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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
Awarded First Prize, in the Primary health care category, at the 2013 BMA Medical Book Awards.
Following the familiar, easy-to-use at a Glance format, this brand new title provides a highly illustrated introduction to the full range of essential primary care presentations, grouped by system, so you’ll know exactly where to find the information you need, and be perfectly equipped to make the most of your GP attachment.
General Practice at a Glance:
- Is comprehensively illustrated throughout with over 60 full-page colour illustrations
- Takes a symptoms-based approach which mirrors the general practice curriculum
- Offers ‘one-stop’ coverage of musculoskeletal, circulatory, respiratory, nervous, reproductive, urinary, endocrine and digestive presentations
- Highlights the interrelations between primary and secondary care
- Includes sample questions to ask during history taking and examination
- Features ‘red flags’ to highlight symptoms or signs which must not be missed
This accessible introduction and revision aid will help all medical students and junior doctors develop an understanding of the nature and structure of primary care, and hit the ground running on the general practice attachment.
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Seitenzahl: 359
Veröffentlichungsjahr: 2012
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Table of Contents
Cover
Dedication
Title page
Copyright page
Contributors
Preface
Acknowledgements
Key to symbol used in the text
Abbreviations
Introduction: how to make the most of your GP attachment
Opportunities with patients
Opportunities with doctors
Opportunities with the primary care team
What can you do
Part 1: The essence of general practice
1 The 10-minute consultation: taking a history
What’s the difference between a focused history and a traditional one?
Focused history-taking in a nutshell
The past medical history
The treatment history
Family history
Where next?
2 The 10-minute consultation: managing your patient
What’s next?
Examining your patient
Investigations
Managing your patient
Tools for management
Treatment
Negotiation
Documentation
3 Continuity of care and the primary healthcare team
Continuity of care
Primary care team
Appointments
Use of time
Preventive medicine
Special interests
Chronic diseases
Home visits
4 Why do patients consult?
Lay referral system
Zola’s triggers
Ideas, concerns and expectations
Biopsychosocial model of health
Diversity and language difficulties
5 Preventive medicine
Preventive medicine in general practice
Primary prevention
Secondary prevention
Tertiary prevention
Quality and Outcomes Framework
6 Significant event analysis, audit and research
What is significant event analysis?
What is audit?
What is research?
7 Communication between primary and secondary care
Why communication matters
Key features of effective communication
Referral letters
Discharge summaries
Phoning hospital colleagues
Getting patients seen or admitted
8 Principles of good prescribing in primary care
9 Prescribing in children and the elderly
Prescribing for special groups
Prescribing for children
Prescribing for the elderly
10 Law and ethics
Consent to treatment
Children under 16 years
Confidentiality
Data protection
Confidentiality and the student
Ethics
11 Child abuse, domestic violence and elder abuse
Child abuse
Domestic violence
Elder abuse and vulnerable adults
Part 2: Common presentations in general practice
Child health
12 The febrile child
Assessment of the child with a fever
Meningococcal disease
Urinary tract infection
13 Cough and wheeze
Cough and wheeze
Croup and epiglottitis
Bronchiolitis
Pertussis
14 Asthma
Acute asthma
Management of chronic asthma
15 Abdominal problems
Abdominal pain
Diarrhoea and vomiting
Constipation
16 Common behaviour problems
School refusal
The hyperactive child and attention deficit hyperactivity disorder
Autistic spectrum disorder
17 Childhood rashes
Rashes and spots in babies
Exanthems
Purpuric rashes
Other common rashes
18 Child health promotion
Immunisations
Child surveillance programme
19 Musculoskeletal problems in children
Developmental dysplasia of the hip
Limping
Growing pains
Flat feet, bow-legs and knock-knees
Rickets
Juvenile idiopathic arthritis
Sexual health
20 Common sexual problems
Erectile dysfunction (impotence)
Premature ejaculation
Loss of libido
Dyspareunia
21 Sexually transmitted infections and HIV
Sexual history
Chlamydia
Gonococcus
Trichomonas vaginalis
Herpes virus (type 1 or 2)
Genital warts: human papilloma virus
Syphilis
HIV
22 Contraception
History
Examination
Contraceptive options
23 Subfertility
Definition and background
Aetiology
History
Examination
Investigations
Management
Pre-conception counselling
Women’s health
24 Termination of pregnancy
Key points to address in the GP consultation
Psycho-social issues to consider in the consultation
What happens in the specialist clinic?
