Friday, November 24, 2017


     IN our life we face the situations ,in which e know what to do , but can not Do it. I am sure no one is an exception to this rule..We know we should not indulge in too much food , but we do .Yesterday was Thanks Giving -so all can see what I mean by this. We know we should exercise , but we don't and there are many other situations where we know what is good and what is right and we still are unable to do it.But in medical practice we see this all the time too. I know and the patient knows that smoking is bad , but still continues to do it ,and the obesity-everyone knows that one must loose the weight , and it never happens. If one considers obesity is a disease, then the 'cure rate' is zero. Even for those who do loose weight, the 5 yer survival or the disease free interval-terms that we in medicine use for cancer- is also zero. In both these conditions,the addictive nature of smoking or eating is very strong and the fault does not always lies with patient. The surroundings -stress,habits of spouse and the environment do play role.But sometimes we can put blame on patient and patient only. I am telling a story of such a patient.
            I saw this patient -72 years old , who had sickle cell anemia. She had episodes of crisis many times . In sickle cell anemia the red cells , which carry oxygen and have hemoglobin in them , are not shaped normally. They look like sickle. And when such a cell tries to go through very tiny blood vessel , it gets stuck and then is destroyed and that causes the attacks of pain . The pain could be anywhere in the body and sometimes patients can get addicted to pain medicines. They do have low hemoglobin.. In some of these patients when these episodes happen frequently,-may be in blood vessels of the lungs , the pressure in lung circuit-pulmonary pressure increases.This is called pulmonary hypertension. This is similar to one that can happen in patients who get frequents clots in lung.So this needs treatment .So when I saw this lady , she had same problems that she was admitted for in past several times . She had several echo cardiograms done in past 2 or 3 years before I started seeing her . She had the usual problems , high blood pressure and the anemia and the pain and mild problem with kidney function. I did order new echo cardiogram as in past she had elevated pressures. The normal pressure is less than 30 . 2 years ago the pressure was high 30es and the increased to 48 and then mid fifties. So there was trend of worsening pressure in lung blood vessels. The new echo cardiogram showed the pressure to 67. Clearly she needed treatment. So I asked cardiologist to do the right heart catheterizing and check pressures directly. This required as the echo cardiogram is good but not 100% accurate and the drugs that are used to treat are very expensive --$40000 per year. So the catheterizing was done and it did confirm the elevated pressure. So I started her on medicines . One of the medicines is Viagra .(it is interesting how the drug companies change the name and the price , So the same VIAGRA when used for pulmonary hypertension id called REVATIO, and the cost is much higher too.).

      We need to do some tests to assess that progress of the disease as we can not do heart catheterizing frequently . So we do check the distance that one can walk in 6 mins,which is very simple and can give us the idea about the improvement . We also need to do other tests . I have seen this patient many times in hospital where she comes in for pain or sickle cell crisis . But SHE HAS NEVER COME TO MY OFFICE TO DO SOME OF THE TESTS  that are needed.. Her pressure continues to be elevated and she continues to be on 2 different drugs . But without certain tests and close monitoring of the blood tests and other things , I can not add more medicines . Every time I talk to her ,she promises me that she will come to office and we have scheduled her for the tests and she never shows up.She does have many more medical problems now than when I started seeing her . Sh has also seen other lung specialist in between. But not in their office . .   

Saturday, November 18, 2017


           We had several mass killings in recent past and I was thinking about it . At the same time , I was reading Hindu script , which was written several hundred years before Christ.The one that I was writing about stated that 'IF ONE CAN CONCENTRATE UPON THE IMPRESSIONS THAT ARE CREATED BY THE KARMAS (FROM ALL THE LIVES)THEN HE/SHE CAN KNOW THE TIME OF DEATH." So this blog is about the Karma and it's effects . I have written about it in past.In Bible also it states that 'Reap as you Sow' The difference though is that in Hinduism, the seeds of Karma continue with multiple births and deaths , and the impressions of Karma or effects can occur in any life. This is different than the Christian belief  in which the effects ENDS with present life . So on the day of judgment , decision is made based on ONE life and if you have done more good than bad , then you go  to heaven and if have done more bad than good , you go hail . So every body is judged on the same day.So I am not sure as what happens in between . In Hindu concept the process is recurring and the NEXT life is based on all PREVIOUS lives. So when we continue to do Karma , we continue to accumulate the effects and this POT, full of all the Karmas that we have done in past lives , is called SANCHIT Karma . When we are born , we come with certain seeds or Karma that are going to come to fruition in Present life.This is called PRARBDHA  KARMA. We do more Karma in the present life and some of them will come to fruition in Present life and some will be stored as SANCHIT Karma to come to fruition in next lives.The current life Karma is called KRIAMAN Karma .
       In this law of Karma ,the EFFECTS or the Fruits of Karma occur AFTER the Karma is done . But in CHRISTIANITY when it is said that the Jesus died for our SINS , the Fruits happened before we did any sins or Karma.
       So for the Hindu concept of the Karma , the Karma has to precede the effects or the fruits of Karma , the effects of Karma ,can not be transferred to someone else ,(I can not suffer for the sins of my parents or my kids), there is no GROUP Karma . So when a group of people miss behave, EACH one has to get the fruits of his or her Karma and there is no group suffering due to group action. So in mass shooting each one of the victims had some unknown Karma from previous lives,that brought them to SAME DESTINY. The effects of the Karma is Recurring, and there is no final Judgment day.
       This concept is closely tied to the concept of reincarnation. One more difference is that just the Grace the God is not enough for getting rid of the Karma. Every one has to go through the effects of their Karma , the Surrendering unconditionally to GOD will help ,but not eliminate the effects . If one looks at the lives of many Indian saints , they all had very hard live,e.g.DNYANESHWAR,TUKARAM,MIRABAI . This has to do with completely neutralizing the effects of Karma from last ALL the lives , so there is freedom from rebirth. The only way to stop the KRIYAMAN karma -one that occurs with our every day life is to not be ATTACHED to the fruits -DO THE ACTION ,WITHOUT EXPECTING THE FRUITS OF THE ACTION.

Saturday, October 21, 2017


      I am always amazed with the new inventions and new techniques in medicine. But some of them are so good and may be an advantage for the patient and for the physicians. But sometimes it adds to the problems . So few years ago I was talking to some one  who happened to little older . She had tried to get pregnant and was not successful . She had test tube baby - fertilization done out side the body , then selected embryos implanted in the uterus. Due to the advanced age of the mother, they were doing blood tests from the mother starting at age 10 weeks . The blood tests were done again done at periodic time . The mother's blood is tested for fetal DNA. This can help detect the Down's  syndrome and some other fetal abnormality . The amount of the DNA is increased as the pregnancy advances. So the mother's blood gets fetal DNA even though the two bloods don't mix. While I was thinking about this , i looked in to it and realize that similar thing could be done for cancer or tumors. So I looked in to it and was surprised that there were some scratchy studies done in the past .

     And then I came across the study where blood tests are being done for very small nodules in the lungs and some as small as 3 mm and some much larger as much as 30 mm . This is called 'liquid biopsy" The studies are being done for breast cancer and the lung cancer and urine for bladder cancer. So I now know local physician involved in this study. I am not sure what would come out , but I was excited to know that some one was doing the study .

     But then I came across a study which was published recently and the lung cancer . They did the blood test in patients who were treated for the lung cancer and had NO EVIDENCE of the cancer. Those who had the positive blood test for ??tumor marker- had higher incidence of the recurrence of the cancer.But here is my problem . So if the blood test is positive and one has no evidence of the cancer , should we treat it with more chemotherapy or just watch it . The problem is that even though the blood test may suggest that some cancer cells are still in the body , not everyone comes with the recurrence , may be the body's immunity takes care of small tumor load. So treating everyone , we may be over treating , and that adds to the cost and the side effects .This problem was much worst when in past some did similar blood tests in high risk patient , who had no evidence of the cancer anywhere in the body, and the tests came back as positive . So now what do you do . Without the actual tumor , one can nor select appropriate chemotherapy and what kind of follow up can we done to see if patient is Responding or not. So when these tests are done we need something more or better to help patients and doctors to make these decisions. Otherwise we have tests and the reports , and no answers or treatment plan . And on top of that it adds to the anxiety on part of the patients and the family . It also may create problems with getting Health insurance and Life insurance .

       I know this blog is not a patient story , but I think it tells the real dilemma that will be added to medical decisions , when medicine is Art and Science combined in my opinion.  

