Saturday, September 25, 2021

DISTRUST OR MISTRUST

     In medicine we come across many situations where I am surprised at the behavior of the patients or the relatives of the patients. I can understand that we all have different experiences in life and also we have different educations and we all are different individuals. So we will think differently and behave differently . But certain things are more accepted than others . So in this pandemic I have seen things that I did not think I had seen in past. So this blog is related to such opinions. 

   I saw this 78 years old lady and her daughter who was may be 58 years old . They came to me for pulmonary follow up. In my routine for this pandemic has been to ask them on signs and symptoms of COVID and now that we have vaccine to ask them if they are vaccinated . So they had no symptoms of COVID infection on our screening questions  and so I was seeing them in office. So when I sked her as to the vaccination for the COIVD , they said they did not have it. So I asked why did you not get it ? The answer surprised me .The daughter told me that they don't trust such shots . So I asked why don't you trust this , Everyone is taking vaccine. She answered that 'In past they have been used as scape goats (African Americans) for medical experiments and so they do not want vaccine'. I did not go in detail. But I am not sure what is cause of this distrust. But I did tell them that if you see the lines that are shown on TV news of the people that are waiting to get vaccines ,it is mixed population - the Asians were much higher than Caucasians  and Hispanic and African Americans were less . But everyone gets same vaccine .

  The second story is of a Hispanic patient. She is 85 years old and has some lung issues and she was admitted to hospital with COIVD pneumonia. On further work up she was also noted to have clots in lungs and she has significantly low oxygen and she was on BIPAP -oxygen given under pressure . She did not want to be put on respirator. So I was talking to the patient and the daughter on daily basis. On the first day she refused the Remdesivir which is a standard treatment for the COVID . So I called the daughter and then the patient agreed The reason was she did not trust any medicine or the vaccine that was related to COIVD . So we did start her on treatment and she continued to need  high oxygen flow . Then the daughter asked me if she could get flax seed capsules and elderberry capsules . So she did not want the standard treatment for the COVID as she had DISTRUST in the medical treatment even though that had some data as to the effectiveness - but had MISTRUST in theses over the counter products WHICH HAD NO DATA  as to the effectiveness !!!!

Sunday, August 15, 2021

PANDEMIC AND HEALTH CARE

       We started with COVID 19 pandemic last year in 2020 and since then medical practice has been affected . We have issues with patients not showing up for follow up when it is utmost important to do follow up  and do follow up tests  and then some showing up when they should not. When I wanted to doo scans to make sure that there was no cancer and patients don't want to do it due to fear of catching COVID, there is nothing I can do but to pray. Fortunately I have not had anyone who had cancer that did not get diagnosed sooner due to not showing up for the scan. But many other factors have played role in frustrations for the medical community with the pandemic and I have not seen that being addressed or even mentioned by news media or our own medical societies . All that they are interested is in FREE CARE FOR ALL. One has to understand that there is nothing FREE-someone is paying for it .We have had issues with supplies that we need to do tests not provided leading to cancel tests . Which means we have to no income and we have to get authorization from insurance company or PCP for doing tests  at a different date  and then getting patients upset as the tests were postponed. So the tests are not done and there is no income ,but the person who does the test is still employed and has to be paid .The list of issues that are going on and have been there for more than a year is long but I wanted to tell one quick story about other issue that I mentioned earlier.

    I think we have COIVID INFORMATION FATIGUE . We have enough information about the disease and it's spread and treatment and complications -that I think anybody could do doctorate in COVID . but still sometimes I come across patients that surprises me . I have a patient who has COPD - the disease that is primarily caused by smoking . She is 75 years old and has been on oxygen due to her condition. She had a routine follow up with me . She is usually accompanied by her family. In spite of the diagnosis of COPD which is caused by smoking ,she has continued to smoke and quit only recently. She came to office and my office and my office told me that I have to do telemedicine follow up. So they were asked to wait in car . SHE WAS POSITIVE FOR COVID and her daughter who came with her to my office was also positive . 

     My patient was vaccinated but her daughter and her son and her son in law were not vaccinated  and one of them is in medical field and works in hops with respiratory problem patients! So in spite of 10 posters on my office front door and check in window and waiting room , they came to my office .Another health care problem with pandemic . 

Saturday, July 24, 2021

TREAT OR NOT TREAT

   In out life we often have to make decision daily as to do things this way or that way . Take this road or do highway. order this food or that food . Take a phone call from this person or not . But in medicine we make the decision which is some times more complex that ordering topping on pizza. In many cases the flexibility of decision is not there. If I see elevated blood pressure or blood sugar, there is no question about if we should treat it or not .We treat it -period. But in certain other condition, we have to make a decision. This brings me to the story for today. 

   I saw this 91 years old male patient for the cough . He had cough off and on for 3-4 months  and he had no shortness of breath or other complaints . He was not a smoker and though was 91 years old , he was overall OK . He had some memory problems but lived by himself  and had not lost weight or had fever . He did not have history of asthma or gastroesophageal reflux - the 2 most common causes of chronic cough The Chest X- ray was done  and that had nothing impressive but some upper lobe scars. So I did some more testing . I di CT scan of chest and that showed some upper lobe scars  and some other abnormality that could go for Old TB. I was concerned  and so I did not do breathing test  and instead I gave him an inhaler for possible asthma  and I asked him to do sputum for tb bacteria. I had planned for doing the breathing test, but his sputum came showing that it was growing TB bacteria. This was preliminary  and the final report in case of TB can take as much as 6 weeks . Some times we can get report in 3-4 weeks if the TB bacteria is of type that grows fast . I had planned to do breathing test but I cancelled it till I get the culture. 

    I called the patient and the son and told them that the sputum is growing something and to be on safe side keep him indoor. Then they came to see me after 2-3 weeks . By then I had received the identification of the bacteria . It was atypical TB . The Mycobacteria is a family name  and the Mycobacterium Tuberculosis is the one which is contagious and MUST BE treated and isolate in the first few days  and also family close contact will be needed to be checked . But the mycobacteria are not like that. They do need prolong treatment and have similar symptoms ,but they are not contagious.So when they came to see me ,I had to decide on the treatment . I had 2 choces one was to treat this 91 years old patient with 3 MDICINES for 18 months or not to treat but watch it . tHt medines used can have liver problem , eye problem . So I had to talk to them . Her was a 91 years old patient who had sputum growing atypical TB  and had no complaints other than some cough. 

