GENERAL PRACTICE

Chapter 16
GENERAL PRACTICE


General practice is a very different experience to hospital medicine. You will meet many new people and encounter all sorts of conditions. You may be exposed to a lot of uncertainty: strange skin rashes, lumps and bumps, aches and sprains, odd-sounding symptoms, to name a few. Do not be afraid to ask. The general practitioner (GP) partners know you are in training and are happy to review patients if you are unsure. Use the opportunity to learn – general practice is one of the few times where you have the privilege of being the sole trainee to several tutors, most of whom are keen to teach. Working in general practice can take some time to adjust to. There is a lot more reliance on clinical skills and picking up signs. Blood tests and imaging aren’t always immediately available to you, which can be daunting at first. However, as you adapt to these challenges most people find that the job can be very rewarding.


What you can and cannot do


You can



  • Run your own surgeries and decide patient management independently.
  • Write and sign referral letters, but always write the name of the GP in charge of the patient underneath your name.
  • Perform any duty expected of a doctor that you are trained for and feel comfortable doing, for example, smear tests, minor surgery, adjusting medication.

You cannot



  • Sign legal documents, for example, prescriptions, sick notes and abortion certificates, whilst you are still ‘preregistration’. Most GP rotations are now in your FY2 year, when this no longer applies.

Referral letters and note keeping


The most important thing is to write referral letters as soon as possible after seeing patients. Practice notes are much briefer than hospital notes, so they may not provide sufficient detail for referral letters weeks later. Some GP computer systems allow you to generate a referral letter from your consultation documentation. This is a really easy way to write a referral letter, as all the relevant information is available when the patient’s history is still fresh in your mind.


General points



  • Stick to a simple format:

    • The first line should tell the specialty team exactly what is wrong, for example, ‘Thank you for seeing this 17-year-old girl with recurrent bouts of tonsillitis’.
    • The next line/s should provide a brief summary of the history and a summary of any relevant examination findings.
    • The last paragraph should clearly state what you would like the consultant to do, for example, ‘I would be grateful if you could therefore consider this woman for tonsillectomy’. Note the wording; you can ask but never tell another professional what to do. In other cases you may simply be seeking their specialist opinion ‘I would be grateful if you could give me your opinion about…’.
    • Always send a list of their medications with the letter.

Public health and health promotion


The most common public health and health promotion matters you are likely to encounter are as follows:



The combined oral contraceptive pill contains oestrogen and progesterone. The combined pill is usually given to younger women but can be given to women up to the age of 50. Most GPs use the combined oral contraceptive pill (COCP) in women under 35. In general, you should use a pill with the lowest concentration of both hormones that gives the patient effective contraception and regulation of menstrual cycles.


There are several issues you must address when starting a patient on the COCP.


As with all patients it is important to take a history and then perform an examination.


Make sure the following points are covered:



  • Sexual health and sexually transmitted infection (STI) risks.
  • Reproductive health.
  • Any regular medications including herbal remedies that may affect absorption of the COCP.
  • Compliance with medication and previous use of COCP or other contraception.
  • History of migraines.
  • Smoking history.
  • Venous thromboembolism (VTE) risks.
  • BMI.
  • BP monitoring – the COCP is contraindicated in patients with a BP persistently greater than 140/90.

The patient should then be counselled on the risks and benefits of using the COCP, so that they can make an informed decision.


Risks



  • Use of COCP will prevent pregnancy but not STIs including HIV and so a second method of barrier contraception is advised, such as condoms.
  • The risk of VTE increases by fivefold when on the COCP.
  • There is a very small absolute increased risk of stroke but no absolute increased risk of myocardial infarction (MI).
  • After 5 years of using the COCP, the risk of cervical cancer increases.
  • The risk of breast cancer increases with use of the COCP but this is small.

Benefits



  • Protects against pregnancy
  • No evidence that use of COCP causes weight gain
  • Protects from endometrial cancer
  • Reduces risk of ovarian Ca and ovarian cysts
  • Reduces menstrual pain and blood loss by menstruation
  • Regulates menstrual cycles

If the patient gives her consent, prescribe a 4-week pack and ask for her to come back in for a check-up thereafter to review use of pill, BP, compliance and side effects. There are multiple different types of pills, so if one does not agree with the patient reassure them and prescribe a different pill.

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Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on GENERAL PRACTICE
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