NO CHOICE

      In medicine we have to make decisions . We have to decide what should be or would be next stage in work up. We may know what is the most likely cause or the explanation or the diagnosis, but we have to make sure that the serious diagnosis is not there. And then we do the work up. That brings me to the story for today. 

   I saw this lady who was a smoker . She had some cough and also clear sputum. She had chest x- ray done and that was abnormal. She them had CT scan of the chest and so she saw me. I saw her and advised her to quit smoking and did additional work up including PET SCAN and breathing test. As expected she had some reduction in lung capacity. She was not born in US and had some history of TB and I thought that the abnormality was most likely due to old TB . But with her smoking I did do the bronchoscopy and that came back OK .She continued to smoke. My plan was to do follow up on CT scan as smoker can develop cancer and sometimes scar cancer can develop in scars . She was lost for follow up.I tried to call her and then sent a letter . She told me that she had lot of copay and so she did not want new scans 

    But she did come back and then agreed for the follow up on CT scan. 6 months had passed since last CT scan and I was worried as she had continued to smoke . I ordered the scan and she did it and it was abnormal. Now I wanted to do PET scan and she told me she will do it but did not do it for 2-3 months . She was also no show for the follow up. I called and she told me the problem was very copay and promised me that she will do it . She did do the new PET SCAN and that showed some abnormality in the lymph nodes that was not clear cut for old Tb. I was concerned about cancer , though I thought that it was due to old TB . But with the new abnormality seen on PET scan I had to make sure . We did have interventional pulmonary specialist . 

   The biopsy was done and there was o cancer and it was due to inflammation . I was sure or may be 90 % sure that the abnormality was due to old infection and inflammation, but had to do the biopsy to confirm as she was smoker and the abnormality was little worse. 

PROBLEMS WITH MODERN DAY MEDICINE

     The medicine has evolved and  we have much more today as help and problems than what we had 20 or even 10 years ago. And I ma not talking about modern day technology or new procedures or medicines . We have started this new thing which is customer oriented medicine. To add to that we have DR Google. Then all the big medical centers and universities have their web sites 'educating' general public. This adds the help to understand the disease but also adds more questions and problems when we are treating patients. I am not against educated patients , but I feel that half knowledge is more dangerous than no knowledge. 

   To add to this we have AI and the branches of medicines that NEVER EVER SEE PATIENT but give reports .e.g. Radiology , Pathology . These physicians usually do not see patients but give reports that are available very easily and sometimes even before the ordering physicians have seen or received the reports. That brings me to the story for today. I saw this new patient 68 years old who was having cough for 2 -3 months. As usual the PCP  gave him antibiotics and some cough syrup and also tried short course of steroids .The cough continued and so then he had CT scan of the chest - lungs. I am not sure why it was done , but in span of less than 2 weeks , he had 2 CT scans. One with contrast and one without and again  not sure what prompted primary care to do that - and yes I did see the notes from PCP and not mentioned as to why this was done . But in any case it was done. That added to the problems . The 2 reports were entirely different. The one report stated mild emphysema and some scarring  while other stated no emphysema but Pulmonary fibrosis of UIP pattern and traction bronchiectasis and honeycombing etc. On top of that the radiologist never compared the old scan with new one even though they were done AT THE SAME CENTER and only 2 weeks apart . 

   The implication of UIP pattern fibrosis and honeycombing etc. is serious . If patient has what is called IPF- Idiopathic Pulmonary Fibrosis -the prognosis is not great and the treatment is expensive. The treatment does Not cure the disease or reverse it , nor the treatment halts it It simply REDUCES THE RATE OF DECLINE. Many patients with PROGRESSIVE PULMONARY FIBROSIS DIE IN 3 YEAR. Patient had already seen the reports. Again each case is different. So I called the radiologist. The answer that I got was not the best. They could not see one of the scans that stated all the bad findings. On top of that the radiologist stated that 'yes it could be some fibrosis'. This is due to not knowing the medications and the prognosis of IPF or progressive fibrosis. The cost is $30000 to 40000 . and has side effects in 30 % of the patients and as mentioned there is no cure or reversal or stopping the damage. 

    The patient has seen the reports and now I HAVE TO GIVE ANSWERS. 

IS IT TOO LATE ?

     We in medicine have diseases that have some treatment, but the treatment is effective when started 'early'. Again some of the diseases .this is very clear. If one does not treat TB or infection quickly , one could have bad outcome. The infection can spread or one can get in to sepsis and die. The TB can  damage the lungs more and cause chronic symptoms and and then can have shortness of breath etc. But in certain diseases, one is on the fence. The treatment of high blood pressure is clear - everyone with high blood pressure must be on medicines to bring it down. But disease like PULMONARY FIBROSIS is different. Not all those patients who show FIBROSIS on CT scan get worse. In my personal estimate may be 20-25 % get worse . In this situation the treatment becomes tricky. The reason is it SOES NOT CURE OR EVEN HAULT the worsening of the fibrosis . In addition to that it is costly and also  the drugs have side effects. When yo look at the days and talk to drug company representative, they show data that if the treatment is delayed , then the response is not as good.SO how do you decide?

     That brings me to the story for today. 