          TO TREAT OR NOT TO TREAT ?WAS MY QUSTION. . 

I decided to watch him with new CT scan and new sputum check and clinically. 

Sunday, July 18, 2021

NEVER SAY NEVER

    We have a saying in medicine . We never say never in medicine. I have written many a times on unexpected and surprises that we see in different patient. But in spite of knowing that we never say never in medicine , things seem to come as surprise  and then we say "there is exception to every rule". That brings me to the story for today . 

  I had known this lady for many years . Her husband was may patient and he had cancer of the lung and when we diagnosed it he had spread of the cancer to liver and he did survive for 4 years or so . She started seeing me after he had died . She had also smoked and she had COPD  and we did the work up. She then developed lung cancer. She was 'lucky' and we had diagnosed the cancer in time - or at least we thought. She did ok but when the surgery was done she had some of the lymph nodes showing spread of cancer. So we did have her see oncologist and had treatment with chemotherapy. She continued to do OK and she had COPD  and she had shortness of breath and needed oxygen .She also had gained weight and she had sleep apnea . I had told her after the diagnosis of the cancer  and the need for the treatment to 'prevent' the recurrence that the recurrence happens most in first year and then less in second  and least in third year after the diagnosis. After 3 rd year the chance of recurrence is not there  and so you are cured if there is no evidence of cancer after 3 years . 

   Five years had gone by after the surgery and she had new scan. She had CT scan and then PET scan. That was abnormal and so she came to me. Five years had gone by since we had diagnosed cancer and she had surgery. So the possibility of old cancer coming again was low or not there . But patients who have one cancer have high chance of having second cancer is high and then depending upon the type of cancer the treatment may be different. The abnormality was in such a location that simple way to do the biopsy was not possible . I spoke to interventional radiologist and he did not feel he could get it and suggested that biopsy with ultrasound guidance through a bronchoscope was better choice . But the interventional pulmonologist did not feel EBUS or navigational bronchoscopy could get the diagnosis. I did ot want open biopsy as this was not a curative surgery and she was oxygen dependent COPD . So the risk was higher . But I had no choice  and so she did see the surgeon and had a biopsy  and it was NOT A NEW CANCER but it was the SAME CANCER that was taken out 5 years ago. 

                   THAT IS WHY IN MEDICINE WE NEVER SAY NEVER!

Sunday, June 27, 2021

SOMETHING NEW

   Medical science is getting better every day. Certain things that we did not even imagine in past have developed  and even today it is very difficult to understand certain developments. But certain things which are easy to understand  and difficult to do are also there. In the treatment of cancer now a days blood cells called Lymphocytes are taken out from a cancer patient and are 'programmed '(??)  and then multiplied and then injected in the patient to take care of cancer. This process is easy to understand . But very difficult to actually know as to what is being done . What does a programming of a cell means ?But it is easy to explain. The new treatments for COPD are also such treatments where it is easy to understand  and easy to explain. That brings me to the story for today. 

  I have seen this patient for 3-4 years and she had episodes of respiratory infection when I saw her for the first time . She is in her early seventies and she never smoked . She had cough  and then I saw her . The chest X-ray was normal  and  treated her with antibiotics and the steroids .She did OK  and I did do breathing test and that came as normal . But she had cough and so she was started on treatment for asthma . She did OK and then she weaned herself of the medicines for asthma . She would get periodic episodes of cough and then she would see me and I would treat her with  steroids and inhalers  and she would linger for few days with persistent cough and then would get better . 

   This continued and then the cough got worse and then in spite of doing steroids and antibiotics and inhalers , she would still have bad coughing spells . I did do further work up and we did CT scan and that was normal. I also did measurement of immunoglobulin - These are proteins - globulins that are important for immunity and they prevent the recurrent infection. She did have low immunoglobulin. So I wanted to  give her replacement for the immune globulin . But her hematologist did not want to do that. In any case she continued to have cough and she was admitted few times for the control of her symptoms. Then  I decided to do the bronchoscopy. When I did the bronchoscopy ,I found out that she had problem with trachea and major bronchial tubes . Normally the trachea has cartilages and that gives trachea the support and it does not collapse. Theses cartilages are semicircular and  also extend to main bronchi . That act like scaffolding . But her trachea would collapse when she would exhale or cough  and that   was causing constant cough. So I told her that we need someone to do a stent  and see if that would work out.. She was seen by interventional lung specialist. But he felt that she would need  surgery and stents may not be enough. So I have to send her to Mayo clinic . 

    So such a stent placement was not there 10 years ago and even when they did do it 5 years ago it was in the infancy and also no  one would have thought of doing surgery on trachea in an adult patient few years ago . I still feel that the cause of this is lack of immune globulin leading to recurrent respiratory infections and damage that was caused by persistent inflammation. I feel that she would need replacement for that in future . Stay tune .

Sunday, June 13, 2021

INADEQUECY OF MEDICINE

     I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis  and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today. 

   I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker  and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker  and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was  showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes  drain different areas  and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did  the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time  and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread. 

     We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.

   So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer  and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes  at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !

   Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?

Sunday, May 30, 2021

ELEPHANT IN THE ROOM

    In medicine sometimes we have extreme positions. The so called pendulum swings to he other direction.I have seen use of certain drugs for a certain condition as routine 'acceptable' treatment  and then suddenly it falls off the favorite train and then no one uses it . Theophylline is one such drug . 20 years ago there were several pharmaceutical companies that were making brand name theophylline  and now there is none. We also use a term  "The elephant in the room". This brings me to the story for today. 

