Saturday, October 29, 2016


   In our life we often talk about the first impression. If some one is going for an interview , we say you must make your first impression great or long lasting. We also say the 'my first impression was not good. ' So the first impression had great value In suspense stories or i movies , we have our first impressions as to who is the culprit . So first impression is very important as it is 'accurate ' in many instances or at least we believe that our first impressions are great and reliable . I am not sure if some one has done any study as to the accuracy of this statement . Nevertheless we depend  on the first impressions .
      In medicine also we have first impressions and we make decisions -consciously or unconsciously about the  reliability of a story or complaints. In my life time of practise of medicine I have been right on many occasions , based on my first impressions.So you must have realized that the story that I am about to tell is either one where I was right or dead wrong . Well it was both .
      I saw this 78 years old patient who was smoker in the office. She had smoked for entire adult life may be 60 years or more. She had exertional shortness of the breath. So she came to me . She had emphysema . She was not having much bronchospasm . I explain this to my patients this was , if the damage from the smoking is more to the bronchial tubes and they are inflamed, then these patients get 'bronchitis and have productive cough and they wheeze. On the other hand if the damage from smoking is  more to the air sacks or the alveoli where the gas exchange takes place , then they don't have much secretion and have no significant wheezes. So this lady had more of emphysema or damage to the air sacks and was not wheezing , but was short of breath and when I walked her she needed oxygen as her oxygen saturation dropped when she walked. So I told her to quit smoking and gave her some medicines and asked her to do follow up. I did see her once on follow up to discuss the test results and again to urge her to quit her smoking,
       I saw her in the hospital in somewhat unusual circumstances . She had leg pain and so the family physician ordered a MRI of the lower spine .It showed an abscess-collection of pus. So the radiologist was asked to drain it . When he gave her sedation , her oxygen dropped and he had to cancel the procedure and I was called. So when I saw her I did not recollect her as being patient that I had seen . I had seen her many months age and that too only twice . She was very frail 78years old and looked like she was chronically sick. She weighted 72lb . She was on oxygen and could not get out of bed . She needed pain meds round the clock. She was started on treatment and then the procedure was done . Her further course was somewhat unusual and challenging . She was on IV antibiotics. But every time the catheter stopped draining the pus and we removed it , she had recollection of the pus . We were unable to find out reason for the collection of pus in first place and let alone recollection. I had talked to her and the family several times and made her DNR. She was discharged to a nursing home .
     When we discharged her  she was barely able to get out of bed and walk 2 feet . She was still on IV antibiotics and still had a catheter . This was her fourth catheter . I saw her on follow up in office in next 4 weeks . I looked at her office chart and was about to ask her as to why she had not seen me for several months , when I realize that she was the same patient who was in the hospital and had needed 4 deranges.She came walking without walker or oxygen and was fully oriented and had clear lungs and good oxygen . So this brings me to my first impression . I knew she was sick and had bad disease , was my first impression and it was correct . Then when I saw her in the hospital she was worse and I felt that her prognosis and the chance of recovery was not that great . So I was partly right . But then she showed up in my office as if nothing had happened , and that proved my impression to be wrong .  

