UNDERSTAND AND ADHERE TO YOUR DOCTOR’S PROGRAM
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First, insist on understanding the importance of the medication and the instructions. Secondly, consider whether following the instructions poses any special problems. Third, adhere to the agreed program. Fourth, if medication remain’s after the course of therapy, destroy it. You must understand the instructions given to you. If you are confused, ask questions: “Could you go over that again?” “I don’t understand what this medication is for.” “Do I really have to be treated in the hospital?” “How much will this cost?” “Are there any risks to this drug?” Ask yourdoctor to write out the instructions. Understand the importance of each drug or treatment.
In some instances it does not matter if you take the medicine regularly; in these circumstances the drug gives only symptomatic relief and should be discontinued as soon as possible. Be sure that you understand whether it is or is not necessary to continue the medication when you feel well.
Consider the entire prescribed program. You may have difficulties not known to your physician. Perhaps you have trouble taking a medication at work. Perhaps you anticipate trouble with a prescribed diet. Perhaps reasons unknown to your physician prevent your undertaking the recommended activity. If more than one medication has been prescribed initially, it may be more desirable for you to take them all at once. When such questions arise, ask in advance. Frequently, if you raise these questions with your physician, your treatment program can be modified so that you can feel more comfortable. The keynote is honesty.
Don’t say that you will do something which you know you will not do. Express your worries. After an agreed program has been prescribed, follow it closely. If you notice possible side-effects from the program, call the physician and inquire. If side-effects are serious, return for examination. Make a chart of the days of the week, and the times when medications are to be taken. Note on the chart when you take the medicines. Don’t look on this as an insult to your intelligence; this practice is universally used in hospitals by trained personnel to insure that medication schedules are maintained accurately. At home, you and your family are the custodians of your health. Do not take this task more lightly than it is taken by professionals.
When pills remain at the end of a course of therapy, flush them down the toilet. There are multiple hazards with a medicine chest containing old prescription medicines. Every year, children and adults die from taking left-over drugs. Children take birth control pills, adults brush their teeth with steroid creams, and the wrong medication is taken because another bottle was thought to be in hand. If you give your leftover tetracycline to your children with their next cold, you are probably not aware that you may cause mottling of their teeth. If the same tetracycline becomes outdated and is subsequently used, you are probably not aware that dangerous liver damage may result. When a new illness occurs, the situation is confused if you have already taken left-over medications. Sometimes it will be impossible to make an accurate identification of a bacteria by culture or the clinical picture of the disease may be distorted. The doctor-patient encounter is your most reliable protection against serious illness. Value the opportunity for such attention, utilize it selectively, and follow to the maximum extent possible the instructions you are given.
LISTEN: FOLLOW YOUR DOCTOR’S INSTRUCTIONS
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If you are a typical patient, you carry out less than one-half of the instructions given to you by your physician. Think back to your last encounter with your physician, After you started to feel better, did you discontinue the medication prematurely? Did you have pills left over from your last prescription? Did you honestly adhere to diet recommendations? Did you restrict or increase your activity as instructed? Did you take medication irregularly, or exactly as prescribed? When a new illness occurred in your family, did you use medication “left over” from a previous encounter? If you did none of these things, you are a remarkable patient.
Let’s look at the consequences of not following instructions:
First, there is the obvious waste of your time and your money. You are seeking expensive advice. As indicated in this book, there are many occasions when you do not require such advice. However, after you seek advice, it is ridiculous not to obtain the benefits. After you have arranged transportation to your doctor’s office, waited until you could be seen, spent time with a trained professional, proceeded to a pharmacy, purchased medication, and finally returned home, you have invested a considerable amount of time and effort. Don’t waste it by not following instructions.
