The worried well

Fabio Capello had his 'Munich Moment' last night. Astonishingly, England somehow managed to thrash Croatia in Zagreb. They beat a team ranked 5th in the world and who had never lost at home in a competitive fixture. The night brought back memories of the famous night in September 2001, when England thrashed Germany. Once again, an England striker scored a hat-trick, the first since that very game in Munich.

I and many others gave up on England after their shocking and inept performances in the 2006 World Cup and this was further compounded by their disappointing failure to qualify for Euro 2008. However, if somehow they can turn the tide and put in more performances like last night, then hope shall prevail. Getting way ahead of myself, Spain were the worthy winners of Euro 2008, 44 years after they last won a major trophy. Who will also have gone 44 years without a major trophy come the World Cup in 2010? England. Let's hope they qualify first.

Last week I mentioned that I wanted to talk about a few amusing patients that I had encountered. Working in sleepy Buckingham, I get to see my fair share of patients who I like to call 'the worried well'. These are people who have too much time on their hands and come to see a doctor because they have nothing else to do. They come with simple and mundane problems, simply desiring reassurance.

One such patient came to see me last week. A man in his 40's cycled in for his appointment. He complained about having back pain. He described it as a muscular ache which only occurred at night whilst he was sleeping. He worked as a gardener and had no problems with lifting, bending or stretching his back during the day. This had been going on for over six months.

The pain would wake him up and he would then be unable to sleep because of the constant aching. When he got out of bed in the morning it would slowly ease and then he'd be fine for the rest of the day. He hadn't taken any painkillers because "I don't like them unless I know what they are for" and he was using a hard mattress, which was going to be changed to an orthopaedic mattress shortly. When I examined his back, he pointed to where it was tender at night, but right then it was fine. There was no pain and he displayed a full range of movement of his back.

People often joke with me, that all I do is prescribe painkillers (specifically paracetamol), but honestly in this case what would you do? I suggested he wait and see if the new mattress makes a difference and to try a painkiller in the night when he wakes up with the pain. I explained that in all likelihood it was a muscular problem, potentially caused by his hard mattress and to wait and see if the painkillers help. "Ah, yes, I thought it might be that. I'll try the painkillers in the night then." If he knew what the problem was, then why not try painkillers himself?

Another person I saw was a gentleman in his late 50's. He came with three problems that he had been "saving up" for me. He had pain in his left shoulder, pain in his left knee and pain in his right ankle. This had be ongoing for the past 2 months. He worked as an oil tanker driver, spending large amounts of time behind the wheel and then having to lift heavy barrels across his shoulders and having to spend a lot of time kneeling under his truck to access the connection system. With that history, what do you think I did?

Like most people, he hadn't taken any painkillers, nor had he tried to rest and take some time off. Understandably he was not in a position to do so financially, but I tried to explain that his pain is a direct result of his occupation and that he needed to take some rest, take some painkillers and allow his body to heel. He didn't seem surprised about this information, "I expected you to tell me that doctor." I then re-iterated the importance of getting some rest and taking painkillers and advised him on the rules of self-certification for taking time off. He left assuring me he would get some rest - but after the appointment I felt what was the point?

Lastly, I saw an eccentric lady this week who wasn't so much 'worried well', but more 'unworried ill'! She came to see me to discuss her cholesterol-lowering medication. "I want to reduce them, because I had a brain haemorrhage recently." That immediately triggered alarm bells in my head. I spoke to her about the haemorrhage that she casually threw into the conversation. Back in March she woke up with a severe headache "as if I had been hit by a cricket bat," and came to see one of the GPs. Rightly concerned about the possibility of a subarachnoid haemorrhage (which presents with a sudden onset of a severe headache - like being hit by a bat), the GP referred her to hospital.

At the hospital she had a CT scan which was clear, but she also needed a lumbar puncture to be certain that she hadn't suffered from a brain haemorrhage. She decided to self-discharge, claiming that no-one had explained to her the seriousness of her condition and she was fed-up of waiting in hospital. Her headache continued for the rest of the week and she also developed numbness and weakness in her right arm for a month or so. More recently, she also had another episode of a severe headache about two weeks ago. So, here was a patient who most likely had suffered with a bleed in the brain, but was carrying on as normal.

I explained to her to gravity of the situation and she was quite surprised by the seriousness of it all. She assumed because her weakness had resolved and her headaches had cleared, she was OK. It was why she didn't come to see a doctor afterwards either. Most galling of all was the fact that the hospital did not even inform the surgery about what had happened. The GP who saw her should have followed up what happened, but nonetheless it was the hospitals responsibility to ensure that the practice was informed.

I've urgently referred her to a consultant neurologist and I hope that she hasn't suffered any permanent damage. In all honesty, she should be OK, often with these types of haemorrhages, the blood is self-absorbed which is why her symptoms improved slowly, but there can be lasting damage. I'll wait and see.

What type of patient do you think you are? Are you the 'worried well' or the 'unworried ill'? Let me know in the comments section.

Take care all,
Thoughts just flow, when do they have to make sense?