A lady with a BIG SMILE!

It was a busy day in casualty and I was on duty. As I was seeing other patients, my colleague handed over me the notebook of a patient and said, “She needs a referral to the higher center because her creatinine is 4.1 mg/dl. Make it as soon as possible” As soon as I finished seeing other patients, I walked towards her to talk. She was 40 years old,  sitting over the bed with a huge smile on the face. She looked a little anxious and I was able to make out that she is visiting this hospital for the first time. I slowly checked her blood pressure and it was 230/140 mm Hg. It is highly unlikely for a 40-year-old female to have this blood pressure unless she has a long-standing kidney problem or an endocrine problem. Then I asked her, “What is your problem? Why did you come to OPD today?”. She replied, “I don’t have any problems doctor. Why did you place an injection in my hand (IV cannula)?. Leave me! I have to go home. I have a son to take care of”. I explained to her that she is having very high blood pressure and we need to find the cause behind it. I also noticed large swelling in both legs and asked her about the duration. She replied, “For the past 2 days” and added that she is having symptoms of shortness of breath while walking for the same period. After I asked about any trouble during passing urine, she said, “It has been very low for the past 2 months”. She denied symptoms of pain during passing urine, fever, cough, weight loss, and low back pain. She is a known diabetic for the past 7 years and hypertensive for the past 4 years. Her family members did not suffer from any kidney or heart diseases. She had her first child 4 years back, through caesarian section. She is living alone with her mother and her husband left 2 years back. She is working as a salesgirl in a dhoti shop. While examining her, there was swelling of face, leg, abdomen, and she was pale. I checked her heart sounds and on listening to her lungs there was fine crepitation both sides, which indicates fluid in the lungs. Again I checked her blood pressure and it was 230/170 mm Hg. She was fluid overloaded and her kidneys are not functioning properly. Then, she showed me the investigation's report, which she had shown it to my friend previously. All those tests were 20 days old and it showed Serum Creatinine – 4.1 mg/dl, Hemoglobin – 10.2 mg/dl, Total Counts – 7300 cells/mm3. I asked her what the doctor did once he saw these reports. She said he advised her to visit a big hospital for further management. I asked her why she did not come early with such a serious issue. She replied with an innocent smile, “I did not get THE LEAVE doctor!”. I was shocked, got more tensed even more and thought “How can she be like this? Someone’s health is more important than work!” I did not ask anything and slowly walked back to my chair, with thoughts running behind in the back. At first, when the patient is the only breadwinner of the family, they often have to strike a balance between their health and work. Particularly when they know that, they are sick with conditions that might require admission. Many doctors including me, always propagate the importance of health and advice on having regular hospital visits or admissions whenever needed. However, what they fail to see (including me) is other major factors play a vital role in influencing the patient’s decision to attend the health care facility. For example, initially, this lady has to think about her daily salary and cannot afford to get her salary cut for 10 days. Then she has to think about her son, since her mother is the only person available to take care of both of them. Thirdly, she is afraid of the diagnosis and the effects it might have in her future work and family. All these 3 months, with her problems, she was doing all permutations combinations to find one solution which might not affect her work as well as personal life. But when she failed, she ended up here. The moment when I realized these little things, I kept quiet and asked her to call someone to accompany her during referral. After 2 hours her mother came, with her grandson over the hip, with a strange look on her face wondering what is happening to her daughter. The little boy without realizing anything started playing with his mom. Again, I had a glimpse of her family, which I have failed to see before. While I was arranging for her referral, she asked innocently “Doctor, those private hospitals will be costlier, right? I cannot afford treatment there!” Then I reassured her that all the expenses will be taken care of by ESI and advised her not to panic since her blood pressure was still 240/140 mm Hg.

Today, I went to the referral hospital and visited her. She was still with that big smile on her face, but now all those puffiness reduced largely. She told me that she is feeling better now and the doctors here have taken many scans and blood samples to find out the cause. She also explained that an ophthalmologist has seen her since she had a problem with the vision for a long duration. Her son was lying over her bed, sleeping quietly. Then I visited the consultant who was treating her and asked him about further management. He explained that she is having both diabetic nephropathy and retinopathy, and so she might have to undergo hemodialysis shortly. I returned home with mixed feelings of worries and happiness. A big journey is awaiting in front of her, once she lands up in dialysis.

The financial status and family support play a major role in affecting one’s health. Even though I have heard and read the above statement many times in my life, thorough many patients, it is being reinforced repeatedly. Had this woman visited earlier, a routine blood investigation and an eye check-up could have helped us in detecting her kidney disease earlier. But it is inevitable, as my guru used to say during our conversations. At last, as a doctor, you end up in providing emotional and moral support to our patients, which i think, is much needed in this era of chronic diseases.