     I saw this 90 years old patient in office and then she was diagnosed to have asthma  and also she was obese and may have had sleep apnea. But she did not want sleep study and so she was on oxygen which is not accepted treatment for sleep apnea now a days. But when the oxygen drops badly during sleep, one can not deny use of oxygen .She was admitted to hosp and she had  multiple problems . She had shortness of the breath and she had swelling in the legs and she has problem with her kidneys.So she was seen by hospital doctor and as expected they had called cardiologist and kidney specialist and pulmonary specialist . So when I saw her she was in hospital for she was in hospital for 3 days . I saw her and she had acceptable oxygen saturation at rest and she has significant edema in legs and her kidneys were not functioning well. She had clear lungs but no one had given her home inhalers which were prescribed for her asthma in past . So i started them. The cardiologist had seen and done echocardiogram  and the heart function was good and he has no other suggestion. The kidney doctor was giving her diuretics and her  her swelling was getting better  and she had some improvement renal function. What struck me in this patient was that her lungs were clear and the oxygen was fine and she still felt short of breath. Certainly it could be due to being 89 years old with low activity  and de conditioning and may be some heart problem and certainly may be even lung issues. But she also had anemia  and they had done the work up and she had problem with production of red cells.( think of red cells as a product of a factory. Let  us take an example of making shirts.So if there are less shirts available in market, then  it could be due to factory not making enough or that they are sold too quickly. - high demand or that there is not enough raw material . The same thing is true about red cells . The raw material - iron B12 or other r=things may not be enough or we have a loss of blood or it could be that the bone marrow the factory is defective.)So she had problem with production of red cells. That is not uncommon in patient with kidney problem. I followed her for few days . What I noticed is that in spite of inhalers and edema getting better and the kidney function improving she was still short of breath.And I also noticed that the anemia was not any better and was somewhat worse . Her hemoglobin -which carries the oxygen in blood was half the normal. So patients with anemia are short of breath as their system has to work harder to provide oxygen as the blood does not carry same amount of oxygen.So I finally called the hospital doctor  and asked her to give BLOOD TRANSFUSION. In past we used to transfuse even with much higher hemoglobin. But then we realize that that was causing problems in future  and so now the pendulum has swung to other extreme and no one thinks of transfusion even though this 90 years old lady was shortness of breath was perfect candidate for giving blood . So this was the big elephant in the room and no one was talking about it or treating it or may be no one could THINK about it .  

Saturday, May 22, 2021

GUT FEELING

    I have talked about some of the new things in diagnosis of cancer . I have also done that in my YOU TUBE  video . If you are interested it's under the name JUST A TALK . But sometimes all the tests that one can do may not going to give diagnosis  and sometimes one has to go by old GUT FEELING. So this is one of the stories where I did that . 

   I saw this female patient who had  an auto accident and then she went to ER. They did do some spine X- ray and scans  and that showed a small pulmonary nodule like 10 mm . She was told to see primary care doctor  and she had no insurance and so she decided to wait for 3 - 4 months till she got insurance . She saw PCP and then she was sent to me .She was less than 60 years old  and she had not smoked for 28 years  and had no pulmonary symptoms. The new CT scan had shown that the nodule had increased by few mm . This was in 4-5 months. I did the work up I did the TET scan and also the bronchoscopy  and I also did breathing test. 

   The  Bronchoscopy was negative  and it was not expected to give me the diagnosis but I wanted to make sure that there was no other cause for the nodule. The Breathing test was OK  and the PET  scan showed mild uptake  and radiologist felt that it could be inflammatory . But in addition to that I also did a new blood test called NODIFY . This is a new blood test  and I think it was approved last year . It tests certain proteins in blood and certain other things and that can give a probability of cancer . So One can calculate the probability based on several characteristics of the nodule -like size , location, spiculation, age , sex of the patient and the history of smoking etc. Then  based on the the blood test reports the probability is recalculated  and it may be increased or decreased. Or the test may not change it at all. So this is a new test and it is more than 95 % sensitive. The test was done in this patient. and it was  reported as reduced probability . 

  So we had low uptake on PET SCAN nd reduced probability on this new blood test  and she was not a smoker . So now we had several options. One was to do a needle biopsy which may or may not give diagnosis. The other option was to wait and watch the CT scan in 3 months  and if it grows then do surgery  and lastly do surgery now . I decided to tell patient to do open biopsy or surgery. It was not based on TESTS that we did but it was based on my Gut feeling  and the fact that the nodule has increased and in my mind ANYTHING THAT INCREASES MUST COME OUT.

  She saw a surgeon  and he decided to do needle biopsy and that showed high suspicion for cancer  and so she had surgery and the surgery did confirm Lung Cancer  and she did very well . 

Sunday, May 16, 2021

VARIOUS FACES OF COVID

    We have seen COVID infection for more than 1 year and I have seen may share of the disease. I do not have vast experience ,but I have seen different presentation and severity  and it is not actual 'changing ' face but it is just the variation in presentation. All the statistics does down the drain when you see theses kind of variation. So the so called 'risk factors' are valid for majority of patients but one can not hold them as 'Gospel truth'.In 2020 earlier part of the disease I saw a 91 years old African American women who had not left her home  and had significant hear problem ,hypertension and had possible heart failure  and may be pneumonia admitted . She was to be discharge to a extended care facility  and so at the time of discharge we did COVID test and to my surprise and horror it came positive.She did not have fever, she had no oxygen issues  and she did not have much cough or upper respiratory symptoms and she also was never exposed to crowd. So how did she acquire it or why she was asymptomatic  and lastly in spite of all the risk factors,she had no problem with 'recovery'? (she was never sick so not sure there was any need for recovery) That brings to me the patient story for today. 

    I saw this 74 years old male patient several years ago. He came to me for cough. He had seen primary care physician and also then allergist and he has had work up. He had allergies and was treated  and then he came to me as the cough continued . I did the work up and he had pulmonary fibrosis - scars tissues in lungs and so he had cough . I told him that we will do work up to find any etiology for the scar tissues and that was done and we did not fond any. So we decided to do follow up and in case the fibrosis gets worse we will star the treatment . I followed him for more than 2 years and the CT SCAN and the breathing tests were OK and did not show any deterioration. He stopped coming  and then after a gap of many months to a year he came to see me and he had some shortness of breath in addition to cough. The cough was also worse. So I did the same tests and nor=ted that on breathing test he was worse . So we started him on treatment with relatively new drug . He was doing OK but continued to have cough and even though I had told him that the cough will continue and not much could be done for it other than giving cough medicines , he was frustrated . He was teaching i one of the centers and the cough was bothersome . So he had called me many times  and I did add some different cough medicines  and at times tried steroids too. So one day he called me and he was having coughing spells and also had chest pressure . He was a older patient and had lung problem and so when he had chest pressure I told him to go to ER. I was concerned about things like heart or clot in lungs . He went to ER  and had CT scan done and that showed no clot. As routine goes he had COVID test done and that was positive. He had no fever and no upper respiratory symptoms. His oxygen saturation was fine  and he looked OK To my surprise, when I saw him in ER he had mask which was not covering nose  and was in hallway. We admitted him for observation only because he was OLD  and had LUNG DISEASE - the so called risk factors . I discharged him after 2 and half days when he had no new complaints . 

