Tuesday, June 24, 2008

Head ache which was not

Mrs. R does not see me as frequently as she did earlier on. Now a grandmother pushing 60, she divides her time between her grown up, well settled daughters abroad and her husband who is here. Therefore when she did visit me the other day, after a lapse of two years, it was a pleasant surprise. Looking at her well preserved person and happy face, my memory went back to over thirty years ago when she first visited me.

Mrs. R was then a young bride married to an up and coming business executive. She came from a semirural background from Andhrapradesh, with small town lower middle class upbringing and could hardly speak English. My smattering Telugu left very poor impression. But what saved the day for us was her ability to speak Urdu with a typical Telangana accent. My Shivajinagar/Cox town patients had forced me to learn the language and thus we could make reasonable conversation and that has stood the test of time. Now she speaks very good English but the Lingua franca between us has remained Urdu!

Soon after her marriage she was thrown into a very unfamiliar and quite unsettling life. She was not familiar with the corporate social life with its own dress code, mannerisms; habits of eating and other norms of behavior which often conflicted with her upbringing. Her husband was a nice enough Youngman but expected her to fall in line, the earlier the better. Inability to speak good and properly accented English was a major disadvantage.

So, young Mrs. R started getting spells of acute anxiety associated with fear. Evenings, when other young persons look forward to, became the times when her anxiety was at its worse. This was the time when she was forced to attend parties and she would dread these outings. Her worry and the feelings of inefficiency and inability to please her husband [he did not say so] added to make her lose whatever self esteem she processed.
Her young husband made her agree to see a psychiatrist who made a prompt diagnosis of panic attacks and put her on medication. These medicines made her worse. This was the time she came to see me.

The presenting problem was frequent episodes of head ache. The history was very typical of migraine. At her first visit she did not reveal her miserable social life. That came later when we became sort of friends. It was not difficult to counsel her as to how to manage her life. With her husband’s active cooperation and her own basic ability she overcame most of her problems and in the course of her life became a fairly successful corporate wife and a hostess.

The headaches however persisted and she would suffer a day or two and get better whatever may be the medication. I even started suspecting whether she made up the headaches so that she can consult with me and unburden herself of whatever may be the problem that was bugging her at that moment. These come and go headaches persisted and both of us were happy. I with the knowledge that she will definitely get better whatever is the medication and she with the knowledge that the head ache came in handy to have a chat with her doctor.

This happy state lasted almost 15 years when her head aches took a serious turn. Her visits with the head ache became more frequent and lasted longer and the usual medications did not seem to work. I kept asking her whether she has any new stress which she has not discussed with me. She kept denying and to a good measure added that she was never more comfortable with her mental state than she is now. She also said the headaches have changed character and location.
Despite her assertion that the headaches she was getting are different it took me three months and a bout of vomiting [by her] to think differently from the usual migraine head ache. Even then, more to satisfy her than with any conviction that I would find any pathology I asked for a CT brain which had just then become available.

To my utter surprise there was a fairly large ring lesion with surrounding edema in the periphery of parietal lobe exactly beneath the area where she was complaining of ache. Now I had the rather onerous job of explaining to her that she had tuberculosis of the brain and she needed a year’s therapy. I took my time and explained over a period of an hour to her and her husband the intricacies of treatment. I could not help telling her that I should have listened to her when she told me that the aches were of a different nature and asked for the test 3 months earlier. The relationship built over a decade came to my rescue. Instead of telling me,’ I told you so, you stupid man’ [she would have been justified in calling me so] she said, ‘I must thank you for asking to doing this test which clearly showed what I am having and is curable, I was so worried that it could be cancer’

Within two weeks of therapy her head aches subsided and she went through with the year’s medication without any problem and fully recovered.

Interestingly, throughout the year her migraine headaches did not appear but they promptly did within three months of cessation of anti TB therapy!

She must have guessed, she said with a smile, ‘I have not come for head ache doctor, but to check with you this problem I am having and went on to explain, which is another story I will write about some other time.

1 comment:

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