Sunday, October 25, 2015

Grace of God -2

         So in the last Blog I described the case where I saw someone that was not at the best level of health and mentally . Again I do not want to take anything from the family as I know everyone of us would like our loved ones to live for ever . Very few of us are 'ready' to let go , and that too when they are very very old and unconscious. So I understand the behavior of the relatives. But what I don't understand is WHY the disparity .So let me tell the other story.
        I saw this 42 years old female for chronic cough . She was anon smoker and had some cough going for long time , may be 2-3 months . She had never smoked . Had no other medical history , other than she had melanoma resected out few years ago . Her physical examination was normal . Her lungs sounded clear and there was no other abnormal findings . The chance of asthma and allergies is very high in patients who are nonsmoker and have chronic cough as main complaint. So I told her the differential diagnosis . I ordered the blood test for allergies , a chest X-ray and breathing test . I gave her sample of inhaler and a short course of steroids . She called me in 2 weeks . She had cancelled the follow up , the breathing test and had not done the blood test . She was feeling great and her cough had gone away . So she had concluded that it was due to allergies and she thought that she would rather go to allergist and do testing , rather than doing blood test for me .My office gives me the charts of all patients that miss the appointment or cancel the work up , like CT scans or breathing tests etc . So We called her and told her to do at least chest X-ray that I had ordered. She did the X-ray . The radiologist called me with the report . It showed LARGE mass in the lung . So I called her and got her to do CT scan. The CT scan showed the same findings . I saw her day after the CT scan was done . She came to me with her husband . I told them that in all probability it Wes Cancer . We need to answer 3 questions , Is it Cancer , Has it spread , and What can we do about it . So I ordered a PET scan , which is accurate in about 85 to may be 88% of the time in picking up the cancer. The Pet scan and the breathing test was scheduled for next day and the Biopsy was day after . The PET scan showed that the mass was highly active and there were lymph nodes and there were 2 skin nodules . All these findings made her inoperative .
      I am not going to talk about the diagnosis or the treatment . What I was bothered with this experience is that this 43 years old female who had done all the right things in life and had her all faculties in tact and significant life left , has inoperable cancer .
                                       HOW DO YOU EXPLAIN  THAT?

Saturday, October 24, 2015


     I see many patients in my practice that have gotten the short end of the stick . And then there are patients that happen to be 'lucky'. I have often wondered as to why certain things happen to some patients. That leads to the so called bad luck or the theory of reincarnation and the laws of Karma . But even though I know the theory and believe in the reincarnation and laws of karma , it does not stop me from getting surprised and wonder about the God's plan . I thought about it when I saw recently some patients.
     First one was a84years old male who was admitted with possible pneumonia . He had significant dementia and was sleeping most of the time . He did answer some questions , but did not know where he was . He did follow some commands . or instructions I knew that he had pulmonary fibrosis and may have some other medical problems. His mantle status and advanced dementia and the age would make him more prone to aspiration , food and the liquids going wrong way and in lungs at times . So I ordered a CT scan and swallow study. The swallow study did confirm my suspicion that he was aspirating. So the speech therapist ordered some instructions . The CT scan did confirm that he had fibrosis . But it also showed a mass in liver . The radiologist wrote in the report that he was concerned about the primary cancer of the liver. I spoke to the family several times and try to get him to be DNR .He was unable to walk . He was sleeping most of the time and did not know where he was and he also had pulmonary fibrosis which caused him to need oxygen all the time . There were some restrictions or modifications on his food as well due to aspiration. But the family did not want to make him DNR and wanted all the work up . So I ordered the PET scan which picks up cancers may be 85 to 88% of the times . The PET scan was positive . So the radiologist felt that he had cancer of the Liver . Another round of talk was done with the family . They wanted biopsy to confirm it . So we had to do the biopsy . Interestingly enough he had history of heart problem and heart attack and stents . So he was on blood thinner . So we had to hold the blood thinner for 5 days before the biopsy could be done . The biopsy was attempted , and it turned out that HE DID NOT HAVE CANCER , BUT HE HAD AN ABSCESS -collection of pus . He was on antibiotics for pneumonia , so we readjusted the antibiotics .
       So here is my question . This patient who was older , had heart disease , had dementia , had aspiration , and had pulmonary fibrosis and could not walk , and he did not have cancer . So with the treatment of infection he was going to be OK if there was anything to be OK with him . And then the next one that I will tell in my next Blog will point out the problem that I sometimes have with the diseases . What is the purpose of beating all the odds of cancer in this patient ? What does God thinks and why does this happen in patients that we mortals can't seem to see the benefit and then when we wish someone not to have fatal disease , they have it . You will get it when I write my next blog soon . 

Friday, October 2, 2015


      I had written in the past about the Emperor's new clothes. This term has been used in medicine for number of diseases, but it was used for pulmonary embolism many years ago . It was so true in past as we did not suspect in the diagnosis in past and so when it presented with some unusual symptoms, we missed it . But exactly opposite thing has happened.For last few years we do CT scan to diagnose pulmonary embolism . Now a days almost anybody and everybody who comes to hospital ER gets a CT scan with minimal or no symptoms suggestive of clots in the lungs. So we tend to diagnose more. The number of CT scans done has gone up by 1000%, again 1000%, not 100%. So it is unusual to miss the diagnosis of pulmonary embolism. But sometimes when we come across certain things quite often , we tend to not pay attention to them. This brings me to some stories that I am going to tell today.
      I saw this new patient who was 57 years of age I saw her in office as a new patient .She was a nonsmoker who had a diagnosis of asthma in the past and was given the inhaler She was using and was OK for a while . But then started having more shortness of the breath . So she saw her PCP and he promptly referred her to cardiologist. The cardiologist did number of tests . He did cardiogram and then the echocardiogram and then did the stress test. She also had holter monitor , which is continuous recording of the cardiogram . All the work up was negative and she was told that heart was OK and healthy. So she went back to PCP and so now she came to me . She was short of breath and also had passed out about 3 times in last 2 -3 months. 3 days before she saw me she was taking out her dog and passed out  and found herself on the side walk . She looked OK but when I checked her oxygen saturation it was 91%. Her lungs were clear and she had no wheezing . I got hold of her cardiac test and they were OK . I made her walk for 50 feet and her oxygen saturation dropped to 85%(normal is greater than 95%)and she was quite short of breath.I knew what the problem was . SHE WAS THROWING CLOTS . I decided to admit her and ordered the CT scan and it did show the clot. She had plenty of them  I had started her on blood thinner even before doing the CT scan . I did call the cardiologist . He decided to do a new procedure in which a catheter is inserted in the artery going to lung and then a clot buster is slowly dripped in . This dissolves the clot more quickly .She did very well .
     So the shortness of breath , passing out and the drop in oxygen with lungs sounding clear were all the clues to the diagnosis. But it took much longer to get to it !