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Case Study

How will you handle this case? - What Will You Do Next?
Dr Vishpala Parthasarathy

Counselling is the focal point of my practice today. With the world experiencing an emotional topsy-turvy, we have to be like the rock of Gibraltar, to whom the patient can turn to in times of great distress, confident that he will get the best advice possible. And for us, what better reward, then a patient saying: 'Doctor, I am perfectly alright, all thanks to you' and that too in a matter of 24-48 hours.

My acquaintance with counselling started when I was with the late Dr ML Dhawale. Once in a case of sterility, after taking the case and scanning all abnormal investigations, MLD told her: "Your work is your baby. Stay committed to it." Somehow that one sentence penetrated. She went away at peace with herself. No advice of trying GIFT, adopting etc, the advice usually given to such patients.

It was then that I understood counselling is advising the RIGHT action in that PARTICULAR CASE, at that PARTICULAR TIME.
From that day to this, has been a rich rewarding haul. I would like to share my learning with you.

Case 1 of this How Will You Handle it series:
Here, I am going to give the case as it happened - sequence by sequence and you have to plan your action, hypothetically, at each step. Then move to the next page for solution (a); then plan the next action, compare with solution (b) & so on. Only in the final stage shall we do the remedy. Counselling mainly solved this case. The remedy had only a minor role to play. Ready? Get set...Go!

Stage A:
The case was taken by my assistant (we will call her the Primary Care Physician - PP). She brought the casebook to me. Information available:

First Page of the SCR:
Female, aged 24, married 6 mths.
H 28, a businessman. Marwari family.
Fa: business. Mo: Housewife
Br 21. Si 18 - in school

Chief Complaint:
Since October 98- Evening rise of low-grade fever, every month for 2 days. Fever with burning soles, polyuria & vomiting.
No excessive perspiration, no appetite, no thirst.

·         Since Aug 98-

1.   Gas, loud belching, pain chest and poor digestion 2-4 /wk: No burning. No constipation. Worse milk.


3.   Urticaria -3/w < sun, tension, bad news.

·         Since Feb 98 -

1.   Monthly Headaches. Frequency is on the rise. AF Sun & loss of sleep.

2.   Colic 2/w

·         Since Jan 98 -

1.   Tremendous weakness & exhaustion < slightest exertion, walking, lifting heavy wt.

Wt - 43.5 kg. Lost 4 kg in 1yr. So, what is so unusual about this case? How will you zero in and prepare your interview?

Stage B:
Yes everything you thought of so far is right:

  1. A newly married girl has no business being so ill.
  2. First, with evening rise of fever, rule out Koch's
  3. All complaints started this year. There must be some problem with her marriage. But then why since one year when she has been married only 6 mths.
    Was it a marriage without parental consent, or forced on her?
    Koch's ruled out.
    It was a love marriage - she is a Sindhi married to a Marwari. She was formally engaged one yr back.

Now the possibilities:

  1. Husband is not good to her.
  2. In-laws are not good to her.
  3. Regrets marriage

Stage C:
In-laws stay in Rajasthan and come only once in 2-3 mths.
Pt lives alone with husband. Husband is very good to her. If she is ill, he even helps out in housework.
Another complaint surfaced: Since June 98, has irregular periods- would come every 55-60 days, with scanty flow, irritability, weakness and leg pain. Now since last 3 mths daily massage on abdomen has normalized the flow. 

·         Explore sex life.

o    Either an inability to cope with husband's demands may manifest as illness.

o    Or a busy husband, returning late, tired, not paying enough attention, may lead to loneliness and attention-seeking symptoms.

Stage D:
Normal sex life. Now what? Ask her point blank: Tell me about you and your problem.
Actually this is the first time I spoke to her. So far the PP who took the case was doling out the answers to me.

Pt answers very slowly: Normal. (PP said: she has a lot of confusion. She herself says she feels confusion in the head.
Qs: What else you want to tell me about your nature?
Anything else you want to tell me?
No, everything is normal.
So, dead-end. What are you going to do?

Stage E:
This line of Qs not leading anywhere, so I just asked her what exactly her problem is. She said I just cannot get up. I am so tired and exhausted that I just cannot cope. I am so tired. Pt looks also very low & unhappy as if lost everything. She clinches this by saying no appetite, I just want to drink something all the time, especially fruit juice.
Now your remedy clearly emerges. Can we just give it and hope everything will work out?

The remedy is clearly Phos-acid 200 - 3 doses were given.
But is this enough?
Now I asked her to detail her whole life from the beginning.