   So here is a older patient with high blood pressure , lung problem-all the risk factors for bad outcome   and was teaching  and had COVID and had no problem due to it. That is why we are not like automobile machine- same model and make but different response.

Sunday, May 9, 2021

NATURE OR NURTURED

    This question is often brought up , is it nature or nurtured. When we have a disease that can not be explained we talk about is it related to nature - genes etc or due to environment -nurtured. And it is very difficult  to answer it . In medicine the studies are done in twins to see if the GENES determine the outcome or how they were brought up . This is seen in studies for depression or bipolar or also for even homosexuality. That brings me to today's story. 

    I saw this patient may be 4 years ago and he had shortness of breath. He was admitted to a hospital  and was seen by cardiologist and lung specialist and hospital doctor and was told that heart was OK and he has emphysema. He decided to come to me  and so I did the work up and told him that he seems to have aortic valve problem and I admitted  and then  had aortic valve surgery. He also had HIV  and he had discontinued the medications  and so we had to start the HIV medicines . He did not come to my office much and he was followed by cardiologist. I did not know what was happening as he did  not come and he had major problem as heart. 

    I did see him every time he was in hospital. The cardiologist told me that he was noncompliant with meds . He was admitted and had shortness of breath and every time when I saw him I felt that he had cardiac problem and when we did echocardiograms, his pumping action was down to 20-25%The meds were adjusted and then he was OK for a while and then he would have same problem . The cardiologist felt that he would improve with the newer medicines . In span of 4 months he has been admitted 3 times  and he has not seen me in office for his COPD in last 2 years. So now for last 6-8 months he has not improved  and now for last 3 months they have told him that he will need a defibrillator. Patient has not made up his mind as to have it done or not. 

   So I  saw the problem with aortic valve  and we acted upon it and he had surgery and he did get better . Now he is worsening and the question is -is it related to his noncompliance or is it that in spite of surgery and medications he had bad genes  and he was going to get worse . 

  ISIT NATURE OR NURTURED  

Saturday, May 1, 2021

WHY ? WE DON'T KNOW

   In medicine and in general our life we see things that can be explained on the basis of our knowledge or logic or science. I have often said that the GOD has kept us guising. The man thinks that we KNOW and then the God or an incidence tells us that we DON'T KNOW everything. Many years ago my professor of Preventive and Social medicine had a heart attack and I went to see him in hospital. In those days we did not have stents  and all the modern things that we have to treat the heart attack. He made a statement to me . 'I don't smoke , I don't eat meat and I eat lots of fish and I don't drink alcohol, I exercise  and my cholesterol is normal. I do or have high blood pressure or diabetes - I still have heart attack !'Since then we have much more understanding of atherosclerosis and heart attack and the risk factors but the basic statement is still true. We have no clue as to why some get sick and some don't. That brings me to the story for today. 

   I saw this male patient of about 70 years of age . He had been smoker and had COPD. He did not have much shortness of breath and he had routine chest X- ray and that was abnormal. So he came to me and then I did the work up. He had bronchoscopy and PET scan and breathing test and biopsy  and he had lung cancer . Based on the tests that we had done he had cancer that could be resected  and there was no evidence of spread of the cancer to any organs or the lymph nodes . So I sent him to thoracic surgery. and he also thought that he needed surgery So he had surgery and the cancer was out. The margins were clean and no blood vessels were invaded  and no lymph nodes showed any spread of the cancer . He was seen by cancer specialist and was told that he does not need any chemotherapy as there was spread . 

    More than a year went by and he was followed by VA cancer specialist and he was doing ok . He came to me  and he was doing fine . Then last time when he came to me he had laryngitis. He had lost his voice and so I was concerned  and I wanted to do CT scan and he told me that his cancer doctor had done the scan and that was fine and I did see the report and he had nothing on the CT scan to suggest any recurrence. So I sent him to ENT to check on throat- vocal cords . He had paralysis of left vocal cord! So ENT doctor did new CT SCAN - 1 month from the last one and he did it with contrast  and that showed that he had recurrence at the site of resection. Just to explain medical anatomy - the nerve that supplies to left vocal cord comes down and goes in chest and winds around left central part where there are nodes and blood vessels  and then goes back in neck and goes to vocal cord. So when there is cancer in middle of left central part this nerve can get caught and the vocal cord can get paralysed . So he had that and I did do biopsy  and he has recurrence. 

    So all the odds were in favor of so called CURE and then he had CT scan  and that did not show tumor and then in one month new CT scan did show the cancer !So do we really know or we are just medical statisticians ?

Saturday, April 17, 2021

COVID UNCERTAINTY

     Since last March 2020, we have been indebted with information on COVID 19  and we still are learning. Last year when I was checking out there were atleast 15 different medications that were tried or given or had some 'promise' and as off today we have very few. Most of the medicines have been proved to be not very successful. But at many places people are still being treated with some of these medicines. Vitamin C and vitamin D are some of them. So some one asked me a question ,Can a fully vaccinated person transmit the virus? And I came across the answer  and may be a proof of the information. 

    I saw this male patient . I had seen him 3 years ago and he was a smoker and had COPD - smoking related lung disease. He had work up and when I did CT scan I found out that he had a kidney mass . I did further work up and send him to  urologist. He had surgery and it was kidney cancer. He did OK and came to see me once and then did not do follow up.After 3 years he came to me as he had abnormal CT scan of the chest. He had COVId infection  in a month  and then he was fine  and on march 1st he had his first shot of the vaccine. He had no major problem but he had chest x- ray as he has had some cough later on . The chest X- ray showed some abnormality and so he had CT scan of the chest . The CT scan showed  a mass or pneumonia. There were 2 spots and so he was sent to me . He has been smoker and had COPD. We decided to do the work up . He had CT scan and at the same time he had second test done for COVID 19.  and that was positive. He had no problems and he wanted to go back to work.So he did another COVID test  and that was negative. This was done in 6 or 7 days after the positive test . He also had his second dose of vaccine  and did very well and had no reaction to it . So this tells me that one could get infection even after having vccine . But patient may have no symptoms  and the course seems to be limited as he was negative in less than 7 days . 

