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 .  

No comments:

Post a Comment