Wednesday, December 30, 2020


     We act in our life with desire  and advice that we can change the fate or outcome. We want to eat healthy food and not smoke and not drink too much of alcohol and not do drugs . I do believe that this is good behavior and everyone should try to do what is right . In medicine we also act and advice patients that certain way of treatment or work up will help us in getting good or desired outcome. I still remember , when many years ago one of my professor of preventive and social medicine had a heart attack . In those days not much was known on heart attacks , but we still knew that smoking and not doing exercise  and cholesterol were main culprit and we also knew that diabetes and hypertension were also risk factors. So when I saw him after his heart attack he made a comment to me saying that he does not smoke and does not drink and has no hypertension or diabetes and he still had heart attack . This type of unexpected medical elements are known to someone who ahs been in practice for long time but what I am talking today is the out come of the treatment or we not getting expected outcome. 

    I saw this patient in hospital. I had seen her sister and one more family member  and one of them had cancer. She has been smoker  and she had quit smoking and then she had shortness of breath .She had 2 years ago heart attack or tales chest pain and was found to have blockages and had stents  done . She was seen by PCP and that was telemedicine follow up and he gave her antibiotics and she did not get better and was still short of breath .So she came to hospital and had abnormal chest x- ray and then had a CT scan done and that showed a mass at the central part of the lung . If one can imagine lung with a stock like a fruit, then this mass was exactly at the stalk area. The main bronchus and the main artery all go in the lung at that area  and the mass or the tumor was pressing on the bronchus and it was narrowed . So there was a high suspicion for cancer and they called a cancer specialist . I was also consulted . I saw her and when I saw her I knew that this was not good . She also had a second mass  and she had shortness of breath  and she was on minimal oxygen supplementation.. The cancer doctor had ordered a biopsy of the lung mass. I explained to her and her husband that I was quite concerned  about a cancer  and that too will nor be operable  and the position was bad and that may compromise the air  and blood going to the one lung . I also ordered a PET scan. She did not feel good on the next day and so the biopsy was postponed  and so was the PET scan. Then the next day she had problem  oxygenation and so we had to increase the oxygen and that continued to get worse  and so I transferred her to ICU.I again talked to the husband and the patient and I also called radiation doctor to see if he could start emergency radiation without the diagnosis of cancer as otherwise that was going to get worse . They felt that getting a stent to open up airway would be better . So we consulted one of the interventional lung specialist . She was transferred to another hospital . As it happened, she had a heart attack and she was started on blood thinner and she had gastrointestinal bleeding  and then she vomited  and had cardiac arrest  and she was on ventilator  and continued to get worse. 

     So we did all the right things , Oncologist was consulted and Pulmonary was consulted  and we also called radiation doctor and then interventional pulmonologist. We had cardiologist see her when she had heart attack  and inspire of that she did not have good outcome. That is what we call fate.

Saturday, December 19, 2020


   When I was in medical school, we had a visiting professor named DR, French .His father had written a book on Differential Diagnosis. The book had various causes of certain symptoms. So if one looks  at the cause of headaches, we will see many causes of headaches from simple tension headache to sinus infection to brain tumor. So it gave a list of possible causes of certain symptoms. One has to understand that the physician or the medical student has to take a detain history  and do physical examination and then narrow it down to 'few' causes.  In those days the lab tests  and radiology was not that advanced  and the Ultrasound examination and CT scan  and PET scan  and angiography etc. were not there. So everything was CLINICAL. Now a days we have many tools at our disposal and that has changes things and helped  and also made it worse. We are depending upon TESTS and not on history and physical examination and then we are going on wrong track. That brings me to the story for today. 

     I have seen this male patient for last few years  and he had smoked many many years ago and had COPD.. Over period of time he had gotten worse  and he was on oxygen and he also had cardiac problem - Atrial Fibrillation. He had few episodes of increased heart rate and i had to admit and then he had ablation and he did better. He lived by himself  and he was some what noncompliant with follow up. I checked his blood oxygen and carbon dioxide  and as expected he had elevation of CO2. In the early part of lungs not working or doing their job- which is to take in oxygen and wash out carbon di oxide, both these are normal. As the disease advances, the oxygen lack starts and then patient needs oxygen . As disease gets worse, the CO2 starts getting elevated. So in his case the oxygen had dropped  and CO2 was now elevated . The sum of these 2 gases in blood is constant ( one of the laws of partial pressure of gases in a mixture) So when CO2 increases the oxygen drops  and if we can reduce CO2, the oxygen will increase. So I started him on a machine - NIV -Non Invasive Ventilator . So he has been on it for a year and seems to have done better . His compliance was not great . I would have liked him to use it for 8 hours or more and he was using it for 4 hours  and that to not daily. So one day he had a fall in bathroom and so he came to ER . He was slightly confused  and had tremors  and the ER physician did CT scan of the brain  and admitted him for altered mental status  and may be TIA - mini stroke. NOONE BOTHERED TO CHECK BLOOD CO2.when we did do the check on it his CO2 was more than the double of normal value. and having oxygen supplementation his oxygen level was too high. THAT WAS THE CAUSE OF HIS CONFUSION AND  THE Fall. We have respiratory center in brain and it is stimulated by LACK of oxygen and Elevated CO2. So when the oxygen level drops , we breath more to compensate for it  and same with CO2 elevation. But with COPD patients the sensitivity to elevated CO2 is gone  and the patients breath only due to lack of oxygen. The elevated CO2 acts like sedative  and cause altered mental status. When one takes away lack of oxygen, the patients will not breath much . So one has to be careful as to how much oxygen should be given. In this case if one would have done HISTORY , they would have known that he was on home NIV  and that means his CO2 must be elevated  and they would have checked blood CO2  and that would have helped .But the knee jerk reaction was to do CT scan of the Brain. Certainly doing a CT scan in any patient with fall  and altered mental status is indicated  and appropriate, but checking blood oxygen and CO2 levels would have clinched the diagnosis .So the differential diagnosis has a list of many conditions that could cause the fall and the altered mental status  and the HISTORUY would have narrowed it down  and on the top of the list would have been retention of CO2!

Saturday, December 12, 2020


       I have tried to avoid talking about the pandemic with COVID as there are so many who have written and talked about it that my blog would be nothing new . But what I have realized in this pandemic is that the disease is not as simple as other diseases that we have encounter in out routine medical practice. It has many faces  and it is possible that we may be having "training on job "type of situation. I had state it in past either on my YOUTUBE CHANNELL or in one of the blogs or may be in some group discussions that out  mortality was high in the beginning as we did not try simpler way of providing oxygen  and respiratory support. Now we are not doing that and the mortality is reduced. So i have stated many times that this reminds me of old Indian Story of 7 blind men and Elephant. There were 7 blind men and they had not seen an Elephant . So they asked their teacher to describe the elephant . So the teacher took them to a place where they could touch the elephant  and 'know' for themselves how the elephant may look like. So one blind man who was touching the back of the elephant said that the elephant is like a wall , The other one who was holding the tail stated that No it is like a rope and thisrt one who was touching the legs stated that no ,no it is like a pillar  and so on. So each one was touching some part of the elephant and felt that he 'knew' how the elephant looks like. That brings me to today's story.

   I have known this patient 74 years old for last several years . When I saw her for the first time she had what looked like a pneumonia  and so she was admitted  and I saw her . She had pneumonia, but it was due to obstruction of a bronchus with a cancer  and she also had COPD -lung disease due to smoking . So I treated her and had her see a chest surgeon and he operated her and the cancer was resected  and she did well and did not need any further treatment in form of chemotherapy or radiation. She was followed and she had no problem . Then early part of last year she was admitted  and she had pneumonia  and I was called again and i saw her . We treated her with antibiotics and she had CT scan  and then I did Bronchoscopy to make sure that she did not have cancer and she did not . We did do follow up CT scan in 3 months  and she had complete resolution of the pneumonia  and CT scan was clear. Last month her husband got sick day before the Thanks Giving  and went to walk in clinic  and was diagnosed with COVID . He did not want to go to hospital and decided to get treatment as out patient and watch . She was OK  and then on Friday after Thanks Giving ,she got sick and she went to ER and was admitted to hospital. I saw her and she needs minimal oxygen and she had no fever and she was not short of breath . The chest X- ray did show that she had pneumonia  and her COVID test was positive. But she also had diarrhea  and so she was dehydrated  and her kidneys were not functioning normally. So we started her on treatment for regular pneumonia a nd also for COVID . The infectious disease specialist also saw her  and she was on steroids , oxygen and Remdesvir. I watched her every day and she was stable for 4 days  and was to complete the treatment t in one more day. And her condition got worse  and she needed more oxygen , So now she was on 12 L oxygen and then next day the chest X- ray got worse and oxygen dropped  and so we transferred her to ICU  and she needed to be on PAP - machine that generated pressure to deliver oxygen -- which we were not using due to fear of spreading COVID only 3 months ago. She continued to need it for 4 days. Shas done better but still not completely out of wood. So she did all the right things . She went to ER when she had problem , got hospitalized and was seen by specialist and was started on treatment with current medications and seemed to improve -only to crash after the treatment was completed I am not sure how to explain this . 