Second, there are serious medical consequences if you don’t follow instructions. The disease may persist; it may come back; you may have complications, side-effects, or drug interactions. The most frequent of these is that your problem may persist. For example, if you have an ulcer, the pain will usually respond within a few days to appropriate treatment. However, the ulcer crater, often large enough to stick your thumb into, has barely begun to heal. If treatment is not continued throughout a period of about six weeks, complete healing of the ulcer crater may not occur and the symptoms of the persisting condition may recur as soon as treatment is discontinued. With urinary tract infection, the symptoms of urinary burning, lower
abdominal pain, and frequent urination usually disappear in the first forty
eight hours of treatment. However, the bacteria which are responsible for the condition may not be totally destroyed for several more days. If antibiotic treatment is not continued until the condition is under control, the infection may come back, necessitating repeated medical attention. As another example, you may not realize that when you go to the physician for a sore throat, your physician is treating you mainly to prevent complications. Serious complications of strep throat include damage to the heart (acute rheumatic fever] and to the kidneys. These complications are unusual if ten days of antibiotic therapy is taken. However, you will feel well after forty-eight hours and may neglect further therapy. This is a major reason that long-acting penicillin shots may be prescribed for strep throats, since the physician is certain by giving you an injection that you will receive all the medication. In every scientific study, shots have proved superior to medication taken by mouth in preventing complications. Oral medication is not inferior, but patients are not reliable in taking it.
Sometimes patients take too much medication. Many operate on the theory that if a little bit is good, a lot is better. All drugs are alien to the body and basically must be considered to be “poisons.” When used in excess of recommended dosage, you may encounter increased side-effects, dependence, addiction, or even death. You are gambling with your life if you increase the dosage when you do not know if this is safe. Finally, drug interactions may occur. If a patient fails to report what medication is being taken, the physician may prescribe a new drug which has unfortunate interactions with the original medication. This represents a breakdown in your communication with your physician. Most important, the patient who disregards instructions contributes to the dissipation of trust between patient and physician. Frequently, the patient who most strongly maintains that the physician “never explains things” is the same patient who disregards instructions. Not following “doctor’s orders” puts a fundamental dishonesty into the patient-physician relations-hip. Future events cannot be correctly interpreted by the physician without accurate historical information. As a result, you receive more shots and fewer medications by mouth, while frequent visits are ordered so that the physician can check up on you. More blood tests are ordered to measure the actual blood levels of drugs you are supposed to be taking. Directness and honesty in the communication between doctor and patient are essential.
LEARN TO OBSERVE YOURSELF
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The careful physical examination requires skill and experience. Some important observations can be made at home and if you can report accurate information on these points you can further help your doctor.
Temperature: Don’t say “fever” or “running a temperature” or “burning up.” Own a thermometer, read the instructions, practice shaking the thermometer down, and be able to report the exact temperature. If you have a small child, own a rectal thermometer and know how to use it.
Pulse: If the problem involves a rapid or forceful heartbeat, know exactly how fast. Feel a pulse in the arm or throat, or put an ear to the chest. Count the exact number of beats in an exact minute, or have someone do this for you. If you think that there is a problem with the pulse, check whether the beat is regular or irregular. Is the heart “skipping a beat,” “turning flip-flops,” “missing every other beat,” or completely irregular? Often a pulse irregularity is gone by the time you reach the doctor. If you can describe it accurately, your doctor may be able to understand what happened. For more information, refer to Palpitations, Problem 53.
Breast: The mammary tissue is normally a bit lumpy. Adult women should carefully examine their breasts every few months in order to detect changes. Do not press the breast tissue between the fingers, but press it against the chest wall. Try several positions-lying, sitting and with the arm on that side raised over the head. Look particularly for differences between the two breasts. If you note a suspicious lump, see the doctor immediately. Many women delay out of fear. Please don’t. Very few lumps are actually cancer, but if the lump is malignant it is important that it be removed early. Often the patient can feel a lump which the doctor misses; help the doctor locate the problem area. Detailed instructions for a self-examination can be found in “For Women Only.”
Weight: Changes in weight are frequently very important. Know what your normal weight is. If the weight changes, know by how much, and over what period it changed.
