .I was not aware of the fact that he had seen the oncologist and they had ordered the PET scan . I wish that the PET scan was not ordered without doing the CT scan . The cancer does not go down in size from 6 cms to 2 cms . So if the oncologist or their nurse practitioner would have checked with the patient on the CT scan that was ordered , and waited for the results of the CT scan , then they would have seen that there was no need for PET scan and we would have not 'wasted ' $3000 for the PET scan .
     I am not sure if the PET scan was ordered by the doctor or their assistant. I am also not sure if the PET was ordered , due to lack of information or it was due to some other reason . But one thing for sure , it was done and  we wasted the money .

Friday, September 27, 2013


    I have been practicing medicine for a long time . Many patients and doctors are not aware of the fact that many tests that we order today or the treatments that we expect on day to day basis , were not there short time ago , like 30 years ago, There was no CT scans or MRI or PET scans , the stents that we expect for coronary artery blockage were not there .The simple Ultrasound examination came for common use in mid seventies , Ct scan in eighty and so on . So I often wonder how we functioned as 'good doctors ' in those (?good old days .)days . Were we smarter, or did we miss lot of stuff . Did we develop keen diagnostic sense , in absence of these super helpful tests .( like blind patients have other senses develop better than ordinary person ).So I am going to tell a story , where this is illustrated in the best way .
    This was a 72 years old male patient , who was admitted to the hospital with irregular heart beats , called atrial fibrillation . He was seen by the emergency MD , then the hospitalist and then by a cardiologist . Pt was worked up and the put on blood thinner and the heart medicines to control the heart rate and then discharged . He had 'routine ' blood tests , the chest X-ray and all was well . He had some arthritis of the hip and some back pain . He came back to the hospital with intractable hiccup . So again was seen by the ER doctor , hospital doctor , and was worked up and had a neurologist evaluate him too . The CT scan of the abdomen was done and a tumor was seen in the liver . The biopsy was ordered and I was called to see patient . The CT scan of the chest  was done  and  it showed a mass in the lung as well . Mind you this 'mass ' was not seen on regular X-ray . So the liver biopsy was done and I did the biopsy of the lung mass . Both showed the cancer and also indicated that it started in the lung . I was quite concerned about the extent of the cancer and so I ordered a bone scan and then MRI of the brain . To my surprise the bone scan was positive and even the MRI also showed 'multiple nodules consistent with metastasis '. I did the MRI of hip and spine and all showed the cancer . This is a guy who was in hospital 2 weeks ago , and was seeing his family doctor on regular basis and was getting regular physical examination and blood test every so often . But none of them were able to detect such a wide spread cancer . WE did not know and we would have NEVER KNOWN  the extent of the spread without these modern day tests . Our clinical sense was useless , until we did the first test of CT scan of the liver .
    So should we be doing these tests in every patient all the time ? I don't think so , but I don't have a perfect answer . There are number of studies looking at low dose CT scan done on regular basis in 'high risk patients '. But what about other cancers and what about the expense and the radiation exposure ? I truly don't know    

