Saturday, November 30, 2013


   I was reading a book . This one I had heard about sometimes ago and scanned it at one time . But I did not read it till few weeks ago . It is written by an Indian lady , Bhawanagari and the title of the book is The Laws of The Spirit world .This is some what unusual story . The author's two sons died in a automobile accident . Then she came to know from some one that the 2 sons wanted to talk to her . So they did what is called auto writing . The mother would put the pen to the paper and then it would write automatically . Sometimes she would ask questions and the sons or the spirits would answer .The book is interesting and makes one think .It supports some my thinking or or understanding . AT times it does not support my understanding . For example I thought that the way in which we come back is due to our Karmas and our attachments , and the way in which we are born in a particular family is due to our 'debt ' to other people and a chance for us to repay the debt . It also is conducive to have effects of  our Karma come to fruition . So it is very likely that we may have our relationships continue in next life as our attachments and debt is maximum with our close family members .Due to our attachments we really have no 'choice' in rebirth . But according to this book ,spirits have a choice and if they do not want to be reborn , they don't have to . The only reason they come back in physical world is to improve the soul .I can understand the latter part , that in spirit world we can not improve or uplift our soul quickly as we do not have physical body . Think about it . When we help some one on the earth , majority of the time we are helping the physical need . i.e. giving food to hungry , or providing shelter to homeless or helping sick .All these things involve physical or bodily help . It does not do anything to uplift spirit. So if we do not have physical body , how can we help to 'score ' good points to uplift ourselves ?
   The part that I do not agree is the one where it states that if we do not want to be born , we don't have to and that we can 'select ' our new mother ( not the father ).I thought that we 'develop ' 'debt' to each other and develop attachments , this is the 'force ' that brings us back in the same network of people . So in essence we will have same circle of people in each life to which new ones are added and some are deleted . The cycle ends when the sum of all the attachments is zero . and we do not have any desires left at the time of death . The book does not say any of these things .
   It has more moral laws and describes the spirit world which is similar to our world on the earth . It has hall of rest and a hall of learning and it ha s a record keeping place . I do not agree with this type of structure . Any way I think the book is good and it makes one think about our own life and behavior. 