Sunday, October 15, 2017


                 I have been in medical practice for many years . More I see , more I realize that NOTHING is perfect. I guise that patients when they come to doctors do not read books and so the presentation of these patients is not always like it is  written in books. . So sometimes it is not perfect  or 2 plus 2 does not make 4. And sometimes you come across these patients in clusters. So this brings me to today's story.

                    I saw this 67 years old male patient for abnormal CT scan of the chest . He was a smoker and he had quit few years ago .He had some cough and he had some clear sputum . He had no fever and had not noticed any blood in sputum . He had though lost 15 lbs of weight in last 3 months and upon questioning , he told me that the food did not taste the same , and so he was eating less and so he lost weight . He did not have any excessive sweating at night . He had chest x- ray and then when it was noted to be abnormal , he had CT scan of the chest . The CT scan of the chest showed a cavitary area in the upper lobe . I told him and his wife that this could be cancer or infection . Or it could be TB . Sometimes we have a tumor blocking the secretions and then that can lead to pneumonia and then the middle part of the pneumonia can liquefy and that can look like this . But sometimes infection without tumor can also have similar appearance . Sometimes TB can look like this  and the RB is more common in upper part of the lung .
           So we did PET scan and bronchoscopy . The PET SCAN showed that the area in the upper lobe was quite hot and there were some lymph nodes that were hit too . These nodes were not seen enlarged on CT scan . I did the bronchoscopy and it did not show any blocking tumor or for that matter any abnormality . The abnormal area was quite large and was almost 10-12 cm and was occupying the entire upper lobe. So I did not do any biopsy . The breathing test did show some reduction in the reserve , but it was adequate for the surgery , in case we decided to take out the upper lobe. There were no cancer cells in the cytology of the samples that I collected .So I spoke to a surgeon and he saw the patient . He decided to do the bx of the lymph nodes first and then if negative , consider taking out the lobe .
        I was OK with it till I got a call from Lab on the samples that I had sent was growing TB like bacteria . So now I am now faced with the decision . This is a ex smoker and the positive PET scan could be due cancer or TB or infection . The lymph nodes could also be due to cancer or infection . Sometimes cancer and infection or atypical TB could be in same patient at the same time . So what should be the next step . Should we do the biopsy and the surgery to take out part of the lung > or should we treat the atypical TB and then do the follow up CT scan . The problem with this approach is the CT scan may not improve in 2 or 3 months. So no change in the CT scan does not mean that atypical infection is not the cause and it does not rule out or rule in cancer . Doing surgery in this patient and then if the surgery shows only Atypical TB , then we have done major surgery for medically y treatable infection , which can be cured by medicines in most cases and surgery in not needed. But it is  cancer and infection together, then the waiting is is not good option , but open biopsy is the only thing that can give us 100 % answer.

      This is what I call medical practice and the Watson -computer can not solve and it becomes art and the science together . 

Sunday, October 8, 2017


      Being in medical practice for so many years , I come across the patients that I can not fully understand the diagnosis. So sometimes I send them to Mayo Clinic or Shands Hospital at UF. I am in a way happy when they come back with no additional diagnosis or different treatment. But then I also feel bad that we can not CHANGE the disease. But sometimes I know the problem and I refer patients to other consultants and the patient comes back with some additional tests and no answers. I can understand the frustrations that patients go through. But I can not not tell my frustrations to patients or the family . I have also a problem when I explain the problems ans still the questions are the same. This brings me to the the patient of today.

      I saw this lady , 72 years old for chronic cough . It started many months ago and then the PCP gave her some antibiotics and then the cough medicines and the inhalers that are uses for asthma .It was OK and she still did have the cough and so she came to see me . She looked comfortable and did not have big or severe bouts of the cough when she was in my office . She had good oxygen saturation at rest. She had couple of family members with her. Her lungs had crackles on examination and that suggested to me that she had some fibrosis -scar tissue in the lungs . Whenever there is injury to lungs -from infection or chemicals or some unknown causes -there is chance of the healing leaving patients with scar tissues . The first symptom of the scar tissue  in the lungs is cough . The fibrosis can get worse quickly --6 months -was at one time called vanishing lung syndrome -or it can last many years and does not shorten the life . So it is unpredictable.
    So I explained them my initial impression . We did the CT scan and the breathing test and the oxygen check on walking . The scared  lung does not allow the oxygen transfer quickly when the demand go up and the circulation is rapid . So her CT scan was consistent with fibrosis and the breathing test did show that the diffusion capacity - the process of oxygen transfer was low at 32 % out of 100%. The walking also dropped the oxygen . So now I had to decide if there is any cause for the scars . The fibrosis for which there is NO CAUSE is called idiopathic or IPF , There are 2 new drugs that were approved only in 2015 and the cost is ONLY $50000 per year. They are not approved for the scar tissues that have a cause .So I did the work up . One of the causes of the fibrosis is conditions like scleroderma or rheumatoid arthritis or lupus. Some times in older patients there may be a problem with swallowing and the food or the liquid can go in to lungs and not in food pipe or esophagues . This can lead to chemical injury on repeated basis and that can lead to fibrosis .
       So I did the blood tests for the autoimmune diseases and did the swallow study. The autoimmune blood tests were strongly positive and the swallow study was abnormal , but not that bad . I did the tests that measures the contractions of the food pipe , as that is abnormal in some autoimmune diseases and so that leads to aspiration . This was severely impaired and the report stated 'consistent with connective tissue disorder '-one of the auto immune diseases . So in my mind the circle was complete . She had some auto immune process which impaired the contractions of the food pipe and that lead to aspiration - food and the liquids going in the lungs and causing the injury which healed with scar tissues and that caused the cough. Some of these auto immune diseases also can cause the scaring in the lungs without the aspiration .
    So I explained the situation to the patient and the family . I told them to see the Gasroenterologist and the Rheumatologist . I sent all the reports to both . The patient came back stating to me that Gastroenterologist did the endoscopy and it was normal . The rheumatologist did some tests and told her she was OK . The endoscopy can not diagnose the aspiration and the scars tissues and the strongly positive blood tests and the esophageal motility problem -all were pointing to the auto immune process. I did show them the reports and the explained them the whole things . And I still had the question -so why I am coughing ?

    I can not give an expensive medicine that has not been approved and proved to help scar tissues in this condition . So I my only way was to call them or send them my notes and my conclusions. 

Saturday, September 23, 2017



      When I was in my medical training, I used to write big notes and my Attending  physicians used to say that no one has time to read the long notes . I still do the long notes and there is a thought process in the notes , But now days , since the President Obama made it mandatory to have electronic medical records , I see longer and longer notes . That does not mean it has any information or the detailed thought process . Since these notes have been computer generated , there is lot material that was in older notes and even in the first note .So to find the REAL new information or the change in the patient , by reading these notes is very difficult. No one has time to read 8 page note . But the government has made it mandatory to have certain things included or documented ' , so we don't have choice . So there are these phrases that make no sense like smoking cessation -in house  and this is in patients who have never smoked .
       But I am not doing this  blog to complaints on EMR . But to tell you  the real difficulty when we have a patient who does not follow the medical advice . Or I want to NOT do something as I feel it is medically not  needed . Say I see someone who has clear cut cold  and patient wants antibiotics . There are several studies that have shown that the physicians are prescribing antibiotics much more often than it is needed -as in case of viral infection. I will have to write many more lines to justify why I am not giving the antibiotics. So many a times most will end up giving in and give a prescription for antibiotic rather than argue with patient and write few more lines to justify his or her decision. This brings me to today's story .

      I saw this patient in my office for abnormal chest x- ray and the CT scan . She was 71 years old and had quit smoking about 10 years ago . she had gone on vacation and was at height of 5000 feet . She got short of breath and so she cut short the vacation and then got down to lower level , She felt better and so she stayed there . She came back to the town and then saw the PCP . The PCP did chest x- ray as she still had some cough. She had no fever and had no chest pain , Her shortness of the breath was better , but not normal. The chest x- ray was abnormal and so she got the antibiotics and the she had a CT scan done . The CT scan showed a mass and a consolidation  or pneumonia . so she was sent to me .
         She came with her husband . She looked ok and did not appear to be short of breath . She sounded clear on her lung examination and her oxygen saturation was good . I knew by looking at her CT scan that she had cancer , that most likely was blocking the secretions and so she had the pneumonia . I knew that she needed the PET SCAN and the biopsy to get to the diagnosis of the cancer . But she and her husband were not convinced . She wanted to wait for some time to do any further testing . She felt that her problem was due to high altitude and it was better . So I agreed to wait for 'short' time of 2 weeks . I told them that if it was not cancer , it should get better in 2 -3 weeks . So we agreed  for 3 weeks . Mind you I had to write few more lines to 'document ' as to why I was not doing the scan and the biopsy sooner .
         So we did the PET SCAN and I was surprised . The spot on the lung was hot and most likely cancerous , but there were 'other spots ' in the lung and in the bones . so I called her and scheduled her to see radiation doctor and the radiologist for the biopsy . I did do bronchoscopy and she had the some changes that were consistent with cancer , but my biopsy came back suspicious , but not conclusive . so I called radiologist to do the additional biopsy . I had to again document this . she refused the Biopsy and she also refused the appointment with the radiation doctor . I was worried that bone spread to spine and the hip would cause the fracture and major problem .

