Twice this past week I find myself somewhat at a loss to see a way forwards for the folks on the other side of the desk. We appear to have strayed into “irresistible force vs. immovable object” territory and I’m not a all sure how we are going to negotiate it. Allow me to illustrate.
Case one:- “Loose lips….”
Enter Brad’ and Ange’ (names as ever changed to protect the …. you all know the rest). Ange’ had her three yearly cervical cytology done a few weeks ago and the result wasn’t exactly normal. There’s a whole argument to be had about the merits of the whole cervical cytology screening programme, but that’s not for here. The point was that her result, for the first time since she began the screening some fifteen or so years ago, was “abnormal” and showed “borderline changes” in the cells. According to guidelines we need to repeat the sample in six months and if all is well she can move on without the need for intensive investigations, but in the meantime she has to live with the ticking time-bomb of “abnormality”.
And then some Smart Alec at work says to her, “Of course that’s caused by a sexually transmitted disease you know!”
So Ange’ rushes home in an histrionic fervour, beards Brad’ in his lair and starts demanding “How could you?”
The upshot, an attendance to the Ambridge Surgery. We go over the whole Cervical Cytology- HPV- Cellular changes- Cervical Cancer, discussion, but in all honesty our grasp of the precise natural history of this process if hazy at best. They have been together for years, but both had partners before committing to one another, and Brad is quite prepared to swear on all that is holy that since then he has been happily monogamous. Now I accept as a male GP I might be unwittingly biased, but his body language, and indeed the mere fact that he has attended with her on the day, leave me inclined to believe him.
We discussed the fact that despite their long term commitment, should the anomalies in her cells prove to be related to HPV infection, that doesn’t automatically call her man’s fidelity into question, but Ange’ remains visibly unreassured. In the end I have to suggest they seek help from a relationship counsellor as this one chance remark has caused such an apparent rift.
Case 2:- “Love me love my cats”
Sid comes to the chest clinic. He has a cough that has been going on for years. It’s worse when he tries to run, and it’s been deteriorating since Joelene bought her kittens a few years back. He’s tried all sorts of inhaler regimes down the years and none quite gets the job done. So now he’s convinced it isn’t asthma he’s got at all. After all surely the inhalers would have kicked in by now. (I keep telling him not to call me Shirley!)
O.k. so they help him after a run, and they reduce the cough to a minor irritation rather than a constant nuisance, but really if it were asthma they’d have sorted it out by now, Shirley?
We go trough the history again. We look at his peak flow readings, before and after inhalers again. All point to the inescapable conclusion that he has obstructed airways, that get better with inhaler treatment.
In short, Asthma.
Worse yet, it sounds highly likely that Sid has an allergy to the little bundles of fluff that are now full grown cougar wannabes, who lord it about the house, lolling over sofas and beds, shamelessly indulged like the child substitutes they so plainly are by the otherwise empty nested Joelene. When we have the temerity to suggest we test Sid for cat allergy he ruefully shakes his head—“She’s already told me the cats aren’t going”.
So we try another asthma treatment.
I wonder, is Kofi Annan busy right now?