Saturday, March 27, 2021


    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


     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.