Patient guide

What does a first visit usually look like?

The doctor first listens: when the problem started, what makes it worse or better, what illnesses you have had and what medicines you take. Then the doctor examines you. The findings of the examination are put alongside your medical history, your family history and the results of your tests and imaging, and the doctor gives an opinion based on all of this.

For this reason, the first visit does not always lead to a complete diagnosis. Sometimes the doctor asks for tests or imaging and gives a final opinion after seeing the results. This follow-up is part of the work, not a sign that your problem was not taken seriously.

What to bring

• Previous test results and reports, including ultrasound, ECG and imaging. Bring old results too, because they show how things have changed over time.
• A list of all your medicines. The name of every medicine, along with supplements, vitamins and herbal remedies, with the amount and the times you actually take them. If you do not have a list, the boxes themselves or photos of the labels are enough.
• Your blood pressure or blood sugar notes, if you measure at home.
• A discharge paper or hospital summary, if you have been admitted.
• Allergies to medicines or foods.
• Family history: high blood pressure, diabetes, blood fats, heart disease, stroke, kidney or thyroid disease, and the age at which it happened.
• Your ID and, if you have one, your insurance card.

If you do not have some of these, do not put the visit off. The doctor will tell you what is needed.

Write a few lines before the visit

When you have several problems at once, it is easy to forget one of them in the consulting room. Write on paper or on your phone:

• What worries you most?
• When did it start, and is it getting less or more?
• In the last few weeks, has your weight, appetite, sleep, energy or bowel habit changed?
• Which everyday activity has become hard for you?

What to ask

• What is my problem, and what may be playing a part in it?
• What test or check is needed, and why? When will the result be ready?
• If you prescribe a medicine: what is it for, when and for how long should I take it, with food or on an empty stomach, what side effects does it have, and will I need follow-up tests? What should I do if I miss a dose?
• Does this medicine interact with my other medicines, supplements or foods?
• What is my target for blood pressure, blood sugar and blood fats?
• When is the next visit? And which symptom means I should get in touch sooner?

It is best to write down the answers or bring someone from your family so that nothing is missed.

A few small points

• If you are also going to have a blood test, ask the clinic whether you need to fast.
• Do not stop any regular medicine on your own for the visit or the test. If you are worried, ask the doctor or the pharmacist.
• If you did not understand something, ask again. A repeated question is not a nuisance.
• If you have a symptom listed under “When should I call urgently?”, do not wait for the visit.

How does a test help?

Many common internal medicine problems, such as high blood sugar, blood fats, anaemia or thyroid disorders, have no clear symptoms for a long time. A test is one of the ways the doctor sees the body from the inside. But it is only one piece of the picture. The number must be read alongside your symptoms, the examination and your history.

Before the test

• Fasting. Not every test requires fasting. For blood fats you may need to fast for 9 to 12 hours, and for liver tests about 10 to 12 hours. Exactly how long depends on the test your doctor has written. Follow the instructions of the doctor or the laboratory.
• Medicines. Do not stop any medicine on your own. If you do not know whether to take your morning medicine on the day of the test, especially a diabetes medicine, ask the doctor or the laboratory before that day.
• Tell them everything. Recent food and drink, medicines, supplements, heavy exercise and your monthly period can change the result. Tell the laboratory.
• To see the trend, have successive tests at the same laboratory as far as possible.

How do we read a number?

Next to each number a “reference range” is printed. This range comes from the results of a large group of healthy people and differs between laboratories and between age groups. So:

• Compare the number only with the range on the same sheet.
• Look at the unit. Two different tests may have different units.
• Being outside the range does not always mean illness. A healthy person sometimes has a number outside the range.
• Being inside the range does not guarantee that everything is fine either, especially if you have symptoms.
• No test is perfect. If the result does not fit your situation, the doctor may repeat the test.

Take the result to the doctor, even if everything is within the range. Do not leave the interpretation to the internet and messaging groups.