   I had seen this 80 plus years old patient. She had some cough and also some shortness of breath . But the her activity level was so low that shortness of breath was not that major problem. She was seen by me and we did the work up and she had high resolution CT scan of chest and breathing tests and walk test . She had Fibrosis . The CT scan confirmed it and the breathing tests also showed that she had reduced pulmonary reserve and the diffusion of oxygen was markedly reduced . The walk test showed that her oxygen was reduced when she walked for 6 minutes. So we talked about the disease and diagnosis and use of oxygen and other medicines that CAN help . The medicines that we us for the fibrosis. are considered special pharmacy medicines , which means they are not available in regular pharmacy . We have to do special forms and attach reports etc and then drug company will approve and check with insurance on coverage etc . The cost is high - may be $20000 plus a year . So they also have FOUNDATION that offers help for copay. The patient has to give information on their income and consent to check on all of this . We gave her the forms and bring them back when completed . She did come for the follow up , but did not want the new medicines. So she continued to have some cough. Then she went to California and stayed there for 6 months or so . When she came back , we went over the same options. In all more than 1 year had passed since original diagnosis and we continued the same path . She would take the forms home and then would not bring them back and would come for the follow up. She was getting old and was on oxygen and also continued to have cough. She had hiatal hernia on the CT scan and the primary care and family wanted that fixed and so she had surgery for that and nothing changed . The new  scan continued to show hiatal hernia - which means the surgery failed.

    Her shortness of breath and need for oxygen was getting worse. We did do the tests like walk test and breathing tests and CT scan and that showed that she was worse. So now after 3 years since the  original diagnosis was made , she agreed for the medicines. We did the form and she was approved and started the medicines. The medicines cause gastrointestinal side effects - nausea and diarrhea and also causes weight loss. She had them and so now instead of increasing the dose , she was taking half the lowest dose and still has same problem - cough oxygen drop and shortness of breath. 

    I am not sure if she would have been better if she had started medicines early. The studies do show that when started early, the RATE OF DECLINE IS reduced . IT does not reverse the process nor does it hault the process , but the worsening is slowed. So may be she would not have reached the point where she is now ,if she had started medicines 3 years ago . I do not have answer.

THE GOOD ,THE BAD AND UGLY

      Sometimes in medicine we have situations where we have to say 'there is good news and there is bad news.' We see that often with many medical conditions like coronary artery disease. Now a days more and more patients are getting CT coronaries and then we detect a blockage on the CT scan. We then have to do  heart cath. where we can see the blockage and then we can fix it . Sometimes a stent is needed and sometimes bypass surgery is needed . So the Bad news is that patient has coronary artery disease and the Good news is we can fix it - say with stents. This type of things happen more often with diagnosis of cancer - bad news -there is cancer -good news is we can operate and cure it. This brings me to the story for today. It is similar but little different. 

    I had seen this patient for sometimes . Her husband was mu patient and he had significant lung condition and also had sleep apnea and cardiac issues . She started seeing me for abnormal CT scan chest .She had seen lung specialist many years ago and had done follow up on the CT scan and that was stable . But then she stopped going and had no CT scan done for 2-3 years. When I saw her she was stable and had no major pulmonary complaints. We did the new Ct scan and the abnormality was stable .Most likely she had scar . But since scar can become cancerous , I continued to do follow up and do new scan in 6 months.2 years must have passed by and then when we did the new scan , there was an increase in the size of the abnormality and the radiologist stated obstruction of the bronchus. So I was concerned and I did do PET SCAN . In PET scan glucose which is tagged with radioactive isotope is given and the scan is done . The glucose tends to be picked up more avidly by cancer cells and so based on the pick up, we can decide if one has high chance of cancer or low chance. The PET scan was done and it showed high pick up. This increased the chance of developing cancer in the scar. I did do bronchoscopy , but that came back with no diagnosis. So I decided to send her to thoracic surgeon.

    He looked at the patient and the scans and felt that it was most likely benign and felt that the surgery would be " messy". I felt that with given PET scan findings of increased uptake and the growth that was seen on the serial scans , we needed to take it out as the chance of cancer was high . She was nont sure . But then we talked with family and her and she agreed . 

   She had the surgery. The surgeon tried to do it with mini incision- VAT or robotic and that did  not work as she had lots of adhesions. So he had to do it with larger incision. The pathology showed that there was NO CANCER. After the surgery she went home , but in that post op period, she had irregular heart beats - though they resolved without treatment, they would or could be life threatening. So she was seen by cardiologist who specialist in electric circuit in heart . She did not want additional procedure and so was sent home with new heart medicines. 

    She went to see her regular cardiologist after discharge. As is so common now a days , she was seen by nurse practitioner and no new tests - work up and no new medicines. She came to see me . I had not seen her in hospital, but I reviewed her medicine list and realized  that she was on new cardiac medicines. So I asked her she told me as much as she could . I went on to hospital site and  realized that she had very dangerous cardiac irregularity. SO I HAD TO CALL THE CARDIOLOGIST HIMSELF AND TOLD HIM TO SEE HER SOON AND DO WHATEVER WORK UP IS NEEDED. 

   So now the GOOD-BAD AND GTHE UGLY. The good part was that she did not have cancer. The bad part was that we had to do surgery to diagnose . The bad part was that she needed open big incision surgery . The good part was that in spite of that her recovery was smooth and quick. The bad part was that she had cardiac issues after surgery. The good part was that was treated and she did well . AND THE UGLY PART WAS INSPITE OF SEEING CARDIOLOGIST AFTER DISCHARGE - THE ARNP AND THE CARDIOLOGIST DID  NOT KNOW THE SERIOUS NATURE OF HER HEART PROBLEM AS MODERN MEDICINE IS PAYING MORE ATTENTION TO HOW E WRITE NOTES AND NOT AS TO HOW WE CARE FOR THE PATIENTS. 

   

ALL THAT GLITTER IS NOT GOLD

     All that glitter is not gold is old saying and in medicine sometimes we have patients that remind me of that. In medicine we try not to have 2 diagnosis in a given patient to explain the symptoms. But sometimes the modern day tests are done and then we have to do work up. That brings me to the story for today.