Sunday, September 22, 2013


   We as human beings want to be right all the times . May be it is related to our ego , when we are right , it gets satisfaction  or may be we enjoy telling " I told you so ", or may because we think we are smarter than other people. It does not matter , as to why we want to be right , but one thing for sure , we like to be right . It becomes more important if we are making money , like in investing in 'right' stock ' or 'real estate ' . or when people appreciate  our prediction being right .In medicine it nourishes my ego . I have written some incidences ,where i was very happy that my diagnosis was correct (and others had not suspected it ) , But today I am going to tell a story that was different .
    I had known this 80 years old female for last 3 or 4 years . I had seen her for pneumonia and then followed her periodically , though not that often . But I also saw her husband . He was coming to me for last 5 or 6 years .He had atypical TB called MAC . I treated him for a year with 3 different medicines and his CT scan had improved  . He hated the medicines due the side effects . But took them as I had told him . There is always a chance that the infection can come back , so I continued to do the follow up . He was 4 years older than her  and she always came with him and always had questions for me .
    Then it happened . She had some belly pain and her doctor ordered CT scan of the belly . With CT scan of the belly , some lower area of the cheat is also included . The belly was OK and her pain was gone , but the left lung showed some fluid  around it .So she came to me . She had no shortness of the breath, no fever or any other complaint . She was 'fine '. I did the CT scan of the chest and it showed the same fluid around the lung and no other findings, that could tell more as to why she had the fluid . I decided to do the thoracentesis , in which I take out the fluid by putting in a needle and catheter in the chest .She was going on a vacation and was anxious to get this done . So  I did it soon and took out 1000 ml of the fluid .She went out of the country for 2 weeks . The fluid showed the characteristics of inflammatory fluid . There was no cancer or TB . But cancer can not be ruled out 100 %by one test . So when she came for follow up I did a  new X-ray , It showed the fluid . The fluid that I had removed and the X-ray that had improved , was now cloudy and the fluid was back . I was not happy The fluid had come back in less than 3 or 4 weeks . I did not want to do the procedure again .So I suggested that she should see a chest surgeon . She wanted me to do. second tap .I agreed to it . The second tap yielded the same findings . The same levels of proteins , and no cancer or infection . She agreed to do a follow up X-ray . The X-ray was done . And it showed the fluid was there .This time I had taken out 1200 ml of fluid . I had talked to her several times and was telling her to get the 'open ' biopsy . My point was that , we did not know what was causing the fluid and we needed to 'fix' the fluid . In such case the chest surgeon would do the biopsy , and then put in a talcum powder . This causes adhesion and so the fluid stops coming back .We had no choice . I was worried that she had cancer , but was hoping that it would be an inflammation . She had no symptoms , so this could be a nonspecific chronic inflammation .
    She agreed and was seen by the surgeon . The operative note stated ,"clear fluid , no cancerous growth , proteinacious  material seen and biopsy done ."She did have talc put in and then in about 3 days was discharged .
    The biopsy came back as MESOTHELIOMA !! I had thought of cancer as the cause of rapidly accumulating fluid . But mesothelioma s not on my mind . So I was partly right , but not happy .

Thursday, September 19, 2013


  We in medicine or even in the general conversation  often say that it is not a gospel truth. So what do we mean by that ? I have used the phrase in my explanation of test results or medical prognosis with the same phrase . But I have found out one fact , when a test is new it is more likely to be more accurate in diagnosis of a disease or predict prognosis . But as we get more experience , we realized that the test is not as good as we thought it to be .Every time a new test comes out we think it to be a gospel truth , but as we gain more data , the reliability of the test goes down . Take for example the test  called PSA . When we started doing it to diagnose the prostate cancer , we thought that it could diagnose the cancer i overwhelming cases , may be 95 %. Now that we have been doing it for long time we have realized that it is not as good and then we also know that at mild elevation it is less accurate than at very high elevated level .The story that I am going to tell , is one such case of high expectation that did not turn out to be true /
    I saw this 63 years old white female for abnormal X-ray . She was admitted with the diagnosis of the pneumonia . She was a smoker . She had cough for long time , which she had attributed to her smoking . But it persisted and then her primary care physician did a chest X-ray and it was reported to show pneumonia . She was started on antibiotics . The X-ray did not get better and so I was called in I did the CT scan and it was looking more like a mass than like pneumonia . I did the bronchoscopy and biopsy . I did not see any tumor when I did look inside , but I still did the biopsy . It did not show any cancer . She did not tolerate the procedure very well . Her oxygen saturation had dropped and she started wheezing and was quite short of breath . I had to give her medicines and nebuliser treatment .She had bad CO PD . I had discussion  with her I told her that I was quite concerned about cancer , but did not have the diagnosis . She seemed to have very  poor lung capacity and so was not a candidate for the resection of the tumor or do open biopsy .So the other option remaining to get the diagnosis was to consider a needle biopsy . Unfortunately the tumor was not at the edge of the lung and the 'chance ' of collapse of the lung with the biopsy . And she had hard time with the bronchoscopy ,she certainly could not have tolerated the collapse of the lung . So after the discussion we decided to do the follow up as out patient and do the PET scan , which was new at that time . The PET scan is a biological scan . When we do Ct scan , we are looking at the structure of the various organs. But does not tell us as to what is the abnormality . PET scan shows the metabolic activity . Every cell needs glucose for the metabolic activity . So in the PET scan glucose tagged with nuclear material is injected . The uptake of the glucose is more in the cancer cells or infection or inflammation. So depending upon the uptake we can diagnose cancer . So we did the PET scan . It was positive in the lung spot , suggesting that it was 'most likely ' cancer  But it also showed that there was uptake in the left breast . The lung tumor was in the right lung and the breast uptake was on the other side .. So one possibility was that she had breast cancer and it had spread to the lung . The PET scan was suppose to be great tool . in diagnosis of cancer , may be 95 % . In a way I was happy . Please note that some nodes in the chest was also  showing uptake . So if she had lung cancer it was not operable . The prognosis with unresected lung cancer is worse compared to breast cancer , as latter responds to the chemotherapy . I sent her to a surgeon .
     The surgeon called me in next couple of days . SHE DID NOT HAVE BREAST CANCER .  As it turned out to be , she had breast abscess and not a breast cancer . The pick up that we saw on PET scan was not due to cancer , but due to infection . So PET scan was not gospel truth and it fooled us . She did have lung cancer .    

