August 2017, Volume 1 / Issue 2

AFPI Karnataka Quarterly Newsletter

Dear Colleagues:

It gives me immen*e pleasure to share with you that the inaugural edition of our newslet- ter has received very positive reviews and the credit goes to our vibra*t editorial team. It will be our endeavor to meet the expectations of our esteemed readers with a focus on bringing high quality content through this newsletter.

It’s my earnest request to all members to actively participate in making this newsletter a most interesting and enriching magazine for family practitioners by way of documenting reflections of your practice experiences and writing articles.

It’s heartening to note that our recent initiative of engaging our members through online case discussion is becoming popular by the day with some interesting topics presented and discussed by our faculty. I’m excited to announce that we have decided to make this a regular fortnightly online education program and are trying to get credit for the partici- pants.

AFPI Karnataka chapter believes in fostering academic partnerships with various stake- holder* having a common goal of educating family practitioners. With this objective, we ha*e been conducting academic activities in collaboration with several institutions. On the 28 ^th of May, we conducted ‘Dermatology Update for Family Physicians’ in collabora- tion with Manipal Hospital Bangalore. With each collaborative ev*nt, we have seen the academic credentials of AFPI scaling new heights.

I would like to thank the editorial team whic* is constantly working to set a benchmark by bringing in great ideas and delivering them effectively.

Looking forward to your active contribution and valuable feedback. Col (Dr.) Mohan Kubendra

AFPI Karnataka will be hosting the next National confer- ence of Family Medicine & primary care (FMPC) at Bangalore in the year 2019

Editorial Note

A dedicated newsletter succeeds only when a large number contribute and actively engage by sending their comments. The task of the editorial team is primarily to edit and present the material in a suitable perspective. The editorial team welcomes all recipients of this newslet- ter, regardless of their affiliation, to send in their papers, experiences, and *ase reports to- wards making this newsletter a rich reading experience.

President
Col (Dr.) Mohan Kubendra mohankubendra@gmail.com

Secretary
Dr. Bhaskara Puttarajanna drbhaskarap@gmail.com

Vice President
Dr. Ramakrishna Prasad dr.rk.prasad@gmail.com

Treasurer
Dr. Ravikumar Kulkarni ravikumarkulk*rni@yahoo.com

Scientific Chair
Dr. Jaya Bajaj jayabajaj@gmail.com

Editorial team
Dr. B. C. Rao badakere.rao@gmail.com

Dr. Roshni Jhan Ganguly roshnijhan@hotmail.com

Dr. Ramakrishna Prasad dr.rk.prasad@gmail.com

Inside this issue

AFPI News

Second Quarterly CME

AFPI Karnataka conducted its second quarterly CME on dermatology in family practice in collaboration with Ma- nipal Hospitals on 28 ^th of May, 2017.

The program was presided over by Dr. B. C. Rao, Mentor AFPI, Dr. Mohan Kubendra, President AFPI Karnataka and Dr. Sachith Abraham, Head of the department of Dermatology, Manipal Hospital. Dr. Murali Srinivas (Chief of *linical services at Manipal) was also present for the inauguration.

More than 70 doctors participated in the program.
The morning session started with a talk on Childhood Eczemas by Dr. Ravi Hiremagalore (Paediatric dermatol- ogist). Case based discussions provided useful insights. Dr. Mukta Sachdev spoke on Acne, a common issue faced by family physicia*s. Dr. Hemavathi Dasappa of AFPI took us through a family physician’s perspective on “Ulcers, Blebs *n* Blisters.”

The morning session was followed by session* on Vascu- litis by Dr. Mukesh Ramnane (Dermatologist at Manipal) and the “Arts and Sciences of Creams and Lotions” by Dr. Srividhya Raghavendran (Family Physician). Dr. Roshni Jhan Ganguly spoke about the different morphology pat- terns of rashes and discussed case scenarios of systemic diseases presenting with a rash. Dr. Jaya Bajaj’s talk fo- cused on skin cancers. A detailed overview on Chronic Urticaria was given Dr Balachandran BV (Paediatric Al- lergist).

The CME concluded with practical discussions and live demonstrations of pr*cedures in De*matology.