Aftercare
25 Menstrual disorders
Menorrhagia
Dysmenorrhoea
Intermenstrual and post-coital bleeding
Post-menopausal bleeding
Polycystic ovarian syndrome
26 The menopause
27 Common gynaecological cancers
Role of the GP in gynaecological malignancies
28 Breast problems
Benign breast disease
Breast cancer
The pregnant woman
29 Antenatal care
The pregnant woman
Antenatal care
30 Bleeding and pain in pregnancy
Bleeding in early pregnancy
Miscarriage
Bleeding in late pregnancy
Antiphospholipid syndrome
Abdominal pain
31 Other pregnancy problems
Common minor symptoms
More serious problems
Gestational diabetes
Multiple pregnancy
Medical disorders in pregnancy
Care of the elderly
32 Acute confusional state and dementia
Clinical presentation of dementia
Clinical presentation of acute confusional state
History
Examination
Investigations
Management
33 Fits, faints, falls and funny turns
Blackouts
Vertigo
Non-vertiginous dizziness
Cardiovascular problems
34 Chest pain
Taking a history
Examination
Investigations
Management
35 Stroke
Role of the GP
History
Examination
Acute management of stroke and TIA
After a stroke
Rehabilitation
36 Peripheral vascular disease and leg ulcers
History
Examination
Investigations
Management
37 Preventing cardiovascular disease
Risk factors for CVD
Reducing risk
Management of hypertension
Management of hyperlipidaemia
Management of raised glucose
How to talk to patients about prevention
Respiratory problems
38 Breathing difficulties
Sudden acute causes of breathlessness
Slowly progressive causes of breathlessness
Vague breathlessness
39 Cough, smoking and lung cancer
Cough
Lung cancer
40 Asthma and chronic obstructive pulmonary disease
Asthma
Chronic obstructive pulmonary disease
Endocrine problems
41 Diabetes
Diagnosis
Management
Future directions for hyperglycaemic control in T2D
42 Thyroid disease
Pathology
The overactive thyroid
The underactive thyroid
Gastrointestinal problems
43 Acute diarrhoea and vomiting in adults
Acute diarrhoea
Vomiting
44 Dyspepsia and upper gastrointestinal symptoms
Dyspepsia
History
Examination
Investigations
Management
45 Lower gastrointestinal symptoms
History
Examination
Management
46 The acute abdomen
Acute abdominal pain
History
Examination
Investigations
Management
Musculoskeletal problems
47 Back pain
Back pain
Cauda equina syndrome
Osteoporosis
Osteomalacia
48 Hip and lower limb
The hip
The knee
Ankle and foot pain
49 Neck and upper limb
Neck pain
Shoulder pain
Elbow pain
Hand and wrist
50 Inflammatory arthritis, rheumatism and osteoarthritis
Inflammatory arthritis
Gout
Polymyalgia rheumatica and giant-cell arteritis
Osteoarthritis
Eyes and ENT
51 Upper respiratory tract infection (including sore throat)
Upper respiratory tract infection
52 Ear symptoms
Ear ache (otalgia)
Ear discharge (otorrhoea)
Hearing loss
53 The red eye
History
Examination
Investigations
Management
Some ‘red eye’ red flags
54 Loss of vision and other visual symptoms
History
Examination
Summary of conditions presenting with visual symptoms in primary care
Focus on age-related macular degeneration
Dermatology
55 Eczema, psoriasis and skin tumours
Skin problems in general practice
Eczema
Management
Psoriasis
Skin cancers
56 Other common skin problems
Acne
Acne rosacea
Seborrhoeic dermatitis
Pityriasis versicolor
Pityriasis rosea
Fungal infections
Warts
Molluscum contagiosum
Cold sores
Shingles
Impetigo
Scabies
Mental health
57 Depression
Depression in primary care
History
Examination
Investigations
Management
Assessing suicide risk
58 Anxiety, stress and panic disorder
History
Examination
Differential diagnosis
Investigations
Management
Treatment
Prognosis
59 Alcohol and drug misuse
Alcohol
Drugs
60 Eating disorders
History
Management
Obesity
61 Psychosis and severe mental illness
Early detection of first episode and relapses
Early referral for treatment
Continued engagement over time
Reducing psychiatric symptoms
Improving and monitoring physical health
Relapse prevention
Other common conditions
62 Headache
Migraine
Other types of headache
Serious causes of headache
63 Tiredness and anaemia
History
Examination
Chronic fatigue syndrome (CFS)
Obstructive sleep apnoea syndrome
Managing anaemia
64 Insomnia
History
Examination
Investigations
Management
65 Allergy and hay fever
Hay fever (seasonal allergic rhinitis)
Perennial rhinitis
Food allergies and intolerance
Anaphylaxis
66 Urinary tract disorders
Haematuria
Infection
Renal colic
Prostate
Urinary incontinence
67 Chronic pain
Causes
Diagnosis
Management
Assessment
Treatment
Further reading and resources
Index
Dedication
We dedicate this book to Dr Grant Blair, gifted GP teacher and inspirational colleague and friend, who died during the production of this book.
This title is also available as an e-book.
