Saturday 20 August 2016

High blood pressure? What's that?

 

Dr.Smruti Mandar Nikumbh-Haval

           It was a busy weekday evening OPD. Various patients were pouring with their multiple problems. I was helping everyone with my best capacity. And then came this middle aged gentleman. Mr. X 40 year old shopkeeper and a known face of the town. He was all OK no complaints as of but slightly panic. Reason a G.P. told him his B.P. was very high. He need lipid profile (?) and physician urgently as his B.P. was 180/130 mm Hg. He went to him for a casual OPD visit of cough and cold. In past he has only faced fatigue, vague chest pain, sweating on and off which was normal according to him as he is on field for work most of the time.
          It was an emergency and need admission preferably intensive care. So many complications came to mind intracranial bleed, MI, target organ damage etc.
         I first noted his B.P. all over again. It was still 180/130 mm Hg. Frightening as I know my resources were limited especially in late evenings as all OPD referral options get close by then at district level. Only option remains is emergency room but this fellow was not ready for admission as next morning he has a big consignment delivery order to handle.
           Human nature money is more important than health. My grandpa always says "Sar Salamat Toh Pagadi Pachas" means health is sound rewards are awaiting for you. Health is wealth.
         I was losing a battle as doctor with a businessman but was determined and with God's wish I took the challenge to treat him as outpatient ambulatory care.
             Sometimes it’s better to take calculated risk and treat patients rather than losing and send for more doctor shopping at the end lose a life. I did his E.C.G. no major changes of MI were there but left ventricular hypertrophy changes were there.
        I gave him usual instructions of salt restriction, diet modification, rest etc along with suitable anti-hypertensive medicines. Also warmed him to come to me for follow up next day as advised.
        He agreed as I was not spoiling his next day deal. We had few periodic sessions of regular follow up and things settle down. Eventually we did his 2 D Echo, TMT to my relief it came normal. We also gave him prophylactic aspirin keeping his lifestyle and high risk nature. He was found to be pre diabetic range with HbA1c 5.9.His father is a diabetic so told him relevant advice in terms of lifestyle modification which I was sure he won’t follow. He LOL my advice saying doctor I don't like sweet. It’s that I am a jaggery sell & dealer during my stock purchase I have to eat it as part of my bread and butter. Nice excuse that was. :P
          We worked as team for next few months & things were under good control. We tried step down therapy but his body was more hungry for anti-hypertensive so we have to maintain 2 drugs with him.
             But after couple of regular visits he disappeared again. I sent so many reminders personally, through friends but he did not turn up for 3-4 months. Till one fine day he came as his old symptoms have begun again and this time chest pain was more severe in intensity. This create panic in his family. His mother and adolescent son brought him back to me. I assessed him. We were back to square one with B.P. 180/130 mm Hg.
               It was my turn to get angry bird now as he had stopped all medications 3 months back due to some family problem and was under assumption that now things are under control. I felt very bad as his old age mother and son was accompanying him but he was so careless for his own health.
I learnt a family medicine principle all over again Patient Centered Care. I was a religious follower of same but this time I forgot to stress on one important element of it - Role of Family and Friends. So vital it was.
         It’s good at times to black male patients emotionally for their own benefit. I scold him but same time made him realize if he still want to take care of his parents in old age, don’t want wife to get widow in middle age and son to lose school education and continue the family business he has to stay healthy. Health is real wealth. It’s not maintenance free you have to take care of your own health. This scold gave him a insight I felt. As I can see his heart weeping silently. Some after load reduction.:-).
            He promised again that he will remain compliant this time onward. Lucky he was as there were no fresh changes in his E.C.G. fresh changes.
            Gradually his B.P. came down, aspirin worked for his chest pain and other cardiac evaluation came normal. But his HbA1c has increased to 6.2. Now his journey towards diabetes has begun all thanks to his own negligence. Ironically this patient's younger brother is also a hypertensive but except once he never came for follow up.
           From this case I learnt that good counseling; compliance won't work long term if we don't involve family and friends in long term management of chronic diseases.
           With my Project SurekhUsha Kavach we try to improve life of many such Mr or Mrs X,Y, Z. It cost 1% knowledge at times and 99 % human emotions in treatment of chronic diseases. Awareness campaigns against hypertensive disorders are very much essential as common man need to know about importance of blood pressure control, regular treatment and complications associated with it if ignored. Thank you. Almighty bless us all.