Upcoming AFPI Events

CME on Psychiatric Disorders in Family *edi- cine

Date: 10 ^th September, 2017
Last date to register: 3rd September, 2017 Venue: *eople Tree Hospital, Yeshwantpur

Orientation Program for Family Medicine Resi- dents

Date: TBA Venue: TBA

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Real Time Learning

Since the publication of our first newsletter, AFPI Karna- taka conducted 3 more Friday evening sessions on the topics: “Diabetes Managemen* for Family Physicians” by Dr. Saikiran S. (Family Medicine specialist) and Mahesh Mrutyunjaya (Endocrinology); “Approach to Delayed Milestones in Early Childhood” by Dr. Gowri Chintala- palli (Family Medicine specialist) and Dr. Ravikumar (Pediatric Neurologist); and “Breast Cancer Clinical Prac- tice Guidelines” by Dr. Jaya Bajaj (Family Medicine spe- cialist) and Dr. Rajashekhar Jaka (Surgical Oncologist).

Following the discussion on Hepatitis B by Dr. B. C. Rao and Dr. Ramakrishna Prasad, Dr. Vinod Babu has sum- marized the discussion which appears in this newsletter. This newsletter also has Dr. Ratna Prasanna’s summary of the session on management of UTI in family practice that was led by Dr. B. C* Rao and Dr. Hasit Mehta.

Hepatitis B in Family Practice

Introduction

Hepatitis B is not only one of the most common clinical encounters to a family physician but also a disease of ma- jor public health concern in Indian setting.

With approximately 36 million HBV carriers (4% of pop- ulation) and lack of awareness among general public re- garding modes of transmission along with overcrowded living conditions and poor hygiene, it is now all more important for family physicians to be aware of the com- mon challenges in diagnosis, management, follow up and prevention of a patient diagnosed with HBV.

This is a humble effort by AFPI to instill confiden*e in FPs to be able to diagnose and manage this disease.

try

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abnormal ALT
levels alone war-
rants treatment regardless of HBeAg status.

Every 6-12 months with LFT, CBC, AFP & USG liver.

Key Take-home points from discussion

http://www.hepatitisc.uw.edu/page/clinical-calculators/ apri or QX Calculator app.

Thanks to Dr. B. C. Rao and Dr. Ramakrishna Prasad for leading this case discussion.

Dr. Vinod Babu, Family Physician drvvinodbabu@gmail.com

Urinary tract infections in general prac- tice

UTI may present with upper urinary tract symptoms, lower urinary tract symptoms, or systemic symptoms. Symptoms can help us to localize the site of infection

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All mentioned symptoms generally occur in adults, whereas presentation may be different in childr*n & the elderly

Symptoms differ with age & site of infection

Predisposing factors for UTI in adults irrespective of gen- der include: Uncontrolled DM, Immuno compromised states (chemotherapy* nephr*pathy, Anemia), Poor Hy- giene, STD, Debilitating illness, bedridden states/ Catheterisation, Preexisting Urogenital illness/Ca*culi

Coitus & Instrumentat*on may precipitate UTI at any age

Predisposing factors differ in males & females & children. Always identify them to prevent r*current infections.

Essentials to be consid*red in history & examination of patient with UTI

Investigations are done to confirm diagnosis & identify the site of infection, detect predisposing factors & identi- fy complications

Investigations to conf*rm diagnosis are:

ogy a. Always ask for post void residue in scan re- quest form specifically as many radiologists don’t perform it routinely

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Investigations to detect predisposing factors: CBC (Anemia), renal functions tests & e GFR (Nephropathy), Sugar control (FBS, PPBS, Hba1c-poorly controlled DM)

Investigations to identify complications: Serum electro- lytes (Dehydration & dyselectrolytemia), CBC (Leukocytosis- sepsis)

Techniques to collect urine sample:

Goal of History taking & examination & investigation of the patient with UTI is to establish the site o* Infection & detect the predisposing factors for UTI & identify the complications of UTI

Management

Symptomatic /Empirical management: Urine Alkalinizing agents, Increase the Fluid intake* Antipyretics, Antibiot- ics, Antispasmodics, Urinary analgesic (like Pyridium)

Choice of antibiotic:

Avoid quinolones & keep them available for TB cases.

