Morning Surgery
Jessie, a young lady – depressed and not sure why. Hard when limited clues. Eventually I assess through the lens of a useful framework for life – Tony Robbins’ 6 human needs- certainty, uncertainty, love/connection, significance, growth, contribution. As I talk about it – it becomes clear that she struggles with uncertainty. A lot of people do but her manner is distinctive. She requires routine and if she loses it she cannot function. She does not have a job for this reason. I screen her for autism before sentencing her to a 5 year wait for diagnosis.
88 year old Beryl. (It’s funny how you can almost guess the age of a patient by their name—Beryl’s never going to be a teenager, is she?) – she’s intermittently shaking, got the jitters. Today she’s fine but it’s occurred 2–3 times in the last few months. Ideally I would bring her in for a quick MOT but there’s no appointments. A big chunk of General Practice is hypothesising confidently or buying time: I hypothesise it’s her blood pressure and explain how adjustments to blood pressure changes when we stand up as we get older are slower and more sensitive to dehydration or low sugars.
‘Next time it happens try drinking a pint of water, eating something with a bit of salt/sugar in it and then lie down for 15 mins. If it’s still an ongoing issue or getting worse let us know and we’ll bring you for a check over’
John, 43, under haematology for his dormant multiple myeloma (blood cancer) has developed weight loss and is understandably anxious. I request an extensive blood panel for tomorrow so we see if it’s related to his cancer.
63-year old Bert who has a Crohn’s disease (inflammatory bowel disease) flare-up – his markers of gut inflammation are through the roof despite recent treatment. I write an urgent message to gastroenterology to expedite his next outpatient review as they haven’t plans to see him anytime soon.
Susan, 60, on Ozempic – one of the weight loss injection medications many elite got wind of and it’s become so popular there’s a shortage. The crampy tummy pain, the nausea, the side effects are getting too much for. She’s barely eating. Certain foods e.g. fatty make side effects worse so we go through diet. Her heart rate is 105 signifying she’s not really doing that well. We trial anti-sickness medication, pain relief and a strict Ozempic-conducive diet for a couple of weeks.
Harry, 40-something, has sinus congestion. His left ear is also painful and hearing is reduced. It became worse after swimming. His left ear drum is retracted and swollen. His right ear has 2 unusual cystic shaped lesions blocking part of his ear drum. I’ve not seen them before but they look benign. I issue decongestants, antibiotics and advise rinsing his sinuses out with saline water. I also write to ENT for guidance on whether these cystic lesions warrant an urgent or routine input.
Benny, 71 – feeling anxious. A bit of a worrier. Coping ok with it. He is quite active, but he lives alone. He has no mobile phone or computer which reminds me of how different the lens each person views the World through can be. I notice an abnormal prostate blood test from 2 years ago which was investigated but worth repeating to make sure it’s normal now, even though he has no new symptoms. Then I teach him a balancing breathing technique called Nadi Shodhana – one of the most foundational breathing techniques in yoga to help his anxiety.
Tony, a paramedic, has been out to see a patient Gerry for a suspected stroke. It turns out his blood sugars are low and he had a hypoglycaemic episode causing slurred speech and reduced consciousness. They treated him and reversed it. He is a bit clueless about how to use his insulin. His wife is at home with him which makes things less risky. I advise them to record his blood sugars before and after meals for 3 days and we’ll get him seen in clinic with our advanced nurse practitioner who can tweak his insulin doses and ensure he understands how to use it.
Tracey has a million things wrong with her at a young age. Diabetes, possible Crohn’s disease. Loads of pain. She’s got a painful foot which she says she tried everything for. She’s stretched it, she’s changed her footwear, she’s on painkillers. She’s trying to improve her diabetes. She throws all of her problems at me in one go and I feel irritated as she complains about everything and everyone as she often does. I get it and I get she’s not happy. We have a good relationship so today when I’ve got limited capacity, I don’t feel bad as I signpost her to see the physio and bring the consultation to a close quickly.
I have a patient in the waiting room but need a break from people and start whipping through 85 scripts and 20 blood results, taking action where needed.
76 year-old Henry – he has had a couple of falls and is having giddy spells. He’s known to have prostate cancer which is well controlled. I notice his bloods on the hospital system show a big drop in his kidney function and a possible infection but no one seems to have done anything about it. I check his numbers and his BP is quite high and will need tight control if his kidney function is as bad as it was in February. His blood pressure when he goes from sitting to standing is fine. We’ll re-check his bloods then review everything. After he leaves, I ponder if I should have just treated his blood pressure there and then as it’s probably contributing to his symptoms. No time to give it much thought.
Lunchtime MDT
At lunch – there’s a meeting to discuss patients needing multidisciplinary team input to ensure shared care and collaborative work which is necessary. Pop out for 15 mins to get some food. I call a friend to vent. We have a weekly ‘chat-shit call.’ We vent with no judgement about work and life. Doesn’t matter whether we’re right or not. We just get it all out. Today I vent about how reception keep dumping patients on top my clinic as if I have some sort of endless bank of energy. How I send emails to people to ask for things or to raise issues and don’t get a response – it’s a joke. It really is. And I’m close to quitting. The truth is, it’s not any individual’s fault that we are not a team but it is the organisation’s responsibility to listen to me and give our team autonomy and space to improve things. Rant over.
