"I'm sorry about the wait," I say as I usher them into the cramped, drab Outpatients cubicle. "As you can see, we have been very busy and are a bit behind".
"So you should be," she snaps. "I've been out there for an hour and a half. This is pathetic. You better fix me or I'm walking out of here now."
I already get the feeling that this will be a difficult consultation, as both women scowl at me.
"So could you tell me what the problem is, Mrs Hodge?"
"You tell me, you're the doctor!"
I scan the GP letter again.
Dear Dr Sheepish:
Thankyou for reviewing this 68 year old woman. Please assess, investigate and manage as appropriate.
Oh dear. I could think of quite a few reasons why the GP had no referring details - but the real reason was becoming quite obvious.
"Unfortunately the GP has not given me much information. I'm relying on you to give me some idea. What have you noticed that has been wrong recently?"
"I have stomach problems."
"What kind of stomach problems?" I enquire - now we are getting somewhere.
"It hurts sometimes. Some times I feel sick."
"How long has this been going on for?"
"Well, are we talking a few days, a few months, years?"
"5, 10, 20? All your life?"
"At least 5 years." The scowl has not moved since the consultation started. I know things are going badly when I degenerate into closed questioning within the first 30 seconds.
"So less than 10?"
"That's what I said. At least 5." The patient is getting agitated. "Aren't you listening? I said 5 years. What kind of doctor are you?"
"OK, where do you feel this discomfort? Does it happen at any specific time? After meals? Does it last long? What do you do to make it better? Is it worse when you lie down? Do you ever vomit or feel like vomiting?" There is no way that open questioning will do any good here.
"Sometimes in my chest, sometimes in my tummy. Sometimes it happens with food. Sometimes I just get it. It goes away after a while. Usually I feel sick but I don't vomit."
The consultation is stalling, so I move the patient into the examination bay, and find some mild right upper quadrant tenderness, and some epigastric tenderness. My money is on gallstones, but there is also a small umbilical hernia.
"So when you get this discomfort, is it mainly in your chest or in your tummy? Can you point to where it is? Have you ever had pain in your shoulder?"
"Haven't we been here before?" Her daughter interjects, as the patient starts waving her hand around her torso. "What kind of question is that? Don't you listen? Why are you asking about her chest and shoulder? She said it was her stomach." I start wishing I hadn't invited her in.
"Firstly, I need to ask these questions because it could be a number of problems. Clearly your situation is not straightforward, and I'm trying to establish what the main issue is. What bothers you most: stomach pain, or nausea?"
It's the patient's turn to chime in. "I told you it was my stomach. What's wrong with you? I came here because of my stomach - 6 years of medicine and you think you're all high and mighty. Why ask me what the problem is? I don't have a medical degree. It's people like you that really disgust me." She all but spits on the floor.
"I'm here to try to work out what is going on. Obviously you don't approve of what I am doing, and we aren't making a great deal of progress with your symptoms." It has already taken 20 minutes of tense negotiation to get the information that I have. Like drawing blood from a stone. "I have other patients waiting, but at the moment I'm prepared to offer you an ultrasound and some antacid tablets to start with, and an ECG. I can see you in 2 weeks with the results or, if you don't wish to see me, you can make an appointment to see one of the other surgeons at the hospital."
"Hang on a minute." Storm clouds start gathering as I hear thunder in the background. "I didn't say anything about not wanting to see you. You're just trying to get rid of me. Go on, close my file, you sick bastard."
"Mrs Hodge, it's clear that this consultation is not working for either of us. I am still prepared to organise your tests and send a letter to your GP, but clearly you are too agitated to continue. If you wish to come back we can discuss the results in two weeks."
"You can take your tests and shove it up your arse. I'm leaving. Where do you get off treating me like a dog?" She and her daughter storm out of the cubicle. I can hear them loudly complaining outside as I pick up the telephone and let the Patient Liaison Officer know that she will be meeting some very upset people soon.