   Then I came across the data from CDC  and also some srtcle from British Medical Journal.They had 5800 cases among 77 millions vaccinated  and some were admitted  and some died.But  that should not surprise anyone . The vaccine is not 100% successful like any other vaccine . I also saw another study  on antibody titre in patients who had solid organ transplants and who were on immunosupressants. Only 17 % patients had antibody titer. So I am sure when antibody titers will be done in patients who had vaccine and got infected, we may get the answer . May be the antibody titers may not be high or adequate in atleast the patients who needed to be hospitalised . But we don't know that yet..

Sunday, April 4, 2021

WHEN IS IT ENOUGH?

    I had a call from a physician asking me to see him as he wanted to do CT scan of the chest due to so called new recommendation on doing low dose radiation CT scan to diagnose cancer of lung . Several years ago we started doing CT scan of chest in current smokers and Ex smokers for 14 years to diagnose cancer of lung early . There was new article  and some added changes but overall it is about the same . But since it appeared  in Newspaper, he wanted to get it done . He had quit smoking 30 years ago and he would not fall in to the recommended patients that would qualify for the CT scan.But that brings me to the story for today. 

    I had seen this patient for last 3-4 years .She is 74 years old female who had smoked for many years and had quit several years - 18 years ago. She had bad emphysema and needed oxygen  and had not much of wheezing. She had shortness of breath and I had done CT scans  and she had some small nodule . We followed the CT scan for 3 years and there was no change in tiny nodules and the radiologist felt that it was benign.The last scan was 8 or 9 months ago and  I had plan to do yearly scan.She saw me  and had pain in belly and so I told her to see Gastroenterologist and also to talk to primary care physician. I told her to take antacid and also ordered a chest X- ray . The chest X- ray was reported as normal. She continued to have pain and the gastroenterologist could not see her for 4 weeks or more  and so when she still had pain ,she went to walk in clinic and they did CT SCAN of chest and also belly. The Ct scan of belly showed masses in liver  and the lungs had nodules that we had seen  and also had some lymph node enlargement . She was admitted  and then we did further work up . We did the PET SCAN  and that showed that the liver spots were hot and the lung nodules were warm not very hot . There was some uptake in lymph nodes in chest but again not very high . So we did the liver biopsy. The biopsy showed lung cancer that has spread to liver.

      I had done chest X- ray done less that 3 weeks before the CT scan  and that had shown nothing to suggest cancer. The PET scan also did not show very high activity in nodules  and also the size was increased,but not very much from the CT scan that was done 9 months ago. So where did the cancer arise  and why we did not see large tumor in lungs  and why the liver mass was 3 or 4 times the size of the nodule in lung where the cancer started  and lastly why was the chest X- ray unable to give even hint of anything happening. 

    And that is why my question - How often (doing a CT scan) is enough . The recommendations are to do once a year  and that would not  and did not catch the cancer early!

Saturday, March 27, 2021

IT WALKS LIKE DUCK, QUACKS LIKE DUCK AND IT IS NOT DUCK

    We often say that if it walks like duck  and quacks like duck it is duck . But sometimes we have situations where our conclusion based on our experience is not right. We have seen this many a times where ordinary people, politicians and news media tell a story and then draw a conclusion and that tends to obvious -but on further investigations the conclusion drawn based on experience is proved to be wrong. The same thing happens in medicine  and that is my story for today. 

    I was seeing this patient for sleep apnea and may be mild asthma . He was obese and over period of few years of follow up he had mot lost any weight and had continued to be obese  and was using the PAP therapy and had no problem with it . He usually had no other complaints  and the asthma part was minimal and he used to use inhalers as needed. Then one day he came to see me . He had cough and shortness of breath and it all started 6 weeks before he saw me . He was seen by his family doctor  and was given antibiotics and some cough syrup . He did not improve and so was given steroids  and different antibiotics. He continued to have problem with cough and some shortness of breath. I saw him in office and he has low normal oxygen and he had bronchospasm and wheezes . I ordered a chest X-m ray and also started him on 2 different inhalers and also different dose course of steroids. I asked him to see me in 2 weeks . The X- ray came back showing a fluid accumulation. I called him  and ordered CT scan  and asked him as to how he was feeling . He was little better as far as wheezing was concerned and he had no fever . His shortness of breath was still there but was better. The CT scan was done and the findings surprised me. He had fluid around his lung  and also a spot on the lung. I called him and told him that we will have to do the work  and that may involve number of procedures and biopsy  and also may need additional consultations . I was concerned about cancer and the presence of fluid may be due to cancer and then he would not be early of surgically resectable cancer . So I admitted him and did drain the fluid  and the fluid was somewhat  locculated -had some different pockets  and the fluid did not show cancer . So we did PET scan and I did bronchoscopy  and there was no tumor . The PET scan which is suppose to pick up cancer in almost 85% of the cases did show that the nodule had some activity and so possibility of cancer was there . So we decided to do needle biopsy of the nodule. The only other option was to ask a chest surgeon to do biopsy under anesthesia . The needle biopsy was done  and it showed inflammation  and o cancer . 

  So  the tests that I di to prove a cancer - it certainly looked like that - was not correct  and it looks like he may have had pneumonia and that caused the fluid  and he does not have cancer .. We have plans for doing follow up on chest X- ray and CT scans in future  and then we will know , but for now it looks like not a cancer . 

Sunday, March 7, 2021

TELEMEDICE - NOT SO TELE

     With the pandemic the insurance companies have allowed to do telemedicine  and many physicians are doing it and some patients demand it and feel that that is alternative to going to physician's office. I have my own frustrations with certain problems and when patients want telemedicine visits. Say one is short of breath, what can I do by talking to patient or seeing him/her on screen without being able to examine lungs  and oxygen level and heart  and so on. So sometimes we have problems with telemedicine visits. But I came across one example where one can do telemedicine  and may be not do it. I know this statement is confusing and so let me tell you the story. 

   I had a call at midnight from some one that I know. His relative had some health issue and so he decided to call me . So I spoke to her. She is 36 years old female who had no major health issues . She had sudden left sided chest pain. It started in the front  and went through the chest to back and also had some jaw pain  and neck pain. She was not short of breath and had no fever . She had no history of asthma. I asked several questions and obtain the story. She was not contraceptive pills. She had no cough and she took ibuprofen and she still had minimal pain. The question was what was the problem and what should she do. I told her that there were 2-3 possible explanations. She may have musculoskeletal pain -simple. But I was more concerned about the serious diagnosis of blood clot in lung  which is possible in young person especially when they are on contraceptive. I was more concerned about pneumothorax - or air leak and collapse of lung . So I told her to go to ER right away.  I told her to let me know as to what happens in ER and told her to have them do CT scan of chest . 

