ACCIDENTAL DICOVERY

     In medicine we do tests  and sometimes we do tests that we expect to be negative. It is like calling someone expecting him to be not home and then leaving message , and taking credit that we did call. When someone has clot in lungs, we try to find out why . So we do the work up. The clot in lungs come from some other source - usually from leg veins  and then a small portion of the clot gets detached and then goes to lungs where it blocks the circulation and that causes the shortness of breath and other symptoms. There are reasons why a clot may form in leg veins - so called DEEP VEIN THROMBOSIS. Usually it happens due to inactivity - long distance travelblog injury  or surgery and also other causes. Immobility leads to stagnation of the circulation and that leads to clot and so this is called PROVOKED.  Then there are clots which form when we cannot see the cause. This is called UNPROVOKED clot. That brings me to the today's patient. 

    I was called to see this patient . He was 70 years old and had some cough and no shortness of breath, He had 3-4 episodes of so called Pneumonia in last few months. He had some chest pain and so he went to walk in clinic and had CT scan done and that showed a clot in the lungs  and so he was admitted. But it also showed a density in the lungs and so there was a concern as what that was. I saw him and he was also seen by hematologist. They had ordered some blood tests - this is to know if there is 'tendency to form clot' so called Hypercoagulation status . For some reason related to abnormality in blood itself which makes forming clot easier. But they also ordered CT scan of abdomen and pelvis . Now I have seen this being done many times as OCULT CANCER can present as Unprovoked Clot. I have not seen any new discovery in past many years when CT scan is done . But in this case it showed  a mass in stomach, Normally the stomach is a hollow cavity or a bag and mass in it is nit obvious on CT scan. But this time it did  and so we have him do a biopsy and that showed a type of a tumor not very common called GIST -gastro-intestinal stromal tumor. 

   So, we have a patient who had pneumonia  and CT scan showed a clot  and also a clot in leg - which is common scenario, but now we also have other abnormality in lung which could be a tumor or pneumonia or clot related  infarcted lung . But he also has a tumor in stomach. 

   We will do  follow up CT scan of lung and also PET scan and then he will need surgery to remove the stomach mass . If the lung abnormality does not clear , he will need biopsy of that too. But for now with clot and need for blood thinner we have not done any surgery or additional biopsies. 

ONE TWO AND THREE ?

   In medicine we have saying that usually we do not have 2 diagnosis . This  does not mean that a patient has only one diagnosis . It means that when a patient presents with a symptom or complaints , we may start with differential diagnosis - what different diseases could explain the problem ,but at the end of work up we have one Final Diagnosis. But sometimes we have exception to the rule. That brings me to patient for the today. 

    I was asked to see this patient who was doing fine . He had seen his  PCP and has had done follow up regularly as I  understand. But had cough and shortness of breath and so he came to ER and then had work up. He was found to have quite extensive pneumonia. He had pneumonia on both sides. The right was much more affected than left side. He had not been smoker and had no previous history of lung problems. He was admitted and the hospital physician started him on antibiotics. He was found to be anemic and  so the work up was done and he had iron deficiency . So he was given iron. 

    I saw him and was some what surprised that he had extensive pneumonia on both sides as he was not a smoker and his only other medical problem was chronic back problem and he ha shad some kind of surgery for that .I asked him questions as to what had happened . He had history of narrowing of the esophagus and he has had dilatation done in past -last one was 7-8 months ago . He had vomited and then started having problem and he had called PCP and then was told to come to ER The vomiting episode was only once and so neither the ER physician or the Hospital physician who admitted had asked or mentioned in their notes .So we did the work up. I did swallow study and X- ray of the esophagus  and sure enough he had severe narrowing of the lower part of the esophagus  and he also had severe reflux . So now we have 2 different problems or may be 3 . He had pneumonia which was caused by aspiration when he vomited  and he also had vomiting due to narrowed esophagus. The anemia may be due to severe reflux with oozing of blood from there . But it also could be due to problem with absorption of iron. Iron deficiency is uncommon in men unless they have loss of blood from peptic ulcer or colon polyps or cancer . 

    But the problem list did not end . We did CT scan of the abdomen and that showed a renal mass - mass in the kidney which was potentially cancerous . So we had initial diagnosis of pneumonia  and then the narrowing of the esophagus  and anemia and renal tumor..   

CHANGING FACE OF MEDICINE

     I have written in past about medicine has changed in last 10 years or so what we never thought was possible has been done routinely. But I also remember when Obamacare came in there was a talk od so called Death squad '. How do you handle he aging population . Do we older members of our society same as younger members or treat them same? I have always maintain that every case should be treated based on INDIVIDUAL and as a GROUP . and I feel the same. But problem is becoming more frequent. That brings me to the talk for today. 

