Family Medicine Consultation Research Articles

O descortinar de um diagnóstico de hematúria: relato de caso

Introduction: The prevalence of lower urinary tract symptoms (LUTS) increases with age. They have significant impact on quality of life and commonly cause adults to seek medical care. When a middle-aged man presents with LUTS, we must consider diseases that affect the prostate, urethra, bladder and detrusor muscle. Case report: A 50 year-old male welder, with a previous history of dyslipidemia, 3,5 pack-years of smoking, and an episode of renal colic with renal microlithiasis came to his Family Physician in October 2012. He complained of dysuria, urinary frequency, terminal hematuria, and hypogastric pain. A diagnosis of cystitis was made and antibiotic therapy was prescribed after obtaining a urine culture. The urine culture was negative. In the absence of prostration, fever, and purulent discharge, and given a previous history of urolithiasis, this episode was reinterpreted as a second episode of renal colic. In August 2013, the patient presented with terminal dribbling, sporadic dysuria, and hematuria on urine dipstick analysis. An assay of total prostate specific antigen, an analysis of urinary sediment, and a transabdominal vesicoprostatic ultrasound were ordered. One month later a bulky neoplastic lesion of the bladder was found on ultrasound examination. Comment: Despite the presence of risk factors for bladder carcinoma (previous smoking and age over 35 years), this diagnosis was not considered at the initial consultation. On follow-up, other confounding factors emerged, including a past history of renal stones and the presence of symptoms suggestive of other diseases more common in this age group. The case report explores the complexity of the differential diagnosis of LUTS in an adult male. This is a common complaint in Family Medicine consultations, pointing to a set of disorders with defined diagnostic and therapeutic guidelines.

Frecuencia de estreñimiento en pacientes de Atención Primaria

Frequency of constipation in primary care patients Objective: To determine how often patients attending family physician’s consultation for whatever reason present constipation, and to verify its association with sociodemographic characteristics, existence of previously diagnosed digestive diseases and drug consumption. Study design: Prevalence study and crossed association. Setting: Primary health care. Participants: A sample of 473 patients selected by systematic sampling in four family medicine consultations. Measurements: Presence of symptoms of constipation assessed by the GSRS scale (Gastrointestinal Symptom Rating Scale). Other variables: previous diagnosis of gastrointestinal tract diseases, medication use, frequency of attendance, and sociodemographic characteristics. Results: 32,0 % of the patients (IC 95 %: 27,5 – 36,5) stated the presence of symptoms of constipation with moderate or strong intensity: decrease in the frequency of the number of bowel movements, increase in the consistency of the faeces, or sensation of incomplete evacuation. The symptoms were more frequent in women (37,3 % vs. 24,0 %; p = 0,004) and in consumers of medication for diseases of the digestive system (47,7 % vs. 23,8 %; p <0,001). A linear statistically significant trend was observed (p <0,001), between the presence of constipation and the total number of drugs used by the patients. Conclusions: The frequency of symptoms of constipation is high in Primary health care patients, especially in females. A linear relationship between the frequency of these symptoms and drug consumption is observed, whereby constipation should be regarded as a common potential side effect in patients with polypharmacy.

Rechazo parental en homosexuales de una unidad de medicina familiar

Objetivo: Conocer la frecuencia de rechazo parental en pacientes homosexuales de una unidad de medicina familiar. Métodos: estudio de tipo descriptivo donde se aplicó el instrumento de Rechazo Familiar de Lozano-Díaz (2010) a 39 padres de familia de homosexuales adscritos a la Unidad de Medicina Familiar n° 195 de Chalco, México. La muestra no probabilística y por conveniencia se obtuvo en la consulta de medicina familiar, con ayuda de trabajadores sociales, concertando citas con los padres de pacientes reconocidos como homosexuales. Resultados: 1) Hubo una mayor actitud negativa hacia la homosexualidad por la rama paterna; 2) Hubo un alto sentimiento de deshonra familiar por tener en la familia un hijo o hija homosexual; 3) Se consideró altamente desagradable la preferencia sexual hacia el mismo sexo; 4) No se aceptan los lazos matrimoniales entre parejas del mismo sexo. Conclusiones: Se puede afirmar que el rechazo parental al hijo/hija homosexual fue considerablemente alto en el grupo investigado. Cabe mencionar que estos pacientes deben ser abordados no sólo individualmente sino en su entorno familiar. La búsqueda de alternativas no biomédicas puede ayudar a la aceptación de la expresión homosexual, disminuyendo la discriminación en el ambiente familiar, y, por ende, en el institucional.