   I got some more texts from them  and I was told that the ER physician did blood tests to rule oy heart attack - a possibility of such is so low in my mind that I did not think it was even there. The test was OK and so was the cardiogram . They did not do CT scan but did chest X- ray and he told them that it was OK . He told them that it was muscular pain  and they will do second blood test in 6 hours to make sure that there was no heart attack. I get a new text at 7 am . The radiologist had read the X- ray and there was a small pneumothorax - air leak - collapse of lung  and they were going to admit her for observation and new chest x- ray .

    So the telemedicine on just telephone  not video -with me  and my suspicion was correct , but to confirm the diagnosis we needed DIRECT VISIT to physician and ER. 

Saturday, February 27, 2021

ATTACHMENT

      I have been in medical practice for many years  and I have myself changed in my thought process. But the main thing does not seem to change . We all want to LIVE. We often say that we have no attachment for living if we have suffering. But I have often seen that NO ONE is ready even under extreme conditions. That brings me to my story for today. 

    I had seen this elderly patient few years ago . Her problems were not major from my stand point and after doing follow up for 2 or 3 times ,she stopped coming. Then after 4 years of gap she came to me . She came with her daughter . She is 82 years old female  and had some shortness of breath and she went to er  and she had chest X- ray done and that showed larger fluid collection on rt side . She was admitted and they consulted lung specialist and he decided to put in a catheter to drain it . Normally we drain fluid and then based on response  and findings of the fluid we decide if patient needs further intervention. But for whatever reason she had the catheter inserted  and then she was discharged . The daughter came with her and she was draining the catheter at home  and when I asked her if they ever established diagnosis , she did not know , though she did know that cancer was suspected. I looked the work up done at the hospital and realized that no diagnosis of cancer was done  and part of the problem was the daughter's refusal to do additional biopsy since the fluid itself did not show cancer cells. She was weak and cachectic  and she was not eating and had lost weight. She was so weak that she could not walk .They had seen oncologist  and they did not like him / her and so they had not done follow up . She had no home help and no direction as to how often to drain the fluid. 

    I talked to them and looked at the reports from her hospitalization. She di have tumor in the covering of the lung and so from such a biopsy . So she did not have it. I told them that one can not get much treatment without knowing the diagnosis of cancer and what type. So i asked a surgeon to do the biopsy and at the same time consider talc powder instillation to stop the fluid from coming back. She agreed and the biopsy was done  and the diagnosis of cancer was established . She came to see me  and she had worsened. She had lost more weight and there was not much fluid left to be drained  and in spite of that she was short of breath and had no appetite and had low oxygen. I spoke to her grandson and also to daughter  and after discussion they decided that they could  not do any treatment and that it will be futile. So at their request i called hospice . They wanted comfort care only. 3 weeks went by and I get a call from the daughter , she had talked to oncologist and they wanted to start her on treatment immunotherapy . So they had cancelled Hospice and they wanted me to get her oxygen and some other stuff from other company .

    (I have often stated that if you ate vegetarian do not go to stake house ,if you go to oncologist they will do chemo/immunotherapy)So none is truly ready 

Saturday, February 6, 2021

CAUSE AND THE EFFECT ??

   In every walk of life we have cause and effect .But sometimes we do not have the perfect explanation. One sees this in everyday evens and we do not even question it. We drop a glass object to the floor, it will break . The wood floats and the iron sinks . But the boat made of steel floats  and so the scientists have found the reasons for such things . But in medicine we have no CAUSE for many outcomes  and effects . In medicine we call it IDIOPATHIC . So we don't know why some people have elevated blood pressure  and so we call it Idiopathic hypertension If someone has Fibrosis in lungs  and we do not know what caused the fibrosis , we call it Idiopathic Pulmonary Fibrosis  or IPF. But this is well accepted  and no one thinks any other way or questions. But sometimes we see common things and have no answer . Certainly there is always a reason but we are unable to answer it and then the patients get frustrated as they have no way of PREVENTING IT .That brings me to the story for today. 

    I have known this patient for many years and she has been ex-smoker and had quit many years ago. Over period of time she worsened . She had diagnosis of COPD  and she was on meds  and still she continued to worsen over period of years, She needed oxygen and slowly we adjusted medicines and she was on all the medicines that we could use. She was also started on oxygen and nebulizes medicines and also steroids. She had some cardiac issues and they seem to be stable. Overall she was doing OK. One of theses days she was admitted  and then had some worsening due to pneumonia. I checked her blood oxygen and carbon di oxide  and she had elevation of carbon dioxide. So we started her on what is called non-invasive -ventilator. This has been done now a days for COPD patients for last few years. This helps the patient's own breath and this supplementation or the help improves the breathing and carbon dioxide  and then the shortness of breath. So she was started on it  and did well for more than a year. One day I get a call that she became unresponsive  and so was taken to ER I went to see her in ER  and the Er physician had already put her on respirator with a tube in her trachea. I reviewed the data . She was using her own machine and in spite of that she had ELEVATED carbon dioxide to such a level that she became unresponsive . So we had no choice of doing INVASIVE VENTILATOR  and that did help. Over period of next 4 days we were slowly in position to reduce the support from the machine  and we did take her off the ventilator. She did OK  and she was started on the noninvasive ventilator at night and just oxygen during day time . I watched her for 3 dyas and she did just fine . We had done many tests . She had CT scan of brain to make sure she did not have stroke  and she did not , We did CT scan of chest and she did not have clot or pneumonia . We did culture of blood  and sputum and treated her with antibiotics  and all the work up was negative  and she did not have sepsis. So why did she have respiratory failure even when she was doing everything right ? 

    I DON'T KNOW  and I will never know .

     Why did her lungs quit suddenly and then in 4-5 days recovered , I don't know . But one thing that I DO KNOW is that I have seen such patients in past and will again see such patients where we do not have the cause that precipitated  the event. 

Saturday, January 30, 2021

EXPECT UNEXPECTED

    We often talk about any  situation when something goes wrong, as Murphy's Law, 'If anything can go wrong, ,it will!' Nothing is exception to this statement  and medicine is also not exception.But I often say that sometimes it is better to not know everything, but know what patient DOES NOT HAVE. So when I see some patients and have some symptoms  and I can not find exact reason for it , I tell them that I don't know what you have , but it is not serious. That brings me to the story of one my patient.