Duration of *reatment

Special points for Geriatric patients with UTI

Special points in pediatric age group

Few points about Recurrent & persis- tent UTI

Summary

Dr. Ratna Prasanna, Family Physician ratnaprasannamysore@gmail.com

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Gleanings

Ymada

A new dru* used in congestive heart failure. It is a com- bination of Secubutiril and Valsartan. When used in Congestiv* Cardiac Failure (CCF) it is significantly bet- ter than ACE inhibitor Enalapril with comparable safe- ty. It acts by boosting the natriuretic peptides and inhib- iting the renin angiotensin aldosterone system [RAAS]. The trials reveal that this drug combination reduced the risk of death from cardiovascular causes by 20%, re- duced the incidence of hospitalization by 21%, and all- cause mortality by 16%. Caution in warranted in pa- *ients with hepatic or renal impairment. There is a dis- tinct possibility that this drug will replace the ACE in- hibitors in the treatment of chronic heart failure in the future. This drug is available in the Indian market and like all new and patented drugs, it is expensive.

Is PCOS an Autoimmune Condi*ion?

Currently, the diagnosis of PCOS is a diagnosis of exclu- sion typically made using the Rotterdam criteria, which require two of the following three to be prese*t: oligo- or anovulation; clinical and/or biological signs of hyper- androgenism; and detection of polycystic ovaries by ul- trasound. There is no laboratory based assay to diag- nose PCOS.

At the annual meeting of the American Association of Clinical Endocrinologists (AACE) 2017 Annual Scientific & Clinical Congress, the development of an ELISA assay that detects serum autoantibodies directed to the 28- amino acid second ex*racellular loop of the GnRH re- ceptor that can be an inexpensive, sensitive, and specific test to identify subjects with PCOS-activating autoanti- bodies, was reported. This finding has the potential to transform our understanding of PCOS and pave the way for significantly more targeted and effective *herapies.

Given the burden of PCOS encountered by family physi- cians in practice, further updates are eagerly awaited.

Can Thirty-Minute Office Blood Pressure Moni- toring reduce overtreatment of white coat hy- pertension in Primary Care?

Abstract

Purpose: Automated office blood pressure monitoring during 30 minutes (OBP30) may reduce overtreatment of patients with white-coat hypertension in primary health care. OBP30 results approximate those of ambu- latory blood pressure monitoring, but OBP30 is much more *onvenient. In this study, we compared OBP30 with routine office blood pressure (OBP) readings for

different indications in primary care and evaluated how OBP30 influenced the medication prescribing of family physicians.

Methods: All consecutive patients who underwent OBP30 for medical reasons over a 6-month period in a single primary health care center in the Netherlands were enrolled. We compared patients' OBP30 results with thei* last preceding routine OBP reading, and we asked their physicians why they ordered OBP30, how they treated their patients, and how they would have treated their patients without it.

Results: We enrolled 201 patients (mean age 68.6 years, 56.7% women). T*e mean systolic OBP30 was 22.8 mm Hg lower than the mean systolic OBP (95% CI, 19.8– 26.1 mm Hg). The mean diastolic OBP30 was 11.6 mm Hg lower than the mean diastolic OBP (95% CI, 10.2– 13.1 mm Hg). Considerable differences between OBP and OBP30 existed in patients with and without sus- pected white-coat hypertension, and differences were larger in indi*iduals aged 70 y*ars or older. Based on OBP alone, physicians said they would have started or intensified medication therapy in 79.1% of the studied cases (95% CI, 73.6%–84.6%). In fact, with the results of OBP30 available, physicians started or intensified medication therapy in 24.9% of case* (95% CI, 18.9%– 30.9%).

Conclusions: OBP30 yields co*siderably lower blood pressure readings than OBP in all studied patient groups. OBP30 is a promi*ing technique to reduce over- treatment of white-coat hypertension in primary health care.

IMichiel J. Bos, MD, PhD; Sylvia Buis, MD, MPH Ann Fam Med. 2017;15(2):120-123.

Our online learning program on Friday night has been success- ful so far. To participate as a faculty / consultant please con- tact Dr. B C Rao or Dr. Jaya Bajaj.

