Yesterday was a pretty good day except that I developed toothache during evening surgery. I don't think it impaired my decision-making abilities but I became rather impatient with people going on about their symptoms or telling me how unwell they felt. I just wanted them to give me the essential information so I could make my decision, tell them what to do and get them out of the door. Yes, toothache definitely makes the consultation more “doctor-centred”. But I finished the evening surgery on time!
During the morning when I was being less directive I noted a couple of examples of “living with uncertainty”. I saw a young child recently arrived from Nigeria with a rash that had been present for a few days. This consisted of large red papules on her upper chest spreading onto her upper arms and under her chin, some of which had blisters in the centre. They looked rather like chicken pox, except that I would have expected such pocks to have been more widespread over her trunk. The other odd thing was that her mother said that she had been seen at a hospital in Nigeria with a similar rash one month ago, and had been given an antibiotic. Chicken pox would not have recurred like that. Unfortunately her mother's English was not perfect so it was difficult to pin down the exact details. So was this chicken pox or folliculitis? I was happy to live with the uncertainty because she looked so well: happy and smiling and playful. I hedged my bets by prescribing some antibiotic (which is also indicated in chicken pox if the pocks get large and red), and we shall wait and see.
Another patient was a woman in her forties who has lower than average intelligence and is very anxious. She complained of dizzy spells since Christmas and left-sided headache, but cinnarizine (dizzy pills) and paracetamol (headache pills) prescribed during several previous consultations hadn't worked. Now this is probably labyrinthitis (a benign self-limiting viral infection of the balance mechanism in the ear), but there is a sort of brain tumour called “acoustic neuroma” which causes dizzy spells and loss of hearing. Unfortunately my patient had noticed muffled hearing on the left for the past three weeks. However, examination showed no abnormality apart from some fluid behind the left ear drum which probably explains the muffled hearing. She was also hyperventilating due to her anxiety. I didn't think that it would be helpful to mention brain tumours to her at this point and I am again going to wait and see.
One thing touched me at the end of the consultation with the Nigerian child. She clearly didn't want to be put back in her buggy. “Girl, you've got to get in there!” said her mother, and then turned to me and explained that in Africa she would have gone on her back. I couldn't help feeling that the child was right to complain.
Another cultural difference I noted about her mother (and have noted previously with patients from Nigeria) was that she seemed vaguely unhappy with the consultation and to imply that she questioned what I was saying. I mentioned this to Martha who suggested that doctors in Nigeria may be more directive and doctor-centred, and that the mother may have found my more open style difficult to cope with. She should have come back in the evening when I had toothache!