REMEMBERING PROF. M.K. MEHRA WITH HIS LECTURE ON TUNNEL VISION

                                              

Prof. M.K. Mehra, FRCS, FRCS, DO was the professor and Head of the Department of Ophthalmology in King George’s Medical College, Lucknow, when we were students during our MBBS days. He was a strict disciplinarian, an outstanding surgeon, an excellent teacher and an exceptional human being. He, and his wife, Prof. Prabha Mehra, who was our teacher of Obstetrics & Gynaecology, were the most respected and loved couple of our college. He was an expert in Strabismus (crossed eye – looking London, talking Tokyo), Neuro-ophthalmology, Retina and Cataract surgeries and we were in awe of his charisma. He was a man of few words and maintained very cordial relationship with his peers and with the administration. This saw the department  grow and get the latest gadgets and imbibe a culture of progress, a trait which continued even after he left the department after his retirement. Dressed in all whites with white gum boots he was a passionate teacher and a very hard task master. Prof. M.K. Mehra was known for his philanthropic work and he took keen interest in the running of a very busy Sitapur Eye hospital, almost 95 Km from Lucknow. This was a lecture, which I could salvage from my old class notes, is on Peripheral Vision Loss.

We usually use the phrase ‘tunnel vision’ when we describe someone with a rather narrow worldview. But that metaphorical meaning is secondary. There is an actual medical syndrome with the same name, a condition when a person’s visual field becomes so physically limited that he or she sees everything as if they were looking through a tunnel. And if that’s not creepy enough, tunnel vision can be a warning sign of several underlying serious health conditions ranging from eye diseases to stroke. A senior colleague of mine, who is otherwise a very responsible and safe driver, met with an accident when he brushed the side of a stationary city bus and he vouched he never saw the bus standing till it was too late! He went straight to his ophthalmology colleague who examined his eyes, vision and visual field and eventually diagnosed him to be a case of glaucoma. Now he is doing well and all he requires is an eye drop at night.

 

What is tunnel vision?

Tunnel vision, also known as peripheral vision loss (PVL) or tubular vision, is a condition when your line of sight is restricted so you don’t see on the perimeter of your visual field without turning your head sideways. People with severe PVL often explain their vision as “looking through a tunnel,” which is how the condition got its common name. Tunnel vision is more serious than it may sound at first glance. A person with peripheral vision loss can only see something when he or she is directly looking at it. This limits one’s ability to avoid hazards or danger while walking, driving a car, or pretty much any daily activity that involves moving around in space.  Depending on the underlying cause, tunnel vision can occur in either one or both eyes.

Normal Vision                                    Tunnel Vision

PVL can have the following symptoms:

• -         The outskirts of your field of vision are dark or blurry, but the middle of your line of sight is clear.
• -         You have bad night vision.
• -         You’re prone to bump into objects or fall.
• -         Reading and driving are challenging.
• -         It’s difficult for you to move around in a crowded or narrow location.

 Tunnel vision may be caused by a variety of underlying health conditions. Identifying the cause is crucial for it improves your chances of preserving your eyesight or even restoring it completely.

1. Glaucoma and other eye diseases

Peripheral vision loss is often caused by eye diseases that involve the retina. The retina contains special cells that sense light called rods and cones. These photoreceptors detect light and transmit information to the brain, allowing us to see. When the retina is obscured or damaged, you may experience peripheral vision loss. Tunnel vision, particularly in the area closest to the nose, is one of the first symptoms of glaucoma, the second biggest cause of complete vision loss in the US according to the American Optometric Association.

Glaucoma develops when the fluid pressure in the eye spikes, causing damage to the optic nerve. The optic nerve connects the eye and the brain, so any damage can lead to vision problems. Apart from tunnel vision, glaucoma manifests itself through the following symptoms:

-         Blind spots

-         Blurry or cloudy vision

-         Sharp pain in the eye

-         Seeing halos around lights

-         Headaches

-         Nausea or vomiting.

Untreated glaucoma can lead to blindness, but early treatment can halt vision loss.

