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 . 

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