Thursday, November 28, 2013


   Sometimes I feel that may be I am obsessed with the idea that critical thinking is important and I may be mistaken that I am the only one who does it . But then I come across a patient , that tells me that everyone is thinking about their system or specialty, and not thinking about the patient as a whole . In past we talked to the primary care physicians as they were actively involved with the care of the patients. But now a days no primary care physician is admitting patients to the hospital and do not come to see the patients . We now a days have 'new breed ' of physicians called hospitalist , many of whom are family physicians by training and as such are taking care of adult patients . In training , the family practice they are taught to to take  care of all the aspects of all the age groups and sex . So they have  training to deliver babies , take care of children , women and adults . But it is not a specialty to take care of complicated , very sick patients . This is not to say that they are not good doctors. I know of several family doctors that are so good that I would not hesitate to go myself or send my family members . Now a days there is a special training to be a hospitalist .May be things will improve . The story that I am going to tell is one such where physician extender providing care and each one looking at his or her own branch becomes an issue .      I was seeing this 71 years old lady for abnormal chest CT scan . It turned out that the  paitent's abnormal X-ray was due to an abnormal protein in blood that can cause enlarged lymph nodes . I was following the X-ray and I had ordered one .The chest X-ray showed fluid around right lung . This was new finding . I forgot to mention that she also had a leaky valve . So I started her on water pill and decided to do a blood test for congestive heart failure . As expected the test was abnormal and so as per my expectation she should have respond to the treatment . I was to see her in office . She saw the cardiologist . or the physician's assistant . He decided to change my water pill order and started her on two different water pills in much larger doses . I am not sure why did he do it . ( his note that I got did not show any rationale as to why he did it ) . She came to see me and was very weak . Her blood pressure was low and she was feeling worst than better . I told her to stop the new medication and ordered a blood test to check on her electrolytes .The blood test was done , but she felt so bad that she ended up in he ER and was admitted to a different hospital . I do not go to that hospital She was seen by kidney specialist and the same cardiology group and by different lung specialist . Her salt in the blood was very low and the lung specialist drained the fluid from around the lung . With the treatment she got better and was discharged .It was felt that the fluid was due to congestive heart failure , but no one tried to answer as to why she suddenly had congestive heart failure .
   She saw me after the discharge and I got the records and asked her to do follow up chest X-ray and asked her to see the cardiologist , not the PA . I personally called him and told him that we need to asses the leaky valve as may be it was getting worse and she may need the work up and surgery to fix it . She did see the cardiology PA again and nothing was done . She was readmitted . This time she came to the one that I go to . So I saw her . The story and the findings were same . She had low salt , fluid around the lung and very very high test for congestive heart failure . The same group of doctors and the PA saw the patient and I also saw her . The hospital doctor called me and wanted me to take the fluid out . My point was that we knew why she had the fluid and we needed to address as to how we can stop it from coming back . The kidney doctor started her on  pills of salt, 4 grams a day (while she was on salt restricted diet of 2 grams ).and started her on Intravenous saline . When I saw the patient her condition was not better and the blood test on congestive heart failure was higher . (normal 800, she came with 10000, and now it was 18000.) I called the kidney specialist . I told him my concerns , that her congestive heart failure  would get worse with this  treatment . He agreed , So I stopped the Intravenous fluids , cut down on the salt pills and did drain more than 1 liter of the fluid . I had noticed something else in her blood tests . I had talked to the cardiologist , but nothing new was panned by him as " echo cardiogram " was not bad . He did not know why the patient was being readmitted for congestive heart failure. As I was mentioning, I had noticed other blood abnormalities . Before I do the drainage of the fluid, I check to make sure that blood clots normally . Her clotting was not normal . I did do the drainage of the fluid , but also ordered the teat to see if her liver was normal . The usual blood tests for the liver were OK . She had no history of hepatitis or excessive alcohol intake . So there was no reason to suspect the liver disease . But with the abnormal blood tests for the clotting , no obvious cause for the worsening "congestive heart failure " , low sodium for which we did not have obvious reason , liver disease was a good possibility . The test confirmed that she had cirrhosis of the liver . I had started her on the different water pill , in anticipation of the liver disease , and she started getting better . In nest 3 days her sodium became almost normal .
     In next couple of days she was discharged . I gave a script to do blood tests every week to check on sodium .
     So we were thinking about congestive heart failure due to leaky valve and elevated blood test called BNP .Though she did have probably both of these conditions , her fluid , low sodium were due to liver disease . Treating low sodium with salt pills , or Intravenous saline or treating as Congestive Heart Failure , would not have helped. We got the diagnosis only after critical thinking.

Monday, November 25, 2013


     I used to tell nurses that one must do 'critical thinking ' One may ask as to what is difference between regular thinking and critical thinking? This was very important to me or to other doctors . We often get calls at night regarding patients . It is difficult to 'use' some one's eyes to know exactly what is going on . So it is very important to for a nurse to tell me exactly as to what is the problem and what is the possible diagnosis and what should be done . So I used to tell them on various cases and how to think and direct us to the right treatment . This then turned to be what is now called as SBAR. S stands for the 'situation ' B stands for background ( of the patient , like patient has history of congestive heart failure or GI bleed etc ),A stands for assessment (what is the impression of the nurse ) and lastly the R stands for the recommendation .(what is the nurse suggesting as the treatment ) . Now a days we have rapid response team or a nurse , who is a nurse from ICU and can give better assessment and advice . But what I want to do is consider this as a class to medical students.I feel that sometimes even many treating doctors . I am going to tell a story of a patient , that this will be obvious .