    Her husband decided to stay home for 1 week and then when he got worse , he came to ER  and had to be put on ventilator and continue to need ventilator for long time  and is sick  and has improved minimally.So he did not do what he should have done  and paid price for it .So I am not sure in this family matters who is right and who is wrong !! ,  

Sunday, November 29, 2020


   We sometimes say 2 steps forward and 1 step backward . But sometimes we have a different situation. We can't seem to go anywhere in life or the situation and we continue to depend upon FEELING rather than the fact. In medicine we often go by statistics or feeling and we do not want to accept it and feel that we are making scientific decision. But if we look at our usual decision in case of any patient's treatment is based on science as much as our feelings. Suppose I see a patient who is smoker  and has cough and blood in sputum and has no fever and has lost some weight, and has chest C- ray showing some spot, we consider cancer as highest possibility  and if that was in India and a nonsmoker  patient and same complaints , we will consider TB as the possible diagnosis as the first one. So we depend upon our experience  and past experience. But sometimes we have patients that has nothing typical and we struggle to decide  and we do tests to get to the bottom of the problem and then after work up are left with same ot more questions than when we started . This is one of those stories. 

   So I saw this 58 years old female who had a cough and the primary care physician had treated with antibiotics  and cough meds  and the cough continued and so she was sent to me , He had done chest X-ray and that had shown some congestion. She had CT scan ordered . The CT scan showed  multiple areas of congestion and she had no fever  and she had some bronchospasm  and some shortness of breath. I did further work up and did treat her with medicines for asthma  and did blood tests to find out the reason for the CT scan abnormality. We did allergy blood tests and also tests for autoimmune disorders like rheumatoid arthritis  and lupus  and also some blood tests for what is called hypersensitivity pneumonia -pneumonia due to allergies  and not infection. We also did breathing tests  and also did follow up CT scan . The scan did not improve  and so I did bronchoscopy and biopsy and that just showed inflammation and not much diagnosis of specific reason for it. So I did try steroids as treatment . I wanted to have her do open lung biopsy. She did see a chest surgeon but did not do the biopsy. After gap of 6 months or more she had COVID infection  and she was hospitalized. She did OK but needed oxygen and then when I saw her in office she had done well. . But the problem continued .So I sent her to the surgeon for the biopsy and she had the biopsy. She called me 7 days after the biopsy asking for my advice as to what to do now . I had not received the report as it was done in a hospital where I don't go. I checked the biopsy report in the computer  and could not make any decision as the pathologist had not given me any specific diagnosis. I called the pathologist  and spoke to him. He told me that it could be any number of things - that has caused the problem and I thought to m myself - I KNEW THAT EVEN BEFORE THE BIOPSY was done. He told me that he has sent the biopsy to Mayo clinic for second opinion  and it should be ready in 3-5 days . 

    I called the patient and told her to see me in 1 week in my office and discuss the diagnosis  and treatment. She came with her daughter . In the mean time I did get the Mayo clinic notes and opinion  and to my disappointment they had about the same opinion as I had before the biopsy was done .' It could be this or that or may be that and that also is possible'- was the report.    


   This is what I called 2 steps forward and 2 steps backward.. Now I have to make CLINICAL DECISION.

Saturday, November 21, 2020


    Telemedicine has been there for sometimes now. But Most of the Insurance companies were not paying for any medical service that is done without direct contact -in person -patient care. I have done antibiotics  and other medicines advice and prescription without getting paid  and that is fine b. But I still don't like to do Telemedicine as substitute for patient bein seen with direct contact. There is difference between watching a movie on TV or computer and attending in person a Broadway play Or attending a basketball game in arena V watching it on TV is not same. But now a days in hospital many consultants are not only allowed to do telemedicine for COVID positive patients , and are encouraged to so . In the beginning it was to save on PERSONAL PROTECTIVE DEVICE . But it has continued. This story is related to that 

   I have known this patient for few years. She is in her early seventies  and has had COPD - smoking related lung damage  and also had weak heart . Her pumping action of the heart was 25% at one time . She had a device inserted called ICD and she had improved . She needed the battery change and so she had COVID test done and that was negative  and she had the procedure . Every patient that has any procedure .surgery, endoscopy done in hospital, has to have negative COVID test She had some problem after the procedure  and she was kept in hospital for 24 hours .She was sent home and then in 2 days she has some shortness of breath and so she came to ER. She had as expected COVID test  and that was positive . I am not sure how she had COVID when she had not gone out of house after discharge. She had many reasons to be short of breath - bad lungs and weak heart. But since COVID test was positive everything changes. Infection Disease specialist was called  and new COVID routine ordered were done by the specialist . He did not see patient . It was telemedicine consult  and she was started on Rendesvir  and steroids were started . The hospitalist also had seen patient. I have known her and so I was called  and I SAW HER IN THE ROOM  AND EXAMINED HER . I also saw CT scan and did not feel COVID had anything  to do with her symptoms  and if it was not for COVID she would be treated for lung and cardiac diseases. She did better with the treatment that I had started or may be due to the treatment of COVID .In any case she was better . But one day I saw her  and she told me she had bad night  and could not sleep and she could not be supine  and walking 5 feet she was short of breath. I asked her if she was seen by Infection Specialist doctor   and hospital doctor. She told me that it was telemedicine call from specialist and when she told her that she was more shor of breath, he told her that we will take it day by day. The hospital doctor saw her very briefly  and was talking to her from door . I saw her and knew what had happened . She was getting lot of fluid as ROUTINE for last 3 days  and with her weak heart she was not able to tolerate it  and so she was in congestive heart failure . I stopped her fluids  and gave her medicines to have more urine . When i checked her next day , she was like new person. Within less than hours of getting medicine she felt like pressure was relieved .

    She continued to improve  and new chest X- ray had nothing to show anything to suggest COVID worsening in lungs . So the Infection specialist  and hospital doctor who did telemedicine  and did not check patient miss the real reason for the shortness of breath. The routine set of orders sometimes need to be changed . 

Saturday, November 14, 2020


    To get a driving license one must take a driving test and also do written test to show that one has enough knowledge of driving  and safety and rules and regulations . But we know that just because one got the driving permit does not make him or her safe driver  and many a times one accident can ruin the insurance risk and also damage the car and also sometimes life . I am often reminded of this when I see certain patients  and I also tend to explain patient on risk of accidents. So this is the story of a patient but it applies to may of today's patients as we are seeing aging population  and also certain patients who recover from stroke who in past may not have survived . 

     I saw this 94 years old patient in my office for congestion and cough . I had known him as husband of one of my patients  but he was not my patient . He came with his daughter as he had lost his wife who was my patient in recent past . He had mild high blood pressure and no other major problems and I had known him to be the care giver for his wife who was fragile and sick  and never thought of his age . He was having cough for last 6 months and has been treated with antibiotics and cough meds by PCP  and he has had 3 courses of antibiotics  and he has done little better but he still had cough and congestion  and so they decided to come to me .He was not in any distress  and his blood pressure was good and his oxygen saturation was on low normal side. He did sound congested and he had what looks like productive cough, but he was not able to cough up easily. He did not have any chest X- ray and so I ordered chest X- ray and also set him to get breathing test . He had no problem swallowing , but I ordered the swallow study . I also gave him some mucous thinning medicine  and also ordered nebulizer treatments  and also put him on medicines -bronchodilator The reason to do the swallow study was my previous experience . In many elderly patients , -even though they may not have problem swallowing- they have some aspiration- food or liquids going wrong way in wind pipe-trachea and then lungs .  

    As it happened he had a fall and he went to ER and was admitted . I had also done CT scan  and hat had shown some infiltrates - what one might see in pneumonia and I had started him on antibiotics. When he was admitted, by hospitalist, he had another CT scan -within less than a week - waste of heath care money-and it did not add to our information. I did the swallow study and also continued what I had started as oi=ut patient , The swallow study did confirm my suspicion that he had silent aspiration. He did not do that every time  and not same with all consistency.. So the speech therapist advised some instruction - some precautions to avoid the aspiration. Over period of next 3 days he got better and oxygen saturation improved and congestion improved  and he was ready for discharge . 

   So he had aspiration pneumonia when I saw him and that got worse when he was admitted  and he was discharged on precautions to prevent aspiration. But as i was saying one can drive safely for months ot years , and then one can get in an accident  and that may be devastating -economically or insurance or health wise. This is my concern when we talk about aspiration. One may do ok 10 times or 100 times or more , but one day or sometimes even everyday one may have SILENT ASPIRATION and that can cause chemical bronchitis - inflammation, that can lead to cough ,congestion and even pneumonia  and if it is bad - sepsis or death. This risk is there. Unfortunately there is no answer to this as we can not be doing feeding tubes in everyone who has this problem . Certainly if one has 3 accidents then the liscence to drive will  be suspended. Same way if one has 3 episodes of aspiration pneumonia, then we should consider SUSPENDING eating and do feeding tube . 