Other Findings: Know your body. When something changes, report it accurately. A change in skin color, a lymph gland on the back of the neck, an increase in swelling in the legs, and many other new events are easily observed. Just as important, knowledge of your body will help you avoid reporting silly things. The “Adam’s apple” is not a tumor, “knobs” on the lower ribs or pelvis are usually normal, the vertebrae at the lower neck normally sticks out like that, and there is a normal bump at the back of the head-the “knowledge bump.” We have seen patients reporting each of these as emergencies.
MEDICAL HISTORY
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THE PAST MEDICAL HISTORY
After hearing your chief complaint and a history of your medical problem, your physician will want to know more background information about your general health. At this point, information which did not appear important earlier may become so. The physician will ask specific questions and will be assisted by direct, reasonably brief answers. You will be asked about your general health, hospitalizations, operative procedures, allergies, and medications. The physician may be interested in childhood illnesses as well as those occurring during adult life. The subjects most frequently misreported are allergies and medications.
If you report a drug allergy, describe the specific reaction which you experienced. Many drug side effects (such as nausea, vomiting, or ringing in the ears) are not allergic in origin. Physicians are rightfully wary of prescribing drugs to which an allergy has been reported. If you report an allergy to a drug to which you are not allergic, you may deprive yourself of a useful method of treatment. When reporting medications, be complete. Birth control pills, vitamins, aspirin, and laxatives are medications. Frequently, the taking of these drugs is not reported. On occasion, each of these may be important in diagnosis or treatment of your medical problem.
THE REVIEW OF SYSTEMS
Next, your physician will usually review symptoms related to the different body systems from head to toe. There are standard questions for each system. Your physician may begin with questions about the skin, then ask about the head, eyes, ears, nose and throat, then begin to move down the body. Questions about the lymph glands, the lungs, and the heart are followed by questions about the stomach, intestines, and urinary system. Finally there will be questions asked about muscles, bones, and the nervous systems. In this questioning, the physician is looking for information which may have been missed previously, and for additional factors which may influence the choice of therapy. A very detailed “review of systems” will only be taken when you are having a complete health examination.
THE SOCIAL HISTORY
Finally, questions relating to the “social history” are addressed. Here, the physician may wish to know about your job, family, and interpersonal stresses. Questions may concern smoking, drinking, use of drugs, and sexual activity. Exposures to chemical or toxic substances may be sought. Questions are sometimes intensely personal. However, the answers can be of the utmost importance in determining your illness and how it can best be treated. Again, a detailed social history should be expected only in a complete health examination.
THE MEDICAL HISTORY AS AN INFORMATION SOURCE
The physician has three major sources of information: the medical history,the physical examination, and laboratory tests. Depending on the illnesses,anyone of the three may be the most important. The medical history is the only source of information which is directly controlled by the patient. It is frequently termed “subjective” by physicians because the information can not be directly verified. To the extent that you provide your physician with clear, accurate data, you increase the probability of an accurate diagnosis and successful treatment of your problem.
The Present Illness
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Next, your physician will want to hear the story behind the chief complaint. This section of the interview will be introduced by a question such as:
“When did this problem begin?”, “When were you last entirely well?” , or “How long has this been going on?” The first fact which the physician shes to establish is how long you have had the problem. Know the answer :J this question in advance. “Yesterday.” “On June 4th.” “About the middle :f May.” If you are uncertain as to the date the problem began, state the .mcertainty and tell what you can. “I am not sure when these problems began. I began to feel tired in the middle of February but the pain in the joints did not begin until the end of April.” The physician can then determine the starting point for the illness. After you define the starting point for the problem, the doctor will want to establish the sequence of events from that time until the present. Tell the story in the order it occurred. Do not use “flashbacks”; you will only confuse yourself and your physician. Do not attempt to tell everything you can remember about the illness, but highlight those events which seemed most important to you. Use short, concise sentences. Do not include irrelevant occurrences in your family or social situation. Your cause is not aided by reference to the relatives who were visiting you at the time, the purchases you made at the shopping center, or the state of international affairs. If you confuse your story, the chances for a successful solution to your problems are decreased. As you recount the sequence of the problem, sketch the highlights as you perceive them:
I was well until I developed a sore throat four weeks ago. I had fever and some swollen glands in my neck. This lasted about a week and then I felt better although still tired. One week ago the fever returned. I began to have pains in my joints, beginning with the right knee. The joint pain moved around from one joint to another and I had pain in shoulders, elbows, knees and ankles. Over the last three days I have had a red rash over much of my body. I have not taken any medications except aspirin, which helps a little.