Other eye diseases that can cause peripheral vision loss are:

Retinitis Pigmentosa is an irreversible genetic condition that affects the way the retina reacts to light. Loss of night vision, central vision, difficulty identifying colors are common symptoms. There is no treatment for retinitis pigmentosa.

Nuclear Cataracts occur when proteins build up in the center of the lens and damage its edges, causing PVL. Blurry vision, light sensitivity, loss of night vision, a yellowish or faded perception of colored objects, and double vision can also occur. Cataracts can be treated by surgery.

Retinal Detachment is a medical emergency. When the retina separates itself from the back of the eye, you can experience vision loss or see floaters in the peripheral field. If not treated in time, retinal detachment can cause complete vision loss.

Optic Neuritis refers to the inflammation of the optic nerve. Infections can cause this condition, but it may also be an early symptom of multiple sclerosis. One must see a doctor if one experiences PVL, feels pain in the eye, sees flashing lights or loses color vision.

 

 2. Diabetic retinopathy

When a person has high blood sugar, it can harm the retina and causes a condition called diabetic retinopathy. This condition occurs because excessive blood sugar injures the tiny blood vessels in the retina and makes blood leak into the retina. At first, it may not manifest itself through any symptoms, but over time, you may notice minor changes in vision, namely difficulty reading, seeing faraway objects, or a reduction in peripheral vision. Later on, dark spots and streaks may begin to appear in your line of sight. Damage caused by diabetic retinopathy is non-reversible, but treatment can prevent further vision loss. If you suffer from diabetes and experience any vision changes, see your doctor and ask for a referral to the ophthalmologist.

 

3. Migraines

Migraines are known to cause visual disturbances that can occur either before or during an episode. Apart from intense head pain, migraine sufferers sometimes experience tunnel vision or complete vision loss in either one or both eyes. Luckily, these symptoms are usually temporary and go away on their own within 20-60 minute. If these symptoms do not resolve entirely after 1 hour, you need immediate medical help. In some cases, visual disturbances are the only symptom of a migraine. This type of migraine is referred to as an ocular migraine, and it is caused by a temporary reduction of blood flow or a spasm in the blood vessels in the eye. People describe an ocular migraine as seeing stars or shimmers in their visual field. Peripheral vision loss and blind spots can also occur. Ocular migraine episodes are largely harmless and usually go away on their own within a few minutes.

 

4. Stroke or concussion

Peripheral vision loss may also be an indication of damage directly in the brain tissue. If a stroke occurs in the area of the brain responsible for vision, it could lead to blurry vision or vision loss. In most cases, stoke affects both eyes. Recovery is not always possible, it all depends on the extent of the damage and the area of the brain affected by the stroke. Some vision can be restored without any medical interventions, but full recovery is relatively rare. Nearly half of stroke survivors with visual field loss experience some improvement, usually 3-6 months after the stroke.

Concussions may result in nearly identical but usually temporary symptoms.

 

5. Alcohol intoxication

Sometimes, peripheral vision loss is not a sign of a medical issue. If you drink too much alcohol, you may experience blurry vision or tunnel vision. Since alcohol is a depressant, it slows down your brain’s reactions and impairs your coordination. If you’ve ever felt dizzy after a few too many drinks, you know what I mean. Now, your arms and legs aren’t the only body parts that get affected by alcohol - your eye muscle coordination can be weakened by alcohol too. This kind of tunnel vision is usually temporary, but excessive alcohol consumption can harm brain cells over time, so it could lead to long-term vision problems too.

 

What can you do if you have tunnel peripheral vision loss?

 Identifying and managing the underlying cause is the best way to treat tunnel vision. This can help prevent it from getting worse. Your family physician and ophthalmologist will work together to prevent further vision loss or completely treat the condition. If you suffer from tunnel vision, it’s also essential to adjust your home setup to avoid injuries and falls: place furniture farther apart, remove any sharp or breakable objects from open shelves or tables, clear the home of slippery rugs or low furniture that can be a tripping hazard, etc. Whenever you notice sudden visual disturbances that are accompanied by sudden confusion, headache, difficulty walking, problems with coordination, or difficulty understanding speech or speaking, seek emergency medical care, as you may be experiencing a stroke. I have in the past, written a blog on Stroke. Please click: https://surajitbrainwaves.blogspot.com/2022/01/stroke-killer-mini-stroke-warning.html

