GUIDELINES AND MEDICINE

       When ever I read the Guide lines on work up or the treatment of a symptom or the disease, I often wonder as to what about people that fall out side the NORMS, or 'usual'. So a particular symptom is seen in say 90 % of the patient with a diagnosis, what about the 10 %. So I know that the working for rare causes may be expensive and time consuming. But what about the standard things that are not 'required' , but is a good idea.  But in the modern day practice of the medicine , we are more controlled by the insurance companies, and hospitals, and medical associations and the government rather than by what is good f fro the patient. So sometimes when I see some patients ,I often question as to the 'cook book medicine'. This brings me to the today's story.

        I saw this male patient in my office. He was a 70 years old male , who had smokes for several years . he has some chronic cough and also had some weight loss. He had worsening of the cough and was treated with usual medicines . I asked him if he got short of breath with activity. This is to assess the lung capacity as he was smoker. He told me that since his arthritis got worse in last 3 or 4 months , he has not been walking. He had hip pain and was treated for the arthritis.  He did not get much better and so then had chest X-ray done . The chest X-ray was abnormal and so then he was ordered to have chest CT scan and then he was referred to me.
       The CT scan showed what looked like a lung cancer . So he came to me . I had chat with him and the family. I told them that we have to answer 3 questions , Is it cancer , Has it spread and What can be done IE what is the treatment choice. I ordered the PET scan and decided to do the bronchoscopy. The PET scan showed that he had positive pick up in the lung mass , but it also showed that there was pick up in adrenal and bones, especially in the pelvic bone and the hip bone , where he was having severe pain .
     So this man had chronic cough and he was smoker and has had no chest X-ray done in last 5 years. I am not saying that the chest X-ray would have Dx lung cancer earlier. But one thing for sure , I tend to do chest X- ray in every smoker and ex smoker every year. This I have done before the new 'Guidelines' came out to do low dose radiation CT scan of chest for high risk patients. But it is not a requirement for the HMO,Quality of care . So most the patients get cholesterol and blood sugar check up and the mammograms done , but not chest X- ray. So hopefully we will be doing the chest X-ray if not CT scans.
    Guidelines are good but when we do only COOK BOOK MEDICINE , we don't do as well !!

OLD ENGINE AND NEW PROBLEM

   Long time ago , I was complaining about the car repair bill to a car .mechanic The cost of the part was not that high, but the cost of the labor was very high. So the answer that I got was not that unexpected.He knew that i was a Physician and that was translated in to to two conclusion, one that I did not have much knowledge of cars and secondly I had money. So he told me that the human body is old machine and there is no change in it for many many years , contrary to that  the automobile engine has changes significantly in last few years and it continues to evolve and change and so it is much more difficult and time consuming to diagnose a problem , so the labor cost is much higher than what I get to see a patient on follow up. I did tell him that if I make a mistake (or some family member or a lawyer conclude for his or her own monitory benefit that I made a mistake,)the patient could be harmed or can die. That is not so with the car . But I had no way of getting my car fixed without him, so I did not argue. This brings me to the story that I am going to tell today.

    I saw this patient 78 years old female for pain in the belly . It actually was flank pain rather than belly pain. The reason I was called in was due to her chronic cough and the possibility of scars in the lung , so called Pulmonary fibrosis. The husband was bed side all the time . So I saw her , She had never smoked and she had some cough . I checked her oxygen saturation and it was normal. On her physical examination, she had some crackers ,which are indicative of scars in the lungs. The CT scan of the belly had shown no new findings , but she had some tumor in the belly ,unchanged from 2014. No one knew the etiology of the small abnormality next to liver , which is on the right side and her pain was on left flank. She did have vertebral fracture and some artritis in the spine.
   So I ordered the CT scan of the chest to check on the fibrosis.I did not do any investigation on he flank pain as Gastroenterologist was consulted. The Gastroenterologist  decided to do endoscopy, which I did not think was going to add anything and it did not. But I was talking to the husband and he was getting frustrated as 'she was here twice and no one can find the cause of the pain.' And he was right . She was in the hospital twice and as out patient had complained to PCP for last one month. So I told him that I think the pain is due to the lumbar spine problem and not due to the gatrointesinal problem . I ordered MRI of the spine and it did confirm my suspicion . She had severe arthritis and fracture of the first lumbar vertebra ,so the pain was due to the fracture. We talked about the arthritis where she would need to see spine MD and the fracture where we could try a procedure where they inject cement in the vertebra and that gives pain relief in majority of the patients. She and the husband agreed .

