Friday, December 6, 2019


    When my children were young and could not find out their books or note books or a shirt or something, my wife would go and find it in less than a minute. Her comment would be 'If you look for it you will find it . But I think it is same thing when I am looking for something in kitchen cabinets. If I can not find it , she can find it in seconds. Again the statement is if you look for it you will see it. I have seen this medicine and I have used a line (borrowed from someone),Your eyes don't see what your mind does not see.But sometimes I wonder if it is 'Not thinking ' or 'not looking'.This brings me to today's story.
     I saw this patient for shortness of breath. She was 77 years old female who had some shortness of breath and it was not bad . But the further work up was done by cardiologist and she had not seen lung specialist . She was told to have aortic valve problem and so she was sent to cardiac surgeon and she had surgery . She had chest x- ray and ultrasound of the heart and cardiac catheterization to make sure that she did not have any blockage in coronary arteries. She had new technique for the surgery.She did very well. In this type of surgery the chest is not opened  and it is minimally invasive  and so she did well. She had some shortness of breath and she saw primary care MD  and then she felt she will recover in some time and she did . She was better.
   In next to few months , she again started having some shortness of breath. She was seeing the cardiologist who told her that her heart was OK.She was tried on some inhalers for possible asthma.She felt little better  and this was continued . But she still did not feel that she was cured.So the Primary care MD sent her to me . She had chest X- ray and that was clear and we did new breathing test .That was almost normal but one could make  a case for mild asthma based on certain numbers or values on it .So I started her on  different inhaler which had 2 drugs  and also a nebuliser
treatment at home . She came to see me couple of more times . I was trying to get some information from cardiologist  and the only ultrasound -or echo cardiogram I could find was one that was done before the surgery for aortic valve.I talked to her  and she saw the cardiologist on follow up and she was again told that she was fine as far as her heart was concerned . I was not much convinced that she had bad asthma, as the cause of her breathing problem.I was concerned about cardiac etiology of her.But with cardiologist doing the follow up I had to do lung work up. But when I could not find any 'cardiac tests' from cardiologist , I decided to do new cardiac  tests. I did call the cardiologist and ordered new echo cardiogram. It showed that she had  different valve which was leaky and the pressure in the lung blood vessels was increased- may be related to the leaky valve . Her old test had shown the pressure was elevated. So the problem was the HEART and the elevated pressure in lung circuit.
    I started her on some treatment and told her to have cardiologist do new cardiac cathetarization. we can treat the pressure with different medications but they would need actual pressure from heart catheterization  . 

Saturday, November 23, 2019


   In medicine we were taught that when you see a patient, try to have ONE diagnosis to explain the problem or the symptoms.So we were allowed to develop differential diagnosis.So each one should be in position to explain as many symptoms as possible with each diagnosis. That does not mean that there is only one condition but this habit tends to make thought process such that one tends to know as many symptoms as possible.of each disease. This brings me to the patient that I was going to tell you about .
     I saw this patient as semi emergency. She was admitted with some nausea and she had no fever . she has not sob but she had some vague chest pain with exertion . so she was worked up . The chest X- ray was normal.She had history of high blood pressure and had coronary artery disease  and so she had work up done too. She was thought to have coronary artery disease, She also had some diagnosis of scleroderma.She had cardiac cauterization   and she had blockage  and so she had stent done The cardiologist called me as her oxygen level was low when he started the procedure  and it continued to be low .

      She looked OK from his standpoint and the procedure went well  and she had no complications.But since  her oxygen was low he called me . I talked to nurse  and then I saw her few hours after the procedure.She looked comfortable  and did not feel short of breath.But she had rales or congestion in the lungs on physical examination. I had ordered the Chest X-ray and that had shown congestion and that was not there in the chest X- ray that was done 2 days ago. I had also ordered the blood test for the congestive heart failure  and that was quite high, Normal is 800 and hers was 15000.She had denied  any problem with swallowing. She had echocardiolgram- ultra sound of the heart  and that had shown to be normal . So I was not sure why would she had congestive heart failure . But when I heard that she also had scleroderma , I also thought about the abnormality in esophagus that can cause aspiration. As I mentioned we try to or we should try to have ONE diagnosis as the explanation. But she was on lot of oxygen  and I had to treat her . So I decided to treat for BOTH the congestive heart failure and aspiration I started her on water pill to treat water in lungs and also antibiotics  and steroids for possible aspiration pneumonia .
      I saw her next day and I had done new chest X- ray . She was doing much better  and her oxygen need was much lower  and the X- ray was not clear but was better. So she had both-Aspiration  and Congestive heart failure .
       By the way no one had mentioned scleroderma in their notes! .                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Sunday, October 27, 2019


      The phrase of 'back to the square one' is very commonly used when we do something as a plan  and that does not work . This probably came from one of the board games  may be chutes  and ladder  when we are going to the higher squares  and suddenly we find our-self going down due to chute. The same things happen when someone is trying to solve the criminal case and the clues lead us to dead end  and then we are back to original level. The same thing happens in medicine , but not often. This brings me to the present story.
      I saw this lady for shortness of the breath. She had smoked  and had diagnosis of COPD  and in past she had lung cancer diagnosed  and she had treatment for it She also had breast cancer  and she had surgery and she was cured. I saw her  and did  act scan  and also breathing test and started her on oxygen. She was started on medicines for the COPD  and then the CT scan showed tiny nodule. I told her that we will need to do the follow up fort the nodule  and it was too small for the further work up to know the diagnosis. Doing bronchoscopy , or doing needle biopsy or doing PET  scan or asking surgeon open biopsy were not options as they would not have given the diagnosis. So we decided to do the follow up . I continued to see her for next year and we did couple of CT scans  and they did not show any any change or growth . She did not come to me for follow up a year. Then she  had shortness of breath and she was hospitalized.I was asked to see her . She was very sick and she had to be in ICU for short time  and even after getting out of ICU. She had new CT scan done  and that was abnormal . The nodule that we had seen was same but she had new 'mass' in rt middle part . She was not in very good shape for biopsy and so we did PET scan  and that did show that the mass was likely to be cancerous -had increased uptake of the glucose.She was never a candidate for the resection  as she had advanced COPD and the location was such that she could not have had resection or entire lung and then also she would not have been cured. I did do bronchoscopy  and I had to get help from anesthesiologist and she did OK . I did see narrowing of the middle part of the right lung and i though that she may have external pressure from cancer or it may be narrowed due to cancer itself. I did do the biopsy and other things  and they came back with 'atypical cells but not conclusive for cancer.
      She was getting better  and i told her that we need new biopsy but she needs to be better  and so after 2 weeks i had do EBUS - biopsy with help of ultrasound , This was done and they came showing no cancer . I knew the CT scan , I knew the PET SCAN  and i also knew her history. She had 2 different cancers  and she also had OXYGEN dependent COPD.So now what I can I do to get to the diagnosis? As you can see every time we did a test thinking that we will get the diagnosis we were back to the square one.
     So I had a surgeon to review her scans  and he called me stating that the situation was very difficult, but he felt that he could do some biopsies  and get the diagnosis. He saw her and did a procedure called Mediastinoscopy  and biopsies came back showing no cancer. So he did see her again and did biopsies through chest  and they also came OK. So she came back to me  and she was hurting from the surgery and we had no diagnosis. I asked radiation doctor to see her and see if they can do radiation WITHOUT the tissue diagnosis of cancer. They were not very happy to do such a treatment without the proof for cancer . This is not like giving antibiotics.
     So I decided to do new CT scan in 3 mo this The month before she was to have new CT scan done she was in hospital  and I saw her . She had developed fluid collection around the lung - same side as was the mass. I did new CT scan  and that did show the fluid  and also that the mass has increased. So there was no question that she had cancer . But we had no proof. So I called the same surgeon  and told him the situation . I was concerned that she had fluid due to cancer and just taking it out once may not be enough.She was also on blood thinner . So I asked the surgeon to do the  catheter insertion to drain the fluid  and do some additional biopsies.
    He did do the catheter and did  not do he biopsies .The fluid was sent for cancer cells  and they came back as No cancer . So we were back to square one - same place that we started after  5 procedures to get the answer. So now I  again called the radiation doctor and asked if they could do radiation without the diagnosis OF CANCER..
   This time they agreed  and she got the radiation therapy without tissue diagnose of the CANCER . 

