Patient guide

What happens at the first visit?

The doctor asks when the problem started, what symptoms you have, what conditions you have had and which medicines you take. Then the doctor examines you and, based on that, may ask for tests or imaging. In many internal medicine conditions, the full picture does not come from the first visit, and the doctor gives an opinion after seeing the test results. This follow-up is part of the work.

What documents should you bring?

• Identity card and insurance card (if you have one)
• Test results and reports of earlier ultrasounds, heart tracings (ECG) and imaging. Bring the paper itself and, if you have it, the film or disc. Old results are useful too, because they show the trend.
• A list of your medicines. The names of all medicines, supplements and herbal remedies, with the dose and the times you take them each day. It is best to bring the boxes or photos of the labels. The MedlinePlus source also recommends carrying a list of all your medicines, vitamins and supplements.
• Your blood sugar or blood pressure notebook, if you measure at home
• A discharge summary or file from the hospital, if you have been admitted
• Allergies to medicines and foods
• Family history: diabetes, high blood pressure, heart disease, thyroid or liver disease

If you do not have something, do not worry. The doctor will say what is needed.

What should you write down for the doctor?

Before the visit, jot down a few lines:

• What is your main problem, and when did it start?
• What makes it better or worse?
• In recent weeks, have your weight, appetite, sleep, energy or bowel habit changed?
• What has become hard in your daily life?
• What worries you most?

What questions should you ask?

• What is my problem and what caused it?
• Which test or check is needed, and why?
• When will we see the result, and what happens if something is abnormal?
• If a medicine is prescribed: what is it for, how and for how long should I take it, what side effects does it have, and what should I do if I miss a dose? (These are the questions MedlinePlus suggests.)
• What is my target for blood sugar, blood pressure or blood fats?
• When is the next follow-up needed?
• Which symptoms mean I should get in touch sooner?

Write the questions down and make notes of the answers. Bringing a family member also helps; MedlinePlus suggests the same.

A few tips

• If you are also going to have a blood test, ask the clinic whether you need to fast.
• Do not stop your usual medicines without the doctor’s instruction, even for a visit or a test.
• If you did not understand something, ask again. A repeated question is not a nuisance.
• If you have symptoms from the emergency list (the guide “When should I call urgently?”), do not wait for the visit.

Why do we have tests?

A blood test is one of the main tools of an internal medicine doctor, because many long-term conditions (high blood sugar, blood fats, thyroid problems, fatty liver, anaemia) have no symptoms at first. A test is only one piece of the picture. The doctor reads it together with your symptoms, examination and history.

Before the test

• Fasting. Not all tests need fasting. Some, such as blood fats, may. The MedlinePlus source says a cholesterol test may require fasting for 9 to 12 hours, and the doctor says whether it is needed. Always follow the instructions of the doctor or laboratory.
• Medicines. Ask the doctor beforehand about medicines on the day of the test, especially diabetes medicines and insulin. Do not leave out a medicine on your own. If you are fasting and take a diabetes medicine, be sure to ask what to do before the day of the test.
• Tell them everything. Food and drink, medicines, supplements and heavy exercise before the test can change the result (MedlinePlus).

After the test: how to read the number

• On the result, a “reference range” is written next to each number. This range comes from testing a large group of healthy people, and each laboratory may have a different range. So compare the number with the range on that same sheet, and look at the unit too (for example mg/dL).
• The MedlinePlus source says healthy people sometimes have a result outside the range. On the other hand, a result inside the range is not a guarantee of health. So the number alone does not tell the whole story.
• To see the trend, it is best to have tests done at the same laboratory.
• Bring the results to your visit and ask the doctor what they mean for you. Do not leave the interpretation to the internet or messaging apps.

What do common tests say?