Some common tests

This list is only an introduction and not a diagnosis.

Blood sugar. These limits are used to diagnose diabetes in adults:

• HbA1c (the average blood sugar over the last two to three months): normal less than 5.7%; prediabetes 5.7 to 6.4%; in the diabetes range 6.5% or more.
• Fasting blood sugar: normal 99 mg/dL or less; prediabetes 100 to 125; in the diabetes range 126 or more.
• Blood sugar two hours after drinking a glucose solution: normal 140 mg/dL or less; prediabetes 140 to 199; in the diabetes range 200 or more.

The diagnosis is the doctor’s. Usually one number on its own is not enough, and the test is repeated.

Blood fats. For adults, total cholesterol below 200 and LDL below 100 mg/dL are given as the “healthy” range. HDL below 40 in men and below 50 in women is counted as low, and 60 or more is better. But the target differs for each person: it depends on age, family history and other risk factors. Ask your doctor for your own target. High triglycerides also raise the risk of heart disease.

Liver enzymes (ALT, AST, ALP) and bilirubin. The doctor looks at the pattern of all the numbers, not one number. A change in these tests is not always from the liver, and other illnesses or medicines can also have an effect. A recent illness may also change them temporarily.

Creatinine and eGFR. They show how well the kidneys clear waste from the blood. The creatinine number also depends on muscle mass, diet, dehydration and exercise. A normal result does not completely rule out kidney disease in its early stages, and the doctor sometimes asks for other tests too.

Blood cell count (CBC) and haemoglobin. A change in these numbers may be related to anaemia, dehydration, infection or other causes. Do not decide on a condition from it yourself.

TSH. A hormone from the brain that tells the thyroid how hard to work. A high TSH usually points to an underactive thyroid, and a low TSH to an overactive thyroid. This test shows that the thyroid may have a problem, not its cause. Severe non-thyroid illness, age over 80 and the first three months of pregnancy also change TSH.

When not to wait for a visit

A test outside the range is usually not an emergency. But if it comes with chest pain, shortness of breath, vomiting blood, confusion or feeling very unwell, go to the section “When should I call urgently?” and, if needed, call 115 (Iran’s emergency number) immediately.

Why measure at home?

High blood pressure usually has no symptoms, so the only way to find out is to measure. Blood pressure rises and falls during the day, and in the clinic it is sometimes higher than at home because of the stress of the visit. The doctor may ask you to measure at home for several days to confirm a diagnosis or to see the effect of treatment. Measuring at home does not replace a visit; it only completes the picture.

Blood pressure at home

The device. Choose a digital device with an upper-arm cuff. Wrist and finger devices are less accurate. The cuff must fit firmly on the arm and not be too small. Take the device to the clinic once and ask the doctor or nurse to watch your method and compare the reading of your device with the clinic’s device.

Before measuring

• Empty your bladder.
• For 30 minutes beforehand, do not eat, and have no tea, coffee, cigarettes or exercise.
• Sit quietly for at least 5 minutes; 10 minutes is better.

While measuring

• Lean back against the chair, with the soles of your feet on the floor and your legs not crossed.
• Rest your arm on a table so that it is level with your heart.
• Roll up the sleeve so the cuff sits on bare skin, with its lower edge about 2.5 cm above the crease of the elbow.
• Do not talk or move.
• Take 2 or 3 readings each time, a minute apart, and write down the time.

How many days and at what time? A common method is to measure for 5 days in a row, each day in the morning before breakfast and in the evening before dinner. The doctor may give another schedule; follow that one. Do not move the time you take your medicines because of the measuring. Write the numbers down and bring them to the visit.

What number is high? Sources do not fully agree on this. One common table counts blood pressure below 120/80 as normal and puts 130/80 and above in the high blood pressure category. Another source says the diagnosis is two readings of 140/90 or more on two different days. The treatment target also differs for each person, for example with diabetes or kidney disease. So your own target is set by the doctor; do not judge the number yourself.

