The biter bit

For me, the most difficult patients are those poor worried creatures who turn up once or twice a year with a new set of vague symptoms that probably don't add up to anything but just might. You get to recognise that intense slightly anxious expression which indicates that you are in for a long consultation. It doesn't matter how robust you try to be, after a little while transference will occur as they project their anxiety on you, and you will start worrying about whether they might not have an atypical presentation of von Ribbentrop's disease after all. Nothing can ever be excluded, and these patients throw your normal responses off balance. You can't say “I'm pretty sure that this is nothing, see how things go and come back if you are still worried” because they won't accept a probable opinion and they are still worried now.

I saw one such patient today, and after going through her latest set of symptoms she told me that she is under stress. She has a new job as a health adviser with NHS Direct, and is finding it difficult advising people who are worried about their health.

Reader, I didn't bat an eyelid.

Conventional wisdom now is that the computer screen should be clearly visible to the patient during the consultation. These are the patient's records after all. That is fine when there are just the two of you in the room, but the presence of a third party can complicate things. Today I was seeing a young woman, and as I flipped back through her consultation notes I found a comment about her distress at her partner's affair. The self-same partner was sitting by her side today. I flipped on quickly, and hoped they hadn't noticed.

I've had some excellent service from the hospital microbiology department lately. Two weeks ago I saw a woman in early pregnancy who had been in contact with chicken pox. Never mind I thought, most people are immune even though they don't remember having the illness. I checked her serology, but unfortunately she was not immune. Our excellent practice nurses took over, contacted microbiology and arranged to give her some human immunoglobulin. Good, I thought, she won't get chicken pox now. Today she came back to see me with an early chicken pox rash. Oh dear! I rang the microbiology department and got straight through to a clinician who was extremely helpful. It turns out that the immunoglobulin does not always prevent the disease from developing but it makes it less severe in the mother, and by mopping up the viraemia it minimises the chances of it damaging the fetus. My patient appears well at present. I have prescribed her a course of aciclovir, and told her that if she starts to feel significantly unwell she should get straight back in touch. Maternal chicken pox can be a serious illness and hospital admission is sometimes required.