Life Story: which came out with lot of prompting and reading between lines. But I am giving it to you as a complete saga.
1975: Born. Eldest of 3. Fa had a Video Library and cable TV business with some other small businesses. Mo would also work with him - leave at 9am, come back at 11pm. They had an elderly servant who looked after the house. Mostly pt in charge, since Mo was out whole day.
1990: Pt finished SSC with 67% and joined degree college. Siblings still in school. Now that elderly servant left and they employed a 12 yr old servant. College was only from 11-4 pm. So pt did most of the cooking. Also took tuitions.
1995: Fa suffered major business loss in chit fund. One person of the chain ran off with all the money. Fa was bust. They had to return people's money. Their only option was to sell off their house and move further into the suburbs. The shop was converted to STD/ISD booth etc. Mo stopped working, since it was too far to travel. Pt started working and got a job with PU. Even to run the house in those days was difficult. It was a very traumatic period. At that time this Jain boy helped Fa - giving him contract work. They became family friends. Gradually their situation improved and things became better. Pt has always been a quiet, hardworking girl. Over a period of time, pt and boy became closer. His family also knew her, as business associates. In Jan 98 they came down from Rajasthan and got them engaged. The marriage, they said would have to wait till the eldest brother's daughter got a match. This Da got married in April. Then they said wait for 2nd marriageable Da to find a match.
Pt's family began getting nervous.

Stage F:
They came from a very orthodox community. So, yes, problem could be they were putting off the event, hoping it would fizzle out.
Pts family impatient. They pressed for action. Boy recognized this and agreed for a quiet temple wedding.

What do you think was the reaction in boy's family? 
The family refused to recognize her. When they came to Mumbai, they stayed in their other flat. H sent pt to her Mo's house. Even when they telephoned, they would talk to the Husband and not to her. This upset her terribly and she became very depressed and all her illness started.

Why was she so upset?
Should she not have anticipated this?
Yes, she should have anticipated it and prepared herself for it. But she was so upset because the in-laws talked to her Fa and brother, as they were business associates and only she was excluded.

I asked her: What does your husband say?
He says everything will be all right when the second Da gets married. What will you advise?

Stage G:
You are thinking the husband is just buying time. The in-laws are very angry and never going to forgive her for going against their wishes and she is continuously going to feel guilty and upset. Soon her husband will also stop sympathizing with her and things will turn sour. This is the ultimate bad scenario.

How are you going to handle this? What will you advise? What is the solution that covers all the aspects of the case?

Possible Solutions:

  1. Tell her your husband is with you, so forget about in-laws. If you are so depressed, you are not repaying him for his goodness and correct action in marrying you against parents' wishes. And the case is closed.
  2. Tell the husband to stop being a wimp and to stand up and demand the rights of his wife.

Stage H:
Yes I was very tempted to do this. But somehow everything was not gelling. All the pieces of Jigsaw were not fitting snugly. Several pieces were left out.
For eg:

  1. If the in-laws were so orthodox and against the alliance, why did they agree for the engagement, they could have flatly refused in the first place, instead of now.
  2. Why did they keep asking them to wait just for a few mths?
  3. Why did the husband also keep telling her that after 2nd Da's wedding, everything would be normal.
  4. Why did the in-laws who were cordial to her, now ignoring her completely.
  5. Why did they continue to be cordial to her parents?
  6. There has to be a solution, which answers all these aspects logically.

Stage I:
Now comes the important reasoning:

  1. Marwari community is the most orthodox of the Indian communities. It is very difficult to get a good match for a girl, especially if it is known that a family is too mod or progressive. I have a friend who still covers her head and wears only saris when her Father in law comes to stay. This after 25 yrs of marriage. Otherwise she is a very mod girl - has her own business etc.
  2. Here, the family itself was quite good. And they accepted their son's choice, though so far they had never had an outcast wedding. But right immediately they had 2 daughter's to marry - rather they had one and then thought better get the other one also married though she is a little young - only 18. After those there is a large gap, and by which time the impact of this wedding will wear off. Right now if the inter-caste wedding becomes common knowledge, their choice of good boys will get limited.
  3. After these 2 weddings they were prepared to accept this girl in their fold. And once they accepted girls in their fold, their welfare became their responsibility. Till now, as far as they are concerned, this girl is not in the picture and they cannot afford to acknowledge her at this juncture. So they do not talk to her. They blank out her existence.
  4. Her father, who is their business associate, they talk to.
  5. The boy somehow understands this, and therefore he is conforming by sending her to her parents' home, when they are visiting.
  6. Everyone here has behaved well, specially the boy who realized that waiting another 6 mths would have been very difficult for the girls' family and so he had a temple wedding.
  7. But once the parents accept, they will have a grand wedding. At this point of my reasoning. immediately our pt jumped up "Yes, that is what they have said!"
  8. So then this proves our hypothesis is correct. And our reasoning paid off. The patient became all right in 24 hrs. The next time she came you should have seen the glow on her face- all symptoms vanished overnight. She put on 1 kg in the next 2 weeks.

So is this the correct solution? Okay, you still do not agree. Fine. We will have to wait awhile. And anyway, finally what is the down side? In the unlikely eventuality that our hypothesis is wrong and in the unlikely eventuality that it does not work out like this, then what will happen? What have we lost?
By that time, in 3-4 mths, our pt will become strong enough to withstand the rejection and go on with her life.
So either way we cannot lose.

But I will certainly let you know after 6 mths., if my gut feel is right or not.