The other day two of my patients were boys who presented so differently.Their stories were a study in contrast.
The first boy came along with his anxious parents.Both of them were school teachers. The boy was around 14 years and appeared healthy.
' What brings you here?' I asked.
' His urine is frothy'.The mother said.Is he having a kidney problem? They were very anxious as a classmate of their son had Kidney disease.
I examined him in detail and could not find anything wrong.Then I asked for a series of tests of urine and Blood and that too were normal.
I reassured the parents and send them off.
The other' boy' came with his father.They were from a village 30kms away. They came with a reference letter from a Local doctor.The ' boy' looked as if he is about 12 years old. When I looked down at the patient file in front of me I was shocked to see the age written as 23.Was it a clerical mistake?I asked the father about the boy's age.Yes it is 23. I read the reference letter.Yes he was referred to me to find a reason for his short stature.
I examined him. His height was 123cm and weight 24 Kilograms. He did not show any features of puberty. He had no hair growth over face, chest, armpits or genitalia.
His penis was small and testicles rudimentary. His voice was like that of a 10 year old child. It seemed as if his body got stuck at 10 years for the last 13 years.
'When did you notice that there is something wrong in your son?' I asked the father.
He told me that once a doctor told him the boy had problems and need many tests to find out the cause,but nothing was done.
Why those tests were not done?
Money was the major problem he said apologetically. 'Also I was sick for several years.So there was nobody to take him to distant City to do the tests.' He added.
He is probably a case of ' Pituitary Dwarfism'. It is an abnormality rarely seen in children.They stop growing early or growth is very much delayed. This is caused by deficiency of Growth hormone . Such children may have deficiency of other hormones also.This may result in lack of sexual maturity as seen in this boy.
Early diagnosis in the childhood is important. Treatment with Growth Hormone Injections usually makes a big difference.But it have to be given before adulthood.By 18 to 20 years the bone plates fuses and further growth is not possible.
Treatment with sex hormones may help this 'boy' to mature.But he will never gain height. He could have gained height if treatment was started when he was around 15 or earlier.
Such contrasting tales I see in my practise regularly. India is full of such contrasts. Over anxious literate and well off parents who know many things and is afraid of all known and unknown diseases attacking their children on the one hand,and the illiterate poor rural folk who accepts everything that is given to them as destiny on the other hand.
India is a land of
Luxury,opulence and high education on one side
and
poverty,illiteracy and ignorance on the other side.
When will this huge divide go away?
Friday, September 19, 2008
Tuesday, September 9, 2008
Diabetes management in the Third World
He is 32 year old male. He is a poor manual labourer ready to do any kind of job.He is also a Type 1 Diabetes patient for last 7 years.
He lived near the place I worked previously.He presented to me 7 years ago with sudden loss of weight and severe fatigue. His blood sugar was around 500mgs. He was treated with insulin and fluids and he became better.A trial of oral tablets for Diabetes was tried but did not work. He could not afford C peptide estimation or antibody estimation to prove that he is having Type 1 Diabetes. As he responded only to Insulin he was assumed as type 1 and treated with twice daily premixed Insulin.
As I moved out from that area I did not see him for few years. Last week he came to me again. He came for some relief to his severe unbearable ear ache. I asked him about his Diabetes.He reassuringly told me that he is taking Insulin injections regularly twice a day.He was not concerned about his Diabetes.He is having this ear ache and discharge for last few months. I examined him and saw that he had thick pus coming out of his right ear. He also had high blood pressure and severe numbness of his feet.
'When did you check your blood sugar?' I asked.
He was not very sure. 'May be 3 months ago', he replied.
What was the sugar value? I persisted
'May be around 300. It was always around that when i check'. He revealed.
'Do you keep your Insulin in refrigerator'? I enquired. I remembered that he used to keep his Insulin at a pharmacy nearby as he or his neighbours did not have a Fridge.
'No .I keep it in a plastic Mug filled with water'.
'Why not in the pharmacy'? I asked.
