WHEN IT RAINS , IT POURS.

   When it rains, it pours, is a common phrase used especially in relation to money or expense. So when we have one unexpected expanse , we end up having to face some other expenses. But I have also seen this when some bad news is seen . It is also said that bad news comes in threes. I have seen this in some of my patients . That brings e to my today's patient.
   I saw this patient more than a year ago.She was a smoker and her mother was my patient , who had advanced COPD. The mother was on oxygen. She had COPD and she was treated and told to quit smoking and she did . She was out of town and was sick and had some X-ray and CT scan done . But some how I did not see her for almost a year. She came back because she had cols and was treated by her PCP and was not getting better . She did not have fever , and did not look to be in any distress. But she was feeling short of breath and had cough with not much expectoration. She did have some wheezes , but not bad and her oxygen saturation was OK . Her mother was admitted to hospital with a viral infection , called RSV- Respiratory Syncitial Virus. This is not uncommon virus and the mother is quite old and has advanced COPD , and so I was not surprised that she needed to be hospitalized. So I thought that she may have the same virus. Her chest X-ray was OK . So I treated her with steroids and some other medicines and ordered chest CT scan .
    She came to see me shortly after the CT scan as the CT scan was abnormal . Actually she came day after the CT scan .The CT scan showed mass in the lung. She was still not feeling good  and the CT scan showed that the mass had pressed on her middle lobe bronchus and the middle lobe was collapsed. So I decided to admit her to give some antibiotics , for possible obstructive pneumonia .
   She was admitted and then I did the further work up. So she had CT Scan of the belly and the MRI of the brain and the PET scan. She also had the bronchoscopy. Her CT scan of the belly showed that there was cancer in her Liver and the Adrenals . The MRI of the Brain showed that she had multiple metastases in the Brain and the PET scan confirmed all the spread and showed that the cancer was also in the BONES . She was obstructed in the right lower lobe and the right middle lobe.
    So essentially she had lung cancer which had spread to liver , adrenal, bones and the brain!
   She will need chemotherapy and radiation treatment , but this what I called , when it rains , it pours! 

GLIMMER OF HOPE

    I have been in practice for many years,and sometimes it makes you humble. You realize that you can not diagnose everything and you certainly can not cure every thing . There is always a factor of luck. And more I  see more I realize that WE are not the DOER , but we are just an instrument of the nature or the GOD or the luck. HE or SHE allow us to feel that we are in control and then in a flash , we feel we have lost the control. I have that feeling many a time and recently on couple of times it hit hard. That brings me to the case today.
     I saw this patient as my last new patient in the office. She came with a note from her surgeon stating SOB-shortness of the breath. I had no other records. So I tried to get some history from her. I also checked hospital computer where she was hospitalizes.She was young lady and had breast cancer diagnosed year ago. She had mastectomy on both sides and also then had both ovaries removed as the cancer was very aggressive. She received radiation treatment and then chemotherapy. She was hospitalized with shortness of the breath and then was found to have fluid around lung and heart. So had surgery and  had a catheter inserted to drain fluid around the lung and the fluid from the heart was drained .
      She was followed by many doctors including a lung specialist. Now she was in my office.I did not know that she was seeing another lung specialist.She was short of breath on any activity and her heart rate was more than 130. I also thought that she may have fluid on the other side also. So I told her that she needs to be in the hospital to find out what could be done,if any , and to first find out what was the cause of the increased  heart rate. She  had seen  heart specialist and he gave her some pills to take for reducing the heart rate. But the problem was that her blood pressure was low and this medicine could make it worse. So I wanted to get her in hospital and find out what can be treated
      So I admitted her and ordered the tests and some treatment. I did a CT scan and it showed that she had blood clot in the lung -which could explain the shortness of the breath and increased heart rate. She also had more fluid on the left , which could explain shortness of breath and increased heart rate. The CT scan also showed that the fluid on the right ,where there was a catheter inserted to drain it 2-3 times , had become locculated-had formed pockets , which means the catheter could not drain it. He blood count-the hemoglobin was half the normal. So all these could explain the problem and were treatable. But couple of things bothers me. Why was it that the oncologist or the cardiologist or the lung specialist did not bother to do the tests.May be because the underlying problem was not treatable- the wide spread breast cancer and I was sure that this bandage approach would only prolong the unavoidable end.
                            BUT THERE WAS GLIMMER OF HOPE !!
      