       Again I had to document . I also called her PCP and again I had to document . So I was doing all this chart charting -may be 10 times and not going anywhere . So I called her to come to my office with her husband and the daughters .

      This is a very nice patient . But some how she was not getting what I was telling her . We did finally got the diagnosis of the cancer and got her to appropriate doctors for the treatments . She always hugs me and shakes my hand and thanks me for taking care of her. But that does not eliminate the need for the DOCCUMENTAION . If she would have done  things that I wanted her to do and done them sooner , I would have much documentation than what I did .

But I guise that is the modern day medicine --more documentation than patient care !!!

Sunday, August 27, 2017


   In physics there is uncertainty principle. But I think it applies to medicine more . We expect certain things and at the end of work we get something else . I recently saw some patients and in each of them I was surprised after I did the work up. We always know that when we start working up a patient with certain complaints or problem, we have some idea as to what may be the final diagnosis or the outcome . If we did not have the idea as to what is the likely diagnosis , then we would not have the direction in which to do the work up.This is called the differential diagnosis. In other science it is called hypothesis. But sometimes the out come is so different that even the physician who ordered the tests is surprised.

      This brings me to my first patient . I saw this 70 some years old male patient who moved in from other state. He was told to have pulmonary fibrosis or scars in the lungs . He had some chronic cough and so he was seen by a family doctor and then when the cough persisted , he was sent to a lung specialist. He did the CT scan and then he was told that he had pulmonary fibrosis . He was followed for may be 3 years and then he moved here . He had new family doctor and so with the diagnosis of the fibrosis , he was sent to me . He was fairly stable . He had some cough , but it was not worse and he had some shortness of the breath,but that was stable too. His lungs had some crackles ,which are typical of fibrosis . So they sound like the sound that one would hear when one rubs the hair in 2 fingers . When I asked him on the last CT scan , he was not sure , but certainly it was not done in at least1 year .  Same was about the lung functions. To assess the extent of the fibrosis and it's effect on the lung functions ,I ordered the CT scan and the breathing test.
      The CT scan report came and I was surprised . IT showed the fibrosis , but it also showed a mass in one of the segments of the lung . IT was about the size of a Quarter coin . I called him up and told him about the possibility of the cancer and ordered the PET scan . When the PET SCAN report came I was more surprised . The PET scan showed the lung mass to pick up glucose , suggesting that it most likely was cancer , but it also showed a mass and the pick up in colon. So now we had a question , Is it colon cancer which has spread to lung , or Does he have two separate cancers,one in lung and one in colon . My problem was that he had such a bad lungs due to scar tissues , that doing a needle biopsy would certainly cause collapse of the lung . And in patients with scars , it might not be well tolerated or if tolerated , it might take long time to heal the lung .
      So he is having colonoscopy and bronchoscopy . Then I will decide , based on breathing test as to the treatment options. Should we do resection of colon cancer and the lung cancer , if he has two cancers . Should we do resection of colon cancer and treat the lung cancer with radiation , or should we treat both conservatively  i.e. lung with radiation and colon with laser or something like that where the risk of surgery is avoided .

    The jury is still out .
     But to make my point , when I saw the patient , I did not anticipate all these problems that I was  or he was going to face . I thought I was doing routine work up for patient who had established diagnosis of pulmonary fibrosis. 

Sunday, August 20, 2017


    I often come across stories about my patients and their families . I t is impossible to know the details of the family relations and the dynamics in short visit which is for medical follow up and not for psychiatric evaluations . But I am amazes at the different 'fate' that all of us have . With my interests in mystic 'sciences' like horoscope , I wonder about the Destiny and law of Karma . Why do people who do adopt children with good intentions have bad out come or fate where the adopted children do not behave with love and responsibility.

    In Hindu beliefs we have some explanation , but when I look at other religions , I do not know any explanations offered. In fact sometimes many questions remain unanswered. The Christianity believes that the Christ dies for our SINS . But how can HE die for the sins that I a doing now? So the answer could be that the GOD knows what sins I am going to do . But if that is true , then it means that I can not decide my own destiny and the the destiny is predetermined or fixed . If that is the case , then it means that I do not have any FREE WILL and then I can not be held responsible got he actions or the sins that I commit. This does not go well with the concept of the GOD .
    In contrast to that when we talk about the Law of the Karma, we talk about WE determining our DESTINY and the  destiny is in future and the Karma - good or bad -precede the destiny. So it does not involve the GOD .So we have free will. Some people will differentiate between the destiny and the future.So what is happening in immediate future is Destiny and what will happen in future is future. But sometimes we can not explain the bad out come of apparently good deed . How do you explain that ?The answer lies in the concept of Hindu religion . We believe that the Time is endless , it does not have the beginning nor end . The Universe comes in existence and it goes down to Unity -something that the science believes how the universe came to today's state .  The only difference is that theses cycles are endless . In fact they have calculated the time of each cycle. and surprisingly, it comes quite close to the calculations done by the scientist . So in these multiple cycles , we have multiple births and we are reincarnated. So the physical body dies , but the 2 other bodies , namely Astral and the Causal bodies continue along with the mind and the intellect and the ego and all the impressions and the desires and the attachments from ALL THE PREVIOUS LIVES. These attachments and the desires make US SELECT our parents or the environment that is conducive for satisfying them and paying back the debt of the bad karma or the SINS . So again God does not DO anything to punish us or die for our SINS but the Laws that have been created determine our destiny or future . We have free will and we can use it to change our future.
      So the effects of our Karma are going to be seen in our future and when we have them , we create new Karma and attachments and desires and that decides the future life and future lives . No one can suffer for us nor no one can take credit for our good actions . We get what we deserve , even though at times the things appear to be unfair. There is a tug of war between the effects of our previous deeds or Karma and our present efforts which comes out of our free will. The effect of the two is proportional to the strength of each force . If our free will is stronger than the effects of the karma our life will go in the different direction , than if the free will is weak . The we will see the full effects of our Karma .   

Saturday, July 29, 2017


   I have been in medical practice for many years ,and over period of time I have seen lot of changes . The sole motive of the Insurance company is to control the cost and the sole motive of the regulations is to avoid fraud . But in doing so we have increased the cost of the health care and made it substandard and made it cumbersome . It is at a  point that I do not know a single medical person -nurse , respiratory therapist or physician, that is happy . I have one person just handling  the fax , one getting referrals, and one doing 50 % of time doing required forms for the DME- oxygen CPAP,nebuliser etc. The insurance companies deny claims and not pay and then any time -even a year down the road DEMAND the refund as they may have made mistake in paying when they should have denied and if we do not refund , then they cut it from next patent's bill!!.There is nothing I can do as no one care for the physicians -not even the physicians societies that I am a  member  of. But that is not my purpose of this blog . My problem is that these regulations and the behavior of the insurance companies has produced substandard care . That is the story about .

     I saw this young lady in my office . She was 59 years old and had some cough and shortness of breath. She had never smokes and was not taking any alcohol. She had no history of high blood pressure or diabetes or for that matter any other medical problem . She did not have asthma . Her chest X- ray was OK. On examination she was in no distress and her blood pressure was normal. She had no fever and her lungs sounded clear and her oxygen saturation was normal. She was little emotional as she was never sick in her life and now she was short of breath and had this cough that would not go away. Her heart rate was little high, but then she was quite emotional.