Sunday, November 8, 2020


     Now a a days one can find anything on Google . One can search any song, any information, any news and anything and everything in medicine. This has lots of advantages . I can tell patients to check out certain things . e.g. portable oxygen concentrator - the machine that absorbs room air  and filters out nitrogen and produces oxygen So when someone asks me about the brands or cost, I tell them to check it out. Same with CPAP cleaning device - CPAP the machine that is used for sleep apnea. Or even I tell people to check out cost of medicines in Canadian pharmacy. So it is not uncommon for me to see someone who has questions based on Google search. Now a days many patients are told to ask their physicians certain questions  and that is also OK with me . I will tell you that people have done studies and they have timed physicians interrupting patients every 20 seconds or so - I ma not be exact in time but it is seconds and not even a minute for sure . So I am aware of that . But I have also known certain web sites asking patients to get second opinion. Again I have no problem with that either but the problem is getting second opinion for certain simple things-where there is no possibility of SECOND opinion is waste of money for sur and may be at times WASTE OF TIME. Say if Blood Pressure is 180/95 That is High Blood Pressure  and there is no second opinion - yeas one may have difference of opinion on which drugs to use or dose etc. but not about the diagnosis . This brings me to the story of the patient . 

     I saw this patient who had some cough going on for 2-3 months , The PCP treated it with antibiotics and some other medicines and he did not get better. So he had chest x- ray . He has no old x- ray in several years . The x- ray was abnormal and he had CT scan as he was ex-smoker The Ct scan did show a mass . So he came to me .We talked for 30 mins  and I explained him that we have to answer 3 questions 1 Is it cancer 2 Has it spread  and 3 What can be done -if it is cancer or suspected cancer . 

    We di the work up. We did bronchoscopy and did PET SCAN  and the breathing test The pet scan did show increased uptake  and that was suggestive of cancer - not 100% and it is never 100% . The bronchoscopy did not give us the diagnosis. The breathing test was Ok acceptable if we wanted to do surgery to resect the part of the lung. So I discussed with him and told him that the high possibility of cancer though we can never say 100%. I told him that we have 3 options 1 see chest surgeon and get an opinion to see if we should do open biopsy and take it out .2 Do needle biopsy which has some risk of collapse of lung and the chance of getting the diagnosis was not 100%  and if negative for cancer I would still consider open biopsy which is only thing that can give 100% diagnosis.3 Do only follow up CT scan in 3 months and see if the the mass increases . 

    To me there is no other option and there is problem with each of these options . The open biopsy may show that it is not cancer and we have done UNNECESSARY SURGERY, The needle biopsy has risk and diagnosis is not 100% ( I have seen recently couple of people with complications that needle them to be admitted to hospital )And wait and watch approach - has problem too. If it is cancer then in 3 months it can spread  and may become INOPERABLE. So ONE HAS TO ACCEPT THE RISK IN EACH OF THESE APPROACHES. 

   The patient after listening to all these wanted to get second opinion. I have no problem with SECOND opinion and I thought that the surgeon - a chest surgeon will be the second opinion. ut he was convinced that one must get second opinion based on his RESEARCH .!

(Just a foot note - there are other new procedures that can be done  and the diagnosis is not 100 % with them either.)


Sunday, October 18, 2020


      In medicine we often have health and sickness and also life and death situations or need for making such decision. This is not surprise at all. But sometimes for a physicians to bring up the topic of DEATH is not well received  and some time patients or the members of the family are not happy that I bring it up. 

   I had seen this patient for last couple of years and she was 75 years old female who had chronic cough  and so she had work up done and she was told to have got Fibrosis or so called IDIOPATHIC PULMONARY FIBROSIS. The disease is uniformly fatal. But in my experience that happens in 20-30 % of the patients  and some get worse rapidly and others slowly  and some never get bad enough. This is not what the medical literature will state. Again this is based on diagnosis by CT scan . Anyway she had fibrosis  and also it was or it had gotten worse. She was short of breath and had chronic cough and I did the work up and she needed oxygen  and she would drop her oxygen level even walking few feet and she needed oxygen 24 hrs a day . She had CT scan - High Resolution CT scan  and she had the typical findings of fibrosis  and so we did routine work up and then started her on a  relatively new medicine called OFEV . This I think was approved by FDA in 2014 or 2015 . She was doing OK and she continued to have problems Due to progressive nature of the disease, I discussed with her and the family on  lung transplant  and she wanted to go to a university center as some of her family was there. The appointment was postponed as the center was in another state. She continued to have very limited activity and was some what stable. She had some cough and she seems to be stable with Ofev . She had appointment with the transplant center after 6 months  and she decided that she did not want to have transplant as she felt 'she was too old '.She then had respiratory infection and she was more short of breath and so she was admitted . She had new CT scan and that again showed fibrosis, but also showed a new density at the edge of the lung . I was not too sure as what that was as it did not look like typical cancer. I asked her to get me old CT scan cd. I looked at it and in old CT scan that area did not show the density. So when she came to my office , she came with her son. I explained them the new findings  and told them that I am concerned about developing cancer . I also told them that if it is cancer she was not a candidate for invasive work up given her poor lung condition . The bronchoscopy would not get to the area as it was at edge of the lung . The needle biopsy - by putting in the needle from chest wall in to the lung was possible but there was very high risk of collapse of the lung as puncturing lung was a possibility . Certainly 'cutting it out ' by surgeon was out of question. So I ordered a PET scan and told them on what could be done as treatment if at alll we can do some without biopsy . 

    At the end of lengthy discussion I also told them that she needs to have living will and decision as to what she would like if she could not breath or her heart stops --the so called DNR status. OI told her that if she would go on ventilator, with her given lung capacity, it will be impossible to wean her off the ventilator. So then the family will have to make decision on so called "pulling the plug". So it will be better if she has discussion with them and make decision in advance. I also suggested that she should consider not going on respirator or make  herself DNR  by signing forms. She seemed to be receptive . But the son told her that he does not think she should be DNR  and we should do everything possible . I told her that that is why she should have discussion with family members. So that will avoid the conflict when the time comes.


Friday, October 9, 2020


    In life most of the time we have situations where average person or for that matter even kids know what is right and what is wrong. Even when child is caught with his hand in cookie jar , he tells mom that he was getting the cookies for mom. So we all know most of the time and there are some situations where the situation is not clear  and one could go either way and both things may be right. We in medicine have certain situations where we could go either way and will be considered right. Just to give an example, one at certain time in our life can decide not to go on respirator  and some may want to do it even with the odds against the survival and we can not fault the decision . I came across such a situation recently . 

     I was asked to see a patient in office for abnormal CT scan . I was told my office that there was a patient who had lung mass per primary physician and they wanted me to see him soon. So I saw the patient soon He was 89 years old male who had not smoked for 40 years. He had dementia  and so the family wanted to put him in day care for day time  and the center needed  chest X- ray  and it was abnormal. So the primary care did CT scan and that showed a mass and so he was sent to me . 

  When I talked to the family - the wife and daughter , the patient did not answer any questions  and he could not tell me the day or the month and also the name of the US president . He had bladder cancer many years ago and he had no pulmonary complaints He looked very comfortable  and had no idea as to what  was going on and why he was in my office. I reviewed the CT scan and talked to the family. He had what looked like cancer . As his bladder cancer was many years ago I felt that this was likely to be due to cancer of lung . So I told them that we normally like to answer 3 questions  Is it cancer , Has it spread  and What is the treatment choice. So I asked them as to what would be the choice of treatment . I told that  I don't think he would be a candidate for surgery due to dementia and age even though the stage of the cancer was resectable. The chemo would be very bad  and should not be considered. So the only treatment  that could be considered would be radiation . I   i also told them that DOING NOTHING would be also an option  and that may not be bad idea as with his dementia, not much could be changed and he was 89 years old . So the good patient and physician could do PET SCAN and offer radiation and good physician and patient or family could consider no treatment and no work up. Either way is right  and wrong 

Sunday, September 27, 2020


     The health care is changing for many years . We used to have family doctors and primary care doctors used to take care of the patients in offices and also in hospitals and also 'answered' to the questions  and treated minor element on phone after hours . But that all ended with HMO - the so called Health Care Maintenance organization that in my opinion decreased the quality of medical care  and also reduced income for many and most physicians  and made money for 3 piece suits - the so called management of theses HMO. Now the dust has settled on that change  and we have gotten used to the change  and have accepted the obstacles that ordinary physicians have to face due to rules and regulations -that are primarily meant for reducing cost and not helping any patients,-we are seeing another problem . This has been brought to surface more due to COVID. This is aging population. So that brings me to today's patients . 

     I was asked to see 2 different patients - happened to be in 2 rooms next to each other . One was 91 years old and other was 02 years old . Bothe of them were awake, alert and orientated . They both had a fall and that was not related to any black out spell or dizziness or anything unusual in the house. They both had rib fractures on right side. Fortunately they did not have much fluid or blood related to rib fractures  and had no puncture of the lung. They were admitted  and I saw them . They were pretty much with the program  and they were not in any respiratory distress. Their oxygen level was normal. So I spoke to the families and told them that we will watch them for a day or so and ask them to take deep breath and that will prevent collection of secretions  and then that can lead to pneumonia. The body does not do anything that causes pain and so with rib fracture of ribs, the patient automatically takes shallow breaths as deeper breaths will cause pain. But this shallow breathing and not coughing as coughing also causes pain , will lead to secretions not being cleared and then getting infected  and that causes pneumonia . So all that we as physicians do is to give pain medicines  and ask patients to take deep breaths every hour or so. So as per my plan they should be ready for discharge in 24- at the most 48 hours. 

