The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 91: Geriatric patient

Doctor has to face additional problems in the evaluation of diseases in very elderly for several reasons. They may be frail and not very ambulant, have impaired hearing or sight, multiple organ (cerebral, cardiac, renal etc) dysfunction, may be away from children or spouse leading to emotional problem, may have some property or financial issues, may be living in an old age home, may be already taking several drugs and so on.

It will be convenient to have a 3 or 4-seater sofa in the consultation room (meant for the attendants), on which the patient may be examined, if he can’t climb the examination coach. Eliciting history may be difficult, in view of the hearing problem or dementia. Special attention to be given to identify and address common diseases in elderly, such as constipation, cataract, prostatic disease, malignancies, insomnia or cognitive disturbances.

Most of the investigations may reveal age-related organ dysfunction, about which very little can be done. If surgery is required the risk/benefit ratio of anesthesia and surgery has to be assessed, keeping non-surgical options also in mind. Morbidity or mortality in very elderly is better accepted by the family by omission rather than commission by Doctors.

Drugs which may be potentially risky, such as NSAIDs, anticoagulants, antihypertensives, hypoglycemic agents, antiparkinson drugs, psychotropics should be used with caution and their dosage to be adjusted according to the age and comorbidities.

In view of the various drugs they consume, periodic monitoring of renal, hepatic, cardiac, pulmonary or cerebral functions, may be necessary. Keeping in touch with their kith and kin, who may be abroad, will make them very grateful and satisfied.

Chapter 92: Pregnant or lactating patient

It’s a complex subject, to know the mechanism how molecules cross placental barrier or lactiferous system and list of such drugs may be very lengthy. As a rule no drugs should be given during 1st trimester, when the formation of various structures and organs in the fetus is expected to take place.

Since the teratogenic potential of several drugs haven’t been fully studied, only essential drugs should be given even during 2nd and 3rd trimester. Some drugs, having low molecular weight, high lipid solubility, high protein binding property and low polarity (molecular charge), readily cross the placental barrier.

Actually there is no ‘true’ barrier in the placenta, it’s a semipermeable membrane, only reduces the amount of chemicals diffusing through it. It’s interesting that the hyperemesis gravidarum seen in the 1st trimester is actually nature’s design to reject foods that may be harmful to the developing embryo.

Some drugs, such as codeine, nasal decongestants, amiodarone, statins, anti-mitotic agents, radioactive iodine, extended release or long acting formulations etc. have to be totally avoided while a woman is breast-feeding.

Drugs are preferably taken once a day, immediately after feeding, giving a long gap for the next feeding. There is a big list of safe and unsafe drugs, both during pregnancy and lactation; you are advised to consult experts or larger text books, for more detailed account on these two subjects.

Chapter 93: Psychosomatic disorders

â€˜It’s more important to know what kind of a patient has the disease, than what kind of a disease the patient has’.

Beware, ‘there are more mental patients outside than inside the asylum’. The human diseases may be broadly classified as somatic, psychosomatic and frank psychiatric disorders. The first and last categories may not be difficult to identify, but the second is the most difficult to diagnose and requires the expertise of an astute physician. To name a few such conditions : hyperacidity & heartburn, irritable bowels or constipation, tension headache or vertigo, cervical spondylosis, hyperhidrosis (increased sweating) or palpitation, chest pain or cardiac neurosis, insomnia etc.

A patient with these disorders, typically comes with a big file, seen by so many consultants (hopefully you are the last), undergone several investigations, but not satisfied and exhibit a sense of insecurity. If we carefully observe the way he narrates the history, laying emphasis on unimportant matters and the pattern of symptoms not fitting into any known entity, refractory to conventional treatment, we have to suspect a ‘functional’ component and deal accordingly.

Generally the patients don’t accept that their problem is functional (or ‘supratentorial’, as our teachers used to put it) and we have to convince them that symptoms of an organic disease are getting aggravated by some emotional stress. At that stage, they generally admit some incident in the background causing stress. There can be innumerable causes for stress in life, listing all of them is beyond the scope of this booklet.

The statement, ‘man is under stress from cradle to coffin’ has been expanded in modern life and modified as ‘from womb to tomb’. However the threshold point for breakdown for any stress varies from person to person, depending on a combination of genetic (nature) and environmental (nurture) factors.

â€˜There are many people in this world, who spend so much time watching their health, that they haven’t the time to enjoy it’. ‘Treat the entire patient, not just his liver’.

Chapter 94: Psychiatric patient

We should realize that ‘all psychiatric patients die of organic diseases’, hence every symptom they have should not be brushed aside as functional. It taxes our clinical acumen and experience to filter an organic disease out of functional manifestations and successful Doctors had mastered this art.

It’s also advisable to avoid surgery on them, unless it’s absolutely indicated and life saving, because anytime after surgery, if the patient goes to another Doctor with a problem, the Doctor promptly advises him to go to the ‘Doctor who operated’ and ‘washes’ his hands.

Subsequently, it becomes very difficult to disown the patient, even if his problems are not related to the surgery. The Doctor must be aware of any possible physical harm a violent or aggressive patient may do to him.

We should keep enough manpower with us, when we are examining such patients and exercise extreme restraint against using any affensive or abusive language with the patients, who may have very low threshold for criminal violence. But at the same time, it may be necessary to take him into confidence in absolute privacy, to get some important clues from him.

A person after an ‘unsuccessful’ suicidal attempt, including a post-burn patient, requires intense counseling, since they have a high incidence of repeated attempts. The family also has to be cautioned to eliminate any possible stressors in his life, as much as they can.

Another very important and sensitive matter is the ‘unwanted’ gossip about a ‘mental’ patient, which can aggravate the patient’s original problem. If someone has stomach or leg pain, no one, not even the next door neighbor, thinks about it. But if someone has a psychiatric problem, entire town talks about it, adding their own anecdotes.

Hence it is very important that utmost confidentiality is maintained not only by us, but also by their family members, especially in ‘borderline’ psychiatric problems.

The fact a person consulted a psychiatrist, leaves a permanent stigma on his personality and may create additional issues. To maintain absolute secrecy, I request the psychiatrist to see the patient in my office and use my prescription pad, to write the treatment.

Chapter 95: Non-compliant patient

It’s said in lighter vain that ‘the patients who don’t take our advice seriously, are our assets’. For a patient who doesn’t quit smoking or drinking, that provides you with best explanation, why your medicines were not working as expected. Similarly for a patient who doesn’t lose weight, that gives you a good reason why his musculoskeletal symptoms were not resolving.

That’s why, one smart Doctor had put up a board outside his room, which says ‘if every patient sincerely followed my advice, I wouldn’t have been able to build this building’. This message is expected to reach deep in the patients’ minds.

When we reach a level of seniority that, we’re confident, that our clients won’t leave us, we can warn such patients that you might not see them in future, unless they mend themselves. For many patients, this works wonders, since they don’t want to go elsewhere for medical advice.

Occasionally one of your regular patients, suddenly goes to some other Doctor, either on the advice of some friend or he couldn’t get your appointment when he wanted.

Dissatisfied with the other Doctor, the patient comes back to you, confesses his ‘mistake’ and asks for an apology.

Exercising good diplomacy, it’s best to say : ‘I’m happy you went to another Doctor, otherwise you would never appreciate the difference’.

The Consultation Room