17. Nhập viện do giới thiệu

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Mr. Aguilera injured himself with a saw and five days later went to his doctor with presenting symptoms of jaw discomfort. It is more than years since his last tetanus booster and the patient has no significant medical history. There were also no significant findings from a physical examination of head and neck and his lungs were clear.

The diagnosis was "tetanus with secondary wound infection" so the wound was cleaned and hydrogen peroxide applied. The patient's doctor referred him for an overnight stay in hospital for observation.

After the treatment was explained to him, the patient signed a form which gave his informed consent and he was given anti-tetanus immunoglobulin. He responded well and there were no side effects or complications. The patient said that because he was a vegetarian, he had special dietary requirements and should not eat hospital food. Also, he lived with his mother who is severely disabled, with hearing difficulties, and needs round-the-clock care. Mr Aguilera asked to be discharged and Dr Hashim gave his authorization.

Letter of referral
Re patient: Michael Marcuccilli, 21 years of age

To:Dr. J.K. Nayar

I'm referring to you for assessment. He is suffering from attacks of palpitations and breathlessness.

The patient is a student. He has suffered from anxiety since he was 13. He came to me 6 months ago. He expressed fears about having heart disease, because his brothers and his father have heart conditions.

When things are going badly, he eats too much. Consequently he is overweight with a BMI of 32, which partly explains his breathlessness. Urine analyses indicate the onset of type 2 diabetes. He said that he had gained weight as a result of the shock of losing his part-time job. It brought on severe palpitations, hyperventilation, and panic attacks.

In the past the patient has been treated with the antidepressant Lofepramine, even though there are no clear symptoms of depression. It is possible that weight gain and tiredness are side effects of the antidepressants.

Other physical symptoms include joint pains, chest pains, muscle pains and dizziness.

He is receiving Diazepam 2 mg t.d.s for anxiety. Because he has a history of asthma, I have not tried beta blockers.

Yours sincerely

a. Yes, Mrs Oswald, there are medications available, but they will only control your symptoms, they won’t get rid of the problem. Psychotherapy takes much longer, but it can sometimes cure. The third choice is ECT —electro-convulsive therapy. Many people are against it, but it can be highly effective and some patients, who have tried everything else, say it is the only thing to shine a light in their darkness.
b. There can sometimes be bleeding with a biopsy, Mr de long. This is because an incision has to be made. We have to cut it open and get a sample of the tissue. There can be bleeding, but that’s rare — about one in every two thousand. There’s also a small danger of infection, but we do our best to prevent this.
c. There is now no doubt that it’s cancer and a hysterectomy — the surgical removal of your uterus — is the best chance for survival. We can’t cure it so it’s best to cut it out. We feel it’s the best treatment option at this stage; better than radiation or chemotherapy.
d. I have to give you a local anesthetic. Do you know what that is? No. Hussein, could you help me here? I want you to explain to your mother that I want to give her something to make her eye numb so that I can get this thing out of her eye. Explain this to her, make sure she understands, and ask her if it’s OK. Tell her that I’m not going to use a needle, but she must keep very still.
Polite phrases
Nurse : I've forgotten your name.
Mrs Stein : It's Mrs Stein.
Nurse : Of course, Mrs Stein. Give me your letter of referral.
Mrs Stein : Here it is.
Nurse : Thanks. So, Mrs Stein, you've come in for removal of varicose veins?
Mrs Stein : Yes. The operation is this afternoon.
Nurse : Confirm one or two things. First, are you on any medications?
Mrs Stein : Yes, I take Venlafaxine.
Nurse : What's for?
Mrs Stein : I take it for depression.
Nurse : OK. Now, tell me about your lifestyle. Report any alcohol or drug problems you have.
Mrs Stein : None, I don't drink and I don't take drugs.
Nurse : Also, tell me if you have had any contact with HIV in the past six months.
Mrs Stein : I haven't had any contact with HIV, no.
Nurse : Fine, and who's paying for treatment?
Mrs Stein : I'm covered by medical insurance.
Nurse : Great, and lastly, you must take off your make-up and your rings.
Hippocrate, the "father of medicine", would not have agreed with the idea of "consenting to treatment". He thought that giving information to patients was harmful, and advised doctors to ‘conceal most things from patients, turn their attention away from what is being done to them, and reveal nothing of their future or present condition’.
Do you think there are ever times when it is necessary to lie to patients or not tell them certain things?
My consultant once took a man who had been complaining about waiting to the resuscitation room and showed him five beds full offive exceedingly ill patients, and demanded to know: ‘Which of these five people would you like me to boot out so we can urgently deal with the lump on your wrist?’
Dr Michael Foxton Confessions of a Junior Doctor