     But as it happens the things don't work out as we like it to. The patients did well . The pain control was good  and the oxygen continued to be good breathing room air  and they did get out of bed and walked with physical therapy. So in my estimate they were ready for the discharge. But the problem was with the age. Both the families felt that they could not go to their prehospitalization level of living. They needed more physical therapy. So they had to be discharged to physical therapy unit. So now comes the COVID problem. We had to have COVID test done  and that has to ne negative . One family did not like one unit that was approved on her HMO insurance  and so we had to look for another one.So what could have been treated as out patient in younger patient, needed hospitalization. What I thought will be only 1 or 2 days became 5 days in one  and 6 days in other. 

Saturday, September 19, 2020


         I have been in medical practice for many years and I did practice medicine when the family practice physicians did go and see patients in hospitals. Then the HMO insurances under misguided thought process decided that 'employing' some physicians who do not have office practice  and do only hospital practice can 'save money' -the sole goal of Insurance company. I still remember that the family doctors complained about this  and then the insurance company decided to 'allow' these physicians to see patients while they were in hospitals , but they will mot be paid. Now you tell me who would see the patients manage  and take risk  and not get paid . So they stopped seeing their own known patients in hospitals a nd thet lead to crop of new group of physicians called hospitalist. This is suppose to help health care. In my view they have added NO BETTER CARE  and have increased EXPENSE. But I am not writing this blog for my view but want to tell about everyday problems that people like me face as consultant. So let me give stories of 2 different patients.

    I have known this patient for long time  and he had sleep apneas and I used to see him every 6 months . When he came to me last time, I was talking to him and realized that he had diverticular abscess - collection of pus due to infection in colon . He had no lung issues  and I admitted him and did work up and got him started on treatment and drained abscess and he was seen by people that could manage this condition- surgeon, infection specialist. He was discharged  and I did not want to see him as his problem was not related to my specialty .By the way he had seen gastroenterologist before I had seen him and decided to hospitalize him. 

     I had forgotten about him  and then the wife called me  and wanted to know if I was out of town as I did not see him. I called her and found out that after the discharge , he was OK  and then in 3 weeks he had seen infection specialist  and he did new CT scan of belly and that showed clot in lungs and so he was admitted . So this time he had LUNG PROBLEM  and he was admitted by hospitalist  and I did not get notified or called to see him. He was discharged  and the patient and the wife had lots of questions like why did he get it . how long the treatment  and the time gap between his CT scan of abdomen and the then the hospitalization. I had no answer as I had not seen him and I had to check the hospital computer  and with the modern day computer generated notes I had hard time getting the information . So I had spent time to get information that was very difficult to get and may not be 100% correct. The hospital doctor - THE HOSPITALIST are not seeing him and have no office  and they can not be approached by this patient, so it becomes responsibility for people like me who have to reconstruct the story based on someone else notes. In this case it was not that difficult but in my other patient I have gotten 6 phone calls on 3 different days for the questions related to hospitlazation when I was not consulted . 

Sunday, September 6, 2020


       The modern day medicine is complicated.The things were simple when we used stethoscope and did not have Ct scan, PET SCAN  and many more cardiac tests  and so on.In the past we used to diagnose cancer and there were limited therapy and we did it. Now a days we have tumor markers  and specific chemo for different types of markers  and mutation and so we need more tissue to diagnose  and then we use different treatments . I do believe that the treatments are more specific for particular type of cancer  and certainly that is much better . But how much it has changed the final outcome is to be seen. ( I know that patients are living longer for sure but not sure how much longer NOW with inoperable cancer than they did in PAST) That brings me to the story for today. 

     I had seen this male patient may be 16 months ago.He had chest pain and he was worked up  and I  saw him and  my work up showed that he had cancer of the lung. Based on the PET SCAN and other things he was thought to be not operable candidate  and I would not go in to the details of the reasons why he was not operable. But he was sent to radiation doctor and also oncologist.He was treated  and he did OK . He did not see me for almost a year . Then he showed up as he was short of breath. I asked him as to what was the status of his cancer . He told me that the doctors have told him it is gone. I had hard time believing that as he had fairly large tumor and the chance that he would be cured was small. But he and his wife were convinced that he had no cancer now. I did the work up and treatments . He had wheezing and so I started him on steroids  and also inhalers  and neb. treatments. I also asked him as to when was the last CT SCAN or Pet scan and he had last CT scan 5 or 6 months ago. So I decided to do new CT scan. He came for the follow up and he was feeling much better , still some shortness of breath, but much better . I had also tested oxygen level and he was started on oxygen and overall he was better .But the CT scan had shown that the mass  had grown . So he had mass or cancer when I saw him and then he had treatment  and the new scan had shown the mass to be smaller . Now the new scan showed it to be bigger . I told him to see the cancer doctors  and did not do any new biopsy. He went to see them  and then he had an episode of coughing up blood . It was small amount  and cleared without any treatment. The radiation doctor called me and wanted me to do bronchoscopy. I did it and he had significant abnormality but that I thought was due to radiation and may be treatment. I did do biopsy and all came back negative for the cancer . But the SCAN was  definitely showing increasing in mass.

   He came to me for follow up  and I told him that even though the biopsy was not showing cancer, I was convinced that he had recurrence of the cancer. Certainly most of the time people don/t want to believe that they have recurrence without the proof. For me the increase in  size of the mass was indicative of the cancer and in this patient who had inoperable cancer, this was easy to see.He went to his cancer doctors  and they wanted more proof . With radiation given to the area where the cancer was diagnosed, the needle biopsy may not get tissue as there will be changes related to radiation and so we may not get the diagnosis by such biopsy. The open biopsy in my mind is futile as the surgery is not curative surgery and will not add to the treatment of cancer. So I would consider treatment for the cancer which was treated  and not taken out, under presumption of recurrence . 


Sunday, August 30, 2020


   In medicine we have seen many a times the sorrow  and the grief and sometimes some or all doctors feel that they help patients to relieve them in their miseries. I also feel that we do certain things to help alleviate the pain and suffering. But sometimes the problems are profound and sometimes simple . Someone with stage 4 cancer wants to beat it  and we know in our heart that that is not likely to happen, but we understand the request  and know that this is VERY difficult to fulfill .But sometimes we have very simple request and we still find it difficult to fulfill it. This brings me to the today's story. 

    I saw this patient who was a 78 years old female. She was diagnosed to have pneumonia  and so I was consulted . When I went to see her ,she was somewhat cachectic patient who was in bed. her caregiver was with her . She was looking good  and not sick and she also had her facial make up well done even though she was in hospital. I asked her some questions  and then the care giver told me that she can not talk and she can understand  and she will answer the questions with her PHONE. She could not write on paper . She was not a smoker  and she had not had any history of excessive alcohol intake. She was diagnosed to have ALS - also known as LOU GEHRIG'S disease.This is neurological disease  and there is slow or sometimes rapid progression of muscle weakness  and it disables the person. She had that and she was unable to do much and she had electric scooter  and also a wheel chair  and has kept up some motility . But the disease affected her jaw muscles and she could not  talk  and also could not swallow. So she had feeding tube inserted directly in stomach called PEG.She had taken water  and then she started with cough and so she had aspirated . So she had shortness of breath and she came to ER  and then chest X- ray wa done  and that showed that she had pneumonia. 

    She was comfortable  and did not need  oxygen supplementation and she had no shortness of breath and no fever.I had seen the chest X- ray and other tests  and she seems to be stable. She answered my questions on phone texting - writing  and the care giver was also giving me most of the answers. I examined her  and told them the aspiration  and also the precautions  and she also had hiatal hernia  and so I told them all the precautions that she needs to follow . Certainly she can not have any thing to eat . As usual I asked them if they had any questions . The care giver and the lady communicated with her very well even though she could not talk and so she told me that patient had a question. The patient could not talk and so she had to write on her phone  and it took some time . She showed me the phone -she had written 'CAN I HAVE A SIP OF WATER ?'

    A simple request  and I was not sure if I could grant it . I had big explanation and told her that she could take a 'chance' by doing it and she may have aspiration and pneumonia . But I did compromise .I told her that she can have a small ice cube on and off . My thought being that the ice will dissolve slowly and the amount of water that is in her mouth would be so small that it will  not cause problem..

Such a simple request and such a complicated answer!!  

Sunday, August 23, 2020


    All of us know that when there is birth,there is death.Anyone who is born, will die. But inspite of knowing this we all are not only prepared for it nor we want to accept it. I was listening to Swami Sarvapriyanand, he is in charge of hermitage in NY,when he narrated a story where this man complains to Lord of Death , that he never was given warning about death approaching. The Lord of Death answered that what do you think was the meaning of thinning hair line  and gray hair  and loss of teeth and wrinkles and sagging skin  and many other things that we notice  and ignore. I find the same thing in my medical practice. And I am not blaming anyone , but I feel that WE are never ready or accept it. My father dies at age of 88 years of age 11 years ago  and he was never sick before his last sickness, i was not prepared for it  and sometimes even today I think of him  and miss him. So I know this is common to all of us . That brings me to the story for today. 

