Interesting patients

More GP today (do you get the impression I rather like this placement?) and I thought I’d share with you a couple of patients who stuck in my mind.

An asian lady peeked round the door hesitantly after being called over the tannoy.  We beckoned her in and she came and sat down, never quite looking at us.  She sat uncomfortably, fiddling with her coat, and I swore she had a look of mild amusement and embarassment on her face.  ”Doctor I’ve still got these terrible pains in my elbows and shoulders these last few months – what can you do about it?”.  The doc whisked up her recent blood tests on the computer screen.

“Your Vitamin D levels are very low – have you been taking the tablets we gave you?”

This turned out to be the source of embarassment.  ”Uh, no doctor I, er, ran out…”

The GP asked why she hadnt returned for the repeat prescription waiting in the reception.  This turned out to be the source of both amusement and embarassment.  ”Er, well I went to the homeopathic doctor and they gave me tablets to take instead…”

The other student and I shared a look and silent giggle, probably unfairly, but the woman knew what she’d done and thought it was amusing too.  As well as embarassing.  The GP, the old pro, took it in his stride as he’d apparently seen it countless times.  A mild telling off and urging to keep taking the “proper” tablets, and she was on her way, assured the pains would go away if she complied.

About mid-way through the morning a large man came bounding through the door about 5 seconds after being called.  He must have moved fast.  ”Hello!  Hello!  How are you?”, he boomed, lunging for us students’ hands for a shake.  ”No need to tell me your names, I’m terrible with them and I won’t be here long enough anyway, oh God its lovely to meet you how are you how are you??”.

Taken aback, but also sharing in his good humour we played along politely.  He seemed to take a particular liking to me, “Ah yes I knew you were a doctor when I saw you outside I did!!  You have the look!  Practicing doctor I assume, yes yes??”

I was wearing my nice shirt and had my NHS lanyard on, but I assured him I was just a student.

He finally sat down and turned his blaring music off.  The GP seemed not to notice any of this while he pulled up the records.  The patient was just here for a review of high cholesterol, and he was calmly told that the levels were ok at the moment.  After laughing away with joy at this he thanked the doctor and us for seeing him.  ”Right then! I’m off to the clozapine clinic…”.

“Oh yes, how is the schizophrenia?”, the GP casually mentioned.

After a further 5 minutes of rocking back and forth and assuring us he was fine and dandy, he rocketted out of the room.  And then came back again to shake us students hands again and wish us luck for the future, again.

“He seems a little high doesn’t he?  Maybe they need to check his meds…”, the GP said off-hand, shaking his head as he called in the next patient.  Us students sat there wide-eyed.

General Practise

The other student didn’t show up today so it was just me and the GP sitting the morning clinic. Over the last few days I’ve sat in, occasionally taking relevant patients (psych or neuro) away to interview them before presenting them to the GP and giving a differential.  I’ve actually enjoyed it alot – the GP is a nice guy who’s been doing the job for years.  We’ve had several chats about the job itself and my aspirations (at the moment) to go into it.  He’s done a fair bit of teaching, with us listening to the odd chest or checking a stiff limb, and I usually ask several questions about each case which are happily answered. Admittedly we haven’t done so many systems exams but I get the impression the doctor has no idea what we’re competent to do.

The morning saw a really good range of patients, and I got to do a ‘flu jab on most of them (I like sticking needles into people). Most of the end of morning slots are reserved for emergency appointments, so of course it’s all worried parents bringing perfectly well children to the doctor. I shouldn’t be so harsh, but when the children come running through the door laughing away it’s hard to see how the parents saw anything to concern them. One day I’m sure i’ll get it as I bring my own little dumpling to another doctor with “the worst cough ever”.

One kiddy wasn’t well, however, and I’m pleased that I clocked this as soon as I saw her. She was 3 years old and was carried in by her mum. Ironically this mum didn’t seem as hysterical as the last few lots with well children. The girl was quiet and pale, wrapped up well under a thick coat which I could see was moving noticably with her breathing effort. Hell, I could hear her breathing from the other side of the room. Occasionally she’d cough, a wet nasty kind of cough which makes you want to clear your own throat. The GP listening to her chest and then let me; bit of wheeze in the lower zones. Mum was instructed about the antibiotics and steroids and sent away to get an X-Ray and blood tests with a warning to go to AnE if things went more tits up.

The doctor explained to me the medico legal side of things in this situation. You don’t want to send a parent away with no clear instructions of what to do next if the child worsens; it’s got litigation written all over it.

A few cases of depression came and went – one was a particularly intense consultation with the doctor repeatedly having to raise his voice and stop the patient shouting.  It was actually a sad case; an Afghani guy was getting no sleep and was in constant pain.  Turns out he was non-compliant with his Vitamin D pills (he was severely deficient) and was seriously stressed out.  After claiming he’d done some violent things recently and was considering suicide, he went away with some citalopram and a psychiatric referral.  Apparently the case was way more complex than I could know at the time; he had a family to support and was unemployed, relying on a diagnosis of  any sort to get benefits.

I got to see a patient with Parkinsons I’d seen before, and I was happy he’d recognised me.  His medication change hadn’t helped much and so the next steps were up for review.  It was good to see how he was getting on; I so rarely get to see the same people twice anymore.

Many of the patients spoke poor english, so the doctor spoke to them in Hindi or Punjabi.  I saw so many I can actually say and understand a few bits myself now!  The funny thing with the languages is that they’re a flurry of words interspersed with totally english words.  This, along with the usual patient gesticulation meant that most of the time I could get an idea of what was wrong lol

An interesting point with many asian patients is their cultural expectations of seeing “the doctor”.  It turns out they always expect to walk away with a prescription: anything will do.  This explained why the GP was so often prescribing Ibuprofen and Paracetamol, much to my amusement.  When asked about the fact that they would pay £7.50 (or something) for that, the guy told me that most of the time they don’t actually cash-in the prescription; they just want something to make them feel they’ve been seen.  Also the local pharmacists knew the score and would do the right thing by explaining about buying the same drug over the counter for far less money.

During my medical school interviews I was shown a video about a difficult patient.  She wanted antibiotics for a cold and that was that.  The GP gave in.  When asked about this by the panel I enthusiastically stated that she should not have been given the drugs and that the GP should have stood their ground.  I asked the GP about this and he said that, like most things, it was more complicated “at the coal-face”.  Much of a GPs work can be made easier by having patients respect your judgement.  Putting up a brick wall regarding ABx does nothing to build on that, as the patient just thinks you’re being a nob.  What my guy says he does is explain himself and point to recent newspaper examples about the drugs.  He weighs up their response and if they arent happy still then he may give them a delayed prescription and tell them to give themselves (or their kids) a few days to see how they get on and only cash-in the script if things havent got better.

The patient probably knows they hassled him and appreciates him hearing them out.  This should build more respect for his future clinical decisions and, as most of the scripts wont actually be cashed-in, do very little harm.  It’s fascinating stuff, the real world.