WEIGHT LOSS

        I have written on this topic in 2013 in one of the blogs . But there were several reasons , that I thought that I will write about it again. i have seen several commercials on TV from National Franchises  and I have heard several radio shows sponsored by people or centers that do weight loss main service, It is a multi Billion Dollars industry.If one considers obesity as a disease then the 5 year 'cure' rate is almost zero.
         When I talk to patients and they are on one or another weight loss program I will always ask as to what exactly they are told or what exactly is the 'plan'. One of the local program which claims to have 'fat loss' than just weight loss, and I agree with the concept that fat loss is more important that just 'weight loss' , I found out that patients are put on 600 calorie  diet, it was not a surprise that patients lost weight . They are asked to not bother doing exercise and are asked to drink lots of water. The water drinking is good idea , but not 4000 ml to 5000 ml. And what about exercise? The studies have shown that overweight patients who engage in exercise on regular basis do much better than normal weight patients who do not do any exercise. So doing exercise even if it did not make any difference in weight loss , it MUST be done. So to advice that no need to do exercise and weight loss with 600 calories , even if it is only for short time , is not good advice.
        I also saw a news, that the scientists were working on a 'pill' which will do the job of exercise. I am not sure I would opt for it instead of real exercise. But I did see a study in which they put normal weight people and obese patients on low or starvation diet and then high calorie diet . The metabolic rate was measured at base line and then with starvation diet and also with high calorie diet. What they found out was what lot of us who have difficulty with weight loss. Both the groups reduced metabolic rate with starvation diet , but obese patients did drop metabolic rate much lower than normal weight patients. And when they were on high calorie diet , the metabolic rate raised much higher in normal weight patients than obese patients. So in short obese patients tend to, 'conserve 'calories more than normal patients under any condition -starvation or high calorie diet condition. This may be the explanation why some patients gain weight just with smell of food while others eat and have no weight gain.
       In spite of all these studies the principles of weight loss remain same.
1 One must have intake less than output.
2 Body fat loss is more important than just weight loss.
3 Muscles burn calories , fat cells do not .
4 So building muscle mass is crucial in long term weight loss.
5.Big muscles 'spend ' more calories.
6. One must do a program ' of diet and exercise that he or she can 'stick with for rest of the life.

SPEECHLESS

     I have been quite comfortable in talking to anyone at any time on almost any topic. I try to limit my talk on politics as it creates problems. Talk leads to  difference of opinion and then that leads  arguments and then shouting and bag words and fight. It leaves bad taste in mouth. So I try to avoid it, though I am not successful always . But today I am telling a story of one of the patients , that made me speechless.
       I was called to see this patient who came with fever. I was not too sure as to the exact reason for my consult, may be because it was sometimes ago or may be because she had some other issues that were more impending than why I was called in . She was a 52 years old female and was not a smoker . Long time ago she was told that she may have bronchial asthma. She had acute leukemia and then was given treatment and even bone marrow transplant. She did OK and then had recurrence. She was treated at out side oncologist at a cancer center and our local oncologist was basically seeing her for need for transfusion or some other problems that her out of town oncologist could not handle. She had fever and chills and it looked like she had respiratory infection. Her oxygen saturation was OK , she had some bronchospasm. Her X-Ray was OK . She was seen by number of consultant including infection specialist and cardiologist and oncologist. So other than doing some nebuliser treatments and short course steroids. She was started on antibiotics by ID specialist. She was doing OK There was no fever but she was feeling tight in chest . So a CT scan of the chest was ordered. It showed fluid around heart. So the cardiologist ordered Echo cardiogram. It confirmed the fluid around the heart . So we called chest surgeon. The problem was that her leukemia was active and blood counts were low and she was needing transfusion every other day. The main problem was platelet counts. The platelets help clotting and one can not do any simple biopsy , let alone major surgery. Draining fluid from around the heart was not going to be easy with low platelet counts. The surgery got postponed for couple of days as in spite of platelet transfusion. Then one day the count was better though not normal and the surgeon did take to surgery. I was concerned but everything went well . Few days down the road the tube that was put in was taken out as it had stopped draining any more fluid . In between the periodic transfusions continued.  days after the tube came out she had some chest tightness and so new CT scan was done and it showed new accumulation of the fluid around the.heart and this time also around the left lung. I recalled the surgeon and the cardiologist, both of them had stopped seeing the patient.New echo cardiogram was ordered and it confirmed the fluid. But her platelet count was very very low. 7000 ONLY when normal low is 150000.
     So the surgeon talked to her and her family,He told them that risk of surgery was very high.I was not sure what to do or how to talk to her. I had explained it to her and her family several times that risk was very high and even if she comes out of surgery the long term prognosis with active leukemia was not very great, So I asked her as to what was her expectation. I was not sure if she understood and accepted the bad prognosis. She told me that she wanted to 'live' foe 2 more years. At age 52 , I was not sure why she wanted to 'live' only for 2 more years. The answer left m speechless. Her daughter was junior in college  and he wanted to be alive for the graduation!
                       