    So my impression was that most likely she had allergies and asthma . The chronic cough in non smoker , with normal chest X-ray is due to asthma and /or allergies in almost 80 % of the time . So I did the allergy blood test and the breathing test and did try her on inhaler for the asthma . I also did the walk test as many patients with asthma wheeze on walking or exercise. I also did what is called sum-maximal pulmonary stress test.
     She came for the follow up . Her allergy blood test was normal and the breathing test showed mild decrease in lung capacity , but did not show obstruction , which would have confirmed the diagnosis of asthma . Her walk test was OK and she did not wheeze and her oxygen saturation on walking was not decreased. Her stress test was abnormal and it was showing the problem to be HEART or cardiac.So I had asked for the echo cardiogram -or the ultrasound of the heart. She had called me in between and so I had also done the CT scan of the chest . The Ct scan showed some fluid /water around the both lungs .I did the CT scan to rule out any fibrosis -which was a long shot as differential diagnosis. The echo cardiogram done through the PCP office was reported normal. So when she came for the follow up I was puzzled. She was very short of breath . The inhaler had not helped . She could not even collect her mail without getting short of breath. And my tests had not shown any specific cause for it . Though she had some water around the lungs , everything else that could explain the cause of it was normal-the heart function.  She was so emotional that she started crying . She was never sick in her life and now she was so bad that she could not function doing day to dat activities . My tests were showing that most likely she had congestive heart failure and that had caused the water built up and so she was short of breath . But the ultrasound of the heart was normal . I was stuck .
     But like in my past medical life I take decisions based on MY heart than what tests show . So I told her that I am  going to get  her in the hospital and treat her for congestive heart failure with water pill and then see how she does . If she does not get better , then I will take out the water and may be do bronchoscopy to find out what was going on.
     I admitted her and started her on diuretic IV and ORDERED ANOTHER ECHO CARDIOGRAM , I saw her about 8 hours after she received the first dose of the diuretics . She was all smile -she hugged me and thought that I was the miracle man  as she was feeling so good that she has not felt in last one month. The echo cardiogram showed that her heart pumping action was 20 %!!!!!
This simply means one of the two things , one -the first echo was not of good quality or not interpreted properly  or secondly -n she developed the heart problem between the two echo. I tend to believe the first one . This is not the first time and it will be not the last time . The insurance companies want to save money . So doing and echo at radiology center or PCP office is much cheaper than a cardiologist consult and then doing echo in his office. So now a days routinely the echos are done by PCP or in a X-ray facility and they are not as good as done by cardiologist .

     So sometimes one has to go by what you feel than by the tests . She did very well after we treated her for congestive heart failure .  

Sunday, July 23, 2017


    In medicine and in life I often find that what could be considered as the TRUTH changes . medicine as such is as much science as art. So like in life or religion the search for the truth comes down to personal persistence .So one has to try hard and go withe the heart . That brings me to some patient;s story.

      I saw this patient , about 78 years old male who had lost 40 lbs of weight over period of 4 months . He had quit smoking 10 years ago and he had no cough or chest pain or shortness of the breath.The primary care physician sent him to Gastroenterology.   The specialist did the colonoscopy and the endoscopy The colonoscopy showed some polyps and they were benign. So he had no diagnosis as to why he was loosing weight. He had no fever , and no other  complaints.His cheat X-ray was reported as normal .
     And then one day he had  a bout of the cough and he noticed blood . His blood in the sputum continued for one day and so he called the primary care physician. He sent him to emergency room. In the ER they did CT SCAN of the chest. The CT scan showed that he had a mass in the middle part of the right lung and there was collapse of the right upper lobe . So I spoke to the patient and the family.
      He had normal chest X-ray. There was no evidence of cancer on the chest X- ray even though by looking back at the CT scan ,which had shown the mass or the cancer , I could not see the cancer , that was inoperable.
      I did the bronchoscopy and he has mass in the upper lobe -that was not seen on the CT scan , and it was causing the blockage of the right upper lobe and that had caused the collapse of the upper lobe.
    So I he had cancer of the lung and it had spread to the lymph nodes and had caused the collapse of the upper lobe , but NOTHING WAS SEEN ON PLAIN CHEST X-RAY!!

     I will tell story of the other patient where persistence on my part gave the diagnosis. 

Sunday, July 9, 2017


         The next one of the 6 enemies is the MOHA or the Delusion. Our entire life is full of delusion . If one considers the difference between the EGO and the SOUL, we will realize that ego is pseudosoul. The soul under the influence of delusion is is ego. When the soul which is immortal and unconditioned confines or appear to be confined within the physical body, is called EGO. The ego is BORN and Conditioned. Under the effects of the delusion or MOHA one does thins or acts differently than he would if he was guided by Intellect.

          In MAHABHARTA, the SHAKUNI MAMA is the representative of the delusion. He was known to be deceptive and create illusion or delusion. Upon the advice of the Shakuni , the Duryodhana asked Pandawas to the geme of Gambling . The deception that was used by the Shakuni worked and the under the influanec of the delusion the Pandawas lost . They not only lost their kingdom , but also the DRAUPADI, their wife. In the symbolic way the Draupadi is KUNDALINI shakti . The Pandawas lost the contol over the KUNDALINI under the influence of the delusion. So when one feels that HE or SHE is the BODY and confined to the limits of the body that is delusion

.            The next one is MADA or the PRIDE.The pride is I , ME ,AND MINE . Because of the pride we do things that at times are deceitful ,cruel and immoral.The 'I' in us makes us do things and act in such a way that otherwise we would not do. The PRIDE in MAHABHARATA, is represented by SHALYA . The Shalya is the brother of Madri the mother of the NAKUL and SAHADEO. So he should have joined the Pandaws in the battle between the PANDAWAS and the KAURAWAS. But the DURYODHANA bribed him with flattery and with gifts . The SHALYA was coming to join the war, Duryodhana arranged the big welcome and the feast of food and gifts and the flattery . The SHALYA thought that it was PANDAWAS and then he came to know that the host was no there than the Duryodhana. he still could hve joined the PANDAWA'S side , but withe PRIDE and the EGO and the delusion , he joined the Duryodhana side. We see it all the time how the fights among the friend and the siblings and the business partners never get resolved due to the PRIDE .

        The last one is MATSARA or ENVY. We all know this quite well. We can not enjoy if something good happans to someone as 'it did not happen to us'. In fact it is due to MATERIAL ATTACHMENT. So if someone gets promotion in job or gets recognised for his or her work or courage etc , we are not happy as we are attached to the same material things. This is the MATSARA or envy. In MAHABHARAT this is represented by KRITVARMA . Hewas the only YADAWA,who belonged to the sama clan as KRISHNA , But KRISHNA was respected , adored and was on the side of PANDAWAS. He became the enemy of Krishna , when the bride that HE WANTED to marry was married to Krishna . This meterial attachment and not having the same success in getting recognizes as was KRISHNA , he decided to join the side of KAURAWAS.

Tuesday, July 4, 2017


      In the last one we talked about the first of the six enemies of the mankind which was KAMA OR LUST . The next one is KRODHA or ANGER. In today's world one need not saay anything more about the anger . The road rage , so common that we hear about it everyday. The anger in politics is seen everyday and has paralyzed the function of the government .
      In MAHABHARATA, the anger is represented by DUSHHASAN. We all know the famous story from the epic of how he dragged DRAUPADI and tried to disrobe her . When the Pandawas lost in gambling and in doing so they lost their wife too. So she was brought to the Darabar and then DUSHHASAN tried to disrobe her . She asked Lord KRISHNA to help her as none of her husbands would or could get up to help her. The Lord Krishna provided her with unending saries . This dded was done in anger . Whenever there is anger it paralyses rational ,intellectual thought process. Some one had said that that getting angry is punishing our self for the mistake of the someone else. The anger can come due to greed, lust ,disappointment and can lead to violence either physical or verbal . Even if anger is justified , say for example when terrorists killed hundreds of innocent victims in the name of religion , one should allow a rational thought process and channel it in such a way that we can catch such terrorists before they can do another act of violence and prevent it in future.

     The next enemy is LOBHA or GREED. In today's world we see it all the tie in our politicians and in common day to day life . People that have billions of dollars will cont to do things that are illegal , immoral and unethical to get MORE. Otherwise how do yo explain the selling of uranium mine to Russians or collecting billions of dollars under the name of charity and spending less than 10 % for the charity. At our level we see this when we see people indulging in food at party or drink at a party. We all eat MORE than we need and we drink much more than we need and can handle .
In MAHABHARATA, this greed is represented by KARNA and VIKARNA. Karna is representative of RAGA which is attachment to things that we like and repulsion from the things that we don't like. This attachment is so strong that it leads to GREED. The funny part of this equation is that we are never satisfied when we get what we want . This is called CIRCLE OF MIND . When we DO an action , it leads to IMPRESSION , which leads to DESIRE and the desire leads to ACTION which again causes the impression and so on and so for. When we do repeated actions , the impressions that it leads to are much DEEPER and the DEEPER the impressions , more intense is the DESIRE . So satisfing the DESIRE does not lead to calmness but in contrast it leads to more intense DESIRE. These desires are stored not in our physical brain , but are stored in abstract form in our ASTRAL
AND  CAUSAL BRAIN.When the physical body dies the desires are not gone as they are still there in astral and causal bodies . So we are reborn to SATISFY our desires . When these desires are not satisfied , we get ANGRY -KRODHA and under the impression of anger we loose the rational thought process and ACT violently.
    I will try to do other ones in next blog.   