A 70 year old patient has been discharged from hospital with some drastic changes in his medication because his blood pressure was dropping too low. It’s really tricky because his heart isn’t functioning well and is causing fluid build-up in his legs and chest. The problem is that the medications which offload fluid away from his legs and chest, also lower his blood pressure. So when you stop those medications, the blood pressure picks up but the fluid collects again. He’s walking a tightrope – step off on one side and you drown in fluid, step off the other and you collapse from low blood pressure. It’s quite an investment of time, energy and expenses to facilitate this delicate dance as he’ll need home visits – does he even want to walk this tightrope? Our system always presume yes. A conversation for another time.
Afternoon Clinic
Jayden, 6 months, constipated with hard stools and hasn’t opened bowels in a week apart from one hard pellet. He’s straining and crying. He’s on formula milk and about to start weaning on solids. We go with mashed fruits/prunes/peas on top of the usual measures such as hydration, massages and warm baths and we’ll review if he needs laxatives next week.
Naomi, 40, a suggestive lady with chest pain. She comes in, smiling and touches me on the arm. ‘Oh hi Doctor.’ She has a well-endowed chest with a garment celebrating rather than obscuring this attribute. She repeatedly points down at her lower sternum, pushing her chest where it’s painful. I maintain eye contact. She’s had a cough which has probably caused a small muscle strain, nothing to worry about. Breast to move on quickly.
60 year old with tummy pain and intermittent constipation and diarrhoea. Sometimes the constipation can cause overflow diarrhoea as the blockage causes the fluid to push its way around the hard stool and come out as liquidy stool. Sumptuous stuff. Treat him with a trial of high dose laxatives and advise him to stay close to the toilet.
91 year old with elephant-sized legs since 2 weeks ago. It’s from fluid collection. Sometimes it can indicate fluid on the chest too but his chest is clear and his numbers are ok. Rather than over-investigate a 91-year old with multiple trips, I go with a practical solution and give him water tablets to relieve the fluid and hopefully reduce the swelling and pain in his legs. We’ll review him with some bloods again in 2 weeks.
Marie, 66, has severe back pain and is struggling to walk. She is incontinent – ongoing for a while. She was seen in the bladder clinic 2 weeks ago who reportedly started 2 medications. The letter communicating outcomes from the clinic has not come through though. She wants the medications but I can’t issue something I don’t know about. She also has chronic pain all over. She also thinks her back pain has progressed to compressing the spinal cord (emergency) as she’s lost sensation around her rectal area. She wants strong painkillers but says everything I’ve suggested won’t work. Hence why someone referred her to the pain clinic but that was 9 months ago and she’s not heard anything. She wants solutions. I can’t help her much but will review her for a face-to-face appointment to assess her back pain to ensure it isn’t an emergency. I’m running 40 minutes late. I’m in a numb, tired state of autopilot now.
Gerti, 35, has a sore throat for 2 days and really doesn’t warrant medical input so I offer him a curt performance.
Asked by the advanced nurse practitioner to pop next door to help her with an 18 year old female with itchy, discharging nipples. Sometimes blood. She’s seen the breast team before as someone referred and had cancer ruled out. Possible breast infection, a bit of a punt as I’ve not seen this presentation before. Antibiotics and moisturisers.
Jose, 2, has started walking with his toes facing slightly inwards. I check his leg length, his standing alignment of his hips, knees and ankles before making sure range of motion in each of those joints are normal. I ask ChatGPT a question on in-toeing (game-changer) and reassure mum and dad 10% of children develop this and it’s usually outgrown by 8-10 years old.
An email comes in from the nursing home asking for antibiotics and medications for haemorrhoids. I pause and contemplate if I have the emotional equivalent of haemorrhoids. That’s how I feel at the moment. Low-grade stress all the time that I do sometimes forget about completely but can get a lot worse in short bursts. I conclude I have emotional piles.Time to surgically remove the problem?
13-year-old with suspected attention deficit disorder. I signpost them to the screening questionnaire and explain they’ll need to find a private provider and we can refer them under the NHS as the NHS waiting list is many years here. He also has a sore throat, so I check him over and advise it doesn’t need antibiotics. Mum isn’t happy. I’m ambivalent, irritable and disinterested.
An email from pharmacy mentioning a medication brand prescribed being out of stock and requesting me to re-prescribe it in generic form.
Then I debrief with Helen, our advanced nurse practitioner, who needs advice with some patients and tests ordered..
Then there’s another 40 pathology results to deal with. Then a few workflow letters from referrals or other agencies to act on. Then 30 prescription requests that need reviewing and signing. I rarely leave work for the next day but today I’m out of juice.
I finally check my emails before I log out:
There’s one that’s come in – a link to a Protected Learning Time session on:
Suicide Prevention.
How timely.
Mindful Medic 