Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, June 10, 2008

Anything Else?

The perils of the open-ended question in a new patient interview:

Me: Tell me about your health.

Patient: I have hypertension and a little arthritis in my knees.

M: Anything else?

P: No, that's all.

M: What medications do you take?

[presenting bag full of bottles, we find:]
  • Cozaar
  • Hydrodiuril
  • Lipitor
  • Zoloft
  • Ativan
  • Ultram
  • Celebrex
M: Why do you take the Zoloft and Ativan?

P: Oh, the Zoloft is for anxiety and the Ativan helps me sleep.

M: Anything else?

P: No, that's all.

M: What about this Lipitor?

P: Oh, I stopped that about three years ago. It's just for people who eat a lot of fat in their diet. I don't think I need it.

M: Ok. When did you last have blood work done?

P: About four years ago.

M: And when did you last see a doctor?

P: About four years ago.

M: Any other medical problems?

P: No, that's all.

M: Are you allergic to any medicines?

P: I get a rash with penicillin, and oh yeah! I have this weird rash that comes and goes. I've seen all the specialists downtown and no one knows what it is.

M: Anything else?

P: No, that's all.

M: Anything run in the family?

P: My brother had a heart attack when he was 42, and oh yeah! I have a 30% blockage.

M: When did you find this out?

P: About four years ago.

M: Anything else?

P: No, that's all.

M: Do you need any of these meds refilled?

P: Just the Celebrex.

M: Most of these other bottles also say "no refill" on them.

P: Oh, I have more at home. I just dumped them out and brought the bottles.

M: How much more do you have at home?

P: About two weeks.

M: How about if I write refills for all of them.

P: Ok.

M: Anything else?

P: No, that's all.

M: Can I do some blood work on you today?

P: Sure. Oh, and I see a cardiologist, rheumatologist and orthopedist too. Can you send copies to them?

M: No problem. Anything else?

P: No, that's all.

M: Are you sure?

P: Yes.

Do you know why dinosaurs have no hair? It's because I pulled it all out this morning.



At Tue Jun 10, 10:38:00 PM, Blogger The Happy Hospitalist said...

he just waisted your time and his

At Tue Jun 10, 10:40:00 PM, Anonymous Anonymous said...

I think his brother was in my office this morning. Ai yi yiiiiii!

At Wed Jun 11, 12:59:00 AM, Anonymous Anonymous said...


I feel your pain. Need some of that Ativan yet??

At Wed Jun 11, 01:33:00 AM, Anonymous Anonymous said...

So why did you refill the meds?

At Wed Jun 11, 02:05:00 AM, Blogger Rogue Medic said...

When was the last time you gave a doctor accurate information?

About 4 years ago.

At Wed Jun 11, 06:06:00 AM, Blogger Evil Transport Lady said...

When did you develop severe brain damage?

4 years ago.

~head desk~

At Wed Jun 11, 08:21:00 AM, Blogger Resident Anesthesiologist Guy (RAG) said...

"Uppity doctors...wanting to know about all this unimportant stuff. That's for me to know, and you to find out".

I feel your pain, only slightly, but I've had a couple encounters like that as well.

Personally I'd like to know what the blockage is now - 4 years later - after not taking their Lipitor.

At Wed Jun 11, 10:59:00 AM, Blogger Rogue Medic said...

Now the blockage is in the carotids and the blockage is 100%.

At Wed Jun 11, 11:20:00 AM, Anonymous Anonymous said...

When you ask a patient what their medical problems are, what is their definition of a medical problem?

To many people, it's defined as whatever reason brought them to the doctor that day, or whatever issues they have that aren't adequately controlled.

If someone has hypertension and it's adequately controlled with medication, does that constitute a medical problem? What about surgery or treatment or major diagnoses in the past? If the problem has been fixed, isn't it by definition no longer a problem?

Do you see where I'm going with this? Doctors and patients often don't speak the same language or have the same understanding of what's important to know.

And maybe sometimes patients with lengthy histories don't want to drop the whole truckload on you right away. Maybe it helps them feel less overwhelmed about their health if they can approach it in bits and pieces.

Just sayin.' ;) Someone has to be the devil's advocate and it might as well be me.

What kind of surprises me is that this patient has all these medications but hasn't seen a primary care doctor in four years. Whoever your predecessor was, he/she didn't do a very good job of explaining to this person why they needed to take their medication or following up to ensure the patient didn't fall through the cracks.

I know it's frustrating to have these encounters, but from my point of view, it's a good thing this patient found you.

At Wed Jun 11, 02:41:00 PM, Anonymous Anonymous said...

I remember this scenario well. Unfortunately, patients do know what doctors think is "important." Once in a blue moon, a patient will show up with a neatly-written problem list and med list, and I am tempted to kneel down and kiss their feet.

Good for you for getting all that history out of him.

At Wed Jun 11, 05:57:00 PM, Anonymous Anonymous said...

This also argues for a shared medical record and an online medical home so you (and the orthopedist, rheumatologist, and cardiologist) can all be on the same page and the PCP can coordinate the care.

At Wed Jun 11, 07:49:00 PM, Blogger Lynn Price said...