For more details, please see www.wiley.com/buy/9780470655511or scan this QR code:
This edition first published 2013 © 2013 by Paul Booton, Carol Cooper, Graham Easton, and Margaret Harper
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Cover design: Meaden Creative
Illustrations: Graeme Chambers
Contributors
Cressida AmielAcademic Trainee in Primary CareImperial College LondonGeneral Practitioner, London
Joanne AthosSenior Clinical Teaching FellowImperial College LondonGeneral Practitioner, London
Catherine BaudainsAcademic Trainee in Primary CareImperial College LondonGeneral Practitioner, London
Grant BlairHonorary Senior Clinical LecturerImperial College LondonGeneral Practitioner, London
Sipra GuhaHonorary Senior Clinical LecturerImperial College LondonGeneral Practitioner, London
Oliver HartGeneral Practitioner, Sheffield
Rosalind HerbertSenior Clinical Teaching Fellow Imperial College LondonGeneral Practitioner, London
Richard HookerHonorary Senior Clinical LecturerImperial College LondonGeneral Practitioner, London
Stella MajorAssociate Professor of Family MedicineUnited Arab Emirates University Honorary Senior Clinical Lecturer Imperial College London
Jan ManieraHonorary Senior Clinical LecturerImperial College LondonGeneral Practitioner, London
Emma MettersAcademic Trainee in Primary CareImperial College LondonGeneral Practitioner, London
Aisha NewthSenior Clinical Teaching FellowImperial College LondonGeneral Practitioner, London
Sian PowellSenior Clinical Teaching FellowImperial College LondonGeneral Practitioner, London
Adrian RabyClinical Lecturer in Medical Ethics and LawImperial College LondonGeneral Practitioner, London
Sarvesh SainiSenior Clinical Teaching FellowImperial College LondonGeneral Practitioner, London
Sonia SaxenaSenior Lecturer in Primary CareImperial College LondonGeneral Practitioner, London
Edward ShaoulHonorary Senior Clinical LecturerImperial College LondonGeneral Practitioner, London
James Stratford-MartinSenior Clinical Teaching FellowImperial College LondonGeneral Practitioner, London
Vineet ThaparAssociate DirectorPostgraduate GP Specialty TrainingLondon DeaneryGeneral Practitioner, London
Anju VermaClinical Teaching FellowImperial College LondonGeneral Practitioner, London
Anna WhitefordUndergraduate GP TeacherImperial College LondonGeneral Practitioner, Hertfordshire
Bronwen WilliamsAcademic Trainee in Primary CareImperial College LondonGeneral Practitioner, London
Preface
General practice has seen huge changes in recent years as more medical care moves into the community. As a result, medical students and junior doctors are spending much more time in general practice – not just to find out about the specialty but to give them the clinical experience they need.
This book attempts to meet those challenges in a relevant, clear and concise ‘at-a-glance’ way. The book is not a dumbed-down version of hospital management. It’s about the unique approach of general practice, where unsorted problems are the staple diet. Here GPs rely on clinical skills rather than huge scanners, and you as the student can understand what is being done and why.
The book focuses on key topics that commonly arise in general practice. It uses a symptom-based approach: patients don’t complain of COPD or heart failure, they say they are breathless. Most of the ailments are common everyday conditions, but importantly our book includes rare conditions that must not be missed. ‘Red flags’ are a key feature. The book makes use of the relevant guidelines to ensure students are kept abreast of current thinking in clinical management. The chapters are written by working GPs, the majority of whom are linked to the academic department of primary care at London’s Imperial College Medical School. We believe this combination gives students hands-on practical advice informed by the best available evidence for practice. There are resources and further reading at the back of the book, which is not simply a dry list of references but a wide range of resources including websites to enhance your learning and broaden your horizons.
For medical students, time spent in primary care is a golden opportunity to meet and assess patients with a huge range of medical problems who present a real diagnostic challenge. It’s also a chance to see how structured medical care can provide excellent management of chronic diseases and how the primary care team link together to deliver care across the practice patch. General practice is also the ideal place to acquire skills such as focused history-taking and thinking on your feet, skills that will serve you well in any field of practice. If you become a specialist, you’ll also find it helpful to be familiar with what happens to your patients before they are referred to you and after you discharge them. This is your guide book to those opportunities. When it comes to your exams, you will find it a useful revision tool. Furthermore, we hope it opens the ‘art and mystery’ of general practice to foundation and specialty trainees in general practice and to practice nurses and other clinical staff who need a concise summary of clinical primary care.
Paul BootonCarol CooperGraham EastonMargaret Harper
Acknowledgements
In addition to sources shown in individual figures, there are some figures from Wiley-Blackwell texts.
Chapter 17 Childhood Rashes
Pictures of ammoniacal dermatitis, Candida nappy rash, seborrhoeic nappy rash, measles, fifth disease, scarlet fever, Henoch–Schönlein purpura, herpes simplex (cold sores), impetigo and molluscum contagiosum from Paediatrics at a Glance, 3rd edition. Lawrence Miall, Mary Rudolf and Dominic Smith. © 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
Pictures of strawberry naevus (haemangioma), portwine stain, meningococcal septicaemia and ITP from Paediatrics at a Glance, 2nd edition. Lawrence Miall, Mary Rudolf and Malcolm Levene. © 2007 Lawrence Miall, Mary Rudolf and Malcolm Levene. Published 2007 by Blackwell Publishing Ltd.