     I have known this patient for many years . He was 78 years old male and he was morbidly obese and had COPD  and also sleep apnea.He came to me  and the work up showed that he had COPD  and OSA, and he had heart problem and high blood pressure. He also had congestive heart failure . I treated him and he was fine . He was very limited in his activity and he basically stayed home  and was taken care by his wife. He would walk in house to eat and take shower  and go to bathroom but no other physical activity and over period of years that I followed he got slowly worse. He was on oxygen  and then the need for oxygen increased  and then he needed 4-5 L oxygen all the time  and in spite of using oxygen, he was short of breath. I do chest X- ray every year and when I did X- ray  I saw a density that was not there in past X- ray. So I did CT SCAN of the chest  and that showed a mass . This was highly suspicious for lung cancer. I ordered PET scan  and that showed high uptake in the mass . His overall status was such that we could not do any invasive test and my feeling was if we get the biopsy positive for cancer we will treat it as cancer and if I am unable to get adequate tissue to get diagnosis of cancer I will still like to treat him for cancer . So I sent him to radiation doctor  and they agreed and gave him radiation under the diagnosis of cancer based on all the tests. 

     He did OK  and continued to live his usual life style. He had gained some more weight and also had swelling of feet.But otherwise he was fine. We did new CT SCAN and the cancer was improved  and there was small amount of scar tissue where there was cancer. Then I got a call that he was in ICU. He had confusion and altered mental status  and so family took him to ER  and he was admitted to ICU as he had elevated carbon di oxide. (The function of the lung is to take in oxygen and wash out or get rid of CO21 In lung disease early stages the oxygen and CO2 are normal , then oxygen drops  and patient need oxygen but CO2 is normal  and in advanced stages CO2 also goes up)The CO2 was so high that he had to be put on noninvasive respirator. He continued to be non responsive to verbal stimuli. The usual treatment was carried out and he did improve somewhat. I spoke to his family some of whom were in medical field , and tried to make him DNR as to me his prognosis was very poor with all the medical conditions  and also obesity and cancer of the lung and heart and lung problem and he would not have very productive life. . 

   It was difficult for his wife to accept it even though she lived with him and he had not done much physically in last 2 years . He finally was made DNR  and then I called Hospice . We still continue to have discussions  and then after 3 more days they agreed for Hospice - comfort care . 


Sunday, August 16, 2020


   Withe COVID 19 , we have been doing telemedicine  and all the insurance companies are paying for it. I have often wondered as to the value of it. In certain cases this works fine , but then a telephone call that I make daily to many patients is not any different than doing telemedicine follow up that we are allowed and encouraged and get paid. I am not sure what is achieved by a cardiology nurse practitioner  calling patient for blood pressure follow up when she is or he is going to depend upon blood pressure reading done by patient at home or in a pharmacy. One could easily do same thing with simple phone call and then insurance companies would not pay for same call and same advice that was given . But now under the name of Telemedicine ,they will pay! I can understand follow up for sleep apnea as all that I see is compliance data  and that I can obtain from computer and ask patient on any problems related to mask or pressure.So that is required and there is not much more needed as physical examination. But I came across a patient  and that is the story for today. 

   I sa this patient may be 2 years ago and he has  had abnormal chest x- ray. He was smoker  and had quit many years ago . As usual I di the work up and he had PET SCAN and bronchoscopy and then breathing test  and then the suspicion  for cancer was very high and so I sent him to chest surgeon. He did not come back to me . He had surgery and it was cancer and he had part of the lung taken out and he also saw oncologist and no chemotherapy was needed. His son called me one day stating that he had coughed up blood  and he has he was afraid to go to ER and also worried to come to office. I had not seen him for 1 year and I was not sure as what had happened since I sent him to the surgeon. So I convinced him to come to office  and then did CT scan . The CT scan was OK  and there were no new lesions  and then I did bronchoscopy and I did not see any lesion and his coughing of the blood had stopped after first day and there was no evidence of any new or recurrent cancer. He has been followed by oncologist and they had done some scans too. So when he came for follow up after all the tests were done,, and it was not telemedicne follow up, i talked to him and the son. He was doing OK . He had sore tongue  and we had given him antibiotics  and I thought he may have had thrush. But I decided to look inside the mouth and I saw something. He had a lesion on his tongue. This was way at the back of the one side of the tongue.. If one had causal look he would miss it as it was on the side of the tongue  and at the back part. I told them that I am concerned about cancer of the tongue. I know how medicine works and so I called the PCP  and told that he must see ENT doctor ASAP. 

    He saw the ENT doctor  and had biopsy of the lesion  and it is cancer of the tongue. 

   I could not have detected this with TELEMEDICINE FOLLOW UP !

Saturday, August 8, 2020


      We often talk about evidence based medicine. I am in practice for many years  and I can tell that in medicine many a times we make decisions based on GUT FEELING. The medical societies often talk about this as clear cut and the people in Ivory Tower of medicine have no understanding as to how in medicine we have to make a decision.In my mind current COVID treatment is in same situation. When I looked at it last more than 20 different treatments were tried  and some with claimed success. One example is Hydroxychloroquine. But I am not talking about COVID in this article. 

   I saw this 72 years old lady many years ago and she had been smoker and she had COPD , She was seen and followed by her PCP  and she  when she had chest X- ray  and that was abnormal she was sent to hospital. We did the work up and she had advanced COPD due to smoking - the damage that happens due to smoking  and she needed oxygen 24/7  and she also had a cavity in the upper lobe  and that happened to be atypical TB . I started her on medicines for COPD  and oxygen and also treatment for the MAC or atypical TB. She did well and she improved  and I did see her for about a year. Her CT scan showed improvement  and she had no new complaints . She then was admitted with shortness of breath and so she was in hospital. I saw her, As expected she was admitted as COPD WORSENING. I had hard time believing that she had COPD worsening  and I was worried that this time it may be heart. So I did a ultrasound of the heart - echo cardiogram. It showed that her heart function was reduced.So I went with my GUT FEELING and that was correct at least I thought I was . We did treat her for both- COPD  and HEART PROBLEM  and she did improve. She was discharged. But before she was sent home, she had seen a cardiologist and she had stress test  and that was normal. 

    She did OK  and then she had an episode of shortness of breath that woke her up  and she was in ER  and as expected the ER physician told the family that she has pneumonia. She had no fever and the episode was somewhat sudden. She had no history suggestive of respiratory infection - not much cough and no sputum and the white cell count was normal. The chest X- ray did show some infiltrates or congestion. Knowing the history , I decided to treat her for heart problem . When the heart does not pump blood out normally, then the water backs up in lungs  and the Lungs which are like dry sponge becomes like sponge filled with water and then patient can not breath as the lungs are heavy. So I started her on water pill and she did improve in less than 24 hrs. The stress test had shown normal heart function, but in my GUT FEELING on both occasions this was HEART  and not LUNGS as the cause of her problems and the evidence based medicine would have suggested this as was COPD  and not heart problem. So I often respect Gut Feeling . By the way I did give her antibiotics for 2 days till I was sure that she had congestive heart failure. 

Saturday, July 25, 2020


    I  wrote in my past blog about how the lung transplant is not like fixing hernia or taking a mole out. It is not a 'cure' by any stretch of imagination when we talk about Lung transplant.But there is more to lung transplant than just getting a match. The kidney or renal transplant is done much more commonly as the kidneys can be obtained even from cadaver or LIVE Donner. But for Lung transplant we need a match only from someone who is dying- but not dead. So who will get it is pure luck. In past we used to do both lungs  and for last more than 10 years or so we are doing single lung transplant . This helps in number of ways. Instead of one patient getting transplant, we have 2 patients getting it . In case of rejection, patient still has one of his own lung.But there are many problems  and issues.Weight or ideal weight is important . One can not be too heavy or too skinny .
    That brings me to the story of my patient for today. I have known this patient for more than 5 years . He was 60 years old male who was heavy and had shortness of breath. He was a smoker and had quit. But the smoking had done it's damage  and he had COPD - emphysema . He had shortness or breath and lots of cough and sputum . He was seen by me  and he was started on medications  and he did better. He continued to work . I had told him that part of the problem is his obesity. The shortness of breath can happen due to obesity and also deconditioning which happens due to lack of exercise. The part of the reduction of pulmonary reserve could be due to big belly and obesity. So weight loss was essential. But he did not loose much . Over period of time he got worse  and then he needed to be on oxygen . He continued to work as he had desk job and he could do it. I did new breathing and he was worse and so I did ask to to consider lung transplant evaluation. He agreed  and he did go and was evaluated by the Transplant physician. They told him that he was a good candidate , but it may take another 6 months or so for him to be perfect candidate or to be on active list . But that can happen only if he would loose 20- 25 lbs of weight, That amount of weight loss would not bring his weight to ideal body weight but that was essential per the transplant MD. The time passed  and he continued to get worse  and the shortness of breath was worse  and his need for oxygen went up . Instead of 2 L he needed 5 L oxygen . He did go back to the transplant group of physicians He had not lost a single LB but instead had gained . So then he did not go to them for 6 months. They told him that he has to loose some weight and they will see him again. I was doing follow up and he was admitted couple of times . Then I did routine yearly chest x- ray and that showed a spot on the lung . The suspicion for cancer was high and so I did PET SCAN  and that was positive  and so he most likely had cancer of the lung , He was not a candidate for any surgical intervention. I did needle biopsy and so I send him for radiation  and then oncologist . 
     The transplant was out of question and he has not lost any weight  and has continued to gain some with not much physical activity. 
   The question that bothers me is that if he has a lung transplant what would have happened. If he had transplanted the lung that developed the cancer , he would not have cancer now  and if it was the other lung -- then the transplant would have been wasted ???

