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.


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


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.

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