After reading these notes I truly became nostalgic and rang up my batchmate, Dr. Jaideep Datta in Dehradun, who spent a lot more time with him while doing his post graduation in Ophthalmology. He too went down the memory lane and remembered how he and madam played gracious host to the resident team when they visited their home during Holi celebrations. He was quick to catch the missing members of the resident team in that evening ritual and enquire about their wellbeing and cause of absence. The couple loved to live their life tastefully, maintained a very beautiful house and were always immaculately dressed and envied by one and all. Those were really wonderful days and these teachers have and will always remain exceptional role models.

DIGITAL ARREST, DEEPFAKE, PHISHING EMAILS AND QR CODES AND MUCH MORE

 

As the digital landscape keeps evolving, so do online scams. If we witnessed an  unprecedented surge in sophisticated cyber attacks throughout 2024, the coming years will only get worse. These aren't your typical email scams anymore - criminals now use cutting-edge technology to create increasingly convincing schemes. The fraud of Digital Arrest has just been busted but victims still are falling prey to it. The scam involves fraudsters impersonating law enforcement officials on video calls, threatening victims with arrest over fake charges, and pressuring them to transfer large sums of money. There are many more dangerous digital threats you need to watch out for, and in this blog I will suggest simple and practical steps to protect yourself and your loved ones from these fraudsters.. 

 

1. Scam Calls and Fake Income Tax Department Messages

With tax season approaching, fraudsters are likely to intensify their schemes by impersonating the Indian Revenue Services Department. These scammers employ phone calls, emails, and text messages to convince victims that they owe taxes or are eligible for unclaimed refunds. Their messages often include phishing links leading to fake IT websites designed to steal personal data or payments. What makes this tactic effective is the use of fear and urgency. In such circumstances, victims are often pressured to act immediately, bypassing rational judgment in the process. While some scammers focus on stealing money, others aim to gather sensitive information for identity theft, which can have long-term consequences.

How to stay safe: The IT Department communicates primarily through official mail. Be cautious of unsolicited calls, texts, or emails. If contacted, verify the message’s legitimacy by reaching out to the Income Tax office directly through their official website or phone number or inform your Chartered Accountant. Never click on suspicious links or share personal details without confirmation.

 

2. Deepfake Scams

Deepfake technology—AI-generated audio or video content—is becoming more accessible, enabling scammers to manipulate trust in alarming ways. These convincing fakes can impersonate anyone, from public figures like Amitabh Bacchan and Mahendra Singh Dhoni to loved ones like children and grand-children, to deceive victims. Imagine receiving a plea for financial help from what appears to be a family member on a video call, only to discover it was a well-crafted fake. This manipulation extends beyond financial scams, as deepfakes can spread misinformation or damage reputations. We have discussed this issue in a previous blog, and if you have missed it, please click: https://surajitbrainwaves.blogspot.com/2023/11/deepfake-cleverly-rebranded-as.html

How to stay safe: Verify unexpected requests for money or sensitive information through alternate channels, such as a direct phone call. Avoid over-sharing personal videos online, as these can be used to create deepfakes. Utilize AI detection tools to identify manipulated content where possible.

 

3. AI-Powered Email Attacks

Modern phishing attacks use AI to compose personalized messages that sound natural and convincing. These emails analyze your digital footprint to reference real events, colleagues, and projects. The messages often mimic your Chief’s or senior’s writing style perfectly, making them nearly impossible to distinguish from legitimate requests. These attacks often target workplace environments, requesting urgent wire transfers or sensitive document access. The AI adapts its language based on previous interactions, making each subsequent message more convincing. And eagerness to comply with the boss’s request and climb us his preferential list is the desire of every junior colleague!

How to stay safe: Implement multi-factor authentication for all business communications. Create clear protocols for financial requests and sensitive information sharing. Take time to verify unusual requests through different communication channels. Use email authentication tools that detect AI-generated content.