    I have known this patient for last may be 10 years and he was late sixties and had diagnosis of chronic obstructive disease. He had continued to smoke. He had some exertional shortness of breath and had some cough  But overall he was stable and continued to smoke . Now a days we do CT SCAN once a year in smokers or ex- smoker for 14 years. So I did new CT scan and this time it showed a nodule or density about 1.5 cm and there was some cavitationin it. The cavitation sometimes indicates infection .But there were some other much smaller nodules also. I was concerned about the him having cancer. So I did PET scan, In PET scan we give glucose and that is picked up by every cell in body. The cancer cells have higher metabolic rate that normal cells and so they pick up glucose much more avidly. So based on the activity, which is reported as SUV - the chance of cancer can be determined . Obviously lower uptake ,the chance of cancer is low . So I di bronchoscopy and PET scan . 

   The PET scan showed increased uptake in the nodule . The bronchoscopy showed no cancer - though with such small nodule bronchoscopy is not 100% accurate. But the bronchoscopy showed atypical TB called MAC. Now I was stuck as I was not sure if he had 2 things - cancer and MAC infection . He had COPD and some what limited lung capacity. The MAC infection is treated with 3 antibiotics for 12-18 months. So I had 2 options -one was to treat MAC infection and then do new CT scan in 3-4 months and see if the nodule decreases. But that duration of therapy may not show much change if it is MAC With cancer also it may or may not change in such a short time. The other choice was to do a different biopsy of the nodule - fine needle aspiration or navigational bronchoscopy and biopsy. 

    I decided to start treatment for MAC and asked interventional lung specialist to see him and do new biopsies . 

    The new biopsies were done and it showed -- findings consistent with infection -MAC. 

     SO HE HAD ONLY ONE DIAGNOSIS. 

WEIGHT LOSS

    In medicine we do vital signs as a routine part of examination. That includes pulse , blood pressure , respiratory rate and temperature . Now a days we have started adding oxygen saturation. and height and weight are also standard to be recorded for each visit. One of the things that I have noticed is that in many offices these things are checked not by physicians but by assistant. I think that sometimes is a problem as weight change is not quickly noticed ,especially  if the BMI is normal. That brings me to the story for today. 

    I have known and seen this patient for last 20 years or so. She was a 70 plus years old female who had a diagnosis of Narcolepsy . And she has been treated with medicines and has been stable on medicines . She also had chronic cough and I did work up and could not find any cause for that. I treated her with different medicines like asthma inhalers and medicines for GERD - reflux of acid and allergies and she still had cough. Over period of time it was better and she was doing fair . Then she started losing weight .  

I noticed it and asked her about it . She was not on any medicines and had no other complaints. She had no gastrointestinal complaints. Normally we worry about cancer  and so we do routine work up for GI . She had CT scan of abdomen and saw Gastroenerologist and they could not find any cause .She came back to me . She had also seen neurologist as she had some weakness and needed walker to walk as had fear of falling. The neurologist did some tests and wanted her to see a different neurologist for  Myasthenia Gravis . The blood test for that was negative . She got appointment in 2 months . She came to me with her daughter. She had continued to lose weight and  so the daughter was concerned . 

    I have seen her for several years and knew that she was losing muscle mass and had lost 40 plus pounds of weight. I told her that she needed a muscle biopsy to find out what was going on. She agreed . I called a surgeon to see her soon and do the biopsy . 

  He did the biopsy in less than 2 weeks and the result was something that I had not known or seen before . She had myopathy but the type that she had was not known to me and so i told her to talk to the neurologist and he also had not known much and she was asked to see a nearby university center neurologist. 

   Weight loss is good when it is due to diet - exercise . But if it is way out of proportion to the change in diet and exercise then it needs to be worked up. If the weight loss is unintentional ,then IT MUST BE WORKED UP and sometimes we come across diagnosis which is rare and may be nothing can be done ,but at least we have the diagnosis.

ONE AND MANY

      Sometimes we see things happening to someone , who has bad things happen to him/ her . Then he gets better and comes out and then again an another calamity hits him. I often wonder as to why this happens . But then when you see the 'etiology' or reason for that , we realize that the cause or causes have common thread. This brings me to story for today. 

   I have known this patient 80 years old or so now for many years. He has been smoker and had COPD - the disease related to smoking. He had continued to smoke in spite of diagnosis of lung problem due to smoking. But then he had abnormality on his chest X-ray and so I did the work up . He had cancer of the lung. Fortunately he was a  surgical candidate and so thoracic surgeon did surgery and part of his lung was removed and he did OK. He continued to smoke and I continue to do follow up in office and CT scan . It looked like he had developed some scaring in the area of the surgery, but since the CT scan was abnormal I decided to do bronchoscopy. This time I saw something on his vocal cords - he had cancer . I sent him to ENT physician and then he was sent for radiation treatment . He did OK. He continued to smoke though had reduced. 

     Next few years I continued to see him . He had lost weight and had some exertional shortness of breath. He also needed some oxygen. Then he was hospitalized and the chest x- ray showed large area of pneumonia. I did not see him during that hospitalization . NO CT SCAN WAS DONE - not sure why. He came to me for follow up and so I decided to do further work up. We did bronchoscopy and also PET SCAN as the density was large almost more than 3 inches .I also did bronchoscopy and his vocal cords were normal and there was no cancer in the bronchial tubes. But the PET SCAN was abnormal. There was no activity on vocal cords and the density that was seen on chest x- ray was not there but had a scar in that area and he had some nodules with some activity. BUT there was new mass in a sinus! and that had very high uptake suggesting  a cancer in sinus. I am  not sure on the new nodules in lungs . But this patient who had lung cancer which seems to be cured and had vocal cord cancer and that also seems to be cured -now has new cancer most likely in sinus.SO IT WILL BE 1-2-3!

