Saturday, April 19, 2014


Sometimes I come across patients that have a what appears to be a simple problem, though we make it complicated and then go on wrong pathway . So then the answer appears to be simple and we 'feel ' very 'prowd ' of our self , and pat on the back , may be too prematurely . This happened to me recently. This just reminds us that we are not in control.
     I had seen this 85 years old female for may be 2-3 years . She had bad lungs and some other usual problems like , high blood pressure and arthritis . Her ambulation was some what limited and she was on oxygen at night . From my stand point she was doing as well as a 85 years old would be doing . She had a regular follow-up with me every 2-3 months. .Her follow up with me was about a month away , and I had  call from the primary care MD . She had seen the family doctor for the shortness of breath or may be it was a regular follow up . She had some cough, and some shortness of breath. So the primary care physician gave her antibiotics. And some cough syrup. He had a chest x-ray done and it showed pneumonia. So she was treated with more antibiotics. The follow-up was done at the primary care physician and she was again treated and had another follow-up x-ray done. The follow-up x-ray continued to show more congestion and now had a small amount of pleural fluid. Subsequently a CAT scan was ordered, and the CAT scan showed that patient had pneumonia with pleural effusion. Subsequently the doctor called me and possibly to see as soon as patient was developing pleural effusion and/or pneumonia was not getting better. I gave her the appointment soon.
       I saw the lady in my office. She had not much in the respiratory distress definitely had some increased cough. When I examined her lungs had some congestion on the backside. She had at least 3+ pedal edema. I checked her oxygen saturation and that was 95 percent on 2 L oxygen which he usually used at homes.I looked at the CT scan , and realised that the patient was not having unresolved pneumonia , but was in congestive heart failure.I talked to the patient and the daughter who was with patient . I told them that I would like to admit patient and treat her for the congestive heart failure . I told them that the fluid that we were seeing in the lung was due to the congestive heart failure and not due to pneumonia .She was reluctant ,and told me that she was in the hospital 3 months ago and had cardiac work up done and it was OK. I did get that report pulled up and she was correct . Her heart function was normal . This time eon examination , she had heart rate which was fluctuating between 120 to 145. It was irregular . I explained it to them that I still felt that she had heart problem . She agreed to get in the hospital , but talked to me about code status . She did not want to be put on any machines . So I signed the DNRforms .
     She was admitted to the hospital and we started treating her rapid heart rate and gave her diuretics . Her heart rate was controlled and the edema was also getting better . I did new echo cardiogram . And it showed that the heart function had dropped down to about 25%, which in past was 60 % , which is normal . The cardiologist saw her and some more adjustment was done in her medications . She was much better and was about to be discharged . The nurse called me and told me that she wanted to see me again , as she had forgotten to ask me a question . I went back to the room and she told me that she wants to be discharged home with HOSPICE . I was OK with that . The Hospice saw her and she was discharged home .It was Friday that she went home . I wanted to see her in office in 2 weeks . I wanted to check on her electrolytes in one week . I got a call from the Hospice on Monday that she died on Sunday .
     So here I was . patting myself that I diagnosed the patient correctly and treated her correctly and she had improved , and how smart I was to do this in spite of last cardiologist saying that she had no cardiac issues and her heart was OK , just 3 months ago . But the Luck , the God . whatever you can call was laughing at me as her destiny was determined and SHE KNEW IT !!!!

1 comment:

  1. Dear Doctor,
    I am right now reaching 50 year. I had been smoking about 10 to 12 cigarettes a day between 1998 to 2008 and brought this down to 8-9 for the past 6 years, Now average 45 a week. For the last 1 year or so once in month get short pain in the upper top of left chest.At times the pain used to be acute and I drink hot water mixed with Ginger , the pain vanishes. My breathing is normal, Can you help me with some advise on the present situation whether I will get an cardiac arrest due to this pain.
    What exactly is the cause??
    What food habits to follow??
    I am now delaying my smoking by having one every 1.1/4 hrs and only between 10 to 1800.