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. 

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.