Sunday, February 4, 2018


     In my practice I have seen unusual cases . Some patients came for the complaints that are related to mu field -pulmonary medicines and the diagnosis was non pulmonary. Some came for pulmonary complaints and the diagnosis was not what was normal or usual . But some times I see patients , that have no pulmonary complaints and still they are referred to me  and then it becomes a challenge. The patient that I saw recently , was one such patient .

     When I see new patients I do things differently than what many do or what we were told to do . In medical school , we are told to start with chief complaints and then history of present illness and then past medical history, family history and personal history and the review of systems and then examination . I start with past history etc and then before examination I ask as to why they are in my office . So I saw this 67 years old patient . He had no significant past history except high blood pressure. H e was not  a smoker and did not drink alcohol  much . He  was otherwise healthy. So when I asked him as to why did he come to me , he answered that his primary care doctor told him that if anyone can help , it would be me. This followed by him telling me that so far he has seen 12 different doctors. So I asked as to what was the problem , he answered that HE HAS HICCUPS ALL THE TIME .! I was not sure as to how this was lung or pulmonary problem.. Granted  that the hiccup is spasm of the Diaphragm.and the Diaphragm is part of respiratory system . But this connection is too remote . Any way he had seen several primary care physicians as he had moved from Tampa. He had seen more than one ENT doctors and Gastroenterology  physicians. No treatment was successful . The hiccups were worse at night though they did occur during day time too. I asked him if he had any swallowing difficulties and he had none . But then he told me that he had some  doctor in Tampa do a study for it . Interesting enough and good for a change - he had the report. Normally I have to be detective in finding as to what kind of test was done and where was it done in most cases. I would say 70 % of the time . It is so time consuming that now a days my office checks couple of computer data on all new patients . Any way the answer was right there .

    He had what is called Esophageal Motility Study .In this test a probe is put in to food pipe or esophagus and the contraction of the esophageal muscles is recorded. The esophagus is like a sleeve and it has circular muscles and the wave of contraction of these muscles squeezes the food down . I have seen many patients that have the problem with this function of the esophagus. Typically we see this in disease called Scleroderma.. When I looked at the report , HE HAD NO CONTRACTIONS . This was the answer of his problem . The test was done the result was abnormal , but no treatment or co relation with his complaints were made. So when he ate solid food , it did not get pushed down and got stuck in food pipe or the esophagus . To dislodge it the diaphragm went in spasm and that is why he had hiccups. During day time he may not have been eating much or as much as dinner time as he was still working . Also he was upright and the gravity helped the food to go down. But after the evening meals, at 8 pm or so , he was going to bed at 9-30 or 10 pm and he was supine and then he got food stuck and so had more hiccups. At least this is my explanation. I explained him my thought and told him that he has to see a Gastroenterologist and there was no real treatment for this . There are some surgeons who do a surgery and it may be effective . I told him to go on liquid diet for 10 days and not have any food or even liquids after 6 pm . My thought was that if there was no solid food , then it will not get stuck and then the spasms of the diaphragms will not be there . But he was not very receptive to my idea and agreed to do it for may be 2-3 days .

       The jury is still out as he did not see Gastroenterologist for a month and I am not sure if he can offer any medical treatment .  

Friday, February 2, 2018


     In medicine we have patients that do not behave as we expect --may be they have not read the medical text books! But after being in practice for long time ,I have realized that whenever there is 'interesting case ' , it is bad for the patient . In past I have seen patients that I thought had cancer and they did not have it -good for the patient and then when sometimes I thought it could not be cancer , it turned out to be cancer-bad for the patient. The case that I am about to tell is one where there is no diagnosis -at least for now .
     I saw this patient in office for some cough and shortness of the  breath . As usual we do some tests and he did have some asthma . The pulmonary function test confirmed it . The chest x- ray was OK and so I put him on medicines for the asthma and he did well . He came back for follow up and he was again having problem . So I saw him . He had some more cough and some sputum and had no fever. His lungs did not sound bad . But he was having problems and so i added some medicines and also gave  short course of the steroids . He called me to tell me that it had helped .

      He came back earlier. The steroids helped , but when he completed the course , he started having problem . He had no fever and not much cough . But he was short of breath and has some cough . The oxygen was little low . The lungs did not have any wheezing. I was concerned. I wanted to get him in hospital . He was reluctant and wanted to try steroids again . I  told him that I  wanted to do CT scan of the chest to make sure that he did not have the blood clots . He agreed . I ordered the CT scan stat. I got a call at 4 pm that he had larger fluid around the left lung and had some mass in pancreas. I called him and told him to come to ER ASAP. We admitted and then started work up . He had PET scan scheduled and I did tap the chest and took out 1200 ml fluid . He had biopsy of the pancreas and the blood tests done for the pancreatic cancer . The blood test came back normal and the fluid that I had drained out , did not show any cancer cells . The biopsy also did not show cancer .

   So now we have no diagnosis . He had larger fluid collection and we don't know the diagnosis . He had pancreatic mass and in spite of the biopsy we don't have the diagnosis . The next step would be to do 'open biopsy' either of pancreas or if the fluid collects , biopsy from inside lungs . The mystery of the medicine continues.