Thirty versus Forty

This year I turned 40.
A milestone in many aspects.
10 years ago when I turned 30 where was I?
It would be interesting to study the contrast.

At 30, I was out of medical college after my postgraduate degree and had just started my career. I was raring to go and was flushed with the initial success of my practise. As I had only few patients to see,I spent considerable amount of time talking to patients, making them understand the disease and how to cope with it. I wondered why the senior doctors in my area are not communicating well with the patients. I was happy to see patients 24hrs a day.

Each difficult case was a challenge to me and I researched and referred books and net till late hours to find a solution to each diagnostic problem. Each new issue of my favourite medical journal was awaited eagerly. I wanted to practise medicine the way it is given in Text Books. I hated when the patient or the relatives said that they are going to a higher medical centre for further evaluation. I looked down in other doctors who referred cases without any reason. My belief in Science was immense. Also I believed very much in my patients and their relative's loyalty to me. I never could imagine one of them going for a malpractice litigation against me. I was ready to teach the staff nurses the finer points of patient care at any time.

I had umpteen number of dreams about my future. Researching and finding out a new breakthrough methodology of treatment for an important disease was one of them. Presenting papers after papers in National and International conferences and publishing them was another.

At medical conferences, I was the baby among the audience. I was up to date in knowledge and was proud about it. I was bombarded with advise from seniors to do that,to do this, and not to do this etc. I was also an early product of technology generation. So, I was the one who showed the senior doctors how to use the Internet and the possibilities of cell phones.

At 40, I am in the middle of my career in practising clinical medicine.The sight of crowded waiting room in my clinic do not excite me, rather it makes me feel tired. I stick to my working hours. Any patient coming outside it, is shown an angry face. Finishing the patient appointments in time is the priority now. Time given for each patient became limited.

I am slow to accept changes in treatment methods. Text Books and journals pile up untouched.

A difficult case is easily referred. Any wish expressed by the patient to go elsewhere, brings up a reference letter from me in a jiffy. My belief in the unknown increased. Each person who enter my clinic is viewed as a possible litigant.

The dream of researching and presenting papers still remain a dream. At medical conferences, I am somewhat a veteran. Young faces are seen all around. Many come to me for advice. I try not to show youngsters my lack of up to date knowledge.


Still I try to maintain the spirit and my standard of practise, may be for another decade.

Read the next part of Thirty versus Forty here

Follow up

I had narrated about many people/patients in my postings. This is a post which will tell you about where they stand now.[as far as I know]

The 31 year old newly wed wife who preferred Insulin to tablets is now well controlled on a single tablet. She also started working part time and looking forward to get pregnant.

The 50 year old lady who took money from me [as narrated in patient taking money from doctor]for her bus ticket returned the amount promptly next month. But I have not heard from the other guy whom I helped on the same day for getting Government certificate.

The 65 years old Type 2 Diabetes patient who disturbed my sleep by missing her Insulin injections for a few days was hospitalised for 3 more times, all around 2 am, with hypoglycemia.The doctor on duty managed her all the time with out disturbing my sleep.

The patient in Another sad 'positive' story is doing well with anti Tuberculosis treatment.His CD4 count is also low and may need anti HIV medicines too shortly.

The guy in Craze for specialist consultation was diagnosed to have Hepatitis B. He went to a Gastro-enterologist for better care, but was unhappy with the lack of communication of that particular specialist.He came back to me again and has now recovered well.He is back in Bangalore working.
The 12 year old girl with Diabetes in Type 1 or Type 2 did not keep her follow up appointments. I hope she is getting treatment and monitoring from some where else, may be from Government run clinics as the family was very poor.

Chronic severe Joint pain of Chikungunya

The rainy season due to the South West Monsoon over the Indian sub continent is over.Epidemic of acute severe joint pain and swellings associated with fever due to Chikungunya infection has also subsided.Now I am seeing more and more patients with Chronic severe joint pain of varying duration, a sequel of Chikungunya infection.

Let me tell you a little more about this virus and the illness it causes in humans.

Chikungunya is a re-emerging, mosquito-borne viral infection causing fever, rash and acute or sudden severe joint pains of several joints.Chikungunya (Chick’-en-GUN-yah) in Swahili an African language meaning “that which contorts or bends up” refers to the contorted (stooped) posture of patients who are afflicted with severe joint pains (arthralgia) the most common feature of the disease.
Chikungunya virus is a single-stranded RNA Alphavirus, from the family Togaviridae. Other Alphaviruses also causing fever, rash and arthralgia, include O’nyong-nyong, Mayaro,Barmah Forest, Ross River and Sindbis viruses. Chikungunya virus is most closely related to O’nyong-nyong, but remains genetically distinct.