Sunday, June 25, 2017


    This blog is non medical. I was re reading the GEETA shloka 9th. As I have stated in the past that it is difficult for me to understand and accept that the Lord KRISHNA would spend or for that matter SANJAYA would spend the time in describing various warriors on the battlefield . So in the shloka 9th Duryodhana says that there various warriors ready to fight for me with there weapons.
    If one considers the symbolism of the real war to WAR WITHIN ONESELF,we have to consider the various obstacles that one faces in the meditative practice.Here comes the other warriors -which are 6 enemies of the practice of the meditation or called SHAD (SIX)  RIPOO(ENEMIES).
These are 1. KAMA (LUST),

     In MAHABHARATA, we have several characters, that could qualify to represent each one of these enemies of the mankind. In today's world we can find many people that could be considered to represent each of these 6 enemies-certainly one can have different opinions about certain figures that are known to all of us , but we will not have much debate on certain other characters,e.g North Korean leader , who probably represents more than one .
   The LUST is not always sexual .It is attachment to sensory pleasurable activities which can never be fulfilled.  It is intense attachment to material world, which is mortal and so are we. But we are holding on to the material things as if we are going to 'take them ' with us when we die. In Mahabharata, the DURYODHANA represents this LUST. He had such a attachment for the land , that he refused to give 'Even the amount that could be on the tip of a needle,' to the Pandawas. This lust is at the level of the mind  and the Intellect, is paralyzed.The physical sense organs are gross and the perception is at micro level , but still in physical body . But the mind is sutler and the intellect is still sutler. The EGO is higher than that. So when we have lust we can't THINK and we ACT at much lower level. The story of the Tulasidas, who wrote the TULASI RAMAYAN , is well known . He was married and his wife went to her parents for short period. He could not live without her so at late night he decided to go to her parent's place . They lived across the river . But he did not care . He went to the banks of the river . The water levels were very high due to rains. So the boatman refused to take him across the river in boat as it was too risky. Tulasidas decided to swim. He saw a wooden log passing by and so he jumped and with the
 wooden log he went across the river. he went to his in law;s place . it was two story house and the wife was in upstairs bed room . he called her , but she was asleep . His desire or lust was so intense that he decided to climb up to the window . He grabbed a rope that he saw hanging from the window  and went to the window and knocked on it , the wife opened the window and the was surprised to see her husband. She was not very happy as it was too embarrassing for her that her husband could not live without her for one night. So she told him to go back . She made a comment that if he would have such an intense DESIRE for the GOD , he would  be better off and would have perceived God by now.When he came to his senses he realized that what he thought was a wooden log was a dead body or corpse, what he thought was rope was a snake and so from that point onward he became a devotee and you know the rest. So if we have the LUST for GOD , it will be better.

  About the other five enemies , we will do another blog.

Saturday, June 17, 2017


      I was reading an old book by one of the Indian authors. There was a story in which there was  a subplot . They had mentioned a story from a book of stories called 'ISAP NITI'. Isap is a slave and he had ability to understand the languages of the animals. So he had these narrative stories , in which the birds and the farm animals and the jungle  animals talk .Each story was telling some moral. So the story which was mentioned in this book was as follows . There was a bird's nest in a tree and the the the new ones had hatched. So one day the farmer comes in and looks at the trees and tells the servants that  the trees need to be trimmed. After listening to the talk that the tree will be cut , the little ones in the nest got scared and so when the mother came home, they told her the story and told her that they have to move , The female asked them as to who was going to do the job . So the birds say that the servants of the farmer. She tells them to relax. This is repeated and each time the servants are ti=old to cut the branches the mother tells the little ones to relax . One day the kids tell mom that the farmer had come again and this time he said that 'I am going to cut the tree tomorrow!" The mother tells the little ones that they have to move right away ! .The moral of the story is that if you want something done , you have to do it yourself if you want to be sure that it gets done . This brings me to my patient story.

       I was called to see 35 years old male , who had chest pain and so he came to ER. He had chest x-ray done  and it showed collapse rule out heat attack. He had a chest catheter inserted and then he had a CT scan  of the chest . The CT scan showed that his lung had partially expanded and there was still significant air out side the lung . He was doing better and was not short of breath and was not needing the oxygen.
      So I saw him and saw the CT scan too . He was more than a pack a day smoker and the CT scan showed  that there were several blebs or blisters on his lung . My feeling was that one of these blisters or bleb ,ruptured and so then the air leaked and the so the lung collapsed. With all these blisters on the lung I was concerned that this can recur and since his lung has not expanded completely , he may need additional chest tube or even surgery. I was worried that trying to insert new chest tube with all the blisters could ,one of them could rupture and then there would be major air leak.

      So i told him that he should be seen by chest surgeon and may be he can do new chest tube or just take him to surgery and clip the blisters and put in some talcum powder .To do this he needed to be transferred to the other hospital. So I called the hospital doctor. and also called a lung specialist in the other hospital and also called the chest surgeon . the surgeon felt the same thing and was willing to accept the patient .
    In doing all this 18 hours passed by and then 24 hrs , since I mentioned to him about the transfer . The next thing I knew was that the hospital doctor calling me telling me that the patient left the hospital with the chest catheter without telling any one . I did not know what to do . He had threatened the same before when different lung specialist had seen him and they did not get along and that is how I needed up talking over. But I had talked to him and the family extensively and printed pictures and told him that he will not do well without medical help. So my hunch was that he will show up and show up at the other hospital .

       I got a call from the other hospital that  he was in the ER !!!!

(In this story the patient decided to do the transfer on his own  rather than waiting for others to do it . I am happy that nothing went wrong , but this was not right thing )

Saturday, May 27, 2017


         In my last blog I talked about the guidelines that are given by the medical society and the insurance companies and the Medicare. but then I realize that even when one follows the guidelines , there is no guaranty  that we can succeed . I have seen this in many cases and the today's story is one of the similar one.
          I saw this 80 years old patient with cough .He had the cough for few months and so the usual tests were done by the family doctor. The chest X- ray was OK and the antibiotics and the other medicines did not help. So he came to me. I was treating his wife for several years and so I knew the patient though not as patient., He was not a smoker and the lungs sounded clear. He had normal chest X-ray and the lungs sounded clear.I ordered the pulmonary function tests  and it was OK There was minor abnormality that could go for the mild asthma.So I tried the medicines for the asthma. It did not help.. He gave me the history that the cough was getting worse with the eating and drinking water. So I suspected aspiration , which means that the liquids or the solids would be going in the lungs rather than the food pipe. So this causes chemical irritation. and that leads to the chronic cough. So I did the swallow study and it did confirm the aspiration . But the speech therapist gave him some instructions.

      The cough was better but was not gone. He had  follow up chest X-ray and it was OK. I had done the CT scan before and it was OK. He continued to me for next couple of months and then stop coming as he  was OK.
        I did not see him for just over a year. He was followed by the family doctor. But then he started loosing the weight. His appetite was down and he had lost weight. So the family doctor did the work up. He had CAT scan of the belly. The CT scan did not show any abnormality in the belly. But it showed mass in the lung .So he came to me . I did the CT scan and then the PET scan as the CT scan showed mass in the lung. The CT scan showed 8 cm size mass. I did the bronchoscopy and it showed lung cancer blocking the left lower bronchus.

    He was referred to radiation doctor for the treatment .
    So the mass that was not seen 14 months ago was now 8 cm .So even if he had chest X- ray done in a years , the cancer would have been diagnosed 2 months ago. But certainly not soon enough to be small enough for resection. (With his age and other issues , he was not surgical candidate. But he was younger still it might have been not the earliest stage .So following  the guidelines of doing X-ray would not have been enough.

