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Medrx

THE INTERVIEW

Recording a patient's medical history
When I record a patient's history, my intentions are to find out:
1.what the symptoms are
2.how severe the condition is
3.what the possible causes are
4.whether there has been a psychological impact.

Finding out what the symptoms are
My approach to all patients at our initial meeting is blunt. I get straight to the point. I usually begin with a brief introduction, such as, 'Hi, Mr Jones, nice day, isn't it? Now, is your problem more getting and sustaining an erection or premature ejaculation?'
Sometimes I am even more blunt: 'Hi, Mr Jones. So your problem is getting and sustaining an erection. How long have you had this problem?'
Usually, the patient is extremely relieved to hear the problem stated so directly and simply. It's as if a great weight has been suddenly lifted from their shoulders. In most instances they are thinking, 'How does he know that I have this problem?'
The direct approach has proven to be the most effective for my consultations. I have tried other more circuitous questioning in the past, such as: 'So, Mr Jones, what seems to be the problem?' This is usually followed by evasive answers with spluttering and stuttering and long drawn-out descriptions of what he thinks may be the problem. What's more the response is often a rehearsed one that has been memorised and gone over in his head for days in anticipation of my question.
Once the initial formality between doctor and patient is broken, there's no stopping the patient from expanding on the problem. They want to get it all out—months and months and sometimes even years of anguish. When I relate the experiences of a previous patient, the reaction is instant recognition of their own problem and an even greater release of anxiety.
Some of my patients have already approached their general practitioners or a psychologist before they come to the clinic. They are sometimes misinformed with comments such as, 'You're too old to be thinking about that sort of thing', or 'It's all in your mind', or 'You've been with the same woman for thirty years now, so how do you expect to remain attracted to her?' This kind of consultation can have very negative results and sometimes produces even greater depression for patients. Some men may simply give up, making no further effort to overcome their problem. Those few who do eventually seek a second opinion and are given more reassuring advice will respond very positively.

*23\4*

ZINC

CAUTIONARY NOTE ON HERBS

Natural medecine

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EPILEPSY AND PREGNANCY

Women with epilepsy are quite often concerned about getting pregnant. There appear to be five reasons for this concern. They wish to know:
if they are likely to hand their epilepsy on to their children;
whether their fits will get worse during pregnancy;
whether it is safe for the baby that the mother should take anticonvulsants drugs during pregnancy;
if there will be any problems in the newborn baby from these drugs;
if they can safely breast feed the baby.
With regard to handing on epilepsy to one’s children – as mentioned earlier, if one parent has epilepsy, the chances of one of the children having epilepsy are no greater than in the population at large. If both parents have epilepsy, it would appear that the risk of a child having epilepsy is about 10 per cent. So in fact the chance of a child inheriting epilepsy, particularly idiopathic epilepsy, is negligible.
As far as seizures during pregnancy are concerned, the situation is not as clear as it might be. There is evidence that for some women, seizure control may deteriorate, while for others there may in fact be no change or even an improvement. A patient told me recently that “she would like to remain pregnant forever” as she had not had a single fit during her pregnancy, compared with six fits in the preceding nine months!
As a general working rule, it is suggested that people who have more than one grand mal fit a month are those who are most likely to have a deterioration in seizure control during pregnancy. The deterioration, if it occurs, is most likely during the first three months of pregnancy. There are a number of theories why this may happen, but none has been proved. It may be of value to check the blood anticonvulsant levels during pregnancy, especially if there is a deterioration in seizure control. The blood levels may fall, necessitating an increase in dosage during the pregnancy.
The main concern for parents is whether the anticonvulsants can harm the unborn baby (foetus). It is known by most people with epilepsy that this is a potential hazard. The effects include physical abnormalities in the baby, a process known as teratogenesis. Abnormalities have been reported in the offspring of mothers on all the commonly used anticonvulsants with the exception of carbamazepine. This is particularly applicable to phenytoin, barbiturates and sodium valproate. Babies born to mothers who have been on carbamazepine have not been shown to have any physical abnormalities, but have a smaller head size than other babies. This has not been shown to be any handicap to the babies who have been followed up for five years.
The risk of abnormalities in the baby is difficult to assess, but it seems to be most common in mothers on polytherapy (receiving numerous drugs), especially if they are on three or more anticonvulsants. The risk in mothers on phenytoin, with or without other medications, appears to be about a 10% chance of the baby showing features of the ‘foetal hydantoin’ syndrome. This syndrome consists of cleft palate, abnormalities of the fingers, possible heart abnormalities and mild mental retardation. Thus, at present, if it is possible, it would seem wise to try to change patients over to carbamazepine before conception. This may not be possible in all patients and, of course, many women will first visit their doctor when already pregnant, at which time there is no purpose in making the change.
Anticonvulsants taken by the mother during pregnancy may have some effects on the baby immediately after birth, as they are transmitted to the baby across the placenta. These include the possibility of a mild bleeding tendency and some drowsiness. In mothers who have been taking barbiturates, the infant may occasionally show features of a withdrawal reaction with irritability, jitteriness and poor sucking. None of these features is [...]

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