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 .  

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