                                 What was I going to say ?I was left speechless. 

SURPRISE !

     I have been in medical practice and sometimes feel that nothing can surprise me. But then comes across the situation where I feel that This one is new or I did not expect this.Sometimes it is patients behavior , sometimes it is other doctor's behavior and sometimes it is the diagnosis. Patients may feel that physicians are not 'involved ' in patients feeling or diagnosis. But Many do and I for one do more than I had thought.May be when we don't expect and get a different diagnosis, then we remember more. This brings me to the Case that I was going to tell.
    I saw this years old male in the office for abnormal chest x-ray . Patient was ex smoker and had quit smoking several years ago.He was pushing a golf cart and it hit his chest. He was out of state and had some pain , but then he for better with Tylenol and so did not go to doctor or ER. Then he was little short of breath. So he saw the primary care physician. The physician ordered a chest X-ray and it was abnormal and so did CT scan and send him to me . The chest X-ray showed the fluid around the lung and then the CT scan showed that it was inoculated. Normally there is very very small amount of fluid around the lungs , primarily to may be allow lungs to expand and contract-like lubricate. But in this case it was not free to go all around the lungs , but was forming a pocket and it was pressing on the lung. If it was a' free fluid' I could 'drain' it with a needle or catheter. But with fluid forming a pocket , I had to have surgeon do the drainage by doing the surgery. So I send him to a surgeon. He agreed with my suggestion and wanted to get cardiologist to 'clear' him for the surgery.        So after all the things were done he underwent the surgery and the pocket of fluid was drained but in doing so he had to 'peel' the covering the lung. This let an air leaking from the lung. Normally we see this quite commonly and so it was not a concern. But then the patient developed pneumonia and irregular heart beats. The oxygen dropped and he had to be watched in ICU. The air leak continued even when he got better. I have seen one patient where this air leak continued for weeks and he needed 2 more surgeries. So I was not concerned , nor was the surgeon. But when this continued for days and weeks . I was not sure as to what could be done. Now a days there are newer techniques to put in one way valve in the bronchial tube. But this needs lot of time under anesthesia to 'localize' correct bronchus -the one that is leaking the air. So I called intervention lung specialist to do this . Just to let you know how rare this is , I have never seen this procedure needed or done . There was another option that I have seen being done is do surgery and cover the 'hole' with pleura.So he was transferred to another hospital . The new lung specialist saw him and felt that he was 'too sick' to try to do the valve . So after another 10 days when the air leak did not stop ,he was taken for second surgery.
      What they found out was shocking to me . HE HAD CANCER IN THE COVERING OF THE LUNG and so the lung was unable to expand and so had continuation of the air leak. I did not anticipate nor did the first surgeon. That was shocking . I had always thought that surgery was 'final' verdict on cancer. So I was shocked to learn that the second surgery showed cancer .  

