CONAN HASSIM May 2012

AIMS By the end of this session, I hope you are More confident about primary care investigations. Provide some knowledge helpful to the AKT. Provide some knowledge helpful to the CSA, in particular balancing up possible patient demand to do tests against the appropriate use of primary care resources. Consider more carefully the responsibility we all have when we complete investigations and in particular the cost of your investigations. Feel more able to be involved in the organisation of practice systems. Develop skills of team working, chairing, summarising and presenting. Provide you with a resource which may be helpful in your work

APPROPRIATE TESTING ? What does appropriate testing mean: Evidence based as far as possible. ( why am I doing this test ? ) Patient orientated. Leading to improved quality of medicine. Appropriate testing should lead to a lower cost to the NHS, patients and individual doctors in the long run. It is an area for debate, and continually changes. Note that appropriate testing does not always mean doing less tests, sometimes you will find yourself doing more tests than you presently do.

EVIDENCE BASED What are the possible sources of information on investigations ? National guidelines and summaries of evidence based practice. Local guidelines Practice guidelines What are the problems with these different sources.

COST OF INVESTIGATIONS The UK national budget for pathology is approximately 2 billion per annum. Individual cost of tests in private sector include Well Woman and Well Man tests for £ 259 each. Cost is not just the cost of processing test but also cost for patient attending for test (time and parking), cost of phlebotomist time, cost for doctor reviewing tests and following up within the practice. In the long run we are likely to take on pathology budgets so the cost will be directly relevant to us.

Number of tests requested by each practice.

Costs of tests for each practice

EXAMPLES Best way of been involved in the learning and retaining information. Imagine you are the new partner in the practice. Consider also how one will discuss the tests with a patient, particularly when patient has expectations that the doctor will do some tests. Consider how one would best present information back to colleagues in your practice. Consider practically how one would deal with the organisation of regular routine blood tests in certain conditions. Allow some debate on various topics. Not always a right answer. Note the focus of these examples is investigations.

TIREDNESS Patient JS, 39 year old male, working in the city and living in Gerards Cross, presents for the first time with a 4 week history of tiredness. What do you do in this first consultation. You make a management plan, but when he sees you in 3 months he feels there has been no improvement. What if anything would you do now.

PRINCIPLES FOR TIREDNESS Illustrates the importance of considering if you have to intervene immediately. Like the delayed prescription, you can give the patient a “delayed” investigation. Can consider treating for the most common diagnosis before embarking on tests.

CARDIOVASCULAR RISK A patient VL, 53 year old female, comes to see you after seeing the practice nurse twice with raised blood pressure of 170/ 100. When you see VL her blood pressure is 149/93, how do you proceed. You subsequently find that VL has a qrisk of 30% and so you decide to start her on blood pressure treatment (lisinopril 10mg) and give her simvastatin 40mg nocte. How would you follow her up in terms of any further investigations.

PRINCIPLES CARDIOVASCULAR RISK Consider how you follow up patients. If one repeats an unnecessary test then this can be repeated for a very long time unnecessarily. Equally if you do not review appropriately every so often something will be missed.

DIARRHOEA IP, 26 year old man, presents to you with a 6 day history of diarrhoea after returning from Spain. How would you proceed? IP comes back to you 3 weeks later, there has been a slight improvement but he still has regular diarrhoea. What would you do if anything ?

PRINCIPLES FOR DIARRHOEA Consider what the most likely diagnoses is and what you are looking for with your investigations. Consider what the treatment would be for the most likely results from your investigations.

CONSULTATION 4 PROBLEMS PATIENT RT, 49 YEAR OLD LADY, PRESENTS WITH A NUMBER OF PROBLEMS INCLUDING : Symptoms of a UTI. Menopausal symptoms and wonders about doing a blood test to confirm this. 4 th toe nail on her right foot is slightly thickened and discoloured, she wonders about a fungal toe nail infection. Discharging boil on her back. Consider what investigations you might do in this case

PRINCIPLES 4 PROBLEM CONSULTATION Though a test may be appropriate consider at what point it is helpful. Always consider what you will learn from the test result, and will it change your management. Always discuss with the patient what the treatment might be. If they do not want the treatment then question whether the test is necessary. Sometimes you will do tests to reassure patients.

BREATHLESSNESS DT, a 69 year old man, presents to you with a 1 week history of breathlessness. He was discharged 2 weeks ago following a total hip replacement during which period he had an MI. After you initially find nothing wrong he returns 2 months later with breathlessness on exertion.

PRINCIPLES BREATHLESSNESS If doing a d-dimer consider carefully if needed. If clinically unlikely to be DVT then consider if worth doing at all. Consider heart failure in chronic SOB, clinically difficult to be sure of diagnosis.

DMARD MONITORING AZ, a 50 year old lady, who is already been treated for hypertension has been diagnosed with rheumatoid arthritis by the local rheumatologist and started on methotrexate. She asks you if you would continue the prescribing of the methotrexate. What investigations would you consider if any ( some baseline tests were done by the hospital ). How would you arrange any further monitoring/ follow up of this patient within your practice. You have a phlebotomist, one nurse and one receptionist working with you. This question is not just about the blood tests but also the organisation of your Practice.

PRINCIPLES OF DMARD MONITORING Having a system of monitoring is as important as what tests are been done.

DEMENTIA RS, a 80 year old man, presents to you with symptoms of dementia. Screening tests confirm the probability of dementia. How do you proceed.

PRINCIPLE OF REFERRALS Consider relevant blood tests for any referral. If blood tests need to be done at out patient appointment this often results in an unnecessary repeat appointment.

Erectile dysfunction Rd, a 40 year old man, presents to you with a one week history of sore throat. When you looking at his throat you notices his breath smells heavily of alcohol. He also tells you about his erectile dysfunction. What tests might you do, if any ?

KIDNEY DISEASE CD, 80 year old with hypertension, returns to you after completing some routine U&Es for her annual hypertension review. The creatinine is 118, egfr 58 ( normal up to 102). How do you proceed in both the short and long run.