This list is only an introduction, not a diagnostic guide:

• HbA1c and fasting blood sugar. The CDC source gives the cut-offs like this: HbA1c below 5.7% is normal, 5.7 to 6.4% is prediabetes, and 6.5% or higher is in the diabetes range; fasting blood sugar of 99 mg/dL or lower is normal, 100 to 125 is prediabetes and 126 or higher is in the diabetes range. HbA1c shows the average blood sugar over the past two to three months. The diagnosis is made by the doctor.
• Blood fats. For adults, MedlinePlus writes total cholesterol below 200 and LDL below 100 mg/dL as “healthy”, and says the right target differs with age, family history and risk factors. Ask the doctor for your own target.
• Liver enzymes (ALT, AST, ALP) and bilirubin. MedlinePlus says abnormal results do not always mean a liver problem, and the doctor looks for the cause.
• Blood cell count (CBC) and haemoglobin. MedlinePlus says changes can relate to anaemia, dehydration, infection or other causes, and do not always mean disease.
• TSH. The brain hormone that controls the thyroid. A high value points to an underactive thyroid and a low value to an overactive one. The source says serious illness, age over 80 and the first three months of pregnancy change it, so go over the number with the doctor.

When should you not wait?

A result outside the range is not necessarily an emergency. But if it comes with serious symptoms (chest pain, shortness of breath, vomiting blood, confusion, very high or very low blood sugar with feeling very unwell), do not wait for a visit, and see the guide “When should I call urgently?”.

Why measure at home?

A clinic reading is just one moment. The CDC source says that because blood pressure changes through the day, the doctor may ask for several readings or for home monitoring with a validated device. Measuring blood sugar at home helps in the same way: it shows the trend, not just one number. But it is not a substitute for a visit.

Blood pressure

The device. Use a validated device. For home monitoring the CDC mentions a “validated device”. It is best to take your device to a visit so the doctor or nurse can compare it with the clinic device. Devices differ; read the instructions for yours.

The method. For home measurement the NHS source says: usually twice a day, morning and evening. Each time, take the reading, write the number down, wait one minute and take it again. The doctor or nurse says how many days to continue. For clinic measurement the NHS advises resting your arm on a table and relaxing it. Ask the doctor, nurse or pharmacist about other details (for example how long to rest beforehand, and cuff size) and read the device booklet.

The numbers. You see two numbers, for example 130 over 80. The NHS counts 140/90 or higher in the clinic and 135/85 or higher at home as high; the CDC starts at 130/80. The sources differ, and the doctor sets your target. One high number on its own does not mean much; repetition and pattern matter.

What to note. The date, time, the two blood pressure numbers, the pulse (if the device gives it) and how you felt (after coffee, after climbing stairs, with a headache). Bring the notebook or sheet to your visit.

When to call urgently? The CDC says that if blood pressure is above 180 and/or 120 and you have symptoms such as chest pain, shortness of breath, weakness or numbness, a change in vision or difficulty speaking, it is an emergency; call 115 (the emergency number in Iran). Even with no symptoms, tell the doctor straight away.

Blood sugar

If you have diabetes, the doctor or diabetes team tells you when and how often to check your blood sugar. This plan depends on the type of medicine, the type of diabetes and your circumstances. The sources read give no fixed schedule for everyone, so do not set the number of checks yourself.

• The device. A finger-prick blood sugar meter or, if the doctor has prescribed it, a continuous sensor. NIDDK says that sometimes the sensor result needs to be confirmed with a finger-prick, for example when you doubt its accuracy or it raises an alert.
• Important times. NIDDK says to check blood sugar before, during and right after physical activity, because blood sugar may fall hours or even days later, especially in people who use insulin or some oral medicines. This warning is not the same for every patient; ask the doctor.
• What to note. Date and time, the number, the time of food and medicine, activity, and any symptoms of feeling unwell. The downloadable report from continuous sensors can also be shown to the doctor.
• Low blood sugar. If the number is below the level the doctor gave you or you have symptoms (shakiness, cold sweat, confusion), have fast-acting sugar straight away and measure again. More is in the guide “When should I call urgently?”. NIDDK says that for many people a level below 70 mg/dL counts as low, but each person’s threshold may differ.

What to do with the doctor

• Bring the numbers to your visit along with the device, so its accuracy can be checked.
• If the numbers are repeatedly far from your target, do not wait for the next visit; get in touch.
• Do not raise or lower your medicine based on your home numbers. Changing a medicine is for the doctor alone.

