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.

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