      So the procedure was done by neurosurgeon.She did well. I saw her about 4 or 5 hours after the procedure and she was OK , But like any other procedure she was out on the oxygen . The procedures are done with light sedation or anesthesia. She had no chest pain or flank pain or shortness of the breath. I told the nurse that we need to wean down the oxygen as we wanted to get her home in the morning. The fibrosis was confirmed and I would have to do the further work up as out patient.
   I get a call from the nurse that she was fine , but her oxygen was low . So I ordered blood oxygen check and it came back alarmingly low .Again she had no complaints. I was not sure as to what may be the reason , but I was worried about a blood clot in the lung due to lack of physical activity . So I ordered a CT scan of the chest . But I was not sure if I could give her blood thinner as she had invasive spine procedure. So I called the neurosurgeon . ( I had 4 different phone calls before I got the right doctor).He had no problem using the blood thinner, but he did not think this was related to the procedure . We had problem with the IV access and so I had to change my order on the CT scan . But then we got good IV and we did the CT scan. I got a call from the radiologist that she did have clots but they were NOT BLOOD CLOTS but it was the CEMENT clots .

     During the entire span of about 6 or 7 hours , I had about 12 calla and spoke to 5 different doctors trying to get the things done .
     Yes the human body -the machine is old , but problems are NEW and by the way there is no extra labor cost that I can bill !

INADEQUACY OF THE MEDICINE

   I have written about the inadequacy of the medicine in past . But when one is in practice of medicine for many years, he or she thinks that everything is routine. But then a patient shows up with what looks like routine case , and then when the final diagnosis is there , one meets with surprise. It has happened to me in the past and sometimes a new patient or an incidence reminds me of the inadequacy of the medicine. The story that I am going to tell is one such story.

       I had seen this 74 years old male patient for at least 5 years.He came to me for a cough and then I did the work up . He was not a smoker and had never smoked . He had some allergies and the cough was kind of chronic and intermittent. He had no other major medical history. He had no TB or diabetes or skin cancer or asthma . The only thing that was different he had was that he had cancer of the kidney few years ago and had one kidney taken out. I did the routine work up . I see chronic cough patients every day. So I did the allergy blood tests and the breathing test and tried him on some allergy and asthma medicines. He did better . But to history of the cancer , he was concerned and so I did or his PCP did CT scan of the chest . It showed a small nodule. So I decided to do the follow up. He had follow up CT scans periodically . First one in 4 months and then every 6 month intervals as there was no difference in the nodule.
    The last time I did the CT scan, the report showed that the nodule was same , but he had some plural-covering of the lung-thickening. It was not all around the lung but only in certain places and that to only at 2 or 3 places . The thickness was barely few mm.I did not know what to make out of this findings. I decided to do the PET scan and the bronchoscopy. He also had started to have some chest pain on the same side as the plural , while the nodule was on other side.
   The bronchoscopy was negative and did not add anything to the diagnosis. But the PET scan showed that the entire pleura was hot or lighted up. This means that something was going on in the pleura. So I sent him to a chest surgeon to do the biopsy of the pleura . He underwent the chest surgery and it showed MESOTHELIOMA!.I had suspected the cancer due to the findings on the PET scan , but never thought he could have mesothelioma. One he had no history of working with asbestos , which is almost exclusive cause of the mesothelioma and secondly he had the cheat pain only for short duration and did not need much pain medicines . But not every case is standard case. As we say sometimes , patients don't read books when they have complaints and have particular disease. .
        So this is what I call Inadequacy of medicine.
    

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.