Saturday, October 19, 2019


   I have been asked many times as to the cause of cancer. We see have seen it in older  and younger people , we have seen it in fat and skinny people , we have seen it in people who have good habits  and bad habits.We have known some risk factors like smoking  and chewing tobacco, and people with exposure to chronic irritants. The sharp tooth has caused oral cancer and KANGRI the heated burner that people in KASHMIR out around their belly to keep warm has caused the cancer of the skin of belly wall.When radium was invented  and people used radium dial wrist watches , there was increase incidence of cancer of the wrist bone.So we know some causes but we do not have any idea as to why some get cancer  and why some don't.This brings me to the story of the patient for today.
     I saw this young women who has some vague chest pain . She was nonsmoker and had no h/o high blood pressure or diabetes or any cardiac problems. She was OK till then . So the family doctors did a chest X- ray. The chest X- ray was abnormal. and so she had CT scan of the chest  and that showed a large mass  and also a smaller mass. She was sent to me . She was very anxious  and was quite concerned . And rightly so as the mass was reported as as most likely as lung cancer in the report, which she had with her and had read it few times . She had noticed the right sided chest pain only 2 weeks ago  and she had no pain before that .She had no shortness of breath or any significant cough, She had not coughed up any blood . Her appetite was good, but she had lost some weight,but she had thought that due to the the problem that she had with eating . I explained it to her and her family that the possibility of lung cancer was high but may not be 100%. We should answer 3 questions -Is it cancer, Has it spread and lastly the choice if treatment if it is cancer.
   To answer these questions we needed the diagnosis of cancer.So we ordered PET SCAN which is good in detecting spread of cancer or presence of cancer - may be 85%of the time. I also ordered the breathing test. and also bronchoscopy. That showed narrowed bronchus  and so I did biopsy  and then the biopsy did come back showing cancer .
   The PET scan was done a day after the biopsy. So when I saw the PET scan report I was not happy. So I called the patient to see me . She had lung cancer and the PET SCAN showed that the cancer had spread to Liver and bones . The chest pain that she had was due to the spread of the cancer to the ribs . So she was not operable. I had called  chest surgeon to see if there was any chance of doing surgery - though it was before the PET SCAN,  and I had done it in spite of knowing that she would not be based on ct scan .
    She had come with her family and they wanted to know the prognosis  and why she had cancer . I had no answer to both the questions. So the nonsmoker,nonalcoholic lady was having lung cancer and that too had spread to other organs such that the prognosis was not very good .

Saturday, October 12, 2019


    In our life and in many a times we see the pendulum of opinion swinging . At one time coffee is bad then someone does research  and then tells us that coffee is good. High fat diet was bad for many years then came low carb is good  and high fat diet is good. I have seen this medicine too . We were told that steroids  are needed to treat COPD   and now it is OK not to use steroid inhaler. We are told that we have epidemic of narcotic use  and addiction .But when we look at it we realize that WE ALL are responsible for it .But then we got to have someone else to be blamed for it - may be then we can collect some money. So blame big pharma . As much as they are  responsible,we all are. I just want to mention that I do not  and did not prescribe these medicines. But with hospitals pushing doctors to get better patient satisfaction, the narcotics were prescribed  and they were more than what was  medically needed. The hospital reimbursement was dependent upon the patent's satisfaction. So we created the dependence  and the addicts . So now the pendulum has gone to another direction and that brings me to the story.
    One my my patient age 90 years plus called me on week end stating that she has chest pain on right side . She was doing weed whacker  and she fell down  and hurt the arm  and the skin -which was thin to begin with tore,She was also badly hurting on right side of the chest after the fall. . She went to ER  and they did chest x- ray  and not sure if they did CT scan. They gave her some medicine and discharged her . She wanted pain medication and the ER MD did not give her any . She was disappointed so she called me .I told her that with weekend , I could not do much ,but she can try some over the counter medications  and if not better then go back to ER again . And she did not feel better and so she went to different ER . The events were repeated . The ER physician gave her muscle relaxer - no pain medications  and discharged .She was having pain 'worse than labor pain' as she described it to me . I told her to come to ER where I can see her and let the ER doctor know that I will come and see her. I did ask her to call her PCP  and she had done it , but now a days no PCP goes to hospital, so that was not an option. She came to ER . I went to see her. The ER physician told me that she would not do any tests  as she told them that the 2 previous Er did all the work up. So I talked to her  and told her that we need to do X- ray of the ribs  and she agreed . We did the X- ray  and she has SIX RIB FRACTURES ! She needed to be admitted.
      The question is why did the ER physicians did not do rib X- ray , why did they not admit her  and lastly WHY DID THEY NOT GIVE HER PAIN MEDICATIONS?This old lady was not addict, she was not going to become addict and she had obviously pain starting after a fall. The answer is in the narcotics fear that we have created  and the hoops that physicians have to jump through to JUSTIFY narcotics prescriptions. So that is what I am calling as pendulum has gone to other side. 

Saturday, September 21, 2019


    I was talking to a friend om mine . We were talking about SAT examination. He stated that that that is very important examination . I made a statement that at a particular time in our life ,things that appear to be very important , do not appear to be that important when we look back at it after several years. The SAT examination does determine which college we can get in . But many a times the college that we join may or may not  and in most instances does not make difference in our future. . When my son graduated from college and went to medical school, one of the guest made a comment that even the graduate of the medical college who stood LAST in the class is called MD. One my patent's son who was with GOOGLE and making ton of money -over a million dollars a year , was graduate of UCF  and his major was physics ! So sometimes we worry and get concerned  and get upset over things that on long term does not matter.That brings me to my today's story.
    I saw this patient about 71 years of age who had moved to Florida from some other state . She was diagnosed to have lung cancer  and had treatment for it  and was 'cured' . She was a smoker  and then she also had history of breast cancer and she had surgery and she was 'cured' of that too. She had smoked for several years  and had COPD. She was compromised  and had shortness of breath  and also had reduced lung capacity. I treated her and she was going better. She had  a CT scan of the chest  and it showed some changes related to COPD   and related to previous cancer but was thought to have them related to her previously treated cancer rather than new cancer. She continued to come for follow up for 6-8 months  and then did not come - very common now  a days since HMO have taken over health care  and 'RISK ' contracts  are becoming common and big business are 'buying the medical offices  and run them . They can not make money unless they cut the cost  and doing so they reduce follow up by consultants and do less testing .
     Then one day - about 1 year down the road,I was called to see her in the hospital as she was admitted for shortness of breath  and pneumonia. I saw her  and when I asked her questions I came to know that she had CT scan done as out patient (No one had bothered to  ask her and she had new CT scan in hospital and that was abnormal . So I wanted to do further work up .) She told me that she had routine chest X- ray and then it was abnormal  and so she had CT scan  and since that was also abnormal she had PET SCAN . So I got hold of the scan  and she clearly had very abnormal CT scan and also the PET SCAN . It looked like she had NEW LUNG CANCER  and the way in which the scans were , she would not be a surgical candidate for resection. Certainly her condition was bad  and from COPD stand point also she was not surgical candidate, She was on oxygen  and was very short of breath. After I treated her with medications , she did seem to improve and one day I did do bronchoscopy to get some tissue . She had hard time with the procedure  and the biopsy came by showing some abnormal cells but not conclusive for cancer.The daughter was not very happy as the PET SCAN was done 3 weeks before the hospitalization and now 10 more days were gone  and we still did not know the diagnosis of the cancer  and so no treatment was started.
     I told them that the condition was such that doing more invasive procedure at that time would put her in worst state  and she will be on ventilate and than we will not be in position to treat. So the best option was to treat her  and allow her to recover her from present illness and then in 4 weeks when she is better then do some additional procedure like doing biopsy of enlarged  and abnormal lymph nodes as reported on the PET SCAN There appear to be tumor wrapping around the  right bronchus  and that appear to be out side the main bronchus . So I asked a another physician to see her to that biopsy  and there were  problem with referrals  and the appointments got cancelled due to physician having emergency  and the primary not giving referral at right time . The daughter walked in my office twice  and asked me to help and was not happy .I called the both the offices  and made arrangements  and then she  had procedure by another physician as the the one that saw her in office was not available. This added to the frustrations  and then she came to see me. The biopsy done by this MD did not show any cancer and so we were at square one . She was not any better  and she was on oxygen  and the daughter was not happy that we did not have the diagnosis  and so there was no treatment started for CANCER. Our conclusion that she had cancer was based on PET SCAN which is almost 88% accurate. So I was convinced that she had cancer , but the biopsies were not showing . One thought that I had was to sent her for Radiation therapy  and asked them to see if they felt they could treat her WITHOUT THE DIAGNOSIS based on PET scan findings . But I decided to call a surgeon. He was very prompt  and he saw her  and did  2 different biopsies from 2 different sites on 2 different occasions.
     So the frustrations that patient and the daughter  and I had about not getting diagnosis IN TIME  and worried about the delayed treatment was real and now looking back at it not very important.
I am still not sure that she has or does not have cancer and I think only time will tell us. 