Picture of chickenpox from Textbook of Pediatric Dermatology, 2nd edition. J. Harper, A. Oranje and N.S. Prose. Published 2006 by Blackwell Publishing Ltd., Oxford.
Chapter 19 Musculoskeletal Problems in Children
pGALS figure used by kind permission of Arthritis Research UK (www.arthritisresearchuk.org) from: pGALS – A screening examination of the musculoskeletal system in school-aged children. Reports on the Rheumatic Diseases (Series 5), Hands On 15. H. Foster and S. Jandial. Arthritis Research Campaign; 2008 June.
Chapter 20 Common Sexual Problems
Picture of vacuum device or pump from ABC of Sexual Health, 2nd edition. John Tomlinson (Editor). © 2005 Blackwell Publishing Ltd. BMJ Books.
Chapter 21 Sexually Transmitted Infections and HIV
Pictures of common STIs from ABC of Sexually Transmitted Infections, 6th edition. Edited by Karen E. Rogstad. © 2011 Blackwell Publishing Ltd. Published 2011 by Blackwell Publishing Ltd.
Chapter 36 Peripheral Vascular Disease and Leg Ulcers
Pictures 36b–d from ABC of Arterial and Venous Disease, 2nd edition. Richard Donnelly and Nick J.M. London (Editors). © 2009 Blackwell Publishing Ltd. BMJ Books.
Chapter 52 Ear Symptoms
Picture of normal ear, nasal polyposis, skin prick test from ABC of Ear, Nose and Throat, 5th edition. Harold S. Ludman and Patrick Bradley (Editors). © 2007 Blackwell Publishing Ltd. BMJ Books.
Chapter 55 Eczema, Psoriasis
Pictures of eczema, psoriasis, basal cell carcinoma and keratoses from Lecture Notes: Dermatology, 10th edition. © R.A.C. Graham-Brown and D.A. Burns. Published 2011 by Blackwell Publishing Ltd.
Picture of malignant melanoma and squamous cell carcinoma from ABC of Skin Cancer. S. Rapjar and J. Marsden. © 2008 by Blackwell Publishing Ltd. BMJ Books.
Chapter 56 Other Skin Problems
Pictures of acne, acne rosacea, seborrhoeic dermatitis, pityriasis rosea, fungal infection, tinea corporis, warts, molluscum and shingles from Lecture Notes: Dermatology, 10th edition. © R.A.C. Graham-Brown and D.A. Burns. Published 2011 by Blackwell Publishing Ltd.
Pictures of pityriasis versicolor and scabies from ABC of Dermatology, 5th edition. Paul K. Buxton and Rachael Morris-Jones (Editors). © 2009 Blackwell Publishing Ltd. BMJ Books.
Picture of herpes simplex (cold sores) from Paediatrics at a Glance, 3rd edition. Lawrence Miall, Mary Rudolf and Dominic Smith. © 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
Chapter 65 Allergy and Hay Fever
From ABC of Ear, Nose and Throat, 5th edition. Harold S. Ludman and Patrick Bradley (Editors). © 2007 Blackwell Publishing Ltd. BMJ Books.
Key to Symbol Used in the Text
A red flag indicates symptoms, signs or investigations which point to serious conditions that must not be missed.
Abbreviations
AAG
acute angle glaucoma
A&E
accident and emergency department
ABCD2
age, blood pressure, clinical features, duration and diabetes risk scoring system
ABPI
Ankle–Brachial Pressure Index
ACE
angiotensin-converting enzyme
ADHD
attention deficit hyperactivity disorder
AOM
acute otitis media
APH
antepartum haemorrhage
APS
antiphospholipid syndrome
ARB
angiotensin-receptor blocker
ARMD
age-related macular degeneration
AST
aspartate aminotransferase
BASHH
British Association for Sexual Health and HIV
BCC
basal cell carcinoma
b.d.