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Case Reports

CMV Esophagitis in a patient with drug resistant HIV

A 37-year-old male patient, a fitness trainer by profes- sion, patient presented with severe epigastric pain. He wa* admitted to the hospital by the gastroenterologist with a working diagnosis of acute pancreatitis. The. The patient reported that the pain was directly related to the intake of food and drink, resulting in a feeling of fullness and a burning sensation on swallowing similar to heart- burn (odynophagia). The increasing discomfort had, dur- ing a course of approximately 4 weeks, caused a de- creased in food intake, resulting in weight loss of nearly 10 kg. By the time of admission, even the intake of fluids had become difficult. The patient was emaciated.

Five years back, the patient had been diagn*sed with HIV infection and h*d been started on anti-retroviral therapy (T*nofovir/Lamivudine/Efavirenz) which he was on at the time of admission. A review of his record from the ART center, a consistent drop in CD4 counts. The most recent count was 54 cells/cubic mm.

. With the patient reporting increasing pain on swallow- ing (odynophagia) ), a gastroscopy was performed, show- ing a deep ulceration in the mid esophagus with its base covered with slough (see Fig1). Figure 1: Endo-

scopic findings in the esophagus of the patient Source: Wilcox, CM et al. Pro- spective endo- scopic charact*r- ization of cyto- megalovirus esophagitis in AIDS. Gastroin- testinal Endosco- py. July–August, 1994Volume 40, Issue 4, Pag- es 481–484

Figure 2: Owl’s eye inclusions in the nucleus typi- cal of CMV infec- tion

Source:https://classconnection.s3.amazonaws.com/12/ flashcards/3011012/jpg/owl_eye1366847227068.jpg. Downloaded on 5/7/17.

Biopsies from the ulcers and plaques were taken. Histolo- gy revealed the presence of owl’s eye nuclear inclusions (see Fig 2) s*ggestive of cytomegalovirus (CMV) esopha- gitis,

Subsequent to this report, the patient received intrave- nous ganciclovir 5 mg/kg every 12 hours for7 days. The therapy was well tolerated with no adverse effects. There wa* a reduction in odynophagia. The patient was dis- charged in a much better condition with the advice to be on or*l Valgancyclovir 900 mg twice daily for 14 days.

An opportunistic infection such as CMV esophagitis in someone on ART raised the concern that his antiretrovi- ral therapy was failing. This could be the result of either poor adherence or the development of resistance. In our patient, a diagnosis of ART Failure was made.

Discussion

Patients with CMV esophagitis presen* with odynophagia or dysphagia, described as difficulty in swallowing or a sense of obstruction—either substernal, epigastric, or in the throat. Liquids are often better tolerated than solids such as meat, which may worsen both odynophagia and dysphagia. Pain may be exacerbated by the ingestion of acidic liquids and belching (eructation). This could resul* in weight loss and dehydration. The endoscopic appear- ance of CMV esophagitis is characterized by large (sometimes >10 cm ² ), shallow, “punched-out” ulcers, ei- ther solitary or multiple, located in the middle or distal part of the esophagus. A diagnosis of CMV esophagitis is confirmed by biopsy and histology findings, immuno- histochemistry, and PCR.

ART Failure is becoming an increasingly common prob- lem as patients mostly go undetected d. Viral load testing is not available at most government ART centers. Lack of awareness among caregivers and cost further complicate the issue. Genotype (drug resistance) testing is rarely done in India. Presently, it is done only at few centers in the country. As a result, in our current scenario, patients are generally recognized very late into the disease, often too late.

In our patient, genotype testing for HIV was difficult due to financial constraints. His ART was modified to Tenofo- vir/Lamivudine/Atazanavir based on anticipated re- sistance profile by the HIV specialist, who is also a Family Medicine physician. A letter was written to the govern- ment ART center requesting a change to the above ART combination. It still took 3 months for *atient to get this therapy through his ART center, which is valuable time lost in treatment at such a critical stage.

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As our relationship with the patient grew, another facet in his case was that his wife was HIV negative. They had fallen in love and despite him telling her about his HIV status, she had married him. They had, however, not con- summated their marriage due to concern for transmis- sion. One of the couple’s regrets was their beli*f that they would never be able to have children together.