Friday, August 16, 2019


      We are always told to look at the Fine Print . The Dish Network  tell us to look at the Fine Print when we sign contract with cable company and now that the cable companies are in cell phone business, they are telling us to read the Fine Print. So we are always ask to see and read the Fine Print.But one may say what is there in medicine that we need to read Fine Print. When we see patients , many of have tendency to see what is important to our field or specialty. And many  and most physicians have PA or nurse practitioners and they do the notes and the consultants tend to get biased and don't do much on their own . Even the hospital doctors - the hospitalist have the same problem . They do not have their own patients  and the ER doctors or ER pa or nurse practitioners tell them the story and then they admit or their PA or nurse practitioners admit the patients I am not complaining  but just stating the facts . I  still do the same old way. See my own patients  and also read the Fine Print  and sometimes it takes more time but it is more satisfying  and rewarding.This brings me to the today's story.
           I was asked to see a patient who came to hospital for shortness of breath and some chest pain. He was a 51 years old male  and was quite heavy. He was never a smoker  and drank socially only.He had shortness of breath and he felt that started 4 weeks ago only . The ER physician did the work up .He had high blood pressure and he also had other work up done. He was admitted to ICU and hospital doctor saw the patient and then the cardiologist saw the patient . The patients that are admitted are seen by ICU doctors who in many case are lung specialist . So he also saw him . There was no reason to call another lung specialist.But his cousin was a physician and patient called him and he asked them to call me . Si I saw him . He had had clear lungs  and his lungs sounded clear  and his CT scan was OK . He had further cardiac work up and all the work up was negative .
     When I saw him I thought that he may have asthma  and so I started him on inhaler. But when I saw him and looked at the blood tests,I noticed couple of abnormalities. He had elevated proteins  and had one particular type of cells elevated. So I did mention it to them and then and did some additional blood tests .
    I saw him for 3 days more  and then when he was cleared for discharged by cardiologist , he was to be discharged. I had mentioned the need for work up in my notes  and also told the patient  and his wife. No further work up or  any mention of the abnormality or need for work up was done by hospital physician or cardiologist or ICU physician .Finally I ordered hematologist to see patient .
     He was discharged  and saw the hematologist as out patient and he has diagnosis of CLL chronic lymphocytic leukemia.So I read the Fine Print and that helped the diagnosis.

Wednesday, August 7, 2019


    I have mixed blog and I do write sometimes about the religion  and the practice of it . I do try to make a sense out of certain behavior or the practices which are done mainly in Hindu religion . But I also have certain opinions about the other religions too. This is my opinion and it has limited value. Just to give  an example , in Revelation, It states that i heard a sound  and i turned  and saw 7 golden candles . I interpret it as meditation and the 'sounds' that one perceives when in Samadhi status , and their relations to the 'chakra' that we have . Certainly one could have a different opinion. There are many other examples I can give . But that is not my purpose of this blog .I had an Email from someone about the old Blog that was related to Indian religious -POOJA , called Satyanarayan Pooja. So I thought that I will y try to explain not the Pooja but the thought process .
      The supreme being is nothing but SPIRIT or energy. It has no qualities  as it has no GUNAS. Unless one has GUNAS or qualities , one can not have Desires . I want to eat Pizza because I have desire . But the Supreme being has none . So HE can not have desire to create the universe.But then there is matter . The matter has Gunas  and  so has desire .But no SPIRIT or the energy and without the energy it can not start the process of creating universe.  So the process starts ONLY WHEN THE SPIRIT AND THE MATTER (PRAKRUTI ) come together , This is important to understand . The supreme GOD is not a GOD FATHER , So one can not kiss his hand  and get favors. But the creation when started has lower level gods  and they are more like positions that are controllers of the 3 inverses. So when we humanize the god - we praise the God , we offer him food we do in HINDUISM SHODASH POOJA - 16 elements of worship , , we are now making the God a human being. So if the God can be pleased, he can also get MAD or Punish for not doing right things . The interesting part about this is that we tend to apply our worlds principles  and then are not willing to accept the results .
      We our self do worship ,but sometimes we do it through priest or we also do it with CD rather than priest . We also pray for others when they are not praying for them self . how can that be effective?.
If one kills someone or kills someone through contractor is he not guilty in both cases ? Direct or Indirect , we are responsible for the action . we apply same rules to the worship .
   In ideal situation , our own KARMA  are responsible for the situations that we are facing and the degree of efforts that we put to change it will make or break it . We have to accept it . But at the same time god can intervene, but not the SPPREME GOD .  .  

Sunday, August 4, 2019


    Now a days we have significant talk about the drug use  and drug addiction. The problem is old  and there are are different shades  and what we used to see in New York in seventies  and eighties is not seen that often. WE ALL ARE RESPONSIBLE FOR THIS . We may not like this statement, but in my mind it is accurate. In hospitals there were surveys from patients about the satisfaction. So to get have higher'scores', the hospital pushed doctors -not directly but indirectly -to give -offer- pain medicines. When I had hernia surgery,after the surgery I took only Tylenol  and Advil. I had prescription for narcotics and i never filled it. I stooped the pain medicines in 3 days. But in the hospitals we offered much stronger medicines  and narcotics  and patients did take them  and some came in to get the medicines only . Taking them for short time is OK But over period of time patients got addicted . Some were addicted  and demanded pain medicines  and some came to hospital and would not give good reports unless got the pain medicines . This part is now corrected . But now we have pot being made 'legal'.So more people are doing it and that is step one. The pendulum has swung on the other side . The government has new regulations  and now I see some doctors doing pain management practice  as it is lucrative. But the problem is not solved . Some of these people that get medicines from these doctors sell it  add then the addicts buy them. This brings me to today/s story .
       I saw this young lady for diagnosis of pneumonia .I went to see her . She was a young lady and
did tell me that she did use drugs.She was a smoker and did not drink alcohol.But she was on pain medicines obtained on streets. But she was not taking them as pills even though they were suppose to be taken orally. She had some cough and fever and she had some right sided chest pain . She came to ER  and she had chest X- ray done  and that showed pneumonia. So she was admitted. When I saw her she was comfortable  and she she seems to be honest about the drug addiction. She was admitted few months ago with sepsis and MRSA infection. She denied using cocaine and did not drink alcohol,She did smoke sometimes , When I asked her on her drug addiction she stated that she used Dilaudil pills.SHE DID NOT HAVE THEM AS PRESCRIPTION but she bought them on streets. She would dissolve them in water and then inject them intravenously to get effect quickly.
      This form of abuse is very dangerous. The pills taken by mouth or drugs used by intravenously or smoking pot or use of cocaine are all risky behaviors. But the injecting pills is especially dangerous . The pills are meant to be taken orally  and so the pill contains talc or other substance that is particulate- has small particles of talc or chalk. This is not completely dissolved in water and when injected gets caught in lung blood vessels - causing pulmonary embolism -smilier to blood clots getting trapped in lungs . This in significant quantity can cause death . 

     I explained this to her  and she seemed to understand. She looked like honest drug addict  and looked like she will try to kick the habit . When I looked at the chart the drug testing was positive for number of other things that she had told me she did not use!

Sunday, July 14, 2019


      I am a firm believer in GOD and also in medicines . Sometimes these 2 things seem to have cross roads. I do believe in chance  and also in probability. If I see someone with stage 4 lung cancer , there is high chance that the survival is limited .But I also know that there are patients who will beat all the odds-in both direction.This is the bell shape curve. Majority of the patient fall in the middle and some will die much sooner  and some will survive more than expected . But that does not mean medicine is wrong. We also see Faith being invoked when the disease is bad and these are the same people that may not have done prayer outside church or may not have helped someone in need. But what I wanted to say that just because one has firm faith does not mean one can neglect medical advice or medical odds.This brings me to today's story.
      I  had seen this 70 plus years old patient in office for cough. She was nonsmoker  and also did not drink alcohol. She had no major medical issues that just high blood pressure and that was well controlled .She had cough and she also had some shortness of breath.I did the work up and the breathing test did show some obstruction and so she did have some element of asthma. I also noticed that the oxygen transfer factor - called diffusion capacity as oxygen is transferred across the lungs in to blood, was reduced . Her chest X- ray had shown some 'chronic changes' . With her cough and shortness of breath and also the lower diffusion capacity, I decided to do high resolution CT scan of the chest .I was concerned that she may have scars or fibrosis in lungs . The CT scan did show fibrosis . I explained it to her that she has both asthma  and fibrosis. I also told her that the fibrosis could get worse  and she will be more short of breath. There were new medicines out  and if she has some worsening in next 3-6 months we could consider the medicines . The medicines were expensive though covered by insurance . The cost would be $30000 per year. But insurance covered the cost. She was followed by me for about 9-10 months  and she was stable . Then she stopped coming . Clinically she was stable. The cough was there but the shortness of breath was better and when I mentioned on medicines , she refused them and told me that the GOD will HEAL. Certainly she was not worse  and she was not interested in medicines or the oxygen use which she needed at night .
       I did not see her for long tome  and may be a year down the road she was hospitalizes .She was short of breath and had very small blood clot in lungs . She needed oxygen and then she was started on blood thinners . I told her that she has not done follow up. The fibrosis appear to be same. She was sent home  and then she came to my office for determining the need for portable oxygen . Her oxygen was very low  and I called her primary doctor  and told him that she needed oxygen ASAP. and I was sending her to hospital ER.I needed STAT CT scan to make sure there was no worsening of the clot . The out side radiology facilities sometimes can not accommodate such emergency and I was worried that if she needed more treatment , she will have to be in hospital. With HMO insurance I have to get everything approved from PCP. She had scars  and the clot was smaller and she was sent home. I was under the impression that she was started on oxygen . She was not . She came to my office next week  and was doing much better The oxygen was better and she was not as short of breath as she was when I had seen her a week ago. She did not have oxygen and she felt she will not need as the GOD will heal, Same thing that she had told me when I had mentioned newer medicines for fibrosis. I scheduled for a walk test where we walk patient for 6 minutes  and monitor oxygen and  decide if they need oxygen and how much. She needed oxygen  and I again talked to her on getting or considering the new medicines for fibrosis. When we talk about use of oxygen , her statement was same -I am fine  and the Lord will heal me.
       Certainly over course of last 2 years or so she has had some ups  and down  and certainly the GOD can heal. But one has to take responsibility and also have to DO efforts to get better . One can not expect high blood pressure or diabetes or pneumonia to be cured without taking medicines  and just praying. Prayers have a role  and it more in some cases  and less in others . But as human beings GOD wants us to do efforts on our part and then he will do HIS part .