Efecto del calcio y la vitamina D en la reducción de caídas de las personas mayores: ensayo clínico aleatorizado frente a placebo

Background and objectiveSupplements of calcium and vitamin D (Ca/VitD) could help prevent falls, although it is unknown whether the effect differs according to the level of physical activity or baseline 25-OH-vitamin D3. The objective is to determine the effect of Ca/VitD supplements in reducing falls and the musculoskeletal function in elderly over 65 years living in the community, who do not have osteoporosis or vitamin D deficiency. Material and methodRandomized double-blinded clinical trial. A total of 508 patients were selected from 35 Family Medicine consultations. The treatment was administered to 398 subjects (Ca/VitD 188 and placebo 210). The efficacy parameters were: incidence of falls, changes in muscle strength in dominant hand and changes in musculoskeletal function. ResultsThe cumulative incidence of falls in the group Ca/VitD was 27.7% (95% confidence interval [95% CI]: 21.0 to 34.3) and 30.5% in the placebo group (95% CI: 24.0 to 36.9) (P=.537). The difference was not significant in the subgroup analysis: male/female, active/inactive physically and level of 25-OH-vitamin D3 higher/less than 32ng/ml. There was no difference in muscle strength in subjects of both groups. The proportion of adverse effects was higher in the Ca/VitD group (14.4 versus 7.1%, P=.019). ConclusionsThe results contradict the recommendation to provide supplements, and it is not an effective and well tolerated strategy. Although they may reduce the risk of falls when there are very low levels of vitamin D, the results are unsatisfactory when elders do not have this deficiency, and it is necessary to consider the possibility of adverse effects.

Role and influence of the patient′s companion in family medicine consultations: "The patient′s perspective"

Background:Companions often accompany the patient in family medicine clinics and may influence the consultation. This study aims to determine the patients’ perspective regarding the role and influence of the companion in the consultation process.Materials and Methods:A cross-sectional study was conducted at the family medicine clinics of a university hospital. Adult patients accompanied by companions during the consultation were interviewed through a structured questionnaire. Attributes with respect to role and influence of companion on the consultation were assessed. Data was entered and analyzed through IBM Statistical Product and Service Solutions (SPSS) software version 18 using the Chi-square test.Results:A total of 100 patients accompanied by companions participated in the study. Majority of companions were present to either provide company (90%) and/or emotional support (90%). Immediate relatives had a role in mobility (P = 0.016) and decision making (P = 0.006). Most companions remained passive and did not contribute to the doctor patient relationship (P = 0.058). Male companions were relatively helpful (54% vs. 25%, P = 0.008) in achieving the expectations from the visit. The companion played a supportive role in 62% of the consultations.Conclusion:This study signifies a supportive role of companion in a consultation which emphasizes the need of consultation models to include the “companion.”

Frecuentación de la población inmigrante versus autóctona en atención primaria: ¿quién consume más servicios?

Objectives To study the frequency of attendance in primary care of immigrant population compared to autochthonous one. To analyse differences in health services use according to geographical origin. Methods A retrospective descriptive study was carried out. All Family Medicine and Paediatrics consultations were analysed using the electronic medical record. Design Retrospective descriptive study. We analysed all the medicine and paediatrics appointments data from the electronic medical record. Location Urban Health Centre, Zaragoza. Participants All patients with an appointment at the Health Centre during a one year period. Intervention Is in line with the reference population with health cards by sex and age. Direct standardisation was performed to avoid differences due to different population distribution. Main measures Number of visits annually to the doctor, on the basis of national origin, sex and age. Results We analysed 110,046 adult consultations (based on a population of 20,675 inhabitants, 20% of immigrants) and 17,647 paediatric consultations (based on 2,452 children, 29% of immigrants). Adjusted annual consultation ratio of Spanish patients was higher than that of the immigrant population (7.1 consultations vs 4.8 in children, and 4.7 vs 2.8 in adults) ( P < .001). Adults from Eastern Europe showed the lowest number of consultations (1.6). In emergency consultations in Primary Care, Spanish children consulted more frequently than immigrants, but immigrant adults consulted more frequently than Spanish adults. Conclusions Immigrant population consulted primary care services less often compared with the Spanish population. There are notable differences according to geographical origin. This can be explained by better health, better use of healthcare system, and other difficulties in accessibility to health systems.

