UNUSUAL CASE

     In my practice I have seen unusual cases . Some patients came for the complaints that are related to mu field -pulmonary medicines and the diagnosis was non pulmonary. Some came for pulmonary complaints and the diagnosis was not what was normal or usual . But some times I see patients , that have no pulmonary complaints and still they are referred to me  and then it becomes a challenge. The patient that I saw recently , was one such patient .

     When I see new patients I do things differently than what many do or what we were told to do . In medical school , we are told to start with chief complaints and then history of present illness and then past medical history, family history and personal history and the review of systems and then examination . I start with past history etc and then before examination I ask as to why they are in my office . So I saw this 67 years old patient . He had no significant past history except high blood pressure. H e was not  a smoker and did not drink alcohol  much . He  was otherwise healthy. So when I asked him as to why did he come to me , he answered that his primary care doctor told him that if anyone can help , it would be me. This followed by him telling me that so far he has seen 12 different doctors. So I asked as to what was the problem , he answered that HE HAS HICCUPS ALL THE TIME .! I was not sure as to how this was lung or pulmonary problem.. Granted  that the hiccup is spasm of the Diaphragm.and the Diaphragm is part of respiratory system . But this connection is too remote . Any way he had seen several primary care physicians as he had moved from Tampa. He had seen more than one ENT doctors and Gastroenterology  physicians. No treatment was successful . The hiccups were worse at night though they did occur during day time too. I asked him if he had any swallowing difficulties and he had none . But then he told me that he had some  doctor in Tampa do a study for it . Interesting enough and good for a change - he had the report. Normally I have to be detective in finding as to what kind of test was done and where was it done in most cases. I would say 70 % of the time . It is so time consuming that now a days my office checks couple of computer data on all new patients . Any way the answer was right there .

    He had what is called Esophageal Motility Study .In this test a probe is put in to food pipe or esophagus and the contraction of the esophageal muscles is recorded. The esophagus is like a sleeve and it has circular muscles and the wave of contraction of these muscles squeezes the food down . I have seen many patients that have the problem with this function of the esophagus. Typically we see this in disease called Scleroderma.. When I looked at the report , HE HAD NO CONTRACTIONS . This was the answer of his problem . The test was done the result was abnormal , but no treatment or co relation with his complaints were made. So when he ate solid food , it did not get pushed down and got stuck in food pipe or the esophagus . To dislodge it the diaphragm went in spasm and that is why he had hiccups. During day time he may not have been eating much or as much as dinner time as he was still working . Also he was upright and the gravity helped the food to go down. But after the evening meals, at 8 pm or so , he was going to bed at 9-30 or 10 pm and he was supine and then he got food stuck and so had more hiccups. At least this is my explanation. I explained him my thought and told him that he has to see a Gastroenterologist and there was no real treatment for this . There are some surgeons who do a surgery and it may be effective . I told him to go on liquid diet for 10 days and not have any food or even liquids after 6 pm . My thought was that if there was no solid food , then it will not get stuck and then the spasms of the diaphragms will not be there . But he was not very receptive to my idea and agreed to do it for may be 2-3 days .

       The jury is still out as he did not see Gastroenterologist for a month and I am not sure if he can offer any medical treatment .  

MEDICAL MYSTERY

     In medicine we have patients that do not behave as we expect --may be they have not read the medical text books! But after being in practice for long time ,I have realized that whenever there is 'interesting case ' , it is bad for the patient . In past I have seen patients that I thought had cancer and they did not have it -good for the patient and then when sometimes I thought it could not be cancer , it turned out to be cancer-bad for the patient. The case that I am about to tell is one where there is no diagnosis -at least for now .
     I saw this patient in office for some cough and shortness of the  breath . As usual we do some tests and he did have some asthma . The pulmonary function test confirmed it . The chest x- ray was OK and so I put him on medicines for the asthma and he did well . He came back for follow up and he was again having problem . So I saw him . He had some more cough and some sputum and had no fever. His lungs did not sound bad . But he was having problems and so i added some medicines and also gave  short course of the steroids . He called me to tell me that it had helped .