     I was called to see this young 50 years old female patient who was admitted with chest pain . She was nonsmoker and ha d not seen physician and was taking any medicines . She was not on birth control pills and was not sedentary . She had  a CT scan and it showed blood clot in the lungs . She was also anemic . She was admitted to hospital and the hospital doctor ordered 'blood thinner ' and gave her blood transfusion . I was also called to see patient . I did not not see any work up for the anemia or as to why this lady would get a blood clot in the lungs . When I asked her as to what was going on I realised that she was having heavy menstrual periods and that is why she had drop in her blood counts .I ordered the work up for both anemia and blood clot. I also called a hematologist , a blood specialist .He saw a patient and changed the blood thinner to a new one that does not need monitoring the blood thinner ( yes the one that is advertised on TV ) I talked to the patient next day , and then called the blood specialist . My concern was that with blood thinner on board, , she would bleed profusely with her next menses . So in my estimate , we needed  Gynecologist to check her out ( as the  pelvic ultrasound and it showed  enlarged uterus and big fibroid)  Using a long acting blood thinner without controlling the menstrual bleeding would not be a good idea .
   So this is critical thinking . Everybody knows that blood clots are treated with blood thinner and anemia needs blood transfusion and some work up . But to change the standard treatment to avoid complications that could occur withe the treatment . THIS IS CRITICAL THINKING .  .

Saturday, November 23, 2013


   We now a days have many specialists . In past , we had family doctor and he took care of everything . If he refereed a patient to a specialist , and the specialist advised a test , the patient would go back to the family MD to make sure that the test that was ordered by the specialist was needed and should be done . That kind of trust is gone , but those family physicians are also gone .Even when the specialist saw the patient , he looked at the entire medical history of the patient . Now a days this has not remain so .It remind me of my residency training days . We had a radiologist who taught us the reading of X-rays . He used to put a chest X-ray on the screen or viewing box , and one of us had to go in front of the class and read it . You are already nervous and not sure about your ability to read a X-ray . I was asked to read one . I saw the X-ray . Did not see anything wrong or abnormal in lungs or heart or any other area .  Then he pointed out to the entire class that the X-ray abnormality . Even though it was a chest X-ray , and there was nothing wrong in the lungs or heart , the X-ray did show the fracture of both humerus . Obviously trying to concentrate on lungs I had missed the 'out side ' bone abnormality, which was as clear as bright Sun . Since then I have tried to see patient in it's entirety, rather than sticking to my speciality .
     The story that I am going to tell is one such story , where I spend more time trying to figure out as to what was happening with the patient , which other consultants had not .
      I saw this 61 years old patient in my office , sent by a cancer doctor . The patient had back pain and was to undergo a back surgery . The routine blood test showed that his white cell count was very high . So he was sent to the blood /cancer doctor . He did CT scans of chest belly , brain and some blood tests . The CT scan of chest showed a nodule and so he was sent to me . Patient had also seen a gastroenterologist for difficulty swallowing . He did the upper and lower endoscopies and told the patient , that nothing was wrong . Did not try to find out as to why he could not swallow . The endoscopy did not show any blockage or tumour , so his job was done . I had noticed some bulge in lower part of the neck . So I mentioned it to patient that we may need to have him see Ear Nose, Throat specialist . He told me he had seen one , who had told him that he 'scraped' his vocal cords and they were OK . He was smoker . He had lost 30 -40 lbs . He was unable to eat , swallow and had some shortness of the breath . His examination was positive for what I originally thought was a mass in the lower right neck . But on further examination , it appeared that the mass was deeper and it was pushing the what could be the right side of the thyroid upward . So the mass that I was seeing was the pushed up thyroid . The lungs were clear . The Ct scan also showed that there was a mass on the right side and it was pushing the thyroid . This mass was about 5 Cm in size and the nodule was 1.5 Cm . The mass was next to the 'hard ware ' that was put in when he had neck surgery . I called several doctors . The first one was the radiologist . He looked at the CT scan and told me the details of the findings , which gave me some idea as to how to proceed and why he was having the swallowing difficulties . Then I called the surgeon who had done the surgery and the gastrienterologist , who had done the endoscopy . He told me that there was no explanation for  his problem . I also called the ENT MD and discussed with him the CT scan finding . I decided to do the PET scan and the bronchoscopy . My thinking was that this smoker may have a small lung cancer , which had spread to the lymph nodes that were so big that they pressed his esophagus or the food pipe and so he could not swallow . I was not sure if it had anything to do with the neck surgery . The PET scan ,which picks up cancer in 85% of the cases . It was positive . The bronchoscopy was OK . So I had radiologist do the biopsy of the neck mass and it showed the cancer .
     I called the radiation oncologist , called the oncologist and the gasroenterologist . He will start radiation , chemotherapy and will need feeding tube to avoid worsening of his swallowing problem in the initial course of the therapy with the radiation therapy .     

