Thanks to afterthoughts…

 Vijayaprasad Gopichandran

Mrs. Kamala was a 56-year-old lady who came to our OP for a routine health checkup. Clad in a dark red well worn cotton saree with oiled, combed, and plaited hair and a large round dot of vermillion on her forehead, she looked cheerful. I elicited a detailed history and performed a selective physical examination. Everything was unremarkable except the fact that she had high blood pressure for 7 years and was on regular medications for it and her blood pressure was under fair control. I ordered some routine laboratory investigations for her and gave her instructions on how and where she should go to get them done. Then, as I sat writing her notes, I initiated small talk. 

 

“How were the rains in your place amma?” I asked. 

 

“Fortunately, we live on the first floor. Water flooded the ground flood apartments in our complex. Things were very bad. We did not have milk or drinking water for three days. But now things have returned to normal” she replied. We had just recovered from the cyclone Michaung in Chennai and the flooding in several parts of the city was devastating. 

 

“Ok, ma, now you can leave with these slips and do the lab tests. Please come back tomorrow with all the reports” 

 

With this she got up from her chair and turned to leave. There was a mild stagger in her step, but it did not seem serious, she recovered from it quickly and walked on towards the exit door. I was ready to see the next patient when Mrs. Kamala turned back and peeped into the door again to capture my attention. She gestured from the door as though asking “may I have a word with you?” I called her in. 

 

“Doctor, I forgot to tell you one thing. I am not even sure if it is important. Do you have time now? Should I say it now?”

 

“Of course, please sit down. What is it that you want to tell?” I said and was curious. This is not something new. It is a common thing that some patients do. They forget some symptom, and they suddenly remember it after they leave. Most of them are too apprehensive to re-enter the consultation area and so they walk away with a sense of dissatisfaction. But some persist and come back to complete the process of asking doubts. Some patients come back even multiple times. I once had a patient who got up and stood in a gesture of leaving but kept asking questions even as he stood there. He started moving backwards towards the exit, all the while facing me and continuing to talk and explain his problems. Sometimes the next patient would also come and take their seat in front of me and start talking to me, while the previous patient would still be talking to me as he is walking out of the room. Having experienced all this, patients coming back to ask questions is not something new. I was prepared for a vague symptom, an unexplained problem. But what came as an afterthought took me off guard. 

 

“Doctor, about 5 months ago, I had a joined work as a babysitter for an infant. The arrangement was for me to stay there overnight and take care of the baby as the mother would go out for night duties. One day during that duty, I was sleeping and woke up in the middle of the night to go to the toilet. I found that I couldn’t feel my left hand, forearm and arm and I couldn’t lift it also. It was completely limp and numb. I got scared and rushed to the nearby 24 hour clinic. There they recorded my BP, said it was very high, gave me some medicine and asked me to immediately go to a tertiary care hospital. I went there. There they admitted me and did a CT scan of the brain. They asked me to stay in the hospital for more detailed testing. But within 1-2 hours my hand became normal. Therefore, I left the hospital without informing anyone. After that my hand has been perfectly normal. I don’t know if this is anything important. Thought I should tell you this.” she said and looked at me with a puzzled expression. 

 

The history sounded to me like a transient ischemic attack, a transient block to a blood vessel supplying the part of the brain that controls the left hand. Such transient ischemic attacks are potenders of a more severe stroke that could happen involving the same limb. So, when we identify someone who has experienced a transient ischemic attack, we take all possible measures to ensure that the ominous stroke does not happen. Ideally, we start them on Aspirin, a drug that inhibits platelet aggregation, thus preventing blood clots, and Atorvastatin a cholesterol lowering drug, which also has an activity of preventing strokes and heart attacks. I let out a sigh of gratitude and said, “Thank God, you decided to come back and tell me this.”

 

I explained to her, “What you seem to have experienced that time is a minor form of stroke. The fact that you had a minor stroke at that time, puts you at a risk of having another one. This time it may not be so mild. Therefore, we need to start you on medications to prevent the stroke from happening.” The moment I finished saying this, I could see lines of worry cross her forehead. In a matter of a few seconds, the tone and mood of the clinical encounter had changed completely. What had just a few minutes ago been a positively reassuring clinical discussion, had changed to something of concern. The change in mood was palpable in the room. 

 

“Do you have any doubts or questions to ask me? Don’t hesitate. I know this is some heavy information to process in such a short interval. Feel free to call me any time with any further questions you have.”, I said this and watched her walk away. 

 

Sometimes all that it takes to change the course of a clinical encounter is just an afterthought….