Saturday, May 6, 2017


       When ever I read the Guide lines on work up or the treatment of a symptom or the disease, I often wonder as to what about people that fall out side the NORMS, or 'usual'. So a particular symptom is seen in say 90 % of the patient with a diagnosis, what about the 10 %. So I know that the working for rare causes may be expensive and time consuming. But what about the standard things that are not 'required' , but is a good idea.  But in the modern day practice of the medicine , we are more controlled by the insurance companies, and hospitals, and medical associations and the government rather than by what is good f fro the patient. So sometimes when I see some patients ,I often question as to the 'cook book medicine'. This brings me to the today's story.

        I saw this male patient in my office. He was a 70 years old male , who had smokes for several years . he has some chronic cough and also had some weight loss. He had worsening of the cough and was treated with usual medicines . I asked him if he got short of breath with activity. This is to assess the lung capacity as he was smoker. He told me that since his arthritis got worse in last 3 or 4 months , he has not been walking. He had hip pain and was treated for the arthritis.  He did not get much better and so then had chest X-ray done . The chest X-ray was abnormal and so then he was ordered to have chest CT scan and then he was referred to me.
       The CT scan showed what looked like a lung cancer . So he came to me . I had chat with him and the family. I told them that we have to answer 3 questions , Is it cancer , Has it spread and What can be done IE what is the treatment choice. I ordered the PET scan and decided to do the bronchoscopy. The PET scan showed that he had positive pick up in the lung mass , but it also showed that there was pick up in adrenal and bones, especially in the pelvic bone and the hip bone , where he was having severe pain .
     So this man had chronic cough and he was smoker and has had no chest X-ray done in last 5 years. I am not saying that the chest X-ray would have Dx lung cancer earlier. But one thing for sure , I tend to do chest X- ray in every smoker and ex smoker every year. This I have done before the new 'Guidelines' came out to do low dose radiation CT scan of chest for high risk patients. But it is not a requirement for the HMO,Quality of care . So most the patients get cholesterol and blood sugar check up and the mammograms done , but not chest X- ray. So hopefully we will be doing the chest X-ray if not CT scans.
    Guidelines are good but when we do only COOK BOOK MEDICINE , we don't do as well !!

Sunday, April 9, 2017


   Long time ago , I was complaining about the car repair bill to a car .mechanic The cost of the part was not that high, but the cost of the labor was very high. So the answer that I got was not that unexpected.He knew that i was a Physician and that was translated in to to two conclusion, one that I did not have much knowledge of cars and secondly I had money. So he told me that the human body is old machine and there is no change in it for many many years , contrary to that  the automobile engine has changes significantly in last few years and it continues to evolve and change and so it is much more difficult and time consuming to diagnose a problem , so the labor cost is much higher than what I get to see a patient on follow up. I did tell him that if I make a mistake (or some family member or a lawyer conclude for his or her own monitory benefit that I made a mistake,)the patient could be harmed or can die. That is not so with the car . But I had no way of getting my car fixed without him, so I did not argue. This brings me to the story that I am going to tell today.

    I saw this patient 78 years old female for pain in the belly . It actually was flank pain rather than belly pain. The reason I was called in was due to her chronic cough and the possibility of scars in the lung , so called Pulmonary fibrosis. The husband was bed side all the time . So I saw her , She had never smoked and she had some cough . I checked her oxygen saturation and it was normal. On her physical examination, she had some crackers ,which are indicative of scars in the lungs. The CT scan of the belly had shown no new findings , but she had some tumor in the belly ,unchanged from 2014. No one knew the etiology of the small abnormality next to liver , which is on the right side and her pain was on left flank. She did have vertebral fracture and some artritis in the spine.
   So I ordered the CT scan of the chest to check on the fibrosis.I did not do any investigation on he flank pain as Gastroenterologist was consulted. The Gastroenterologist  decided to do endoscopy, which I did not think was going to add anything and it did not. But I was talking to the husband and he was getting frustrated as 'she was here twice and no one can find the cause of the pain.' And he was right . She was in the hospital twice and as out patient had complained to PCP for last one month. So I told him that I think the pain is due to the lumbar spine problem and not due to the gatrointesinal problem . I ordered MRI of the spine and it did confirm my suspicion . She had severe arthritis and fracture of the first lumbar vertebra ,so the pain was due to the fracture. We talked about the arthritis where she would need to see spine MD and the fracture where we could try a procedure where they inject cement in the vertebra and that gives pain relief in majority of the patients. She and the husband agreed .

      So the procedure was done by neurosurgeon.She did well. I saw her about 4 or 5 hours after the procedure and she was OK , But like any other procedure she was out on the oxygen . The procedures are done with light sedation or anesthesia. She had no chest pain or flank pain or shortness of the breath. I told the nurse that we need to wean down the oxygen as we wanted to get her home in the morning. The fibrosis was confirmed and I would have to do the further work up as out patient.
   I get a call from the nurse that she was fine , but her oxygen was low . So I ordered blood oxygen check and it came back alarmingly low .Again she had no complaints. I was not sure as to what may be the reason , but I was worried about a blood clot in the lung due to lack of physical activity . So I ordered a CT scan of the chest . But I was not sure if I could give her blood thinner as she had invasive spine procedure. So I called the neurosurgeon . ( I had 4 different phone calls before I got the right doctor).He had no problem using the blood thinner, but he did not think this was related to the procedure . We had problem with the IV access and so I had to change my order on the CT scan . But then we got good IV and we did the CT scan. I got a call from the radiologist that she did have clots but they were NOT BLOOD CLOTS but it was the CEMENT clots .

     During the entire span of about 6 or 7 hours , I had about 12 calla and spoke to 5 different doctors trying to get the things done .
     Yes the human body -the machine is old , but problems are NEW and by the way there is no extra labor cost that I can bill !

Saturday, April 1, 2017


   I have written about the inadequacy of the medicine in past . But when one is in practice of medicine for many years, he or she thinks that everything is routine. But then a patient shows up with what looks like routine case , and then when the final diagnosis is there , one meets with surprise. It has happened to me in the past and sometimes a new patient or an incidence reminds me of the inadequacy of the medicine. The story that I am going to tell is one such story.

       I had seen this 74 years old male patient for at least 5 years.He came to me for a cough and then I did the work up . He was not a smoker and had never smoked . He had some allergies and the cough was kind of chronic and intermittent. He had no other major medical history. He had no TB or diabetes or skin cancer or asthma . The only thing that was different he had was that he had cancer of the kidney few years ago and had one kidney taken out. I did the routine work up . I see chronic cough patients every day. So I did the allergy blood tests and the breathing test and tried him on some allergy and asthma medicines. He did better . But to history of the cancer , he was concerned and so I did or his PCP did CT scan of the chest . It showed a small nodule. So I decided to do the follow up. He had follow up CT scans periodically . First one in 4 months and then every 6 month intervals as there was no difference in the nodule.
    The last time I did the CT scan, the report showed that the nodule was same , but he had some plural-covering of the lung-thickening. It was not all around the lung but only in certain places and that to only at 2 or 3 places . The thickness was barely few mm.I did not know what to make out of this findings. I decided to do the PET scan and the bronchoscopy. He also had started to have some chest pain on the same side as the plural , while the nodule was on other side.
   The bronchoscopy was negative and did not add anything to the diagnosis. But the PET scan showed that the entire pleura was hot or lighted up. This means that something was going on in the pleura. So I sent him to a chest surgeon to do the biopsy of the pleura . He underwent the chest surgery and it showed MESOTHELIOMA!.I had suspected the cancer due to the findings on the PET scan , but never thought he could have mesothelioma. One he had no history of working with asbestos , which is almost exclusive cause of the mesothelioma and secondly he had the cheat pain only for short duration and did not need much pain medicines . But not every case is standard case. As we say sometimes , patients don't read books when they have complaints and have particular disease. .
        So this is what I call Inadequacy of medicine.