EVERYTHING RARE

       Sometimes I see patients that I can not figure out as to why they have so many problems or why certain things happen to certain people. Many years ago I went to see one of my professors, who taught us Preventive and Social Medicine, who was hospitalized for heart attack. He was 50 some years old and had heart attack. He said that 'I don't smoke , I don't drink, I do not have high blood pressure or diabetic ,then why did I get the heart attack.'I did not have answer.I find myself in such situation many times . So the story that I am going to tell is one such case.
     I had seen this patient for several years and she had many major problems and I had treated her and referred her to Mayo clinic and UF. She had repeated episodes of coughing blood and many other issues. I could not find any reason and nor did Mayo Clinic. But the UF did find some abnormal blood vessels and did cauterization of the same. She continued to have same problem and so I sent her back to get the cauterization  done . So this would have been her 4th or so procedure to stop the bleeding. She went there and had the procedure done on Friday and came back on Saturday. She was fine on Sunday.She started having shortness of the breath on Monday and so she called 911 and they brought her to the ER on Monday evening. So I get a call from the ER MD that she was there and the chest X-ray showed 'complete collapse 'of the left lung. She was put on BIPAP. She was admitted to ICU. So the ICU doctor called me and told me that she was admitted and she wanted to see me. So I saw her in the morning of Tuesday. She had second X-Ray and the left lung was still collapsed. I saw the notes of 3 doctors and saw their plan. Patient needed Bronchoscopy. My suspicion was that after the cauterization, she must have had some bleeding and had some blood clots that blocked the left bronchial tube and so the secretions could not come out. So the lung collapsed. So she needed to have the bronchoscopy and sucking out of the blood clots or the mucous to 'open' the lung. She did not want to be intubated and put on respirator. But without doing that it was impossible to do the procedure. The suction channel of the bronchoscope was too small and we might have gotten in trouble. So I called a chest surgeon and he agreed to do it and the patient agreed.So the bronchoscopy was done under anesthesia and had to be left on respirator. I saw the new chest X-ray and it had shown 50%improvement but was not 100%clear. So I decided to do the bronchoscopy again. The patient agreed and so I did the bronchoscopy.
       What I saw surprised. Her left bronchial tube was quite narrowed. There were plenty of mucous plugs and I lavage with saline . But my main concern was that the narrowing of the bronchus. My concern was that unless that we treated , she would get the collapse of the lung again. But I had to confirm it first as the narrowing was MY IMPRESSION. No one else had suggested it , nor at UF nor in ICU nor the surgeon who did the brochoscopy. So I spoke to the radiologist and ordered High resolution CT scan . It showed that left bronchus was quite narrowed, it was less that half the size. I called a interventional lung specialist and asked him to look at the CT scan and he agreed . So he did the balloon dilatation of the left bronchus and then we got her of the respirator.
      So this patient had complications to the treatment ,which I have not heard any other patient getting it. The disease is rare, the treatment is rare and the complication that occurred is I guises is rare
        

THE UNPREDICTABILITY

    I have been in Medicine for so many years that nothing should surprise me. But as in Life , we have uncertainty or unpredictability in Medicine. Usually most of the cases behave as we think or predict. But then there are cases that we come across that throw us off completely. I had 2 of them recently. So the first one is my today's story .
    I had seen this male patient , about 70 for may be 2 years. He used to see another lung specialist for several years and then switches to me when the his own physician left private practice or his insurance. In any case he was doing OK for several years in spite of damages bronchial tubes and some COPD.I had given him antibiotics and done chest C-rays and done lung function tests. He was fairly stable . So when he came for a routine follow up I did not think much. He was doing OK, had some chronic cough and no fever . He had some episodes of dizziness. He had lost some weight , may be 15 LB  and had some decreased appetite. Patients with damaged bronchi , called Bronchiectasis , can get infection with atypical TB - called MAC . The symptoms are weight loss , low grade fever , decreased appetite, worsening cough etc. So I was thinking of doing CT scan and brochoscopy. But then I checked his blood pressure and it was low normal at 100. So I had him stand up and rechecked it . it dropped to 60 . So I was alarmed and decided to admit him . He agreed.
    I got him in the hospital and started him on IV fluids and ordered some blood tests to diagnoses low functioning Adrenals. I also ordered the CT scan. I was going to do bronchoscopy and treat him with medicines till we could get him to Endocrinologist. But then he had episode of irregular heart beats and I had to call heart specialist. With medicines the heart rate was controlled, but the blood pressure continued to be low. So I suggested cardiologist to change the medicine , but it never was done. The he had some nausea and the the hospital doctor ordered the CT scan and some X-ray. That suggested small bowel obstruction. So they called a surgeon. I was not convinced as he had good bowel movement. (He had colostomy)But the surgeon decided that he needed surgery and he had surgery. He continued to have issues with blood pressure and the heart rate some upchucking.
   I was speaking to the wife and was not sure if surgery had helped in any way . But then when his oxygen need went up and wife told me that he is bringing up stuff all the time , I knew that he was aspirating . The surgeon had thought that surgically there was no problem and wanted to give diet /food. I decided to do new CT scan and and put in stomach tube- NG TUBE. Immediately I got 1100ml fluid and the CT scan showed dilated esophagus. So I knew that the problem was not bowel obstruction, but food pipe-esophagus problem . This was coming up and going in the lungs and was causing damage and the pneumonia. With his oxygen low I transferred to ICU.
   He was little better in next 2 days and then he had problem with bowels and had stools coming out from the incision and so needed second surgery. This set him back and he now was on respirator. He was loosing weight and was having problem with blood pressure and heart rate . We continued to struggle and he continued to get weak . We could not do any further studies as he was too sick. By now he had lost 30 -40 lbs He could not eat or cough or do any physical activities . The family decided to make him DNR.
     So the patient that came to my office for regular follow up and was having low blood pressure and weight loss , and I thought that I could get him out of hospital in 3-4 days , stayed in hospital for more than a month and continued to get worse.