Sunday, July 19, 2020


    We often have situations when we are told that one is too early or too late. Many a time when the diagnosis of cancer is done , we sometimes have to say it is too late. But sometimes I h seen patients, I have to say either too early or too late. I have recently 3-4 patients that this has happened  and the problem is that it is not anybody's fault. If there is some it is bad luck . 
      I had seen this patient for last few years . When I saw him for the first he was smoker and he had quit.. He had exertional shortness of breath and he came to me  and he had COPD. the lung disease that is caused by smoking . By then he had quit smoking for few years  and so i did the work up. He had the  medications started  and I did do a CT SCAN  and he had a bleb or bullous. The damage to lung tissue can cause  a blister or like a grape area which has not much going to that area  and that causes problem. If it is larger then it can press on normal lung tissue  and that can lead to more shortness of breath. So the CT scan did confirm a larger bleb and I thought that if we can get it cut , it would help the remaining lung to expand  and that may help the breathing problem. Certainly there  was a risk in surgery  and it may not help also. But if that bleb would rupture, it would cause collapse of the lung and more issues which would have to be dealt as emergency.He wanted to get a second opinion and so he went to Mayo clinic  and they did agree that that needed to be taken care  and they also found out some opening in the septum of the heart's upper chamber  and they felt that that needed to be  closed  and so they did that and then he had the bullectomy. He did very well and the shortness of the breath was better. He continued to work and saw me periodically.
        About 3 years ago, he started having problem and then we did additional work up . He  had new tests  and his breathing test was getting worse  and that decline was noted  and so I did adjust the medications  and he had also gained some weight and so i also did the sleep study and also asked him to see cardiologist. He had sleep apnea  and he was started on CPAP  and he did better . He also joined gym and some diet and did better. The cardiology work up was OK  and he lost some weight and was doing better. He was also sent to Lung Transplant evaluation and they felt he was bad but not bad enough to have lung transplant and so they decided to watch him . For last 6 months or more he had done follow up with me  and also heart doctor and also lung transplant . He continued to get worse  and then my work up showed some infections  and so we did treat him . I had done few CT scans  and did also bronchoscopies . The some of the unusual infections were treated by Infection specialist  and that was going on for 6-8 months  and he continued to be followed by all of us. He was felt to be a candidate for transplant , but may be little too early  and so he was just followed up. 
    He continued to have good  and bad days  and i saw him few times  and then I received a note from transplant doctor . The note stated that he had cardiac problem and taking it to account his age  and cardiac problem and other issues he will not be a good candidate for transplant and they were closing the file . I had not seen him recently and so I  called him  and came to know that he was in the hospital where I do  not go. So I pulled up his hospital records. He had more shortness of breath  and he saw cardiologist and they admitted him for high heart rate . They did the work up and his heart had worsened  and he had weak heart muscles  and they did start him on medications. He decided to see Mayo clinic  and they sent me a letter that he had too many problems including getting old  and he will not be good candidate for transplant . 
   So 3-4 years ago he was a good candidate but it was little too early , now he is not a good candidate as it is too late. I have seen this happen too many times I will write about other patients next time. 

Sunday, July 12, 2020


    I often see patients with abnormal CT scan or chest x- ray. I had written an article  titled Darwin,Mouse and Me . The article was related to the Theory of evolution proposed and accepted by scientific community  and how it is supported by genetics that we know today and was not known or thought about when Darwin proposed it . But I had some objections about as to WHY did evolution happened . So I stated certain genes  and mutation that happens in them which explained some of the diseases. But this mutation does not support the theory of Survival of Fittest  and Procreation as the causes given by Darwin . The mutation that causes the host to die soon like breast cancer gene BRCA1 and BRCA2 .So why would this mutation occur? I had suggested Law Of Karma as the possible explanation. The editor of the magazine that did published it had a question as to could be due to certain toxins that we get exposed to it. So the toxins do play the role in development of cancer  and now a days we are inundated with commercial by many layers on Talc exposure , Round up exposure , Zantac  and many other things that may have contributed to development of cancer. But why only some get it and not all develop cancer ?But that is not the point of the discussion. But this brings me to today's story.
    I saw this 72 years old male patient who had smoked 2 PPD for many years.He had some cough and some shortness of breath. He had chest X- ray done by PCP  and it was abnormal  and so he had CT scan and that showed a mass. So he was sent to me.He has been smoking  and also drinking 5-6 drinks a day He had clear lungs  and I told him the possibility of the cancer and the work up. We talked about the PET SCAN  and the biopsy and that included either bronchoscopy or needle biopsy or even open biopsy.He was not very agreeable. He was not very happy  and did not want too many tests.His concern was radiation exposure that according to him can cause cancer. I told him that radiation for chest x- ray is very low  and even CT scan has more radiation exposure but it is much less than the dose used to treat cancer. After discussion he agreed for PET SCAN  and that was positive and that did suggest high possibility of cancer. He was smoker and had a PET positive mass and so the chance of cancer was high. He did not want any more tests  and so after the discussion we decided to do new scan in 3-4 months He did not want it that soon  and so we agreed to do it in 5 months . He had new CT scan in 5 months  and to my surprised the mass had not grown but was slightly smaller.So he did not want to do anything . I told him that he still has possibility of cancer and biopsy was indicated to confirm or rule it out .He did not want it. He was more concerned about the radiation and that causing the cancer. He had not cut down on smoking or drinking alcohol. He was firm about not doing more CT scan. So we decided to do follow up in office in 6 months.
     He came back and he was feeling fine . I asked him on smoking and he had not reduced from 2 PPD  and no change in alcohol intake . He told me that he has smoked for more than 50 years  and it was very difficult . I asked him that is 50 years of smoking was not enough? After the talk he agreed to do the CT scan  and the CT scan was done  and to my surprise the CT scan showed significant reduction in the mass. He was happy . He did not come for follow up  and then after a year he came for the follow up .He was still smoking and drinking and had not worsened  and did not want CT scan  and still worried abut the radiation causing cancer and not worried about smoking causing cancer or drinking alcohol and it's side effects on body .
   He did not have cancer - at least as off today .

Sunday, July 5, 2020


   IN medicine ,we often get new tests  and many a times they are useful and sometimes create problems I had talked about a test in past called liquid biopsy. It was testing tumor DNA. This test is being used successfully in diagnosing recurrence and also the follow up of treatment . In the beginning this was started as early diagnosis of lung  and breast cancer with nodule. The problem that happens is what do you do when nodules are small or not there  and one finds tumor DNA , then what do you do ?The same that has happened to me in one of the patients that I see.
    There is a new test that was approved recently . It is for the diagnosis of lung cancer , But it is not for the diagnosis but to get a probability of cancer when someone has lung nodule.Now a days we have been doing more CT scans of the chest as there was screening Low dose radiation CT scan approved be medicare  and other insurances  and so we can do a CT scan in patients who are smokers or ex smokers for 14 years  and so on, . So there are calculators developed based on the size , location, smoking history  and age  and sex and type of nodule. Theses do not give any diagnosis of cancer ,but give the probability of cancer . They are used in making a decision  on further course of action. So a new test was added . So one calculates the probability based on the above mentioned criteria  and then blood test is added as additional factor in calculating the probability of the same
So I saw this patient who had quit smoking 30 years ago and had CT scan of chest She is 70 years old  and had not much pulmonary symptoms  and had some cough  and so during work up CT scan was done . She had some nodules  and one was 10 mm. This is minimal size for doing PET SCAN . So I did PET SCAN  and that was OK which means the nodule did not pick up glucose , which means it was not hyper metabolic. So I decided to watch it with CT scans . over period of time we did do new CT scans  and they were stable but the radiologist reported the size to be 8 or 9 mm instead of 10 mm . The last CT scan it was reported as increased by 1 mm. Just to clarify , 25 mm make  and inch . So this was very small  and I did not know what to say . So I did new PET scan and that did not show any glucose uptake.That was good but radiologist reported that slow growing cancer may not pick up on PET scan. But then I did the new blood test, The probability calculated based on all the factors before the blood test was done, For those who may be interested there is Mayo clinic calculator which you can google.After the blood test the PROBABILITY OF NODULE BEING CANCER INCREASED ALMOST DOUBLE. So now the problem
    She has not smoked for 30 years . The nodule is barely if at all increased by 1 mm in 10 months  and she has no symptoms . So what should be done . The bronchoscopy would not give diagnosis - which I have done . The needle biopsy may be attempted but with given size may not give the diagnosis. So should I do open biopsy ?
    So in this case it has created more questions than answers!