    He was a young male and has not been smoker.He was fine till one day when he was working on a house . He was hard working - physically hard working male and he used to buy homes and work on them and then sale them. So one day when it was little cold in Florida, he was working on a house. He was out side and so he had a jacket and was working  and he noticed that he felt hot and took out the jacket and he noticed that he was sweating . He had some shortness of breath. No major chest pain. He saw his primary care physician and was told to get COVID test done . He had no fever and no cough and no other problems . He did the test  and that was OK . He was told to see me or may be he decided to see me. I asked him on any chest pain and he did tell me that he had some chest pain but it was short lasting but now he has some more shortness of breath.I examined him  and his blood pressure was normal, he had no fever and he had good oxygen saturation  and his lungs were clear and he had no wheezing like asthma.He had normal heart sounds and there was nothing abnormal on physical examination.I thought that his symptoms were atypical and did not look like lung problem ,but he was short of breath on doing things that he could do without efforts in past.I thought that he could still have mild asthma , but it was not very clear cut.So I decided to do work up. He had COVID test and that was negative. He had no cough and no fever  and lungs were clear. I ordered CT scan of chest and a breathing test  and also pulmonary stress test. I gave him  an inhaler to help breathing in case he had asthma. The breathing test was normal  and the CT scan showed some abnormality. He had what was described as 'ground glass densities' The ground glass densities is very small areas of ' haziness' The window glass is clear and the shower glass door is not clear . So that is called ground glass density. I could not figure out as to what might have caused this  and infection could be one of them  and so I spoke to him and he told me that he was little better but was still short of breath and he had no new complaints . I ordered some antibiotics and told him that he needs to see cardiologist ASAP as I was concerned that he may have heart problem , the sweating and shortness of breath and some chest pain all could be due to coronary artery disease . So I called a cardiologist to see him soon. He was seen in 1 day and the cardiologist was convinced that he HAD SEVERE CORONARY ARTERY DISEASE. and wanted to do cardiac cath. to find out any blockage. But all the slots were filled in the lab. and so he admitted him of Friday, the day that he saw and did procedure on Saturday. HE HAD  SEVERE BLOCHAGE IN THE CORONARY ARTERIES  AND NEEDED surgery!

    So I knew that this was not lung problem  and suspected it was heart, but was not sure . 

   So one must know  what it is not even if one does not know what it is.

Saturday, January 23, 2021

WHY?

   We do not the future  and that is why every newspaper and many magazines have weekly or monthly horoscope. We also have psychic readers and Taro card readers.People make lots of money telling people as to what is going to happen love life and job market and so on. But we in medicine have the firm but wrong belief that we can predict as to what is going to happen , the so called prognosis. But I have come to a firm conclusion that what we are doing is more of a statistics  and a chance  and probability and we could be wrong . But then I wish we could have some more TESTS that could bring us to 100% prediction of future. When I used to go for a movie in my earlier years  like 10 or 12 years of age,when hero was being followed by villon, my cousin used to shout warning the her that the villon was right behind him . But if hero knew that then the story would end right there , but in life we have similar situations. I guess then there won't be FREE WILL or Law of Karma.That brings me to the story for today . 

   I saw this patient for a short time . He was life long nonsmoker  and he had some cough and was admitted 3 months ago and had abnormal chest x- ray. The X- ray was abnormal  and so had a CT scan and has a small nodule less than 2 cm . The work up was done and had needle biopsy and he had cancer of the lung. He had never smoked  and he still had lung cancer. So he had further work up with PET SCAN  and there was no spread of the cancer and so he has surgery done in November . The cancer was operated and there was no suggestion of spread to lymph nodes and the borders were clean and nothing to suggest need for any additional treatment.He did well and recovered from the surgery and was doing good . Then he had some vague pain in the belly and he came tp hospital. He had CT scan of belly and also chest X- ray . The CT scan of belly was abnormal and had a mass that was pressing on the duct that drains the bile  and so he also had CT scan of chest and that showed a cavity. This was near the suture line of the previous operated cancer. So it looked like he had recurrence of the cancer that was taken out. The further work was started . 

     So 3 months ago or less he had no evidence of spread of cancer  and so had surgery and no test could have shown that in short period of 2 or 3 months he has now a cancer that has spread to a point that it is not possible to do much surgery. WOULD IT NOT BE NICE IF WE HAD SOME TEST THAT COULD PREDICT THIS OUTCOME ?

Sunday, January 17, 2021

MORTALITY

      Since we were born we know that we will die - well may be not when we are in our childhood , but certainly we know about the death even when we act as invincible as young adults.One can see this in the risks that are taken by teenagers. But at the same time we want to live for EVER. All the  TV  and radio commercials that we see are related to extend life expectancy and also how to look or feel young. This is from skin care products to various nutritional supplements which is billion dollar industry. And I see this in many of my patients. There is nothing wrong with the attitude that we must do everything to prolong life or make it better  and that is the role of medicines and physicians. But that thought process should not obscure the reality that everybody dies. That brings me to story for today. 

    I saw this patient 90 years old . He was diagnosed to have cancer of rectum.He was treated with radiations  and he was doing OK but the cancer was mot cured and so he was now on CHEMOTHERAPY. Then he was admitted with what looked like pneumonia  and then had further work up  and was found to have obstruction of lower lobe bronchus on right side and that was biopsied  and it was cancer  and to surprise it was not spread of rectal cancer,but it was new Lung Cancer. So ow the radiation therapy physician was called . He was not a candidate for surgical resection and so radiation was started and it was completed  and then he got more chemotherapy. He had the side effects  and was weak and had no appetite  and has drop in blood counts  and he had some shortness of breath. He also was confused  and he has reduced responsiveness. He had the full work up and had CT scan and consult with cardiology - he also had atrial fibrillation and so had cardiologist to look at him  and also infectious disease doctor  and lung specialist.- This is very typical now a days as primary care doctors do  not come to hospitals and the hospital doctors call various consultants. The CT scan showed collapse of the lower part of the lung  and this was related to the blockage from the cancer that was diagnosed 3 months ago and treated with radiation , but now he had more fluid around the right lung. I thought that this could be due to inability of lung to expand due to blockage from inside due to cancer or could be due to cancer spreading to the covering of the lung - pleura . In any case I felt that this was not good . He was severely anemic  and cancer doctor nurse also saw patient. I felt that there was not much that would change much by doing more interventions as diagnostic test. HE was 90 years old  and had 2 different cancers  and bot did not seem to have been cured  and also he had side effect from chemotherapy. My feeling was that we could treat him for fluid  and that may help him but beyond that doing additional therapy was not going to change much on long term.I also thought that since the  fluid was  locculated - had formed a pocket - may be due to radiation, putting a catheter would be better idea in this 90 years old patient. I did not feel doing more chemotherapy would change much . When I asked patient when he had improved in his mental status as to what he would like to do. He wanted to know why we can not do surgery on lung and rectum? I did not think he either understood or accepted the reality of having 2 cancers and the prognosis.