  I have seen at least 3-4 patients who were older than 89 years of age . The  good part was hat though they were old they all were in fairly good health  and had some issues but not depilating. But they were old. The second part was that 2 of 3 were also menially clear and one had fair amount of memory loss. The common factor was that all 3 had a pulmonary nodule that was PET positive . So I saw 2 of them who had a nodule  and that had grown in time . I had seen them and decided to do follow up CT scan and the nodule grew and so we did do PET scan and then showed that the nodule had uptake suggesting that it was cancerous . The growth and the positive PET SCAN was almost 100% suggesting that it was cancer. Now a days we have techniques like Navigational bronchoscopy ,which gives us diagnostic yield much higher than what we could have gotten in past with simple bronchoscopy. We also have better technique of needle biopsy. But we decided not do it as they were not interested in getting chemotherapy. So there was no need for tissue type - what kind of cancer it is as chemotherapy is based on type of cancer. We did radiation therapy - a short one 5 sessions in all 3  and that is suppose to give cure in many - may be 80% in these small cancers . 

    Then I saw this 4th patient, who has weak heart and had fluid around the lung and then when I treated it with diuretics the fluid is gone but now he has a nodule which is growing. So he is 95 years old who has heart problem and has increasing nodule - how do you handle it -stay tuned .

DISTRACTION

     Sometimes we have situation where we see things that are more prominent and miss what may be subtle but more important. I f you have gone for murder mystry dinner show , you might have realized this. The obvious suspect is not the correct answer. I remember when we used to have a radiologist who used to teach us how to read chest x- ray. He would show a x-ray  and ask one of us to read it. We would read the most prominent findings  and then miss the subtle but important findings. He wpild put up x- ray that looks normal as far as lungs and heart are concerned but had fracture of upper arm bone which would be missed by Intern. I have seen this in my life again ' A subtle fracture of shoulder was missed even by radiologist when there were other findings in lungs like fluid .But the story that I am going to tell is similar but little different.

     I was asked to see this patient in hospital.. She had presented to hospital ER with back pain . She was a88 years old lady who had back pain for 3 months . Her PCP had  done x- ray of the lower back and had treated with some muscle relaxant and pain meds . She continued to suffer and so came to ER , She used to stay in Florida for 4-5 months  and then go back to upstate for 6 months or so. She had a physician up state whom she trusted most  and she would have been considered snow bird. She had not smoked for 50 years  and had been followed by number of physicians at both places .The x- ray of the spine was done and she had some arthritis . The Chest x- ray was done and that showed a mass lke density in upper lobe  and so I was asked to see her. I saw her and had discussion with her  and her daughter in law . I told them that she may hve a cancer of the Lung and we could do biopsy to confirm or rule it out . She was not very keen on doing any procedure and since she was nonsmoker , I decided to do PET scan as out patient . For now she was being treated for possible pneumonia by hospital doctor and I continued that . Certainly CT scan was ordered by me  and then I saw her next day. The Ct scan confirmed the abnormality that was seen on plain x- ray. I talked to her son this time and he had all old reports in a file - not a common things to see. He showed me a report where there was some infiltrates in same area where this time a mass was seen . That report was almost 9 months old. So she had something but no CT scan or any other  additional tests. So, I told them that it is possible that she may have a slow growing tumor may be be like carcinoid which can grow over period of many months or even years . She had back pain. and that was not worked up. I ordered CT scan of the spine  and that showed abnormality in lumber 3 vertebra. Oncologist was seeing her and had ordered a bone scan. I asked radiologist  to the biopsy of the spine . She was agreeable as I had told them that she could have cancer that has spread to bone. The biopsy did confirm cancer. 

    So, she had most likely lung cancer that spread to spine and that was causing pain for last 3 months. She came with back pain and that was not worked up by hospital physician and they were distracted  by lung abnormality  and then when we started doing work up for the back pain , the diagnosis of cancer spreading to spine was established . I had called radiation doctor for radiation even before we had the diagnosis of cancer established. 

MEDICINE AND ME

    I have been in medicine for many years and sometimes things become routine. We sometimes feel that not much new is going to be seen especially if one is doing subspecialty and not general medicine. But then you see a case and that tells me that no 2 things are same. I see pulmonary patients and so my practice has may be 10 common diseases that I see. One of them is COPD , the disease that is caused by smoking .I see all sort of stages from mild to severe and some end stage. Due to common factor of smoking I also see patients who have COPD , develop cancer of the lung. But we also have surprises at times.

    I have been seeing this patient for many years . He has been smoker and has not quit smoking even though the disease is severe. He also had diabetes and he had developed abnormal chest x- ray many years ago . We did work up and he had a cavity and it was related to atypical TB called MAC . The treatment of this MAC is prolonged and takes 18 months . So he was started on 3 medicines and then when he continued to have positive sputum for MAC bacteria ,I added 4th drug and that was given for a year . He responded to that and the sputum was negative now - showing no evidence of MAC. I told him that we can stop MAC medicines when he comes for the follow up .

