A CURIOUS CASE

   I had an interesting case-sorry-patient last friday. I was winding up my clinic that evening. Nothing special, the usual dry grind of few headaches,the itching eyes and a few glass corrections.It

was around 5.30 pm and the mosquitoes had started early rounds and light was fading.Then my 

friend who had designed my house landed with a friend of his, an elderly man about 64 years of age

and his wife. Another 100 bucks and I yawned.The patient seemed apprehensive as he settled on his 

chair and stared vaccantly at me.

    My friend volunteered that they had come from umbai recently and wanted a change of glasses. I began tapping my table in an idiotic way as usual and gazed back at  the gentleman, a retired executive it seems .He remained silent. The wife put an end to the uneasy  silence and remarked-' since one month he is unable to read mathrubhumi paper,and so can you change the glasses'.So without further questions I took my barber set- sorry - trial frame ,adjusted it  casually on his nostrils, removed it and asked him to put back his old glasses and barked' read that  chart '. The patient was staring at that chart for about 60 seconds and was playing deaf.I was getting  angry. The wife now took the initiative-' come on, can't you see the english letters over there ?.The patient concentrated hard on the chart and exclaimed 'ma'. i came to his rescue 'but that alphabet is 'M' in english ,no?.The patient was agitated. I asked him whether I should change to malayalam chart.Now my friend was agitated 'he is a retired executive ,sir '.Then the patient revved up and  began to read all the alphabets slowly and steadily and completed it successfully. I felt something was wrong somewhere. I then gave him my near vision chart and asked him to have a go.It took him  about 3 minutes and with great difficulty began to spell out each alphabets of each word ,offcourse the smallest font which we consider as normal. i was bewildered and asked him to read the word instead. The man said 'no, I can't'.This is getting interesting  and my mind got on to the 'alert' mode  from the 'auto pilot'.There was nothing wrong with his eyes on further examination. Does he have any  memory loss, I asked. My friend was quick to answer ' sir , he was asking about your name about 5 times in the waiting room despite my repeating it.but when I tested his recent memory, it was normal except that there was a time lag.Then I told them his eyes were normal,but he needs a neurologist consultation as early as possible and suggested the doctor and a proper referral was given . They returned a little disappointed.

 But for me the headache was only beginning. what could it be ? It was the first case of learning or

 reading disorder in the elderly, I was seeing in last 30 years of practice. The fake neurologist within

 me was driving my mind crazy.My first probable diagnosis was a vascular disorder of the brain, a

 clot or bleeding somewhere near the visual cortical areas considering the short onset ' one month'. the

 second possibility was a space occupying lesion of brain, but no headache or motor symptoms??.

 could it be an early alzheimer? for the next 2 or 3 hours my brain was on the overkill--deducting,

 subtracting, multiplying,deleting with endless possibilities.My wife was on a speaking spree 

regarding some family affairs and I was like that aprehensive patient gazing at the non-existent 

cobweb overhead . Could it be an acute depressive disorder or some degenerative disorder ??. Only

 an M R I scan could reveal or rule out most of these conditions. But will the patient go to a neurogist

 ? Everything was possible in India. I slept little that night with annoying dreams of my contractor? or

 was it a govt servant or archeologist throttling me.

      As soon as the morning dawned at 8.45 am,I felt refreshed and the ' case' had been conveniently

 transferred to my recycle bin. At around 4 pm when I was on my  coffee break, my missus informed

 me some doctor had called. The mobile was laughing at me when I called back . . It was the young

 neurologist and excitement engulfed me as I introduced myself. The voice at the other end was also

 highly excited 'sir , I had seen your case. Know what the MRI scan revealed ?. multiple large tumors

 of the brain ,the largest one on the temporo- parietal region ,Malignancy offcourse. I had admitted

 him then and there and at the insistence of the bystanders have discharged him for treatment in

 Mumbai.He may need a chemotherapy and radiation. but the presentation is so rare and am going to

 present this case in the next neurologist meeting'.

  

      I felt curiously elated and my heart rate was on the roll. Within 10 minutes I had regained my

 mental balance and was soon ashamed. What am I doing ? Not for one moment have i thought about

 my patient and what mental agony he would be in? The last 24 hours has indeed changed his life. yes

 offcourse he was only a fascinating' CASE' for us. I  wondered when  nother junior specialist will

 refer me as his pet  'CASE'. No I don't want to be nother CASE, oh God !! NO WAY ! !!