IT IS NOT POSSIBLE !

      In medicine I never say never. This is due to the uncertainty of medicine. In medicine there are 3 factors  namely Host -Agent and Agent. So depending upon all 3 the response is determine. The agent may be same and it can cause different response in different hosts  and the host may be the same and the agent may be different and the response will be different and the same with reaction between the different agents and different hosts and different environment ,that the response will be different. The example would be mold in home or office and all the people working there have same reaction or may be not the same degree of reaction. Not everybody have same nasal allergies with allergy pollen season. This is known , but then sometimes we have problem with diagnosis as the incidence of allergic reaction is not known, This brings me to story for today.

     This patient came to me for evaluation of possible asthma. He had seen different lung specialist and had severe asthma diagnosed and has been treated with many different medicines and he still had problem. He was offered  additional treatment with biological shots and he did not want it. I tested him for allergies , There is a immune globulin called IgE. which is elevated with allergies and that was markedly elevated and he has several allergies on testing for allergies , but most of them were mild. The option of treatment was limited with allergies and severe asthma needing steroids many times. I also did CT scan of the chest and he had lots of mucous and dilated  bronchi - what we could see in uncontrolled asthma. To see if he had additional fungal infection I did bronchoscopy and tests came back OK

    I talked to him and adjusted meds and offered him biological shots and he wanted to wait. He did do better with my medicines , but the CT scan did not show much improvement . He still had congestion. Then one day he came back for follow up and his lungs were clear and oxygen was normal. He was happy and I was happy. And so I said to him that 'looks like the medicines are working .' Then he said 'But I am not taking medicines .'NONE AT ALL '.He said I stopped all the medicines.

    I was stunned , but thought that there must be something in his home or office or surroundings that was causing his asthma and somehow he must have eliminated it . And I was correct but not in the sense that I thought. HE HAD STOPPED STATINS THAT HE WAS TAKING . I did do new CT scan of the chest . And the lungs were almost clear.

    I continued to do follow up and for last 2 years he has not had much problem and he has not taken asthma medicines on daily basis. He still needs inhaler PRN. - as needed especially when he has resp infecetion. But otherwise he has no problem . 

   So, it seems like he had allergies to STATIN THAT CAUSED THE LUNG INFILTRATES AND AGRAVATED HIS MILD ASTHMA . I have not know this allergy . So my statement that ANYTHING UNDER SUN INCLUDING THE SUN CAN CAUSE ALLERGIES is true 

REFERRED PAIN

           In Medicine we talk of REFERRED PAIN. This means there is pain at one place and the origin of the pain is not near by organ ,but somewhere  farther out. Sometimes there may be pain in upperpart of the belly on right side and that could be from liver of gall bladder .But then there could be right shoulder pain or shoulder blade and that could be from not from shoulder problem but could be from gall bladder. The nerve supply to gall bladder and right shoulder is common and so one could have right shoulder pain and have no shoulder problem ,but have gall bladder problem. Again this is when someone has gall bladder attack.  This not ordinary shoulder pain, but intense pain. That brings me to story for today. 

       I saw this new patient in the office. She was mid 70ies and was sent to me by a psychiatrist. She had moved here from a town 250 miles away from our place. She had complaints of breast pain or as she described -' my breasts are hurting - tender.' The primary care had done the work up and had chest x- ray and EKG and had found nothing. When the pain continued and there was no etiology found for that , he sent her to a psychiatrist. He evaluated her and found no depression and no psychiatric cause . So then he sent her to me. I got her old records from primary care physician and also x- ray report , which was normal. When I asked her about the pain, she said there is pain as if there is a band of chest tightness. and she held her hands on both sides of the breasts. There was nothing in her physical examination. Her blood pressure was normal and her lungs were clear. And the oxygen saturation was ok . I reviewed her primary care records. I also had records from previous physician. I realized that she has been complaining about this pain for more that 6 months . The previous physician had asked a chest surgeon to evaluate and he had done a procedure called MEDIASTINOSCOPY. In this procedure under anesthesia a scope is introduced through incision above sternum and then biopsies are done . They found nothing. But she continued to have pain/ pressure. One thing that I noticed that she had lost weight . In last 8 months she had lost 60 lbs. The weight recorded from previous physician and 2-3 visits by local PCP showed that she was gradually losing weight. 

     I decided to order a new CT scan. I knew something was wrong and there was a problem in her chest . I the CT scan did confirm my suspicion. She had a mass in the posterior part of the mediastinum and the tumor was invading and pinching nerve . This was causing the 'Band like pain'. The tumor was causing the pain and was also causing the weight loss. The mediastinoscopy cannot reach back side structures -near spine , where that was causing the pressure on nerves and causing pain .So we did the biopsy of that mass . We started treatment with radiation and the pain was resolved .

    This pain on the chest wall and breasts is called referred pain as it was due to pressure on nerves from tumor which was farther from the breasts or chest wall.  

CAN YOU PREDICT DEATH ?

      This is very interesting question. I am not talking about someone sick in ICU and is on respirator and falling blood pressure. I am talking about can we predict death in a regular walking -talking patient ,who has no cancer. But recently I came across a form that I had to complete where the first question was 'Is patient likely to die in one year?' This is recent and it was a patient who was to undergo minimally invasive cardiac surgery. As a lung specialist, I often get forms to ;CLEAR' the patients for various procedures or surgeries - endoscopies to cataract surgery to colon resection and so on. The risk of any surgery is increased when the patients have lung problems and the lung capacity is compromised. This brings me to the story for today.