twice daily
BMI
body mass index
BNF
British National Formulary
BP
blood pressure
BPH
benign prostatic hyperplasia
BRAO
branch retinal artery occlusion
BTS
British Thoracic Society
CAMHS
Child and Adolescent Mental Health Service
CBT
cognitive behavioural therapy
CBT-BN
cognitive behavioural therapy for bulimia nervosa
CCDC
Consultant in Communicable Disease Control
CCP
cyclic citrullinated peptide
CHPP
Child Health Promotion Programme
CMHT
community mental health team
CNS
central nervous system
COCP
combined oral contraceptive pill
COPD
chronic obstructive pulmonary disease
CPA
care programme approach
CPAP
continuous positive airways pressure
CPN
community psychiatric nurse
CRAO
central retinal artery occlusion
CRP
C-reactive protein
CSF
cerebrospinal fluid
CT
computerised tomography
CTS
carpal tunnel syndrome
CVA
cerebrovascular accident
CVD
cardiovascular disease
DCIS
ductal carcinoma
in situ
DDH
developmental dysplasia of the hip
DEXA
dual energy X-ray absorptiometry
DJD
degenerative joint disease
DMARD
disease-modifying anti-rheumatic drug
DRE
digital rectal examination
DVLA
Driver and Vehicle Licensing Agency
DVT
deep vein thrombosis
ECG
electrocardiography/electrocardiogram
ED
erectile dysfunction
EDD
expected date of delivery
EEG
electroencephalography/electroencephalogram
eGFR
estimated glomerular filtration rate
EMS
early morning stiffness
ENT
ear, nose and throat
EPU
Early Pregnancy Unit
ESR
erythrocyte sedimentation rate
FAST
Face, Arm, Speech Test
FB
foreign body
FBC
full blood count
FSH
follicle-stimulating hormone
GAD
generalised anxiety disorder
GC
gonococcus
GCA
giant-cell arteritis
GDM
gestational diabetes
GGT
gamma-glutamyl transpepstdase
GLP
glucagon-like peptide
GOR
gastro-oesophageal reflux
GORD
gastro-oesophageal reflux disease
GPSI
GP with a special interest
GUM
genito-urinary medicine
Hb
haemoglobin
hCG
human chorionic gonadotrophin
HDL
high density lipoprotein
HELLP
(syndrome characterised by) haemolysis, elevated liver enzyme levels and low platelet count
HiB
Haemophilus influenzae
type B
HIV
human immunodeficiency virus
HPV
human papilloma virus
HRT
hormone replacement therapy
HSV
herpes simplex virus
HVS
high vaginal swab
IBD
inflammatory bowel disease
IBS
irritable bowel syndrome
IgE
immunoglobulin E
IPSS
International Prostate Symptom Score
ITP
idiopathic thrombocytopenic purpura
IUD
intrauterine device
IUS
intrauterine system
JIA
juvenile idiopathic arthritis
JVP
jugular venous pressure
LCIS
lobular carcinoma
in situ
LDL
low density lipoprotein
LFT
liver function test
LH
luteinising hormone
LMP
last menstrual period
MCA
Mental Capacity Act 2007
MCV
mean cell volume
MI
myocardial infarction
MMR
measles, mumps and rubella
MMSE
Mini Mental State Examination
MRI
magnetic resonance imaging
MSU
mid stream urine (test)
NICE
National Institute for Clinical Excellence
NSAID
non-steroidal anti-inflammatory drug
NSU
non-specific urethritis
OCP
oral contraceptive pill
o.d.
once daily
OSA
obstructive sleep apnoea (syndrome)
OTC
over-the-counter
PCOS
polycystic ovary syndrome
PD
panic disorder
PEFR
peak expiratory flow rate
PID
pelvic inflammatory disease
pMDI
metered dose inhaler
PMH
past medical history
PMR
polymyalgia rheumatica
PMS
premenstrual syndrome
POAG
primary/chronic open angle glaucoma
POP
progestogen-only pill
PPI
proton pump inhibitor
PSA
prostate specific antigen
PUVA
psoralen with ultraviolet A (treatment)
QOF
Quality and Outcomes Framework
RA
rheumatoid arthritis
RBC
red blood cell
ROM
range of movement
RR
respiratory rate
RSI
repetitive strain injury
RSV
respiratory syncytial virus
SCC
squamous cell carcinoma
SEA
significant event analysis
SIDS
sudden infant death syndrome
SMR
standardised mortality ratio
SPF
sun protection factor
SSRI
selective serotonin reuptake inhibitor
STI
sexually transmitted infection
SVT
supraventricular tachycardia
T1D
type 1 diabetes
T2D
type 2 diabetes
TB
tuberculosis
TENS
transcutaneous electrical nerve stimulation
TFT
thyroid function test
TG
triglycerides
TIA
transient ischaemic attack
TSH
thyroid stimulating hormone
U&E
urea and electrolytes
URTI
upper respiratory tract infection
UTI
urinary tract infection
VA
visual acuity
VDU
visual display unit
VEGF
vascular endothelial growth factor
VUR
vesico-ureteric reflux
WCC
white cell count
WHO
World Health Organization
Introduction: How to Make the Most of Your GP Attachment
‘What you do in general practice is refer patients with serious problems and get rid of the trivia’ (medical student about to start a GP attachment). If only life were so simple …
General practice gives you opportunities to work with patients, doctors and the primary care team in ways which it may be difficult or impossible to find elsewhere in your undergraduate training.
Opportunities with Patients
Unsorted problems
.
