Itching for a diagnosis
http://www.100md.com
《英国医生杂志》
1 Department of Family Medicine, Box 356390, University of Washington, Seattle, WA 98195-6390, USA wphllps@u.washngton.edu
This real patient illustrates real challenges of general practice: incomplete information, evolution of illness, clinical uncertainty, and providing good care in an imperfect system.1
Mrs Prior caught the attention of her general practitioner during her husband's scheduled consultation. Caring for the "secondary patient" is part of general practice, occurring in up to 18% of encounters.2 This initial evaluation was necessarily brief, yet dealt with three problems: itch, rash, and cystitis.
Blood tests are sometimes used as a temporising tactic, but in this case they identified cholestatic liver disease before jaundice became evident. By the time Mrs Prior returned for a consultation of her own, she was frankly jaundiced and her liver tests results were very high.3
Painless jaundice made some respondents on bmj.com predict cancer. Itching made many put primary biliary cirrhosis at the top of their list. Macro-cytic anaemia suggested chronic disease, including alcohol misuse. The rapid rise in bilirubin and liver enzyme concentrations suggested a more acute process.4 Mrs Prior deserved the early ultrasound examination she had to pay for privately.
The patient and her family were most worried about ovarian cancer. The ultrasonogram showed no evidence of that malignancy but could not rule out cancer obstructing the common bile duct or infiltrating the liver. The consulting gastroenterologist recommended routine referral with a possible delay of 21 weeks. Respondents wanted to fast track this patient to consultation, diagnostic tests, and treatment. Few felt it was appropriate or necessary to call this a cancer case just to get the patient prompt care.
After the ultrasonogram we knew that Mrs Prior had gall stones and obstruction.5 Even if she had another coexistent disease, she needed urgent relief of the obstruction. Chronic progressive liver disease and even metastatic cancer are not emergencies; obstruction of the common bile duct is.
The general practitioner faced two communication challenges. Firstly, what to tell the patient? Respondents agreed they would tell her she has a liver problem that may be serious and she needs more tests. The second challenge was for the general practitioner to be the patient's advocate and negotiate prompt assessment in secondary care.
Mrs Prior's general practitioner worked the patient into his schedule, identified her problems, ordered key diagnostic tests, followed her course, recognised the urgent need for intervention, and helped the patient and her family understand the process. What more can you hope for? Only that the consultant system meets this patient's needs.
Competing interests: None declared.
References
Heathcote J. Abnormal liver function found after an unplanned consultation: case outcome. BMJ 2004;329: 500.
Orzano AJ, Gregory PM, Nutting PA, Werner JJ, Flocke SA, Stange KC. Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network. J Fam Pract 2001;50: 113-6.
Heathcote J. Abnormal liver function found after an unplanned consultation: case progression. BMJ 2004;329: 342.
Beckingham IJ, Ryder SD. ABC of diseases of liver, pancreas, and biliary system: investigation of liver and biliary disease. BMJ 2001;322: 33-6.
Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system: gallstone disease. BMJ 2001;322: 91-4.(William R Phillips, clini)
This real patient illustrates real challenges of general practice: incomplete information, evolution of illness, clinical uncertainty, and providing good care in an imperfect system.1
Mrs Prior caught the attention of her general practitioner during her husband's scheduled consultation. Caring for the "secondary patient" is part of general practice, occurring in up to 18% of encounters.2 This initial evaluation was necessarily brief, yet dealt with three problems: itch, rash, and cystitis.
Blood tests are sometimes used as a temporising tactic, but in this case they identified cholestatic liver disease before jaundice became evident. By the time Mrs Prior returned for a consultation of her own, she was frankly jaundiced and her liver tests results were very high.3
Painless jaundice made some respondents on bmj.com predict cancer. Itching made many put primary biliary cirrhosis at the top of their list. Macro-cytic anaemia suggested chronic disease, including alcohol misuse. The rapid rise in bilirubin and liver enzyme concentrations suggested a more acute process.4 Mrs Prior deserved the early ultrasound examination she had to pay for privately.
The patient and her family were most worried about ovarian cancer. The ultrasonogram showed no evidence of that malignancy but could not rule out cancer obstructing the common bile duct or infiltrating the liver. The consulting gastroenterologist recommended routine referral with a possible delay of 21 weeks. Respondents wanted to fast track this patient to consultation, diagnostic tests, and treatment. Few felt it was appropriate or necessary to call this a cancer case just to get the patient prompt care.
After the ultrasonogram we knew that Mrs Prior had gall stones and obstruction.5 Even if she had another coexistent disease, she needed urgent relief of the obstruction. Chronic progressive liver disease and even metastatic cancer are not emergencies; obstruction of the common bile duct is.
The general practitioner faced two communication challenges. Firstly, what to tell the patient? Respondents agreed they would tell her she has a liver problem that may be serious and she needs more tests. The second challenge was for the general practitioner to be the patient's advocate and negotiate prompt assessment in secondary care.
Mrs Prior's general practitioner worked the patient into his schedule, identified her problems, ordered key diagnostic tests, followed her course, recognised the urgent need for intervention, and helped the patient and her family understand the process. What more can you hope for? Only that the consultant system meets this patient's needs.
Competing interests: None declared.
References
Heathcote J. Abnormal liver function found after an unplanned consultation: case outcome. BMJ 2004;329: 500.
Orzano AJ, Gregory PM, Nutting PA, Werner JJ, Flocke SA, Stange KC. Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network. J Fam Pract 2001;50: 113-6.
Heathcote J. Abnormal liver function found after an unplanned consultation: case progression. BMJ 2004;329: 342.
Beckingham IJ, Ryder SD. ABC of diseases of liver, pancreas, and biliary system: investigation of liver and biliary disease. BMJ 2001;322: 33-6.
Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system: gallstone disease. BMJ 2001;322: 91-4.(William R Phillips, clini)