     I have known this patient for many years . He was  70 years old patient, who had chronic cough . I had done the work up and that included breathing test and Chest x-ray . We even did the CT scan of chest . He had mild to moderate asthma or obstruction on his breathing test. The x- ray was ok and so I gave him inhalers to treat the asthma. He used it and came back and told me he does not know when to use as he did not find any change in cough. So he would  not use it. I also did swallow study to see if he was aspirating-food or liquid going wrong way -instead of going in food pipe , esophagus ,it would go in wind pipe or trachea. This would then trigger the cough reflex. He did have aspiration. But then again he did not feel he had any problem with swallowing. So he did not do anything . I continued to follow him for more than 5 years  and he did well with no hospital admission or major pneumonia. 

   Then he saw a cardiologist and they diagnosed him with a heart valve problem and they wanted to do minimally invasive heart surgery to fix it. I cleared him for the surgery and he did well. He came back to see me. He was doing good and had uneventful recovery from the heart surgery. He however had urinary retention and he was diagnosed with enlarged prostate and needed surgery to fix that. Just as a rule risk of lung problems is increased when the surgery is close to lungs Say for example amputation of a toe is much less risky that having lung surgery with compromised lungs. Now he needed prostate surgery. I cleared him for the surgery. He did well and then was to be discharged. And then HE ASPIRATED . The aspiration caused major pneumonia and his oxygen dropped . He developed respiratory failure and then was struggling. He and family made decision not to put him on respirator and so then hospice was called and he died . 

    So the patient that survied heart surgery dies after prostate surgery -CAN TOY PREDICT DEATH?  

IT IS SIMPLE FLU -IS IT ?

       We all have heard of Flu and how it is a viral infection and there is vaccine for that. The vaccine are good and prevent diseases. But in case of Flu it is 'hit or miss'. There are seasons when flu vaccine are not that effective and some others where it's effective,  In my last several years of practice I have seen Flu where people get better in 4-7 days and then there are some where the fatigue and cough and malaise continues for weeks.  But then there are some where the diagnosis is done in 1-2 days and then we use antiviral medicines and people get better. And then there are EXCEPTIONS to rule. Which brinhs me to the story for today. 

      I had seen this elderly male who was 82 years old and had a nodule on his chest x- ray. He came to me and had work up done . He had had hypertension and had chest pain and that was worked up and he had CAD coronary artery. He had work up and then had blockage and then had stents. During the work up he was found to have this new spot on the lung and so he came to me 

     We did the work up and then he had breathing test and also PET scan. He had descent lung capacity and the PET scan did show increased uptake suggesting the spot to be cancer. I had options of surgery - radiation treatment. He wanted to have it removed. I sent him to a chest surgeon and he agreed and the patient had the surgery. It was cancer and everything was good and he did not need any additional treatment like radiation or chemotherapy. 

    Over period of next few weeks he developed fluid around his lung and had some cough. He thought it was a set back and was worried - could it be cancer? I treated him with steroids and the fluid went down to minimal. He continued to do well. And then he had flu.

     He went to ER and was treated with antiviral medicines and he did not feel better . He saw primary care and was given steroids and antibiotics . He continued to have sough and could not eat well and lost weight. He was congested and had no energy . He could not do much waking and exercise . He used to go to gym before this Flu infection. He did not have fever and his oxygen saturation was normal . He came to me and he looked 'bad.' As mentioned no fever and no shortness of breath . But he looked mineable. I decided to hospitalize him . The standard rules don't apply as he had no fever - no shortness of breath and no pneumonia . The does not meet the criteria for hospitalization. But when you look at patient , the story was different. HE was old patient who had heart problem and had lost part of the lung with cancer and he was not recovering from this SIMPLE FLU quickly and he needed better care that can be done in hospital . I ADMITTED HIM !

   SIMPLE FLU CAN BE BAD IN CERTAIN HOSTS - PATIENTS. 

IS IT EVER SAFE

     In medicine we have many terms used and one of them is 'cure rate' or recurrence rate. This is tru especially in cancer diagnosis. If we have a patient who has say 1 cm lung nodule  and we  do surgery and it is taken out , and we have no evidence of spread of the cancer at the time of surgery, we call it a success. But is it really a cure ?The answer is yes and no - many will be cured and some will have recurrence of the cancer . We usually do  follow up CT scan for 3 years as the majority will recur in 3 years and if there is no recurrence of cancer in 3 years then we are 'safe' and the chance of recurrence is very little. This brings me to the story for today. 

  I saw this lade few years ago. She was a nonsmoker and had kidney cancer taken out several years ago - 5- 6 years ago. She was followed by a cancer specialist and he did CT scan every so often . One of the CT scan showed some nodule - a tiny density . He told her there is not much and wanted to redo new CT scan . She came to me and I reviewed the scan and really she had very tiny nodules . At the given size not much could be done as diagnostic test. The bronchoscopy, of needle biopsy or open biopsy could not have ben done to get tissues diagnosis. The PET scan is good for cancers that are at least 8 mm in size . Sometimes we do get it positive for little smaller but then most of the time it comes back negative and then radiologist states - too small to be picked up on PET scan- and we have spent money and sometimes patients get wrong impression. So we decided to do follow up on CT scan . 

     I continued to do  new scans for 3 more years , which means the renal cancer now was diagnosed 8 years ago. But the last 2 scans were showing some growth - still less than 8 mm. Then the last one was 11 mm -one of the nodules -the one that was growing . I decided that she will need biopsy  She was having difficult time with appointment  for biopsy and she finally was scheduled for the biopsy. 

     AND THE BIOPSY SHOWED KIDNEY CANCER !

So the cancer took all most 9 years to recur in lungs . That is why we should call not a cure , but 'disease free time '. 