When not to wait

• If your blood pressure is above 180 over 120 and you also have any of these signs (chest pain, shortness of breath, back pain, numbness or weakness, a change in vision, trouble speaking): call 115 (Iran’s emergency number) immediately.
• If the number is this high and you have no symptoms, contact the doctor without delay.

Blood sugar at home

If you have diabetes, the doctor will tell you which device to use and how often to measure your blood sugar. Common times to measure are before meals and at bedtime, but the number of times is decided by the doctor, based on your type of treatment.

• Wash your hands with soap and water and dry them completely. Do not use alcohol to clean the fingertip.
• If you see an unexpectedly high or low number, test again with a fresh strip. No device is 100% accurate.
• Write down: the date and time, the number, what you have eaten, medicine, exercise, and anything unusual such as illness or stress.
• Take the device and the notebook to every visit.

Many people with diabetes have a target close to 80 to 130 mg/dL before meals and below 180 about two hours after a meal, and below 70 is usually counted as low. This is only an example; your target may be different, so ask the doctor.

If your blood sugar stays above your target for several days in a row and you do not know why, contact the doctor. Read about the symptoms of very low or very high blood sugar in the section “When should I call urgently?”.

A simple notebook

A notebook or a sheet of paper is enough, with columns for the date, time, the number (blood pressure or blood sugar), and a line for “what I have eaten or done”. A phone works too. What matters is that the record is regular and that you take it with you.

A simple rule

Every medicine written for you is for a specific problem, and its amount and timing have been set by the doctor in view of your whole body. So do not start any medicine yourself, do not stop it, and do not change its amount, even if you feel better or have noticed a side effect. If you have a side effect, first talk to the doctor or pharmacist; the amount or type of medicine may need to change, and that decision is theirs.

Always carry your medicine list

On a sheet of paper or in a note on your phone, write:

• The name of each medicine, its amount and the time you take it
• Supplements, vitamins and herbal remedies
• Medicines without a prescription that you take now and then
• Medicine allergies

Take this list to every visit and every trip to the emergency room. If several different doctors prescribe medicine for you, the list makes sure everyone knows about each other’s medicines.

When you receive a new medicine, ask

• What is it called, what problem is it for, and how long will it take before I see its effect?
• When, how many times and for how long should it be taken? With food or on an empty stomach?
• What side effects are likely, and what should I do if I notice them?
• Will follow-up tests be needed?
• Does it interact with other medicines, supplements, food or alcohol?
• What should I do if I miss a dose?
• How should it be stored? Is there a cheaper or equivalent type?

If the instructions are not clear, the medicine differs from before, or the pack you received is different from usual, ask the pharmacist right there.

A few points for taking medicine regularly

• Feeling well is not enough reason to stop a medicine. High blood pressure and high blood sugar often have no symptoms, so having no symptoms does not mean the illness is over. How long a medicine is needed is decided by the doctor; ask.
• Do not skip doses, and do not take less than prescribed to save money. If cost or a side effect has become a problem, tell the doctor; there may be another way.
• Do not give medicine to others and do not take other people’s medicine.
• Use a weekly pill box or a phone alarm as a reminder.
• Keep medicines out of children’s reach.

I forgot a dose, now what?

The answer to this question differs for each medicine. So ask on the day you get the medicine and write it on the pack. If you have not asked, do not make up missed doses on your own; ask the pharmacist or doctor.

When should you tell the doctor?

• A new or troublesome side effect after starting a medicine
• You have received the medicine and do not know how to take it
• Another illness has been diagnosed, or another doctor has written a new medicine
• You have to stop a medicine, for example because of cost or because the supply has run out

If after taking a medicine you develop sudden shortness of breath, swelling of the face or throat, or severe weakness, do not wait to call the clinic: call 115 (Iran’s emergency number) immediately.

Why do food and movement matter for the whole body?

