Friday, March 27, 2020


      I have talked about the aging population in past. We in medicine  and also in society seeing the older or aging patients. I have at one time seen 3 patients in the hospital who were over 90 years old. So my last one was on over 90 patient. This one is similar to that one , but little more complicated and not as clear cut in some  cases. This is going to be an issue in future  and we will have think deeply.
   I saw this patient almost 93 years old . He had persistent cough and also has been treated with medications like antibiotics  and cough medications . He continued to have cough and he came to me sent by one of my other 89 years old patient. He was nonsmoker and had no fever and no shortness of breath. He had not lost any weight and the cough was there for more than 4-6 weeks. He was comfortable  and came to my office with his girl friend . He came walking in my office  and  he looked much younger than his stated age. He had no memory problem and no major issues other than some circulation problem that he had few years ago . He was on very minimal medications. He had good appetite  and he had no other problems. So I talked to him on common causes of chronic cough in nonsmoker . These are asthma . allergies and re flux of acid from stomach to esophagus.  I ordered a blood test for allergies  and also a chest x- ray  and breathing test to see if he had asthma . I gave him a sample of an inhaler  and then do follow up in 4 weeks .
     He  had blood test  and also the chest x- ray . The X- ray caught me with surprise . It showed that there was a blockage of bronchus  and his lower lobe on one side was collapsed. I did not know what to do - I knew what to do but was stunned due to the possibility in this older nonsmoker patient. I called him and ordered a CT scan  and then bronchoscopy. I was concerned about doing any biopsies if there was amss or a tumor in the bronchial tube blocking it. So I called help from anesthesiologist . The CT scan confirmed that he had a tumor blocking the bronchus. So we did the bronchoscopy with anesthesia . This was the precaution. The bronchoscopy did show the he indeed have a tumor  and that was blocking the main bronchus going to right lung. The appearance was quite smooth and this may be a tumor called CARCINOID . Some people say that carcinoid is benign tumor which sometimes spread  and some say it is cancer that very rarely spreads . In any case this tumor tens to bleed on biopsy  and i did not want to take that chance in this patient . So I did some lavage  and then talked to patient and family .
     The problem is that he has blockage and that will not go away . That is causing cough. If we need to do surgery , we will need to take out entire lung . We may not have enough bronchial tube stump to cut out the entire lung. We do not have the diagnosis.So what can we do in this 93 years old who otherwise is in good health  and looks much younger.
  I have talked to chest surgeon and radiation doctor  and also to patient and done PET scan . We will have to make a decision and it will not be easy. 

Sunday, March 15, 2020


     We are having aging population. I have seen at times 3 patients with age greater than 90 years at one time in hospital. In spite of the problems that the patient and the relatives  and the society faces , almost every patient that I see wants to live to be 100.. I think I am seeing more  and more patients who are older  and have some medical issues that have become or will become problem . Many a times when I see patients who have chronic cough  and they  are advanced age  and other basic work up is negative  and usual treatments do not work and the cough continues, I tend to order swallow study to make sure they do not have aspiration , which means the the food particles or liquids go in wing pipe / lungs instead of food pipe . This causes cough and then leads to inflammation. This causes cough . Many a times swallow study comes back abnormal but not bad enough to stop eating, but I feeling is that one can do well 100 times  and then one needs only 1 episode that leads to the problem . Just like you can drive well without the accident for 100 days  and then you get in an accident. Some times the problem is bad  and the patients  are not willing to do feeding tube or make all liquids 'thick ' to help prevent aspiration..But today I am going to tell additional problem that we ALL are facing - medical persons  and patients  and the family and in tern the society.
     I have seen this 93 years old male for last 4 years . He had some cough and some shortness of breath . He had heart problem and had surgery and also had valve problem and was followed by cardiologist . he was active and did OK for 2 years or more . He had some fibrosis in lungs  and that was causing the cough and some shortness of breath. He stopped following me  and then after the gap of 10 months I saw him in hospital. He had developed dementia  and he had been moved to Memory Unit by family. He got sick an so he came to hospital. We did the work up and he had fibrosis and that seems to be stable on CT scan . He also had pneumonia  and he also had corona virus - but not the COVID 19. I knew that he must be aspiration as the age had advanced  and he also now had dementia. We treated the respiratory problem and he received antibiotics  and steroids  and also received bronchodialaters . He did well . His lungs improved  and he had not much cough and oxygen improved . I also did swallow study and he had aspiration . The speech therapist felt that if he could follow certain precautions ,he could eat certain way , he would not need feeding tube . The family had told me in advanced that they would never consider feeding tube. So they were happy to know that he can eat though with certain precautions. I was not too sure how much he could understand  and follow. Since he had MEDICALLY improved,, we started talking about discharging him. The memory unit did not feel he could go there as he was too weak  and we had started physical therapy . But he was not doing much and not following much of the instructions. The family wanted him to be in hospital till he got BETTER.But the medical problems were much better and he was ready. I was not sure that there was much physical therapy potential due to his dementia . So we were in bind . The dementia was not going to get much better and the physical therapy may or may not work The family was not ready for taking him home  and that would have been too much of a care. The physical therapy unit would be good , but how much could he do ?
      This situation is not uncommon and one does not have to be old .But we see this in older patient more often. I don't have answer for this socio-medical problem. 

