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.