Saturday, October 22, 2016


     In medicine like in many things in life or other sciences we have rules and they do apply in many cases or under many circumstances . But we also talk about exception to the rule. In medicine we have the same thing . When we see a patient and try to diagnose the disease that may be causing the symptoms. So when we see some one with high blood pressure we  don't try to work every patient for etiology for the elevated blood pressure . Again if we see very young patient with elevated blood pressure we WILL DO tests to find any cause of the elevated blood pressure -so called secondary hypertension.In medicine we are often told that the cause of symptoms is more likely to be due to ONE diagnosis , rather than 2 or 3. So this is one of the stories where there was a exception to this rule .
      I saw this patient who was seen by number of physicians before me . He came to see me referred by a family doctor. When I went the room in my office to see him , he was lying down on the examination table. In my practise this is very unusual as most of my patients are sitting in a chair ,waiting to be seen . So this was a 65 years old male who was referred to me for the evaluation of abnormal CT scan of the chest . He was admitted to the hospital in recent past his first primary doctor with chest pain . He was seen by a cardiologist and the had heart catheterization  and it showed the blockage and so a stent was put in. He was discharged in spite of him complaining that he still had chest pain . So in less than on week he went back to the ER with chest pain and he was readmitted. Again the cardiologist saw him and told him that his heart was OK and no further work up was needed. He was discharged and the primary care physician saw him in office . The pain was still there and so he did a CT chest . The CT chest showed number of small nodules and some abnormality in bones including spine. He was sent to a lung specialist . As I understand he was told that he needed to do follow up on CT scan in future. He still had lot of pain and so he decided to change physician . The new MD sent him to a orthopedic doctor who ordered MRI of spine . It showed abnormality in vertebra. But no further action was done. He was now referred to me . He was not sitting in a chair as he was hurting badly and there were no additional tests ordered. I saw the CT scan report and it clearly specified that patient had bony abnormality in ribs and spine that was 'consistent with metastasis '. Patient was smoker had quit smoking NOW . So most likely he had some kind of CANCER that had spread to the bones and it was causing the chest pain .
     I decided to admit him . My worry was two fold . One is the pain control and other was the abnormality seen in first thoracic vertebra . If something would happen to this vertebra , he may be paralyzed . So I talked to radiation oncologist . I did further work work up in the hospital . The CT scan of the abdomen and the pelvis did not show any source of the cancer. The bone scan confirmed the spread of the cancer to several bones . I also got the old history that he had prostate cancer 5 years ago and had surgery and radiation treatment. But the PET scan showed increased up tale in several lymph nodes. It also showed some uptake in colon .So I consulted a chest surgeon who did the biopsy of the lymph nodes in the lung and it showed the LUNG CANCER . So we had the diagnosis . But the question was does he have second or even third cancer ? Remember the rule in medicine is not to look for more than one diagnosis . So here we had diagnosis of lung cancer , which could explain the entire picture . was elevated PSA -a blood test that indicates possibility of prostate cancer . We had done bone biopsy and it was OK But it was not done from the exact place where the bone scan was showing abnormality . So I decided to ask radiologist to redo it , but this time with help of CT scan . So the biopsy was from possible metastatic lesion . It showed prostate cancer . So he had 2 different cancers . The pain was not from the lung cancer ,but was from the prostate cancer spreading to bones .I am not sure if he has third cancer colon We have not done colonoscopy yet .


Thursday, October 6, 2016


     Now a days it is fashionable  to talk about the targeted treatment or approach in the patient care . I often wonder as to what did the physicians did in the past . Was it not targeted  or was it not patient care ? But in the commercials that I see on the TV , especially on cancer treatment I see the word used frequently. But I do not find any difference or at least not anything better. But I find more often treatment being given per BOOKS rather than targeted to individual patients. So the treatment that is offered is more often determined by COMPUTER medicine rather than by Human being who happens to be physician. So one of the story that I am going to tell is one example of this targeted (?) therapy.
    I have known this 78 years old male patient who was smoker for entire adult life . He had COPD ,related to smoking. He was getting more short of breath and then had to be put on oxygen . He still continued to smoke . The when he was hospitalized he had a CT scan of the chest done and it showed a small nodule . The size was around 1cm. With his given condition and the given size , diagnostic procedures to get the biopsy would have been impossible . We can do bronchoscopy , a PET scan or needle biopsy, or open biopsy . But the given oxygen dependent COPD and small size we could not do any definitive test to get the diagnosis.So I decided to do follow up CT scan . The new Ct scan was done in 3 months and the nodule had grown and it was now 1.5 cm . In between he had developed  swelling of the feet and further work up showed that he had Liver problem . As it turned out  he was drinking 5-8 drinks a day and it had caused cirrhosis of the liver. So now we had to treat it . Medicines did help the swelling. Then he was admitted to hospital with shortness of the breath and the new CT scan done showed clot in the lungs . So now he needed blood thinner.. I spoke to radiologist about doing the biopsy of the nodule. I had done the PET SCAN and it did show increase activity suggesting that this nodule was most likely to be cancerous.. The radiologist felt that it was too risky to do biopsy due to the recent clot and the location . So I talked to the patient and the family and it was determined that we will wait and do follow up on the scan . He was discharged to rehab place . He came to see me in the office . He was still quite weak and short of breath,but felt better. So after discussion we decided to ask RADIATION ONCOLOGIST to consider radiation treatment without the diagnosis of the cancer , but based on PET scan finding and the growth seen on CT scans. So I got a note from him. He wanted a biopsy of the lymph node that was shown to be hot on PET scan but was not enlarged .
       He was readmitted and this time he had fracture of vertebra and needed treatment. So I decided to do new CT scan and it showed the nodule and did not show any enlarged nodes. So in span of 4 months the nodule was bigger and no lymph nodes were seen. So I thought that radiation oncologist would agree to do the radiation treatment without the biopsy . I did not feel that lymph node biopsy would be positive or give any additional information to alter the treatment. But the radiation oncologist insisted on the biopsy . So I called 2 different doctors who do such biopsies. Both of them looked at the CT scan and the PET scan and felt that they could not do the biopsy as the nodes were too small and it was too risky.
      So I have this patient who has oxygen dependent COPD , cirrhosis of liver , clot in the lung and vertebral fracture and had aortic aneurysm. So it would be 'targeted 'therapy if we could give him radiation to the nodule rather than looking at the PET scan and feel that if the lymph nodes are positive , we would need different field of treatment .
    By the way patient for now has decided to go with Hospice 