Most patients come with a problem, not a diagnosis. This is a prime opportunity to talk to patients who do not yet have a diagnosis and hone your diagnostic acumen.
Learn to take a focused history
.
There is probably no better place to practise taking a focused history than primary care.
Management
.
Planning management with patients with relatively simple problems is an ideal place to start thinking through management issues, gets you into the habit of integrating management thinking into your clerkings and gives you practice negotiating your plan with the patient.
Patients at home
.
Visiting patients at home gives a much broader insight into their lives and what makes them and their families tick. It provides a chance to see how people live with their illness, in their home with their family and in their own community.
Opportunities with Doctors
One-to-one
.
Generally, you will be attached to a practice individually or in pairs, usually with one tutor taking main responsibility for you. There will be few other opportunities in your career for such a close learning relationship.
Looking after your learning needs
.
This is a great time to think about your personal learning needs and to set yourself some goals. Am I confident using an ophthalmoscope? Can I examine the cranial nerves? One-to-one sessions with your GP tutor are a great opportunity to look at your personal learning needs and find ways to address them. The tutor may be able to find you a patient with the problem you want to explore – diabetic eye changes, aortic stenosis.
Get feedback
.
Such a close working relationship is ideal for gaining worthwhile feedback on your performance. Ask for feedback if it is not offered.
Opportunities with the Primary Care Team
Multidisciplinary learning
.
You’ll probably work with different members of the primary care team during your attachment. It is an opportunity to see the different skills that different disciplines bring and how the team relate to each other and work together.
Being where healthcare happens
.
Most patients’ problems are dealt with in primary care, by the doctor, by the practice team or by the wider community team. Whichever branch of medicine you go into it is crucial to understand how care is delivered in the community. This is even more important if you end up as a hospital doctor as your GP attachment is often your only opportunity to see life beyond hospital (although if you are lucky you may get a 4-month foundation post in general practice).
What Can You Do
1
The 10-Minute Consultation: Taking a History
At finals you could spend 20–40 minutes clerking your patient. So how can a 10-minute consultation in general practice produce an adequate assessment?
Continuity of care means the patient and their history are often familiar.
The 10-minute consultation is an average. A quick consultation, like a repeat medication request, saves time which can be spent on trickier problems.
You don’t need to do everything in one consultation. It can help to watch a problem develop over several visits.
Making diagnoses is honed through practice, enabling GPs to recognise patterns of illness quickly. This is not ‘taking short-cuts’: it’s about the expertise to focus on key areas.
As a student, don’t rush to assess a patient in 10 minutes. Take the time you need to understand your patient’s problem fully. Speed comes with experience.
What’s the Difference between a Focused History and a Traditional One?
Traditional history-taking is useful when you first learn to interview patients as it teaches you a structure and a list of questions to ask.
You’ll notice senior doctors often ask surprisingly few questions, yet get a better view of the problem.
This ‘focused history’ requires judgement about what to explore and what to set aside. Judgement is based on many things including knowledge and experience.
Learning focused history-taking is an important transition between student and doctor. General practice is the ideal setting to practise this because you will see many undiagnosed patients on whom to hone your skills.
Focused History-Taking in a Nutshell
Listen
‘What can I do for you today?’
Students often hope to save time by getting straight to the point with direct questions. The opposite happens. You get a better foundation for exploring the problem if you give the patient the time to tell their story from their perspective: start with an open question and then listen.
The
‘golden minute’
(give the patient a minute to speak without interruption) gives your patient time to frame their problem in their own way.
‘Go on … tell me more …’
If the patient falters, encourage them to carry on. Use non-verbal encouragement through head nodding and eye contact.
‘You were saying the pain is worse at night …’ Reflection
can get help your patient going again.
Don’t fear
silence,
particularly in emotionally charged situations. Give the patient space to formulate their thoughts.
Clarify
‘When were you last completely well?’
Establish the timetable of the patient’s symptoms.
‘Can you describe the pain?’
Analyse each symptom. Mnemonics can help, such as SOCRATES: Site, Onset, Character, Radiation, Associated factors, Timescale, Exacerbating/relieving factors, Severity.
‘What do you mean by indigestion?’
Understand what the patient means, especially if they use medical terms. ‘Migraine’ often means ‘bad headache’, ‘blood pressure’ may mean dizziness, headaches or almost anything else.
Ask
red flag
questions to detect serious underlying conditions. In back pain, ask about incontinence and urinary problems, history of cancer and TB.
Explore Beliefs
‘What are your thoughts about this?’
The patient may have a very good idea of their diagnosis, ‘It’s just the same as my aunt had.’ Equally, they may have a very misleading idea, ‘This website said it’s typical of
Candida
infection.’ Knowing your patients’
ideas
may help you diagnostically, or help your patients away from incorrect formulations.
‘In your darkest moments what do you think this might be?’
