(1994; 115 pages) [French] [Spanish]
Chapter 6. STEP 1: Define the patient's problem
A patient usually presents with a complaint or a problem. It is obvious that making the right diagnosis is a crucial step in starting the correct treatment.
Making the right diagnosis is based on integrating many pieces of information: the complaint as described by the patient; a detailed history; physical examination; laboratory tests; X-rays and other investigations. A discussion on each of these components is outside the scope of this manual. In the next sections on (drug) treatment we shall therefore assume that the diagnosis has been made correctly.
Patients’ complaints are mostly linked to symptoms. A symptom is not a diagnosis, although it will usually lead to it. The following five patients all have the same complaint, a sore throat. But do they all have the same diagnosis? Let's look at them in more detail.
Exercise: patients 3-7
Define the problem for each of the following patients. The cases are discussed below.
Man, 54 years. Complains of a severe sore throat. No general symptoms, no fever, slight redness in the throat; no other findings.
Woman, 23 years. Complains of a sore throat but is also very tired and has enlarged lymph nodes in her neck. Slight fever. She has come for the results of last week's laboratory tests.
Woman student, 19 years. Complains of a sore throat. Slight redness of the throat; but no fever and no other findings. She is a little shy and has never consulted you before for such a minor complaint.
Man 43 years. Complains of a sore throat. Slight redness of the throat; no fever and no other findings. Medical record mentions that he suffers from chronic diarrhoea.
Woman, 32 years. Very sore throat, caused by a severe bacterial infection, despite penicillin prescribed last week.
Patient 3 (sore throat)
The sore throat of patient 3 probably results from a minor viral infection. Perhaps he is afraid of a more serious disease (throat cancer?). He needs reassurance and advice, not drugs. He does not need antibiotics, because they will not cure a viral infection.
Patient 4 (sore throat)
Her blood test confirms your clinical diagnosis of AIDS. Her problem is completely different from the previous case, as the sore throat is a symptom of underlying disease.
Patient 5 (sore throat)
You noticed that she was rather shy and remembered that she had never consulted you before for such a minor complaint. You ask her gently what the real trouble is, and after some hesitation she tells you that she is 3 months overdue. Her real concern had nothing to do with her throat.
Patient 6 (sore throat)
In this case, information from the patient’s medical record is essential for a correct understanding of the problem. His sore throat is probably caused by the loperamide he takes for his chronic diarrhoea. This drug may produce reduced salivation and dry mouth as a side effect. Routine treatment of a sore throat would not have solved his problem. You may have to investigate the reason for his chronic diarrhoea, and consider AIDS.
Patient 7 (sore throat)
A careful history of patient 7, whose bacterial infection persists despite the penicillin, reveals that she stopped taking the drugs after three days because she felt much better. She should, of course, have completed the course. Her problem has come back because of inadequate treatment.
These examples illustrate that one complaint may be related to many different problems: a need for reassurance; a sign of underlying disease; a hidden request for assistance in solving another problem; a side effect of drug treatment; and non-adherence to treatment. So the lesson is: don't jump to therapeutic conclusions!
Example: patient 8
Man, 67 years. He comes for his medication for the next two months. He says that he is doing very well and has no complaints. He only wants a prescription for digoxin 0.25 mg (60 tablets), isosorbide dinitrate 5 mg (180 tablets), furosemide 40 mg (60 tablets), salbutamol 4 mg (180 tablets), cimetidine 200 mg (120 tablets), prednisolone 5 mg (120 tablets), and amoxicillin 500 mg (180 tablets).
This patient states that he has no complaints. But is there really no problem? He may suffer from a heart condition, from asthma and from his stomach, but he definitely has one other problem: polypharmacy! It is unlikely that he needs all these drugs. Some may even have been prescribed to cure the side effects of another. In fact it is a miracle that he feels well. Think of all the possible side effects and interactions between so many different drugs: hypokalemia by furosemide leading to digoxin intoxication is only one example.
Careful analysis and monitoring will reveal whether the patient really needs all these drugs. The digoxin is probably needed for his heart condition. Isosorbide dinitrate should be changed to sublingual glyceryl trinitrate tablets, only to be used when needed. You can probably stop the furosemide (which is rarely indicated for maintenance treatment), or change it to a milder diuretic such as hydrochloro-thiazide. Salbutamol tablets could be changed to an inhaler, to reduce the side effects associated with continuous use. Cimetidine may have been prescribed for suspected stomach ulcer, whereas the stomach ache was probably caused by the prednisolone, for which the dose can probably be reduced anyway. It can also be changed to an aerosol. So you first have to diagnose whether he has an ulcer or not, and if not, stop the cimetidine. And finally, the large quantity of amoxicillin has probably been prescribed as a prevention against respiratory tract infections. However, most micro-organisms in his body will now be resistant to it and it should be stopped. If his respiratory problems become acute, a short course of antibiotics should be sufficient.
Box 5: Patient demand
A patient may demand a treatment, or even a specific drug, and this can give you a hard time. Some patients are difficult to convince that a disease is self-limiting or may not be willing to put up with even minor physical discomfort. There may be a 'hidden' psycho-social problem, e.g. long-term use and dependence on benzodiazepine. In some cases it may be difficult to stop the treatment because psychological or physical dependence on the drugs has been created. Patient demand for specific drugs occurs most frequently with pain killers, sleeping pills and other psychotropic drugs, antibiotics, nasal decongestants, cough and cold preparations, and eye/ear medicines.
The personal characteristics and attitudes of your patients play a very important role. Patients' expectations are often influenced by the past (the previous doctor always gave a drug), by the family (the drug that helped Aunt Sally so much), by advertisements to the public, and many other factors. Although patients do sometimes demand a drug, physicians often assume such a demand even when it doesn't exist. So a prescription is written because the physician thinks that the patient thinks... This also applies to the use of injections, or ‘strong drugs’ in general.
Patient demand for a drug may have several symbolic functions. A prescription legitimizes a patient's complaint as an illness. It may also fulfill the need that something be done, and symbolize the care of the physician. It is important to realize that the demand for a drug is much more than a demand for a chemical substance.
There are no absolute rules about how to deal with patient demand, with the exception of one: ensure that there is a real dialogue with the patient and give a careful explanation. You need good communication skills to be a good physician. Find out why the patient thinks as (s)he does. Make sure you have understood the patient's arguments, and that the patient has understood you. Never forget that patients are partners in therapy; always take their point of view seriously and discuss the rationale of your treatment choice. Valid arguments are usually convincing, provided they are described in understandable terms.
Your enemy when dealing with patient demand is time, i.e. the lack of it. Dialogue and explanation take time and you often will feel pressed for it. However, in the long run the investment is worthwhile.
Patients may come to you with a request, a complaint or a question. All may be related to different problems: a need for reassurance; a sign of underlying disease; a hidden request for assistance in solving another problem; a side effect of drug treatment; non-adherence to treatment; or (psychological) dependence on drugs. Through careful observation, structured history taking, physical examination and other examinations, you should try to define the patient's real problem. Your definition (your working diagnosis) may differ from how the patient perceives the problem. Choosing the appropriate treatment will depend upon this critical step. In many cases you will not need to prescribe a drug at all.
STEP 1: Define the patient's problem
- Disease or disorder
- Sign of underlying disease
- Psychological or social problems, anxiety
- Side effect of drugs
- Refill request (polypharmacy)
- Non-adherence to treatment
- Request for preventive treatment
- Combinations of the above