Acute myocardial infarction: an easy diagnosis in general practice?

In the imminent myocardial infarction Rotterdam (IMIR) study, contacts by patients with their general practitioners for symptoms of potential coronary artery disease were registered. Those who had acute myocardial infarction were diagnosed on the basis of the modified World Health Organization criteria, and those with this definite diagnosis were then compared with the initial diagnosis made by the general practitioner at the moment of contact without laboratory assistance.

Of the 1,343 patients included in the study, 93 (seven per cent) had `definite' acute myocardial infarction and another 37 (three per cent) had `possible' acute myocardial infarction according to the diagnostic criteria used.

At the time of contact with the general practitioner 41 (44 per cent) of the 93 patients with definite myocardial infarction were recognized as such by the general practitioner, while in another 31 (33 per cent) the general practitioner diagnosed `imminent' myocardial infarction.

Of the 1,213 patients free of acute myocardial infarction at the time, 40 (three per cent) were incorrectly diagnosed by the general practitioner as having `acute' myocardial infarction.

In the 22 patients who in fact had acute myocardial infarction but in whom the general practitioner did not make this diagnosis at the time, it was found that there was an absence of physical signs and, similarly, in patients who subsequently did not have infarction the presence of physical signs was related to a falsepositive general practitioner diagnosis of myocardial infarction.

In view of the inaccuracy of the general practitioner's provisional diagnosis of acute myocardial infarction, we believe that electrocardiogram and enzyme tests should be carried out systematically in all patients who present to general practitioners with symptoms of potential coronary artery disease. Laboratory support should be readily available and we support the idea of having a special diagnostic service.

     

Patients' difficulties in obtaining appointments — a general practice audit

Information on delays in obtaining appointments in a city practice was collected. The results showed that although overall 89% of patients could be offered appointments with one of the doctors by the next day, only 60% chose to accept one, the remainder electing to wait for a particular doctor or surgery time. When patients making urgent requests for appointments were analysed separately, it was shown that 98% were offered same-day appointments and 96% accepted. Only 17% of patients making an urgent request expressed a preference for a particular doctor or time, compared with 68% of non-urgent requests. The frequency of urgent requests was greater for patients under five years of age and lower for those over 65 years old. The study suggested that longer waiting times for an appointment were the result of patient choice for a particular doctor or time, which in turn was dependent on the degree of urgency, rather than the unavailability of appointments.     

Upper gastrointestinal endoscopy — a view from general practice

An open-access upper gastrointestinal endoscopy service for general practitioners is described. Between July 1981 and May 1985, 391 endoscopies were performed on 354 patients. In contrast to the results of other studies, demand for endoscopy and the pick-up rate for major lesions has remained steady, and the number of requests for barium meals has fallen by almost a quarter. Major lesions — cancer, gastric and duodenal ulcers and severe oesophagitis — were found in 33% of patients. Oesophagitis accounted for 28% of positive endoscopies and 18% of positive endoscopies in patients with barium negative dyspepsia. With scarce resources there may, however, be a case for `selective' access to upper gastrointestinal endoscopy in the future.     

Learning general practice — the experience of one trainee

I report my experiences in learning general practice as a vocational trainee with 12 months divided between two general practices at the end of a three-year course. A parallel between developmental milestones and a trainee's educational development is drawn and the reasons which brought patients to me as a trainee are analysed.

I suggest the trainee year should be a dynamic time of learning and that trainees should be in an educational environment including progressively less authority. The trainer/trainee relationship, like the doctor/patient relationship, is all important.

     

Acute pancreatitis in general practice

During an eight-year period, 13 patients suffering from acute pancreatitis were seen in a three-doctor rural practice. The incidence was greater than most published hospital series would suggest. With one unusual exception, all the cases were mild, in that there were no complications or fatalities. In some of the patients the clinical features were such that the diagnosis might have been overlooked. Eight of the patients were managed at home. There was a strong association with biliary tract disease.     

Medical audit — a preliminary report from general practice

As three single-handed practitioners who work in the same health centre, we decided to review our work in clinical management and preventive medicine. We used data contained in a simple medical information system but, where necessary, referred to the original problem-orientated medical records. The results showed that we did not always reach standards which we considered satisfactory but we feel this type of review is worthwhile and could be applied in many general practices.     

Side effects of desensitization for allergy—a general practice survey

Following the unexpected death from acute anaphylaxis of a patient receiving house dust mite desensitization, general practitioners throughout Hampshire were asked about their experience of desensitization and its side effects, by means of a questionnaire. From a total of 695 doctors, 452 (65 per cent) returned valid questionnaires. Sixty-three doctors (14 per cent) did not use desensitization at all, while 20 (4 per cent) used more than 20 courses per year, mainly for patients with hay fever. The majority of doctors were modest prescribers of five or less courses per year of any one preparation. Apart from the fatal case which stimulated this enquiry, one other death was reported.     

Acute low back pain: patients' perceptions of pain four weeks after initial diagnosis and treatment in general practice

In a nationwide study of the treatment of acute low back pain with and without radiation in general practice in the Netherlands the subjective well-being of patients was evaluated by means of a short questionnaire sent to patients four weeks after the initial contact with their general practitioner.

After this period pain had disappeared in 28% of the patients, was diminished in 47%, was unchanged in 2% and was aggravated in 4%. There was no difference in the pain score of patients with and without follow-up encounters with their general practitioner. In all instances patients with low back pain without radiation fared significantly better than those with radiation. Radiation of pain was not constant — during the four-week follow-up period it developed in 19% of the patients originally without radiation and it disappeared in 44% of the patients originally suffering radiation.

     

Rheumatology in general practice — a survey in World Rheumatism Year 1977

Rheumatological complaints accounted for 10·6 per cent of new presentations in this general-practice survey. Spinal problems formed almost half of this total and led to a greater degree of disability than other locomotor system disorders. Active participation in the treatment of pain by the practitioner's use of manipulation and injection techniques is shown to be quite feasible in general. Forty-six per cent of all hospital referrals were simply requests for physiotherapy, and we suggest that physiotherapy departments should offer open access and so lead to a marked reduction in over-strained rheumatology consultant outpatient clinics.     

The management of hypertension — a study of records in general practice

We investigated the management of a group of 322 hypertensive patients by 71 general practitioners in the Lothian Health Board Area by a survey of the general practitioners' records. Eighty-five per cent of patients were diagnosed by the general practitioner and 57 per cent were cared for entirely by him. Two thirds of the patients were women. Hospital referral was more common in men and in patients with high initial blood pressures. One third of patients had only one blood pressure recorded before treatment. The result of treatment as measured by the latest diastolic blood pressure was similar for patients treated by the general practitioner and those referred to hospital, being 100 mm Hg or less in 77 per cent of patients.     

The distribution of episodes of illness—a research tool in general practice

The frequency of episodes of illness which 315,000 people brought to their doctors' attention in one year is shown to follow a geometric distribution. Some of the potential applications of this distribution in general-practice research are given.