Patient Cases at the UHTC and RHTC

The last couple days we have been going to the Urban Health Training Center and the Rural Health Training Center as part of our community medicine posting- we are finally getting to see patients all day every day (and no lectures) : )

Here are just a few of the cases we have seen to give you an idea of the patient population and the health problems they face. Note that most treatment given at these outreach centers is just symptomatic and not necessarily curative.

On Friday at the RHTC I was able to see two elderly women suffering from chikungunya (don’t feel bad if you have no idea what that is- I didn’t until I got here). Chikungunya is a virus which is spread by mosquitoes (similar to how malaria is spread)- the disease was first described in Africa and was very rare until recently. In 2005-2006 there was a widespread outbreak of chikungunya in southern India- after heavy rains and flooding (think standing water and mosquitoes). The virus is generally not fatal although some deaths have been attributed to it. Patients suffering from chikungunya generally present with fever, rash of the limbs and trunk, and arthritic symptoms in multiple joints- can be debilitating. The women I saw both had swollen joints and decreased mobility. The physicians said that the crippling joint pain is the most common and pronounced symptom. The fever generally subsides after a day or two while other symptoms, mainly the joint pain, can last up to weeks or even months (generally longer in older patients). There is no specific treatment for chikungunya- at the RHTC treatment is given for relief of the painful joints- anti inflammatory treatment. (The physicians said that in some clinics steroids are being given.)

A mother and her two sons came to the RHTC- all were patients. The mother had malaria and was given quinine tablets for treatment- she presented with fever and chills for days. Her 3 year old son had a terrible case of scabies and an upper respiratory tract infection. He was given antibiotics, skin cream for the scabies, and advised to take an antiseptic bathe. Her 13 year old son was unable to walk or sit in a chair without assistance. This was the first time he had been brought to the clinic- the mother wanted to know what was wrong and what could be done. After a very brief physical exam and patient history the physician suspected muscular dystrophy. The mother reported that her son developed normally until the age of 7- after which he just got worse. Aside from his physical disability his mental function is normal. He is the product of a consanguineous marriage. The family was referred to SDM hospital- orthopedic department for further care. However, the physician was skeptical as to whether or not they would actually take their son to the hospital (due to a lack of transportation, money, etc.).

Side note- in the past few days I have asked a few physicians about consanguineous marriages in India and why they appear to be so common. Here is what I was told… primarily people don’t understand the medical problems that can result in children that come from a consanguineous marriage (congenital abnormalities). They reported however that the number of consanguineous marriages has decreased to about 50% overall- definitely more common in the villages and rural areas than in urban settings (this is down from about 60-70% 10-15 years ago- the result of education about these congenital abnormalities). The reasons given for arranging a marriage between family members were as follows. Since most parents arrange the marriage and since children generally take care of their parents in old age- parents figure that if both members of the couple are family both have some personal stake in taking care of the parents in old age… thus, the parents are guaranteeing that they will be taken care of in the future. Also, if both members of the couple are individually related to the parents this makes certain that any inheritance will be kept within the family. When the parents die whoever (husband or wife) inherits their land, money, or other property is sure to be family.

Maybe the most disheartening case was one I saw at the UHTC. A 19 year old female came in complaining of loss of energy and fatigue. The patient was clearly anemic and malnourished. In taking the patient’s history this is what the physician found out… the woman had recently lost an infant and complained that her in-laws (whom she lives with- it is customary for the daughter-in-law to move in with her husband’s parents) were giving her a hard time about being an unfit mother. She reported that the family was not giving her any food- she said she had eaten dirt she was so hungry. She said her child died because the family was not giving her enough food to produce sufficient milk for the infant. She said her husband, who works in the field during the day, is not sympathetic and sides with his parents. The physician treated her with antidepressants, nutrition supplements, and advice on free feeding programs in the area.

Along with the above cases there was a woman who presented with fatigue and appeared anemic. After a blood test she was found to have a hemoglobin of 5 (should be around 14). There were countless children with skin infections (the result of poor hygiene)… most of them had scabies and due to scratching the skin had been broken, increasing the risk for secondary infections- which most had (presenting as skin boils averaging 1-2 cm in diameter). Oh and a family of 5 all suffering from gastroenteritis- mother, 7 year old son, 3 year old son, 2 year old daughter, and 7 month old daughter. The physician treated them with antibiotics, oral rehydration solution, and a stress on personal hygiene. And on a more positive note today a 98 year old woman came in to the RHTC, after walking 2 km from the neighboring village, to inquire about getting some new glasses. She had broken hers and wasn’t able to see very well with the old pair she had found at home. Aside from the glasses request she was healthy (and probably the cutest old lady I’ve seen- Eva and I took her picture) : )

Our days spent at the UHTC and RHTC have been an amazing opportunity to learn about medicine, about healthcare in India, about treating a patient population with limited resources, and most importantly about compassion. I feel fortunate to have been able to see and learn from patient cases that are not likely to appear at the University of Iowa Hospitals and Clinics.