      He came back earlier. The steroids helped , but when he completed the course , he started having problem . He had no fever and not much cough . But he was short of breath and has some cough . The oxygen was little low . The lungs did not have any wheezing. I was concerned. I wanted to get him in hospital . He was reluctant and wanted to try steroids again . I  told him that I  wanted to do CT scan of the chest to make sure that he did not have the blood clots . He agreed . I ordered the CT scan stat. I got a call at 4 pm that he had larger fluid around the left lung and had some mass in pancreas. I called him and told him to come to ER ASAP. We admitted and then started work up . He had PET scan scheduled and I did tap the chest and took out 1200 ml fluid . He had biopsy of the pancreas and the blood tests done for the pancreatic cancer . The blood test came back normal and the fluid that I had drained out , did not show any cancer cells . The biopsy also did not show cancer .

   So now we have no diagnosis . He had larger fluid collection and we don't know the diagnosis . He had pancreatic mass and in spite of the biopsy we don't have the diagnosis . The next step would be to do 'open biopsy' either of pancreas or if the fluid collects , biopsy from inside lungs . The mystery of the medicine continues.   

AGE OLD PROBLEM

      I have been in practice for many years and I have noticed the aging population. Now a days it is not uncommon to see patients in their eighties.It is very easy to say that everybody should be treated according to the disease and not according to their age. Some older patients are well preserved and have sharp mind . But the body is like house . So often we see  30-40 years old house and it looks good and has no problems . But when one looks at it , the windows are old and not according to the new standard, or the roof may need to be fixed and the plumbing is old .Many a times when I see older patients who are accompanied by their younger relatives , they are not demented, but when one starts asking questions , we realizes that memory is not as sharp and sometimes the understanding capacity is less than what might have been at younger age. But the family members are not aware if this as they see them everyday. When one does the same routine everyday , early dementia is not obvious. -going to the same place to eat or do shopping or doing same thing like goinfg to same friends or relatives . But when one is given little complex and not the routine task or direction , then the ability to follow the instruction is not as good as younger people.But my main concern is aging body. That brings me to today's patient .

    I have known this patient for last 1 or 15 years , Now she is 91 years old . She lives by herself and her daughter and the grand kids help her. She has heart problems and has been under care of cardiologist . She had fluid around the lungs 7 or 8 years ago and I took it out . It came back and so after doing the procedure 3 times , I had called surgeon and had a catheter called PLEUREX inserted . It can stay for months to year and one can drain the fluid as needed by attaching it to bottle with vacuum bottle  . Her fluid was gone and the drainage was not much and so the catheter was removed . She did fine for may be 3 years . Then she had some fluid and she was OK , Her shortness of the breath was not bad as her activity level is limited . I watched the fluid with periodic chest X- ray and it did not see to be any worse or for that matter any better. As long as she was fine I did not do the drainage with needle..
    She then had fluid around her heart and had elevated pressure in lungs called pulmonary hypertension . The cardiologist 'watched' the fluid around the heart and it did get better. So the she has some shortness of the breath and she was again in the hospital , So the cardiologist felt that I should 'drain' the fluid -same one who did not want to drain the fluid around the heart. She was on blood thinner and I had to hold it and then do the procedure . She did well but had small amount of air around the lung after the procedure . I was worried as if that gets worse then she would need insertion of tube to sick out the air . But my thinking was that her lower part of the lung is chronically collapsed and so it can not expand and so the gap was filled by the air . I did new chest X- ray in 4 hours and the fluid was back and the air was gone. Since then she is in hospital 3 times . We 'adjust' the meds and sent her home and she does OK and is back again . She does not look any different or is not in any distress, but she feels short of breath . The fluid is also same as was 2 months ago.. But again the cardiologist and the family feels we need to treat the fluid . In my estimates she has multiple , chronic problems and they will not be fixed at age 91. But everyone sees the fluid and that they feel can be 'fixed' .So now I have to treat it .
    She is 91 years old and has multiple problems and she will probably have similar issues  and doing more procedures is risky. Thia is what I call AGE OLE OR OLD AGE PROBLEM . .  