Sunday, July 7, 2019


     We all have gone through life sometimes feeling that we could change certain things . When we were younger and did not get that A grade we thought we could have done something something and could have changed the grade - may be done more study or behaved better or something else . When we lost a tennis match , we felt we could have handled a serve better or done more practice. At that particular moment, we field the desperation and feel that our life is changed for ever with that one change or decision. But then when we look back at it after several years , these incidences have not made any major impact on our future life . I see the same thing sometimes in my patients . That brings me to today's story.
     I saw this patient in my office by chance.It was Friday and  I had a text from one my friends, who is a cardiologist that there was a patient who was short of breath and if I could see him soon. I normally do  not see patients in the afternoon on Friday .But I told him that I could make an exception and see him on same day- the Friday.So I told my office to call the patient and saw him at 2 pm. I am in the office on Friday but do not have scheduled patients, He came in . He was a 76 years old male who had acute bronchitis  and he was coughing and has wheezes. He was also short of breath.He came with his wife . He has been smoker in past and had quit may be 1-2 years ago and has had shortness of breath before . But after quitting smoking he had improved  and he did not need any medicines  and he had not been on any inhalers . He did not have any pulmonary function test in past or had any chest X- ray in recent past. I examined him and he had had significant bronchospasm and he was short of breath. He also had very low oxygen saturation on examination. So he needed a chest X- ray , a breathing test , oxygen  and antibiotics  and steroids . He also was going to need medications to be given by nebuliser to help the wheezes. I thought that it would be better if he is in the hospital. He was quite stubborn and did  not want to be admitted.So I called in prescriptions  and also told him to do chest X- ray ASAP as I would have changed my plan if he had pneumonia. I told him to call me or go to ER if he felt more short of breath. I also called a company to provide oxygen at home .
       The radiologist called me with the report that his chest X- ray showed a mass . I  had to call him with the news  as that meant that he may have cancer . I called him and told him of the findings  and told him that we will do CT scan soon .
    He had a CT scan and that did show a  mass.He had improved  and he was had been on steroids  and also nebulizer treatments  and also other inhalers and he was not short of breath. We did breathing test and I wanted to do bronchoscopy. He was not sure  and postponed the tests couple of times . The CT scan did show the mass and so I did PET scan and that also showed that the mass did pick up suggesting 90% chance of cancer .His breathing test showed that he had significant reduction in pulmonary reserve. I had extensive discussion done with him on several occasions,The options of therapy for the lung cancer is surgery or chemo or radiation. Due to poor breathing capacity he was not a candidate for the surgery. But he did not want me to do the biopsy and and wanted to see surgeon. So I sent him to one . The surgeon told him that he could not have surgery as the surgery and the resection of the part of the lung would leave him with need for respirator. . He decided to see another surgeon for the opinion . The opinion was again the same. Every time he had done something he would walk in my office  and wanted to talk to me  and I did for short time. I also told him to see radiation doctor . The mass was not very large and short course of radiation would have achieved the 'cure' in many patients . But he was bent on having surgery.
     One of the surgeon did biopsy of lymph node - I am not sure what that would achieve  and that was negative for the cancer.,He did have needle biopsy  and then when cancer was confirmed he did have radiation .He has continued to come to me  and he has clear lungs  and he has not been using any inhalers and nebulizers . He feels fine  and after almost a year of the treatment , he has no evidence of cancer .

  So it was very important for him to have surgery and he wasted time , money and also had some surgery that did not change much  and it did not change anything in his life -at least for 1 year so far. 

Friday, July 5, 2019


     I have started a YOU TUBE CHANNEL  to talk about various things . I will be adding one short video at least every week .
If you like this blog , PLEASE watch it , like it and subscribe to it .
Check it out under JUST-A-TALK .
I will continue to do the blog too .  

Saturday, June 29, 2019


       In every aspect of the life we often say that the system works . If a murder is solved after several years , we say that the system works. We have been witnessing the political drama unfolding in DC.
I am not sure if the system is going to work - either way whatever your political view may be - Democrats are feeling that the system did not work in 2016 election and the republicans feel that same way about the Democratic party candidate  and the FBI and the DOJ behavior.But I am talking about the day to day life where we come across things  and feel that the system did not work. All of us have 'misconception' about our ability and be often 'feel' that we do not get what we 'deserve'. But I am talking about much simpler things like DEATH CERTIFICATE. That brings me to the today's story.
       I saw this patient 5 years ago. she was 38 years old , obese  and had multiple medical problems . To my recollection she was not working and she had medical disability at that young age . She was not a smoker nor was alcoholic , but had bad hand dwelt in her life . She had Lupus a deadly disease in some  and many who have that diagnosis. She also was obese  and she had TB-yes tuberculosis  and had part of the lung taken out . In patient with Lupus,patient have multiple organ involvements - from skin to lung to kidney to pressure in lung circuit. She had scar tissues in her lungs  and also had chronic pain and also had obesity  and sleep apnea. She was short of breath and she did not do much exercise  and had not lost much weight . The combination of all these factors had led to shortness of breath. I am sure if she could loose some weight ,  and exercise she may have have been that short of breath, Fortunately her fibrosis or scar tissue in her lungs though bad was stable. The pressure in lung circuit - called pulmonary pressure was mildly elevated . Her oxygen would drop bellow critical number and so she needed oxygen when she would walk . But being young , she did not like the idea of carrying the oxygen and so she was not using it most of the time . The oxygen transfer factor that we measure, was less than one third of normal and so no wonder she needed oxygen and was short of breath. She had sleep apnea  and was not using the pressurized mask that she should use . But in all in spite of all these she  was stable  and we did not  and could not change any medicines .
     One day I got a call that she was in ER . In last 5 years or so that I took care of her , she was never in ER or hospitalized. I saw her in ER. She was quite short of breath and  needed high flow oxygen delivered with pressurizes mask. Her husband was bed side . She had respiratory infection and that caused the pneumonia  and since she was compromised ,she had acute respiratory failure . The ER doctor had started her on antibiotics  and steroids  and CT SCAN was planned soon . I discussed the situation with them  and she was to be admitted to ICU. I told them that if the things do not work out she will be intubated  and put on respirator and then we will see how she responds . With given pulmonary compromised the weaning off the respirator would be difficult if not impossible.
       As I thought she was intubated  and she had many other problems that are associated with sick patient . I would not discuss them at this time . But at the end of 17 days she was on maximum support on the respirator and she was on 100 % oxygen and high pressure  and also had problem with blood pressure  and also with blood count and she was not waking up..The discussion was on going with family on the poor out come and so finally we talked about the HOSPICE  and withdrawing the life support . We knew that the end was near with or without life support . So may be on day 20 or so we stopped the respirator  and she passed away. We now a days have ICU doctor  and also Hospitalist and so I did talk to husband but did not expect death certificate to be brought to me .
    15 days after this event my office staff told me that the husband was in my office to talk to me . I was not sure as to what was the reason . But I thought that he may have come to have  'closure' as he had not known all the problems that she had even though I had had told them when I met him in ER  and then in ICU. I brought him in and he told me that they do not have the body to do the funeral. I was shocked . The lady dies more than 2 weeks ago . He told me that the hospital doctor mentioned a 'fall' in the death certificate  and so the case was sent to medical examiner . Since the county did not have their own it was sent to different county ME . I did not know the name or the person. So I was not sure as what and how I can help. But I told him to call the ME office  and tell them to call me to clarify any medical issues that may be holding the release of the body. I gave him my cell number. I git a call from the him that the ME secretary told them that she could not do anything  and if I wanted I can call them . But it was up to ME . They would not call me . So I got the number  for the ME office  and called them I could not talk to ME but I explained the situation to the secretory and told her to have ME call me if he still has any  questions or concerns before releasing the body.
     A day latter  I had death certificate brought to me  and I signed it  and told office staff to call the husband  and inform him that  it is done.  So the system should have worked and the family should have gotten the body much sooner . But it did not , but finally the system DID WORK - BETTER LATE THAN NEVER. 