Making sense of polarities in health organizations for policy and leadership

Making sense of complex adaptive clinical practice and health systems is a pressing challenge as health services continue to struggle to adapt to changing internal and external constraints. In this Forum, we begin with Dervin's Sense-Making theories and research in communications. This provides a conceptual and theoretical context for this editions research on comparative complexity of family medicine consultations in the USA, models for adaptive leadership in clinical care and social networking to make sense of health promotion challenges for young people. Finally, a Sense-Making schema is proposed.

A consulta a três

The presence of a third party in doctor-patient relationship, occurring often in Family Medicine consultations, raises ethical issues which, to date, have been scarcely debated amongst Portuguese physicians and seldom generated specific guidelines. This paper reviews the available fonts of ethical guidelines (physicians Code of Ethics, international conventions, bioethics institutions and pregraduate teaching). At the light of these guidelines, clinical vignettes are then discussed: adolescent contraception, consultation in the presence of relatives of competent patients, giving bad news, care to the disabled and their carers, consultation in the presence of students or doctors in training and the delegation of care to doctors in training. Ethical thinking, using the principles of beneficence/nonmaleficence, autonomy and dignity, is illustrated and strategies are offered for family practice. The conclusions are for the need of teaching, training and counselling in medical ethics, as well as for more specific ethic guidelines.

The Effect of Patients’ Met Expectations on Consultation Outcomes. A Study with Family Medicine Residents

ObjectivesTo know the patients’ expectations and the fulfillment of these at family medicine consultations by resident doctors and to assess their effect on some consultation outcomes.DesignA prospective cohort study.ParticipantsPatients attending family medicine consultations held by 38 resident doctors: 1,301 eligible patients, 702 filled in all questionnaires.MeasurementsBefore each visit, the patients’ expectations about that particular consultation were registered. Right after the visit was over, their perception of several aspects of the communicative interaction with the doctor was measured. Later, patients were interviewed on the phone to know how their expectations had been fulfilled, how satisfied they were about the consultation, how they had followed the doctor’s suggestions, if they were going to seek further care for the same cause later, and the evolution of their clinical problem. Logistic regression was the main analysis used.ResultsThe most common expectations were the doctor showing interest and listening (30.5%), getting some information about the diagnosis (16.3%), and sharing problems and doubts (11.1%). The rate of main expectations that were met was 76.5%. Satisfaction with the encounter was associated with the clinical evolution [odds ratio (OR) 2.23; confidence interval (CI): 1.32–3.75], and the fulfilling of the patients’ main or two main expectations was significantly related to all the measured outcomes (satisfaction OR 3.51, CI: 1.73–7.8; adherence OR 1.80, CI: 1.11–2.92; clinical evolution OR 1.54, CI: 1.01–2.35; and seeking further care later OR 0.54, CI:0.36–0.81)ConclusionsPatients prioritize expectations of a more general sort when they attend primary care consultations and residents fulfill these acceptably. The fulfillment of expectations seems to affect the studied outcomes more than other factors.

Aplicación de la agenda de calidad en una consulta de atención primaria

Introduction Heavy caseload is a significant concern to primary care physicians. The use of consultations can be reduced through the application of strategies directed at the user, the health professional and the organization. One of these strategies is consultation management. Objective To improve the dynamics of family medicine consultations through demand rationalization, improved accessibility and user satisfaction. Material and method An intervention plan was implemented. The intervention consisted of appointment organization, evaluation of caseload before and after the intervention, the degree of user satisfaction with the adopted measures, and evaluation with the care received. Results Consultation management decreased demand and increased scheduled consultations (activity was maintained constant), while users perceived a decrease in waiting time. Conclusions Healthcare activity can be rationalized through appropriate consultation management. Moreover, improved accessibility to the system leads to good user satisfaction.

A Collaborative Needs Assessment and Work Plan in Behavioral Medicine Curriculum Development in Vietnam.

An important aspect of family medicine education in the United States and abroad is behavioral medicine. Interpersonal and communication skills, mental health assessment, and sensitivity to diverse patient populations are areas of curricular importance. This article describes the behavioral medicine portion of a family medicine consultation with Vietnam, in progress since 1999. The needs assessment for behavioral medicine reveals few monetary or personnel resources available for training family physicians or caring for patients with mental health problems. Challenges of conducting crosscultural consultations are many and include confronting language barriers,