"When was the last time you had your sanity checked?"

"About 4 years ago. I'm certifiable."

"Is there anything else?"

"No. That's all." .... "Oh! I forgot; I'm supposed to wear a straightjacket at all times."

At Wed Jun 11, 09:20:00 PM, Anonymous Anonymous said...

Straightjacket? Do you have an extra one for me?

At Wed Jun 11, 09:46:00 PM, Blogger Mike said...

Anon 11:20... why do you assume the previous primary doc didnt do a good enough job of explaining why the patient neede dto take the meds. Its obvious to me the person is not interested in listening to the primary. He's more impressed with the Cardiologist and Rheumatologist. And I'm sure THEY coudlnt explain it well either, right?

When are patients supposed to take responsibility for their own health. I suppose if the guy had a stroke, it would be the previous primary's fault because he didn't explain how treating his BP was important to prevent a stroke, right. Please. And here's the world's smallest violin playing just for him.

At Wed Jun 11, 11:14:00 PM, Blogger Doc said...

Sounds like the next prescription should be for Aricept.
And the next question should be: May I speak with your spouse?

At Thu Jun 12, 09:20:00 AM, Blogger Artemis said...

At least you got SOME information - I hate it when the response is "it's in the computer system, just look it up" but the patient has been referred by a doc who isn't in our hospital network and can't seem to grasp that we are UNABLE to "look it up"...

Hang in there!

At Thu Jun 12, 10:32:00 AM, Anonymous Anonymous said...

From Mike: Anon 11:20... why do you assume the previous primary doc didnt do a good enough job of explaining why the patient neede dto take the meds. Its obvious to me the person is not interested in listening to the primary.

Dude... you're assuming too.

We're only hearing one side of the story here.

At Thu Jun 12, 11:38:00 AM, Blogger Evan said...

This is why I frequently review the med list before I even start the appointment with the CC. It makes most everything else make more sense anyway. I know it's not open-ended but it establishes the situation of the PMH a little more clearly to allow me to think properly about the CC. I will ask a different set of questions about cough if someone is on lisinopril, for example, than if they're not.

At Thu Jun 12, 01:39:00 PM, Blogger CrankyProf said...

Ah, the doctor's office...where the question, "Are you on crack?" may or may not be rhetorical...

At Thu Jun 12, 01:49:00 PM, Blogger Rogue Medic said...

If your doctor is on crack, you should probably switch to a different, less excitable, doctor. :-)

At Thu Jun 12, 09:49:00 PM, Anonymous Anonymous said...

Good job getting all that info. Are you also a dentist? 'Cause that was like pulling teeth.

word verification: icnplzu
I can please you? Really?

At Fri Jun 13, 10:26:00 AM, Anonymous Anonymous said...

Wow. A doctor who actually asks questions. Doesn't that violate the First Law of Medical Practice, which is that "Nothing which the patient knows that the doctor doesn't know could possibly be of the slightest interest or value to the doctor" ?

At Sat Jun 14, 06:30:00 PM, Blogger Kim said...


I learned the hard way to ask patients in triage what meds they were on BEFORE I asked their problems because once they are on meds (or had their bypass or their appendectomy or hysterectomy) they consider the problem solved!

Then I can work backwards from the meds to the dx!

Thank god my hair is thick, or I'd look like Sinead O'Connor back in the '90s!

At Sat Jun 14, 08:06:00 PM, Blogger Joeymom said...

I always feel bad when I get asked abut medicines because I always forget the albuterol inhaler. I haven't used it in years, but still, I have one for a reason... and the doc might want to know about it...

At Thu Jul 03, 05:43:00 AM, Blogger Leigh said...

Or then again, sometimes it happenes like THIS (I'm the patient here):

Going to see rheumatologist#2 about weird arthritis-y thing that's already cost me both knees and is now attacking ankles and lower spine. Orthopedic surgeon has wielded hypodermics, saw, hammer, and screwdriver with panache, but has no idea what we're looking at other than it's not RA or lupus, it's fast-moving, and it's Not a Good Thing. Rheumatologist#1 has punted.

Sit down and make a nice spreadsheet: every surgery, every medication, every major symptom for the last twenty years. Relax, folks, it's only little over a page long, the (probably) relevant stuff is only the past three years, and it's nice and concise in with dates, symptoms, surgeries and illnesses, and meds in labeled columns. I just didn't want to forget anything that might be a clue to aid diagnosis of weird arthritis-y thing, you see.

Print it out and proudly present it to rheumatologist, along with all prior lab work. She ignores my spreadsheet, glances briefly at lab work, feels my knees (artificial, yet hot), and after five minutes total office time, prescribes . . . an antidepressant. An NSRI, plus a caveat that I'm obviously not depressed, but still . . . and, oh, by the way, I also have fibriomyalgia, she says. News to me.

I take the NSRI as prescribed for over a month, and it doesn't do a damn thing but make me very sleepy. All the time.

I'm still my chipper and busy self, still pissed off by the pain and swelling but bashing on regardless. But since I was on the tail end of insurance coverage and the rheumatologist was my last shot at a diagnosis, weird arthritis-y thing is now mine own to have (forever) and manage (I hope).


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