THE MESSAGE AND THE MESSEHGER

     We have a saying that don't kill the messenger. But sometimes the message is bad and not easy to accept, then people kill the messenger. In medicine I have seen it personally. In spite of advances in medical science, we have diseases that are simply bad  and no matter what treatment you offer, it is not enough and certainly no cure. I have had that experience in past and I am sure I will have that in future. This brings me to the story for today. 

    I saw this 70 plus years old male patient ,who had some cough and some shortness of breath. He had moved here from near by place and was seen by lung specialist and followed by them for 2-3 years. He was ex smoker and had not smoked for may be 10 plus years. He had breathing test done and CT scan done in past. He was started on inhalers and he was OK. Then he started coming to me . I saw him and then I felt that he did not have much of COPD or obstructive lung disease which is related to smoking, but had FIBROSIS. I did do new CT scan of chest - called NRCT -HIGH RESOLUTION CT scan and also did breathing test. The Ct scan showed fibrosis and that was significant. I got hold of old CT scan reports and he did have FIBROSIS IN OLDER CT SCANS ALSO. We di assessment for need for oxygen and he needed oxygen. So now he was on oxygen and I discussed with him on the diagnosis of fibrosis and told him that he had it in past and seems like he was getting worse ,and so we needed to start him on medicines for fibrosis. The problem with medicines for fibrosis is 3 fold . Number one is that it DOES NOT CURE OR REVERESE the process. It slows down the decline. I tell patient that the reduction in lung function continues and does not stop , but the rate of decline is reduced - it continues rob dollars but instead of $100 , it now takes only $50 or so. Then second issue is it does not reverse anything. So the damage which is there does not get better , And lastly , it is expensive. My be as much as $25000 per year. So we need forms to be completed and get patient approved and then copay and other things that are associated with these orphan medicines. There are 2 medicines for the fibrosis - now for last 3 months 3 . I ordered one and the insurance denied the coverage. I was not sure why and we appealed and went through circle of calls and transfer and did not come to any conclusion. Then I realized  that they covered other medicine and not one that I had asked for.

    In between there was a drug trial going for the medicine - same one but as nebulizer and not a pill and we got him in it . He continued to have cough and continued oxygen . He did not get worse on his breathing test, but he felt he was NOT GETTING BETTER OR CURED. I had to tell him that he is not going to be cured and the disease will continue to get worse INSPITE of medicines . 

   He was not happy and dropped out of the study and decided to seek second opinion.  

   The message was not good and so he did not like it . 

  

THE GOOD AND THE BAD NEWS

      In medicine we often say there is a good news and a bad news. Many a times when I see patient who has abnormal CT scan and then we do the work to get diagnosis, and then the biopsy shows cancer, i sometimes say that there is a good news and a bad news . The bad news is that he has cancer but the good news is that it has not spread anywhere and we can do surgery. But sometimes the situation is different. That brings me to the story for today. 

    I saw this patient who has been a smoker in past and had chronic lung disease, COPD. She was doing good. She had routine Chest x- ray and that was abnormal and so we did do a CT scan of the chest done and that showed a mass . We did usual work up . She had PET SCAN and had  breathing test and also Biopsy. The PET scan showed activity in the central mass on right side and also some in thyroid . We did do the biopsy of the lung mass and that was lung cancer . The thyroid biopsy was also positive for cancer. The tumor in the lung was such that it had spread to nodes in the center of the lung  and so there was no way we could do the surgery. So we decided to do radiation and chemotherapy. The tumor was blocking the bronchial tube and so I we asked for radiation treatment . She had both and did well . 

    The new scan showed that the mass was smaller  and uptake was also reduced . So she was doing good , but she had cough and that was bothering her. She was treated with steroids and she felt better but still had cough. So, I decided to do bronchoscopy  and that was to see if she still had tumor.. What I saw was a significant narrowing of the bronchus which was blocked by tumor. The opening was so much narrowed that I could not see beyond it . It was inflamed  and that probably was the cause of her cough , So, the cancer was not there but the radiation had  killed caner , but also caused narrowing  and so she had cough . 

    There was no medical treatment for such mechanical blockage. I am not sure if we could dilate  it and open it.

 SO THE GOOD NEWS WAS THAT THERE WAS NO CANCER , BAD NEWS WAS R=THAT SHE HAD POST RADAIATION NARROWING WHICH MAY NOT BE IN POSITION TO OPEN UP.

WHEN YOU HAVE ONE YOU MAY GET SECOND

      In medicine we are taught to have one diagnosis and then differential  diagnosis. Which means one is more likely the explanation of the symptoms , but there are alternatives to that also, which is differential diagnosis. But not to have 2 separate  diagnosis for 2 different symptoms. This meant we have to have explanation for 2 different symptoms as one diagnosis not 2. But that is for symptoms at one given time . I want to talk about cancer and want to state that when there is one cancer, then one has higher chance of getting SECOND CANCER. That brings me to the story for today. 

    I saw this lady for abnormal CT scan chest. She was not a smoker and had COVID pneumonia. She was doing better but the pneumonia on the CT scan was not gone. She had no fever and had cough and clear sputum . No chest pain and the weight was stable. She did not have wheezes. I decided to do a follow up CT scan as the x- ray improvement lags behind clinical improvement, which means patient feels better but x- ray take longer time to improve. The new CT scan which was done 6 weeks down the road did show improvement , but the congestion or the abnormality did not improve on one side -right was better but left was still the same. She was feeling better and so I decided to do Bronchoscopy and then if that was OK , do new CT scan. The bronchoscopy did not show much abnormality and the tests that I did did not show any TB , bacteria or fungus or cancer. But this is never 100% and so we did new CT scan in another 5-6 weeks. The left side continued to be abnormal  and right side cleared . So I did PET scan and that showed increased activity in left sided abnormality . The uptake was not very high  and sometimes inflammation and infection can also have mild increased uptake of the glucose. I told her to see chest surgeon. The thoracic surgery did the surgery and that part of the lung was taken out and she had lung cancer . The good part was that there was no spread and she did not need any additional radiation or chemotherapy.

