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Creating Waves of Awareness

Mr M.A, a columnist in a regional news paper, consulted me during the initial days of my practice. He was very much troubled with a nasal discharge, with occasional sneezing, since many years. Initially, he had taken Allopathic and Ayurvedic remedies with no benefit. The discharge was watery, salty and hot. The flow used to get aggravated while straining and stooping, especially while performing Namaz. While taking that case, he said,
"doctor, I feel the discharge is coming from my brain." Immediately, I scolded him for "diagnosing" a rare condition. I told him that the discharge is from the mucus membrane of nose and para nasal sinuses. Considering his presenting totality, I prescribed Natrum mur 30. He again came with no special relief. I repeated the medicine and also suggested him to practice Pranayama. He continued my treatment for two months and stopped coming. After a long gap, he came to me with a file containing several investigation reports and a discharge summary. The report shows that the nasal discharge was Cerebro spinal fluid (CSF), leaking through the defect in the cribriform plate of the ethmoid bone. As per the discharge summary, a surgical repair was done using a graft, and the leak is now completely stopped.

I got ashamed of myself for missing the diagnosis, mainly because, he could diagnose it in-spite of being a non medical person. I had studied CSF rhinorrhea in 3rd year BHMS, but could not recollect my memory when a real patient came to me. If we are wisely attentive, we can definitely learn so many things for our patients!

Moral of the article: Do not miss the diagnosis by saying that it is very rare. Practically, there is no difference between 99% possibility and 1% possibility, because that one patient could be our patient!

Dr Muhammed Rafeeque, BHMS, PGNAHI.

CSF rhinorrhea:

EMedicine Article

Views: 1786

Comment by Dr. Wequar Ali Khan on September 13, 2010 at 8:35am
Thank you for sharing this case and its moral.We should always weigh what the patient utters even if it sounds unrealistic and lofty.
Comment by DR. Sushil Bahl on September 13, 2010 at 10:52am
Dr Rafeeque, Any one of us can commit a mistake in provisional diagnosis, but the success lies in admission of mistake and consequent rectifications.
Comment by Debby Bruck on September 13, 2010 at 12:34pm
Dear Dr Rafeeque. Thank you for your courage in telling us this story. To learn from the moral of making a mistake. We truly do learn from our errors and this will impress upon us even more to 'listen' to the patient's own words and not to interpret and translate them in most instances into homeopathic language. We are glad to hear that this person persisted to search for healing and found surgery to alleviate this physical defect. Blessings to you. Debby
Comment by Gina Tyler DHOM on September 13, 2010 at 1:44pm
I agree Dr. Rafeeque,I had a patient just recent who said she had a verry rare genetic disease that not many on this planet have.
I took her full lenthy case,and ignored her
(i have a rare genetic disease diagnosis) Went by her indicated presenting symptoms (physical/mental/emotional) found her constitutional prescription and she is now 99% well.
Comment by Dr. Girijadevi TK on September 14, 2010 at 1:27am
Dr.Rafeeque, you need'nt get ashamed for missing the diagnosis.I have a story.A colleague & a friend of mine, an Ophthalmologist by profession used to have nasal discharge whenever she hold old papers on doing her duty as a charge officer of an ESI hospital.I had seen this continuously for 4 yrs and she did nothing as treatment thinking that it was allergic rhinitis.Recently with somebody's persuation she had a thorough investigation & got it diagnosed as CSF rhinorrhea and had a surgical repair using graft!!So Allopathic doctors themselves will miss the diagnosis of such a rare condition!
Comment by Dr Rajneesh Kumar Sharma MD(Hom) on September 14, 2010 at 5:26am
Really too good.
Comment by Dr Muhammed Rafeeque on September 14, 2010 at 7:06am
Thank you all for your valuable comments.

In order to diagnose CSF rhinorrhea, the CSF can be collected by asking the patient to do valsalva maneuver Laboratory tests of CSF helps to confirm the diagnosis.
Comment by Dr Neena Singla on September 14, 2010 at 9:51am
When I was working with Dr Jugal Kishore I had also seen a case of CSF rhinorrhoea, He was reluctant to go for surgery and we treated him symptomatically and he was better.
Comment by Dr. Poonam Batra on September 14, 2010 at 1:20pm
Thanks for sharing, many of us face this but daring like you mention at common platform, this is the way we learn.
Comment by Dr Muhammed Rafeeque on September 15, 2010 at 12:28am
Thanks for the comments.
This dictum is cent percent true: A good surgeon is one who knows when not to operate the patient! Surgery is not indicated for all cases of CSF rhinorrhea. When the defect is large with a higher risk of meningitis, it should be closed immediately. When the defect is small, we can give symptomatic treatment. Now this person is still my patient- with a list of diagnosis: HTN, DM, IHD etc. That surgery could only save him from meningeal infection, but still he is sick!


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