Friday, March 21, 2014


   I often see patients , where I think about the diagnosis and try to work up to get to the  diagnosis. Unfortunately the answer does not go well as it may be indicative of bad outcome.So the happiness that we got the diagnosis does not last that long.The story that I am going to tell is one such case.
   I saw this patient few months or a year ago.She was seen by me for abnormal chest X-ray and CT scan. The CT scan showed some lymph nodes enlargement. I was not impressed , but decided to do follow up on it. I then got additional history , that explained it very well . She had something called monoclonal gamapathy.The minor lymph node enlargement can be seen in this condition.I was going to do just follow up on scans .
   Few months down the road ,she had belly pain and her primary care physician did a CT scan of the belly.It was OK as far as belly organs are considered, but had fluid around the lungs.So she came to me .I was not sure as to why she had fluid , but thought of heart as she had a murmur.I ordered a blood test for the diagnosis of congestive heart failure.and started her on a water pill.The test came back as elevated suggestive of the diagnosis of congestive heart failure.So the treatment was was correct.She was seen by cardiology nurse practitioner ,and he increased the  dose and that caused the drop in blood pressure and she ended up in the hospital . She went to a hospital,where I don't go .She was seen by another MD and he did take out the fluid  twice . IT showed the findings to be consistent with the diagnosis of congestive heart failure.She was discharged.
    She was again admitted in the hospital with similar problem . Since she knew that I don't go the other place ,she decided to come to our hospital .She had low sodium (salt content)and kidney failure. The fluid was worse and the blood test for heart failure was 10 times higher.I spoke to the kidney specialist and started her on larger dose of diuretics.I was not sure as to why she was getting the fluid back all the time . Her cardiologist was seeing her , but it was not clear as to why she had the heart failure.I spoke the cardiologist as most of the time she was seen by his nurse. I did do a liver scan and it was abnormal and so I thought that she had a liver disease .I started her on different treatment and she got better. She was discharged .
   She came to me and continued to have ups and down . So I called the cardiologist and asked him to see her personally and may be do a cardiac cath, She did have a leaky valve . I was not too sure if she needed that valve to be repaired .
   The cardiologist saw her and told her that she should go to Mayo Clinic. She made the appointment. But got admitted to the hospital . This time she was sick and had multiple issues.Had significant worsening of kidney function and her blood pressure was low. Then she had complete shut down of the kidney. Her lungs were filling with water. She needed more oxygen.
    We still did not have the diagnosis . Going to Mayo was out of questions she was too sick. I decided to do a biopsy of fat pad from her belly . The surgeon called me asking as to why I wanted such a biopsy in this sick patient . My problem was convincing the family that she had something that was not going to get better. I needed the diagnosis. So I asked for the biopsy.
   The patient did not want to do any aggressive treatment or go on machines.But I had to get the family members convinced . The biopsy was done . She continued to get worse and then the family did make the decision of doing 'comfort care'.I talked to them ,did write DNR, Do not resuscitate order and checked the computer for the biopsy report. SHE DID HAVE WHAT IS CALLED AMYLOIDOSIS!. In this condition this material gets deposited in various organs and also the heart and that caused the heart failure. So we did get the diagnosis , but it was not helpful to the patient.  

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