Saturday, June 1, 2019


      The question that I raised or we have heard in past as a joke.But sometimes in practical life we see the similarity. There is also saying that 'it was so simple that anybody could have done it but no one did it as everybody thought that some one will do it" I am not sure if that is due to procrastination.May be it is due to being lazy. What ever may be the cause, we see this quite often. Look at doing year end taxes. Ever year we see TV station showing the crowd at post office t 11th hour of April 15th. So why do people wait? But I am going to tell a story where I am not sure what is the cause of the passing the bug - may be ignorance , may be something else.
       I have seen this patient for a while . He had shortness of breath and some cough .So we did work up and found out that he also had sleep apnea and also he had low oxygen . He was also diabetic  and he also had some cardiac problems  and he had pacemaker put in..So he was followed by cardiologist. I did start him on a new medication for the fibrosis or scar tissue in lungs  and also on oxygen. He needed treatment with pressurized mask for sleep apnea ,but he did not like it. So one day he was in my office for the follow up. He was doing OK and I was not going to change any medicines . We did talk about retrying the the mask for sleep apnea.I was about to done and when I did look up at him, he was going to fall - he passed out . I put him on floor  and had my secretary call 911.He had pulse  and also oxygen was OK. The paramedic came in and his blood sugar was little low  and he woke up and was taken to ER.I was not called in and when I checked it he was doing OK  and was seen by cardiologist and he was discharged in 2 days . He was doing good .
     He came for the follow up in 3 months  and he was OK .I wanted to do new CT scan to check on his fibrosis. So I had my office schedule it . He was sitting in the chair and my secretary was talking to him and he rolled his eyes  and passed out . She called me  and we called 911 and i forced coke as much as he could take as he was diabetic  and I thought that he may have low blood sugar. He was taken to ER  and was admitted like last time  and I was not called . He was again seen by cardiologist and then discharged in 4 days. No CT scan was done. So I did CT scan and his fibrosis was stable .
    He had elevated PSA  and was told to have prostate cancer and was sent to Radiation doctor to treat the cancer. While in the office he again passed out and was admitted to hospital.I WAS CALLED THIS TIME - I am not sure why as his lung condition was stable. Again he was seen by cardiologist  and was told that he will need something called LOOP RECORDER ,to see if he had some irregularity of heart. I reviewed the old record.He had 2 echo cardiogram during previous hospitalization. IT HAD SHOWN THAT HE HAD defect in septum which separate the upper chambers of the heart. That had caused for the blood to go from left side where the pressure is higher to right side where the pressure is low . This leads to elevated pressure on right side  and less blood going to body . This can lead to the episodes of black out spells. I talked to him and called his regular cardiologist  and asked him if he could do the further work up and the treatment as the one that was seeing him was going to do the monitoring, which would not add or diagnose the problem, He agreed .    The patient was sent to a third cardiologist - pediatric cardiologist - as such defects are common in children and they are better at  diagnosing. So this third cardiologist did part of the cardiac catheterizing and called a 4th cardiologist to do additional procedure to make sure that he did not have blockage in coronary arteries . The diagnosis that was made in last 2 ultrasound of heart was confirmed . The hole in the chambers was there  and the blood flow was going from left to right side -normally there should none  and no mixing should happen-was confirmed.So now he was sent to 5th cardiologist to see what could be done . I was not sent any report. I was talking to patient to get update  and knew about the procedures that were done . I do treat elevated pressure on right side circuit of the heart to lung  and none of these cardiologist can 'FIX' the hole  and he will need heart surgeon to fix it.
     So it took 5 cardiologist to diagnose the problem!

Saturday, May 18, 2019


    I was brought up in my medical education in much different way than how the medical education is done today.In seventies we did not have ultrasound , CT scan or PET scan. We did not have stents to open up blocked arteries  and there were limited blood tests. We physicians relied on our 'clinical sense'.Now a days I see nurses walking with laptops  and so also the hospital doctors . Before patient is seen , they see the data in computer , sometimes entered by the nurses and others. So the 'DIRECTION' of thought process is 'predetermined' . The history and clinical examination have become secondary and many of my patients when they are admitted  and seen by different physicians , have told me that the stethoscope is not used on daily visit.And I do agree that with modern day CT scan , X- ray and MRI and different blood tests and Ultra Sound examination and  other tests , the clinical examination and the sense have become secondary. But being 'old timer', I still do the things MY own -old way. And this does pay. I do not have nurse practitioner or PA to give me 'help' or give me the direction .So my opinion is unadulterated.This brings me to my today's patient.
      This was a 50 years old male patient that saw me for the first time . Due to the computer entry or so called EMR - Electronic Medical Records , I do some reversal in asking questions . So he was nonsmoker , nonalcoholic patient who had no other history than HIV. He was fine till about a month ago and or may be less. He started having shortness of breath and so he went to ER and was admitted to hospital that I  don't go . He was seen and worked up by hospital doctor and was also seen by lung specialist and also by cardiologist.  He had CT scan of the chest and the ultrasound of the heart and many other tests  and blood tests He was told that he had emphysema - the disease that patients get -damage to lungs -when they are smokers. He was given an inhaler and discharged home . He had no improvement in his shortness of breath, but he was sent home . He came to me sent by his PCP. I did the history  and physical examination. He could not sleep as he had more shortness of breath when he was supine  and would wake up short of breath  during night.He could not walk to keep his garbage out at curb and he had some dry cough. His examination was unremarkable. His oxygen saturation was 97% which normal and good in spite of being short of breath  and only thing that was abnormal was his heart rate -it was high at 130 to 135.
     I reviewed his reports from the hospital records  and the CT scan had shown one bleb - which  made them to tell him that he had COPD -emphysema. He did not have emphysema. He had ultrasound of the heart and it showed minor abnormality . His pumping action was mildly reduce at 45% instead of 55 to 60 % being normal. I told him that he did not have COPD  and i was concerned that he has heart problem . I ordered some tests in my office -breathing test and walk test and pulmonary stress test. I personally called a cardiologist and told him to see ASAP.
     He came for the pulmonary stress test in next 3-5 days. I had given him a different inhaler  and he told me that it had not helped and he could not sleep at all last night and had to sit in chair as he could not lie down in bed . His oxygen saturation was same - normal and the heart rate was high and the lungs were clear. He had seen the cardiologist and he was told that they will do the cardiac stress test , but they did not think he had heart problem.I told him that I was going to admit him as I  was sure that this is cardiac and only way to sort it out was to get him in the hospital.
     So he was back in the hospital within less than 3 weeks of his last one . I ordered number of tests , but I ordered another ultra sound of the heart even though he had one just 4 weeks ago, I called the cardiologist and told him to see him personally  and not depend upon PA.A blood test called BNP , which goes up in congestive heart failure was 8000, the normal is 800. . The echocardiogram showed that his heart function was 20 % and he had 'Severley Leaky ' aortic valve . In spite of knowing this I could not hear any murmur. ( that is the inadequacy of physical examination ) The cardiologist did the cardiac cauterization  and the diagnosis of leaky valve was confirmed and he was transferred for replacement of the valve . (There were few more things that we did due to his HIV , but they were not related or causing the shortness of the breath)
      So the hospital doctor and the 2 cardiologist  and one lung specialist could not or did not think about the heart problem , may be being misdirected by TESTS  rather than history which was classical for shortness of the breath due to heart problem . 

