Sunday, December 11, 2022

WHY DO WE DIE

     We often see people that have lived for ever. I have recently seen at least 3 patients on same day who were 90 years plus old  and were good in health and then I see patients who are mid forties and have multiple elements and are not in great health and don't do well and die at early age. Some die young and some old  and some are retaining their faculties even at advanced age and Others don't have it at  at younger age . What determines the TIME OF DEATH .That brings me to story for today. 

   I have known this patient for many years may be 10 years .He had smoked in past and had COPD . Over the years of my follow up he got older and also had some worsening of he disease. He could not do much physical activity and needed oxygen . And in spite of using oxygen he was short of breath. But he was stable from my stand point. One day he had some trouble eating  and as per his story it was less than a week  and so he was admitted to hospital  and he ha d work up and he had canner of the food pipe or esophagus. I saw him in the hospital. I had extensive discussion with him  and his son and daughter who were out of state . His wife had dies 3 years ago. The hospitalist had admitted him and had not known him and had not started his usual medications for COPD nd so he was quite short of breath. He was seen by oncologist and then they had called a surgeon for possible surgery. I saw him and i knew him well from medical stand point . He was not a candidate for surgery as he had severe COPD  and would not have survived the major surgery to cut out esophageal cancer. I told hi that and also to his family . They had known that.as they had seen the father walking and using oxygen etc. The oncologist also called radiation oncologist and the plan was to do both- radiation and chemotherapy. I had told him that the chemotherapy may be too much  and the side effects may be worse and with his COPD he may not do well and there won't be quality. I had suggested Radiation and told him that that will get him some time . The other physicians convinced him that if he does both he has a 'chance 'of cure , which I knew was remote. Who does not like the thought of being CURED of cancer. So he and the family agreed.

     He was discharged and the plan was to star the treatment in a week or so. But he was readmitted with pneumonia . The esophageal cancer had blocked his food pipe  and he had stent, but he had vomiting and then that went in his lungs  and he had shortness of breath and he needed to be admitted . After 2 weeks of treatment it looked like he was getting better . No treatment for cancer was possible at this time . It looked like that will have to wait till he gets stronger  and infection to be gone. But one day he became worse and I called family and told them to come back and in next 36 hours he died. 

    My question is what decided that he would die in less than a month after diagnosis of cancer and could not get any treatment. I have some thoughts. The short answer is that the KARMA WHICH WERE GOING TO COME TO FRUITION had come to fruition and this physical body had done it's job  and so it was time to go. 

    You may check out my You tube video under JUST A TALK . 


Sunday, November 27, 2022

PERSISTENCE PAYS

   In medicine sometimes persistence pays. We see things and with previous experience we think we know the diagnosis  and then the tests are carried out and the diagnosis is not obtained . So sometimes the persistence pays. In past it has also happened that we think that there is cancer or some other diagnosis  and then the tests show something different. But one has to go by what we think  and continue the work up. This brings me to the story for today. 

  I had seen this patient in office for the shortness of breath. She had been smoker in past  and had quit many years ago and she was getting short of breath and so the primary care doctor sent her to me .I knew that she must have COPD the disease that happens when people smoke and over period of time it must have gotten worse. So I did the work up . She had o chest X- ray in long time . I did the chest X- ray and breathing test and AAT a genetic test to see if she had lack of certain enzyme that can cause emphysema in smokers. The chest X-ray came showing some abnormality and so I did CT scan. The CT csna showed 2 masses  and she had it quite close to center of left lung. I did PET scan and in Pet scan  glucose is used and that is picked up by every cell in the  body and the concentration of the  glucose pick up is measured. .Higher the pick up more likely to be due to cancer. So the PET scan is 80% accurate in picking the diagnosis of cancer. So there are cancer where the metabolic activity of the cells is not much higher than normal cells and so the pick up is not that high. This is seen in very slow growing cancers. And there are infections that will be positive on PET scan . So it is not 100% . Her Pet scan was positive and so I was sure that she had cancer of the lungs . I did bronchoscopy and I did see narrowing of the bronchus and I was sure that the biopsy will be positive for cancer, but it did not. So, I did ask radiologist to  do needle biopsy. . That also did not show cancer. I had told family that most likely based on our tests , she had cancer. But we did not get the tissue diagnosis. 

    I sent her to a chest surgeon   to consider open biopsy . I thought that was the only 100% test to get the diagnosis of cancer. I was sure that she had cancer. The surgeon called me Her lung function was not that great  and so he wanted to redo needle biopsy with larger needle - so called CORE Biopsy.She had the core biopsy  and that showed the CANCER!

    So the persistence paid.

