My first ward round after returning from holiday was “challenging”. Special Care Baby Unit was full. Twin boys, 3lbs each, born four weeks early when their mother developed malaria, looked like wizened, tiny old men. A two week old baby who had needed help with breathing in the local hospital; when it looked hopeless (and the bill had exceeded £650) the machine was turned off, but the baby survived and was discharged to our unit. The baby’s mother is now having trouble producing milk because of lack of suckling for the past fortnight. This is her first baby, perhaps we could encourage lactation using drugs. Is she going to be able to afford to buy formula milk? Another baby with fever, one with hyperbilirubinaemia (neonatal jaundice), another with an infected umbilicus. Problem solving with best guess therapy.
When we moved on to the in patient ward, I was surprised to hear that a middle aged female patient was suffering from depression. It had been only three weeks since I did a teaching session introducing the nurses and medics to mental health problems, and now they were diagnosing depression. Sure enough, the physical symptoms were present, tiredness, difficulty sleeping, poor appetite, lassitude, dizziness. Dizziness seemed a bit strange, but different cultures often have different terms to describe their symptoms. “Heavy neck” is common here, for example. But dizziness with depression? It didn’t seem to fit.
What about her other symptoms? She was sad, miserable and felt there was something wrong inside her belly. “So you admitted her for depression?” I asked. “No, for high blood pressure following a miscarriage ten days ago,” replied the nurse. I started to explain that symptoms of depression commonly occur following loss or bereavement, and this is natural. I was just getting into my pompous stride explaining about adjustment disorder when the medic said, “But she didn’t want the baby. She already has five children and wants to be sterilised.”
Then I took a look at her medication chart. High doses of a beta blocker had brought down her blood pressure from 160/100 to normal levels. But the side effects of this medication were responsible for her physical symptoms. I hope we can control her essential hypertension with a different drug, without giving her a different set of side effects.
It’s tricky, practising medicine in a different culture, being unable to speak the language fluently. You don’t get a comprehensive picture of the clinical situation at first, just a snapshot. If this seems reasonable, you agree with the management plan and move on. But if something strikes you as strange, not in keeping with the usual pattern of symptoms and signs for a condition, you switch from intuitive to hypothetical-deductive mode. To do this, you need to get more of the story, more background. It’s a bit like being Sherlock Holmes. I just wish the diagnosis/solution turned out to be “elementary” more of the time.