Saturday, May 4, 2019


     In medical practice sometimes I wonder as why I end up seeing some patients . I do not seem to have much contribution to their specific care and still sometimes I am asked to see them and then it seems that they want to come to ma for follow up. The only way I can explain this is by law of Karma. Something sometimes that we had in past that brings them to me . I will tell you about one such patient .
      I saw this 76 years old male in my office . Due to language barrier he was accompanied by 3 other family members. Sometimes in medical office where the exam rooms are small, this is overwhelming . It also takes longer time to get to the real story. But here the family was well versed  with his medical problems and had the reports with them too. They were genuinely concerned. He was admitted with bleeding from the stomach , which turned out to be due to ulcer and then the work up was done . He was a smoker and heavy alcohol uses  and had liver disease due to excessive alcohol intake . The routine chest X- ray showed that he had spot on the lung and so a biopsy was done  and it showed lung cancer . Due to some blood abnormality , further work up was done  and diagnosis of prostate cancer which had spread to bones was done . So to summarize, he had alcoholic lever disease  and lung cancer and prostate cancer . He had seen oncologist and chest surgeon. So I was not sure as my role . But as I always do I saw the patient and told them on the need for the breathing test to make sure that he had adequate lung capacity to cut out part of the lung containing the cancer as that seemed to be the plan . But when I examined the patient, he had an enlarged lymph node in neck.So I told them that the biopsy of that node was very important as if it had cancer cells, there was no reason to do the resection. If the cancer has spread then the surgery would be futile.We scheduled him for breathing test and then the follow up .
       I did not see him for may be 6 weeks or so  and then one day they came back.He had missed the appointment for the breathing test. I had received no reports or any communications from the primary care doctor or oncologist or the surgeon. But the family had the reports . I was not sure as to what was the reason for their follow up. So he had surgery and the diagnosis of the cancer was confirmed .One lymph node was positive for cancer and it was close to food pipe or esophagus.The lymph node was there and they did not do biopsy but he was sent to ENT throat doctor  and had diagnosis of cancer of the lung. So now he had 3 cancers and liver disease and lung disease due to smoking and the lung cancer had spread to lymph node . So the chance of recurrence was high . They had planned radiation lung and tongue  and then chemotherapy. The family and the patient has several questions for ME . This is in spite of seeing the oncologist and radiation doctor and multiple other doctors .
    I was not sure why they came to me ,but I explained them the radiation side effects to swallowing and also the side effects of the chemo . They were not aware of some of the side effects, So I TOLD THEM TO TALK TO THE ONCOLOGIST AND RADIATION DOCTORS  AND told them he may have difficulty with swallowing and may need feeding tube.

Sunday, April 28, 2019


     In medicine one does see number patients at the same time  and in sub specialty practice we see similar patient all the time  as there are limited number of common diseases . But even though the diseases are common each patient is different. But there are some differences in the disease process and differently the behavior  and the reaction of each patient.I see this everyday  and sometimes the contrast is so glaring that I have to  write it.
      So I saw this patient several years ago , She was 84 years old  and had severe COPD - damage to lungs due to smoking.She continued to smoke  and then was more short of breath. Then she needed to be on oxygen.Her chest X- ray changed  and she had a nodule  She did not want to do CT scan and was not interested in CT scan . She did not want o quit smoking . She became irregular in follow up and then would miss follow up . We did follow up and she finally agreed to do CT scan and she did have a nodule. She did not want work up and she was not a candidate for open Biopsy or even needle biopsy. She did not want any work up anyway. Over period of time I did not see her and then when I saw her the nodule had grown and she was also older and she had started to be in wheel chair.
She did not want to do CT scan and then when we did it the nodule had become a mass - bigger . Her daughter came in picture  and we had a a talk and we did not do much work up . Then she was admitted to hospital with pneumonia , She was sick and needed more oxygen and she was quite short of breath. and she was worse She had CT scan done  and had pneumonia  and had increase in mass .By now she was 90 years old .  She was very sick and no biopsy could be done as she could not have tolerated even bronchoscopy. She was seen by cancer specialist and they agreed that she was not candidate for much work up and also for much treatment given her dementia , oxygen dependent COPD.
     She was discharged home . We had discussion and she was seen by oncologist  and no further work up was done . She lost some weight and had more dementia . She did not come to see me . The daughter came to me to talk without any formal appointment. When I could not justify signing form to continue oxygen and other medications without seeing in office, she did come . She was cachectic  and she was followed by a group of oncologist and the daughter had taken her to different oncologist and radiation doctors in hope that they would offer her something NEW. They all wanted biopsy as chemotherapy could not be done without knowing exact nature of the cancer-tissue type The oncologist did not offer her any or she did not want any. The daughter walked in my office one day and had CD of CT scan that was done by different group of oncologist and they wanted to do biopsy. So she wanted  my opinion. I told her that I could take CT scan to radiation doctor as the mass was 11 cm now. She wanted to see what I would suggest. The radiation doctor called me and saw her and told her that the biopsy was needed. She was admitted for congestion and we went through the same discussion . She was 92 years , on oxygen all the time , had dementia  and could not walk even 20 feet . The 2 daughters were bedside  and I had my discussion including calling Hospice . One daughter wanted that but the other one that came to my office did not want to make her DNR or hospice  and wanted the biopsy . The biopsy was done  and the pathologist called me.She had CANCER . I talked to the daughter  and she was extremely surprised "Oh NO " she shouted . Now I was surprised . All the doctors she had seen in last 2 years had all told her that she has cancer .So why was the surprised and not willing to accept the inevitable?
       I saw this 73 years old female  and she had CT scan and she had a nodule . 9 mm She was non smoker and so we decided to do follow up on the CT scan. so in 1 year or more it went to 11 mm -increase by 2 mm . Sometimes this kind of variation may be due to sectioning . So I decided to do follow up. She was followed up by PCP  and did not come to me ,But then was admitted to hospital for pneumonia .I saw her ,. She had pneumonia in the same area  as the nodule and so it was difficult to assess  any change in the nodule. She was treated  and discharged. She came to me  and I did chest X- ray and it was improved . I ordered the CT scan and then the follow up. She did not do the CT scan and missed the follow up. The PCP called me  and wanted to to know if I wanted the CT scan or plain chest X- ray and I did CT scan . The Ct scan showed that the pneumonia that she had 6 months ago was gone and the nodule now was 15mm. So I called her and saw her in office . I told her that in roughly 3 years the nodule has grown from 9 mm to 15 mm and it could be very slow growing cancer and we need to do the work up. So I wanted to do PET scan  and Biopsy. I asked her how much active she is .She was working for 4 days a week and on average she was walking 10 miles a day .She had no cough , shortness of breath or weight loss or any complaints.But then she surprised me by saying that 'I am too old - how long I am going to live , is it worth doing all this work up etc'
          So this is 73 years old patient, who is working 4 days a week  and has no shortness of breath and is walking 10 miles a day  and has 15 mm nodule who does not want to do the work up. And the other lady is 92 years old is on oxygen all the time  and has dementia  and has mass of 11 cm  and her daughter wants her to do everything and not even consider DNR status . WHAT MORE PARADOX CAN YOU SEE . 

Saturday, April 6, 2019


       In US we have health care crisis  and  the cost is way out of hands . We are spending money that we don't have . We have patients that DEMAND work up and we have physicians that order too many tests as they are afraid of malpractice  and want to make more money . We have hospital which has cost which is out of this world. and the medicines  are so costly that even well to do patients  can't afford. Lawyers are advertising on TV to sue anybody for any reason  and are looking for any bad out come  and or bad side effects . No wonder the cost of health care is out of hand . And to make it worst NO ONE CARES  and no party or politician has any clue how to fix it . Some believe that competition will reduce cost , others believe that government taking over will fix the problem and neither is ready for listening to others  or TALK to people like me - not any physician's associations -none of them have  any understanding how we practicing physicians work and face problems .
     This brings me to today's patient story . I have known this patient for last few years . She has mild  asthma  and recently I was thinking that her problem was due to heart problem and the the work up did confirm that she has leaky valve  and irregular heart beats  called atrial fibrillation that was contributing to her shortness of breath. She was followed by cardiologist and she is doing better. So the other day I had a call from the hospital that she was admitted . I went to see her . She had some upper respiratory symptoms  and she saw her primary care physician  and he gave her some antibiotics  and then ordered chest X- ray . The X- ray was OK and the fever was gone . But she was still 'congested '  and so she  and her daughter decided that she should come to ER. They did not call primary care any other doctor. As it is USUAL now a day ER did the CT SCAN of the chest . She had no fever  and had normal oxygen saturation and normal white cell counts. The CT scan was OK.
I saw her . She was started on 2 antibiotics by hospital doctor. Her lungs were clear and she had no fever and the CT scan did not show  any pneumonia . She was comfortable  when I saw her and did not need oxygen . But as a 'routine she had CT scan and as a routine she was started on IV antibiotics. I was consulted  and so was cardiologist and kidney specialist . She had mildly abnormal renal function and she was followed by them as out patient . The nasal smear came back positive for a virus --COMMON COLD VIRUS !!!

   So she had cold and she was admitted for 2 days . She was hospitalized for 'observation . This means hospital makes more money rather than regular hospitalization . The hospital doctor makes money  and so does the cardiologist and kidney doctor  and I . So we have spent lots of money for treating COMMON COLD !!!