Saturday, November 12, 2022

LESSIONS TO LEARN

     The medicine is fluid. Everyday we get new information and new tests and new drugs and treatments . Sometimes what we learned in past may be partly true or may not be true at all. The classic example that I can give is frontal lobotomy where frontal lobe of brain was removed as a treatment and I think he got Noble Prize for that. But now we know that that is not correct and no one does Frontal Lobotomy any more .But certain principle still guide us They are almost eternal in that sense. The work up of anemia is one of them. But I often see patients who have anemia or low blood count get iron as treatment and many a times that may not be the problem. This brings me to the patient for today. 

     I saw this patient in my office . She was one of my patient's wife and had been diagnosed to have CIOD  as she was smoker . So she had bad lungs - damaged from smoking and she must have been so bad or advanced that she was on oxygen all the time . She had no recent work up and so I decided to do new work up. But then she felt more short of breath and so went to ER and was admitted . She was found to have anemia - her hemoglobin which is normally 14 grams,  was less than half at 6 grams . So the hospital doctor ordered gastroenterologist to see her . No anemia work up as to the cause of anemia was done . Th gastroenterologist saw her and told that she does not need any work up in hospital  and she should be worked up for anemia as she had normal stools and there was no evidence of blood loss . I was notified of her hospitalization 3 days down the road . I saw her and realized that her worsening of shortness of breath was due to anemia rather than COPD . But she also had wheezing and she was not started on any bronchodilators which she used to have at home . I started her on her usual inhalers and did anemia work up. She also had some other problems . 

     Her condition improved and her shortness of breath was better as she was started on medicines and she had a blood transfusion. But the anemia work up showed that she had abnormal protein. Just to give an idea we have raw material that is needed to make hemoglobin - like B12 , Iron, Folic Acid  and vitamin C and some other  and then there is factory - which is bone marrow. We tend to lose blood  in conditions like stomach ulcers or diverticular disease or polyps in colon  and colon cancer  and in younger ladies menstrual blood loss. So one has to find out if anemia - low count is due to poor or lack of raw material iron being one of them or if factory - the bone marrow is defective or if we have blood loss. In this patient the work up showed that she had problem with bone marrow . The abnormal protein which is produced by overgrowth of certain cells in marrow leads to reduction in production of red cells which carry hemoglobin

     So her shortness of breath was made worse by low hemoglobin and that was due to somewhat unusual cause of abnormal growth of certain cells in marrow and iron will not work 

      LESSION LEATNED !. 

Sunday, September 18, 2022

DO WE NEED 'TESTS' FOR DIAGNOSIS

      We in medicine have seen pendulum swinging from one end to other in many aspects of medicine. We have seen popularity of different tests or treatments . With time we may have n=better tests or the tests becomes less reliable with more tests being done. CT scan or PET scans can be considered belonging to this category. When the PET SCAN came in we thought that it was going to be 100%  accurate in getting diagnosis of cancer. But as more and more tests were done and we gained more understanding in to the tests, we realized that the accuracy of getting diagnosis of cancer , was reduced and not closer to 100%.But now we know that it's close to 85% . But sometimes things that we assume based on history and physical examination, are not 100% and we need additional information . Sometimes we order tests to confirm our suspicion  and then we are surprised. That brings me to story for today.

       I saw this 60 years old male who came to me for shortness of breath. This was going on for years  and he has seen new PCP and he had sent him to cardiologist .He was nonsmoker  and had history of high blood pressure and mild diabetes. The cardiologist di the work up and the work up did  not reveal any cardiac problem and he came to me. He had shortness of breath for long time. His physical examination was unremarkable. His lungs were clear and he had good oxygen saturation. He was obese  and may have had sleep apnea, but that was not related to his current problem or complaints. I thought that he had increased BMI  and overweight had caused decreased activity and exercise  and so he was DECONDITIONED . So the shortness of breath was due to that, especially as cardiac problems were ruled out . But I was going to do the work up . My presumption was that the work up will be good  and then I can tell him on weight and lack of exercise and shortness of breath. 

    I did do the pulmonary function studies  and to my surprise he had moderate obstruction - indicating ASTHMA . So even though he had shortness of breath for long time and the lungs were clear  and oxygen was fine - he had asthma .So sometimes we need TESTS to diagnose !!

Saturday, August 27, 2022

IS THERE END TO IT?

        I have often seen patients that have medical problems  and the treatment is started  and patients  and the physicians look for the completion of therapy. Certainly this is not true for high blood pressure or diabetes, in many cases the treatment is life long . But say someone has lung cancer  and we decide to have surgery  and so when the surgery is done  and that is successful, the so called treatment is over-complete. Pneumonia would be other condition . Do antibiotics  and the treatment is done with. But in some patients we end up having one thing leading to other. This is such a story.