Saturday, March 18, 2017


   When it rains, it pours, is a common phrase used especially in relation to money or expense. So when we have one unexpected expanse , we end up having to face some other expenses. But I have also seen this when some bad news is seen . It is also said that bad news comes in threes. I have seen this in some of my patients . That brings e to my today's patient.
   I saw this patient more than a year ago.She was a smoker and her mother was my patient , who had advanced COPD. The mother was on oxygen. She had COPD and she was treated and told to quit smoking and she did . She was out of town and was sick and had some X-ray and CT scan done . But some how I did not see her for almost a year. She came back because she had cols and was treated by her PCP and was not getting better . She did not have fever , and did not look to be in any distress. But she was feeling short of breath and had cough with not much expectoration. She did have some wheezes , but not bad and her oxygen saturation was OK . Her mother was admitted to hospital with a viral infection , called RSV- Respiratory Syncitial Virus. This is not uncommon virus and the mother is quite old and has advanced COPD , and so I was not surprised that she needed to be hospitalized. So I thought that she may have the same virus. Her chest X-ray was OK . So I treated her with steroids and some other medicines and ordered chest CT scan .
    She came to see me shortly after the CT scan as the CT scan was abnormal . Actually she came day after the CT scan .The CT scan showed mass in the lung. She was still not feeling good  and the CT scan showed that the mass had pressed on her middle lobe bronchus and the middle lobe was collapsed. So I decided to admit her to give some antibiotics , for possible obstructive pneumonia .
   She was admitted and then I did the further work up. So she had CT Scan of the belly and the MRI of the brain and the PET scan. She also had the bronchoscopy. Her CT scan of the belly showed that there was cancer in her Liver and the Adrenals . The MRI of the Brain showed that she had multiple metastases in the Brain and the PET scan confirmed all the spread and showed that the cancer was also in the BONES . She was obstructed in the right lower lobe and the right middle lobe.
    So essentially she had lung cancer which had spread to liver , adrenal, bones and the brain!
   She will need chemotherapy and radiation treatment , but this what I called , when it rains , it pours! 

Saturday, February 25, 2017


    I have been in practice for many years,and sometimes it makes you humble. You realize that you can not diagnose everything and you certainly can not cure every thing . There is always a factor of luck. And more I  see more I realize that WE are not the DOER , but we are just an instrument of the nature or the GOD or the luck. HE or SHE allow us to feel that we are in control and then in a flash , we feel we have lost the control. I have that feeling many a time and recently on couple of times it hit hard. That brings me to the case today.
     I saw this patient as my last new patient in the office. She came with a note from her surgeon stating SOB-shortness of the breath. I had no other records. So I tried to get some history from her. I also checked hospital computer where she was hospitalizes.She was young lady and had breast cancer diagnosed year ago. She had mastectomy on both sides and also then had both ovaries removed as the cancer was very aggressive. She received radiation treatment and then chemotherapy. She was hospitalized with shortness of the breath and then was found to have fluid around lung and heart. So had surgery and  had a catheter inserted to drain fluid around the lung and the fluid from the heart was drained .
      She was followed by many doctors including a lung specialist. Now she was in my office.I did not know that she was seeing another lung specialist.She was short of breath on any activity and her heart rate was more than 130. I also thought that she may have fluid on the other side also. So I told her that she needs to be in the hospital to find out what could be done,if any , and to first find out what was the cause of the increased  heart rate. She  had seen  heart specialist and he gave her some pills to take for reducing the heart rate. But the problem was that her blood pressure was low and this medicine could make it worse. So I wanted to get her in hospital and find out what can be treated
      So I admitted her and ordered the tests and some treatment. I did a CT scan and it showed that she had blood clot in the lung -which could explain the shortness of the breath and increased heart rate. She also had more fluid on the left , which could explain shortness of breath and increased heart rate. The CT scan also showed that the fluid on the right ,where there was a catheter inserted to drain it 2-3 times , had become locculated-had formed pockets , which means the catheter could not drain it. He blood count-the hemoglobin was half the normal. So all these could explain the problem and were treatable. But couple of things bothers me. Why was it that the oncologist or the cardiologist or the lung specialist did not bother to do the tests.May be because the underlying problem was not treatable- the wide spread breast cancer and I was sure that this bandage approach would only prolong the unavoidable end.
                            BUT THERE WAS GLIMMER OF HOPE !!

Saturday, February 18, 2017


        I have written on this topic in 2013 in one of the blogs . But there were several reasons , that I thought that I will write about it again. i have seen several commercials on TV from National Franchises  and I have heard several radio shows sponsored by people or centers that do weight loss main service, It is a multi Billion Dollars industry.If one considers obesity as a disease then the 5 year 'cure' rate is almost zero.
         When I talk to patients and they are on one or another weight loss program I will always ask as to what exactly they are told or what exactly is the 'plan'. One of the local program which claims to have 'fat loss' than just weight loss, and I agree with the concept that fat loss is more important that just 'weight loss' , I found out that patients are put on 600 calorie  diet, it was not a surprise that patients lost weight . They are asked to not bother doing exercise and are asked to drink lots of water. The water drinking is good idea , but not 4000 ml to 5000 ml. And what about exercise? The studies have shown that overweight patients who engage in exercise on regular basis do much better than normal weight patients who do not do any exercise. So doing exercise even if it did not make any difference in weight loss , it MUST be done. So to advice that no need to do exercise and weight loss with 600 calories , even if it is only for short time , is not good advice.
        I also saw a news, that the scientists were working on a 'pill' which will do the job of exercise. I am not sure I would opt for it instead of real exercise. But I did see a study in which they put normal weight people and obese patients on low or starvation diet and then high calorie diet . The metabolic rate was measured at base line and then with starvation diet and also with high calorie diet. What they found out was what lot of us who have difficulty with weight loss. Both the groups reduced metabolic rate with starvation diet , but obese patients did drop metabolic rate much lower than normal weight patients. And when they were on high calorie diet , the metabolic rate raised much higher in normal weight patients than obese patients. So in short obese patients tend to, 'conserve 'calories more than normal patients under any condition -starvation or high calorie diet condition. This may be the explanation why some patients gain weight just with smell of food while others eat and have no weight gain.
       In spite of all these studies the principles of weight loss remain same.
1 One must have intake less than output.
2 Body fat loss is more important than just weight loss.
3 Muscles burn calories , fat cells do not .
4 So building muscle mass is crucial in long term weight loss.
5.Big muscles 'spend ' more calories.
6. One must do a program ' of diet and exercise that he or she can 'stick with for rest of the life.

Saturday, February 4, 2017


     I have been quite comfortable in talking to anyone at any time on almost any topic. I try to limit my talk on politics as it creates problems. Talk leads to  difference of opinion and then that leads  arguments and then shouting and bag words and fight. It leaves bad taste in mouth. So I try to avoid it, though I am not successful always . But today I am telling a story of one of the patients , that made me speechless.
       I was called to see this patient who came with fever. I was not too sure as to the exact reason for my consult, may be because it was sometimes ago or may be because she had some other issues that were more impending than why I was called in . She was a 52 years old female and was not a smoker . Long time ago she was told that she may have bronchial asthma. She had acute leukemia and then was given treatment and even bone marrow transplant. She did OK and then had recurrence. She was treated at out side oncologist at a cancer center and our local oncologist was basically seeing her for need for transfusion or some other problems that her out of town oncologist could not handle. She had fever and chills and it looked like she had respiratory infection. Her oxygen saturation was OK , she had some bronchospasm. Her X-Ray was OK . She was seen by number of consultant including infection specialist and cardiologist and oncologist. So other than doing some nebuliser treatments and short course steroids. She was started on antibiotics by ID specialist. She was doing OK There was no fever but she was feeling tight in chest . So a CT scan of the chest was ordered. It showed fluid around heart. So the cardiologist ordered Echo cardiogram. It confirmed the fluid around the heart . So we called chest surgeon. The problem was that her leukemia was active and blood counts were low and she was needing transfusion every other day. The main problem was platelet counts. The platelets help clotting and one can not do any simple biopsy , let alone major surgery. Draining fluid from around the heart was not going to be easy with low platelet counts. The surgery got postponed for couple of days as in spite of platelet transfusion. Then one day the count was better though not normal and the surgeon did take to surgery. I was concerned but everything went well . Few days down the road the tube that was put in was taken out as it had stopped draining any more fluid . In between the periodic transfusions continued.  days after the tube came out she had some chest tightness and so new CT scan was done and it showed new accumulation of the fluid around the.heart and this time also around the left lung. I recalled the surgeon and the cardiologist, both of them had stopped seeing the patient.New echo cardiogram was ordered and it confirmed the fluid. But her platelet count was very very low. 7000 ONLY when normal low is 150000.
     So the surgeon talked to her and her family,He told them that risk of surgery was very high.I was not sure what to do or how to talk to her. I had explained it to her and her family several times that risk was very high and even if she comes out of surgery the long term prognosis with active leukemia was not very great, So I asked her as to what was her expectation. I was not sure if she understood and accepted the bad prognosis. She told me that she wanted to 'live' foe 2 more years. At age 52 , I was not sure why she wanted to 'live' only for 2 more years. The answer left m speechless. Her daughter was junior in college  and he wanted to be alive for the graduation!
                                 What was I going to say ?I was left speechless. 