Friday, November 22, 2013


    I have  almost always believed that when patient says something , we as physician should believe in it . I think patients know their bodies and can direct us to correct diagnosis , if we pay enough attention .Now there are exceptions to the rule . But in many cases patient will be right .Now there are patients who may have 'drug seeking behavior or they may be 'malingering ' . But these are exceptions to the rule . I have tried to practice , what I believe .So this one story is how I almost did not believe , but still follow my dictum and got the diagnosis .
    I was called for a consult on this 31 years old female who was admitted with cough and had diagnosis of pneumonia ..She was somewhat obese lady who had delivered about 9 or 10 months . She had gastric bypass for obesity and had lost more than 100 lbs , She had no other history . Her main complaint was that she had pain on left side . The CT scan done had shown no clot in the lung and had shown the pneumonia . Her physical examination showed that she was wheezing and could not take deep breath due to pain . She was started on antibiotics . She did not have much fever . I started her on a short course of steroids and continued the antibiotics .Sometimes when patients have pneumonia , they have pleurisy , and so they get pain . Next day when I saw her , she was better . I had also given her some inhaler and treatment for asthma type symptoms and she felt much better . We continued the same treatment for the next 2 days and then as she was better and had no fever and had all 'cultures ' negative switched her to oral medications and discharged  her .
     She was put on antibiotics and short course of steroids . She came back in in less than 2 weeks . She had completed the course of antibiotics and the steroids and then started with the pain , lot of cough and so decided to come to hospital . The chest X-ray was better and there was a repeat CT scan and that showed 'improvement ' in the pneumonia . Her white cell count was normal ( which goes up with infection) , her X-ray and CT scan was better and there was no positive culture . We restarted her on antibiotics and consulted Infection Specialist .He suggested to do a bronchoscopy . I did not think I was going to get any more information , but I did it . There was lot of inflammation in the bronchial tubes . All the cultures , including vial cultures and TB and mold , came OK . I did check on her immune globulin.Sometimes when patients have deficiencies of these special proteins , they can get frequent , unusual infections . But they came back as normal . By now her X-ray was almost normal and there was no wheezing . Her white cell count was normal . I had also done a test for lupus and it was OK too . Her cough continued and she now had pain on both sides of the chest due to coughing Now she started having headache . So I did sinus X-ray . It was normal too .So now I was lost . I had told her that she had pneumonia and may have asthma and the cough will continue for next 2-3 weeks. Once the inflammation was better then the cough will go away . The pain was muscular , due to coughing .So then started saying that she was having problem with the swallowing. She had never told me or any other doctors about this . When I asked her how long she had this problem , she told me 4 or 5 weeks .
     I was not sure what to do . We had planned to discharge her .and all her tests were OK and the finding that were abnormal were now normal . I almost thought that may be she is afraid to go home , may be there are issues at home or may be the new baby care is too much . But I reminded myself . I MUST PAY ATTENTION TO THE PATENT'S COMPLAINTS ! I ordered the swallow study . To my surprise , the study showed that she was ASPIRATING . Which means , when she was drinking the liquids , it was partly going in her lungs . I was shocked . I had no explanation as to why she was doing this . We see this quite commonly in elderly patients or patients with stroke or Parkinson's disease , but at age 31 one I had no thought I thought of myesthenia or multiple sclerosis .In  these conditions one could have swallowing difficulties . I ordered the test for Myesthenia Gravies and ordered the neurologist to see patient . I also asked for the MRI of the brain . The neurologist specifically asked to look for Chiari malformation  and he was right The MRI DID SHOW THE CHIARI 1 MALFORMATION .
     So the puzzle was solved . She had Chiari one malformation , in which it can press on certain nerves , which in turn can cause difficulty with swallowing and this can lead to aspiration . This caused the pneumonia . The recurrent aspiration of liquids (some are acidic ) caused the inflammation and so she continued to have the cough.    . 