    I saw this patient in my office who was seen by other lung specialist in past. She had abnormal CT scan of chest  and the physician had done bronchscopy  and she had MAC -the atypical TB called mycobacterial intracellular and so she was started on medications but somehow he did not do much follow up and so she came to me. She came to me . We did the follow up on CT scan and also did new sputum for TB bacteria  and then continued to do the follow up. She was doing OK  and at the end of almost 1 year of treatment we did new CT scan . The treatment for this disease is usually for 18 months , Or 6 months after the sputum is negative. This is done as the chance of recurrence is high if treated for shorter duration. The CT scan showed some worsening of the findings  and so I did do new bronchoscopy  and that showed that she still had MAC. So I added 4th medicine . So now she was on 4 drugs  and we had already exceeded 18 months . But then i did do new sputum check in 3 months  and that was negative . The scan was OK and she had no complaints. So we were happy  and we had plan to stop the medication in short time. But we did new sputum check  and IT SHOWED A DIFFERENT MYCOBACTERIUM.  

    So now we are stuck with treating her with NEW DRUG  and for HOW LONG ?

   But I know there is a light at the end of tunnel. 

    

Saturday, July 30, 2022

NON SMOKER AND LUNG MASS

     We often talk about the smoking and the lung cancer. The incidence of lung cancer is high or 20 times that of nonsmoker. So when we see a spot on the lung it is easy to make decision . But even though the incidence of cancer is low in nonsmoker, it is not zero. So the decision making is difficult. The general public has a belief that the incidence is zero. That brings me to  the story of today. 

    I saw this new patient 55 years old male who had abnormal scan. He had no major complaints  related to lungs, but in 2019 he had car accident and he had been to er and had work up. He had a CT scan of chest and that had shown a spot on the lung , size of dime. He was told to do new , follow up scans .He did not do any scan till now in 2022. It may have been due to the belief that the non smoker do ont get cancer or may be that it was pandemic and since he had no symptoms , he thought he was OK .Any way he did not do new scan till 2022. The scan showed that the spot had increased in 3 years and it was now of a size of quarter  the coin. His primary care physician send him to me. He had been non smoker and has no cough , fever , chest pain or weight loss. He had no shortness of breath.

   His physical examination was unremarkable . He was not on any medications. I saw the scan . The mass had increased  and so i had discussion with him  . I told him that we have to do work up and then decide if we can do surgery to take it out. The usual things that I tell patients is that we need to answer 3 questions , namely is is cancer , has it spread  and what is the treatment . So I have ordered  PET SCAN , a breathing test and bronchoscopy. There is a tumor called carcinoid which some people call a cancer which rarely spread or benign tumor which can spread . I thing it may be carcinoid and only 100% way to know is to take it out. When we tried to schedule the tests , he wanted to postpone them . 

    So there are 2 points , one is that if he was a smoker he would not have waited for 3 years to do new scan or see lung specialist  and now that we know THAT IT HAS GROWN he was not in hurry to take steps to take it out . This comfort comes from the feeling that nonsmokers are immune to getting cancer. He may have cancer or carcinoid , the slow growth rate suggests that this may be carcinoid , but one cannot be 100% sure till surgery is done.

Sunday, July 24, 2022

NEW TESTS AND NEW QUESTIONS

    We have great progress in medicine in last few years - as I can say 'in front of my eyes.' We did not have pet scan 40 years ago and CT scan was easily available for us in medicine for only 40 years. But sometimes the new tests add to answers and help in making decisions in maedicine  and sometimes it add to more questions. We started about what was then called as Liquid Biopsy few years ago  and that was trying to detect TUMOR DNA in blood or urine  and that would help to detect cancer at earlier stage - in hope that it was 'curable'. We also have some newer tests called NODIFY2 where detecting certain protein would help us to calculate probability of cancer . So we can do calculation without the tests and then redo it after the blood tests are done and see if the probability is 'increased' or 'decreased'. But still that did not give us the diagnosis. This brings me to case for today. 

    I saw this patient in office may be 67 years old , She had routine ? CT scan . So few years ago the Medicare approved doing CT scan of the chest to detect Lung Cancer at earlier age without having abnormal chest x- ray in certain group of patients. The smokers and nonsmoker  for 14 years are  included. So this patient was having CT scan done - which is called LOW DOSE RADIATION SCREEING CT SCAN OF CHEST . (There is a special code for doing this tests) So when she had CT scan in 2018 there was no abnormality . She continued to have new scan yearly except in 2020. Due to COVID in 2020 she did not have the scan . She has no major  symptoms like cough , fever or chest pain or shortness of the breath. So she had new scan in 2022  and when that was compared to one done in 2021 ,she had new nodule ,size of 9 mm . For some 15 mm make an inch . So it is very small but not of that size that we can just do follow up as that could be due section variations . (The sectioning variation may be due to size of cuts in CT scan ) She came to me . I saw the CT scan and decided to do the test called PET scan . In PETS scan one is injected with glucose  and that is picked up by ALL the cells in body and then a scan is done  and where ever the glucose concentration is high compared to normal cells in that organs will indicate cancer or infection or inflammation.. The cut of for doing this test is 8 mm as the nodules bellow that size may not have enough cells to 'show up ' on the scan . So she had borderline size for PET SCAN and i did that and the activity came as 'borderline . I have also ordered blood tests called NODIFY2 which is good for nodules with size of 8 mm minimal. Again borderline size . I don't have the report yet . But now I have a patient who has 9 mm NEW nodule and the PET scan is borderline pick up. The size is not large to do needle biopsy, and now we have to make a decision as to what to do. We can do open biopsy and take out 1/3 of lung and get diagnosis. Or we can do follow up CT scan in near future - may be in 3 months .So the new tests have not added much to help us change the course of our action is diagnosing the cancer. If I did not have PET SCAN ,I would have done the follow up on scan only . So by doing the PET SCAN i now have more question as the metabolic activity was not 0 but was lower level where I HAVE TO MAKE A JUDGEMENT CALL !! 