 

4. QR Code Phishing

QR codes have become part of daily life and are being used everywhere, from restaurant menus to payment systems to the push cart vegetable seller. Criminals exploit this familiarity by placing malicious QR codes in public spaces and sending them through emails. These codes redirect users to fake banking sites or automatically download malware to phones. Scammers place fake codes over legitimate ones in popular restaurants and stores. Some even mail QR codes disguised as package delivery notifications or parking tickets. Because users cannot see the embedded link before scanning, these codes can easily deceive even cautious individuals.

How to stay safe: Use your phone's built-in QR scanner with security features enabled. Check the URL preview before opening any QR link. Avoid scanning codes in unexpected places or from unknown sources. Install mobile security software that screens QR codes before processing them.

 

5. Cryptocurrency Scams

As cryptocurrency continues to gain traction, scammers are increasingly targeting digital wallets. Fake investment opportunities, phishing schemes, and malware designed to steal wallet keys are just a few of the tactics being used. One common scam is the “pump and dump” scheme, where scammers inflate a cryptocurrency’s value through false hype, sell their shares, and leave investors with worthless assets. Since cryptocurrencies are decentralized, it is almost impossible to recover stolen funds, making them an attractive target for cybercriminals. Advanced malware capable of intercepting transactions or accessing wallets is are a constant threat.

How to stay safe: Store cryptocurrency in hardware wallets rather than online exchanges. Enable multi-factor authentication for all crypto accounts. Avoid downloading apps or software from unofficial sources, and thoroughly research any investment opportunities before committing funds.

 

6. Tech Support Scams

Modern tech support scams use sophisticated pop-ups that freeze browsers and display official-looking company warnings. These alerts often include countdown timers and authentic-sounding error codes to create urgency. Scammers now operate professional-looking call centers with trained staff who sound knowledgeable about technical issues. These operations target both home users and small businesses, offering to remove viruses or fix performance issues. They often install legitimate-looking software that actually contains monitoring tools.

How to stay safe: Never call phone numbers from pop-up warnings. Use official support channels for technical help. Avoid granting remote access to unexpected support calls. Keep software updated through official sources. Install reliable antivirus software with anti-scam features.

 

7. Package Delivery Scams

The explosion of online shopping has created perfect opportunities for delivery scams. Fraudsters send emails or text messages claiming issues with a delivery and provide phishing links to “fix” the problem. Clicking these links can install malware or lead to identity theft. Recent scams include fake delivery driver apps that request location access and personal information. Some criminals even leave fake delivery slips on doors with QR codes leading to malware downloads.

How to stay safe: Track your packages through official retailer websites. Be wary of unsolicited messages about deliveries, especially if they include links or request payment details. Verify delivery issues directly with the courier’s customer service.

 

8. Card-Declined Scams

Card decline scams exploit the frustration of failed online purchases. Scammers create fake shopping sites that deliberately decline valid cards multiple times while secretly processing charges. These sites often offer popular items at suspiciously low prices. The scams usually target holiday shoppers and people searching for hard-to-find products. Some operations even send confirmation emails for declined transactions, leading victims to try multiple cards.

How to stay safe: Shop only on established websites. Double-check the legitimacy of websites and offers before entering payment details. Use credit cards instead of debit cards for better fraud protection. Monitor account activity regularly. Set up banking alerts for all transactions.

 

9. Malicious Apps

Malicious apps now mimic popular software perfectly, including user reviews and ratings. These apps often provide their advertised functions while secretly harvesting data or running cryptocurrency miners. Some target specific banks or payment services, waiting for users to log in. Security researchers identified thousands of fake apps designed to steal financial information, with new ones appearing daily. Many bypass app store security through clever coding techniques.

How to stay safe: Download apps only from official stores like Google Play or Apple’s App Store. Read reviews carefully and check developer information. Monitor app permissions and battery usage. Remove unused apps regularly. Use mobile security software that scans for malicious behavior.