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Brief Description about the author
Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh);  M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med; Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA; Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine; C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka; Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum

Blog: drsmrutihaval@blogspot.com
        drsmrutimhaval.blogspot.com

Area of practice- Sankeshwar, Dist – Belgaum,Karnataka. Epidemiology of your area in brief: It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes, hypertension, asthma, hypothyroidism etc.

Sunday 7 August 2016

About a young couple and their fight with stigma of infertility


 Dr.Smruti Mandar Nikumbh-Haval

About a young couple and their fight with stigma of infertility


              Hypothyroidism is a kind of under diagnosed disease in rural area unless or until it reaches to the goitre stage. Biochemical diagnosis is an easy way to diagnose it in early stages. Good and reliable labs is a big challenge in rural area.
              Mrs. Patil is just one such patient for me.She was dealing with her primary infertility 2 years post marriage.She and Mr. Patil are a happy go lucky couple where Mr. Patil  is a project manager where Mrs. Patil  is a house wife .
             Before coming to us in month of march Mrs .Patil was suffering from sudden onset of weight gain ,irregular menses,change in voice,facial puffiness,lethargy,depressed feeling - all classical symptoms of hypothyroidism but due to lack of knowledge about it she never approach any doctor.
              Irregular menses was a regular complaint for her since menarche but no one ever investigate for her actual cause.Afraid of developing neck swelling and changed voice she approached my mother in law who is a practising OBG consultant and a generalist practitioner too.In rural area female patient still prefer a female doctor as they find more comfort with them.
              We at Rukmini Hospital,Sankeshwar diagnosed many cases of hypothyroidism in last one year as we find few symptoms are hypothyroidism are very common in this area.
              But Mrs. Patil  was a classical case hence she immediately ordered a thyroid function test which showed her TSH > 150.
             As I deal with many hypothyroid patients now post my successful CCMTCD course from CDI,Pune my mom in law send her to me.The couple was very anxious when they mate me as they saw a young doctor sitting next to them.They were in doubt whether to continue with me or not as one of there fear was we practice in a family set up.Just to retain patient in set up my mom in law sent them to me.
            Appreciating there anxiety I stated my discussion with them and made them understand that its not a major disease but if we don't treat in time it can cause some complications .Also I  made them understand that what ever symptoms she is suffering now are all because of hypothyroidism and once we correct that with thyroxine they will reduce.
           We started her with 100 mcg thyroxine daily and advised repeat follow up TFT after 8 weeks.After 8 weeks her voice was clear,facial puffiness was gone and her weight has also reduced but menses were still absent.We did few modification in dose and decided to wait for another 2 months as HP axis may take some time to adjust but still amenorrhoea persists.
           She happen to mention then that she usually resumes menses only when she used to get hormonal supplements from experts for same.Then I thought of PCOS and refer her back to OBG consultant to rule out PCOS  and hormonal regulation of menses along with ovulation induction if indicated .To God's grace she did not have PCOS and  responded well to HRT and ovulation induction.She is carrying now and hope will deliver a healthy baby.

Conclusion:
         Take home message I learnt from this patient is patient education,counselling and in time diagnosis is very important.Only treating the symptoms superficially is not the only thing but going to the root cause is equally important. If prior physicians would have thought of hypothyroidism in her adolescent age she could not have reached this stage of severe presentation. Every patient is a new lesson to learn which we may not be able to learn in our medical school.
       At last thank you almighty for giving me transient healing hands and power to counsel, educate patient correctly. Also I am thankful to CDI team for teaching me right principles of management of thyroid disorders.:)  

Suggestions for strengthening rural healthcare and Role of WoRSA:To create database or educational materials this will help primary care physician in rural area all over the world in awareness of about hypothyroidism. Our south East Asia belt is more prone for this as our soil lacks iodine. Good regular biochemical and clinical screening can help to reduce its prevalence.WoRSA can grant some screening programmes in rural area to improve rural people’s health.

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Brief Description about the author-
Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh);  M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med; Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA; Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine; C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka; Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Blog: drsmrutihaval@blogspot.com
        drsmrutimhaval.blogspot.com

Area of practice- Sankeshwar, Dist – Belgaum,Karnataka. Epidemiology of your area in brief: It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes, hypertension, asthma, hypothyroidism etc.