Saturday, November 2, 2013


      I used to watch , and I still do watch sometimes the cartoon of Tom and Jerry . Each time one tries to cheat other or try to defeat other . But the things seem to be working much better for Jerry and go against Tom . Sometimes I feel the same way when I am treating patients . I try to find out 'best ' treatment for one condition and when it is successful I pat myself on my back . But then something else pops up . Then I try to do something for that condition and then third thing pops up.
     The story that I am going to tell you is one such story . This has no sad or great ending, but it 're enforces ' my belief in reincarnation .This is a 59 years old male patient that I saw few years ago . He had diagnosis of asthma . He had never smoked and was mildly obese . He had  problem with his aortic valve and surgical repair for the same .For whatever reason he was difficult to control . I tested him for allergies , and they came negative . I tested for Immune globulin , to see if he was lacking the immune proteins , that would continue to have inflammation and would make the asthma worse . The were normal . I tested for for an enzyme , lack of which can cause emphysema . It was OK too . After seeing him for 6 or 9 months I was not sure what else could be done . i had done CT scan and it had shown no major finding in lungs , but had hiatal hernia .He was hospitalized few times and may a times his symptoms started quite suddenly. There was no respiratory infection, which is common cause for asthma attack . It occurred that his asthma was due to the Hiatal Hernia . Due to hiatal hernia there is a weakness of the sphincter between the stomach and esophagus. This was causing the asthma worsening , according to me . I told the patient  my thought process and told him that we should consider fixing the hernia . This meant a surgery .He agreed . The surgery was done and his attacks of asthma improved . I cur down on his asthma medicines and now he was on only inhalers . We had stopped steroids. and other medicines and he was fine . I was very happy .
        All most a year had passed . He had seen me in office couple of times and was not admitted for long time . Then I got a call from the ER . He had chest pain , shortness of the breath and his blood pressure dropped . The wife had called 911 and paramedics took him to ER In the ER they found out that his left lung had collapsed . There were blisters or called blebs and one of them rupture and like a car tire his lung collapsed .The ER physician put in chest tube and it expanded his lung . He wanted to admit him . But the patient and his wife did not want to be admitted to that hospital as I don't go there . He was transferred to the hospital , that I go . He was fine . The chest tube was still leaking  air , telling me that the 'hole ' in the lung had not healed .When I reviewed the chart , I realized that when he collapsed the lung , his blood pressure had dropped . This was dangerous sign . I got the CT scan from the other hospital .It showed that he had number of blebs . So he could get similar episodes as these blebs could rupture. I discussed with the patient and his wife . I wanted to have him a surgery to fix the problem . I called the thoracic surgeon .He agreed and patient underwent surgery .The surgeon did a procedure where a talc is blown in . The talc causes inflammation and it acts as 'glue'.  In next few days he was discharged . I had known but forgotten to mention that he had similar episode 20 years ago on the right side and had surgery for it .
       He was admitted again in 4 months for atrial fibrillation , irregular heart beats and was tested and then put on blood thinner . His asthma was quite stable during all this time .He was doing OK for 6 months . And then I got a call from ER again. He had left sided chest pain and so as per my instructions he came to ER . The CT scan showed that he had collapsed the lung . DUE to the surgery that we did , there was no major collapse , but there was some air collection on medial side . He was OK and he was not short of breath , his Oxygen level was normal .I was not sure what else to do . I called the surgeon and he did a mini surgery and put in 2 chest tubes to suck out the air that had leaked . He did well and went home . I am afraid that he may get another episode. The only good part is that (hopefully) with his surgery , his lung can not collapse to cause major problems .
     But I am amassed that this nonsmoker  had aortic valve replaced , had bad asthma , that we control with hernia surgery , then he gets collapse of the lung , not once , not twice , but 3 times . (if you consider the one that occurred on the right side several years ago .)