COINCIDENCE

     When we say that it is a coincidence,it means we did not expect it or the chance of the thing happening was too low and so when that happens , we call it a coincidence .It is not uncommon to have the family members to go to same family doctor as that is what the family doctor is or was suppose to be , -treat the family . But to see same specialist for the similar condition is less likely. But again the high blood pressure or the diabetes are so common and do depend sometimes on common environmental factors , such as diet , exercise or life style, that the husband and the wife can get similar condition and then go to same specialist . In my specialty COPD could be one such condition as it is related to smoking and many couples do or did smoke together . So that is not a coincidence . But today I am going to tell you about a patient that is rather unusual and so it is a coincidence.

       Many years ago I saw this fire fighter , who was about 50 years old . He had retired earlier and had some cough . He was short of breath and had no chest pain or weight loss . In fact he was obese. He had no fever and had no other problems . We did the routine work up and it turned out that he had some scars in the lungs . We did the further work up  and did the breathing test and also did some blood work up . He had reduced lung capacity and also had reduced ability to transfer the oxygen , which is  seen in patients with scar tissues or fibrosis. He was young and so we decided to do the open lung biopsy.His blood tests were not very specific for any particular condition like lupus or rheumatoid arthritis.The open biopsy was done and it confirmed the diagnosis of the fibrosis . But we had done the biopsy to find out the reason for the fibrosis and so the biopsy was difficult one to get the diagnosis . So it was sent out to Mayo Clinic . The report came as 'fibrosis and the inflammation most likely due to connective tissue disorder , may be scleroderma'.The blood tests were not very specific for the connective tissue disorders. So I did call a specialist for the same , rheumatologist.
      He decided to start him on some drugs . The patient did not like the doctor , but did do follow up with him . But unfortunately he had pancreatic inflammation related to the drug that was used . He decided that he did not want to see anybody else , but me . I did try to send him to other university centers , but he refused. So I had no choice to give him steroids . This did help him to some extent , but he gained some weight and then had sleep apnea .  He continued to get worse over period of next 5 or more years and needed oxygen 24/7. He was young patient and so I wanted to send him for transplant evaluation , but he told me hr was too old and he feels that the transplants are for young adults and he did not want to take them away from some kid who would benefit from this better than he.To make the long story short , he dies about 6 or 7 years after I started seeing him .

      Fast forward to 2016. I saw this lady in my office for the chronic cough and her last name was same as this patient . The name is German  and I had difficult time pronouncing it . So I remembered it quite well . I had seen her when he was sick , but most of the follow up he had come alone as they had mentally challenged son. So when I saw her I knew that she must be his wife , even though there was a gap of 4 years or so . So I did work up on her and she had fibrosis . She also had scleroderma and she had classical finding of the scleroderma .She had circulation issues , she had very bad esophagues and had some aspiration and many other things that are seen in scleroderma. I sent her to a different rheumatologist and she is very happy with her , She has not progressed as far as her fibrosis is concerned and she is stable.

           So this is what I call coincidence. The husband and the wife , who are not genetically related had similar or same diagnosis, which is other than diet or smoking related and has nothing to do environment.  