His explanation was like this. The pharmacy in which he used to keep his Insulin had closed few years ago.Also somebody had told him that Insulin if not kept in a Fridge, should be kept under water.
Here is a Type 1 Diabetes patient who is storing his Insulin improperly and thereby reducing its potency. He is taking this low potency Insulin and is checking his blood sugar rarely.His blood sugar is always high and now he is developing Diabetic nephropathy and neuropathy.Due to this poorly controlled blood sugar he had also developed acute ear infection about which only he is bothered.
What should I do?
I told him the importance of keeping the Insulin in a cool environment.I asked him to see anyone of his neighbours have a Fridge.If not I told him to buy an Earthen pot, put water and few pieces of ice in it and put the insulin in it so that it is submerged in water.I also gave him a week's course of antibiotics for his ear infection and few anti BP tablets. I refused his offer of consultation fee.
Should I have done more? Should I have donated a refrigerator to his house? Or should I have helped him in any other way?
I don't know.
There are thousands of such Type 1 Diabetes patients through out the third world. Only very fortunate few survive more than 10 years after diagnosis.
Let us hope the future will be bright for such patients. Let us work for more just world.
He lived near the place I worked previously.He presented to me 7 years ago with sudden loss of weight and severe fatigue. His blood sugar was around 500mgs. He was treated with insulin and fluids and he became better.A trial of oral tablets for Diabetes was tried but did not work. He could not afford C peptide estimation or antibody estimation to prove that he is having Type 1 Diabetes. As he responded only to Insulin he was assumed as type 1 and treated with twice daily premixed Insulin.
As I moved out from that area I did not see him for few years. Last week he came to me again. He came for some relief to his severe unbearable ear ache. I asked him about his Diabetes.He reassuringly told me that he is taking Insulin injections regularly twice a day.He was not concerned about his Diabetes.He is having this ear ache and discharge for last few months. I examined him and saw that he had thick pus coming out of his right ear. He also had high blood pressure and severe numbness of his feet.
'When did you check your blood sugar?' I asked.
He was not very sure. 'May be 3 months ago', he replied.
What was the sugar value? I persisted
'May be around 300. It was always around that when i check'. He revealed.
'Do you keep your Insulin in refrigerator'? I enquired. I remembered that he used to keep his Insulin at a pharmacy nearby as he or his neighbours did not have a Fridge.
'No .I keep it in a plastic Mug filled with water'.
'Why not in the pharmacy'? I asked.
His explanation was like this. The pharmacy in which he used to keep his Insulin had closed few years ago.Also somebody had told him that Insulin if not kept in a Fridge, should be kept under water.
Here is a Type 1 Diabetes patient who is storing his Insulin improperly and thereby reducing its potency. He is taking this low potency Insulin and is checking his blood sugar rarely.His blood sugar is always high and now he is developing Diabetic nephropathy and neuropathy.Due to this poorly controlled blood sugar he had also developed acute ear infection about which only he is bothered.
What should I do?
I told him the importance of keeping the Insulin in a cool environment.I asked him to see anyone of his neighbours have a Fridge.If not I told him to buy an Earthen pot, put water and few pieces of ice in it and put the insulin in it so that it is submerged in water.I also gave him a week's course of antibiotics for his ear infection and few anti BP tablets. I refused his offer of consultation fee.
Should I have done more? Should I have donated a refrigerator to his house? Or should I have helped him in any other way?
I don't know.
There are thousands of such Type 1 Diabetes patients through out the third world. Only very fortunate few survive more than 10 years after diagnosis.
Let us hope the future will be bright for such patients. Let us work for more just world.
Sunday, September 7, 2008
Is it AIDS doctor?
A 48 year old man came to my clinic with his brother. The man is working in one of the Persian Gulf Countries. He was in Persian Gulf for the last few years but was not regularly employed.He was staying with and was dependent on his friends and relatives most of the time. 5 months ago he was fortunate enough to get a good job. Finally he started sending money to his family in India.
