Thursday, February 19, 2015


    It is often stated that the third time is the charm . So when I see some patient who has been married 3 times , and the last marriage has lasted longer than first two, then they say that third time is the charm . Or in many other cases , when first two times there was no success , then trying third time it is said the the third time is charm . But sometimes it is not a charm first or third or may be fourth time . So this a story of my patients  where there was a 'good ' news fourth time in one case and 'not so good' news in other case,.
      I saw this patient sometimes ago for a follow up . He was seen by me for last 10 years or so . About 12 or so years ago was the first time when I saw him He had a mass in his right upper lobe . We did the work up and then he was diagnosed to have a lung cancer. Luckily he was operable and the cancer was resectable . He underwent surgery and the good news was that he did not need any additional radiation therapy or chemotherapy. So we continued to do follow him up and he had no recurrence. But in  2009, he had routine chest X-ray, It was abnormal and so we did CT scan and then it turned out that he had a another cancer of the lung . So 12 years ago we took out right upper third of the lung and now in 2009, we had to take out left upper third of the lung . Again the good part was that we diagnose the cancer early enough that he did not need any additional treatment. So I continued to do the follow up . In 2013 he had some urinary problem and then the work up showed that now he had kidney cancer. He was getting old. He also had some other issues and the renal tumour was small. So the decision was made to treat it with Radio frequency ablation.He did good and the follow up in 2014 , a year down the road, there was no recurrence of the kidney cancer.So he had THREE CANCERS and each time we were successful in 'curring' the cancers.
      But the story does not end there . I did chest X-ray in late 2014 and it was OK . So we decided to do follow up in 6 months . He was having some shoulder pain and so he was referred to an orthopedic surgeon . He did MRI of the spine and shoulder MRI .The MRI showed MASS IN THE LUNG , NOT SEEN ON CHEST X-RAY done 3 months ago . The PET scan was positive and he has new cancer of the lung. He is not a candidate for surgery . So we will end up with radiation and may be chemotherapy . So three times  he had cancer that was cured , but the fourth time ??? not a charm !! 

Sunday, February 8, 2015

Differential Diagnosis

      When I was in medical school, we used to read a book called Differential Diagnosis by Dr, French.I had a pleasure of meeting the son of this author, who was also a physician.So when we have a patient with any complaint and certain physical findings , we are asked to do the list of possible diagnosis. This is called the differential diagnosis. But what I am talking about is not the same . But this story is related to my recent patient where there was an issue related to common check up that occurs in a physician's office.
      I saw this patient who had COPD ,and was admitted to hospital for shortness of the breath. She was elderly and was oxygen dependent . She had pneumonia. She was quite short of breath and had to be put on large steroids. She took long time to improve. So I had to continue the steroids for longer time . One day the nurse informed me that her blood pressure was elevated. I thought that it may be due to use of steroids which tend to retain salt and water. The elevated blood pressure could be also due to respiratory difficulties . In any case we had to treat it and she was started on medications . In next couple of days her blood pressure seemed to fluctuate from normal to high . I was not sure on the etiology of this fluctuation of the blood pressure. But then the nurse found out an interesting fact which explained the cause of this variation in the blood pressure . The blood pressure in the right arm was high and the one in the left arm was normal. It was interesting to know that along with me there was a cardiologist and a hospital doctor seeing patient , and none of us thought of checking the blood pressure in both extremities at the same time . I ordered the Doppler of the both upper extremity to check on to make sure that there was no blockage of the arteries going to the arms. As I expected there was narrowing of the artery going to the left arm , the right side was OK. So due to this narrowing there was lower blood pressure on the left side.
      There was nothing needed to be done as the treatment as there was no compromise of the circulation.But the main thing for the future was the information that I gave to the patient, that the right arm pressure is the correct one and not the one on left , which was lower.