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.

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.

Life..Just before Death..But not Less

 Dr Sonia Singh

Hello friends,  I am Dr Sonia Singh, in charge of the multi drug resistant tuberculosis (MDR TB) ward at Indira Gandhi Institute of Medical Sciences in Patna.

I would like to share my experience about MDR TB patients who have the right to get treated and cured like other patients, but many a times they are devoid of their rights as a patient and as a human!

I write about a student of class 12. He acquired MDR TB infection most likely from the hostel. He was admitted in MDR TB ward and we started treatment after pre treatment evaluation. His general condition at the time of admission was fair so he tolerated medicines well. To our surprise, he was not accompanied by any family member or relative and he did not call them when asked. Finally he confessed that he did not want anybody to know about his disease else they might boycott him at every level; in the family, society and the school. We counselled him nothing like that would happen and that the family is meant to give all kinds of support at hours of need.

He had high blood pressures, so along with MDR TB drugs antihypertensives were planned. Then the patient said that he was afraid to see the nurse and we thought about the possibility of white coat syndrome. He was finally discharged after 7 days. We counselled him again; although he was suffering from a difficult condition , if he adhered to the drug regime he would be totally cured and would be a healthy person in the society. At the same time we advised him to use mask to avoid spreading infection to others. He left our ward happily and is coming for follow up in OPD along with his parents .The best part was that he continued to study throughout his stay in the hospital and was very much concerned about his future and career. (Picture: the patient reading a book )

I conclude my story with mixed feelings. When I was  appointed, my fellow colleagues discouraged me from joining such an infectious ward but my family supported me. They said being an FP I should not turn away from my duties towards society as MDR TB is a new threat to society.I read detailed literature about MDR TB and MDR TB wards and found that health professionals were prone to get infection. So I presented the design of MDR TB wards with adequate ventilation, Ultra Violet Germicidal Irradiation Techniques (UVGI), use of N-95 respirators and also trained nurses to work with full safety. Rest I leave to Almighty!

Some patients often complain that they are ill treated by DOTS-PLUS supervisors and counsellors. We approach them and request not to hate patients but to help them.

We also advise yoga, meditation, positive thinking, listening to music etc. to patients so that they are able to cope with tough situations of life with ease.

I know, it is not so easy but at least a full attempt should be give to Lives..just before death!

Human kindness

Amanda Howe

©AmandaHowe2016

My friend walked down the lane
Was entranced by the green wood,
And the wet lushness,
And the long horizons,

And lost himself amid this English fervour.
He asked a working man for help,
Who sent him home.

We laughed, and ate,
And were glad of our time together.

I thanked my neighbour later -
He asked about my friend
“Nigeria” I answered.
He nodded wisely -
“I didn’t think ‘e cum from round ‘ere”….

I would be glad
If more dark strangers met such kindness
In this land.

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My area of practice is in the edge of a city, with poor people and some better off, but the region (Norfolk) is very rural by English standards. Our students go to practices where the nearest hospital can be 40km away. The epidemiology is typical, mostly NCDs of lifestyle and ageing, though with farming accidents commoner because of the local employment in that area.

When I first came to Norfolk the non-white population was only 3% though it has risen in recent years., especially in the university and hospital areas in the city. As my poem suggests, foreigners can still be a novelty in some parts. I thought of this story when the UK voted to leave the EU, much of which was led by the press and rightwing politicians promoting the fear of immigration-hence the last part of my poem.

©Amanda Howe July 2016

Adjustment to the Mississpippi Twang

  Shailey Prasad Brief 

 The drawl was unmistakable. It was long, rich, and seemed to have stories untold in it. More important, I had no idea what my patient had just said. It was my first week working in rural Mississippi as a family doctor, and all the warnings that my colleagues in Detroit had given me kept ringing in my ears. I could not seem to get a decent history from him. Was I doomed as a family doctor? Was it ridicule that I heard in his voice?

Time passed. I stuck around and built a practice that was as varied and challenging as any I had imagined. Slowly, I was integrated into the workings of the small town and countryside–the football games, the crawfish boils, the school plays, and graduation. That was the backdrop of all clinic encounters, the context for the pictures being described.

The work seemed to flow from clinic to hospital, from homes to school clinics. The key context was that of the “community.” I was like an essential monument in town–“Doc.” It seemed like I had come a long way from fearing “The Drawl.” And then, in the middle of shrimp season, I heard a voice through the back door of the clinic. It was the patient with the strong drawl again–this time I understood it–dropping off a gift, several pounds of fresh shrimp, “for the Doc and the clinic.” We got to talking, and he mentioned that he was thankful that I was taking care of his kin–a cousin with depression, a grandson with asthma, his Maw-maw with arthritis, and his Pa with a “bad heart.” I looked at the clinic appointments. I had seen 6 generations of his family in the past month. I thanked him for the gift: that night, my family cooked up those delicious, fresh-caught gulf shrimp.

Fewer silos, more community, more comprehensive primary care–these are what I remember of my time as a rural doctor. As we discuss the future of health care delivery, I think about building community and planning for local needs. We need to understand the backdrop, the colors that enrich the lives of the folks we work with.a

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Description about the author: Shailey is a Professor of Family Medicine and Community Health and does research in Health Policy as it pertains to Rural Health at the University of Minnesota 

Area of practice: Currently in Minneapolis, MN. Formerly in rural Mississippi and in Tribal/Rural areas of southern India 

Epidemiology of the area described: Significant concerns of Non-communicable diseases with new emerging infectious diseases 

Suggestions for strengthening rural healthcare: Get young folks discover the fun and passion of Rural Health Care.

 Originally posted on: http://www.zocalopublicsquare.org/2012/02/26/what-you-city-docs-miss/ideas/up-for-discussion/

A spiritual indigenous story

 Priscila Goré Emílio

Video with the testimony of Priscila Goré Emílio a indigenous Kayngang psychologist from south of Brazil. This video was recorded during the "1st State Seminar of Health of Traditional Communities: indigenous and Maroon - Rio Grande - Brazil‏" ("I Seminário Estadual de Saúde das Comunidades Tradicionais - Indígenas e Quilombolas " - http://www.sinsc.furg.br/site/isesct/ ).

Note by editor (10/07/2016): Regarding some questions about "Evidenced Based Medicine", this story is about the personal spiritual experience and how this changed the person regarding understanding its people. The focus of sharing this experience is not discussing the treatment in the western medicine, it is to see this special community moment and the important role that it has. It's much more about cultural competence and understanding it.(Mayara Floss)

Fieldwork in indigenous communities of Vale do Ribeira

Fábio Junqueira

"It was a really nice experience being part of this action with the Guaranis, we left a bit of ourselves and learned a lot. It was remarkable! After the activities, conversation circles with the communities and the health team, we put a lot of thought to a broader concept of health, and also social, cultural and environmental determinants.

How can we ask for a healthy life in a sick plane? The natives Guarani inspired us and showed us we need to discuss the creation of societies truly sustainable, we must resume the harmony between humankind and nature and value the social diversity and the different ways of life, for instance, those from native peoples and from different indigenous nationalities.

We believe that putting thought to these issues is essential in the current formation of the health professionals. We would like to thank the indigenous leaders who welcomed us so warmly and also thank the indigenous health team from Miracatu, the Prof. Paulo Abati and the medical students. As a complementary reading I suggest the book: "O Bem Viver" by Alberto Costa!"

Contact: fjunqueira@pucsp.br