      I also did CT scan to follow the disease and few months ago he had some lymph node enlargement. That could be due to MAC and so I did new CT scan and the nodes were bigger . The MAC was doing better but the nodes were slightly larger. So we deiced to have him see another physician to do biopsy of the nodes . He waited for few days  and then missed follow up and . So I called his wife and him and got the procedure scheduled . The biopsy was done  and now he has lung cancer . The diagnosis was small cell cancer.. The small cell cancer is not surgical condition- it cannot be resected ,but can be treated with chemotherapy . With his COPD  and nodes involved  and tissue diagnosis of small cell cancer he is not a surgical candidate. But my problem is that I was going to stop the medicines for MAC .But now chemotherapy to be started , it will suppress immunity  and that can flare up the MAC . So I am forced to continue the medicines untill such a time when  and if he will be off chemo. 

DON'T ASK DIRECTION TO PLACE THAT YOU DON'T WANT TO GO !

   I have always said in medicine, that do not ask the for thr direction to the place that you do not want to go. In medicine many a times we tend to do 'routine' tests and then when the reports come back have difficulty in explaining the report . When I was doing internship , I had done a test on a patient and that came back abnormal. When asked  the cardiologist on the case  as to why the test was abnormal. His answer was ' I would not have done the test and then I don't have to explain the results.". I have tried to follow yhat principle in my medical life. 

    I saw this new patient. He was 55 years old  and he has some eye problems and so he went to see doctor. He had cataract surgery and he was told that he may have a disease called sarcoidosis. He was sent to me I saw him and he had no lung or breathing complaints and he was nonsmoker .His examination was unremarkable. He had done a blood test which is specific for sarcoidosis .It is called ACE  level - Angiotensin Converting Enzyme level. The only condition in which this is elevated is sarcoid. The Fan=mily Physician had done that  and it was elevated . He had CT scan of the chest done and that showed some abnormality in lungs  and as I expected it also showed that he had some lymph nodes enlarged . This was consistent with diagnosis of sarcoid. So  based on eye examination and elevated ACE level and now the CT scan findings -- all pointed to sarcoidosis .But we needed the biopsy . The findings on CT scan had minimal abnormality in lungs  and the nodes were enlarged . So I decided to have the nodes biopsied . So I sent him to another physician who did a procedure calle EBUS . In this procedure  the biopsies or aspiration of lymph nodes is done with a needle 

   The procedure was done and samples were sent . The biopsy did come back showing sarcoid as the diagnosis. But the sample was also sent for what is called flow cytometry. In this test cells are analyzed  and that showed some abnormality . I am not sure if we had explanation for this . I am not sure if the cells seen were due to sarcoid  and inflammation or was there different cause . So I had to send him for additional tests and send him to cancer specialist  to rule out lymph node cancer . Again that adds to the tests  and in all probability he has sarcoid  and not a cancer . But since we did the test  and that showed some abnormality, we have to do additional tests. 

DIFFERENT STROKES FOR DIFFERENT FOLKS

    We have saying that there are different strokes for different folks What I may like or enjoy others may not like or enjoy. But in medicine the computer generated treatment will not be different for 2 patients but will be different based on patient's and their family's choice. I have realized this long time ago and so the medicine is as much a Science as it is Art .That brings me to the story for today. 

  I had seen 2 different patients in my office . One was a 93 years old female who had abnormal CT scan of the chest . She had a nodule . The spot on the lung is called nodule when the size is less that 2 or 2.5 cm - roughly less than an inch. It was may be half an inch in size . She was otherwise doing OK and we decided to do minimal work up. With that size it was difficult to do biopsy if not impossible and  she has no symptoms from it . I did do the PET scan. It showed that there was some activity but not very high . So we decided to do follow up CT scan . She continued to have no complaints . We did do the new ct scan and then another one . At the end of 8 months or so the nodule had grown by may be 3-5 mm  and so after discussion I did new PET SCAN .The PET SCAN this time showed more activity that before . So I had discussion. It most likely was slow growing cancer . The size increase though minor and the increase in PET scan uptake was suggesting that it was slow growing and so we had discussion. I suggested BOT TO DO BIOPSY or surgery ,but do radiation treatment . For a small nodule we can do what is called stereotactic radiation ,which is 5 sessions of radiation and the success rate is vert high for such a cancer . We will not know what type of a cancer it is and so no chemotherapy or immunotherapy will be offered. She did not want chemo or surgery and so the decision was easy. She did very well. 

   I also saw another patient. He was 90 years old and had some dementia . He had some cough and he had CT scan done by his PCP  and that was abnormal and so he came to me .I looked at him and then found out that he had prostate cancer in past and he had several CT scans in past We could find out 2 old Ct scan  and the nodule had grown over period of one year. By chance the new Ct scan report had not bothered to check old scans and so I had to pull them out . I spoke to patient and family. I suggested doing a PET scan and then consider work up if it had increased uptake. They were reluctant for any work up. I was not sure why did they come to me if they did not want any work up. After I had more explanation the daughter agreed for PET scan ,but she was still not sure if they would go ahead with radiation -short course like I did in other patient . So the similar age patents , similar growth in nodule ,but thought process was different .