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. 

THE COOK BOOK MEDICINE

    In my blog related to Health CARE I have used this term . The cook book medicine would be something that a computer would do , if it is used to diagnose or treat a patient . So one would ;ffed' in the information and then the computer will analyze the data and come to a conclusion and then advice the treatment for the disease that it diagnosed. In case of Health Care management the cook book medicine is different. One would follow certain 'decision tree' and then decide if a TEST is warranted. This would help to reduce the cost , if everyone follows the same rules and there is some protection from malpractice if these cook book format is used. But today I am talking about different type of cook book medicine which is followed, without a THOUGHT PROCESS. In hospital several Ct scans are done with no obvious thought process. So let me tell about this patient ,that I think where a cook book approach was done without THOUGHT PROCESS.
       I was seeing this 60 years old patient , who had COPD. She was a smoker and had continued to smoke in spite of the diagnosis of COPD. She was short of breath and needed oxygen at night as her oxygen level would drop at night , when she was asleep. She also had chronic pain and was disabled. She had pain in the belly and so as is done now a days , she had CT SCAN of the belly. The CT scan did not show any thing in belly or pelvis that could explain the pain , but showed fluid around a lung . So she called me. I ordered a chest X-ray and it did show significant fluid. She was short of breath and when I called her , she told me that she was more Short of breath now . So I decided to admit her .Next day I took out 1200 ml fluid . I did also a CT scan of the cheat. Now she needed to be on oxygen even during day time.The fluid came back positive for CANCER. But the pathologist was not sure as to the ORIGIN of the cancer. We did PET scan and the cancer was limited to the chest only. The main concern was about the chemotherapy. The surgery was out of question -for cure -as there was cancer in the fluid.The radiation had no role as it was not a localized cancer. The chemo was the only option and to select the  chemotherapy ,we needed to know EXACT TYPE of the cancer. So I called a chest surgeon. He did do open biopsy to get more tissue to do additional testing and also put in a catheter to drain the fluid. The biopsy was done but it took more than a week to come back and it turned out to be MESOTHELIOMA. But it took more than a week to get the final answer. The biopsies were sent for second opinion as the differential was between lung cancer and the mesothelioma. As the treatment and the prognosis and the monitory gains are much more or different with two diagnosis , the differentiation was very important.
    In the past the mesothelioma had no treatment and surgery was not an option. But now a days some surgeons do the surgery. It is extensive surgery. There are two kinds of surgeries, but in either case the surgery is EXTENSIVE. So when we got the diagnosis of mesothelioma was established for sure , she was told to see a surgeon at a referral center. I was some what surprised at the decision taken by the oncologist. This patient had advanced oxygen dependent lung disease and was NEVER a candidate for ANY kind of lung surgery, let alone extensive one for mesothelioma. So the patient did go and see the surgeon , who told the same thing that we knew , HE WAS NOT A CANDIDATE for the surgery.
     This is what I call COOK BOOK MEDICINE.When one does follow all the instructions in the recipe he does not use own thought , but follows the instructions exactly as told. But I hope medicine is not a computer making decisions. So surgical consult was a waste of time , money and time.   

DEFYING ODDS

    I have often said that medicine is nothing but statistics, at least on day to day diagnosis and treatment. When we tell patients that you have bronchitis or pneumonia or even for that matters high blood pressure and we will treat 'it' this way or that way, we are using statistics. We don't know if the antibiotic that we are using is going to work in EVERY CASE or the blood pressure medicine that we selected is going to be the 'right' one for him or her . But we know that in 'majority ' of the cases 'it works' and so we use it. But there are exception to the rules or the statistics.These are the patients or the conditions that defies the all the odds.This is one of those stories.

