Thursday, January 20, 2011

Loose motions Leela

‘I am your old patient, Mrs. Leela’ the voice said at the other end of the phone line. Here old patient means not elderly but patient of some years standing. Leela is a common name and my practice has its quota of Leelas. I couldn’t place this Leela by her voice. The silence must have made the lady realize that I was finding it difficult to place her. She said,’ I am loose motions Leela’. Here what she meant was that she has had loose bowel movements which I had treated her for some time back and she expects me to remember her. This gamut too failed because I couldn’t remember any Leela who took treatment for diarrhea recently. My memory too is not that great and that adds to the problem. I said so to her.’ No, No, your memory is OK, I came to you three years ago for the problem and you cured me’.

‘What is your problem now?’ I asked.

‘Same, I have loose motions again.’ She replied.
‘Why don’t you come and see me’ I asked her. ‘You are too far away from where I live and I am afraid to travel’. This is a genuine problem. ‘Why don’t you prescribe some medication on phone which I can try?

I told the name of a commonly used drug which is given for infective diarrhea. ‘Doctor, I have already tried it, it is of no use, she said. ‘Who gave the prescription’ I asked’. ‘Dr S did one week ago’, she replied.

Dr S is a practitioner in her area. ‘Why don’t you go to him and tell him you are no better?
‘I did and he scared me, he wants me to go to hospital and get colonoscopy done [colonoscopy is passing a fibreoptic soft tube up the lower intestine and seeing the innards. Usually done when one doesn’t know the cause. In advising her Dr S was not wrong. I told her that.

‘But you cured me last time, I had the same problem’. She would not leave me in peace.
‘What was the treatment I gave you? Do you have my old case notes or prescriptions? I asked her.
She said, no and insisted that she come and see me.

She gave me no options. I agreed to see her and to see that she does not have any mid journey crisis, gave her a prescription for a bowel slowing drug and asked her to see me next day.

She came in next morning with a put on smile as though she was my long lost friend. Three years is a long time to remember a face for a person whose memory and recall is none too great. I still could not place her. Now she has got me it no longer worried her. She has been having these bouts of diarrhea which lasts from a week to two weeks and she gets better after taking medication with local doctor [meaning the hapless Dr S]. This time however she is not better despite his medication which she took for more than a week. The prescriptions she showed me had most of the common antidiarrhoeals.

Here was a problem. Could she be a diabetic and could this be a rare neuropathy due to diabetes? Sometimes these wild hunches of mine do work. She said she was not a diabetic but she has Gout and takes medications and before I asked her she said Dr M [M is a doctor who specializes in joint ailments] has asked her to take the drug for life. I asked her the name. She said goutnil. Goutnil is trade name of a drug called colchicine given for acute attacks of gout and certainly not to be taken for life. ‘How many tablets a day you are taking? I asked. ‘Three, that too when I have severe pain, when not in pain, I take one and sometimes none’. [Not really following take for life advice]

Here was the diagnosis. Gout causes severe pain and swelling of the small joint of hand/feet. The preferred joint is that of big toe. Colchicine is a very good drug to manage acute attacks but to prevent recurring attacks another drug called allopurinol is given, sometimes for life. Colchicine in many patients causes diarrhea. In Loose motions Leela’s case, likely culprit.

‘Did Dr M tell you to take it for life? I asked her.

She was silent for a while and said,’ Dr M gave me this drug to take for two weeks and then come and see him. It is very difficult to see him, he has a nasty receptionist, and getting appointment is difficult. So I asked my cousin who also has gout. He takes medicine daily and his doctor has told him, it is for life. As I also have the same problem I too thought it is for life’.

The patient who came in for intractable diarrhea ended up getting advice on management of gout. She stopped colchicine and her diarrhea disappeared.

It is six months since her visit and there has been no call and hopefully both her gout and gut are quiet.

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