Friday, August 31, 2018


      I was reading an article from one of the Indian magazine . It was about the statistical probability and the prayers. But the question that arose in my mind is can you change the destiny with efforts or prayers? There is  story of a king in Mahabharata , where the king knew that he was going to die of snake bit .So he gets out of his Kingdom and becomes easy  pray for the snake . This brings me to my today;s story .

    I have known this patient for several years . He had bad lungs and had sleep apnea .He was obese and had cardiac issues . He had open heart surgery too . he was doing OK . But he had multiple problems . One day he was hospitalized for pneumonia and then he had pus collection in the pneumonia -what is called lung abscess . He needed antibiotics for long time . He improved , but the chest X- ray and the CT scan continued to show the abnormality I continued to do follow up for several years . I had also done Bronchoscopy and all the work up was negative for cancer . This  continued for 5 years . Then he had back problem and went for surgery . He had major problem and was in and out of hospital and needed antibiotic . He did improve . The a year down the road he was in hospital for heart problem . I did  see him and did CT scan of the chest . It showed the same abnormality , which was due to old abscess may be 4-5 years ago . But there was a new nodule . So we decided to do some work up . He was ot in the best shape , but we did follow up CT scan and then the PET scan . The nodule increased in size and so I did send him to Radiation doctor . . We decided to do the biopsy . The needle biopsy was done and it showed the lung cancer . It was very small and so we did radiation treatment called steriotactic radiation. He did well and the repeat CT scan and then the pet scan did not show any cancer . He did OK for next 5 months . Then one day he had nausea and vomiting and felt weak and could not do much walking and so he came to hospital.
I saw him and then the work up was done . He had no sign of the cancer where he had biopsy confirmed cancer , but the other nodule - which has been stable for few years was minimally enlarged . But he had nodules in Liver . We did additional work up and he has cancer in spine and liver and lung . The biopsy was done and it was confirmed that he had what looked like lung cancer , but the type of cancer that he had this time was different than the first one that we treated 6 months ago .

     He was seen by radiation doctor and cancer specialist . Next 2 weeks down the road his condition deteriorated to a point that we decided to put him on Hospice .

    So we watched the nodule and it was stable and we treated the cancer that we diagnosed , but we could not  'change' the outcome or may be destiny  or LUCK !!! 

Friday, August 3, 2018


      Recently I came to know about the old IBM building new IBM computer for medical diagnosis. The thought process of making a diagnosis is like computer . The history is like data fed in to computer and so is the physical examination and then the computer will make some 'Differential Diagnosis 'or the various possibilities , based on the data fed . The possibilities in Differential Diagnosis are listed in order of probability. So the number one would be most likely and the last one on the list would be least likely. So the precess is similar when we do not use computer and use the Human Brain as the computer.. We do not us the computer in day to day medical life and we do not need one and  it may be time consuming and may be even confusing . I was told that the new IBM computer is more accurate than the best of best clinicians . My issue with this process is the problem of the Data that is fed . The computer gives the diagnosis based on information that is given to the computer. The human brain is same . If we as physicians do not put in or get accurate information , the diagnosis can not be accurate. This brings to my my today's story.

      I was called in on a consult for this patient who was 38 years old . He was diagnosed to have pneumonia by hospital doctor . When I saw him , his mother was bedside . He was a nonsmoker and did  not consume alcohol He was working in a office and had no dust exposure. He was sick for almost 6 or 8 months . He had gone to walk in clinic and was told to have bronchitis . He was given antibiotics and sent home . he continued to have problem and so he went to see family doctor . He was given cough syrup and some more antibiotics . The chest x- ray was ordered . He continued to feel poorly and now was short of breath . He went back to family doctor and was given an inhaler. He was told to do CT scan . His copay was too high and he did  not do it . The shortness of breath got worse and so he came to ER and was admitted . In ER the CT scan is done and he was told to have pneumonia. I saw the patient . He had some congestion on the back side of the lungs. He was on oxygen . When I saw the CT scan I was more concerned . The CT scan had extensive congestion ,in both lungs . It was not like typical pneumonia . So I was not sure  as to the cause . He did not have much fever .
    I ordered the blood oxygen and when it came back with low oxygen , I decided to transfer him to ICU. He was also anemic and he told me that he knew that and was told to take iron . ( I was not sure why a young male would get iron deficiency anemia  ) I ordered number of tests and antibiotics . I also called the infection disease consultant . They ordered more and ordered HIV or blood test for AIDS . So I talked to them . While taking history , I had asked him as to the sexual history as the thought of AIDS causing the anemia and the chronic sickness and atypical pneumonia had crossed my mind . He had told me that he did not use any drugs and he had not had any sexual exposure in last 20 years . So I was shocked when the test for the AIDS came positive .Thai solved all the mystery. The anemia and the chronic sickness, and the atypical pneumonia etc were all related to HIV .

      So the Brain computer of mine did not get the data of some risk factors was not 'entered ' . But the Infectious Disease doctor , did not pay any attention to that information and just went with 'instinct' . The instinct was correct !