Saturday, July 16, 2022

ART, SCIENCE AND MAC

     I have often felt that there is an ART in medical science. But most of the time doctors feel that medicine is science and not art and many a times in controversial cases we are held accountable as we did not treat as science. But there is individuality  and there must be variation n work up and treatment of the same disease in different situations. If I see a mass in a very old person, who has dementia and is wheel chair bound, i will have different choice of work up and treatment than when I have another patient who is 40 years old and has all his faculties intact and is physically also fit . This applies to almost every disease. The control of diabetes is much more strict when we are treating younger person than we are looking at 80 years old person . The damage that can happen with low blood sugar is bad and the chance of missing it in elderly person is high and so we allow the blood sugars higher than what would be acceptable for younger patient. This brings me to todays story .

   I saw this lady who was a nurse  and she was in her mid fifties . She had never smoked and she has some cough for long time. She saw a lung specialist and he did the usual work up and then did follow up. She had CT SCAN and breathing tests and some inhalers tried on her . She had no shortness of breath and she has no chest pain and she looked OK. She did not have any weight loss and no low grade fever. But she had abnormal CT scan of chest done. So she had bronchoscopy  and that grew a bacteria called MAC. This is also called mycobacterium Avium or MAC for short  and also falls under NTG -NONTUBERCULOUS MYCOBACTERIA. She was sent to Infectious Disease specialist  and he sent her to me for whatever reason. She being a nurse was somewhat aware of the treatment options and the side effects etc and wanted my opinion. The treatment for MAC which is a chronic condition and it needs treatment which is prolonged . The current treatment is that with 3 drugs for 18 months . The medicines are given either daily or 3 days a week depending upon the disease severity . The medicines are continued for 12 months AFTER the sputum shows no bacterial growth after the treatment is started . One of the medicines has sometimes effect on Liver and so we need to watch blood test for liver damage . Other one can cause problem with vision - optic nerve and so we need to check the vision periodically  and so we need close watch . If the sputum continues to shoe the bacteria ( it's mycobacterium and not the bacteria )then we have to start 4the drug. Some may have problem with stomach.

    So, she wanted to know my opinion if she could avoid it . Here is art  and science mixed . Ideally if she has 2 samples positive for MAC then she needs treatment - this is science . But if we can watch her clinically and with CT scan and also with sputum culture then that will help . I have no test that can tell me if a particular patient will get worse or not. So it becomes purely an art . The science is -TREAT and the art is treat or not treat and just WATCH . There is risk in either approach - she can have side effects with medications or she may get worse without the treatments. 

        Now you know what I mean by ART and SCIENCE mixed in medical practice. . 

Saturday, July 9, 2022

GGOD AND BAD NEWS

    When we see doctor, many a times people say that there is a good news and bad news . Like " you have diabetes is the bad news , but it's mild and we can treat it easily is the good news '. But sometimes we see patient who has cancer it's impossible fond much good other that may be that we can operate and cut it out . This story is something like that but much different. 

   I saw this 68 years old female in my office . She had some cough and had been going on for 2-3 months and then had a chest x-ray and that showed abnormality and so she had CT scan and she came to me She had not smoked for many years and she had no weight loss or fever or shortness of breath. She was little overweight and came with her friend. She had clear lungs and her oxygen saturation was good. I saw her CT scan and she had a mass in the left middle part of the chest and it was very large almost 7-8 cm . The location was such that she could not have been operated and also the lymph nodes in the center of the chest called hilum were also involved. This makes it inoperable stage. I told her like I tell every patient with suspected cancer that we have to answer 3 questions . IS IT CANCER - HAS IT SPREAD - WHAT CAN WE DO - TREATMENT CHOICES . The surgery was out of question due to location and the lymph node involvement . That left us with chemo and radiation. But we needed the diagnosis . Any time we exclude surgery as treatment choice, that is not a good news as the radiation and chemotherapy are not 'curative ' treatments. But we needed a diagnosis . So we proceeded with biopsy  and PET SCAN . The GOOD News was that the cancer was limited to LUNGS  (though inoperable) At least I told her that that was the good News. The biopsy was done and that showed the cancer to be what is called 'SMALL CELL CANCER'.

