Question the Meds

In my practice I try to apply some common sense, adopting a colleagues’ phrase “common things are common”.

This is particularly useful in the diagnosis of new problems that have eluded diagnosis, and I apply a lesson learned from a fellow resident (a PharmD before med school) who told me: new problems, ask about new meds.

So, if my patient has some new problem as part of the history (when did this start) I’ll follow up with ‘any new medications, or change in your meds, around then? (This is often fruitless despite the time investment to go through the meds, the list, then ‘when did that medication start’ conversations, but it’s time well spent).

Many times the reason the patient gets dizzy on standing is the new BP medication, or a BP med that has dehydration as a mechanism stacked onto decreased oral intake…

I’ve made a couple of good diagnoses recently, and it was directly because of questioning the timing of the new meds and the new symptoms, one patient with their second trip to the ED for an unexplained metabolic acidosis (who was taking a seizure med that said ‘metabolic acidosis’ as a known problem with it), so making the call to the pt’s doc for a re-admission and oh-by-the-way I believe the problem is this med that causes this problem. Nice way to have an admitting doc think you know what you’re doing…

Metformin causing diarrhea is a med-school diagnosis, so why it took the med student following me to make it I don’t know, but the patient and family were thrilled to have a reason for their debilitating symptoms. (Thanks, unnamed MS4!)

There are some others, but you get the message: temporally relating new meds then new symptoms, common things are common, and always question the medications.


Comments

  1. This is the bread-and-butter of what neurologists do, every time we’re asked to see someone with some kind of change in behavior. It can be easy, it can be hard. One problem is learning how to decode the PDR. There are so many vague symptoms that are reported with almost every medication that you can’t fall into that trap. What do you do when everything the patient is taking can cause that, and while it’s easy to incriminate the last prescribed medicine, sometimes it’s the fact that the last one was like the straw-camel’s back problem rather than THE cause. So it usually takes a little delving into the depths of the PDR and getting a sense of frequency, intensity, and maybe even googling a bit.

    The other big problem is that now that everyone has internet access, often the patient or a family member just absolutely knows what the problem is, and cannot be convinced that they’re not correct. So you find yourself drifting into the Socratic method sometimes to talk them through it (but, of course, sometimes you don’t have to, because they’re right).

  2. CardioNP says:

    I had a great MD preceptor when I was a newbie NP. She routinely looked at new meds as a cause of new conditions, so I got into the habit of evaluating new meds early in my NP career.
    The case that really cemented this was a pt w/ AMS, new hyponatremia – his psychiatrist had just started Wellbutrin.
    He got admitted, Wellbutrin D/C’d and his Na improved and sx resolved.
    I prefer Micromedex to the PDR or Epocrates for looking up med interactions/side effects.

  3. I live and work in Thailand and here I find most any medication is drastically overprescribed. The cause, doctors are paid a seriously substandard salary and the pharmacy at the hospital is the number one profit center. So take my 4 year old into the hospital (most doctors work out of a hospital here) for a bit of a fever and a runny nose and they will try and write a half dozen prescriptions of antibiotics and steroid creams. I am a big believer in “If you don’t need it, don’t take it” So a lot of prescriptions don’t get filled out. Fortunately to date the little guy has only had to take antibiotics for scarlet fever. He is still talking about the strawberry on his tongue. As an example last week there was HFMD going through his school, he of course got it, wife insisted on taking him to the doctor and he came home with a bag of antibiotics. They are working away in the septic tank, the spots are gone and my little champ is terrorizing as normal. Anyways, I think sometimes if someone is a rational person and and has all this information at our fingertips, it can be a very good thing.