His illness also started 5 months ago.He began getting loose stools. Some times there was blood in the stools.He lost all his appetite and became thin.His friends asked him to see a doctor. He did not had a health insurance or other benefits.He knew that seeing a doctor there means lot of money.He applied for leave to come to India for treatment,but it was rejected. He continued to suffer and lost around 20 kilograms in weight. Sensing something wrong his boss gave him leave.Thus he presented before me.
He was extremely ill looking, thin and emaciated. He said he is having frequent tummy pain along with loose stools.Some times it is mixed with blood, which he attributed to Piles. He was pale and his blood pressure was on the lower side.I asked him to lie down. I examined his abdomen. He had a fairly large and hard palpable Liver.He also had pain on pressing his lower abdomen on the left side.For me the diagnosis was obvious.
I asked him to do some blood tests and an Ultra sonogram of his abdomen and come back to me with the reports in 2 hours.
Both of them went out but the patient's brother returned immediately, came close to me and asked
'Is it AIDS doctor?
I wish it was AIDS. I replied.
His face showed his confusion.I explained. Probably it is advanced Colonic cancer which had spread to Liver. If in operable the chances of survival are very slim.
If it is AIDS I can offer a lot and he will live healthy for long.But......
The Ultrasound scan suggested my impression was correct.He was referred to higher centre. Subsequent CT Scan and a colonoscopic biopsy confirmed the diagnosis.
Yesterday was his day of surgery.It was planned to remove the colonic tumour and to give chemotherapy later for the Liver lesion. His brother called me in the afternoon.He was crying when he said that the colon tumour was in operable as there was adherence to Urinary bladder. They just did a diversion of bowel to abdominal wall so that he wont have obstruction to bowel movements. His days are numbered.
Colonic cancers especially on the left side are slow growing and are diagnosed early because of alteration in bowel habits and bloody stools. When diagnosed early it is a curable cancer.
This patient because of his circumstances delayed seeking medical help which now proved was suicidal.
His illness also started 5 months ago.He began getting loose stools. Some times there was blood in the stools.He lost all his appetite and became thin.His friends asked him to see a doctor. He did not had a health insurance or other benefits.He knew that seeing a doctor there means lot of money.He applied for leave to come to India for treatment,but it was rejected. He continued to suffer and lost around 20 kilograms in weight. Sensing something wrong his boss gave him leave.Thus he presented before me.
He was extremely ill looking, thin and emaciated. He said he is having frequent tummy pain along with loose stools.Some times it is mixed with blood, which he attributed to Piles. He was pale and his blood pressure was on the lower side.I asked him to lie down. I examined his abdomen. He had a fairly large and hard palpable Liver.He also had pain on pressing his lower abdomen on the left side.For me the diagnosis was obvious.
I asked him to do some blood tests and an Ultra sonogram of his abdomen and come back to me with the reports in 2 hours.
Both of them went out but the patient's brother returned immediately, came close to me and asked
'Is it AIDS doctor?
I wish it was AIDS. I replied.
His face showed his confusion.I explained. Probably it is advanced Colonic cancer which had spread to Liver. If in operable the chances of survival are very slim.
If it is AIDS I can offer a lot and he will live healthy for long.But......
The Ultrasound scan suggested my impression was correct.He was referred to higher centre. Subsequent CT Scan and a colonoscopic biopsy confirmed the diagnosis.
Yesterday was his day of surgery.It was planned to remove the colonic tumour and to give chemotherapy later for the Liver lesion. His brother called me in the afternoon.He was crying when he said that the colon tumour was in operable as there was adherence to Urinary bladder. They just did a diversion of bowel to abdominal wall so that he wont have obstruction to bowel movements. His days are numbered.
Colonic cancers especially on the left side are slow growing and are diagnosed early because of alteration in bowel habits and bloody stools. When diagnosed early it is a curable cancer.
This patient because of his circumstances delayed seeking medical help which now proved was suicidal.
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