Friday, January 20, 2017


     I have been in medical practice and sometimes feel that nothing can surprise me. But then comes across the situation where I feel that This one is new or I did not expect this.Sometimes it is patients behavior , sometimes it is other doctor's behavior and sometimes it is the diagnosis. Patients may feel that physicians are not 'involved ' in patients feeling or diagnosis. But Many do and I for one do more than I had thought.May be when we don't expect and get a different diagnosis, then we remember more. This brings me to the Case that I was going to tell.
    I saw this years old male in the office for abnormal chest x-ray . Patient was ex smoker and had quit smoking several years ago.He was pushing a golf cart and it hit his chest. He was out of state and had some pain , but then he for better with Tylenol and so did not go to doctor or ER. Then he was little short of breath. So he saw the primary care physician. The physician ordered a chest X-ray and it was abnormal and so did CT scan and send him to me . The chest X-ray showed the fluid around the lung and then the CT scan showed that it was inoculated. Normally there is very very small amount of fluid around the lungs , primarily to may be allow lungs to expand and contract-like lubricate. But in this case it was not free to go all around the lungs , but was forming a pocket and it was pressing on the lung. If it was a' free fluid' I could 'drain' it with a needle or catheter. But with fluid forming a pocket , I had to have surgeon do the drainage by doing the surgery. So I send him to a surgeon. He agreed with my suggestion and wanted to get cardiologist to 'clear' him for the surgery.        So after all the things were done he underwent the surgery and the pocket of fluid was drained but in doing so he had to 'peel' the covering the lung. This let an air leaking from the lung. Normally we see this quite commonly and so it was not a concern. But then the patient developed pneumonia and irregular heart beats. The oxygen dropped and he had to be watched in ICU. The air leak continued even when he got better. I have seen one patient where this air leak continued for weeks and he needed 2 more surgeries. So I was not concerned , nor was the surgeon. But when this continued for days and weeks . I was not sure as to what could be done. Now a days there are newer techniques to put in one way valve in the bronchial tube. But this needs lot of time under anesthesia to 'localize' correct bronchus -the one that is leaking the air. So I called intervention lung specialist to do this . Just to let you know how rare this is , I have never seen this procedure needed or done . There was another option that I have seen being done is do surgery and cover the 'hole' with pleura.So he was transferred to another hospital . The new lung specialist saw him and felt that he was 'too sick' to try to do the valve . So after another 10 days when the air leak did not stop ,he was taken for second surgery.
      What they found out was shocking to me . HE HAD CANCER IN THE COVERING OF THE LUNG and so the lung was unable to expand and so had continuation of the air leak. I did not anticipate nor did the first surgeon. That was shocking . I had always thought that surgery was 'final' verdict on cancer. So I was shocked to learn that the second surgery showed cancer .  

Sunday, January 15, 2017


       Sometimes I see patients that I can not figure out as to why they have so many problems or why certain things happen to certain people. Many years ago I went to see one of my professors, who taught us Preventive and Social Medicine, who was hospitalized for heart attack. He was 50 some years old and had heart attack. He said that 'I don't smoke , I don't drink, I do not have high blood pressure or diabetic ,then why did I get the heart attack.'I did not have answer.I find myself in such situation many times . So the story that I am going to tell is one such case.
     I had seen this patient for several years and she had many major problems and I had treated her and referred her to Mayo clinic and UF. She had repeated episodes of coughing blood and many other issues. I could not find any reason and nor did Mayo Clinic. But the UF did find some abnormal blood vessels and did cauterization of the same. She continued to have same problem and so I sent her back to get the cauterization  done . So this would have been her 4th or so procedure to stop the bleeding. She went there and had the procedure done on Friday and came back on Saturday. She was fine on Sunday.She started having shortness of the breath on Monday and so she called 911 and they brought her to the ER on Monday evening. So I get a call from the ER MD that she was there and the chest X-ray showed 'complete collapse 'of the left lung. She was put on BIPAP. She was admitted to ICU. So the ICU doctor called me and told me that she was admitted and she wanted to see me. So I saw her in the morning of Tuesday. She had second X-Ray and the left lung was still collapsed. I saw the notes of 3 doctors and saw their plan. Patient needed Bronchoscopy. My suspicion was that after the cauterization, she must have had some bleeding and had some blood clots that blocked the left bronchial tube and so the secretions could not come out. So the lung collapsed. So she needed to have the bronchoscopy and sucking out of the blood clots or the mucous to 'open' the lung. She did not want to be intubated and put on respirator. But without doing that it was impossible to do the procedure. The suction channel of the bronchoscope was too small and we might have gotten in trouble. So I called a chest surgeon and he agreed to do it and the patient agreed.So the bronchoscopy was done under anesthesia and had to be left on respirator. I saw the new chest X-ray and it had shown 50%improvement but was not 100%clear. So I decided to do the bronchoscopy again. The patient agreed and so I did the bronchoscopy.
       What I saw surprised. Her left bronchial tube was quite narrowed. There were plenty of mucous plugs and I lavage with saline . But my main concern was that the narrowing of the bronchus. My concern was that unless that we treated , she would get the collapse of the lung again. But I had to confirm it first as the narrowing was MY IMPRESSION. No one else had suggested it , nor at UF nor in ICU nor the surgeon who did the brochoscopy. So I spoke to the radiologist and ordered High resolution CT scan . It showed that left bronchus was quite narrowed, it was less that half the size. I called a interventional lung specialist and asked him to look at the CT scan and he agreed . So he did the balloon dilatation of the left bronchus and then we got her of the respirator.
      So this patient had complications to the treatment ,which I have not heard any other patient getting it. The disease is rare, the treatment is rare and the complication that occurred is I guises is rare

Saturday, January 7, 2017


    I have been in Medicine for so many years that nothing should surprise me. But as in Life , we have uncertainty or unpredictability in Medicine. Usually most of the cases behave as we think or predict. But then there are cases that we come across that throw us off completely. I had 2 of them recently. So the first one is my today's story .
    I had seen this male patient , about 70 for may be 2 years. He used to see another lung specialist for several years and then switches to me when the his own physician left private practice or his insurance. In any case he was doing OK for several years in spite of damages bronchial tubes and some COPD.I had given him antibiotics and done chest C-rays and done lung function tests. He was fairly stable . So when he came for a routine follow up I did not think much. He was doing OK, had some chronic cough and no fever . He had some episodes of dizziness. He had lost some weight , may be 15 LB  and had some decreased appetite. Patients with damaged bronchi , called Bronchiectasis , can get infection with atypical TB - called MAC . The symptoms are weight loss , low grade fever , decreased appetite, worsening cough etc. So I was thinking of doing CT scan and brochoscopy. But then I checked his blood pressure and it was low normal at 100. So I had him stand up and rechecked it . it dropped to 60 . So I was alarmed and decided to admit him . He agreed.
    I got him in the hospital and started him on IV fluids and ordered some blood tests to diagnoses low functioning Adrenals. I also ordered the CT scan. I was going to do bronchoscopy and treat him with medicines till we could get him to Endocrinologist. But then he had episode of irregular heart beats and I had to call heart specialist. With medicines the heart rate was controlled, but the blood pressure continued to be low. So I suggested cardiologist to change the medicine , but it never was done. The he had some nausea and the the hospital doctor ordered the CT scan and some X-ray. That suggested small bowel obstruction. So they called a surgeon. I was not convinced as he had good bowel movement. (He had colostomy)But the surgeon decided that he needed surgery and he had surgery. He continued to have issues with blood pressure and the heart rate some upchucking.
   I was speaking to the wife and was not sure if surgery had helped in any way . But then when his oxygen need went up and wife told me that he is bringing up stuff all the time , I knew that he was aspirating . The surgeon had thought that surgically there was no problem and wanted to give diet /food. I decided to do new CT scan and and put in stomach tube- NG TUBE. Immediately I got 1100ml fluid and the CT scan showed dilated esophagus. So I knew that the problem was not bowel obstruction, but food pipe-esophagus problem . This was coming up and going in the lungs and was causing damage and the pneumonia. With his oxygen low I transferred to ICU.
   He was little better in next 2 days and then he had problem with bowels and had stools coming out from the incision and so needed second surgery. This set him back and he now was on respirator. He was loosing weight and was having problem with blood pressure and heart rate . We continued to struggle and he continued to get weak . We could not do any further studies as he was too sick. By now he had lost 30 -40 lbs He could not eat or cough or do any physical activities . The family decided to make him DNR.
     So the patient that came to my office for regular follow up and was having low blood pressure and weight loss , and I thought that I could get him out of hospital in 3-4 days , stayed in hospital for more than a month and continued to get worse.