Tuesday, 12 February 2008

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.


The Shrink said...

On feeling twitchy about an anxious patient last week, so checking serum rhubarb etc, it transpires the lethargy and agitated depression and changed sleep pattern is through myelodysplasia.

This happens at least once a month.

This just heightens my anxiety on dealing with anxious folk, they may well be right, somthing might be wrong after all!

Elaine said...


I told you I was ill.

Anonymous said...

Regarding the screen thing, aren't there sometimes less than desirable things on some peoples records that they may not be pleased to see?

Not necessarily malicious, but you know, things they may be in denial about that could cause fuss?

Ms-Ellisa said...

(same as Harry)

... like this case with the affair? And what about confidence issues, if a third party is present at the time, but the record however contains information shared before?

Anonymous said...

As regards the computer screen - my GP's practice still relies on hand-written medical records. Hard to believe in this day and age, I know but it's true :-(

Anonymous said...

Not just Maternal Chicken Pox, As a casualty Reg (18 months worth) I have sent two adult chicken pox's direct to ITU (do not pass MAU, do not pick up MRSA). The pathology is from a pneumanitis leading to low PaO2's and general poorliness.

Calavera said...

Hah, I love Elaine's comment! Hilarious!

You know, I've never seen the doctor's computer screen, ever (well I've not been many times at all, but when I have, I always remember thinking whether the doctors peppered my records with personal comments like, "Is a medical student" or something of the sort, because all the doctors seem to know that I'm a medic and yet I never remember telling them!)

Anonymous said...

We invest a lot in our IT but there are still some times that it just slow's you down. During some of these 5min follow-ups it's so much easier to write in the chart. I've also started doing my dictations with the patient in front of me. I think people appreciate the openness. Hopefully someone will come up with a more user freindly charting system (that's stable) and won't slow me down. www.waittimes.blogspot.com

Lala!! said...

GP's who communicate rule ok!!!

See my blog for life as a patient...and yes one who is ill!!!!!!!!!!


would love your questions and comments please!

Dr Andrew Brown said...

Thanks everyone for the interesting comments.