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OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Some time back, I wrote a few English words. If these words are followed up properly, they can help in history taking, which is an art by itself. We know that 90% of the diagnosis can be made only by history taking.

I introduced a word "tempo" in the history taking e.g. "tempo" of sudden appearance of very high fever in a healthy man who now becomes severely ill with fever. This will bring in dengue fever (which is a very rare fever) in the differential diagnosis, otherwise not.

This time, I am introducing a new English word which is known as "Sequence". This word will help many family physicians to elicit a proper history and make a good diagnosis. It is dedicated to my late chauffeur who passed away on 3.12.2001.

This chauffeur was with me for 25 years and was my right hand during my car travelling and had received an award for bringing me to Birla Matushri Sabhagar for my lectures sharp at 7.25 am on every Sunday 180 times, in 15 years. I am handicapped by his demise, but if all of us can learn something from the "mode of his death", I shall feel that my handicap is at least paid off in some direction.

It is worth noting the "tempo" and "sequence" of the event when this gentleman fell ill. I wrote in the past that, when doctors, their family and their relatives are the patients, they present with very unusual illnesses and iatrogenic events.

At the age of 62, he had never been for a check up to any doctor because he was always healthy. But he was consuming a large quantity of tobacco and gutka. On 1.12.2001 while driving some family members, he complained of sudden bursting headache on Nepean Sea Road. My daughter-in-law who is also a medical practitioner thought of cerebral haemorrhage and told him to stop. But since the car was coming to me, he said he could continue to drive another 2-3 minutes to reach me. By the time he reached me, my daughter-in-law was extremely upset and emotional and requested me to take over the driverís seat and take him to the hospital. I did the needful and rushed towards the nearest hospital.

While driving, I asked him about the complaints. According to him the severe bursting headache, which he got for the first time in his life, had disappeared within 3-4 mins and was not associated with vomiting. But he was now complaining of "discomfort and ache and heaviness in the left arm". When I asked him about the chest symptoms, he said he has been having "burning" (definitely burning and not heaviness). He did not have a drop of sweat on his body or nausea or vomiting.

By the time I reached the hospital (in 10 minutes), he came walking behind me very fast for an urgent ECG which was taken within 4-5 mins and was absolutely normal. Then I looked at him and showed me by gestures that his left arm was having unusual sensations. In the meantime, the cardiologist came to his seat and suggested that since his ECG was normal, he should be observed and happily requested me to leave the chauffeur there who would be looked after like a VIP (at that time, I had a fear of my chauffeur developing VIP syndrome).

In fact, I left the hospital within 5 mins and explained to the chauffeur that he was being admitted in ICCU for observation and I would inform his family. I got a telephone call next morning that my chauffeurís ECG was normal and he was given thrombolytic treatment. But at night, he developed left sided hemiplegia and went into coma. The CT Scan of the brain showed a cerebral haemorrhage on the right side. The neurosurgeon refused to operate thinking that it was a very high risk. He expired after 24 hours.

What is to be learnt from this case is the sequence of events and the tempo.

1. Sudden severe headache developing in a man of 62, should remind you of either a sub-acute haemorrhage (where even the CT Scan can be normal and only CSF will show RBCs) or carotid dissection or sagittal sinus thrombosis which can be missed even on a scan.

2. Headache coming and disappearing is against any cardiac event.

3. The patient complaining of discomfort in the left arm should have a detailed neurological check up. Even if the ECG changes appear, e.g. gross changes like myocardial ischaemia can appear in a patient of cerebral haemorrhage.

4. After taking history, a full clinical examination of the patient must be done. Only at my request the patient was examined and that too, only blood pressure was recorded and found to be 200/120 mm Hg.

5. The patient having severe hypertension should not be given even Aspirin, forget about the thrombolytic treatment.

6. In such a patient, thrombolysis should be offered after 2-3 hours since he is already in the ICU and he has come within few minutes of the complaints. It should be started only after definite pattern of infarct has developed and the troponin levels are very high.

Finally, the "sequence" of the event and the "tempo" of the headache have made the diagnosis of a small cerebral haemorrhage easier. The headache was a "thunder" headache of short duration. After the headache subsided, during the time when the ECG was taken, the patient was complaining of "a funny sensation in the left arm"! This sequence of "thunder" headache followed by some symptoms in the left arm could have given away the diagnosis.

The severe hypertension (for which he had never seen any doctors in his life time) could have confirmed the diagnosis and demanded a CT Scan to exclude a small cerebral haemorrhage. Of course even then he had more than 90% chances of dying. But with the iatrogenic complications, the chances became 100%.

So now in addition to tempo of the symptoms, I am adding the English word "sequence" to help the family physicians and all of us to make a better diagnosis in future.

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