Diaries of primary care physician from rural india: November 2015

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.But if you search for them you will get one.
Mrs. Patil is just one such patient for me.She was dealing with her primary infertility since 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.
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.:)

It was a lazy Saturday evening of my OPD. Suddenly one of my hospital attendant came & told me, “Madam,one OPD patient is waiting for you. Would you like to examine him? He has a bad pus filled, fowl smelling, dirty wound over his one of the foot.” She made a face. But I decided to help him. As I am a primary care physician and helping him is my duty.

I asked my attendant to send him to my OPD. This was my first encounter with Shintre family. I saw one 18 years old young boy was accompanying his 78 years old grandfather who was suffering from left diabetic foot.

It seems he was known diabetic and hypertensive since last many years and was taking treatment from CHC near by because he cannot afford a private physician. He was a poor, illiterate fellow, surviving with his wife in different house. His pension income was 500/- only. The treatment he received from CHC was theTb.metformin 500mg OD and Tb. atenolol 50 mg OD. (Not so preferred combination in old age diabetic person unless indicated).He also had some heart problem (? IHD) in past but no details were available.

The patient was having deteriorating wound day by day even after dressings by CHC staff. The family came tome as they overheard I am a diabetic educator and were hopeful that I will help them in this worsening situation.

This was a tricky call for me. As I have to decide to treat him in my OPD or refer him to surgeon. But family members were not ready for surgical intervention and requested me to do the most needful I can to my best capacity.

I made my mind to take the challenge & win this battle of diabetic foot. I was determined to save this foot as amputation is not the solution .A thorough patient education, family members counseling, appropriate BSL control and wound care is must as treatment.

I carefully assessed the foot.It was full of pus, slough, dorsum of foot skin was destroyed. Tendons, even some part of metatarsals was visible. The third toe of foot had dry gangrene at distal phalanx and proximal phalanx has developed wet gangrene changes. He has no pain sensation; temperature sensation over the foot. Mild crude touch was intact.

I was worried for changes of gas gangrene and maggots .But to our luck wound has no maggots or crepitus changes. First thing I did was cleaned the wound properly. Removed the pus & slough as much as I can in that sitting. Then washed it properly with betadine, normal saline, spirit and gauze pad. While using gauze pad for dressing I follow one rule taught by my surgery teacher.”Not to use cotton straight on the wound. The small threads of cotton got stuck or attached to slough and margins which delays the wound healing.” Hence I used simple gauze made up of dressing bandage roll. I also immunized him with a tetanus toxoid injection.

I know sending pus culture was a must thing but due to limitations of both my reliability of resources and patient’s economic status I have to cancel that investigation. But I did other relevant investigations like CBC, Sr.creatinine, Sr.urea, lipid profile,BSL fasting & post prandial, ECG, X ray foot.

To my relief X ray has no changes of Charcot joint,osteomyelitis or gas gangrene. But his Hb was low, creatinine, urea, BSL were high.

After evaluation of investigations I switch him to pre-mix insulin, aspirin atorvastatin, oral haematemics and low dose ecitalopam as he was very depressed and anxious about the entire process. I used tramadol and paracetamol as analgesics as since the beginning I was worried for his renal function, hence don’t want to use NSAIDs group drugs (many doctors give diclofenac injection intramuscular quite often as routine without considering renal status.)I also stopped his CHC started metformin and atenolol which has no much role in his treatment now. His blood pressure was 130/80 mm Hg; hence we did not give any antihypertensive.

About antibiotics from my past experience of treatment diabetic foot I empirically started with parenteral cephalosporin and oral linezolid (IV injection ceftriaxone 1 GM BD x 7 days, Tb linezolid 600MG BD x 21 days total). We stopped parenteral cephalosporin after 7 days as he responded well to them and switch tooral cephalosporin (Tb cefixime 200 MG BD x 21 days total).

Slowly he started showing improvement .His pus reduced, wound looks healthy and granulation development was visible. But the third toe was still a concern. It’s the gangrene changes were not resolving. One day during the dressing, the tendon holding the third toe rupture and by next visit the toe was unstable. This happened after 4 months of meticulous dressing.

In this situation I have to take a call of amputation– painful but important. I discussed the possibilities with family and the patient .they gave me the consent for same as by now it’s only a toe they were sacrificing and not the whole limb.:-).

With their permission I did the amputation with a pair of scissors .It bleed profusely post amputation as patient was on aspirin but later after giving a good pressure bandage, stump started healing fast and appropriately.

Initially for almost 2 months we did twice a week dressing.Once wound started healing well we reduced it to once a week. During this treatment anemia correction and use of aspirin works like magic wand. The patient has zero pain, temperature sensation minimal touch sensation over the limb on day one. But as we started regular supervised dressing series he resumed his pain, touch sensation to almost normal level. At times he used to scream, beg and yell for euthanasia .But this pain was worth bearing because birth of new foot has started in his life.

Now Mr.Janaba Shintre is doing well. The diabetic foot is almost healed now. He has resumed his day today activities well.

This journey with this patient as primary care physician and diabetic educator taught me a lot. This experience underline few important aspects of patient centered care like good compliance to treatment ,faith in treating physician, role of good patient and family’s education etc. In this process we had many problems. I supported him when he used to get depressed due to fights, avoidance by family members and society due to his foul smelling wound. But his determination helped both of us to fight and win this battle against diabetic foot within 6 months of time. :-).We respect our patients hence to keep his spirit alive to motivate others for foot care we gave him the award “best patient treatment compliance of diabetic foot”. Hope this will spread a positive message in society.

I know many excellent diabetic foot treatment options are there like VAC dressing, debridement, bactigrass dressing, grafts, platelet derived growth factors etc. But for rural area set up they are still very expensive. We cannot offer them to patients routinely here.

The take home message from me with this case is a good patient education helps in improving compliance to the treatment by patients. This can also be emphasized through caring behaviour of treating physician. Every diabetic foot does not require amputation. With systematic and periodic care we can save limb from horror of amputation and followed disability.

At the end I thank Almighty for giving me transient healing hands of a physician. Thank you. :-).