All in a day’s work

Andrea Priestley

doi:10.3399/bjgp14X680617

Another duty doctor day and some blood tests have been received, faxed for urgent attention. They reveal hypothyroidism and renal dysfunction. Further enquiry into the notes introduces me to a 74-year-old Asian lady who had seen my colleague recently with general malaise and tiredness. The laboratory has run further tests and panhypopituitarism is suspected in view of a low random cortisol and low FSH. The books tell me that panhypopituitarism can present insidiously. Its prevalence and incidence are low and in a practice of 10 000 there may be just three or four patients with this condition.

Clearly immediate action is needed so I call her at home. She does not answer the telephone so I decide to visit. It is 3.30pm and I have an hour until urgent surgery starts. I receive a warm welcome from her son with whom she is now living. She has recently arrived in the UK having been persuaded by her son to move in with him. She had been working until only a few years ago as a teacher to the young and old in India. Despite the language barrier she conveys a strong sense of herself, coupled with a gentle spirit. She is mildly hypertensive but there are no visual disturbances. Her son shares his great concerns about his mother’s health and her deterioration over the past year as well as her reluctance to seek medical attention.

And so to sharing the news, through a distressed son to a lady who holds a humble respect for life and our human passage through it; for whom, as it transpires, medical tests are not the be-all and end-all. Nevertheless she holds a deep respect for the medical profession. Time is ticking and my urgent surgery beckons. Yet I am struck by the need for care and respect in sharing this news accurately and in seeking her informed decision regarding the next steps.

The obvious answer would be to accept the offer of a confirmatory blood test tomorrow morning and take the hydrocortisone tablets; to accept the endocrinology referral, MRI head scan, and further blood test monitoring and thyroid replacement in due course. That would be the textbook management. But people are not textbook cases. This is a lady with deeply-held beliefs of her place in the world.

And so we come to an agreement, a shared decision. She accepts the hydrocortisone tablets and will see me in a couple of weeks. Through her son’s interpretation skills she impresses upon me that she does not wish to slip towards further unwanted tests. I accept this, hoping she will feel better with the medication and gain faith in me and the treatment offered.

Happily she comes to see me a month later feeling much improved. She accepts the addition of levothyroxine but continues to decline further tests or a hospital review. After 6 weeks she is delighted to tell me how well she feels. She is able to enjoy walks once again and no longer requires a daytime sleep. Her appetite has improved and she doesn’t feel so cold. She agrees to a meeting with the endocrinologist and the MRI scan. The MRI scan showed no tumours but an unexpected subdural haemorrhage. This was thought to have resulted from a fall some weeks before she received her hormone replacement therapy; an indirect consequence of then undetected panhypopituitarism.

My unease over the lack of blood monitoring has lessened with time and she has recently agreed to annual thyroid function tests. She is a sensible lady who prefers to be guided by her symptoms. It has been a privilege to gain her trust and to see her improve with treatment.