    The thought that bothers many patients is that if they would have the diagnosis SOONER - EARLIER ,then it would be smaller an the surgery to give CURE would be there. So what would be the good news in the diagnosis of inoperable cancer ? The answer is the SMALL CELL CANCER CANNOT BE OPERATED and the treatment of choice is chemotherapy. So even if I had seen her 2-3 months earlier when the tumor was sat 2 cm , it still would be treated with chemotherapy . So in this case the BAD NEWS is that she has cancer  and the GOOD NEWS is that it is  type OF A CANCER THAT IS ALWAYS TREATED WITH CHEMO AND NOT SURGERY !!

Sunday, June 12, 2022

GREAT TALKER IS GOOD LISTNER

    I have been in medicine for many years and I have realized that many times all that one has to do is to listen to a patient's story . Now I can also say that many times the diagnosis is simple or straight forward and the talk may not help e.g. straight forward asthma. But when there is a diagnostic dilemma we need more history , so we can order tests that can clinch the diagnosis rather than ordering tests that may take us on wrong path and delay in knowing what a patient has. That brings me to my story for today. 

     I had known this patient from my evaluation in office . He was 73 years old and was quite obese. He seemed to have sleep apnea, but did not want sleep apnea. He had also smoked and had COPD - the disease that one gets due to smoking. He had be started on oxygen and his activity level was very limited and he had not done any diet. He went to ER one day. He felt weak. The ER doctor saw him and did some routine tests and was admitted .The hospital doctor saw him and at the request of patient. I happen to see the doctor and he told me that he has admitted my patient and has called me for the consult ,but 'he looked ok and should be ready to ho home in 1-2 days . ' I went to see the patient. He had his family with him . I asked him as to what was the reason that he came to ER he was not short of breath but felt weak. I told him to tell me what exactly happened . So he told me that he was sleeping on floor - rather unusual thing in this country. But then when he tried to get up he could not  and he had to crawl to his bedroom. He barely pulled himself in the bed  and then when he had to go to kitchen he had to crawl again and so then his family called 911 and he was brought to ER. I am a lung specialist .But I told him to raise his arms and he could barely do it  and to me it looked like shoulder problem may be rotator cuff injury , but he told me that it was worse than his usual shoulder problem. I asked him to raise the legs  and he could not. His oxygen saturation was ok and his lungs were clear . His chest X- ray was fine and routine blood tests were OK. But I was concerned about his weakness and so I ordered CT scan of cervical - neck spine and also Lumbar spine  and consulted a neurologist. 

     The scans were done  and they showed as expected lots of arthritis. So then the neurologist ordered a MRI of spine  and concluded that he had a SPINAL STROKE . He suggested physical therapy. He felt that there was issue with spine  and that will need physical therapy and some time . He signed off the case. Next day he looked weak and little short of breath  and then I send him to a monitor bed as I was concerned about worsened neurological status . The spinal stroke is where the function bellow  certain level of the spinal cord there is muscle weakness or paralysis. I talked to him and his family. I told them about my fear that he may have paralysis of breathing muscles and then may need respirator. He told me that he would never go on respirator  and wanted to sign papers right there . His family also felt the same thing and so we made him DNR . I called the neurologist  and talked to his associate as he was not in the office  and told him my fear of what is called ASCENDING POLYNEUROPATHY. In this condition the weakness ASCENDS from lower level to higher level So when respiratory muscles get involved then one cannot breath. He came in and agreed  and started treatment. Patient did not want any artificial support to sustain life  and so in next 24 hours he passed away. 

     The story that patient had was suggesting that something was happening  and this was not  the usual 'weakness ' that happens in many older patient who are obese and who have other lung and heart problem like this patient had. Just allowing patient to tell what exactly happened  helps  and then diagnosis becomes clear. 

Saturday, May 28, 2022

TO TREAT OR NOT TO TREAT

   In medicine we have many of us who are nonflexible. I f i check blood pressure on a patient and the recording is 150 / 95 , there is no question in my mind or for that matter in any physicians' mind as to treat or not treat. The high blood pressure must be treated ,we will treat it.If the blood sugar is high we treat it though it may depend upon age of the patient - but if the sugar is high, then we will treat it. Ig we see 80 years old person and fasting blood sugar is may be 110 we may not treat it but if the patient is 30 years old we will treat it . So there is some variation in treating diabetes . The same holds true in case of elevated lipids - cholesterol - though most of the cardiologist have lost the flexibility and treat even 90 years old with same medications  and that may be due to combinations of factors like insurance company asking us to do check marks  and then pharmaceutical company pushing for the drugs  and so on. But most of us weigh the benefit V  risk. The story that I am telling story  today is one such patient. 

