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Previously I posted about a patient who had symptoms of giddiness and vertigo, but turned out to have a heart attack instead.

This time, I saw a patient with 3 episodes of giddiness over one week. He also experienced cold sweat during these episodes. Additionally, he felt physically tired – so much so that he could not walk his usual 2km – he had to stop after half the distance.

When I saw him, he was not terribly distressed but was drenched in sweat. Worried that it might be a heart attack, I advised him to go to the emergency department for further evaluation.

Turns out it wasn’t a heart attack – his X-Ray showed some signs of a chest infection. He had not complained of fever, cough, or breathlessness; his description was more of fatigue – a sense of tiredness and feeling weak. Good thing we had the investigations done for him…

Three patients in a row today with low blood pressure. For sure, they needed to be hospitalized; none of them (or their families) wanted to go. You can see that they understood the gravity of the situation, they nod their heads at the explanations – bleeding from the gut, possible malignancy, infection (sepsis). Their faces did not show much distress or worry. It looked like they had already made up their minds.

I could understand that the elderly lady vomiting blood was reluctant to go because it was near the all important new year holiday season. But I didn’t understand why the lady with severe anemia (of unknown cause) did not want to get it sorted out. The family of the patient* with sepsis decided to keep their options open – wanting to observe the situation and possibly reconsider hospitalization.

With their minds more or less fixed on not going to hospital (that’s why they got me in for a housecall in the first place), convincing them otherwise is very hard. Supporting them with what they want is all that can be done. Injections to stop vomiting (blood), anti-acid medications for presumed gastric bleeding, antibiotics for infection, etc.

I’m not sure what their outcomes might be – whether the families might convince patients to eventually visit the hospital. But we can only do so much. Outcomes can’t be controlled.

*the patient had dementia, and so the family had to decide for him

She passed away in 36 hours, quietly and peacefully at home. The atmosphere in the home was also quiet and peaceful. No panic, no rush, .. just doing what is required. In fact, there was a sense of relief that this happened now, and not during the Chinese New Year season.

The day before, I was called in to see her as she had deteriorated – she had stopped eating and her breathing pattern had changed. She was still alert, opening her eyes and even moving her limbs a little; she reacted when she could hear her husband in the hall.

Her family already knew that her death was impending but needed a professional opinion to confirm this to be the case. Once this was provided, the necessary care and arrangements could follow. There was not much in the way of medical care, as there were no distressing symptoms. It was more a question of knowing and preparing.

Supporting the patient and family in this way is an important role for healthcare professionals. As professionals we often feel the need to do something – prescribe medication, intervene, etc. That is still necessary in many cases, but for this patient (and the family) having the prognosis confirmed was what really mattered.

Physicians don’t take the diagnosis of cancer lightly. In the usual case, thorough investigations are done – blood tests, scans, biopsies, etc. before the diagnosis is made. This is so that subsequent treatment can be planned and optimized for the patient. However, this is not always possible for home care patients, nor is it always necessary.

Two recent patients come to mind.The first patient was in her mid-nineties with a breast lump and enlarged liver – found by examining the patient. She was referred to hospice care and passed away within 3 months. The second patient (also about ninety years old) had a growing patch of discoloration in her mouth (previously biopsied 1 year ago and told no cancer). Similarly, no further investigation was made and she received palliative care at home before passing away in a matter of months.

These patients certainly did not want further investigations to confirm the diagnosis – it was enough to have examined the patient. In fact, home clinical assessment and close follow-up was able to provide a more accurate picture of the second patient’s condition. Neither did they need a hard ‘technical’ diagnosis to guide further treatment – they had wanted to remain comfortable and receive palliative care at home.

In the past when hospital based care was more visible than home care, this way of managing patients (without a ‘hard’ diagnosis) might have been perceived as inappropriate or less than a reasonable standard.  Some physicians may have felt uncomfortable about not having a firm diagnosis in these cases.

But this is all a matter of context. It is about understanding the patient’s situation and needs, rather than having to fulfill technical or organizational needs (and definitions). Going back to basics – hands on examination of patients – may be just the thing that is needed and that provides patients the feeling that they are cared for.

Few days ago, I saw an elderly lady with chest pain, leg swelling and irregular heartbeats. She was staying at home with a helper, the rest of her family being away overseas. Being a foreigner, she was worried about going to the hospital because she wasn’t sure how to handle the paperwork, administration, etc.

Fortunately, her neighbor was at hand to help. In fact, it was this caring neighbor that had arranged for me to visit the elderly lady. She was prepared to help arrange transport, etc. to get the patient to hospital. In this case, she would be getting the help of yet another neighbor!

We eventually persuaded her to be transferred to the hospital where she was then admitted. It was good to see such community spirit, with neighbors pitching in to help each other. One wonders if the patient would have deteriorated, were there no neighbors to help…

I often get called to see patients at home with vertigo (vertigo is a spinning sensation or feeling unbalanced). They’re too giddy to even stand, and so can’t visit the clinic. Most of the time this is usually harmless and gets better with some medications and rest.

Recently, I saw a 60+ year old patient who complained of giddiness and vomiting. He has had previous episodes of giddiness that the doctor diagnosed as vertigo. When I examined him, he was sweaty and his blood pressure was low. He recalled being breathless for the last 2 weeks after suffering from a bout of flu.

Turns out he had a heart attack. He was sent to the hospital and underwent heart surgery in a matter of hours. The give-away was the low blood pressure that should not happen with vertigo. Apart from vertigo, other causes of giddiness that may be potentially serious:

• Low blood pressure
• Heart failure/ Heart attacks
• Strokes
• Migraines

Good to know that there is increased support for patients with dementia and mental health in the community. The condition affects about 40,000 people in Singapore today, but this number is expected to double by 2030 as the population ages.

Indeed, a good number of patients seen on house calls have dementia and mental health issues. These are often challenging and difficult to manage.

http://www.straitstimes.com/singapore/health/increased-aid-to-tackle-dementia-mental-health-issues