Saturday, March 7, 2020


     I saw some one in my office  and she had come to me for second opinion . I did minimal work up and saw the records from the previous consultant  and told the diagnosis . She had come to me as she did ot know what her diagnosis was  and I told her what I thought and then I also told her that we could do treatment or consider open lung bx to confirm my diagnosis.They were impressed  and so I told them that sometimes 3 rd doctor appears to be smart as the first 2 doctors have done the work up and that helps to come to conclusion easily. But what I want to tell today is little different.I am not sure why this happens in medicine . But may be it is due to overconfidence in one self or may be the eyes don't see what the mind does not think or may be we are spending too much time in doing NOTES IN COMPUTER . I just saw a study . The average time spent by a physician in doing a note is 17 minutes per patient - this is not time spent in seeing patient and average duration of  time allotted for follow up is 15 minutes .
    I saw this 78 years old female for shortness of breath. She had high blood pressure  and she had never smoked . She had problem with her aortic valve  and she had surgery to replace it . This one is minimally invasive done with a catheter she had done well. She had seen this cardiologist for many years  and he had told her that she has no cardiac issues. Her primary care physician  did a chest x- ray and also gave her an inhaler which is used  to treat asthma. She felt some minimal improvement  and so he gave her  nebuliser  medications. She had not much change  and so she came to me . I did the work . We did the breathing test and had minimal proof for asthma  and so I gave her different inhaler. My thinking and the work up was pointing to cardiac issues  and not pulmonary problem . But the cardiologist had assured her that there was nothing wrong with her heart..I asked her if her cardiologist has done any tests or just told her that she is fine from cardiac stand point . I never got the answer. I requested the records  and it took long time to get them . I could not find any NEW cardiac tests after she had surgery for the aortic valve. So I ordered a echo cardiogram - ultrasound of the heart and called the cardiologist on his cell phone. I told him that I have ordered a CARDIAC test  and I feel that her problem is cardiac and so may be he can check her out for the same. He agreed.The echo cardiogram was interpreted / read by him  and she had a different valve leaky and also the valve that was repaired was also leaking and the pressure in the lung was elevated due the leaky valve. I called her  and started her on diuretic and told her to call the cardiologist as she needed further work up including heart cauterization. A month passed by and nothing was done  and she got more short of breath and so she went to ER . Now she had fluid collected around her lung and she needed oxygen . I saw her  and started her on diuretics to be given intravenously  and by putting in a needle drained 1100 ml of fluid from around her lungs . She felt great . But the cardiologist that saw her agreed with me  and did cardiac cauterization . AND  he told her tha same findings that were seen 2 months ago on echo cardiogram and told her that she needs new valve . She was sent to a cardiac surgeon .
    So why did the first cardiologist did not diagnose her cardiac condition - I don't know  but I have my theory.