So, staying safe is a choice that you always have. All you have to remember is if you are a law abiding citizen you can get a notice or two from various government departments but in every department there are avenues to address your notices and no one can digitally arrest you or force you to pay huge sums of money at short notice. On your behalf you will have to be careful with unknown apps, pop up messages, browsing doubtful websites, scanning QR codes in public places, and making digital payments using free to public Wi-Fi connections. Use your phone’s in-built QR scanner with security feature enabled and never call phone numbers from pop up warnings.

THE OLD SCHOOL GROOMING OF CHILDREN

All parents want their children to be successful, to accomplish worthy achievements in their lives, and to become adults who know how to navigate their lives without worries. There is no doubt that alongside the innate qualities of children, our functioning as parents can have a considerable impact on their behavior, learning skills and character. Therefore many parents are willing to do everything in their power to pave the way for this desired success for their children. There are many theories about how this can be done, and there are innumerable psychologists, researchers, and parenting consultants who agree on the effectiveness of some of them and recommend that you apply them as well. Parents, on their part, stop at nothing; from taking heavy loans for their education, to making arrangements for their safe and secure study atmosphere the take a lot of pains.

My parents were not exactly of genius grade, but were extremely well read. Our home always had a room which only had books, and both my parents would spend their free time reading them. Their policy of rearing children was mostly hands on, but as we brothers and sisters were 7 years apart, I saw a trend that I am trying to document after so many years.

 

They would ask the children to perform chores regularly

When children are required to do chores from an early age, feelings of responsibility, confidence, and ambition develop in them. These simple chores play an important role in building children's personality, and my parents would often say that they themselves were given chores from their parents when they were young, and they were required to do them. So, I would take a bag full of wheat to the aata chakki (flour mill)on my cycle carrier or accompany my father to the fish market and carry his bags. These chores were never related to any remuneration in the form of pocket money, and I was told that this was my contribution towards running of the household.  

 

They were not afraid to set high expectations of their children

Having high, realistic expectations of children will help them understand the direction they should pursue later in life. Children whose parents expected them to continue to higher education usually do so as long as the parents conducted themselves in a way that helped their children succeed in school. The trick is to set a high enough expectation threshold so that children will aspire to reach it, but keep it within the possible range to prevent them from feeling frustrated or insecure. Every child will not be Albert Einstein and Marie Curie, so it is important to understand their aptitude and then inspire them to excel in their chosen field – sports, music, performing art, literature, whtever that may be. Every child is unique and different. It is the job of parents to bring out that uniqueness and help it shine bright.

 

They helped children acquire coping skills

Children who get everything they want without trying or waiting for their turn may find it difficult to cope with challenges at school and even in their future workplace. To prevent this, my parents gave us the tools to deal with anger, delay gratification, or deal with situations that are needed to finally achieve success. At the same time, they didn’t deprive us of the opportunities to use these tools. This way we learnt how to survive small challenges in childhood, and were prepared to overcome more significant ones in adulthood.

 

They taught us not to fear failure

Teacher and educator Jessica Lahey, who wrote the bestseller "The Gift of Failure," notes that the role of the parent is to manage and minimize risks, rather than eliminate them entirely. She says successful parenting involves understanding that failure is a big part of success, and parents who raise successful children teach them not to fear failure or to feel ashamed when they do fail. Many parents find it hard to watch their children fail without helping them or scolding them, but failure helps children develop a strong character and independence. My parents always said that we learn a lot more from our failures than our successes. Failure is just a stepping stone towards success. So long as you are getting up to fight again, there is nothing wrong with failure.

 

They emphasized the importance of social and emotional intelligence

My parents felt that high social intelligence was just as important as success in various school subjects. This is because those with well-developed social skills were also more likely to succeed, impress others, graduate with a degree and gain full-time employment. The most important things that must be taught to children in order to promote their social skills are to cooperate with their friends, to empathize with others' feelings, and to help without being asked to do so. It is more important to be likeable, rather than a bully.

