Page 10 - Town & Around - June 2021
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10 Town & Around June 2021                                                          Tel: 01485 540620 email:
       Piles and Tribulations - Notes from a Rural GP

       Dr David Ince, The Burnhams Surgery, Burnham Market
         n an attempt, readers, to try and prove I am not a one trick Covid-  although some patients require hospital admission for both their safety
         Pony, I have made a decision this month to take a break from the   and treatment, it is a treatable condition and once the underlying cause
       Icoronavirus.  And to distract from the pandemicitis and vaccine   has been treated then full recovery of mental function is the rule.  It can
       fatigue that we are feeling I thought I would try and smother this article   be difficult to differentiate between delirium and dementia and some
       in a light hearted non-covid soothing literary balm.   people may have both conditions.
        There will be no statistics, mention of vaccinations, deaths or ITU   Although delirium is caused by a complex interrelationship of patient
       admissions.  Nor will there be syndromes starting with the word ‘long’   vulnerability and exposure to a precipitating factor, in a general practice
       (including but not exclusively covid, Corbyn and John Silver).   setting it is normally either advancing age or the pre-existence of mild
        So what shall we talk about?  What did we used to concern ourselves   dementia which makes the patient vulnerable to delirium and then, in
       about before Covid?  I have had a think about the clinical encounters I   90% of my anecdotal experience, the precipitant is one of infection,
       have had over the past few weeks -  The 80 year old with chest tightness   dehydration or drugs (including alcohol).  By far the commonest cause
       having just had heart bypass surgery, the 3 year old with severe   of an elderly patient becoming acutely confused is an infection, typically
       constipation, many itchy rashes, the alcoholic lying on the floor of my   urine or chest.  It is amazing how mentally unwell a previously normal
       consulting room at 10am claiming only to have had one small glass of   older patient can become with a urine infection.  It is disturbing for the
       wine that day, the lady who had suddenly lost vision in one eye, the 25   family and upsetting for the patient but, once treated, there is normally
       year old with a severe headache, the wife of a demented man who had   complete resolution of symptoms.
       become aggressive and had started wandering around the village asking   Anyway, back to the confused man on the home visit.  It wasn’t going
       passers-by to arrange his passage back to India (he is originally from   well.  Having removed my string backed gloves and theatrically opened
       Peckham and has never been anywhere more exotic than Bournemouth),   my Gladstone bag I performed a full examination.  I could find nothing
       a paramedic ringing who was with someone refusing admission, the   wrong with him.  Normal oxygen levels, clear chest, no temperature,
       addict ringing having ‘lost’ their medication.      heart ticketyboo, no signs of a stroke.  I tested his urine – all clear.  He
        The rich tapestry of general practice life is still very much alive.    hadn’t taken any drugs and the drinks cabinet was locked (worst luck as
        One patient sticks out in my mind.  I was telephoned by a lady who   I was parched by this point).  This was testing my technical expertise.  I
       had become increasingly concerned about her acutely confused husband.    was about to throw in the towel and suggest I arranged the big white
       Normally a sprightly octogenarian who I have known for 15 years and   taxi with the blue lights to take him to the hospital when he asked if I
       would normally drive himself to the surgery, over the previous few days   could get the district nurse to look at a pressure sore on his hip that he
       he had become agitated, confused and drowsy.  He wasn’t eating or   had been dressing himself so as not to bother them.  A clue I thought –
       drinking and had taken to his bed.  He wasn’t complaining of any pain   perhaps an infected pressure sore would come to his (and my) rescue.
       and he denied any problems.  So I dusted off the old driving gloves   So I removed the dressing and underneath was a nice, small,
       (string-backed), cranked up the practice Bentley, donned some protective   uninfected pressure sore – no likelihood of this causing the confusion.
       clothing (depressing cotton, washable scrubs rather than the traditional   It was then that I noticed the dressing he had been using.  I asked him
       Harris Tweed of my medical forefathers) and I popped out to see him at   where he had got it, ‘just out the drawer’ was the reply.  The dressing
       home (yes, readers, a home visit – imagine that).   was the perfect size for his small sore but on closer inspection it appeared
        On arrival, he had managed to get up and was sitting in his   to not be a standard dressing.  It looked like a dressing but had some
       conservatory.  He recognised me but was slightly ‘shifty’ (a medical   small writing on it which confirmed that rather than having applied a
       term) and distant – trying to put on a show of normality when clearly he   soothing dressing, he had applied one of his wife’s out of date strong
       was not.  He denied any problems but was confused and unable to   morphine patches which had sat in the drawer since her hip had been
       answer some simple mental assessment questions (as an aside if your   replaced.  We had the answer.  The patch was removed, an appropriate
       GP ever starts asking you who the Prime Minister is or the dates of the   dressing applied and over the next day he returned to his normal self.  I
       Second World War then you are in trouble, if he asks you to take 7 away   returned to the surgery with the remaining morphine patches which I
       from 100 then it is big trouble).                   was tempted to apply to my person and lie down in a darkened
        Acute Confusional State or Delirium was first described more than   consulting room for the rest of the afternoon to recover.  But I didn’t
       2500 years ago – it is derived from the Latin word delirare (deviate from   have time for that as reception rang to say Mrs Friday Afternoon
       a straight track) – and is an acute, fluctuating syndrome of altered   Abdominal-Pain had just rung to say she had developed severe
       attention, awareness and cognition caused by an underlying condition   abdominal pain and could I telephone her back urgently.  It was only
       or event in vulnerable people.  The duration is variable and the degree   Tuesday.
       of severity ranges from mild to very severe.  The good news is that,   I wish you good health.
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