YOU KNOW , BUT YOU CA'N'T DO

     IN our life we face the situations ,in which e know what to do , but can not Do it. I am sure no one is an exception to this rule..We know we should not indulge in too much food , but we do .Yesterday was Thanks Giving -so all can see what I mean by this. We know we should exercise , but we don't and there are many other situations where we know what is good and what is right and we still are unable to do it.But in medical practice we see this all the time too. I know and the patient knows that smoking is bad , but still continues to do it ,and the obesity-everyone knows that one must loose the weight , and it never happens. If one considers obesity is a disease, then the 'cure rate' is zero. Even for those who do loose weight, the 5 yer survival or the disease free interval-terms that we in medicine use for cancer- is also zero. In both these conditions,the addictive nature of smoking or eating is very strong and the fault does not always lies with patient. The surroundings -stress,habits of spouse and the environment do play role.But sometimes we can put blame on patient and patient only. I am telling a story of such a patient.
            I saw this patient -72 years old , who had sickle cell anemia. She had episodes of crisis many times . In sickle cell anemia the red cells , which carry oxygen and have hemoglobin in them , are not shaped normally. They look like sickle. And when such a cell tries to go through very tiny blood vessel , it gets stuck and then is destroyed and that causes the attacks of pain . The pain could be anywhere in the body and sometimes patients can get addicted to pain medicines. They do have low hemoglobin.. In some of these patients when these episodes happen frequently,-may be in blood vessels of the lungs , the pressure in lung circuit-pulmonary pressure increases.This is called pulmonary hypertension. This is similar to one that can happen in patients who get frequents clots in lung.So this needs treatment .So when I saw this lady , she had same problems that she was admitted for in past several times . She had several echo cardiograms done in past 2 or 3 years before I started seeing her . She had the usual problems , high blood pressure and the anemia and the pain and mild problem with kidney function. I did order new echo cardiogram as in past she had elevated pressures. The normal pressure is less than 30 . 2 years ago the pressure was high 30es and the increased to 48 and then mid fifties. So there was trend of worsening pressure in lung blood vessels. The new echo cardiogram showed the pressure to 67. Clearly she needed treatment. So I asked cardiologist to do the right heart catheterizing and check pressures directly. This required as the echo cardiogram is good but not 100% accurate and the drugs that are used to treat are very expensive --$40000 per year. So the catheterizing was done and it did confirm the elevated pressure. So I started her on medicines . One of the medicines is Viagra .(it is interesting how the drug companies change the name and the price , So the same VIAGRA when used for pulmonary hypertension id called REVATIO, and the cost is much higher too.).

      We need to do some tests to assess that progress of the disease as we can not do heart catheterizing frequently . So we do check the distance that one can walk in 6 mins,which is very simple and can give us the idea about the improvement . We also need to do other tests . I have seen this patient many times in hospital where she comes in for pain or sickle cell crisis . But SHE HAS NEVER COME TO MY OFFICE TO DO SOME OF THE TESTS  that are needed.. Her pressure continues to be elevated and she continues to be on 2 different drugs . But without certain tests and close monitoring of the blood tests and other things , I can not add more medicines . Every time I talk to her ,she promises me that she will come to office and we have scheduled her for the tests and she never shows up.She does have many more medical problems now than when I started seeing her . Sh has also seen other lung specialist in between. But not in their office . .   

