Friday, January 12, 2007

JigSaw Puzzle

As a doctor ,I am always solving puzzles when I come across patients.From the time a patient walks in ,my mind starts thinking about what he is going to say as his prime symptom.Many a times I see a patient get up with difficulty and walk with some difficulty to the chamber, giving the impression of some back or joint problem that he might narrate , but it is really the cough or some unrelated symptom that he wants attended to. Sometimes the patient starts describing about giddiness from morning making me think about vertigo but just on touching him realize that he is raging with fever.

Recently it was the case of my mom which had presented as a puzzle and later got solved gradually after giving me some anxious 3 weeks.She came down from Goa mid December and was aghast seeing her. She is basically slim not overweight at any time and quite active,but this time she looked frail and tired.I was seeing her after about 7 months.I decided to get her thoroughly assessed after the 23rd function.Her weight was 40 kg,down by 5 to 7 kg,and her blood pressure was 180/90.She was never a hypertensive patient till now,readings being in the range of 130/80. She has chronic stable angina since 1992 . On Friday, 5th Jan , I took her to Dr. Kumbla , my cardiologist friend. Her weight had improved to 41 kg by then . Her ECG , Color doppler was normal , only her BP had shot up to 220/110 probably due to anxiety and exertion. Dr. Kumbla suggested to give Losar H in addition to her usual tablets and do the relevant blood tests . After 2 days rest I took her to the pathologist on 9th Jan.In the evening I got the reports and was extremely anxious.Her Haemoglobin was 8.9 only , ESR was 60 , Blood Sugar was normal , she was never a diabetic , Blood urea 60 and creatinine 2.1 , both kidney function tests and both reasonably raised to give some concern . On phoning Dr.Kumbla , he changed that new tablet to tab Torsemide and asked for abdominal ultrasound and renal color doppler studies.

Next day I rung up Dr Nitin Chaubal , the famous sonologist whose opinion is sought after, all over Mumbai. He called me at 10 am after the power supply is restored post load shedding that goes on in town.I was greatly relieved that after the tests he said there is nothing wrong in the renal vessels as well as the kidneys themselves and rest of the abdomen. Oh what a great relief from all the thoughts about chronic renal failure that were torturing my mind.In the evening I took all reports to Dr. Kumbla and here is what I said about the jigsaw puzzle getting solved started.

I could fortunately manage to locate Dr Kumbla in the overflowing crowd of patients that was spilling on the lane outside.He was returning from his ICCU and Doppler units located behind his consulting rooms.On seeing the reports again, he said to continue the treatment and do the kidney function tests again after 10 days.He also said 'I can't understand why the urine report is showing blood +++ when the sonography is normal.' Suddenly he looked up with a sparkle in his eyes and asked ' Is she taking Aspirin ? ' I said ' Yes '. ' Stop that immediately ' he said ' That is what has caused all the problems '.

Then the logical explanation follows.Long term aspirin use had created chronic gastritis which led to loss of appetite over the years and ensuing Nutritional Anaemia and deficiency of folic acid and Vitamin B12. Aspirin also led to Haematuria . Her restricted diet intake led to muscle wasting and might have contributed to raised creatinine levels. The followup reports will confirm our logical conclusions.

Clinically she is already looking better, her weight has gone up by 1 kg , her walk has improved , her stoop is much less and she is interacting more, compared to her being quiet and withdrawn when she had arrived here.

This is part of a Doctor's life solving puzzles every day and deriving the utmost pleasure on seeing happiness on the patients face. What presents initially can be very misleading to the ultimate outcome. Many a times patients give an irrelevent history skipping very important issues and the other extreme of patients helping in the diagnosis by giving valuable suggestions.In the end it is always enjoyable solving these everyday mysteries.

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