    So we all know that we are going to die  and are not mortal but even at age 90years  and with 2 cancers one is not ready for inevitable end of life.

Saturday, January 9, 2021

MAYO CLINIC

      I have been in medical practice for many years  and have seen very easy patients and diagnosis  and some patients who are difficult and some diseases which are difficult . I have sent some to Mayo Clinic for opinion and see what would they do in such patients. As far as i recollect I have not had any glaring change in my diagnosis or my decision in patients that I have sent there. This is GOOD for me and my confidence but not GOOD for patients as they did not get any different treatments . There have been some cases where I have disagreed with their opinion  and I do tell this to patients. But if they do not have any treatment option and I want to try something, I have told patient to try what I am suggesting and then decide in due course of time. But sometimes I come across patients that want second opinion and I know that there is no SECOND OPINION. This brings me to the story for today.

    I saw this patient who was sent to me by a surgeon who also does some family medicine practice . The patient was nonsmoker for many years and was not living close to me of the surgeon. He was in another area 2-3 years ago and had some chest discomfort and so he had a CT scan  and that had shown very tiny nodule and then he had no further work up. He had some cough and so the PCP did the chest X- ray and that was abnormal and so he did new CT SCAN  and that showed a mass - rather larger 5 cm size mass. So he was sent to me . I di explain it to him on the high possibility of cancer and did start the work up. I did PET scan and berthing test and also bronchoscopy . Even though the mass was larger it was not seen from inside at the time of bronchoscopy and the samples came back negative . I had expected that and I had told him on doing needle biopsy . I saw him in office on each time and also talked to him many times. He seemed to understand  and was ready and then I get a call from radiology that he has refused the biopsy  or did not want to schedule it . I talked to him again and he seemed to have agreed  and then he did not get it done  and I was told that he wants to go to Mayo Clinic. I feel that if he has cancer we are delaying the diagnosis  and the treatment  and I had also told him that if he feels he does not have cancer, we could repeat the CT scan  and see if the mass has reduced in size or not. I have seen some patients in which the tests point towards cancer but they are not good candidate for biopsy or they refuse the work up and the follow up CT scan shoes improvement. But it is rare. and the Mayo Clinic is not going to do anything different - either do the biopsy or wait and do new CT scan. 

Sunday, January 3, 2021

TIME AT LARGE AND SMALL SCALE

    The time as we know  and experience is different than the time that was told to us by Einstein. We presumed that the time is independent unit  and then Einstein proposed  and proved that the SPACE -TIME is constant and only thing which is unchanging is speed of light. So when the object is moving in SPACE the time is shortened compared to an object which is stationary. So the space - time unit is constant. If the movement is more ,the time shortens. If some on takes a watch in an ordinary plain and flies around the earth, then the watch similar to the one which is on the plain will run faster as the watch on plain time is shorter. Certainly at the ordinary speed , we do  not have ability to perceive the difference but it is there and can be proved . The unit of time that we are used to see is hours  and minutes and seconds and then micro and milliseconds etc. The unit of the time that was describes to be the SMALLEST that can be measured is called PLANCK SECOND  and is defined as time it takes photon - a particle of light to travel PLANCK DISTANCE  . So then came Planck unit and Planck constant for quantum theory etc. Certainly at a larger scale we have millions and billions and trillions etc. But in Indian mythology which was known or created we have much more time measurements than what has been thought out by science .We have both micro level time and macrolevel time measurement . I am amazed at the thought process of these measurements.

   To start we have more than one system and there will be some variations in the numbers . So the smallest time in Hinduism is called TRUTI . This is the time it takes to TEAR A  SOFT PETEL OF A LOTUS . So this is TRUTI . 100 Truiti make on LAV

30 LAV make 1 NIMESH

15 NIMESH make 1 KAASHTHAA(8 SECOND)

30 KAASHTHAA  make 1 KSHAN 4 MINUTES)

6KSHAN make 1 GHADI (24 MINUTES)

2 GHADI make 1 MUHURT (48 MINUTES)

30 MUHURT make one DAY -24 HOURS 

28 DAYS make 1 MONTH 

2 MONTHS make 1 SEASON

3 SEASONS make 1 AYAN 

2 AYAN make 1 YEAR 

1 MONTH of Human is 1 PITAR DAY 

360 HUMAN YEARS =1 DIVINE YEAR

12000 DIVINE YEARS =1 DIVINE YOG (YOOGA) =1 HUMAN MANVANTAR =4320000 YEARS

71 DIVINE YUGAS =1 MANVANTAR 

14 MANVANTAR=1 DIVINE YUG=1 DAY OF BRAHMA =1 HUMAN KALP

4.32 BILLION YEARS =1 BRAHMA DAY

100 BRAHMA YEARS =2 PARARDH = 1 DAY OF VISHNU=311.04 TRILLION YEARS 

1 MANVANTAR is the life span of one MANU 

There are 14 MANUS and currently 7th MANU is ruling.

There are 4 YUGAS that we commonly know They are in proportion of 4:3:2:1

So SATVA TUGA IS 1728000, YEARS 

TRETA YUGA IS 1296000 YEARS 

DWAPAR YUGA IS 864000 YEARS KALI YUGA which is current YUGA is 432000 years. 

1 MANVANTAR IS =306720,000 YEARS 

There are 86400 seconds in a day but there are 17496 millions TRUTIES in  a DAY 

SO ONE TRUTI is 300th of a second . 

SO NOW YOU KNOW THE SMALLEST AND THE LARGEST MEASUREMENT IN HUNDUISM 

                      HAPPY NEW HUMAN YEAR 2021 !!