    I saw this 84 years old patient. She had chronic cough and the PCP had treated with meds and antibiotics and cough meds and steroids, She had a chest X- ray done  and that was showing some chronic changes . She came to see me with her daughter. The cough was going on for more than a year. I did a CT scan and the breathing treatment. The CT scan showed damaged bronchi and mucous plugging  and and some other abnormality . I decided to do Bronchoscopy  and also some sputum culture for acid fast bacteria. The bronchoscopy showed that she had damaged bronchi and mucous  and the cultures came back showing bacteria called MAC. (If you want to know on MAC please see my YouTube  channel  under JUST A TALK on MAC or check out NTM )This is bacteria which  grows in damaged lungs  and also causes more damage. And patients have chronic cough sometimes blood in it and low grade fever  and night sweats and weight loss etc. Her sputum cultures also showed MAC . So under ideal conditions she NEEDS treatment . The problem is that the treatment consists of at least 3 drugs for 18 months . One of the drug can affect Liver and other one has potential for eye. So we monitor liver and eyes . So I discussed with her and her daughter on the treatment  and the medications and follow up and the monitoring etc. After the discussion they decided that they did not want the treatment . I agrees with them with one condition. WE HAVE TO MONITER HER with CT scan  and  clinically. There is a possibility of worsening if untreated . 

     So we have a disease  and we decided not to treat taking in to account her age her symptoms and understanding of the disease  and risk of worsening. And I have some older patients that WE have decided to watch  and they have done well without the treatment .  

Saturday, May 7, 2022

MIND OVER MATTER

     In past I have stated that 'The eyes does not see what Mind does not sees' have seen several examples of this statement when I take care of patient. It may be memory problems which are not picked up by patients or their families to the doctors or nurses not seeing what is in front of them as their mind did not think. I had mentioned of patients that was sleeping  and the family sitting around  and thinking that she is doing 'fine' and the nurse also thinking gthe same and also the doctor who saw her .Then when I ordered the blood oxygen - carbon dioxide to know that she was in serious trouble due to elevated CO2 which acts as sedative. I THOUGHT OF ELEVEATED COO2 in this patient with poor lung capacity and so I COULD SEE it . But somehow others did not THINK OF it and so they did not SEE it. The story that I want to tell you is similar .

     I saw this young man who had seen other doctors  and had come to see me as second opinion. He has been having shortness of breath for almost one year and he complained about it to his PCP. He was non smoker and he did not seem to have any cough or wheezes . He had no chest pain and this had creeped up over period of time . So the PCP sent him to a cardiologist . The cardiologist with his blinders did the cardiac work up. He did the tests to rule out cardiac issues as the cause of shortness of breath, He had Echocardiogram  and stress test. He was seen  and then after the tests he was not called with reports  and as expected he thought that the tests were OK. He had follow up 3 months after the first visit with the cardiologist. When he saw the cardiologist, the cardiologist went over the tests  and realized that his pulmonary artery pressure was elevated. Let me explain this medical thing. The blood from which the oxygen has been taken out  and retuned through veins to right side of the heart . The Right side of the heart called Right Ventricle pumps it to the lungs where it gets the oxygen and then it goes to Left Side of the heart . The Left side chamber called Left Ventricle pumps to body . So we have 2 circuits -one right side of heart to Lungs and other Left side pumping to body . The blood pressure that we measure  is the pressure that left ventricle generates when it pumps to body but the Right side pressures  cannot be checked without doin g Echocardiogram. The normal blood pressure is 120 to 140  and the normal Right side pressure is 25. So his pressure on right side was 60 . This is called PULMONARY HYPERTENSION. 

      I am not talking about the diagnosis of pulmonary hypertension and the work and the treatment, but I wanted to point out that the cardiologist who saw him first time and did the work up had also read the echocardiogram which had shown elevated pulmonary pressure . But the elevated pressure was SEEN and the REPORT was dictated by the same cardiologist . So why was that not noted at the time of report generation ? The answer is YOUR EYES DON'T SEE WHAT YOUR MIND DOES NOT THINK !!


Saturday, April 23, 2022

NEVER NEVER 100%

    In medicine we go by statistics. Take a simple example of bronchitis or pharyngitis. In medicine we see a patient and if the complaints and the physical examination fit =s in to the diagnosis then we treat with antibiotics. We don't necessarily do a throat culture or blood count or X- ray etc. as investigation. We just treat it and we get to be correct most of the time . Out=r decision is based on statistics and we are correct most of the time . The bad part is nver 100 %. This is a story of a patient when we did not get to be right and still we felt good.

