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 .  

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 !!