Why does this matter?

Diabetes, high blood pressure, thyroid conditions and blood fats usually need long-term treatment. A medicine works when it is taken properly. If you stop a medicine or change its dose yourself as soon as you feel better, or because you are worried about a side effect, the condition may get worse again or a new risk may appear.

Do not start, stop or change the dose of any medicine without talking to the doctor. This rule is the same for diabetes tablets and insulin, blood pressure medicine, thyroid medicine and all others. The MedlinePlus source says that if you have a side effect, do not stop without telling the doctor; you may need a different dose or a different medicine. The NIDDK source also says of thyroid medicine: never stop without talking to the doctor.

The medicine list

Keep a list of everything you take and carry it in your wallet or on your phone (MedlinePlus):

• Prescribed and over-the-counter medicines, vitamins, supplements, herbal remedies and herbal distillates
• For each one: the name, what it is for, what time and how (before or after food)
• Allergies and side effects you have had before

Show this list at every visit and every time another doctor or a pharmacy gives you a medicine. If you have several doctors, each needs to know what the other has prescribed.

When starting a new medicine, ask the doctor or pharmacist

• The name of the medicine and why it is taken
• How and at what time to take it, before or after food, and for how long
• What side effects are possible and which ones should make me get in touch
• Does it interact with the medicines, supplements, foods and alcohol I use?
• What should I do if I miss a dose?
• Is a follow-up test needed? When?

This is the list that MedlinePlus suggests. Write down the answers, and if you can, bring someone with you.

A few practical points

• One place and one time. For regular use, a pill box with the days of the week or a phone reminder can help. If you are not sure it suits you, ask the pharmacist.
• Over-the-counter medicines. According to the NHS, painkillers such as ibuprofen and aspirin can make indigestion worse, and should not be taken regularly without telling the doctor and pharmacist, especially if you have high blood pressure, kidney disease or a stomach ulcer.
• Herbal remedies and supplements. The NIDDK source says some herbal remedies can harm the liver. Tell the doctor before taking one.
• Side effects. If a medicine causes discomfort, do not stop it; tell the doctor or pharmacist. There may be a simple solution.
• A medicine for blood pressure or thyroid, when the test result has become normal. This means the medicine is working, not that it is no longer needed. The decision to continue is the doctor’s.
• Follow-up tests. Some medicines need regular tests. For example, the NIDDK source mentions follow-up tests for thyroid medicine after starting and after every change.
• Running out of a medicine. Make an appointment before it runs out. If for any reason you cannot get a medicine (cost, shortage), contact the doctor so another option can be given; do not stop it yourself.

When should you call?

• If you are confused about how to take a medicine, you have a side effect, or the shape of your tablets or the medicine the pharmacy gave you is different from usual (MedlinePlus).
• If you have felt worse since starting or changing a medicine.
• If you develop emergency signs (the guide “When should I call urgently?”), call 115 (the emergency number in Iran).

One point before you start

No food or supplement is a “definite cure” for diabetes, high blood pressure or fatty liver. The NIDDK source says there is no clear evidence that any particular food or supplement manages diabetes, and that you should talk to the doctor before taking any supplement. The right eating plan for you depends on your medicines, age, weight, kidneys and other conditions. If you use insulin or some diabetes tablets, a change in food or activity can lower blood sugar too far; talk to the doctor before making a big change.

Food: what the sources share

The sources agree on these points:

• Vegetables, fruit, whole grains, pulses. The World Health Organization recommends at least 400 grams of fruit and vegetables a day for adults.
• Less salt. The World Health Organization says less than 5 grams of salt a day. The NHLBI gives a sodium goal of 2,300 mg a day and says 1,500 mg lowers blood pressure even more.
• Less sugar and fewer sweet drinks. The WHO says free sugars should be under 10% of daily energy. NIDDK suggests drinks without sugar, such as water. Fruit juice and fizzy drinks also raise blood sugar.
• Less saturated fat and processed food.
• Portion size. NIDDK gives the “plate method” as an example: half the plate non-starchy vegetables, a quarter high-fibre starchy food (such as brown rice, pulses, whole grains) and a quarter protein.