Saturday, June 20, 2020












Friday, June 19, 2020


  There is a saying that stitch in time saves none. If one does things in time then one does not have to worry about getting things worse. The saying is is related to clothes  but it also applies to our every action and every decision that we make or action that we do . It may be diabetes  and eating sugars or blood pressure  and salt intake. . If we do not do action in time  and the diabetes or blood pressure gets worse  and has complications , then acting in right way will not help us as much as if we would have taken precautions early. I have seen this in many patients and that brings me to today.s patient.
    I saw this patient who was 78 years old  and had some dementia . He came with family  and i could not figure out why he came to me . He had some abnormality , He was in hospital and he had pain the belly. He had CT scan of the belly done  and that showed some abnormality in lung and so had CT scan of the chest done  and that showed a very tiny nodule. He had seen primary care doctor  and he sent him to me . He had also seen Gastroenterology  and he was planning to do endoscopies . I had no reports  and I got them  and I was surprised He had very tiny nodule in lung  but had a mass in pancreas  and also in liver . The patient of the family did not know about it  and they were surprised . I explained it to them that he seems to have cancer that seems to have spread to liver and may be lung . The endoscopies will not help but he needs diagnosis of cancer by biopsy  and then we can decide as to the treatment . The Lung nodule was too small  and there was no way anybody could do biopsy of the nodule. So I decided to do the PET scan to know the extent of the cancer and scheduled him to have biopsy of the Liver
  He had the biopsy and that did confirm the diagnosis of cancer He had pancreatic cancer  and the biopsy did show that liver spread was confirmed . I saw them in office  and told them the diagnosis  and the treatment options of chemo . I also told them on chemotherapy and the side effects  and the 'prognosis' . I told them that the pancreatic cancer with spread to liver is not good news They decided to go ahead with chemo. I had told them to consider future choices  and also the poor prognosis  and DNR or Do Not Resuscitate status . Thew were not sure.
    He was admitted  in hospital  and he had received chemo and the blood counts were low . He had some pain and that was due to enlarging Liver metastasis.He was given pain medications  and that caused more confusion and I again talked to the familyb. I told them that in spite of treatment he was not doing well and the cancer had increased and they need to see the oncologist  and see they could consider radiation which has less side effects  and may be do no treatment ts .We also talked about the DNR .
    He was discharge  and then was readmitted  and it happened . I had expected it. He had cardiac arrest and they did CPR  and he had to be put on respirator  and also had rib fractures  and collapse of lung and had to have tube put in chest to re expand the lung. We had the discussion and they agrees after 3 days to make him partial DNR . Now the decision had to made to withdraw the machine - respirator . That was much more traumatic to his wife  and sons . But once someone is on respirator , we can not withdraw without doing the forms for withdrawal of LIFE SUPPORTS .
THIS IS I CALL STITCH IN TIME . If they had made the decision in advanced for DNR, we would ot have gone through he suffering for patient - the tubes , rib fractures, chest tube  and also the family to make the withdrawal decision . . 

Saturday, June 13, 2020


    When we look at the God or the so called Brahmam id described as all pervading, limitless omnipresent etc In the religious words, it has no limit from what is called DESH,-KAL,-VYAKTI -means space ,time and identification.As one can imagine everything anything that we know has space limitation , time limitation and specific identification limitation.But the God or Brahmam has none of these limitation.What is chair is not a pot is the last limitation.. In these days we feel the same about covid  and that brings me to the story of patient for today.
    I was called to see this 67 years old male for shortness of breath and a clot in lungs. He was a male patient who had no history of smoking or drinking alcohol and had history of well controlled high blood pressure. He had some calf pain few days ago and then on the day of admission. He used to walk 3 miles  and he started having shortness of the breath and so he decided to come to hospital. He also had right sided chest pain and he had then CT chest  and that showed large clot in the right lung and some on left side as well. He had history that his daughter had coagulation factor problem and she has significant clots  and was in ICU few years ago. So the siblings  and parents were tested  and he had same problem but he was not treated for the problem as he did not have any problem .So from the history of his own illness and the history of the coagulation problem  and also the ct chest it was clear that he had pulmonary embolism  and he had it most likely due to certain coagulation factor problem. He had no fever and no cough and no exposure to anybody with covid  and he had no symptoms of upper respiratory infection. So he really did not have anything to suggest COVID infection. But one of the things that we know is that in patients with covid , they do get blood clots . So automatically test for covid was ordered . This meant that he will be transferred to the floor where the hospital kept all covid and suspected covid patients . The test takes sometimes 2 days to get results . HE REFUSED. He did not want to be on covid ward while waiting for the results .
    So now the question came up as to what to do .We have been so much afraid of covid - rightly so in many instances that we are going overboard  and have lost all the common sense. I saw a cardiologist washing potato chips bag and a salad dressing single serving bag. So the covid is like God pervading all our actions  and seems to present every where !

Sunday, June 7, 2020


     The famous line from Hamlet, is not uncommonly experienced or can be applied in medicine, by both physicians and patients. Sometimes it is very easy to make decision and sometimes it is not so easy. If I see a patient with Asthma ,who has shortness of breath and wheezes, I have very easy decision. I must start him on certain treatment . The patient also has not much difficult decision . Sometimes I do see patients who do not like to take medicines  and feel if they avoid allergens or take allergy medicines, then they will not need prescription drugs. But majority of patients who have symptoms , it is very easy to start medications. But then we see patients where the decisions are not that simple,the question arises as to which path one should take it.Say I see some one with a mass or a spot on the lungs  and I feel we should do open lung biopsy or do surgery to take it out and find out if it is cancer. So for me this is easy if I think the chance of cancer is high. But for patient it may be not that easy . This is a major decision as it involves major surgery and it may not turn out to be cancer after surgery.So in some cases decision is simple for physician and and patients  and in some cases easy for physician and not so for patient . The third possibility is where it is difficult for patient and physician also.So that brings me to the case for today.
     I had seen this 69 years old patient with spot on the lung . As usual we did the work up. The bronchoscopy was negative to get the diagnosis  and the PET SCAN did show that the spot was hot or had increased uptake suggestion cancer. The Pulmonary Function Test or the breathing test did show that she had good reserve to cut out out part of the lung. So I suggested seeing surgeon and she did see one  and he also told her to do the surgery and so she had surgery and indeed it was cancer of the lung. So as one can see I  suggested surgery - easy for me , the patient did agree for the surgery - some what easy -may be not as easy for her as was for me , but not very difficult. The surgery though did show that some of the lymph nodes were positive for spread of cancer. So I suggested doing radiation . The cancer spread to lymph nodes increases the chance of recurrence  and so I suggested it  and it was easy for me based on the data that I know. She did see the radiation doctor  and she got radiation . Again somewhat easy for patient to accept or make the decision. I had also told her to see medical oncologist.I wanted to know if in addition to giving radiation to kill some cancer cells that may have been left in some of the lymph nodes,if there was a need for chemotherapy. Here comes the difficult decision. The oncologist saw her  and suggested her to get in a TRIAL'She called me . The trial of new drugs is done when we do not have 100% evidence of benefit of using the drug . So this is a investigation to see if the medicine will help to reduce incidence or recurrence. In this trial, some patients will get the new medicine that is being tested to see if it works  and other patients will get NO MEDICINE OR SO CALLED PLACEBO . So the patient called me to know what she should do. In this case the decision is very - very difficult for me  and also for the patient as we will not know if patient is getting the drug or placebo I am not sure if the oncologist will know it or not - as is the case in some of the double blind studies (where both patient and physicians do not know to avoid having any bias).
     I don't know . WHAT DO YOU THINK YOU WOULD DO ?

Sunday, May 31, 2020


    In medicine we are often faced with diagnostic dilemma.We see patients  and many are simple  and routine . But then we come across some of the patients,that trigger our thought process and puts our medical knowledge to test. We do more tests  and also do some explanations  and try to get to the diagnosis . But sometimes I wonder if it really matters in certain cases. I have heard that there a professor in NY that seeks advice from allover world in case of very unusual cases  and then she is able to help get the diagnosis. But I am not talking about that kind of diagnostic problem. I am talking about something else.We may do tests  and find out something that may give us the diagnosis  and there may be no answer as far as treatment is concerned or may not make difference in out come or life.
    This brings me to the today's case. I saw this lady in my office may be 8 months ago. She was a 68 years old female who was smoker  and was admitted with shortness of breath and then was diagnosed to have pneumonia . The work up was done with CT scan and then bronchoscopy and that showed that she had COPD  and also cancer of the lung.. The further work up was done  and she had spread of the lung cancer to bones  and her left hip was affected . She saw me  on office after the discharge . I don't recollect why she came to me  and not do the follow up with the lung specialist who did see her in the hospital. But any way I did not have much to do . She did breathing test in my office  and I started her on some inhaler for COPD.I had extensive discussion with her son and her  and told them that she will need Radiation treatment to the hip for cancer spread as otherwise she might get fracture  and pain . She had been seen by oncologist and she had not seen radiation doctor  and I managed to get that done . So she was treated by oncologist and also radiation  doctor  and she was treated with chemotherapy and radiation to lungs  and also to hip.
   I saw her in office may be 2 more times  and then she was admitted to hospital for pain in the leg and hip . So she was seen by me in the hospital. She had a blood clot in the left leg  and she had further work up by oncologist and she has fracture of hip. Just to mention here the incidence of blood clot is much higher in patient with any kind of cancer. and that is due to blood clotting too quickly in patients with cancer.So she had clot and we started her on treatment for it . During the work up she was found to have mass in kidney. As per report the the mass was there in past and the oncologist was aware of it . But the mass had grown to much larger size in spite of treatment for lung cancer and so the possibility of kidney cancer was there . She had hip fracture  and clot in the same leg . So the oncologist ordered the biopsy of the bone . This was the same area that had shown spread of cancer in previous tests but it was not confirmed by biopsy. It was also the same area where the radiation was given . The biopsy was done  and that came back with 'no diagnosis' .
      So now we have this patient who has lung cancer  and spread to bones  and had treatment with chemo and radiation  and also now has enlarging kidney mass  and fracture of hip due t cancer and clot in leg due to cancer  and immobility and also has new mass in lungs  and has COPD. Due to the previous radiation to hip we are very limited in giving her more radiation to the hip , so she can not do much or any walking  and we still do not have the diagnosis of kidney mass .
    But does it really matter on long term prognosis ? We could do biopsy of kidney though we do not do it normally due to fear of spread of spread with biopsy . She has new lung abnormality and also rest of the problems - and all of this in spite of the treatment with chemo. and radiation . So it appears that the prognosis is poor even if we get diagnosis of second cancer - that of kidney  and or spread of lung cancer  and the quality is poor as she can not walk due to pain and fracture  and our options of treatment of the fracture are very limited due to previous radiation given to the same area.
   DOE IT REALLY MATTER weather we get the diagnosis or not ?

