HOUSE AND OUR BODY

    In recent past we are seeing longevity increasing. I am seeing older patients in my practice. It is not unusual for me to see many patients over 80 years of age  and also I see patients older than 90 years of age every week. Some are weak and have some memory problem and some have many medical issues. Some are fully oriented and almost independent and some cannot do much on their own. Some of the families accept the aging process and have limited expectation, but then there are others who have unrealistic expectations. That brings me to the story for today

    I have seen  2 older women at one time Bothe were over 90 years of age . One has been seen by me for many years and she had some cardiac issues and she had some fluid around the lungs  and she also had sleep apnea and so i had done follow up. She started having some problem at night , she had some shortness of breath and she called me and then came to me. She was concerned that the her PAP -the pressurized device that is used for sleep apnea was not working well. I saw her and after examining her that the problem was not with PAP but was due to her heart valve having problem ,She had murmur and also was short of breath and was waking up due to water accumulating in her lungs . The chest x- ray that I did confirmed my suspicion . She was followed by a cardiologist and he had told her that she was fine . I echocardiogram and then had her see the cardiologist . She was diagnosed with severe narrowing of the aortic valve  and he suggested doing a surgery - relatively new type of valve repair called TARV . She did not want it and so we adjusted some medicines and she did ok. She did OK and then had a fall and has some bleeding in brain but did OK But she was getting weak  and so she had to start living with her daughtercard month passed by and she had pain the belly and she came to ER , She had Gall Bladder attack. She now was quite weak and was in no position to undergo gall bladder surgery. So we did a drain and she responded to antibiotics Her numbers - blood tests and oxygen and fever etch was better. But she was weak and tired and could not eat. She could not do any walking and needed help even getting out of bed . She and the family had made decision that she did not want any aggressive treatment. So we decided to try to discharge her home with meds .While I was talking to her and her family , I told them that the house that we have owned looks good and have no obvious  problems ,but the it is old  and slowly somethings go wrong . the paint is pealing and the roof may start leaking or the plumbing may be also an issue. The aging body is like old house  and even though one 'looks' good all the organs are old and they start giving out under stress. One has to understand that .Unfortunately not all patients and families either understand the limitations or accept it. 

SURPRISE

    In medicine I don't like surprises. The surprise is not good for patient  and not for the physician. But we do have them  and since we are not 'all knowing ' the surprises do occur. The story that I am going to tell you, is one of such patients. 

   I saw this patient for abnormal CT scan .The lady was a smoker and had quit 2 years ago and had some persistent cough and so had chest X- ray done and then CT scan. The CT scan did show a mass in the central part of left lung . I saw her and I knew that in all probability it was cancer and the bad part was that due to the location of the mass - dead center of the lung where main bronchus enters the lung - it was not operable. I did the Pet scan and the miss did pick up glucose and was hot and then I did bronchoscopy. It showed that there was a mass in the bronchial tube and that was partially blocking the tube. In such cases the surgery is not possible as there may not be enough bronchial tube to resect / cut. If the cancer is also in central lymph nodes then also surgery will  not be successful. The biopsy came back as SMALL CELL CANCER. The small cell cancer is treated with chemotherapy and sometimes radiation .She was seen by both the physicians - radiation and also oncologist and received treatment.

   She was seen by me few times and she needed oxygen and had done overall OK Then one day she was short of breath and so came to ER and the x- ray showed complete whiteness of the left part of the chest . In X- ray there are only 2 colors - air is black and everything else - fluid - tumor - collapse of lung - all look white . The CT scan was done and the left lungs was collapsed and there was fluid around it . The natural conclusion was that the fluid was due to cancer and that had caused the collapse of the lung. The treatment would be to drain the fluid and then the lung expands. 

   The catheter to drain the fluid - which was though to be very large - was inserted. But then only small amount of fluid came out. The X- ray barely changed - the lung continued to be collapsed . I was nnot happy and that was not expected . But what had happed was that the lung had collapsed DUE TO EXTRISIC PRESSURE from the tumor on the covering of the lung and so the fluid was secondary  to that and the lung was unable to expand . So the catheter did not help much. So, now only option was to do new chemo and may be radiation and see if the lung would expand . The chance of lung opening is not very good . 

   When we see chest x- ray with fluid and collapsed lung in 90% of the time when we drain the fluid the lung expands , but the surprise that the lung could not expand was not a good news for the patient. 

ONE AFTER OTHER

    In medicine we have some of theses saying that is true in majority of cases , but there are exception. The patients have not heard them and so sometimes we have problem . What may be true in many patients or cases , may not apply for one  of the patients. We in medicine go by probability  and that is statistics The 2 words that we talk are 'probable' and 'possible'. Anything and everything is possible , but not everything is probable. The probable is what can happen in majority of cases - say more that 50%. But possible means it can happen but not more than 50 % . So if it can happen 1 in a million it is still called possible though not probable. That brings me to the story for today. 

  I saw this patient in my office . She had a lung nodule and that was less than an inch in size. We did the work up and she had bronchoscopy and PET scan and also breathing tests. She was a smoker and has some shortness of breath, The CT scan had shown the nodule and it also had shown another nodule of 6 mm in size. 25 mm make an inch . The PET scan showed that the larger nodule was positive and the smaller one was not picking up any activity. Certainly that could be a scar or cancer , but with not enough number of cells it was negative on the PET scan. The lungs functions were showing some compromise  and she still had enough reserve to have part of the lung taken out . 