 

Their motto was quantity over quality

While there was no correlation between the number of hours spent by mothers with children and children's behavior, scholastic achievement or personal well-being, there was a significant correlation between the quality of this time and all three indicators. Therefore, there is no need to feel guilty if you work long hours, as long as the time spent with your children at the end of the day is not devoted to passive activity like playing card games with friends or knitting. They would talk to us like they would to an adult, listen to our experiences, and try to share the important moments of their day with us. Those were pre-television days and we were the centre of their world. This was not the time for discussing disciplinary problems or scolding children and it was invariably a pleasant atmosphere regardless of what happened throughout the day. One meal together was the rule and all would sit together and tell something new that we had discovered that day in our books or school or workplace.

 

They helped us to develop tenacity

My parents felt that encouraging children to perform challenging or difficult activities and not to give up immediately will prepare them for success in later stages of their lives. Perseverance and persistence are among the things that are necessary to teach children at a very young age since a child without a "fighting spirit" will find it difficult to develop this trait later in life. Do not help your children with a task you know they can do themselves, they’ll thank you in the future. I fell many times from my bicycle even after I learned how to ride it properly, just because I tried some stupid tricks on wheels. Every time there were admonishing and reprimands but the bicycle remained my companion throughout my school and college days.

 

My parents treated us as independent entities

Along with the desire to help children get on the right track in life, it's also important to maintain a balance and remember that children are people in their own right. My parents felt that excessive protection of children may delay their development and prevent them from being able to think for themselves, solve problems, and cope with difficulties. Therefore, they made sure to let us feel that they we make our own decisions. This helped us to develop preferences, a unique taste and an understanding of the impact they have on our lives. My siblings were very different from me, but that was expected, and there was never any comparison.

 

They would never "extinguishing fires"

Many parents treat parenting as a "fire-fighting" task and conduct themselves every day in a way that enables them to take control of specific problems as soon as possible. However, finding the quickest solution as soon as possible does not meet the ultimate goal of raising children to become successful adults. They have to learn to fight their own small battles, and hold yourself back for bigger wars. Perhaps, that occasion will never come. Once the preliminary parenting sermons were spelt out we were let off the hook, and even if we fared or behaved badly, our parents acted as role models and not fire fighters. Once in a schoolyard fight I busted the nose of a school mate. I was made to go to his home in the evening and apologize in front of his parents. His father had a hearty laugh and told me “to kya hua, larke to sab kam lark e karte hain” (so what? Boys always settle differences with a fight!}

 

My parents three Commandments: efficient, stable, friendly  

Some children find it difficult to behave their best simply because they don’t fully understand what is required of them. This is because many parents find it difficult to educate their children consistently, punishing them only for some of their negative actions and not commending positive behavior. Successful parenting is deliberate and goal-oriented, and you have to remember that every time you talk to your child in order to convey some message to him or her. The consequences for inappropriate behavior should be clear and proportionate, same with rewards for positive behavior. If your response to your children’s behavior is effective but also stable and friendly, your children will understand how to act and at the same time you’ll be able to maintain an open channel of communication with them and they won’t be afraid to reach out to you in the future. Follow my parent’s the three commandments, and you’ll raise independent, successful and happy children.

REMEMBERING PROF. N.N. GUPTA WITH HIS LECTURE ON NUMBNESS OF THE FEET

 

Prof. N.N. Gupta was the Head of the Department of Medicine when we were in our clinical semesters in King George’s Medical College, Lucknow. He was always immaculately dressed in formal whites with a starched and ironed white apron and was a strict disciplinarian. He was so punctual that you could set your watch when his car would reach the Medicine portico. His Chief Resident would receive him and his teaching round would start almost immediately. He looked keen and sincere and was an extremely meticulous person and a passionate teacher.  Unlike the spontaneity of Prof S.N. Chakraborty, his classes appeared to be choreographed and rehearsed to perfection. His Senior Resident would come first and after taking our attendance, would write on the blackboard the topic and the skeletal framework of the upcoming lecture. Then NNG, as he was fondly called, would come and deliver invariably an outstanding lecture. He would always start in time and finish in time, ask a few questions, mostly to his team of residents and postgraduate students, and leave. This is one of his lectures which I could salvage from my notes on “Management of Numbness of Feet’.