        I saw this patient who was 75 years old. He never smoked and had no major problems other than high blood pressure. He had history of renal stones and so when he had pain in the belly, he went to ER.He had CT scan of the belly and it showed the stone, but somehow he passed it. But in doing the CT scan of the belly we include some lower part of the lungs and vise verse. So in the lower part of the lungs they saw a nodule. This was at the edge of the lung. So then he was sent to me . He then had a dedicated CT chest and it confirmed the nodule. There were no additional nodules or any other abnormalities.
     I saw him . His had no complaints and his lungs sounded clear. He had no swollen glands. So He had PET scan and it showed very low uptake. This meant the chance of cancer was quite low. He was quite concerned. So I did bronchoscopy. It was negative and no infection was there and  no cancer cells were seen. But I did not expect it to be positive as the nodule was way out of my bronchoscope reach. But there was about 6weeks between the Ct scan of the belly and the PET scan. The size of the nodule had gone down by 2 mm. He was quite concerned. So I sent him to a chest surgeon. The chest surgeon saw all the scans and the reports and felt that the possibility of cancer was very very low and advised to repeat the CT scan in 3 months. He came to me for follow up after the visit with the surgeon. He was quite anxious. I told him the criteria that we us and the chance of cancer in nonsmoker and with slight decrease in the size and negative PET scan uptake ---which is extremely low. But I realize that he was still concerned.
    So I spoke to radiologist . The radiologist told me the same thing , the chance of cancer was low and we should do follow up CT scan . But with the patient's anxiety , I asked him to do the needle biopsy. He agreed. So he had the biopsy.
               THE BIOPSY SHOWED CANCER OF THE LUNG!

     So here is a guy . who never smoked which makes his 'chance' of getting lung cancer 20 times less than smoker. He had slight decrease in size , again making the chance of lung cancer less likely. The PET scan was negative ,making chance of cancer may be less than 12 or 15%.But he still had lung cancer.
             THIS IS DEFYING ODDS

FIRST IMPRESSION

   In our life we often talk about the first impression. If some one is going for an interview , we say you must make your first impression great or long lasting. We also say the 'my first impression was not good. ' So the first impression had great value In suspense stories or i movies , we have our first impressions as to who is the culprit . So first impression is very important as it is 'accurate ' in many instances or at least we believe that our first impressions are great and reliable . I am not sure if some one has done any study as to the accuracy of this statement . Nevertheless we depend  on the first impressions .
      In medicine also we have first impressions and we make decisions -consciously or unconsciously about the  reliability of a story or complaints. In my life time of practise of medicine I have been right on many occasions , based on my first impressions.So you must have realized that the story that I am about to tell is either one where I was right or dead wrong . Well it was both .
      I saw this 78 years old patient who was smoker in the office. She had smoked for entire adult life may be 60 years or more. She had exertional shortness of the breath. So she came to me . She had emphysema . She was not having much bronchospasm . I explain this to my patients this was , if the damage from the smoking is more to the bronchial tubes and they are inflamed, then these patients get 'bronchitis and have productive cough and they wheeze. On the other hand if the damage from smoking is  more to the air sacks or the alveoli where the gas exchange takes place , then they don't have much secretion and have no significant wheezes. So this lady had more of emphysema or damage to the air sacks and was not wheezing , but was short of breath and when I walked her she needed oxygen as her oxygen saturation dropped when she walked. So I told her to quit smoking and gave her some medicines and asked her to do follow up. I did see her once on follow up to discuss the test results and again to urge her to quit her smoking,
       I saw her in the hospital in somewhat unusual circumstances . She had leg pain and so the family physician ordered a MRI of the lower spine .It showed an abscess-collection of pus. So the radiologist was asked to drain it . When he gave her sedation , her oxygen dropped and he had to cancel the procedure and I was called. So when I saw her I did not recollect her as being patient that I had seen . I had seen her many months age and that too only twice . She was very frail 78years old and looked like she was chronically sick. She weighted 72lb . She was on oxygen and could not get out of bed . She needed pain meds round the clock. She was started on treatment and then the procedure was done . Her further course was somewhat unusual and challenging . She was on IV antibiotics. But every time the catheter stopped draining the pus and we removed it , she had recollection of the pus . We were unable to find out reason for the collection of pus in first place and let alone recollection. I had talked to her and the family several times and made her DNR. She was discharged to a nursing home .
     When we discharged her  she was barely able to get out of bed and walk 2 feet . She was still on IV antibiotics and still had a catheter . This was her fourth catheter . I saw her on follow up in office in next 4 weeks . I looked at her office chart and was about to ask her as to why she had not seen me for several months , when I realize that she was the same patient who was in the hospital and had needed 4 deranges.She came walking without walker or oxygen and was fully oriented and had clear lungs and good oxygen . So this brings me to my first impression . I knew she was sick and had bad disease , was my first impression and it was correct . Then when I saw her in the hospital she was worse and I felt that her prognosis and the chance of recovery was not that great . So I was partly right . But then she showed up in my office as if nothing had happened , and that proved my impression to be wrong .  

