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 .  

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