 

That feeling of numbness in feet and toes can be caused by a variety of conditions. Numbness is often accompanied by a tingling feeling, or crawling of ants, or pins and needles sensation, or simply walking on cotton or inability to feel the ground/floor. Patients have different ways of expressing this sensation. The cause may not be serious - it can be as uncomplicated as paresthesia (foot 'falling asleep'), however, it may be as serious as diabetes, multiple sclerosis, or a symptom of a much more serious condition. Whatever the cause may be, it's essential to address the numbness in feet. Avoiding doing so may affect your ability to walk.

 

Typical causes of numbness  

Numbness of the toes generally occurs due to conditions that affect the nerves or blood vessels of the foot. The most common causes of toe numbness include:

·        Compressed nerves of the foot from footwear

·        Injury to the foot

·        Nerve damage (neuropathy)

·        Poor blood circulation to the foot, usually due to diabetes and peripheral vascular disease

·        Diabetes

·        Irritation of nerves in the lower back (possibly due to a herniated inter-vertebral disk)

·        Frostbite

·        Stroke

·        Multiple sclerosis

·        Vasculitis (inflammation of the blood vessels)

 

Diagnosis

A detailed patient history is mandatory

·        History of Diabetes

·        When was Diabetes detected

·        History of glycemic control

·        History of target organ involvement

·        History of hospital admissions

·        History of previous foot involvement

Both legs and feet are to be inspected carefully

·        Dorsal and ventral aspects

o   Skin - Healthy, intact or cracked / Dry or shiny/ Turgor and texture/ hair loss

o   Blisters, Bunions, Corns, Calluses

o   Colour change with position – palor on elevation, rubor on dependency

·        Digits and Web spaces

o   Nails Normal and shiny or thick, dry, brittle / Pink in colour or discoloured

o   Fungal infection in nails or web

o   Ischemia

o   Gangrene

o   Nail beds clean and supple or dirty and rough

o   Ac. or Ch. Paronechoea

·        Deformities

o   Toes - Hallux valgus, Hammer toe, Claw toe, Prominent Metatarsal head

o   Forefoot and ankle - Flat foot, High medial arch, Rocker bottom foot, Charcot foot

·        Vascular examination

o   Peripheral pulses

o   Subpapillary venous plexus filling time (N</=3sec.)

o   Colour changes – Cyanosis, Dependent rubor, Erythema, Gangrene

o   Oedema

o   Temperature gradient

·        Neurological examination

o   Light touch – cotton wool

o   Two-point discrimination

o   Pain – pinprick

o   Vibration perception – tuning fork

o   Temperature perception – hot & cold

o   Deep tendon reflexes – ankle and knee

o   Babinski test

·        Examination of footwear

o   Is it well fitting and well padded?

o   Is it abnormally worn out at any site?

o   Is the sole padded and soft or thin and hard?

o   Are the dangerous pressure points or foot ulcers sufficiently offloaded?

o   Is the footwear front closed?

Very vital information is hidden in the footwear the patient is wearing and wecannot afford to miss them.

 

Management

Dealing with occasional numbness

1. Exercise - Sitting or standing in one place for a long time may cause numbness. To counteract the problem, stimulate circulation in the foot by asking the patient to move around. A short walk, or moving the foot while sitting down, will help too. In addition, bear in mind the following:

·        To begin with, regular exercise can help prevent numbness. So be sure to incorporate physical activity into your daily schedule.

·        If high impact exercises, such as jogging, causes numbness in the feet and toes, try lower impact exercises, such as swimming or cycling.

·        Before starting workout, advice to stretch well, wear appropriate shoes and exercise on level surfaces.

2. Change positions - Certain sitting positions may cause numbness in feet. Ask the patient to avoid sitting on their feet or sit cross legged  for a long period of time. Should they have to sit for long hours, they should elevate their feet periodically to increase the blood flow.

3. Avoid wearing excessively tight clothing - Pants, socks or other tight garments worn on the lower part of the body might restrict blood flow to the feet, causing numbness.

4. Massage the foot - Massaging the area of the foot that feels numb will help increase circulation and reduce the effects of occasional numbness.

5. Keep feet warm - The cold may cause numbness and tingling. Reduce the effects by staying warm with a pair of woolen socks, or heating pad or heated blanket.

