Sunday, January 28, 2018


      I have been in practice for many years and I have noticed the aging population. Now a days it is not uncommon to see patients in their eighties.It is very easy to say that everybody should be treated according to the disease and not according to their age. Some older patients are well preserved and have sharp mind . But the body is like house . So often we see  30-40 years old house and it looks good and has no problems . But when one looks at it , the windows are old and not according to the new standard, or the roof may need to be fixed and the plumbing is old .Many a times when I see older patients who are accompanied by their younger relatives , they are not demented, but when one starts asking questions , we realizes that memory is not as sharp and sometimes the understanding capacity is less than what might have been at younger age. But the family members are not aware if this as they see them everyday. When one does the same routine everyday , early dementia is not obvious. -going to the same place to eat or do shopping or doing same thing like goinfg to same friends or relatives . But when one is given little complex and not the routine task or direction , then the ability to follow the instruction is not as good as younger people.But my main concern is aging body. That brings me to today's patient .

    I have known this patient for last 1 or 15 years , Now she is 91 years old . She lives by herself and her daughter and the grand kids help her. She has heart problems and has been under care of cardiologist . She had fluid around the lungs 7 or 8 years ago and I took it out . It came back and so after doing the procedure 3 times , I had called surgeon and had a catheter called PLEUREX inserted . It can stay for months to year and one can drain the fluid as needed by attaching it to bottle with vacuum bottle  . Her fluid was gone and the drainage was not much and so the catheter was removed . She did fine for may be 3 years . Then she had some fluid and she was OK , Her shortness of the breath was not bad as her activity level is limited . I watched the fluid with periodic chest X- ray and it did not see to be any worse or for that matter any better. As long as she was fine I did not do the drainage with needle..
    She then had fluid around her heart and had elevated pressure in lungs called pulmonary hypertension . The cardiologist 'watched' the fluid around the heart and it did get better. So the she has some shortness of the breath and she was again in the hospital , So the cardiologist felt that I should 'drain' the fluid -same one who did not want to drain the fluid around the heart. She was on blood thinner and I had to hold it and then do the procedure . She did well but had small amount of air around the lung after the procedure . I was worried as if that gets worse then she would need insertion of tube to sick out the air . But my thinking was that her lower part of the lung is chronically collapsed and so it can not expand and so the gap was filled by the air . I did new chest X- ray in 4 hours and the fluid was back and the air was gone. Since then she is in hospital 3 times . We 'adjust' the meds and sent her home and she does OK and is back again . She does not look any different or is not in any distress, but she feels short of breath . The fluid is also same as was 2 months ago.. But again the cardiologist and the family feels we need to treat the fluid . In my estimates she has multiple , chronic problems and they will not be fixed at age 91. But everyone sees the fluid and that they feel can be 'fixed' .So now I have to treat it .
    She is 91 years old and has multiple problems and she will probably have similar issues  and doing more procedures is risky. Thia is what I call AGE OLE OR OLD AGE PROBLEM . .  

Monday, January 1, 2018


     When we say that it is a coincidence,it means we did not expect it or the chance of the thing happening was too low and so when that happens , we call it a coincidence .It is not uncommon to have the family members to go to same family doctor as that is what the family doctor is or was suppose to be , -treat the family . But to see same specialist for the similar condition is less likely. But again the high blood pressure or the diabetes are so common and do depend sometimes on common environmental factors , such as diet , exercise or life style, that the husband and the wife can get similar condition and then go to same specialist . In my specialty COPD could be one such condition as it is related to smoking and many couples do or did smoke together . So that is not a coincidence . But today I am going to tell you about a patient that is rather unusual and so it is a coincidence.

       Many years ago I saw this fire fighter , who was about 50 years old . He had retired earlier and had some cough . He was short of breath and had no chest pain or weight loss . In fact he was obese. He had no fever and had no other problems . We did the routine work up and it turned out that he had some scars in the lungs . We did the further work up  and did the breathing test and also did some blood work up . He had reduced lung capacity and also had reduced ability to transfer the oxygen , which is  seen in patients with scar tissues or fibrosis. He was young and so we decided to do the open lung biopsy.His blood tests were not very specific for any particular condition like lupus or rheumatoid arthritis.The open biopsy was done and it confirmed the diagnosis of the fibrosis . But we had done the biopsy to find out the reason for the fibrosis and so the biopsy was difficult one to get the diagnosis . So it was sent out to Mayo Clinic . The report came as 'fibrosis and the inflammation most likely due to connective tissue disorder , may be scleroderma'.The blood tests were not very specific for the connective tissue disorders. So I did call a specialist for the same , rheumatologist.
      He decided to start him on some drugs . The patient did not like the doctor , but did do follow up with him . But unfortunately he had pancreatic inflammation related to the drug that was used . He decided that he did not want to see anybody else , but me . I did try to send him to other university centers , but he refused. So I had no choice to give him steroids . This did help him to some extent , but he gained some weight and then had sleep apnea .  He continued to get worse over period of next 5 or more years and needed oxygen 24/7. He was young patient and so I wanted to send him for transplant evaluation , but he told me hr was too old and he feels that the transplants are for young adults and he did not want to take them away from some kid who would benefit from this better than he.To make the long story short , he dies about 6 or 7 years after I started seeing him .

      Fast forward to 2016. I saw this lady in my office for the chronic cough and her last name was same as this patient . The name is German  and I had difficult time pronouncing it . So I remembered it quite well . I had seen her when he was sick , but most of the follow up he had come alone as they had mentally challenged son. So when I saw her I knew that she must be his wife , even though there was a gap of 4 years or so . So I did work up on her and she had fibrosis . She also had scleroderma and she had classical finding of the scleroderma .She had circulation issues , she had very bad esophagues and had some aspiration and many other things that are seen in scleroderma. I sent her to a different rheumatologist and she is very happy with her , She has not progressed as far as her fibrosis is concerned and she is stable.

           So this is what I call coincidence. The husband and the wife , who are not genetically related had similar or same diagnosis, which is other than diet or smoking related and has nothing to do environment.