A paradigm shift

As our therapeutic relationship evolved, we worked with the patient and his wife to change their outlook towards their future. We explained that HIV infection is not a death sen*ence and millions of *atients are living healthy and fulfilling lives after their diagnosis. We also spoke about the multiple safe and simple options for them to consummate their marriage and even have children. It is now well known that among serodiscordant couples (where one partner is HIV positive and the other is nega- tive), if the posit*ve partner’s viral load is undetectable (which is the goal of ART), the risk of transmission to the uninfected partner even with unprotected sex is extreme- ly low. In fact, a large international study (where there were participants from India as well), found zero trans- missions among serodiscordant couples when the positive partner’s viral load was undetectable. This risk can be fu*ther reduced by offering preexposure prophylaxis (PrEP) to the negative partner. These conversations and messages helped him and his wife to change their out- look. The couple were counselled about the possibility of them having children after his present infection is con- trolled (viral load becomes undetectable after appropriate switch in ART).

It is nearly 4 months since we first saw this patient and we are happy to report that our patient who came with little expectation of improving has gained nearly 10 Kg since switching his ART. His CD4 has rise* from 54 cells/ cubic mm to nearly 260 cells/cubic mm. *hey still have not consummated their marriage but are moving in that direction.

Personally, thi* case resulted in a paradigm shift in my thinking about HIV infec*ed patients. My purpose of this case report was to show that motivation and counselling in a patient suffering from HIV/AIDS (CMV esophagitis with ART failure in this case) can bring in a complete change in their thought process and outlook towards the disease and their future* T*e realization that HIV can be effectively controlled even in the face of ART failure that enables a patient to lead a healthy and fulfilling life has the ability *o transform outcomes for patients and their families.

Dr. Soumy*jit Chatterjee, Family Medicine Resi- dent, St. Philomena’s Hospital schatterjee1988@gmail.com

Dr. Ramakrishna Prasad, Family Physician, St. Philomena’s Hospital
dr.rk.prasad@gmail.com

Practice Experiences

Doctor as the detective: A case of painful muscle spasms

The call came again from Mr. Devarajan’s apar*ment. I had gone there the same afternoon and found him fairly alright though his arm was still twitching a bit. He was able to swallow food and was comfortable and even spoke to me with some optimism which had cheered me. Now, comes this call of *istress.

Devarajan was a senior executive in one of the top food processing companies with its headquarters in Ba*galore. When this incident occurred some fifteen [now 20] years ago, I was the company’s medical advisor and would visit twice a week in the afternoon. The company had built apartments next to the office for twenty odd senior offic- ers with *uilt in amenities, befitting a successful compa- ny. Devarajan and his family were occupying one of these. My practice being close by, I got not very infrequent calls from these in-house families whenever there was an ill- ness that needed to be attended to at home. Lately calls from Devarajan had become frequent and urgent and what was worrying was that I had not been able to find out what was wrong with him.

I saw him sit*ing hunched up with head held up. There was uncontrollable twitching of the face and lips with drooling of sali*a. His jaws were clenched tightly and he could open the mouth with great difficulty. Neck was held rigidly at a tangent. Lower limb, abdomen and trunk muscles were less affected and he was able to walk with- out any difficulty. Hands and arms were also rigid but not to the same extent as muscles of the face, jaws and neck. He was not able to speak with any degree of coherence. Going by the past experience I gave him an injection of Diazepam and oral clonazepam with baclofen [all are muscle relaxants].He settled within a few minutes and I was sure he would be ok at least till morning.

Devarajan began having these problems a month ago one evening. Though certain that these were caused by unop- posed motor impulses from the brain I did not know the cause. Other conditions which cause rigidity and spasm like Parkinson’s disorder and Motor neuron disease have a chronic course and there is usually a history of many years. Another factor was that h* was too young to have any of these. A brain scan did not reveal any abnormality.

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E*aborate blood studies, opinion from two well-known neurologists did not produce any result except the pre- scription which controlled the acute symptoms as de- scribed above. There was even a su*gestion for a psychi- atric consultation! I wondered how a person can volun- tarily bring on these painful spasms just to mimic an ill- ness even if he did have some psychiatric disorder.

The management was worried as the man’s work was suf- fering and he could hardly attend office as he was doped most of the time [thanks to my ministrations] thou*h during the day his problems were manageable. Devara- jan’s misery had me worried and puzzled. Worried be- cause of his suffering and no long-term solution in sight and puzzled because I was unable to find a cause even with all the expert help that was available.

