Wednesday, December 23, 2015


       We are often happy , proud and boast when we are right or feel YOU did help someone . But at times this sis not so , In medicine it happens more often than in other professions . Sometimes we suspect cancer and we work to find or may prove that we are right. But when we get the diagnosis we are not happy as the diagnosis is not the best diagnosis. and the prognosis is not good. I had similar experience recently . The key in this story is different than I started this blog .

      So I saw this female who was about 70 years old who had chronic cough . She was seen by other doctors outside the country and had some investigations . She had no shortness of the breath and when I told her to cough all that she would cough would be spitting saliva . Her lungs sounded cleat and her X -ray was OK and the oxygen saturation was normal . I ordered the allergy blood tests and then did the breathing tests. It showed no obstruction or suggestion of asthma . I did try her on medicines for asthma and for allergies . She may be got little better but continued to have cough . Again it was only saliva and not real sputum . She was lost for follow up as she went out of town . I saw her again after a gap of few months . She had seen a cardiologist  as she was short of breath too . He did a echo cardiogram and then scheduled the stress test . So when she saw me she told me that she was quite Short of breath . I did make her walk as I do it in every patient when they complained of shortness of the breath . She could walk barely 30 feet. Her oxygen did drop little bit and she was not wheezing . But I could hear a loud murmur that I did not recollect hearing it . So I did a ct scan to rule out scars and send a note to the cardiologist . I wanted to tell them that her shortness of breath was real and was worse . I could not figure out as to why . But  a blood test was ordered . I got a text from the cardiologist that the stress  test was OK . Then came the diagnosis . Her hemoglobin was less than half the normal . So she was admitted for the work up and the blood transfusion . The further work up showed that she had acute leukemia . She was started on chemotherapy .
    So when I saw her for the first time , which was a year ago , my impression was that she did not have major issues , but I still did the work up . The last time when I saw her , I was quite concerned that SHE HAD something . though I could not figure out as to the cause of her shortness of the breath . But I knew that she had something . Unfortunately it turned out to be acute leukemia -not the best diagnosis and the prognosis .  

Saturday, December 19, 2015


      All of us know about the self destruction of the cassette in the episodes of Mission Impossible. In medicine we know there are many example of cell destruction . The red cells will die in 120 days from the time they are released in the circulation . The platelets , which are important  for the clotting have life of 7 days . Same thing happens with many tissues and many times There was a time when an experiment was done to see as to how long cells can continue to multiply if they are provided adequate nutritional support and environment in the Lab.In the beginning it was felt that the cells has unlimited ability to multiply. But then it was realised that when new chicken broth was added as nutritional support , thew were adding New Cells . Subsequent work showed that each cell has Fixed Limit. This is called Hafflick factor. When the skin of old mice was transplanted in younger mice the the cells lasted longer . However the limit was there.So this about the medicine , but the Self destruction that I am talking today is about behavioral destruction. I have seen this in my medical like. But this one of the story.
     I saw this 40 years old female in my office for chronic cough. She also had some shortness of the breath . She was in ER few times . This had started few months ago and she had seen a lung specialist I saw the old -2 months old Ct scan . It showed that she had Interstitial lung disease . I saw the old record . She had some lymph node enlargement and the lung specialist had done biopsy of the nodes and told her that 'everything was OK' .I decided to do new CT scan and the pulmonary function tests. The Ct scan did show that she was worsening in the inflammation in the lungs and breathing test did show that scars had affected the test. The process of transferring the oxygen is called diffusion and that is impaired when there are scars .This is called Diffusion capacity . I did do another broncoscopy and biopsy , but no definite diagnosis was established So I asked a chest surgeon to do the open biopsy . It showed specific reason for the inflammation and the scars . I had done all the tests to rule out that etiology called connective tissue disorder (Lupus or Rheumatoid arthritis etc )I started her on steroids and tried to send to Mayo clinic or other centers , but had problem with her insurance . She continued ti get worse. So I sent her for transplant evaluation . She was felt to be a good candidate, and they decided to start the work up , so that she can be put on Active list . The it happened . She was admitted for shortness of breath . Someone did a Drug test on the urine and it showed positive for cocaine .She got worse and needed 50 L oxygen .But she was not accepted for the transplant as she had used cocaine . They would not accept her till she is 6 months drug free .
                      THIS IS WHAT I CALL SELF DESTRUCTION ! 

Saturday, December 5, 2015


      We often talk about people being 'lucky' . When we watched the super ball or NBA play offs , we see that some games are won not by dominance of one team over other team, but sometimes it's shear luck . Otherwise why would at buzzer someone throws a ball and it is nothing but the net . No one , not even the player who threw the ball in desperation, thought that it would go . But it did . So that is the luck ,In medicine also the luck plays the roll , Sometimes the patients are lucky and sometimes the doctors are lucky .But most of the physicians will not say so , and will take the credit for diagnosing something unusual or diagnosing something which was not indicated by the symptoms . But I know better . I don't think I can take any credits or discredits when things go unexpectedly right or wrong respectively. There is a saying by a physician who invented the antiseptic technique or the hand washing before the delivery, to reduce infection '.I dressed the wound and God healed it .'So true! I n the Hindu scripture it says , 'You have right to the action , but not to the fruits of the actions ,' This does not mean murderer is not responsible for his or her actions.This brings me to the today's story.
       I saw this patient in my office few months ago . He was a young man who had cough for several months . He had tried over the counter medicines and antibiotics and some other stuff. It had not worked . So he was referred to me . He was not a smoker and had really no past medical problems . He did appear to me to be anxious. I did chest x-ray and breathing test and allergy test . The x-ray was normal and the breathing test was almost normal . I could make a case for mildest form pf asthma , but it was OK . The allergy test did show allergies to molds. I did put him on some medicines and then he missed follow up . I thought that he may have gotten better or gotten tired of going to doctor as nothing was positive . But then one day he showed up. His mother had passed away and he was out of town when she got sick. He was so upset that he spent 6 hours with her when she had already died!He simply could not stand loosing her . I can relate to it easily as I have lost my mother last year.I told him the concept of life after death and the Astral world and told him some books to read . I restarted him on inhaler and send him to an allergist . The allergist did the allergy tests and gave him some medicines . I had not seen him for may be 7-8 weeks . The one day when I was going to my office from hospital. ,I got a call from the emergency room physician , He was in ER with shortness of breath. The physician wanted to know if I wanted to see him in office sooner or wanted to know if I had any suggestions. He had done the chest X-ray, cardiogram , blood test to rule out heart attach and congestive heart failure and regular blood count.All the tests were normal . His oxygen was normal but he had shown in ER with cough and shortness of the breath . I was in the car . I was not too sure as to his problem . He certainly was worked up by me and nothing was found out granted  it was 6 months ago.I don't know what happened , but I told the ER physician that since this was 40 years old patient , who had shown to ER with the complaints of shortness of breath,we should at least do CT scan to rule out clots . Mind you I did not think that the CT scan was highly indicated or was going to be informative . So the CT scan was done . I was in office when the ER physician called me . He said , 'You just saved this young man's life . He has significant clots in lungs , both lungs 'I gave some more orders and went to see him after the office . He was treated and was discharged . But I had DONE NOTHING. I happen to throw the ball at the buzzer and scored the 3 points to win .But I was really lucky , or may be the patient was really lucky.