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.