Look for hidden agendas and explore your patients’
concerns
. Patients with headaches often worry about brain tumours or meningitis. They rarely volunteer this for fear of looking foolish, maybe because they’re afraid they may be right. Your diagnosis and treatment may be spot on, but if you haven’t uncovered these concerns and put your patient’s mind at rest, you send away a worried patient.
‘What are you hoping we can do?’
What are your patient’s
expectations
for treatment. When you come to plan management, taking your patient’s expectations on board will help you achieve
concordance
with your patient (see Chapter 2).
Above all, don’t try to guess what your patient is thinking. There’s no point reassuring your patient about something that never worried them. Their real concerns (which might seem bizarre to you or to the next patient) may be life and death to them.
Summarise
‘Let me see if I’ve got this right …’ Once you have grasped the patient’s problem, summarise it back. This checks your own understanding, and reassures the patient that they’ve been understood.
The Past Medical History
The past medical history is essential background to the presenting problem. The GP may not need to explore it in a familiar patient, or if the records are to hand.
‘Have you had any serious illnesses?’ ‘Have you seen a specialist or been in hospital?’
Don’t list random diseases, ask general questions about the past, and …
Ask specific questions relevant to the presenting complaint. Ask
‘Ever had migraine?’
to the patient with headaches.
The Treatment History
‘Can you bring all your medicines to the surgery with you?’
Drug side effects and interactions cause huge amounts of iatrogenic illness and many hospital admissions. A secure drug history will allow you to spot current problems and prevent your own prescribing causing future ones.
The drug history is a back door route to past medical history. You may only discover that your patient is hypertensive from the drug history.
Ask about over-the-counter drugs and recreational drugs. Remember, the most important of these are alcohol and tobacco.
Family History
Enquire about illness in relatives rather than a list of conditions. Ask for anything that has come up as a possibility in the patient’s history – like diabetes in the family of a patient presenting with thirst and weight loss.
Where Next?
From the history you should now have a good idea of what’s going on. If you haven’t, sit back and think what else you need to fill out the picture. Use the history to make sure you find out all you need to help you make a diagnosis and plan management. If that takes time, it’s time well spent. Remember 80% of diagnoses are made on the history and in many conditions (e.g. epilepsy, migraine) a secure diagnosis can only be made from the history, so use it well.
2
The 10-Minute Consultation: Managing Your Patient
The previous chapter went into some detail about effective history-taking. This chapter shows how to use the information you gained to plan the management of your patient.
What’s Next?
Having taken a careful history, you may have all the information you need, but more likely you may find yourself in a situation where you have some ideas about what’s going on but not all you need to know. The big question now is not ‘what’s the diagnosis?’ but ‘what’s next?’ What do you need to do to take management to the next stage?
Examining Your Patient
Most clinical skills guides think of the history and examination as one item, but it’s worth thinking of the examination as part of your investigations and plan it on the basis of what you’ve discovered in the history.
As with the history, the
focused examination
explores areas chosen because they are likely to be important based on what you have found in the history.
It’s more revealing to do a thorough examination of the system where you believe the problem lies than a ‘fishing trip’ which skims over everything.
Always do the examination that the clinical situation demands. Patients who need a rectal exam in surgical outpatients need it just as much in general practice.
Investigations
Investigations are of two main sorts – for diagnosis and for management. For instance, a random blood sugar test is very useful to confirm the diagnosis of diabetes, but of little use in diabetes management while glycosylated haemoglobin is the opposite. Choose investigations on the basis of how they will help you in each of these two areas. Why not a long list of investigations like on ER? Because every investigation you do has false positive potential. If you test for something that is clinically unlikely the risk of a false positive may be higher than the likelihood of a true positive.
Managing Your Patient
If you’ve taken a careful history and chosen your examination and investigations well you will have a good idea of what’s going on with your patient. That is not necessarily the same as having a formal diagnosis. In general practice you often don’t have a complete diagnosis but manage uncertainty through reducing risk by ‘safety netting’. For instance, in a patient who presents with mild flu symptoms, it’s not particularly helpful to patient or doctor to confirm the diagnosis of flu through virological testing, so the patient is advised on the basis of diagnostic probability of suitable management. Acknowledging that they might (rarely) develop a life-threatening viraemia or (more commonly) a bacterial pneumonia, one also advises the patient of what to do if they become more ill, what specific warning symptoms to look out for and what to do if these arise. (There may be other reasons for being sure about a diagnosis: in 2009 when the H1N1 flu epidemic appeared in the UK with real concerns about its virulence, exact diagnosis became extremely important and extensive virological testing was carried out.)
Tools for Management
Ordering pathology tests is not the only way forward. Reviewing a non-critical problem after a week or so may give time for the clinical picture to evolve or the patient to find better ways of explaining the symptoms. This is particularly useful in primary care where patients tend to present early, before the clinical picture has recognisably evolved. ‘Come back in a week’ must be for a reason and not just prevarication! A second opinion from another GP colleague or other member of the primary care team often helps: the practice nurse or community midwife may be the best person to help you plan care.