Diabetes. Carbohydrate raises blood sugar, so count fruit, pulses and potatoes too. If you do not inject insulin, according to NIDDK the plate method may be enough. The NHS says not to start a very strict, very low-calorie diet without advice from a specialist. Cut down on alcohol; with insulin or some medicines it can lower blood sugar.

High blood pressure. The DASH diet, according to the NHLBI, takes in more vegetables, fruit, whole grains, low-fat dairy, fish, poultry, pulses and nuts, and less saturated fat, sweets and sweet drinks. The portion numbers vary with daily calories.

Fatty liver. NIDDK says losing 3 to 5 percent of body weight reduces liver fat, and sometimes 7 to 10 percent is needed for inflammation. Weight loss should be gradual; rapid loss and malnutrition make the liver worse.

Reflux. Triggers differ from person to person, and not eating in the hours before bed helps (see the condition page “Digestive problems”).

Activity

• How much. The World Health Organization recommends at least 150 minutes of moderate activity a week for adults, and stresses that any amount of activity is better than none. For diabetes, NIDDK gives the same 150 minutes (about 30 minutes on most days), resistance training about twice a week, and balance and stretching exercises two or three times a week. The NHS also gives 150 minutes for high blood pressure, diabetes and fatty liver.
• Starting. If you have been inactive for a long time, start slowly and ask the doctor before a new programme. Balance exercises may be risky with nerve damage or poor eyesight.
• Diabetes and exercise. NIDDK says to check blood sugar before, during and after exercise (especially with insulin or some medicines), wear suitable shoes and look at your feet after exercise. Water is usually enough, and sports drinks contain a lot of sugar and calories.
• Older adults. The WHO page read for this guide gives no separate figure for people over 65. The doctor or a physiotherapist decides the programme that suits your age, joints and conditions.

When should you stop exercising?

Stop if during activity you have chest pain or pressure, unusual shortness of breath, dizziness or fainting, or signs of low blood sugar. If the chest pain or shortness of breath is severe, call 115 (the emergency number in Iran).

First of all

In Iran the emergency number is 115. If you see any of the signs below in yourself or someone else, call straight away. Do not wait for a clinic appointment, and do not drive yourself; the sources advise this too, because an ambulance can start treatment on the way. During the call stay calm, give the exact address and, if you can, note when the symptoms started.

If you are not sure a sign is serious, do not be afraid to call. Judging it is the job of the emergency staff, not you. This list is not complete and is not a substitute for an examination.

Heart attack

Common signs:

• Pain, pressure or heaviness like squeezing in the centre or left of the chest, lasting a few minutes or going away and coming back
• Pain or discomfort spreading to one or both arms, the shoulder, neck, jaw, back or upper stomach
• Shortness of breath (sometimes before the chest pain)
• Cold sweat, light-headedness or feeling faint, nausea or vomiting, a feeling like indigestion
• Pale skin, or blue or grey skin

In women, older people and patients with diabetes the signs may not look like this. According to the CDC, women are more likely to have unusual and unexplained tiredness, nausea or vomiting, sometimes without clear chest pain. MedlinePlus says these groups may have little chest pain or none, and instead have shortness of breath, tiredness and weakness; a “silent heart attack” with no symptoms also happens. NIDDK says patients with diabetes who have diabetic nerve damage may not feel chest pain at all. So sudden severe tiredness, shortness of breath or new weakness, especially in people with diabetes and in women, is worth a call. Do not put persistent chest pain down to heartburn.

What to do: Call 115. Sit down, lean on something and stay calm. If the person becomes unconscious and is not breathing, start chest compressions (CPR) until help arrives, if you are trained. Do not start any medicine without the instruction of a doctor or the emergency operator.