Saturday, October 1, 2016


        The modern day medical care is considered comprehensive . The ICU have started collaborative  rounds , which includes physician,nurse, case management, respiratory therapist . pharmacist and some other. The idea behind this concept is that such collaboration will help improve patient care and it will be comprehensive . So now a physician present in ICU 24/7 will help critically ill patent's outcome. This now implemented in ICU across the country. Certainly it will improve some care in some patients and it will also increase the cost of health care as billing will be changed and most likely it will be higher. But what I would have like to think is better care by individual physicians and better communication among patients and doctors and among different physicians. I often see computer generated notes which are neither accurate nor informative and tends to state things that are exaggerated especially the Time spent . If one would add the recorded time in the notes , there would be no time left in a day of 24 hrs. But my question is why do we have such a behaviour and the thought process ? I want to talk about couple of patients in this regards.
     I saw this patient for pneumonia. He was 84 years old and had not smoked for many years . His chest x-ray showed pneumonia and some fluid around the lung . So I did CT scan and it showed fluid . So I drained the fluid and it was positive for lung cancer . I called oncologist and they saw him promptly . But a month went by and no treatment was started as they were trying to decide on which drug regimen protocol to use . Patient got more short of breath , and that was in spite of regularly draining the fluid with a inserted catheter. So he as admitted and it showed a clot in the lung and now more /new fluid on the other lung. So the ER doctor called  at 10 or 11 pm. I started him on intravenous blood thinner . and ordered to check the legs for a clot in the legs. The incident of such clot in patients with cancer is very high and they may need treatment life long or as long as the cancer is there. I also knew that he may need the drainage of the fluid and may need putting a catheter to drain it as needed -just like he had it on other side . The treatment for cancer was not yet started  and that may also need insertion of a port . So essentially he would have needed -potentially 3 different surgical procedures in near future. This meant we will have to hold the blood thinners. Taking this account I had started the blood thinner that could be stopped and the blood thinning would return to normal in less than 6 hrs.
     The next morning I went to See the patient and was surprised to note that the IV blood thinner that I had ordered were discontinued and a pill was ordered. This new pill takes effect immediately and patients can be discharged quickly. But it takes 2 full days to reverse the effect of blood thinning. So while he is on this pill no surgical procedure could be done and will have to be off it for 2 days . I had to change the orders again as we needed to have catheter inserted for fluid and a filter to prevent clot travelling from leg to lungs and get port inserted to give chemotherapy. So why the oncologist give pill?
     The patient got all three procedures done and then about 4-5 days down the road we started the pill and he went home I think the problem is that the thought process that I went through when I started the IV blood thinner was not done by the oncologist , nor was my note seen and it was a knee jerk reaction to start the pill which is correct treatment in most but not in all .