    I saw this patient 68 years old who was a current smoker . He had some cough and he had no other complaints. He had had chest x- ray  and that was OK but he had had a CT scan in past that had shown abnormality . The old CT scan was from 2 years old . I got hold of  the report of the CT scan and that had shown a nodule. he had not had the new or follow up scan  and so I decided to do new CT scan . The CT scan showed that the nodule had increased by quite a bit . To be exact the nodule was 9mmx6mm and now it was 16mmx11 mm We did the bronchoscopy and also did the PET scan . The PET scan uptake was mildly increased, The breathing  test showed adequate lung capacity. The PET scan uptake was minimally increased but we can see that in very slow growing cancer as the metabolic activity of theses cells is not very high and so the uptake could be low..I discussed the case with patient and the family . I also called a chest surgeon. The surgeon was sure that he had slow growing cancer and I also felt the same thing and the problem was only 100 % test is to do open biopsy. 

   He has the open biopsy and the report showed no CANCER and it was a scar with lots of inflammation. So that was good .I was happy that he did not have cancer we don't have to worry about recurrence, but we were 100 % wrong. So in medicine there is no 100 %  right or wrong!!

Sunday, March 13, 2022

LEARNING CURVE

     In medicine we have certain diseases called as Syndrome. Theses are the symptoms or signs that are bundled together and we OBSERVED them in a patient and then in other patients together . e did ont know why certain things were together but we knew they were together  and so they were coined tern a syndrome Over period of time we knew the cause for the disease  and then found out why different organs seemingly unrelated were involved. When a new disease pops up we have a learning curve. The most recent example is that of COVID. We started with many assumptions  and then as we saw more patients , we realizes that what we thought as the right thing was not right and was wrong . The use of BIPAP or noninvasive ventilation is classical and so is use of steroids. We were told that we should not use steroids and then a study came out that use of steroids reduced mortality and morbidity and now in every patient we use steroids .But I feel that we are still in a phase of learning curve - may be it is flattened but it is still there. 

      That brings me to the story for today. I saw this new patient who was having intermittent fever for last 2-3 months  and so his PCP did out patient CT scan of chest and then when he got the report, he was asked to be admitted for further work up and doing a bronchoscopy. I saw him He was a 68 years old male patient who had lymphoma  and that was diagnosed many years ago and he had some radiation and then chemo. He was treated in Italy  and also here .He had COVID infection around X-muss and did not have much problem getting over the infection. He then had the vaccination for COVID. He continued to do ok but had some low grade fever off and on. He had no weight loss and he had good appetite and he never had very high fever. I talked to him and his wife  and then he was started on broad spectrum antibiotics  and we did do new CT scan to rule out any blood clots. I did do a bronchoscopy and there was not much of abnormality and I sent samples for bacteria and mold and TB and also cancer cells. He had test for COVID and that was negative . He had no positive microbiological culture. But then he had fever again. He had some additional studies  and a new COVID test. And that was positive this time. So I was not sure what to make out of it . The tests done 4 days apart one positive and one negative. I spoke to the infectious disease specialist and we decided to start him on treatment for COVID. But we also did antibody titer for COVID. AND HE HAD NO ANTIBODIES FOR COVID. So after having the COVID infection and having vaccine for COVID, he did not produce the antibodies and so he probably was having persistence of virus in body  and that was causing low grade fever off and on. This is my conclusion. 

                                This is my learning curve - and based on that we have treated him. 

Friday, March 4, 2022

Disappointment

   The life is full of success and failures  and we have many disappointments , may be in our own life or job or kids or team that we follow for any game and so on. But sometimes we expect certain things and then the final outcome is worse that what we expected . This in MY VIEW is due to Hidden and unseen KARMA -FALA - Fruit of our past Karma that we are not aware of. Again this is my view based on what I understand of The Law of Karma. But in medical life we don't want it but we have to face it. This is the story of one such disappointment.
     I had a call from PCP . He had seen a patient who had cough and he treated  and then when it did get better, he did chest x- ray. He not only ordered the X- ray he did personally see it. He was not happy as he thought he saw something  and the radiologist had not reported it and so he did CT scan and he was right. The lady had a mass - or suspected cancer. So he called me and I saw her in office .We did the work up which is to do the PET scan and there was increased in the uptake of the glucose in the mass. she had breathing test and that showed that she has good lung capacity in case we needed  to do surgery and cut the part of the lung that has cancer . I was happy to some  extent as even though she had cancer - most likely , she was resectable  and hopefully the surgery would be curative . So i sent her to a thoracic surgeon. He saw her and she was scheduled for surgery. In between she was seen by neurologist as she had some tremors of one of the hands . He did do a MRI of the brain - which is rather routine than for any specific suspected diagnosis . To his surprise she had a mass in the brain. So the chest surgery was cancelled or put on hold. I came to know about it when we called her to find out on date of surgery.She was sent to oncologist and a neurosurgery. But we had no definite diagnosis of cancer. So I called her and scheduled her for needle biopsy of the lung mass. I also called radiation therapy doctor to see her. 
   So in this case the primary care physician was right in doing the CT scan and he did find out the cancer and sent her to me . I did do the work up and was happy that we could sent her to thoracic surgery for cutting out cancer. No one had suspected brain metastasis at the time when we all - the primary care - myself - thoracic surgery suspected it. I don't think the neurologist suspected it either. So this was great disappointment - what was thought to be curable cancer was now only treatable cancer  and chance of cure was reduced to minimal.