Sunday, March 31, 2019


   Recently i came across some cases in my friends  and colleagues where I can not explain how  and why . Let me tell you on these patients . We recently lost a physician who was very young and had never smoked . He ad lung cancer and that did spread to brain and he died  in spite of all the treatments that he could get at various centers. Then there is elderly friend our our family who also never smoked and had lung cancer diagnosed. She is lucky and it was detected early and so she had surgery and it is in early stages  and there is good chance (Why good chance  and not 100 % chance ?) that she will be cured . And there was another case of a  cancer in a another physician who was completely unselfish , devoted her life to God  and community and again never smoked or had alcohol . She also dies of cancer. We all see this  and experience this in our life  and fail to understand why this happens.Some people ask me as to why some one gets cancer . And certainly there are definite causes and risk factors like smoking and also chemicals  and pesticides. In absence of obvious causes how do you explain the cancer and suffering that it brings in . And then why a stage 1 cancer is cured in some  and not in others . We have technology that can tell us -sometimes- as to who may recur  and who may not , buy not always So what is the answer to all these questions ?
      But I may have some possible explanation based on my faith and Law of Karma  and reincarnation. I am sure this will not be acceptable to all  and also those who may accept the Reincarnation also may have difficulty to explain why would someone get CANCER and suffering .
The Law of Karma states that EVERY Karma has a fruit  and one will ave to accept it sometimes -in this life or next or next. We are reborn for several reasons .
 1 We must pay the debt that we have accumulated with other individuals .
2 We have to have to accept the fruits of our actions
3 We must fulfill our unfulfilled desires  and we not do that without PHYSICAL BODY .
4 We need PHYSICAL body if we want to UPLIFT  our self . (when we help someone which is Good Karma - most or all of then are related to helping physical body , e.g. food shelter, sickness,or any comfort .
    So we must have physical body and to have NEW physical body after death of old physical body there has to be Rebirth. But then the question arises as to who wants to suffer  and who will have Desire to suffer ?
    To answer this one must understand that the Karma is done every second with MIND and BODY . When the two come together then the Karma is complete . The intention behind the MENTAL or Physical Karma will determine the Effect or the fruit . If I have transient bad thought about some one  and O do not ACT on then it may not or will not have ant fruit . But if I continue to have a thought ALL the time -say lust or some other it will create enough impression that I will have to fulfill it in pr there will be fruit to the thought. If I have a physical action which happened but there was no Thought behind it -I kick some one by accident and I had no intention of the kicking - I will not have much fruit , but if I have intention of kicking someone and I act on it , then I will have Fruit to it .
    One more thing to remember is that our PRESENT life is sum of effects of many Karmas  and not one Karma . So there are many forces and effects that determine the final effects  and so the FINAL EFFECT  may not be such that we can RECOGNIZE THE ORIGINAL KARMA - as it is sum of many karmas .
     This may explain the things that happen to us that we can not explain easily based on our ACTIONS in this life or even if we believe in Reincarnation , can not TRACE to one isolated Karma , that could have caused it .

Saturday, March 9, 2019


    In  past I have always stated that there is a limitation in medicine. I was taught to do physical examination before ordering tests . But even before one could put his hand on patient to examine , we were suppose to take history.Now a days then things have changed  and most of the physicians that I see and meet  do reverse way . They sit at the computer and see the X- ray and the labs  and the 'other notes' and then go to see the patients. Some times there is not much of history or even physical examination . They depend upon  nurse practitioners or ER physicians who in tern depend upon their nurse practitioners .I am still old timer and do my OWN history and physical Examination. But I have realized that the history and physical examinations also has limitations  ans sometimes we get diagnosis with TESTS rather than history or examination .This brings me to today's patient

    I was asked to see this new patient in the hospital . She was 72 years old patient who was having dry cough and so she saw her PCP . he gave her some medicines  and then did chest X- ray and then told her that she has allergies  and she should take some over the counter medicines for allergies . She continued to feel poorly and did see PCP and there was no change in treatment . Then she saw cardiologist as she was  also having some swelling of the feet and shortness of the breath. He gave her some medicines  and was going to do some more tests . But then when she was checking out at front desk , she was noticed to have significant shortness of breath . So she was admitted and I was called in . She had some lung scan done to rule out clots  and that was OK. But she has some fluid around the right lung. So the CT scan was ordered.
   When I saw her she was having dry cough . This was going on for last 2 months . She was getting short of breath for 3-4 weeks . She had worsening edema in legs . She had never smoked  and she had lost some weight , When I asked her about that she told me that she feels 'full'  and so could not eat more . On examination she had reduced air entry on lower part of right lung and she had edema . When I examined her belly , it was obese  and I felt it was 'tight' or firm . I could not feel much  and I did note that in my note . The CT scan showed 2 spots on lungs one on each side  and fair amount of fluid on right side. I told her the possibility of cancer and decided to do the procedure where upon I take out fluid . I took out more than 1000ml of fluid  and I ordered PET scan . The PET SCAN picks up cancer in body . It is about 88 to may be 90 % . The PET scan is done where glucose is injected  and the glucose pick up by cells is recorder . The cancers have higher metabolic rate  and so the cancer cells pick up glucose at much higher rate than the background . Since it is metabolic or biological scan we do not see the structure or the anatomy . So it is accompanied by CT scan . The lung Marses were positive suggestive of cancer. But to my surprise there was big tumour in pelvis  and it was 14 cm  and it was positive . She also had some fluid in belly. She had told me that she had hysterectomy and her ovaries were taken out partially . So it was a shock to me that she had cancer in pelvis . The fluid came back positive for ovarian cancer,

      So in spite of taking adequate history and examination, I did not anticipate the diagnosis . So sometimes one needs to get diagnosis which was not suspected . 

Sunday, February 17, 2019


          There is saying that the Honesty Is the Best Policy , but is  it really true?In life we have incidences where the honest answer may be crude or cruel or not pleasing . In Ganapati ATHARWASHIRSH, it is state the 'I will say Pleasing and Truth'. In personal relationships between the husband and wife and children and friend, this is true.But even in many other aspects of our life we don't have ti lie but we can still say truth without hurting the other person or the relationship.Sometimes we can not tell our boss what we 'feel ' about him or his decisions. We still can say the fact or the truth. In medicine this holds very well. I have come across this on number of occasions. This more often happens when we have a patient who has cancer . This brings me to the today's story.
      I had seen this 75 years old lady who was smoker and had some lung issues . Over course of my follow up she developed a mass in the lung . In all probability it was cancer and so we did do the work up and then i sent her to surgeon  and it was taken out. She did well- had some problem post op. But overall did OK. She needed oxygen after surgery , that was arranged at home . She was doing better and then may be 18 months or so after the surgery , when we did the follow up CT scan she had a mass . We had her see radiation  and oncologist . She had needle biopsy and then the recurrence of the cancer was diagnosed. She had localized mass and so she received radiation. She then saw oncologist , who decided to start her on some chemo . In spite of the chemo she developed new nodules and so the chemo was changed . Now she had multiple nodules in both lungs  and radiation was not option and so she had continued the chemo. She has been old  and has some dementia . She has COPD  and does need some oxygen .She was admitted to hospital with multiple issues , including anemia related to chemotherapy and also had low salt and worsening kidney function and also had swelling of the legs . Further work up showed that she had clot in the legs  and  for some unknown reason (at least to me ) someone ordered a CT SCAN of the belly and that showed a mass in colon.
She was in no shape to do any invasive procedures for diagnosing colon cancer , but more than that , diagnosing colon cancer would alter any treatments . Due to fear of bleeding from colon mass if she was started on blood thinner and with her low blood counts , we decided to do insert a filer in one of the blood vessel so that clot from legs would not travel to lung- embolism..
   When the radiologist went to insert the filter he realized that the entire blood vessel was filled with clot. So he could not do the procedure. But more of  a problem was that the clot occurred in the blood vessel as it was compressed by external tumor. So the narrowed blood vessel developed the clot and that was blocking the drainage  and so she had swelling of the legs . So then we had a catheter inserted in that blood vessel and clot busters were started . Now she will have to be on blood thinners too.
      So we have 80 years old patient  who has spread of a lung cancer , who also has anemia  and kidney failure and oxygen need for COPD , and has possible colon cancer and the a tumour that is pressing on one of the major veins that has clot. You get the picture. No matter how successful we are in treating the clot , her long and may be even short term prognosis is not very good . I did try to talk to her family as she has some dementia about this . But the cancer doctors and their nurse practitioners have not said a word about bad prognosis and so we are doing the bandage approach without being able to treat the underlying cause of the problem . The need to be honest but not blunt  and compassionate but still telling truth.