This was the state of unsatisfactory affairs when Devara- jan had to go to Chennai on some errand for a week. He called me son after his return. I went to see him. He was not home. I went to his office. He was busy with work and welcomed me with a big smile. He was completely fit and there was no evidence of any illness at all and it was so since a week! Devarajan said when he was at Madras he went to see a doctor who practiced Ayurveda [Native medicine] and since he started the medication he has be- come free from all the symptoms that has been bugging him for the past one month. He just wanted me to see him free of the spasms and share the good news with me. I don’t know who was more relieved, the doctor or the patient.

I have on occasions, though rarely, come across such cures. Though there is no evidence that alternative ap- proaches have cured a particular condition which we, al- lopathic pract*tioners have been unable to cure, the cure itself is most welcome. Though how the medication brought on the cure was a puzzle, I was relieved that I no longer had to worry about Devarajan and see his misery.

This happy state of affairs did not last long. A week later he called me again as the problem had recurred and a telephonic *onsult with th* Ayurvedic practitioner ended in doubling the dosage with no relief. This was the time I started looking for causes other than are normally known. Reference to a text book on advances in neurology made mention to acute onset of symptoms such as experienced by Devarajan, in persons exposed to pesticides, who have a genetic predispositi*n. But how is Devarajan, living in the well-appointed flat, be exposed?

The flats are trea*ed once a month for vermin with insec- ticides. Could this be a cause? But why is he having this problem almost daily? Then it occurred to me. The possi- ble cause could be the clouding that is being done al*ost daily to the whole campus to ward off the mosquitoes. The pois*nous [to the mosquito] cloud contained organo- chlorines and there was indeed a reference that these can cause the symptoms.

I saw *o that he stayed out of the campus. That cured him. He was one of those rare individuals who had a genetic predisposition to develop acute and painful muscle spasm and fasciculation when exposed to pesticide spray!

There are a few take home points from this case.

Firstly, my search for the incidence of muscle spasms with excessive salivation did not yield any results on Pub- Med. I eventually found references using the search words, “acute poisoning along with other signs and symp- toms”. N*rrowing the search to the words, ‘muscle spasms and inhaled pesticide’ did not yield any additional information.

The second point is to refrain from the tendency to dump patients whose complaints don’t fit into a clear diagnosis thoughtlessly as having a psychiatric illness.

Third point is the importance of follow up, when you s*e a patient for the same problem sever*l times, often the cause becomes obvious, especially so when you make house calls.

Last, one should not give up.

Dr. B. C. Rao, Family Physician badakere.rao@gmail.com

Why should I be a generalist? A Special- ist’s view

It often happened in my practice as a Urologist that I was the first point of contact for few of my patients. While I could address their Urological problem reasonably well, but my appreciation and management of their other problems, especially non-surgical; was under avera*e. I was providing treatment for a part of the whole problem list, at times only a small part. An old adage – A Physician says hello to the heart while a Surgeon shakes heart’s hand* I ‘did shake hands with the heart’ but had forgotten to ‘say hello’! Consequently, I decided to rel*arn how to say a hello with a smile…while I shake hand.

My journey started with the IAPC certification course that I undertook in 2012 to manage my Oncology patients bet- ter. During that course I realised that all my other pa- tients also needed me to be a better “overall” doctor and so the M. Med from CMC followed. It has brought much *ore understanding and enlightenment to me in manag- ing the patient I treat as a whole. It has also been an en- riching and hu*bling experience.

I probably felt that that non-Urological part of patient management was ‘not my job or responsibility’. That’s an incorrect approach and attitude. I now believe that every medical professional needs to be a good general doctor over and above anything else. We owe it to our patients, society and our calling; to be so.

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I also feel the reverse is equally true! Most of us as family Physicians are better at managing some conditions / dis- orders of a certain system, than others. We are good at these things, it comes more naturally to us, we have a knack of it or whatever you call i*. And therein lies the desire to do bette* in that field, the seed to be a Specialist. And we owe it to ourselves to find that domain and pursue it. Wouldn’t it be great if every Generalist formally / infor- mally pursued to be better at one speciality? Of course, never stop being a Generalist.