     She saw the oncologist and he did follow up and new CT scan. The CT scan showed new fluid around her left lung where the cancer was taken out. She came to me and had no idea of the new fluid as she had not had any call from oncologist. I decided to treat her with prednisone as sometimes patients get fluid related to the surgery and that is due to inflammation from surgery. If she did not improve , I will have to drain fluid with a catheter. We did follow up in 4 weeks and the fluid was gone.

    I continued to do follow up as she also had sleep apnea and some cough off and on. Overall she was stable for next 2 years . Then one day she had blood in the stool. The work up was done and she had colon cancer. She had surgery and has done well. The point that I want to make is that when someone has one cancer diagnosed , they have higher chance of getting second cancer over period of time -it could be other lung cancer and I have seen that also or it could be another organ cancer. One has to be watchful. 

IS IT JUST LUCK?

      In medicine we act based on what we think or know as facts. But many a times the facts are based on statistics. When we treat someone with  bronchitis- cough with yellow sputum, fever and wheezes= we treat with certain antibiotics and expect it will help and cure the respiratory infection. I believe that treating with antibiotics to cure him his based on FACTS .But in reality it is based on statistics and experience that antibiotics work in certain infection. But it may or may  not. But I often used to say that if one puts one hand in boiling water and other in ice cold water , 'statistically ' he is at comfort. That brings me to the story for today. 

    I saw this 70 years old male who was a smoker for cough and congestion. He had been smoker for 50 plus years and had no desire to quit. He had cough and wheezes and we did work up. he had breathing test and chest x- ray and was started on some bronchodilator. He continued to see me for 2 years and was doing OK .He had COPD and that was mild and he was active and cough improved . Then when I did new chest x- ray , he had abnormality . When I called him and wanted to do CT scan, he wanted to hold off and wanted antibiotics. So I did that and the repeat chest X- ray continued to show the abnormality . We did work up and he had cancer diagnosed . He underwent surgery and cancer was taken out. But he had some lymph nodes positive for cancer spread and so i sent him to oncologist and radiation doctor. He was told that the chance of recurrence in increased when the nodes show spread and he should have chemotherapy and or radiation . He did not want any further treatment. 

     I continued to do follow up and in next year or two, he had ne scan showing new mass . Again we did the work up and he had new cancer. I sent him to thoracic surgery and he did not feel surgery was an option as he had cancer spread to lymph nodes and so we decided to do radiation and suggested chemo and he was not sure . I continued to do follow up and he was doing OK . He had continued to smoke and the breathing test did not show much worsening. He did get radiation and no chemo.

   I continued to do the follow up and did periodic CT scan . 2 years or so after the second cancer. He was doing great and he had continued to smoke and was having no new complaints. He had new CT scan and he had some chest wall pain. The CT scan showed that he had new tumors and the ribs on rt side were also involved  and showed cancer. I sent him to radiation oncologist and medical oncologist . He was started on radiation and immunotherapy. He had some additional medications for pain . Almost 2 years have passed and he has continued to smoke  and has had new scans and breathing test . The breathing test does not show any significant worsening from previous one . He does not need oxygen .He has not been on any cancer medications for more than a year .AND HE IS AGAIN CANCER FREE . 

NOT SURE WHAT SHOULD HAVE HAPPENED TO HIM STATISTICALLY !!

MEDICAL DILEMMA

       In medical practice, we see different types of patients . Some that want medicines and others who are reluctant to take medicine. Some want every test in the world and others don't want any tests - including ones that could help diagnose and treat the element. One of the problem that I face is that if the medicines are not taken at right time then the disease could progress. But we do  not have clear cut understanding as who will will get worse and who will be OK. Certainly high blood pressure , diabetes and cancer are exception and I am sure there are many others conditions including  infection. But one infection is such that we have some variation. That brings me to story for today. 

    The MAC or Atypical Mycobacterial Infection ,also called Mycobacterial Avium is one such. I have seen many patients and some are old and some are young. This is  a chronic infection and may present as cough , abnormal CT scan of chest or may have additional complaints .Recently came across few patients , that taught me that we have a CLINICAL CHOICE . 

    I have seen 2 patients both over 80 years of age now who had MAC. One had it more than 5-7 years ago and we treated it . The treatment is for 18 months with 3 drugs and many do  not like it. This lady continued to have problem and we treated her. Then a new medicine came in and we added that and she was cured. She had no new pulmonary complaints and she seems to be doing OK But after a gap of no treatment for more than a year she had some more cough and so I did do CT scan and then sputum check and she had recurrence of the MAC. I talked to her and started her on medicines. But within a month or two , she called me and told me that she has decided to stop it and just want to see what happens . We have talked to her on dangers of not taking medicines , and then continued to do follow up. In next 18 months , she had no problem and continues to have no worsening of CT scan and no positive sputum cultures. The same thing has happened to one of my other patient . She had MAC and abnormal CT scan and we did try treatment and she could not take medicines as she felt miserable .So after 8 months of treatment she stopped it. We have followed her for 2 plus years  and initially the Ct scan was worse , but in spite of no treatment, the CT scan was stable or may be little better. She has stable weight and we have not done any treatment. 