6. Wear the right shoes - High heels or shoes that pinch the toes may cause numbness in the feet. This may also arise from wearing shoes that are too small for the patient’s feet, especially while exercising. They should opt for comfortable shoes that fit well.

7. Ask them to seek emergency treatment if their foot numbness is accompanied by symptoms such as weakness, paralysis, loss of bladder or bowel control, or slurring of speech.

8. Pregnancy may also cause swelling in the feet and toes, which could result in numbness. This is reversible and can be addressed by exercises and warmth.

 

Dealing with Numbness Related to Diabetes

1. Get a diagnosis - Chronic numbness in the feet and toes is often due to diabetes. The feeling of numbness occurs because it damages both the nerves and causes poor circulation in the feet. Numbness is usually one of the first symptoms of diabetes, so be sure to get Blood sugar estimation done, both fasting (11 hours fasting) and post prandial (1 ½ hr. PP). It can be extremely serious for a diabetic, as they may not be able to feel pain, which may be caused by heat, punctures or blisters in the feet. In addition, due to the restriction of blood to the feet, diabetics' feet heal at a slower pace. Consequently, infection is a serious concern. With scarce blood supply the bacteria get the liberty to proliferate in a pharmacological sanctuary.

2. Manage diabetes - The best way to prevent circulation issues and neuropathy is to keep the blood glucose levels in check.

·        Check blood sugar levels regularly.

·        While the numbness in feet may make it difficult to exercise, the patient should try to stay active. Aim for 40 minutes of exercise / brisk walking each day.

·        Eat well. Opt for a healthy, balanced diet that includes fruits, vegetables, whole grains, beans, fish and low-fat dairy.

·        Drastically cut down fat from your patient’s diet.

·        Avoid food that triggers blood sugar spikes - primarily anything sweet.

·        Insist on regular use of prescribed medicine and insulin.

·        Smoking can make the symptoms of  diabetes worse. Suggest quitting..

3. Lose weight - Obesity can be a contributing factor to numbness in the feet and toes. Consequently, losing weight will help alleviate the symptoms. In addition, it may also help lower blood pressure (which may also have an effect on the numbness).

4. Use products designed for diabetic foot care - Compression hose and socks help stimulate circulation, thereby decreasing numbness. Special lotions that contain capsaicin, may also be applied in order to relieve the numbness. Protective and well padded footwears are a must. Patients should never remain bare feet.

5. Avoid analgesics – NSAIDs are to be avoided in diabetics as their kidneys are at risk.

 

Dealing with chronic numbness, caused by other conditions

1. Treatment for injuries - Numbness can occur as a result of injuries to the feet, toes, ankles, head or spine. In which case, an orthopedist, neurologist or surgeon may help treat the injury and relieve the numbness.

2. Enquire about medications your patient is already taking - Numbness may also be caused by chemotherapy drugs and many other prescription drugs. If they experience numbness after starting a new medication, your patient should go back to the doctor who prescribed them. On this note, it is important to never stop taking your medication without talking to the prescribing doctor first.

3. Add vitamin supplements - Numbness may also be caused by a lack of vitamin B12 or other vitamins.

4. Prescribe medication for chronic conditions - Numbness in your feet and toes may also be a symptom of a number of underlying conditions, including multiple sclerosis, arthritis, Lyme disease and more. In which case, it is important that you treat and take medication for the underlying condition.

5. Reduce alcohol consumption - A numbing sensation in the limbs, particularly the feet and toes, may also be caused by heavy alcohol consumption.

Prof. N.N. Gupta was a wonderful clinician and even his bed side teachings were something we all looked forward to. He would make his residents demonstrate clinical signs like shifting dullness, systolic murmur, Adson's Test and we were expected to try the same tests during our evening ward teachings. Those were the days when we learnt how precious our time was with the patient, and how important it was to respect him and thank him for his cooperation. Prof. N.N. Gupta always greeted every patient and never failed to hold his hands, even when he was talking to us. He would invariably thank them before leaving their bedside. Every patient felt like a V.I.P and profusely praised him and his team. This was his way of stamping brand KGMC in our minds and hearts.