EXCEPTION TO THE RULE

     In medicine like in many things in life or other sciences we have rules and they do apply in many cases or under many circumstances . But we also talk about exception to the rule. In medicine we have the same thing . When we see a patient and try to diagnose the disease that may be causing the symptoms. So when we see some one with high blood pressure we  don't try to work every patient for etiology for the elevated blood pressure . Again if we see very young patient with elevated blood pressure we WILL DO tests to find any cause of the elevated blood pressure -so called secondary hypertension.In medicine we are often told that the cause of symptoms is more likely to be due to ONE diagnosis , rather than 2 or 3. So this is one of the stories where there was a exception to this rule .
      I saw this patient who was seen by number of physicians before me . He came to see me referred by a family doctor. When I went the room in my office to see him , he was lying down on the examination table. In my practise this is very unusual as most of my patients are sitting in a chair ,waiting to be seen . So this was a 65 years old male who was referred to me for the evaluation of abnormal CT scan of the chest . He was admitted to the hospital in recent past his first primary doctor with chest pain . He was seen by a cardiologist and the had heart catheterization  and it showed the blockage and so a stent was put in. He was discharged in spite of him complaining that he still had chest pain . So in less than on week he went back to the ER with chest pain and he was readmitted. Again the cardiologist saw him and told him that his heart was OK and no further work up was needed. He was discharged and the primary care physician saw him in office . The pain was still there and so he did a CT chest . The CT chest showed number of small nodules and some abnormality in bones including spine. He was sent to a lung specialist . As I understand he was told that he needed to do follow up on CT scan in future. He still had lot of pain and so he decided to change physician . The new MD sent him to a orthopedic doctor who ordered MRI of spine . It showed abnormality in vertebra. But no further action was done. He was now referred to me . He was not sitting in a chair as he was hurting badly and there were no additional tests ordered. I saw the CT scan report and it clearly specified that patient had bony abnormality in ribs and spine that was 'consistent with metastasis '. Patient was smoker had quit smoking NOW . So most likely he had some kind of CANCER that had spread to the bones and it was causing the chest pain .
     I decided to admit him . My worry was two fold . One is the pain control and other was the abnormality seen in first thoracic vertebra . If something would happen to this vertebra , he may be paralyzed . So I talked to radiation oncologist . I did further work work up in the hospital . The CT scan of the abdomen and the pelvis did not show any source of the cancer. The bone scan confirmed the spread of the cancer to several bones . I also got the old history that he had prostate cancer 5 years ago and had surgery and radiation treatment. But the PET scan showed increased up tale in several lymph nodes. It also showed some uptake in colon .So I consulted a chest surgeon who did the biopsy of the lymph nodes in the lung and it showed the LUNG CANCER . So we had the diagnosis . But the question was does he have second or even third cancer ? Remember the rule in medicine is not to look for more than one diagnosis . So here we had diagnosis of lung cancer , which could explain the entire picture . was elevated PSA -a blood test that indicates possibility of prostate cancer . We had done bone biopsy and it was OK But it was not done from the exact place where the bone scan was showing abnormality . So I decided to ask radiologist to redo it , but this time with help of CT scan . So the biopsy was from possible metastatic lesion . It showed prostate cancer . So he had 2 different cancers . The pain was not from the lung cancer ,but was from the prostate cancer spreading to bones .I am not sure if he has third cancer colon We have not done colonoscopy yet .

     THIS THE EXCEPTION TO THE RULE !