  She did have lung surgery and the nodule was cancerous and all the other things - like lymph nodes, margins and covering of the lung etc. were ok and so she had a high chance of having 'cure. 'She was sent to an oncologist and he told her no need for any additional treatment and she had her family were happy. She was happy . He did new CT scan in 3 months  and that was OK but the smaller nodule had grown by 2-3 mm , So the oncologist wanted to do PET SCAN in 3 months . She saw me and I saw the CT scan and the growth though only by 2 mm was bothersome . So I called the surgeon and pushed for having new PET SCAN done sooner . The PET scan was done  and she had pick up in the nodule though faint. I talked to the surgeon. Interestingly enough her lung function had not gone down much in spite of having a part of the lung removed . So the surgeon did do second surgery and took out the nodule that had grown  and IT WAS CANCER . The good part -if there is anything good about having cancer - was that it was a different  type of cancer . If it was of same type then that means she had a spread of a cancer in first place and that would not have been a good news . So she seems to have had 2 separate independent lung cancer starting at the same time - something that we don't see commonly . Or to state it differently, it is possible but not probable to have 2 lung cancers in the same lung at the same time . But she did !!

INSANITY

   Someone had said that the definition of Insanity is to doing the same thing over and again and expect different results. Certainly I am not talking about  learning or trying to be successful. There one can improve and achieve the goal . There was a Royal Air Force pilot and he had successful mission bombing Germany. But then in one of the missions his plane was shot and he lost his leg. He was POW and Germans made a prosthesis for the leg . They never expected but he got the leg and he escaped . He was back on missions to bomb the Enemy . He was again caught and lost second leg  and he had new prosthesis and he escaped again .In spite of losing both legs, one day he was trying to ride a horse and he fell off 30 or so times before he could ride. This type of repeated efforts is worth appreciating. But I was talking about some other reputations, where doing same thing over and again is not going to change outcome. 

   I have known this patient for many years . Had some low oxygen and then had pneumonia. He also had chronic pain pain and was on pain medicines - narcotics and so her carbon dioxide was high and so oxygen was low . I did work up and found out that he was having aspiration and that means water or food was going wrong way in the lungs causing injury and inflammation and pneumonia. He had further work up and he had very poor function of the food pipe. The contraction of the muscles of the esophagus are not there. She was sent to a surgeon and she had a surgery and that did not work. Unfortunately I have seen this too often . In this condition food stays in  food pipe and it comes up and then trickles down the lungs. Unfortunately patient has difficulty of swallowing . He went from one GI specialist to other . Every one did the same thing - endoscopy . Every time different medications were tried - not much different from one other and she gets pneumonia and then gets admitted . HE has no change in medicines or symptoms , and he has changed GI specialist 10 times locally and out of the our place .He gets endoscopies every time he has seen ne doctor. I have told him that only 100 % almost -100% will be to not eat through mouth but have a feeding tube put in for nutritional support. He does not want it and we are doing same thing over and over again ,expecting different results. 

( This is esophageal motility disorder called Achalasia )

MEDIACAL PROBABILITY

   In past I have stated that in medicine we treat patients many a times based on probability. But at the same time the probability is based on science  and so we know based on education and studies and experience that certain diseases are likely to be present and certain are not likely. But that is never 100%. So, in medicine we talked of 2 words one is Probability and other is Possibility. To understand this I will say that everything is possible but not probable. The word probability means that that the chance is more than 50 %. So it is possible that I will be President of US but it is not probable that I will be President. That brings me to a story for today. 

   I saw this patient who happen to be spouse of my other patient. She was 70 years old and has never smoked , but was exposed to second hand smoke from her husband. Sh started with cough and the PCP gave her some antibiotics and some cough syrup and then the cough continued and so he did chest x- ray and that showed some abnormality and so more antibiotics were given . She had o fever and she has no chest pain and she has stable weight . She had no shortness of breath, She saw me and we did the work up ..I though she may have mild asthma and so did some work up like Pulmonary Functions studies and also allergy blood tests called IGE and RAST. I also gave her some inhalers and steroids - prednisone . She felt better but still had cough . The steroids did help the cough  and when they were stopped she had cough . So I decided to do CT scan and I was surprised. She had a mass like density in upper part of the lung. So we decided to do Bronchoscopy . That was done and no obstructing cancer was seen and the biopsy showed inflammation and there was no bacteria or TB or mold. I decided to allow the body ti=o heal and so did follow up CT  scan in 6 weeks or 8 weeks . The CT scan did not change much . Now I was stuck. She had what looks like pneumonia but that was not getting better and so I did PET scan . The PET scan tends to pick up metabolic activity of the cells  and when there is cancer or infection, there will be cells which are more metabolically active than normal cells, and so they show more glucose uptake.The test is 80 % accurate . In case of my patient it did not show much pick up. I was stuck . I had suggested her to se thoracic surgery to do OPEN BIOPSY. .She came to my office for the follow up. I though that based on the low pick up we could wait and do new Ct scan .The size of the 'mass like density ' was also smaller. So I decided that we will do new CT scann in future  amy be 2-3 months . She had seen the surgeon same day that I saw her  and he felt the same thing, that based on PET SCAN findings , we should wait  and not do surgery now. OUR DECISION IS BASED ON PROBAILITY of cancer being low with low pick up on PET scan. The possibility of cancer is still there but it is less probable based on low pick up on PET  SCAN  and also on smaller size of the mass. 

   Let us see what happens . By the way her cough is gone with inhalers alone.

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..