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. 

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