High blood pressure, high blood sugar and high blood fats often come together and raise the risk of heart and vessel disease together. Balanced food and regular movement help all of them at the same time. So you do not need to make a separate plan for each problem. This page is a general guide. If you have a particular illness (diabetes, kidney disease, heart disease), your food and exercise plan should be set with the opinion of the doctor or a nutrition specialist.

Food

General principles for adults:

• Fruit and vegetables: At least 400 grams a day.
• Salt: Less than 5 grams a day, which is about 2 grams of sodium. Salt raises blood pressure. Cut down on the extra salt at the table and watch ready-made and salty foods too.
• Added sugar: Less than 10% of daily energy, that is about 50 grams (12 teaspoons) on a 2,000 kilocalorie diet. Less than 5% has more benefit. Keep in mind soft drinks and sweetened fruit juice.
• Fat: Total fat 15 to 30% of energy, saturated fat less than 10% and trans fat less than 1%.
• Alcohol raises blood pressure and triglycerides.
• Cigarettes and tobacco damage the heart and vessels, and nicotine raises blood pressure. Stopping lowers the risk of heart attack and stroke; if you want to stop, ask the doctor for help.

If you have diabetes, it is best to make a personal food plan with the doctor or a nutrition specialist. Diabetes does not necessarily mean giving up all the foods you like; sometimes only the portion size or how often you eat them changes.

Movement

• Adults should do at least 150 minutes a week of moderate-intensity physical activity, such as brisk walking. 150 minutes means, for example, 30 minutes, five days a week.
• At least two days a week of muscle-strengthening exercise, such as wall push-ups, is also recommended.
• Break up long sitting. Too much sitting and lying down goes with a higher risk of heart and vessel disease.
• Any amount of movement is better than none. If you now do almost no movement, start with ten minutes and build up gradually.

If you have heart disease, are older, or have been inactive for a long time, talk to the doctor before starting heavy exercise.

If during movement you get pain or pressure in the chest, severe shortness of breath, light-headedness or a feeling of fainting, stop at once. If it does not go away with a few minutes’ rest, look at the section “When should I call urgently?” and call 115 (Iran’s emergency number).

Where do we start?

Nobody changes everything at once. Choose one change you can really keep up: for example one more serving of vegetables, five minutes’ walk after dinner, or less salt at the table. At the next visit, show your blood pressure and sugar notes and see with the doctor what has had an effect.

First of all

In Iran the emergency number is 115. If you see any of the signs below in yourself or someone else, call 115 immediately. Do not wait for a clinic appointment and do not drive yourself: the ambulance can start treatment on the way. While calling, stay calm, give the exact address, and if you can, note the time the signs began.

If you are not sure whether a sign is serious, call. You do not have to make the diagnosis; that is the job of the emergency staff. This list is not complete and does not replace an examination.

Heart attack

Common signs:

• Pressure, heaviness or squeezing in the middle or left of the chest, which lasts a few minutes or goes away and comes back
• Pain or discomfort that spreads to one or both arms, the shoulder, neck, jaw, back or upper abdomen
• Shortness of breath, sometimes before the chest pain
• Cold sweat, light-headedness or a feeling of fainting, nausea or vomiting
• A feeling like indigestion, such as burning or fullness in the chest and upper abdomen
• Pale, blue or grey skin

The signs are not always classic. In women, older people and patients with diabetes, chest pain may be slight or absent, and instead there may be shortness of breath, unusual and unexplained tiredness, weakness or nausea. There is also a “silent” heart attack that passes with almost no signs. In patients with diabetes who have nerve damage from diabetes, chest pain may not be felt. So sudden and severe tiredness or weakness, or new shortness of breath, especially in these groups, is enough reason to call. Do not put lasting chest pain down to the stomach.

Call 115 immediately. Sit down or lean on something, with your legs bent, and stay calm. If someone has collapsed, is not responding and is not breathing, start chest compressions (CPR) until help arrives, if you are trained. If the doctor has prescribed a heart medicine for you and taught you how to use it, use only that, exactly as you learned. Do not take a medicine yourself that the doctor has not written for you.

