By HANS DUVEFELT
Medication and allergy lists seem to be the most important part of a medical record to keep up-to-date and accurate. But we all see mistakes too often.
I think it shouldn’t be possible to get into an allergy without describing the reaction. Because without this information the list becomes completely useless.
The other day I saw a patient who needed an urgent CT angiogram. The allergy list read ‘All Contrast Materials’, which is not even ‘structured data entry’, and so is not recognized by the computer if my EMR (Me again, Greenway!) computed tomography.
After much research, the “allergy” in this case turned out to be a multitude of non-specific chronic symptoms after multiple CT lumbar myelograms over a short period of time many years ago.
Some people claim to be allergic to penicillin because “it never works”. Others list ciprofloxacin or sulfa drugs as they get a yeast infection after taking them. Others were mildly nauseous after their first dose of an SSRI like fluoxetine or tired after starting gabapentin.
Some symptoms listed as allergies are poorly understood. For example, morphine causes itching in many patients, and even skin manifestations like reddening and sweating. But it’s usually not a histamine-mediated symptom, or an allergy. Other opioids, like hydromorphone, tend to have a lower risk of itching.
Cough caused by ACE inhibitors is not a true allergy, but we often note it in our allergy lists. People suffering from this side effect can safely switch to angiotensin receptor blockers, ARBs.
Angioedema due to ACE inhibitors is a serious allergic reaction with a significant risk of cross-allergy also due to ARBs. It is therefore essential to distinguish between the two in our lists of allergies.
One of the few things specialists look for in us is a history of medications and allergies. They often ignore and repeat the tests we had done, for example. But a good allergy story is something we can and should try to collect for every patient.
The big challenge is that patients often don’t remember the details of their allergies or side effects years after the fact. So, principle number one is to carefully note new reactions when we hear about them.
My personal tip with new patients with long lists of declared allergies is to ask, “Are you almost dead from any of these drugs that I see listed as allergies?” This is the first step in a reality check of the true extent of their allergies.
The other list we could do better with is the LIST OF PROBLEMS. Since we switched to electronics, it has gained momentum and become much less useful than before. I just reread a post I wrote about it eleven years ago.
Hans Duvefelt is a rural family physician born in Sweden in Maine. This article originally appeared on his blog, A Country Doctor Writes, here.