Stroke

Sudden signs, according to the NHS and CDC:

• Face: one side of the face has dropped or the smile is lopsided
• Arm: weakness or numbness in one arm; cannot hold both up
• Speech: slurred or confused speech, difficulty finding words or understanding
• Vision: blurred or lost vision in one or both eyes
• Balance: dizziness, falling, being unable to walk
• A sudden severe headache, with or without nausea and vomiting
• Weakness or numbness on one side of the body, sudden confusion and memory loss

What to do: Call 115 at once. Note when the symptoms started; according to the CDC, the time helps choose the treatment. Call even if the signs go away after a few minutes. The NHS says to get medical help straight away even if the signs fade. Do not take the patient to hospital yourself.

Very low blood sugar (severe hypoglycaemia)

Low blood sugar happens in diabetes (especially with insulin or some tablets). Signs: shakiness, cold sweat, hunger, a pounding heart, dizziness, confusion, blurred vision, headache, slurred speech. The NIDDK source says that for many patients a level below 70 mg/dL is low, but each person’s threshold differs and you should ask the doctor. Very low blood sugar can lead to loss of consciousness and seizures, and is dangerous.

• Awake and able to swallow: have fast-acting sugar straight away (fruit juice, a sweet drink, glucose tablets or gel). After 10 to 15 minutes (NHS), check blood sugar again and repeat until it is back in the target range. If the next meal is a long way off, have a snack.
• Unconscious, having a seizure, or unable to swallow: do not give food or drink. Lay the person on their side (recovery position) and call 115 at once. If glucagon has been prescribed for the person and someone is trained, use it as trained. The NHS says to get emergency help if there is no glucagon, if there is no improvement after 10 minutes, or if the person has drunk alcohol. Stay with the person until help arrives.

Very high blood sugar and diabetic ketoacidosis

High blood sugar sometimes leads to ketoacidosis, which is an emergency. According to the NHS the signs are: thirst, passing a lot of urine, stomach pain, nausea and vomiting, diarrhoea, breathing deeper than usual, a fruity or nail-polish-remover smell on the breath, drowsiness or confusion, and blurred vision. It usually develops over about 24 hours, but sometimes faster.

If these signs come with high blood sugar, or you are confused or drowsy, or you have not been diagnosed with diabetes before, call 115 at once. The NHS says to go to emergency care too if blood ketones are above 3 mmol/L (or urine ketones above 2+). If ketones are only a little raised and you feel unwell, contact your diabetes team straight away. Do not drive yourself.

Digestive bleeding

Signs:

• Vomiting blood: bright red blood or material like coffee grounds
• Black, tarry stools or stools with blood

MedlinePlus says gastrointestinal bleeding is a sign of conditions such as a stomach ulcer, haemorrhoids, or inflammation of the oesophagus or bowel, not a disease in itself.

Call 115 at once if you vomit blood or have black, tarry stools, especially if you feel very unwell, confused, dizzy, or pale and sweaty, you are breathing fast and shallowly, or you have stomach pain (NHS). The same goes for severe stomach pain or sudden chest pain along with these signs. If the vomiting of blood has stopped and you have no other signs, the NHS says you still need to see a doctor urgently, the same day. Do not drive yourself.

Severe shortness of breath

According to the NHS, call 115 at once if:

• you are gasping, choking or cannot speak
• your chest is tight or heavy, or pain spreads to the arm, back, neck or jaw
• your lips or skin have turned pale, blue or grey
• you have suddenly become confused

MedlinePlus also says sudden or severe shortness of breath that stops you breathing and speaking is an emergency. The cause may be the lungs, the heart, anaemia or something else; making the diagnosis is not your job.

Contact the doctor (not the emergency service) if shortness of breath has got worse during ordinary activities or when lying down, your ankles are swollen, or you have had a cough for more than three weeks.

Very high blood pressure

According to the CDC, blood pressure above 180 and/or 120 together with chest pain, shortness of breath, numbness or weakness, a change in vision or difficulty speaking is an emergency, and you should call 115. Even with no symptoms, contact the doctor straight away.

If you are not sure

Call the emergency number and explain. For a non-urgent question, call the clinic. Ask the doctor at the clinic about the warning signs specific to you. Keep your list of medicines and conditions to hand so it can be used in an emergency.