The disease was first described by Marion Robinson and W.H.R. Lumsden, following an outbreak along the border between Tanzania(erstwhile Tanganyika) and Mozambique, in1952. Since 1953, the virus has caused outbreaks in Africa and South Eastern Asia, including India, Sri Lanka, Myanmar, Thailand, Indonesia, the Philippines and Malaysia, which are well documented. There is historical evidence that Chikungunya virus originated in Africa and subsequently spread to Asia. Phylogenetic studies support this theory, with Chikungunya virus strains falling into three distinct genotypes based on origin from West Africa, Central/East Africa or Asia.

Chikungunya is transmitted by the bite of the infected Aedes mosquito from an infected person to a healthy person. The disease does not get transmitted directly from human to human (i.e. it is not a contagious disease). In a pregnant woman with Chikungunya there is risk of transmitting the disease to her foetus.
The fever starts usually about 2 to 3 days after the entry of virus into the human body. There will be severe chills and shaking of the body at the onset of fever.At the same time the joint pain and swelling starts.The patient will not be able to move with in minutes of onset of illness.The joints of hands mainly the metacarpo phalangeal and proximal inter phalangeal joints become warm swollen and very painful.Wrist and elbow are also affected to a lesser extend.The joints of ankle,feet and to a lesser extend hip are all affected.
Itchy reddish raised rash is typically seen[70%] when the fever subsides, which in most of my patients was by 3 days.Many patients and Physicians confuse it with drug rash due to allergy to the medicines the patient took for fever and joint pain.
Rash is typically seen on the cheeks, nose and outer part of ears.The ear lobe is typically painful to touch. The rash is also seen over the trunk and limbs with severe itching which lasts for only 2 days. There will be painful swelling of ankle and shin with dark red discoloration. Painful oral ulcers are also seen during this time.Last year I had few patients with enlarged cervical lymph nodes, which disappeared in few days.

Although rare, the infection can result in meningo-encephalitis, especially in newborns and those with pre-existing medical conditions. Pregnant women can pass the infection to their foetus. Severe cases of Chikungunya can occur in the elderly, in very young ones (newborns) and in those who are immuno-compromised.

Chikungunya outbreaks typically result in several hundreds or thousands of cases but deaths are rarely encountered.
Differential diagnosis of Chikungunya includes Dengue and Dengue Haemorrhagic Fever,
O’nyong-nyong virus infection and Sindbis virus infection.
It has been reported that attack rates in susceptible populations may be as high as 40-85 per cent and the ratio of symptomatic to asymptomatic patients is about 1.2:1.

Children are less likely to experience joint pain, but may have other features such as febrile fits, vomiting, abdominal pain and constipation.

The discoloration of the nose usually lasts for months.I call it the seal of Chikugunya as I can identify a person who had Chikungunya in the recent past seeing that seal.
Some patients may remain feverish for some more days. The joint pain become less in few days. In about 60 percent of the patients the ilness including the joint pains last only about a week.They become completly all right with only a little bit of tiredness remaining.
But in about 40% of patients joint pain increases or persists.The chronic joint pain of Chikungunya resembles that of Rheumatoid arthritis. The joints commonly involved are the wrists and the knees.The ankle and smaller joints of feet and hands are also involved.Stiffness of these joints in the morning lasting more than 30 mts is typical. The patient feels better as he/she continues to move the joints.
The joint stiffness and pain lasts for about 3 months in about 30% of patients in my practise. But in an unfortunate 10% it may last indefinitely.

Lab Diagnosis of Chikungunya fever

Virus isolation and PCR techniques are costly and is available in very few centres. Serological diagnosis is possible only after a week of onset by detecting antibodies. As the treatment is mostly symptom specefic diagnosis will not alter patient management much. So the typical triad of fever, acute onset joint pains and rash along with a low white cell count in blood sample is sufficient enough to diagnose Chikungunya fever

Treatment of Chikungunya fever

Paracetamol 10 to 15mg per kg body weight given 3 to 4 times a day reduces the fever.It is needed only in the first 2 to 3 days of illness.

Non Steroidal anti inflammatory agents have to be given liberally to reduce the pain and swelling. This may have to be continued for few weeks in some patients with persistent joint pain. Renal and Gastric safety have to ensured while taking such medicines.
Short course of steroids like Prednisolone also helps in resistant cases.
Other analgesics like Tramadol are also useful.
Disease modifying anti rheumatic agents like Chloroquine have been found useful in some studies.Personally I feel Chloroquine is not of much help as it is a slow acting drug taking almost 3 months to be fully effective.

Most of the patients who turned to alternative systems of medicine for relief came back to me saying there is no relief to pain.Many had to take NSAIDs along with their Ayurvedic and Homeopathic medicines which proved that other systems have nothing much to offer.

In short Chikungunya fever is easy to diagnose but not that easy to treat, but to those who suffer it is pure hell.