By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 2: In the elderly patient, actively inquire about non-prescription medication use (ex: herbal medicines, cough drops, over-the- counter drugs, vitamins).
Skill: Clinical Reasoning
Key Feature 6: As part of the ongoing care of all immigrants, inquire about the use of alternative healers, practices, and/or medications (ex: ‘‘natural’’ or herbal medicines, spiritual healers, medications from different countries, moxibustion).
Skill: Clinical Reasoning
I am going to jump back to a case I was involved with in medical school because it is my best illustrator of the importance of actively inquiring about nonprescription medication use.
In my third year I met an elderly man who was admitted to hospital by my attending physician for hyponatremia and not coping well at home. His wife had been out of the province visiting family for about a month, and he came to the Emergency Department because he was just feeling unwell. I won't use this case to explore hyponatremia, partly because I cannot even remember what the diagnosed etiology was for it in his case, but mostly because it more effectively highlights another skill in medicine, the importance of obtaining a good medication history.
When I met this patient on the ward, he had been admitted a day or two ago, and was responding well to the treatment for his hyponatremia. Things seemed fairly uncomplicated and the plan for discharge was that he would likely go home in another day or so. Then things took a turn. The patient began having nausea and vomiting, complained of just feeling sick all around, and his blood pressure was pretty rapidly trending down. What the heck could've happened in the hospital to make him so sick so fast? He didn't have any signs of infection and the therapy he was receiving would have been highly unlikely to cause these signs and symptoms as side or adverse effects. I was unsure of what was going on here, so I returned to the basics: ABCs (he was still stable for now so I moved on) and a good clinical assessment. I reviewed his history very thoroughly with him, looking for any clues I could find to detect a possible reason for the turn in his medical status.
While I was not the person who did the admission consult for this patient, I imagine they did a good job of inquiring about medications, both prescription and over-the-counter. But as I was gathering the history from this gentleman, on review of the medications he was taking at home, he noted that there was something additional he had been taking for the past 20 years for rheumatoid arthritis, something he was getting shipped up from a doctor in Mexico. He didn't know what it was, but it worked better than anything else he tried here in Canada so he continued to have it sent up. My bet is that he may not have mentioned this medication to the person who took his admission history, perhaps because he thought it was not relevant to say, perhaps because he did not want to say he was taking a medication from a doctor in Mexico, or perhaps for another reason or two. In any case, we now knew there was another medication he had been taking at home and the indication for why he was taking it. This, combined with his cluster of signs and symptoms in hospital, led the attending physician and I to think it was possible that this medication from Mexico contained a glucocorticoid, and so we began empirically administering glucocorticoid therapy for presumed glucocorticoid withdrawal. He responded well. He stopped feeling unwell and his blood pressure returned to normal. Fortunately, the patient had a son who lived nearby who was able to go to the patient's house and collect the medication for us, which confirmed his medication from Mexico was prednisone. This was a case of glucocorticoid withdrawal and it happened because of a medication that was not on his list of prescribed medications. This case emphasised for me the importance of actively inquiring about nonprescription medications. While this is certainly important on review of all patients' medications, this is particularly relevant with elderly patients as they are more likely to be using multiple medications than younger patients. A review of prescription medication use by Statistics Canada reports, "Reflecting a well-established association, prescription drug use rose with age from 12% among 6- to 14-year-olds to 83% among 65- to 79-year-olds" based on data from 2007-2011 (Statistics Canada, 2015).
In the patient encounter, whenever taking a history, it is always relevant to briefly review what medications a patient is taking. And if a patient is having any new concerns, always consider whether this could be a medication side or adverse effect (just like if a patient has a history of chronic disease you have to wonder - whenever there is a new presenting complaint - if it could be a sequela or exacerbation of chronic disease, or if it is a new unrelated concern). If this is a patient being seen in followup, it can be as brief as asking if there are any changes in the medications they have been taking at home since the last visit, and if they've started anything new from another health care provider or anything over-the-counter such as vitamins or herbal supplements. I also think this is a great opportunity to review if there are other treatment modalities the patient is benefitting from, such as physiotherapy or counselling. In any case, some patients may not wish to share with their doctor that they are trying unconventional or not traditional Western medical treatment. Perhaps for fear of physician disapproval, or simply because they compartmentalise Western medicine as treating the physical body and other medicine as treating the spiritual self, or for a slough of other reasons. So, it is important to inquire about the use of alternative therapies in a nonjudgmental way. After I've reviewed with patients the medications they are taking, I further say something along the lines of, "Many patients use over-the-counter medications, vitamins, herbal supplements, or seek treatment for medical issues directly from different health care providers. Is there anything else you have tried to manage your symptoms?" My hope is that this normalises the fact that many patients are seeking treatments beyond that provided by the physician, and that they then feel safe enough to share with me if they too are seeking other therapy.