If I could, I would also urge my no*-para-q*asi clinical colleagues to not ‘gi*e up’ on the clinical training they *ave received and if necessary brush it up and put it to good use. There always is *nd will be a need for good Family Physic*ans and we can use all the hands which are ready to help.

So let us continue to learn-unlearn-relearn. Let us, in our hearts, go back to school; and remain there for good.

Referr*l

All doctors must constantly learn to make, receive and reply to a referral. If involving a colleague, of any cadre, can improve a patient’s management; it’s always worth it. Before a referral I always ask and answer a group of ques- tions. WHICH patient am I going to refer? WHY am I going to refer? WHEN am I going to refer? HOW am I going to refer? To WHOM am I going to refer? And lastly WHAT am I going to do with the end result?

Many Urological ailments (or of other specialities for that matter) need to be treated on chronic care *asis and will remain a part of a Family Physician’s day to day practice. So, let me answer the above questions from an FP’s per- spective.

Which – I should refer the patient in whom I am not sure what is happening and how to manage it.

Why – I may need to refer a patient to diagnose, to evalu- ate, to decide treatment, for intervention, for routine fol- low up, for a new development, for an eme*gency or for a second opinion.

When

‘when’.

–

The ‘why’ of * referral will also decide the

How – Talking directly to the concerned doctor is a good add on but not a replacement of a written / e-mailed / messaged, documented format. The referral letter should contain the background (Medical & non-medical) of the patient, reason for referral and what is expected of the pe*son referred to.

Whom – Identify the person*s) to refer to, preferably beforehand, from the viewpoint of the patients I serve, their residential location, their financial *nd medical in- surance status and their preferences. Better the profes- sional relations and rapport with the doctor referred to,

better the outcome.
And if the rapport is
good, often it is not
the patient who makes the referral journey, only the infor- mation to and fro.

What – Clearly stat* in the referral letter as to what do I expect to achieve from the referral. An* be ready to incor- porate that in the future management of t*at patien*, once achieved. I will be looking after the patient before and after the referral, and hence a feedback about the patient to the referral person is always a good idea.

Keeping the above discussion in min* and one’s individu- al prowess, every doctor can determine which patients DO NOT NEED TO BE REFERRED.

Following is a list of common urological conditions which an FP might routinely treat and a workable list for those conditions where an FP might consider a referral; addi- tion / subtraction being a matter of personal disc*etion.

UTIs – Urosepsis, severe UTI with complicating factors (Uncontrolled DM, obstruction, renal dysfunction, neu- rovesical dysfunction, nosocomial, MDR, etc.), recurrent, refract*ry, UTIs with unusual features (Culture negative), with foreign bodies like catheter, UTIs at extremes of age, post treatment abnormal finding (Clinical or investigato- ry)

rent, with infection, with renal failure, post-intervention

problems

BPH – To rule out malignancy and to define other associ- ated factors, with haematuria-infection-retention-renal dysfunction-stones, worsening on treatment, treatment side effects, post-intervention problems
All cases of non-BPH obstruction in urinary tract should be referred.

spermia, failed conservative management, with genital

anomaly or disease.

Sexual dysfunction – (Male patie*ts only) – Those in whom PDE*I is contraindicated or fails or creates a side effect, those with priapism

All suspected / proven cases of TRAUMA,

TUMOUR,

referred.

All children with suspected / proven CONGENITAL ANOMALY, AMBIGUOUS GENITALIA, should be referred.

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I* a planned follow-up to the Urologist is requested at pri- or referral, the patient should be referred back according- ly with progress / *nvestigations re*orts as planned.

My sincere thanks to team Newsletter and AFPI for this op*ortunity.

Dr Hasit Mehta, Urologist & Family Physician drhasitmehta@gmail.com

Resident’s Corner

There is never a lost cause

This dates to the first year after my medical schooling. I had joined the Neuro-Anesthesia departme*t, NIMHANs as a junior resident to primarily work in the Intensive Care Unit* for 12 months on a contract basis. I was the only non-anesthetist working in the department and was often referred to as a “kid”.