Saturday, February 5, 2022

PREDICTABALY UNPREDICTABLE

      In our life we have things that we expect and they do happen and then things that come as absolute surprise. So we have things that are predictable  and we know that things are going to unfold in certain way and so we have expectation and our mind is ready for it and so the impact is not that much. But when we have things happen which we did not expect , and then we face them we are not expecting them and so we are not prepared for them and we are shocked. So that brings me to the story for today. 

     I have been seeing this patient for many years and he has had multiple problems but main was pulmonary fibrosis . He also had aortic valve problem and I ha =d told him that needs to be fixed and he  saw cardiologist and they did not feel it was that bad . After about 1 or 2 years they felt that the valve needed to be repaired  and so he was admitted . He had check up for carotid artery and he was found to have narrowing and so he had stent and then he had stroke. . So then he partially recovered from it. His wife helped him and he had missed follow up and after a gap of 8 months ,he came to see me. He was doing OK from my stand point and had some limitations on walking. But is wife was with him After the visit was done , he asked me if I could help his wife. I said sure , what is the problem. He told me that she ha shortness of breath and so she went to ER and had CT scan and that was abnormal. The Ct scan showed a large mass. So I agreed to see her in 2 days as emergency. I had neve seen her and since she was in ER and was not admitted , I presumed that she was OK . I saw the CT scan before she came to my office. I knew that the mass was large and was not in best position and so I had scheduled her for biopsy. She came for the appointment  and when I saw her and checked her she was not in the best shape, She was diagnosed to have COPD  and has been on oxygen and she was short of breath and when I checked her , her heart rate was vey high and her oxygen was very low. The heart rate was 170 and so I increased the oxygen and told them that she will need to be admitted . The mass was close to major blood vessel -pulmonary artery going to right lung and it was encasing the artery and also the bronchus . So that was bad to start with and I had anticipated difficulty with getting biopsy and also the treatment part. Certainly she was not surgical candidate  and the option of treatment was radiation and chemotherapy. But now with the heart rate issues and oxygen problem I was not sure as to how much can be done at this stage . 

    So I was aware of the fact the CT scan was not very great for the treatment but did not expect that we will have such a difficulty now even without even having done work up. This is predictably unpredictable.

Saturday, January 15, 2022

ONE IN A MILLION

     We in medicine are many a times sure on our thinking and diagnosis. Again this is based on our education and experience and statistics. As I have mentioned in my previous blogs , the entire medicine is based on statistics. If I see someone with cough and fever and yellow sputum, I would diagnose as having bronchitis or pneumonia if on physical examination there are abnormality. We are correct in our thought process  and diagnosis  and planned treatment. We don't do the sputum culture to start antibiotics or which one to give. Again this is based on statistics. But sometimes we are wrong . and then we say or thin this is one in a million. That brings me to the story for today . 

    I have known this 90 years old male for last 90 years or so. He had mild lung problem like asthma and he had been on inhalers and was quite stable. One day I got a call from his physician that he did a CT SCAN and he has cancer. I was shocked . He was 90 years old  and he had not smoked for more than 30 years ago I had seen him 3 weeks ago and he was stable. His last chest x- ray done 15 months ago was OK . So I was surprised . But the CT scan had shown a mass and that definitely looked like cancer. I told my office to call him and set him up for PET scan and biopsy. My office called the patient  to set it up . He had a grand daughter  and we had to call her . But then I got a call from her and she told me that he had a fall and he was taken to ER and then was admitted .They were doing work up to make sure he did not have bleeding or stroke. The work up was ok and he was still littlle confused . He was in the hospital where I do not go. But the granddaughter wanted me to check the chart and make sure that what they were doing was OK with me. The lung specialist planned to do the biopsy like I had planned  and he did . There was narrowing and there was some susicion of cancer but then when he checked the pus came out from that area . I continued to check  and he had infection and no cancer was detected on biopsy. He was started on antibiotics  and he was discharged on IV antibiotics 

   I spoke to them on telephone as he was too weak and could not come to office. Hew as doing better and last chest X- ray was much better. So it looks like he did not have cancer but had lung abscess - infection and pus in lung that looked like cancer. 

   This kind of thing does not happen often but only one in million .