Thursday, September 12, 2013


      Today's medicine has become so specialized that no one wants to take care of the patient in it's entirety. I have noticed this last few years more  than in the past.I often see notes stating that " OK with me for the discharge ". But if one looks at the patient , then it is realised that there are many things that are going on which would be obvious to causal observer , like blood count may not be normal or need for oxygen may be high or something else. But at times the boat is missed .The story that I am going to tell is one such , in which case everybody did their job , but patient did not get the benefit from it .
     It was Saturday, and I had a new consult . The diagnosis was 'pleural  effusion ' patient had fluid collection around the lung . I don't like these types of consults on a weekend . This has nothing to do with the patients , but the difficulties that I have  getting things done on weekends If I decide to do the drainage of the fluid , then I need to get ultrasound tech to help me . On weekends there is only one in the hospital He may be busy doing ultrasound in ER or one for the admitted patients or in OB So I have to arrange it according to their schedule . They are very helpful and bend backward to to help me , but still at times it takes time . In any case I went to see the patient. She was a 47 years old female who was recently discharged from the other hospital with similar problem She had history of a heart valve replaced few years ago and was on blood thinner called coumadine . This is given to prevent a clot forming on the mechanical valve . The blood thinning prevents the clot formation, but also makes patient prone to bleeding .She had also history of hepatitis c . She was admitted to other hospital and was seen by a cardiologist , a gastroenterologist and a lung specialist . She had a large fluid collection and the lung specialist had drained a liter of the fluid 2 days ago She was discharged and was admitted to the hospital in less than 3 days .
      I saw her . She was as such comfortable , not short of breath at rest , but got short of breath on doing any activity .I reviewed the new X-ray and new labs , but also looked at old data Patient was seen by the same cardiologist who had seen her in the other hospital In his note he had written one line ,"cardiology stable " The note was dictated by his nurse practitioner  and there was nothing new in it than what was dictated in the other hospital . There were no diagnostic test or treatment suggestions . The admitting doctor had dictated the not , but in the plan of care , the plan was to get different consults . When I saw the patient she also had gastroenterologist's note She had some fluid in the belly and he had put her on some diuretics When I saw the patient , she also had fluid in the belly . The problem was more complicated than I had anticipated . Draining fluid was the least of them . The question was why ? Why did she have fluid , why did it come back that soon , what was the reason for the fluid in the belly and were the two related ?For me to drain the fluid I had to stop the blood thinner in the pill form  , put her on shots of the blood thinner . But she also had low platelets , which also help clotting . If the fluid came back so quickly , what good it wound do to  drain it again, unless I could treat the 'cause ' of it's formation In between I had requested the report of the CT scan of the belly It did confirm that she had fluid in the belly . She also had liver abnormality( that I had suspected ). So now it was more complicated , but it was becoming more clearer as to what was her diagnosis .
      My feeling was that she had hepatitis c , and now it had caused the liver disease, may be cirrhosis and it caused the fluid in the belly . There may be a hole in the diaphragm  and the fluid in the chest or around the lung was relate to the liver disease . The platelet count was low , due to liver disease and taking out fluid from either the chest or belly , would not help her She was going to need more than just a fluid drainage . She needed treatment for the liver disease . May be procedure to reduce the pressure in the liver , which had caused the fluid or may even a liver transplant . I did not think that there was a constriction of the heart , which might explain some of the symptoms . But it needed to be ruled out .
      I called liver transplant MD , had him look at the CT scans and .other labs and told him the story . He agreed to transfer the patient and then work her up and treat her .