Tuesday, September 14, 2010

Basic Care by Doctors for Patients

There have been articles (and even books) written about what a patient should expect from a doctor, but I have found none of them to be of practical use. Let me tell you about the basic behavior I expect from my medical residents. Some if it is what I call "good housekeeping", some of it is common sense, and some of it is based on over 25 years of experience of taking care of ward and office patients. This list is not complete, and it is not a check list of what the doctor should do, because check lists are mechanical, and are not insightful for the doctor. Rather, if your doctor does NOT do several of my suggested actions, it may be time to find a "luckier" doctor for you, i.e. one who is more thorough with his/her patients.

Every patient should be asked about past transfusions (most usually occur during childbirth, so ask specifically). If any transfusions before 1985, do blood test for Hepatitis C antibodies, and, if positive, for Hep. C. RNA.

Ask about blood donations (immediate check for Hepatitis A,B,C, syphilis, West Nile disease, etc.).

In the appropriate neighborhood or background, skin test for TB on high risk patients. Always skin test on admission to a hospital, rehab center, assisted living, or nursing home. Patients from the Caribbean, especially the DR, have usually had BCG vaccine to protect against bovine TB, but the PPD should still be planted. Ask about prior TB skin tests, + or -.

Check on last Tetanus booster (at least one every 10 years), and Pneumovax and cervical herpes vaccine if appropriate. Offer flu vaccine.

Ask about any foreign travel in the past 5 years, and any illnesses while traveling or shortly after return home. Ask if took malaria prophylaxis, if appropriate.

Over age 50, one test for Vitamin B-12, as well as 25-OH Vitamin D. Also test for Vitamin D and Calcium after any bone fracture.

ANY patient put on steroids for longer than one month should be placed on Fosamax or its equivalent to help prevent steroid-induced bone loss.

If patient requests Viagra or its equivalent, check free and total testosterone level as swell as prolactin level. If either testosterone test is low, check the pituitary FSH/LH.

In irritable bowel disease, always check for lactose intolerance and celiac disease/malabsorption. Both can occur at any age.

There are only two acceptable reasons for not doing a rectal exam at the annual physical: no rectum, and no finger.

If no mammogram in the past year, examine breasts.

In hospital visit, always SIT DOWN. The patient should not feel rushed. You should always at least take the patient's pulse for physical contact and reassurance.

Ask about allergies, and request copies of written Xray reports and all past operative reports.

Ask about any veneral diseases, specifically herpes.

Last ophthalmology, dental and GYN visit, and any abnormalities. Can the patient read street signs at night when he/she drives?

Birth control used, sexual satisfaction with partner, and sex of partner.

Any stresses in life. Children or parents with mental or physical problems. Do you like your job?
When was your last vacation? Do you exercise regularly? Do you fall asleep easily? Any pets at home?

Check blood pressure in both arms. If over 50 (or 40 with certain medical conditions such as diabetes), listen for murmurs in the carotid arteries in the neck.

Do NOT tell the patient your own problems. You are wasting their time, because you are there to help them with their problems.

Keep a shadow chart in code of embarrassing facts the patient does not want released, and NEVER copy the shadow chart (OK to verbally give info to treating doctors with secrecy caution): e.g.; adultery, uses cocaine, prior pregnancy and surrender for adoption or abortion, bisexual, hole in nasal septum, lax anal sphincter.

Only try to diagnose treatable diseases (e.g. atrial fibrillation due to hyperthyroidism, and not atrial fibrillation secondary to cardiac amyloid).

The test may not be the patient's, so always repeat any abnormal blood test before you alarm the patient.

If the patient has syphilis and you suspect neurosyphilis, send the spinal fluid only for a VDRL, and never for an FTA, because no one knows what to do with a positive CSF FTA. Remember that Lyme disease is also caused by a spirochete, and is the cause of many false positive VDRL/RPR screens for syphilis.

Ask about orgasms. Ask about suicidal thoughts or attempts or plans. If sex drive low or sex with partner infrequent, ask about masturbation.

Undiagnosed Addison's disease can kill, and you won't make the diagnosis if you don't think of it.

If you have been on prednisone or other oral steroid in the past year, ask the doctor about stress doses of steroids if admitted to the hospital with an acute illness or infection, or for surgery.

If there is a dog in the house, the dog should get the monthly drop on the neck to keep Lyme ticks off.

If the patients says 2 drinks/day, ask how big the drinks are. (In some groups "two beers" means "two six-packs".)

Last menstrual period, and consider pregnancy test (must be done on every hospital admission.).

Ask the patient (1) what he/she thinks is medically wrong, and (2) if there are any other questions.

Most important: try to deduce the patient's model of disease, because any prescribed treatment that is in conflict with this model will not be properly applied.

(Trivial) if patient is low in serum potassium, check urine potassium, and serum magnesium; serum PTH usually not needed.

If kidney stone, 24 hour urine collection for Ca++, urate, and Ox-- so can treat to prevent further recurrences (if untreated, 50% have recurrent attack in 5 years).

Ask about unprotected sex (there is always some), and berate patient appropriately.

ALWAYS skin test for TB (and strongoloides as well?) when immunosuppressing with steroids, imuran, etc.

You may not be worried about lung cancer, but if you are a smoker your doctor should tell you that you are 100% guaranteed to develop emphysema, and spend the end of your life on an oxygen tank if you live long enough.

Why does the dentist go into the other room when taking dental Xrays if they are so safe?

Your doctor should never complain to you about his/her personal problems, but bitching about Medicare, HMO's and Electronic Medical Records is perfectly appropriate.

Never be afraid to leave a doctor because you don't want to "hurt his/her feelings". You should always find a doctor with whom you are gemutlich. I always tell my patients that my ego is not on the line: I give them my best professional advice, and they take it or not.

50% of our current medical knowledge will be obsolete in 5 years, but we don't know which 50%.
Leeches for high blood pressure, anyone?: (They did work , which makes it all the more surprising that the Red Cross will not let anyone with high blood pressure donate blood!)

And finally, do you feel "good" about your doctor?

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