Sunday, February 10, 2019


     Many years ago I was talking to a state elected congressman, who happened to a physician. He was telling the difficulties that physicians have to a good politicians and why the lawyers have no problems. Many of the politicians are lawyers. His point was that we physicians have single tract mind . If a patient comes with history of smoking and has coughed up blood and has abnormal CT scan of the chest showing a mass, we KNOW that it is highly likely to be a cancer and we KNOW only one way to do the work up.We will not tell to just watch it grow unless off course the patient is demented or has lots of co morbidity.But even though we may not do the tests or the work up due to the circumstances , we are very certain that the mass is cancer and we do not entertain any other thought. Now take an example of a lawyer. There is a divorce case and custody battle or case of tenant and land lord.Who so ever pays the money the lawyer is on his side and he will argue if needed in court that his client is right. There is no one side which right . But for medicine , high blood pressure is to be treated and there is no argument or 'other side ' , Same with high blood sugar or any other number of cases that I can tell . So the physicians are taught to have one particular way of thinking and we do not have to change our opinion due to some one paying me more money. So we can not be good politicians who can listen to both sides and can be swayed by one or other arty that gives them more money. But that brings me to the story for today .
       In medicine I am seeing more and more older patients and it is not uncommon for me to see few 80 years plus  and some 90 years plus patients.This has changed me and my decisions  and also the way in which one can approach the same issues that we had before. I saw this patient who was 90 years old . He has coronary artery disease and had high blood pressure and also was short of breath. He had some COPD ,  and needed some bronchodialater -medicines to treat his wheezing or bronchosasm.But on further investigation I realizes that he also had elevated pressure in lungs or what is called pulmonary hypertension.The medicines that I could offer for that were expensive and are special pharmacy medicines , which means they are to be ordered through the drug company and need right heart catheterizing to be done . The cost runs $30000 -year $30000 -I did not make mistake in adding a extra 0 .So the company wants to be sure that there is elevated pressure and the value is high enough to need treatment. So he needed cardiac catheterizing. The cardiologist was not in favor of doing an invasive procedure in this 90 years old patient . But the patient wanted it and so finally it was done . It did confirm the diagnosis of elevated pressure and I tried to start him on medicines .Due to the high cost of copay, I could get only one drug started and he did do little better.
So at each step of the decision I was 'OPEN' to treat or not treat this patient as the benefit of these medicines and the cost and the side effects may not be of value in this patient.
    In few months he continued to be stable  and had to be on oxygen 24 hrs a day and also was short of breath . The he developed more shortness of breath and the chest X- ray done did show worsening of the congestive heart failure . We had to pit him in the hospital and he had some fluid. In average patient I would drain it with a catheter insertion. But in his case - who was 93 years old now I was very hesitant to do such a procedure and decided to try to just 'watch' it with medicines being given .
So even though I KNOW the best way , I am WILLING to wait and watch . This s a change in my though process . BUT I WILL NEVER BE READY FOR THE POLITICAL ADVENTURE !!!!

Sunday, January 27, 2019


     As a child we used to read a book called ISAP NEETY , Isap was a slave and he could talk to or communicate with animals . There used to be a another book called PNACHTANTRA . In that book also there were short stories and the animals could talk . Every story in these books had some moral to be concluded and that was stated at the end of the story . In one of the story there was lady who had a mongoose. That was her pet . She also had a infant child.She had to go out of the house to get some water from the well.The child was sleeping and so she decided to go out in back yard to fetch some water. It took her some time to come back.When she came back she saw the mongoose at the door of the room with blood on it's face . She concluded that the mongoose attacked the child when she was out. She threw the water pot at the mongoose which almost killed the mongoose. She ran in the room where the child was sleeping sound and there was  a dead snake next  to the child . So when she was out , snake came in the room and the mongoose saw the snake  and attacked the snake  and killed it . So the mongoose killed the snake  and not the child . But the lady jumped to conclusion. This is not uncommon for all of us . We JUMP to conclusion without having checked all the information. That brings me to story for today .
       I saw this hospital as second opinion He was 74 years old male who was primarily followed by VA.He was a smoker and inspite of diagnosis of COPD , he had continued to smoke.He also had coronary artery disease and had 5 stents. He also had circulation problem and had shortness of breath on walking 50 feet or less. His breathing test had shown severe compromise and the flow rate was 22%only. He was in hospital  and had CT scan done . The CT scan showed a nodule. The lung specialist that was called saw the patient and wanted to do Bronchoscopy . The patient was short of breath and the nodule was too small to have adequate sampling with regular bronchoscopy. So there is a relatively new technique called navigational bronchoscopy .The computer with help of CT scan 'guides' - navigates- to get to the small nodules that are not seen with the scope. In my experience , this needs anesthesia  and is not greatly successful in getting sample or diagnosis unless one is expert in doing it . The patient refused the procedure and so I was called in to see him . HE was obese patient  and had smoked and was fairly well aware of his medical problems. His fear of the procedure was that with anesthesia, he may end up on respirator and then will have difficult time to get off it .And in my opinion he was right.In addition to that he had 3 CT scans at VA and  he knew the results  and he thought that he had nodule in the past . Not only he was aware of the CT scan findings , but he had 'access' to the reports . I told him to pull up the reports in the computer and he was right . HE DID HAVE NODULE REPORTED - SAME AS WAS IN THE CT SCAN THAT WAS REPORTED IN NEW CT SCAN! So with his advanced lung disease, the nodule being there before I suggested to do follow up on the CT scan in 3 months and then consider PET scan . He was not a candidate for open biopsy  and the newer Radiation technique for smaller nodules is only 5 sessions and it has great cure rate. So if indeed he has cancer one could confirm the likelihood of it being cancer -nor 100% and no tissue type known - by PET scan and treat it .
     Just because there was a nodule does not mean cancer especially if he had it for a while . I agree that this still could be cancer but the diagnostic test should not cause more problems . So jumping to do a test was premature  and just like that lady was hasty in concluding that the mongoose hurt her child. 

Saturday, January 5, 2019


     We often use this term , PERSPECTIVE - Often it is stated that one should not forget perspective in life . In medicine we need to remember this more than in any other field. But I have felt that we HAVE FORGOTTEN it . I know how the things are done in past  and how they are done here . But I also know how things are done in other counties, including India  and how we are doing things here in US . I do not want anybody to think that I am  suggesting DEATH  agencies or more control on health care decision. But sometimes it is frustrating. I think the problem may be partly if not solely due to cost of health care is not being not paid by relatives - by the people who make the decision.It may be due to lack of understanding the ability or for that matter inability of the modern day medicine . But in any case we have a problem . The health care cost not the only thing to be considered in these matters , but also the suffering of the patient as well as the relatives who make the decision. I saw 2 patients recently  and that brought me to write this blog .
       I saw this patient few months ago . He is 78 years old and has the usual issues that many at that age have . He had hypertension and has had strokes and had developed dementia . He had atrial fibrillation in which the heart can throw clots and that can eat up the brain piece meal . This  leads to loss of brain tissue and that leads to dementia . So he did have dementia . But with the strokes he also had problem  the swallowing and so he had lost some weight and then the family agreed to have feeding tube for the nutritional reasons and also to give him some medicines which otherwise he could not swallow . He was tried on blood thinners to prevent clots  and he had blood loss and blood counts dropped . So he was taken off them . So on one side he had high risk of clots and so he should be on blood thinner , but on other hand he could not be on it as he had drop in his blood counts and so not being on the blood thinners the chance of getting mini strokes increased and that can make the dementia worse , On top of that he had developed severely leaky valve and that in tern caused the pressure in the lung to be increased . So he had aspiration pneumonia and had feeding tube and dementia and heart problems .
     I talked to his wife who was the medical power of the attorney and tried to have her agree for DNR- not to put on machines. He was seen by cardiologist and they stated that nothing could be done about his valve or the atrial fibrillation other than trying to control the heart rate. He did better with the antibiotics and then was discharged . He came back in  1month with episode of fall and low blood pressure and an abscess on the scalp. He had low blood counts again and needed to be transfused  and he was on antibiotics and he also had to have the surgery to drain the abscess. He was not only demented but was very uncooperative and would swing and try to hit doctors and nurses and would constantly curse. It is not his fault as he did not know much as he had dementia. I talked to the wife  and told her the limitation . We certainly can give antibiotics, which we did . We can transfuse him which we did . But the dementia and the aspiration and the leaky valve and the pressure built up in lung was not going to get any better . But she would not agree for DNR. The treatment is bandage approach as we are not treating the main problem dementia and stroke and the heart problem and so we treat the symptoms . But we are not 'helping' him or her . I am sure it is painful to watch our own relative 'suffer'  and be in hospital , but I do not know the reason for the not doing him DNR. She has  no liability for the bill  and may be the after life belief system  , may be fear of loosing husband - whatever it is , it is not helping her or him or the health care cost .