Treatment
Writing a prescription at the end of each consultation suggests bad practice. Often explaining to your patient the nature of their symptoms and how to live with them, giving health advice on exercise, diet or smoking offers your patient a better chance to manage their own health. Figure 2 shows some of the different options available to you and your patient.
Negotiation
We’ve moved a long way from the doctor giving orders to the patient to follow. Patients who haven’t understood or engaged with the importance of the treatment, or who don’t trust the doctor or believe in his or her diagnosis are unlikely to comply with it. Careful explanation of your plan and taking on board the patient’s ideas and expectations (yes, ideas, concerns and expectations once again!) is crucial to acheiving concordance, a negotiated plan that both you and the patient believe is the best way ahead in this particular situation.
Documentation
Once you’ve finished your consultation you should carefully document what you’ve discovered, planned and agreed. Your patient’s future management and safety and your own medico-legal survival depends on the quality of these notes.
3
Continuity of Care and the Primary Healthcare Team
Continuity of Care
A major benefit of our primary care system is to be able to provide care continuously over a number of years, building a history of the health of the patient and developing a trusting relationship. In urban practices it is common to have a population of about 30% lifelong patients, 30% staying only a year and the rest staying somewhere in between.
Patients register with a practice, ideally as a family. The records of the patient and the rest of the family are available to all the professionals in the practice. This knowledge of the family can add unique value to the doctor–patient relationship and quality of care. For example, the GP will be attuned to any significant genetic predispositions or be aware of the stresses that may be occurring in family life.
In some practices patients can see the same doctor at each visit, but increasingly there will be several doctors working on a shift system so this may not be possible. Patients are encouraged to see the same doctor for a particular illness or condition, and communication between doctors becomes central to maintaining continuity of care.
Primary Care Team
Primary care doctors work in teams which vary from practice to practice (see Figure 3): nurses, dietitians, counsellors, physiotherapists, phlebotomists and others. They will be supported by a practice manager, receptionists and secretaries. Completing the team are externally employed primary care professionals such as district nurses, including specialist nurses for mental health, palliative care and a range of other specialist services. Effective care depends on good communication through meetings, notes and discussion. In most practices the doctor is the pivotal member of the team. This requires recognition of the skills of all the other members as they all play a vital part in the successful provision of patient care.
Appointments
Most patients are seen by appointment at the practice. Patients will be seen on the same day if their medical condition requires it. The initial appointment may be with a nurse or a doctor. Increasingly, patients are choosing to see a nurse where the request is for a procedure (e.g. a dressing or an injection). Nurses have demonstrated their particular training in developing and adhering to protocols of care. Some nurses have academic qualifications or special training and are recognised as nurse practitioners. They are able to demonstrate a high degree of knowledge and skill, especially in some well-defined areas such as managing minor illness including prescribing certain medications and increasingly in managing chronic illness such as hypertension.
Use of Time
The supreme advantage of primary care is the ability to see a patient as often as necessary. The diagnosis may be unclear at the initial appointment but the patient may be seen again later. It is now easy to organise investigations at the hospital with the results sent back to the practice as rapidly as if requested by a hospital doctor. It has been shown that providing these facilities to primary care is economical.
Preventive Medicine
Primary care is in a prime position to promote the prevention of disease and ill health. This may be by the administration of vaccination programmes or the recognition of early factors leading to chronic ill health such as the management of obesity, smoking or high blood pressure (see Chapter 5).
Special Interests
Some GPs develop an interest and extra training in a particular area of medicine, such as minor surgery, gynaecology, management of drug addiction or diabetic care and accept referrals from other practices or from GPs within their own practice. Most GPs with a special interest (GPSIs) see this as only part of their work.
Chronic Diseases
Chronic conditions are well managed from primary care. Most patients with diabetes or hypertension need not be referred to a hospital clinic. It is in this area the practice team comes into its own (see case study).
Home Visits
Home visits are increasingly rare in modern urban primary care because of increased mobility of patients, easier access to appointments and the awareness that three or four patients can be seen at the medical centre in the time it takes to carry out a single visit. However, they do occur when patients are genuinely unable to attend the clinic. This may be for an acute condition but more commonly for disabling chronic conditions – or in rural practices where distance and transport make it difficult for patients. Occasionally a visit is necessary because a mentally ill patient needs to be examined with a view to organising a ‘section’ prior to compulsory admission to hospital. On such occasions a joint visit may be carried out by the GP, a psychiatrist and an Approved Mental Health Professional (AMHP).
Other visits will be to elderly patients, patients in need of palliative care and occasionally when the doctor feels that knowledge of the patient’s living conditions would be helpful. Visits to the elderly will often be in support of the district nurse, and palliative care visits may be in conjunction with a specialist (e.g. Macmillan) nurse who is trained to give support to the patient and advice to the GP and the district nurse.