The physician may interrupt the story to ask specific questions. At the end of the story questions may be asked about problems which you have not mentioned. By making your account well organized and allowing the physician to request additional information, you provide information in the most effective way. If you have several problems to recount, the story of each may be told separately, or they may be intertwined in a single narrative. The physician may provide guidance to the most appropriate procedure in the individual
case. Supporting information may be extremely important. Know which medications you have taken before and during the course of the present illness. If necessary, bring the medication bottles to the physician. If you are pregnant or could be pregnant, tell the physician. If x-rays or laboratory tests have been performed during the course of the illness, attempt to make these materials or a report of the results available to the physician. If you are allergic to any drugs, mention these. If other physicians have been consulted, bring those medical records with you. Attempt to be a careful observer of your own illness. Your observations, if carefully made and recounted, are., more valuable than any other source of information.
The Chief Complaint
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Following the initial greeting, the “chief complaint” is usually the first information sought by the physician. This question may take several forms:
“What bothers you the most?”, “What brings you here today?” “What’s the trouble?”, or “What is your biggest problem?” The purpose of such questions is to establish the priorities for the rest of the medical history process. Be sure you get it right. Know in advance how to state your chief complaint: “I have a sore throat.” “I have a pain in my lower right side.” Any of the problems listed in the second section of this book may be your chief complaint, and there are hundreds of less common problems.
Think of the “chief complaint” as the title for the story you are about to tell the doctor. Do not give details of your illness at this time. Instead, title your illness appropriately and provide the doctor with a framework for understanding your problem.
Sometimes, you may go to the physician with more than one problem.
You may not be sure whether the problems are related or not. Identify this situation for the doctor. “I seem to have three problems: sore throat, skin rash, and cloudy urine.” The physician may then investigate each of these areas.
Tell it like it is. If you have a sexual problem, do not say that your chief complaint is that you’re “tired and run down.” If you are afraid that you have cancer, do not say that you came for a “checkup.” If you mislead the physician because of embarrassment, the real reason for your visit may never be determined. You will compromise the physician’s ability to be of assistance. An honest description is your best guarantse of having your problems attended correctly.
The Office visit
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A visit to the doctor’s office can often be a mysterious undertaking for many patients. This chapter will help you understand the general procedures a physician followS-when you come to the office with a medical problem. In addition it will stress the importance of your active participation in these procedures and the advantages of strictly following your doctor’s instructions.
THE MEDICAL HISTORY: TELLING IT LIKE IT IS
The “Medical History” is the most important communication between the patient and the physician. The ability to give a concise, organized description of your illness is essential to good care. The patient who rambles on about irrelevant details and doesn’t mention real fears and problems is his or her own worst enemy. Inability to give a good medical history is expensive in terms of both your dollars and your health.
Most people do not realize that every physician uses a similar process to learn a patient’s medical history. Obviously, the physician must organize information to be able to remember it accurately and reason correctly. Knowledge of the process can help you give accurate information to your doctor. The physician organizes information under five headings: the chief complaint, the present illness, the past medical history, the review of systems, and the social history. Physicians will not always request information in the same order, but the following definitions will help you recognize the purposes of the medical interview in which you are participating.