The Neuro-Medic*l ICU (NMICU) *as six bedded and there was always a scarcity of beds. We had this patient being shifted from the Emergency Room (ER), with histo- ry of breathing difficulty. On evaluation, this was a known case of Myasthenia Gravis (MG) with a history of recur- rent hospitalizations for his respiratory failure. In his medical condition, he would have no strength in his mus- cles including his respiratory muscl*s, *nd he would be laboring for air while being fully conscious. Were he not provided mechanical ventilation, , he would succumb. He was lucky to get a bed in the NMICU, as another pa- tient had just been shifted out.

The patient was a senior engineer in one of the govern- ment companies in Bangalore and his cost of hospital care was well taken care of.

He had a devoted wife who had seen these hospital admis- sions before and was prepared for this time’s ride too. But for me it was a new learning experience.

The patient was put on a ventilator, treatment as per Neu- ro ICU protocols was followed. He received Inj Neostig- mine 3-4 times a day and felt stronger for 2 hours after each dose. It was [distressing] to see his strength go out of his muscles as the drug effect wore out. The nurses worked hard to make sure he was comfo*table and did not develop bed sores. He would communicate with the ICU team and his family by scribbling on a note pad. I soon learnt his expressions and worked as his transla*or when he wanted to communicate.

I was growing in m* knowledge and clinica* skills as I was continuing to work there I would start the day at 8am and work till 8pm with half a Sunday off* I started mastering

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ICU protocols, ventilator management, establishing cen- tral venous lines, doing bedside tracheostomy etc. While I progressed with my clinical skills, our patient continued to be dependent on the ventilator. It was8 months and he did not seem to remit.

The neurologist took a call and wanted to get a thymecto- my done for him. He was shifted to a corpora*e hospital and a well-known cardiothoracic surgeon removed his thymus and he was shifted back to our NMICU. The post- surgery m*nagement protocols were followed and he con- tinued to be on the ventilator. Months passed b* and his dependency on the ventilator continued and in addition he developed an open surgical wound w*ich refused to heal.

His strong-willed wife was beginning to lose hope. All these months, she and I had developed a friendship and we both were coaxing each other that he would improve and walk home. She who was a house wife took up a li- brarian’s job to support her family. Her daughter was go- ing to take her 12 ^th grade exams.

Soon it was 11 months and he was going in for multi- organ failure. His wife and me could not look into each other’s eyes. I felt I had failed on my part to convince my- self and her that he would walk home. I did not know what she was thinking. And after 11 months of NMICU stay, he passed away.

The man who orchestrated this great c*re, where a com- pletely ventilator dependent person who could not even op*n his eyes due to muscle weakness was managed for almost a year with no lung infections, with no bed sores, no deep vein thromboses. taught me the value of life. He was the head of the Neuro Anesthesia Department. I was going into depression by this loss and wondered it was worth working this hard to prolong his life. When I asked his wife if we should have done it any differently, she re- plied that her engineer husband was a fighter and appre- ciated our efforts in striving to get him his remission.

I asked the HOD if we should have let him go long ago. To which, he narrated a story, that 10 years earlier, he had r*ceived a call while he was in the operation theater. There was a case in the ER with breathing difficulty. And since he was busy with a surgery case and all o*hers were busy too, he asked the nurse to shift the patient to the OT. The nurse with the help of a ward boy in the ever-busy hospital rushed/ the patient on the ER cot itself to the side room of the OT. The HOD immediately intubated the patient who was drowning in his own lung secretions due to myasthenia gravis and shifted him to the NMICU. The patient survived and lived 10 years to come back again to the same hospital and same doctor, but this time luck was

The HOD asked me if he should have given up on the patient then? The HOD asked me if he should have given up on the patient this time or last time.

Dr. Syed Abu Sayeed Mubarak, Family Physician, Bangalore.

MASALA

I was surprised when the couple asked me,’ when did you return from gulf’ I said I never went to Gulf’. But your man told us you had gone to Gulf when we came last Thursday before last, they said. Now I understood, my assistant had pronounced, Golf as Gulf!

Compliment?

He came to see me after ten years. These ten years he has been seeking help with someone else. I have stopped wor- rying about those who leave me for better medical pas- tures but I still am curious to know why they did leave me in the first place and more so wh* did they come back. I get some interesting answers, but what this man said took the cake. He said,’ an old enemy is better than a new friend!’

www.afpikar*ataka.in

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