Danger of reading between the lines with GP letters

Q I am undergoing tests at my local hospital, and in the letters about my condition they send to my GP, both the doctors I have seen have referred to me as a “pleasant man” at the start. Why do they do this? Someone told me it was a euphemism for middle class. They also said if a doctor writes you are delightful, they are being sarcastic. Is that true? A In a word, no, it isn’t true. In the dim and distant past, the letters sent by hospital doctors to GPs were not seen by patients and may have contained derogatory language. But for many years now that has changed, especially as patients should receive a copy of their outpatient letters.

There are strict guidelines about how they should be written, so they should be factual, easy to understand and polite.

It could be argued that including descriptive terms such as “pleasant” or “delightful” is unnecessary, but these are complimentary and it does convey to the GP the hospital doctor felt the consultation went well – and believe me, this is often not the case!

So please, rather than looking for a hidden meaning, take them at face value, and be proud that the doctor found you to be so pleasant. Q I’m 56, and for years have had intermittent bouts of diarrhoea. I’ve had blood tests and had my stools checked for both blood and inflammation on several occasions but nothing has ever shown up. I also had a colonoscopy a few years ago and that was normal too, so I was told I had irritable bowel syndrome. I’ve tried excluding various foods and that hasn’t made any difference, so I’ve just been living with the fact that some days I keep needing to dash to the loo. Recently I read about someone with similar symptoms who turned out to have microscopic colitis, so I’m wondering if this is what I have and, if so, how do I get a diagnosis? A In microscopic colitis the wall of the large intestine (the colon) becomes inflamed. This can lead to bouts of watery diarrhoea, sometimes with abdominal pain, cramps or bloating.

However, unlike other forms of colitis, such as Crohn’s disease or ulcerative colitis, blood and stool tests are often normal and, when the colon is viewed by a camera during a colonoscopy, the bowel wall lining looks normal.

Diagnosis can only be made when a biopsy – a tiny sample of tissue from the colon wall – is taken and sent to the laboratory for analysis. It’s a condition that is most common in people aged 50 to 70 and more likely to occur in women than men.

Those with auto-immune diseases, such as thyroid disease, rheumatoid arthritis or psoriasis, are slightly more at risk.

Some studies have suggested certain medications, such as non-steroidal anti-inflammatories like ibuprofen, antacids and SSRI antidepressants, may also be linked to the condition.

Once the diagnosis has been made, microscopic colitis can usually be treated with the oral steroid budesonide, which is taken at a relatively high dose for six to eight weeks, then slowly tapered off.

If these do not help, then more powerful immunosuppressant drugs can be used. Microscopic colitis was a relatively unknown condition until recently and has almost certainly been under-diagnosed in the past as it was not common practice to take biopsies from a normal-looking colon when a colonoscopy was done.

So, it would be worthwhile contacting your GP to ask if you can be referred for another colonoscopy, when biopsies will be done.

Q

I’m 81 and have been treated for high blood pressure for years. I started on one medicine, then a couple of years ago a second was added. The dose of that gradually increased, then six months ago a third pill was included. I’m also on a statin.

Recently, I’ve felt lightheaded when I get up in the morning and a bit dizzy, so wondered if I was on too many pills. When I checked my blood pressure on the machine in the surgery reception, it was normal and I was told to drink plenty of fluids when I get up. That hasn’t helped, so what do I do? I don’t want to be a nuisance, but I’m worried I’m going to fall over. A I wonder if you have a condition known as postural hypotension. Normally when you stand up, blood pools in the legs, which reduces the blood flow to the heart and triggers a fall in blood pressure.

Special receptors in the aorta normally detect this immediately and trigger a reflex action to increase the tone in the leg veins, which corrects the blood pressure within seconds.

However, if this reflex mechanism is impaired in any way then the fall in blood pressure is more sustained and can lead to feeling lightheaded and dizzy. This can be caused by drugs used to treat high blood pressure, especially if several different types are used, and tends to occur more in those over 80 (it’s thought around 25 per cent of people in your age group who are on treatment for high blood pressure have postural hypotension).

People with other underlying conditions, such as diabetes and renal disease, are also at higher risk.

It can be diagnosed by checking your blood pressure when lying down, and then after standing up for a minute.

Blood pressure is given as a reading of two numbers: systolic, the top figure, is the force at which your heart pumps blood around your body. The lower measurement, diastolic blood pressure, is the resistance to the blood flow in the vessels between heartbeats.

When you stand up, if the top measurement is 20mm mercury lower than when you were lying down, it’s likely you have postural hypotension.

Treatment usually involves slight alterations in medication, either reducing the dose or switching to a long-acting version, which your GP can do.

Lifestyle modifications can help too, such as getting up from lying or sitting to standing very slowly and then standing still for a while. And make sure you drink plenty of water to avoid becoming dehydrated.

Staying active and keeping muscles strong are also important in helping to reduce your fall risk, so try to do some exercise every day as well.