KARMA AND THE EFFECTS

           We had several mass killings in recent past and I was thinking about it . At the same time , I was reading Hindu script , which was written several hundred years before Christ.The one that I was writing about stated that 'IF ONE CAN CONCENTRATE UPON THE IMPRESSIONS THAT ARE CREATED BY THE KARMAS (FROM ALL THE LIVES)THEN HE/SHE CAN KNOW THE TIME OF DEATH." So this blog is about the Karma and it's effects . I have written about it in past.In Bible also it states that 'Reap as you Sow' The difference though is that in Hinduism, the seeds of Karma continue with multiple births and deaths , and the impressions of Karma or effects can occur in any life. This is different than the Christian belief  in which the effects ENDS with present life . So on the day of judgment , decision is made based on ONE life and if you have done more good than bad , then you go  to heaven and if have done more bad than good , you go hail . So every body is judged on the same day.So I am not sure as what happens in between . In Hindu concept the process is recurring and the NEXT life is based on all PREVIOUS lives. So when we continue to do Karma , we continue to accumulate the effects and this POT, full of all the Karmas that we have done in past lives , is called SANCHIT Karma . When we are born , we come with certain seeds or Karma that are going to come to fruition in Present life.This is called PRARBDHA  KARMA. We do more Karma in the present life and some of them will come to fruition in Present life and some will be stored as SANCHIT Karma to come to fruition in next lives.The current life Karma is called KRIAMAN Karma .
       In this law of Karma ,the EFFECTS or the Fruits of Karma occur AFTER the Karma is done . But in CHRISTIANITY when it is said that the Jesus died for our SINS , the Fruits happened before we did any sins or Karma.
       So for the Hindu concept of the Karma , the Karma has to precede the effects or the fruits of Karma , the effects of Karma ,can not be transferred to someone else ,(I can not suffer for the sins of my parents or my kids), there is no GROUP Karma . So when a group of people miss behave, EACH one has to get the fruits of his or her Karma and there is no group suffering due to group action. So in mass shooting each one of the victims had some unknown Karma from previous lives,that brought them to SAME DESTINY. The effects of the Karma is Recurring, and there is no final Judgment day.
       This concept is closely tied to the concept of reincarnation. One more difference is that just the Grace the God is not enough for getting rid of the Karma. Every one has to go through the effects of their Karma , the Surrendering unconditionally to GOD will help ,but not eliminate the effects . If one looks at the lives of many Indian saints , they all had very hard live,e.g.DNYANESHWAR,TUKARAM,MIRABAI . This has to do with completely neutralizing the effects of Karma from last ALL the lives , so there is freedom from rebirth. The only way to stop the KRIYAMAN karma -one that occurs with our every day life is to not be ATTACHED to the fruits -DO THE ACTION ,WITHOUT EXPECTING THE FRUITS OF THE ACTION.

ADVANCES IN MEDICINE AND THE NEW QUESTIONS WITH IT

      I am always amazed with the new inventions and new techniques in medicine. But some of them are so good and may be an advantage for the patient and for the physicians. But sometimes it adds to the problems . So few years ago I was talking to some one  who happened to little older . She had tried to get pregnant and was not successful . She had test tube baby - fertilization done out side the body , then selected embryos implanted in the uterus. Due to the advanced age of the mother, they were doing blood tests from the mother starting at age 10 weeks . The blood tests were done again done at periodic time . The mother's blood is tested for fetal DNA. This can help detect the Down's  syndrome and some other fetal abnormality . The amount of the DNA is increased as the pregnancy advances. So the mother's blood gets fetal DNA even though the two bloods don't mix. While I was thinking about this , i looked in to it and realize that similar thing could be done for cancer or tumors. So I looked in to it and was surprised that there were some scratchy studies done in the past .

     And then I came across the study where blood tests are being done for very small nodules in the lungs and some as small as 3 mm and some much larger as much as 30 mm . This is called 'liquid biopsy" The studies are being done for breast cancer and the lung cancer and urine for bladder cancer. So I now know local physician involved in this study. I am not sure what would come out , but I was excited to know that some one was doing the study .

     But then I came across a study which was published recently and the lung cancer . They did the blood test in patients who were treated for the lung cancer and had NO EVIDENCE of the cancer. Those who had the positive blood test for ??tumor marker- had higher incidence of the recurrence of the cancer.But here is my problem . So if the blood test is positive and one has no evidence of the cancer , should we treat it with more chemotherapy or just watch it . The problem is that even though the blood test may suggest that some cancer cells are still in the body , not everyone comes with the recurrence , may be the body's immunity takes care of small tumor load. So treating everyone , we may be over treating , and that adds to the cost and the side effects .This problem was much worst when in past some did similar blood tests in high risk patient , who had no evidence of the cancer anywhere in the body, and the tests came back as positive . So now what do you do . Without the actual tumor , one can nor select appropriate chemotherapy and what kind of follow up can we done to see if patient is Responding or not. So when these tests are done we need something more or better to help patients and doctors to make these decisions. Otherwise we have tests and the reports , and no answers or treatment plan . And on top of that it adds to the anxiety on part of the patients and the family . It also may create problems with getting Health insurance and Life insurance .

       I know this blog is not a patient story , but I think it tells the real dilemma that will be added to medical decisions , when medicine is Art and Science combined in my opinion.