Stress diabetes
I was posted as an Assistant Surgeon in a district hospital in my hometown on the West Bank of the Irrawaddy. The hospital was a hundred- bedded district hospital but due to poor communication, low level of health knowledge and awareness, cases were admitted in serious condition and in very late stages. Staff strength of medical officers was limited and we were very busy. Being a native of the town, I could not go away on leave, and needed to take 24 – hour duty, sleeping at the hospital on alternate days. In the evenings, I did home-visits to check on patients from my GP practice in a horse cart. At the same time, I worried about being transferred to remote places. I was much concerned about seriously ill patients struggling for their lives. It was very sad seeing patients die in the wards, and confirming the final cause of death at autopsy.
Carrying on this routine for months, I felt exhausted and eventually fell ill. While being treated with pick- me- up treatment, a junior doctor examined the urine and sugar was detected. The only symptom was mild diarrhoea for more than a week. I was transferred to Rangoon General Hospital and admitted for three days. I was tested for glucose tolerance and eventually diagnosed by a professor as diabetes mellitus and the discharge certificate stated the diagnosis of “DM with autonomic nervous diarrhea”.
Do not miss or over- diagnose
Patients should be properly investigated to reach a definitive diagnosis and should not be satisfied with the relief of symptoms and getting some kind of treatment. Doctors or healthcare providers should not miss the diagnosis/ “under-diagnose” /misdiagnose or “over- diagnose”. For example, a patient diagnosed as cancer of the liver instead of chronic hepatitis; or as hypertension although the criteria for diagnosis of hypertension are not met, causing unnecessary concerns. A senior medical director from the Department of Health was diagnosed with hepatocellular carcinoma and referred to a medical centre in Singapore where he was diagnosed as chronic liver disease. The Director spent a large sum of money to get medical checkup abroad. To avoid over-diagnosis, there should be case definition or operational criteria. We cannot absolutely rely on a single laboratory result. If the condition was not severe enough the follow- up or continual results or test should be done and reviewed. Only when the definitive diagnosis is made can the patient follow the instructions or compliance with therapy or medications effectively. On the other hand, a missed diagnosis of a case of peptic ulcer perforation would have the serious consequence of life- threatening peritonitis.
Hypoglycaemic symptoms
I was diagnosed as diabetes mellitus and prescribed Diabecon (Chlorpropamide). On that very day, I had hypoglycaemic symptoms: palpitations, tremor of hands and sweating and immediately recognized the condition. Then I took one teaspoonful of sugar. One day, I was coming back home from an operation theatre watching operations and did not notice time passing. Symptoms were recognized halfway to my sister’s apartment on 36th street, upper block. The door of the room was open and I stepped in for three or four steps. Luckily, I noticed that the people around were not my cousin and sister. I apologized to the inmates and left, saying “Sorry; wrong apartment”. My elder sister’s apartment was situated in the next building. I immediately ate a large bolus of rice when I finally made it to her place because I was in a state of confusion and would otherwise lose consciousness. I continued taking antidiabetics for a year or two and eventually stopped on my own decision.
Laboratory examination
After a lapse of twelve years, I was selected to attend a short training course in the United States of America. The chemical abnormality had not changed and sugar was still present in the urine. I became worried and took medicines again and even added a traditional medicine powder. One day, I ate less breakfast and felt hypoglycaemic near lunchtime while studying in the class room. Eventually, I had a medical examination done at the Boston Joslin Diabetic Centre. Luckily, I had bought health insurance premium during the three months course and I did not need to pay out of pocket.
The surest test for the diagnosis of diabetes mellitus was oral glucose tolerance test.(Glycosylated haemoglobin testing was not available then). A loading dose of glucose was given and serial blood specimen were tested for glucose at half- hour intervals.
Patient name- U Ye Hla, Hospital registration number- 373641 Date 28 February 1978
Does it make sense?
A University clinic doctor referred me to the world-famous Joslin Diabetic Centre, where a Professor examined me. I had a little bit of thyroid enlargement and drooping of eyelids which he noticed and asked me about. I told him that I had had these since birth or childhood. He gave a final diagnosis of “chemical diabetes” which required no medicine or diet restriction. Then he asked, “Does it make sense?” Yes it made sense! Even then I did not take medicines and there had been no need to limit sugar. I was fine afterwards with the present diagnosis. Actually, my condition was impaired glucose tolerance and the test was repeated in the Boston Joslin Diabetic Centre, after priming with carbohydrate meals for three days. My sugar level fell to normal at three hours after glucose load (the glucose becomes normal after one a half or two hours in normal persons).
Whilst in Myanmar, I was diagnosed as mild diabetes by a senior physician, diabetes mellitus by a biochemist and diabetes by a professor of Medicine who prescribed anti-diabetics. Actually, my condition could not be designated as frank diabetes but it can change to frank diabetes (said to be around five per cent a year). Or it may not progress. Therefore, two hours post-meal blood glucose test should be done. For any practicing doctors you should not miss the case or under diagnosed or miss the diagnosis or over-diagnose.
Author Information
Ye Hla
Director (Research) (Rtd)
