Saturday, March 17, 2018


        We have number of  attachments in life.Some have attachment to smoking and some to alcohol, some to drugs and some for some other. Many patients tell me that the smoking is very difficult to quit . so there are lots of attachments and we have difficult time quitting them . But the attachment to the BODY is the one that is the worst and none can not leave it till end. Even the best and learned one can not get detachment from it. I have seen this all the time . I am no better , but most of us want to LIVE and not LEAVE the body no matter how disease reddened it may be . That brings me to the today's story.

      I have seen this patient for last 10 years. He has been smoker in past and when I saw him he had breathing difficulties. Hr had diagnosis of COPD -smoking related lung problem . He was quite sick when I saw him  and he needed to be put on oxygen . He had severely reduced lung function and over period of the time he got worse and in one of the hospitalizations , he had to be put on respirator. . I was concerned as to how to wean him and if we could wean him off the respirator. But we did it . He was OK but needed to be on the oxygen all the time . He also had very limited walking ability . AS the time went on , he was in hospital few more times . The function of the lungs is to get in oxygen and get rid of carbon dioxide . When the lungs fail first thing is the oxygen drops . When the disease progresses , the carbon dioxide can not be washed out and patients start retaining it . So he started having that problem . That leads to sleepiness and fatigue and lack of energy. He started having that . So I talked to him and his wife . He was started on  breathing machine which can deliver breath and oxygen and it is done with a tight fitting mask . This helps the function of the lungs . We started him on that for the night . The machine helps the lings and the muscles of the breathing . So during day time they do not get fatigued and patient feels better . He did get better . He was on it for more than 3 years and was doing OK . He did need the machine to be adjusted due to carbon dioxide retention. Slowly his ability to walk was reduced and the lungs were failing . So he had to use the machine had to be used during day time too . So now he was on it during night and then may be 6 hrs during day time -not continuous but total 6 hrs during day time.

     There was not much I could change . We treated him for his respiratory infections and gave him steroids off and on and he did OK . He did ask me one day ''Am I going drown the drain slowly?"I could not answer yes , but I did tell him that not much can be changed .
     I do yearly chest X-ray and most of the time breathing test . His lung function was so poor that I did not do it again. The chest X- ray was done and it shows a mass . This was highly suggestive of cancer . It was not very small . So I called him and his wife . Our options of treatment or for that matter work up to get diagnosis . Even doing the bronchoscopy was very risky as he may end up having more problem. The needle biopsy was impossible and open biopsy was out of question. . So only thing we can do was to do PET SCAN . The PET scan id about 85% accurate in predicting cancer if the PET is positive.
     I talked to them several times about the limited or not much options and suggested consider radiation evaluation and HOSPICE . He did not know what to do and I have not completed any additional tests as he did not want it and did not want to consider HOSPICE YET !!


Saturday, March 3, 2018


      In medicine we were told that when we see patients , and the patient has multiple complaints , try to find out one diagnosis . In most of the patients , one diagnosis explains all or most of the symptoms. Try not to have more than one diagnosis. Again this did not apply to the things that patients had it like hypertension and diabetes and the heart attack history. So if one comes in with shortness of breath and headache and fever  and say chest pain , try to find out one diagnosis to explain all the symptoms . Once one is in medicine for many years , he finds out that there is always exception to the rule. So the story of my patient that I am going to tell one such story .
         I saw this patient for abnormal chest CT scan  He had cough and had chest X - ray and it showed some nodule and so the PCP did chest CT scan and then the CT scan was abnormal and so he was sent to me . He was 70 years old male and had history of heart attack and had some high blood pressure. He had cough and some white sputum . He had not lost any weight and has no fever and no weight loss. He had cough for may be 3 months . He was not smoker . The CT scan showed multiple nodules . All of them were very small. they were like dots and some may be like small pea. The PET scan , which picks up cancer in 85 % of the cases of the cancer , has limit on the size and so these were too small to be picked up . The PET scan needs size of at least 8 mm, preferably 10 mm. The nodules were 3-4 mm . The needle biopsy of then nodules was impossible as they were too small. The open biopsy could be done , but which nodule and with the given size and the lack of any symptoms , we decided to d the bronchoscopy to rule out atypical TB called MAC.

    The bronchoscopy was negative for cancer and the other tests on the lavage and the bushings were also negative for cancer and the TB or any mold .So we decided to do the follow up on the CT scan . I followed him for year and half and the CT scans .Some of the nodules disappear and some got smaller.. His cough was better and he had no other problem . He came for the follow up. I did Ct scan after 2 years  and it showed that one of the remaining nodule has grown . So I did PET SCAN . The PET scan did show activity in that nodule . He also had some other smaller nodules and they did not get picked up on PET scan..I did do new bronchoscopy and the work up was negative for cancer . But I was concerned and so We did needle biopsy of the nodule that had grown . It was cancer - type of  a cancer that is treated with chemo.But at the same time I got the report on the bronchial lavage , it showed MAC - atypical TB .

     So we had 2 different diagnosis. -both of them will need treatment at the same time.