Stroke

The signs are sudden:

• Face: One side of the face has dropped or the smile is crooked
• Arm: Weakness or numbness in one arm; cannot hold both arms up
• Speech: Slurred speech, confusion or difficulty understanding what others say
• Vision: Blurred vision or loss of sight in one or both eyes
• Balance: Dizziness, being unable to walk or losing balance
• A very severe and sudden headache with no clear cause
• Numbness or weakness on one side of the body, confusion or sudden forgetfulness

Call 115 immediately, and note the time the signs began and tell them; treatment gives better results when it is started early. Call even if the signs go away after a few minutes: it may be a “mini-stroke” and still needs to be checked immediately. Do not take the patient to hospital yourself.

Very low blood sugar

Low blood sugar happens in patients with diabetes, especially those who take insulin or some tablets. Signs: shaking, cold sweat, hunger, pounding heart, dizziness, confusion, blurred vision, headache and slurred speech. For many people with diabetes, a blood sugar below 70 mg/dL counts as low, but you should ask the doctor for each person’s exact limit. At night it may show itself as nightmares, heavy sweating or tiredness on waking. A very low blood sugar can lead to loss of consciousness and seizures and is dangerous.

• You are awake and can swallow: Take a fast-acting sugary item, for example about half a glass of regular fruit juice (not low-sugar), half a can of regular soft drink, a tablespoon of sugar or honey, or glucose tablets or gel. Wait 15 minutes and check your blood sugar again. If it is still low, repeat. If the next meal is more than an hour away, have a snack.
• The person is unconscious, having a seizure or cannot swallow: Do not put food or drink in their mouth. Lay them on their side and call 115 immediately. If the doctor has prescribed glucagon for them and someone has learned to use it, use it as taught, and in any case call 115. Stay beside them until help arrives.

Very high blood sugar and ketoacidosis

High blood sugar sometimes leads to a state called diabetic ketoacidosis, which is an emergency. The signs usually come over about 24 hours, but sometimes faster: thirst and a lot of urine, abdominal pain, nausea and vomiting or diarrhoea, breathing deeper or faster than usual, a fruity smell on the breath, drowsiness or confusion, and blurred vision.

If you have these signs and you have diabetes, or your diabetes has not yet been diagnosed, or blood ketones are above 3 mmol/L or urine ketones are “2 plus”, call 115 immediately. Do not drive yourself, and take your medicines with you. If ketones are lower but you feel unwell, or your blood sugar does not come down with treatment, contact your care team the same day.

Digestive tract bleeding

Signs:

• Vomiting bright red blood
• Vomit that looks like coffee grounds
• Black, tarry stool
• Stool with dark or bright red blood

If you vomit blood or a material that looks like coffee grounds, call 115 immediately, even if the vomiting has stopped. Do not drive yourself, and take your medicines with you.

Black, tarry or bloody stool, even without vomiting, is a sign of bleeding and must be seen the same day. If you also feel unwell, weak, confused, dizzy or pale, or have cold sweat or fast breathing, call 115 immediately.

Severe shortness of breath

Call 115 immediately if:

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

Do not drive yourself. Take your medicines with you.

In milder situations, see a doctor (not necessarily the emergency room): shortness of breath during ordinary tasks or when lying down that has got worse, shortness of breath with swollen ankles, or a cough that has lasted more than three weeks. If your shortness of breath is worse than usual for you, you are coughing up blood, or one of your legs is painful or swollen, see a doctor the same day.

Very high blood pressure

If your blood pressure is above 180 over 120 and you have any of these signs, call 115 immediately: chest pain, shortness of breath, back pain, numbness or weakness, a change in vision or trouble speaking. If you have no signs and only the number is high, contact the doctor without delay.

If you are not sure

Call and explain. For non-urgent questions, call the support number. Ask the doctor about the warning signs specific to you, and always keep your list of medicines and illnesses within reach so it can be used in the emergency room.