Thursday, December 30, 2010

Cough Cure

I could hear her violent bouts of cough through the door leading to the waiting room. She came in with her son who has been my patient for some years now. This was the first time she was seeing me. A well preserved and groomed lady of around 65 years, when asked what the problem is, began,’ can’t you hear my problem, this cough; I am having this since the last three months. I have tried many medicines but of no use’ she stopped to let go another bout of cough.
The list of medications consisted of three types of antibiotics, several anti allergic drugs including oral steroids and currently she has been taking copious quantities of syrup of codeine and suffered as a consequence, severe constipation.

I asked,’ where are the prescriptions’?

‘What prescriptions? I don’t need any prescriptions? I am a doctor’. She stopped at that.
Her son added,’ doc, I should have told you, my mother retired as professor of Pharmacology from Orissa few years ago and she has come here for a visit and has come to see you only because I forced her to.’

This explained a lot of things. She has been a senior teacher of Pharmacology and knew in depth all about medicines, but had no practical knowledge about diseases! Having retired she must have felt odd to seek help from her colleagues, most of whom must have been her students. She had made a self diagnosis [many] and has been medicating herself.

I was a worried man. I am dealing with senior medical personality who has come to seek help from a GP at the instance of her son. We GPs are considered as know nothings by many specialists and like many of us GPs thinking them to be doctors with blinkers on and knowing more and more of less and less. In reality both these assumptions are incorrect. I did not know what to make of this lady, a senior professor and teacher who has been neglecting a cough for over three months. But saying so will only make matters worse, this I know by experience.
For a while I kept quiet. By then she had told me few more complaints which were not very relevant like not sleeping well, dry mouth etc.

I asked her,’ have you got any tests done’? She said no but has been planning to get some done. This was like adding insult to injury. Three months of cough and no tests done!

I proceeded to examine her. But for repeated bouts of dry cough, she was alright with fairly clear lungs. I told her so and said I will have to get some tests done which included a chest X-ray, blood and sputum tests. She asked me,’ what you are suspecting? You think I have TB? Sounded more as an accusation than a statement. ‘In this country, madam, that is the first illness that I would want to exclude, though I don’t think it is TB, but one can never be sure ‘. ‘Then what do you think it is? This is another problem we doctors face. When I am not sure how can I tell her what is the problem? I told her that is the reason why I was getting these tests done. She would not leave me. You must have some idea before you asked for these tests’ she said. I had to reply. I said,’ madam it can be any illness starting from TB to asthma to cancer. No, No, No, I cannot be having cancer; I have never smoked in my life, asthma! I don’t have any breathing difficulty, it must be something else’. How can I argue with this professor that all the three diseases are still possible and why. It is simply a waste of time and prolonging the argument which was taking us nowhere.

I felt it is best o keep quiet. She said at last, ‘OK, we will do the tests and get back to you’.

Couple of days later, she and her son returned to see me with reports of the tests done.
One look at her told me that something was seriously wrong. Her face was ashen and her lips and hands were trembling. Here was a lady who was frightened out of her wits. I made them sit down. Even before I asked her any question, she said,’ doctor you are right, I have miliary tuberculosis’. Miliary tuberculosis is very serious form of tuberculosis where in the tubercular germ has widely disseminated and the patient is very seriously ill. I asked her how does she know. She showed me the radiologist’s report which accompanied the chest X-ray. It read,’ fine diffuse nodular opacities in both lung fields. Consistent with military tuberculosis. Please correlate clinically’

The X-ray reader sees and reports on what he sees. He has no clinical experience as he does not see the patient. His job is to report what he sees and that is what he has done. Strictly speaking he should have stopped at diffuse nodular opacities seen and not hinted at military TB. That is the clinician’s job. But the radiologists do commit this mistake of suggesting which they should not do. Our professor has put this finding and her cough and surmised that she has serious form of TB.

I went through the other reports. She had very high percentage of a type of white cell called eosinophil. Eosinophil developed over thousands of years to particularly attack worms [not germs] which infest our body. Especially so, those worms which tend to travel around in our tissues. Coming from Orissa the diagnosis was very easy to make. She had Filariasis.

In Filaria, after the infected mosquito bites, the released larvae of the filarial worm migrates and gets stuck in the lung tissue where the eosinophils too go in large numbers and attack them. The reaction results in small pinhead sized nodules which are seen in the X-ray. The same happens in a different way in TB where another specialist cell called Lymphocyte does the same. X- ray picture of both is near identical. The flood of eosinophils is also seen in the blood much more than what is normally seen. In fact this condition is known as tropical eosinophilia.

I explained to her in detail and also prescribed the 15 day course of a drug called Diethyl Carbamazine that will bring about a near miraculous cure.

She brightened visibly. Next ten minutes were spent not in thanking me but in giving me a lecture on Diethyl Carbamazine.

After all, was she not a professor of Pharmacology?


Anonymous said...

An eye opener for many of us. Many times patients are thankless. Any how the job is done- All for good.

Dr.V.S.Krishna murthy

Amrita said...

Yeah really,it is a eye opener for me too.

Gopakumar said...

Uncle, this was a wonderful read. Gopu

Mukesh said...

I agree, this is really an eye opener.