  The contrast to that we have a young lady who had abnormal CT scan and then diagnosed as MAC and treated her. After 3-4 months she had  positive sputum and so we added 4th drug and she did well and we could stop medicines after 18-20 months of treatment and she did good for 1 year . She had low weight and new scan showed worsening  and so we wanted  to start medicines and she did not want. So after 6 months of observation , we did testing and she agreed to start medicines.

   So in the older patients no medicines has worked so far , but in some other younger patients it has not .

VITAL SIGNS

     In medicine we  have something called vital signs . These include pulse rate ,blood pressure ,temperature and respiratory rate. These are recorded in every patient - in out patient settings and also in ER and in patients setting  or hospitalized patients . The reason these are called Vital Signs , as they tell us about any  disease that needs immediate  treatment. If the Blood Pressure is high or low , it needs treatment and same with temperature - fever or hypothermia  and so on. In an average day in office - clinic , we do not have major issues with anything that needs emergency treatment related to Vital Sings abnormality. Certainly if Blood Pressure is very high we treat it and of someone has fever we treat it . This brings me to the story of this patient for today.

    I had seen this patient few times . He had abnormal CT scan of the chest and after doing the work up , we had done bronchoscopy , PET scan and breathing test and determined that he needed surgery and he had under gone surgery to take out part of the lung that had the growth. It was not a cancer . But we had done follow up CT scan as he was ex-smoker .This time he came to me and had a CT scan that was good , no abnormality was seen. But when I checked his pulse and oxygen saturation , the pulse was 33pwe min. This is very low heart rate - pulse rate . The Blood Pressure was normal , He had no shortness of breath or chest pain . He was not feeling dizzy He felt 'fine'. I checked hos pulse and heart rate to make sure that it was low. I tried to call his cardiologist and could not get anyone to call me . So I called his primary care and told him to see him ASAP. I was concerned that he would need to be admitted or may need pacemaker. 

   The patient and his wife were not very happy as 'he is fine '. I insisted that he goes to his primary doctor NOW . I also called him and he agreed to see him. He was seen and had HEART BLOCK , which means his electric circuit in heart was broken. He was sent to ER and he needed pacemaker . He was ot very happy and initially refused to have pacemaker ,but I called his wife and then he agreed  to have pacemaker. 

      The Vital signs are recorder thousands of time in office and this is one of those rare examples where they proved to be VITAL  and save life .  

WRONG TEST BUT RIGHT ANSWER

        I have seen in medicine, a test is done and then something that we did not anticipate comes out and then we don't know what to do. I remember ,when I was doing internship, I had done a cardiac test and that came back abnormal and I asked my attending cardiologist as to how to explain the result, he answered 'I would not have done the test and so I don't have to give explanation. But this time it was different. That brings me to my story for the patient.

    I have known this patient for few years . He had sleep apnea and he has been on CPAP and had done well. He had some weight loss but nothing major. He also had some other issues but they were stable. He had no major medical problems and so many a times out talks used to be things other than medical problems. He needed new primary doctor and I had suggested a name and he went to him and was very happy. He had seen me and I had told him to get routine chest x- ray as I like chest x- ray once a year . He had quit smoking may be 25years ago. He had some asthma and I had treated him for bronchitis in past and so I had told him to do x- ray.

    He called me one day . He had my cell phone number. So he texted me that he had seen Primary care physician and he was complaining of right sided chest pain. He was seen by PCP and they ordered a CT scan of chest pain. The CT scan showed LEFT UPPER LUNG MASS .So the pain was on the right side and the CT scan showed mass on left and that does nit explain the pain . But the liver ,which is in belly and on right side showed masses. Now that would explain the pain on RIGHT SIDE. So the patient was sent to cancer doctor - oncologist. The oncologist is the physician who treats CANCER with chemotherapy. But there must be CONFIRMED DIAGNOSIS OF CANCER to treat with chemotherapy. Without a tissue diagnosis , this doctor cannot do any treatment. The oncologist ordered PET SCAN and wanted radiologist to do biopsy . The patient  called me as the oncologist wanted MRI of the Liver. He was frustrated a little bit and so he called me 

   I got hold of the PET SCAN pictures and took it personally to interventional radiologist. He agreed to do the biopsy ,and did not feel that MRI of liver was needed. The biopsy was done and it showed NOT A LUNG CANCER, but showed COLON cancer , which had spread to liver and lungs . 

     So, the pain that he had MAY HAVE BEEN due to liver metastasis, or could be something else But a CT scan of CHEST was ordered and that showed  Lung masses on RIGHT ,. The discovery of lung masses and liver metastasis was accidental.

     

EVERY GOOD THING HAS TO COME TO END

      I have talked about  many of may patient without  disclosing any identity, Sometimes i have to change their age , sex and other part of the story , keeping intact the core of medical story intact. I also talk about things that have happed in distant past and not current. I have seen patients that have defied the medical odds.. So I am going to tell you couple of stories when the GOOD THING did come to end . 

     I had seen this patient several years ago . After a simple gall bladder surgery, she could not come off respirator. I was called in and I checked her and then consulted a neurologist as I felt that her lungs were fine and the problem was in her respiratory muscles. The neurologist saw her and did not feel there was any neurological cause and told me that it was my problem. I called the surgeon and asked him to do muscle biopsy and the biopsy showed that she had a very rare form of myopathy. She remained on respirator for fo years to come. Over period of time she did get worse and needed feeding tube and became bed bound. Every time I talked to her , she had to write her answer as she had tracheostomy and she would write the number of years that she was seeing me . After 34 plus years , when she was admitted to ICU with pneumonia, she requested me to be disconnected from the respirator. After long discussion, she was she was taken off the respirator and passed away peacefully. ALL GOOD THINGS MUST COME TO END. 

I will tell ypu about couple of my other patients next time.