Saturday, May 23, 2020


     In our life we say this not too infrequently. We apply for a job  and the interview goes well and then we have second interview  and then we get rejected  and we are back to square one .Sometimes people date  and things are going well and then there is engagement and then they break up , again back to square one . In medicine we also see this sometimes . After extensive work up we are still at same level of confusion or state as we were before the work up. This brings me to today's patient.
   I had a call from a cardiologist requesting to see one of his patients . She was 71 years old female  and has progressive shortness of breath, He saw her  and the cardiac work up and the heart was 'fine' . She was also seen by a lung specialist for 3 years  and was told that she had some damaged bronchi and may be COPD . She was started on medications  and she was not getting any better . She had 3 CT scans  and several pulmonary functions studies . At one time the cardiologist thought of a condition of Polymyalgia rheumatica, and started her on steroids  and had her see specialist - rheumatologist , Some additional tests were done  and the steroids were continued with weaning schedule for the steroid dose. She had gained weight due to steroids  and she was still short of breath  and also needed some oxygen . She came to see me with her husband .Their frustration was that they did not know the diagnosis  and she was not better and may be worse . She was now on oxygen that she did ot have a year ago .They had all the records from previous pulmonalogist - This is very unusual -most patients come with no records  and then I have to request them . So I reviewed the records .
        I saw the CT scan reports  and the notes  and the lung function data . She had several of them . The Ct scan had mentioned some scars  and also the breathing test had shown that the mechanical function of the lungs - taking breath in and forcing it out - was almost normal -about 80 % -Nothing to suggest ASTHMA or COPD , but the diffusion - how oxygen is transferred from air sacks to blood - was markedly reduced  and also it had gotten worse in last 6 months . No wonder she needed oxygen supplementation. I though of 2 conditions - one where ver tiny bronchi get inflammation and get clogged up called Bronchiolitis Oblitarance  or Pulmonary Fibrosis.
    I did a High Resolution CT scan  and that did show FIBROSIS . So I told her that we could start her on medications which will help . It does not CURE nor does it PREVENT PROGRESSION , BUT IT REDUCES RATE OF PROGRESSION .I alos told her that only way to get exact diagnosis was to do OPEN LUNG BIOPSY.
  They wanted to know the diagnosis . So I sent her to a surgeon and she had biopsy. The biopsy showed that she had fibrosis , but the local pathologist sent the specimen to Mayo clinic for opinion
I had a call from Mayo clinic pathologist as he was not too sure on the diagnosis  and wanted to KNOW THE CLINICAL PICTURE . So I spoke to him in great detail describing him the CT scans  and the Pulmonary Function tests  and also the other problems . After the discussion he concluded that MOST LIKELY SHE HAS FIBROSIS OF UNKNOWN CAUSE  and so from my stand point the treatment would be what we had prescribed  and got on hold due to the open biopsy.
                        SO WE ARE BACK TO SQUARE ONE !!

Friday, May 15, 2020


    In medicine,we often write a diagnosis as RULE OUT --THIS OR THAT . This means we suspect but do not have proof for it.The unfortunate problem with this system is that we can not order a test to RULE OUT  any particular diagnosis.So if I see a patient with a mass  and has all the tests pointing to cancer on CT scan, I can not say that it is cancer of the lung. So I would say RULE OUT CANCER.But I can not order say PET SCAN without writing the diagnosis as CANCER OF LUNG.
But sometimes we know that it is not Cancer  and we want to prove that it is not  and so we order tests . Our ordering tests are based on our CLINICAL SENSE  and possibility and probability of various diagnosis. This brings me to today''s patient.
     I saw this patient , who had moved to our area. She was 68 years patient who had smoked many years ago . She had no major problems but has minimal cough . She had history of sarcoma in past and she was followed by family physician in her place . She had seen cancer specialist few times after the sarcoma was operated , but she was stable  and so she was followed by family doctor. .She came here  and she came to see me . She had Ct scan done by her doctor here  and that was abnormal and sp she came to me She had no chest pain , fever, cough or shortness of breath.
   The CT SCAN showed some swollen lymph nodes in chest  and tiny nodules. I could not get any old records and she felt that she never had old CT scan of chest.She had no pulmonary problems  and so I talked to her. If the lymph nodes were due to cancer , that is not a surgically curable state .The lymph nodes are enlarged due to cancer of lymph nodes like Lymphoma or may be due to a SPREAD of Cancer  and so in any case that is not surgically resectable or curable state . The lymph nodes get enlarged due to infection or cancer.She had no constitutional symptoms and so I decided to do follow up CT scan . She had come to me almost 6 weeks after the ct scan and so I told her to get old CT scan and do follow up CT scan in 3 months . If the nodes were due to inflammation, they should improve  and if not better , we will do biopsy .
    She had new ct scan  and she did not show any change in Lymph or nodules in lung . In normal situation , when no change has occurred, we tend to conclude that that is less likely to be cancer , though 3 months is not long enough and so tend to do follow up CT scan again . In her case she had history of sarcoma  and sometimes it can come back after long time.She was concerned  and she WANTED TO KNOW as to the cause . I told her that sometimes in a condition called sarcoid , we may have swollen lymph nodes  and nodules in lungs . But she wanted to know . In this case I had to get a biopsy .I had 2 options , one was to do Biopsy through bronchoscope  and ultrasound guidance or have surgeon to do biopsy . The sample obtained with bronchoscope  and ultrasound - called EBUS  are very small and they may not be 100% diagnostic . So I decided to have her see thoracic surgeon. She needed definate diagnosis  and even though my level of SUSPICION WAS LOW , I sent her to surgeon .So when I suspect Cancer I call it do biopsy to RULE IN , this time it was to truly RULU OUTE

Saturday, May 2, 2020


    All of us know what are the common signs or symptoms of early cancer.Some of warning signs of caner are described by cancer society or  many other institutions. So we know that persistent cough, non healing ulcer in the mouth unexplained weight loss etc are well known to doctors  and even to common public. But some other symptoms are not so well known  and some doctors may not know about it . Sometimes they are treatable  and sometimes they are not and the treatment of cancer it self will be the treatment for them. So these are called 'para-neoplastic syndrome'. They are thought to be related to certain chemicals that the cancer cells secret and their effects on body.I have seen this few times  and my last patient had it.
    So I saw this 60 years old male patient who had persistent  cough and he started loosing weight. He do=id not go to doctor for 3 months  and then when he had lost 30 lbs of weight, he decided to .go a doctor. He had been smoker  and had  had continued to smoke.He had chest x- ray done  and then a CT scan . The chest X- ray showed collapse of left lower lobe  and he had mass in middle of left lung and had some fluid around his left lung . So all the signs were that of Lung Cancer. He came to me , but he had also been sent to cancer specialist and also radiation doctors. But they can  not do anything until the diagnosis is established. I saw him in office . He was a very tall guy and he had lost so much weight that he was weak and had difficulty walking and so he came in a wheel chair . He also had clubbing of nail - changes in nails where the curvature of nails changes  and there is some thickening of skin at nail bed. This change happens in any chronic lung conditions ,but now a days we do not see it often as we have antibiotics  and the diseases that used to be chronic get treated quickly.He had muscle weakness . and also had clubbing and weight loss. He then had PET SCAN  nd that was positive for high uptake in left middle part and so there was high chance of cancer.

   So I did do bronchoscopy  and he had a mass obstructing left main bronchus .It was friable  and I did do biopsy and it came back for suspicious cancer. So I did not have definitive diagnosis  and he was not a surgical candidate  ad so we did needle biopsy and that did give us the diagnosis.He was started on treatments .
     I saw him in office . He had weakness  and also clubbing and also low blood count  and also had LOW sodium . I discussed with him on the para neoplastic syndrome. He HAD  WEIGHT, which is due to chemical secreted by cancer. This one called Cachectin - though no such chemical had been identified . But it cause weight loss. He had ANEMIA   and that is well known  and that is also Indirect effect of cancer. He also had low sodium  and that is due to a hormone secreted by tumor ,which is like hormone called ADH. and lastly is the clubbing which is due to any chronic pulmonary disease. And some patients have elevated calcium  again due to cancer. These  and some other that are not related  directly due to cancer but indirectly from some chemical secretion .