A case of hypertension

You are consulted by MB, a 58 year old lady. She is single and works as a manager with a leading advertising agency, keeping up with a lot of deadlines. During the visit, which was mainly related to some minor elbow complaint, you discover a raised blood pressure of 170/95 mmHg. Subsequent visits confirm the raised blood pressure. She is known to suffer from dyslipidaemia, with a LDL-cholesterol of 4.5mmol/L and a total cholesterol of 6.3mmol/L. MB does not smoke. How would you manage this case?peer-reviewe

General practice

The remarkable rate of development of medical knowledge and pharmacology affects all medical specialties and in particular general practice, since the latter embraces various aspects of different medical fields. Certain areas of medical practice, such as Hormone Replacement Therapy (HRT), hypercholesterolaemia and drugs affecting the Renin Angiotensin System (RAS) feature in a vast amount of literature which is constantly being updated. The increasing awareness of the previously unknown effects of HRT on one side, and the widespread prevalence of cardiovascular disease in the case of hypercholesterolaemia and drugs affecting the RAS have contributed to this large amount of studies. On the other hand, certain areas of practice such as atopic eczema and anti-thrombotic therapy have been rather quiescent as far as developments are concerned, but revolutionary treatments have recently been introduced in both areas, namely the calcineurin antagonists and ximelagratan. The latter is a very promising drug which can replace warfarin, while the former are the first steroid-sparing medications which effectively control atopic eczema. Keeping abreast with recent developments is a further hurdle which the modern general practioner has to contend with in order to offer valid treatment options, and to be able to answer questions by increasingly well-informed patients.peer-reviewe

Adult learning theories and medical education : a review

Adult learning theories describe ways in which adults assimilate knowledge, skills and attitudes. One popular theory is andragogy. This is analysed in detail in this review. The importance of extrinsic motivation and reflective practice in adult learning is highlighted, particularly since andragogy fails to address adequately these issues. Transformative Learning is put forward as an alternative concept. Using the three recognised domains of knowledge, skills and attitudes, ways of applying these theoretical concepts in medical education are subsequently discussed.peer-reviewe

Promoting family medicine

The year 2002 saw the publication of a landmark white paper in the United Kingdom entitled "Shifting the balance." It proposed redistribution of funds with the lion's share of the NHS budget going towards Primary Care services. Soon after, the white paper was approved, and at present 75% of the NHS budget is directed towards primary care.1 This underpins the importance and priority which the government in the United Kingdom gives to primary care in order to have an effective health system.peer-reviewe

An evaluation of palliative care education in the specialist training programme in family medicine

Aim: The study aimed to evaluate the teaching in palliative care (PC) provided during the Specialist Training Programme in Family Medicine (STPFM) in Malta. Methodology: A questionnaire was used, based on two other validated questionnaires used in a similar population. Fifteen topics commonly encountered in PC were analysed. Results: Twenty-two (74.4%) trainees returned the questionnaire. All trainees received exposure to palliative care patients, but only 5 (22.7%) felt involved in their care and only 6 (27.3%) ever used a syringe driver. Most PC teaching in the STPFM was formal in nature. Trainees felt that palliative care subjects were covered well in the STPFM, but non-medical areas received lower scores. Trainees’ confidence closely mirrored the scores for subject coverage. The Half-Day Release Programmes were the most useful palliative care teaching resource. A correct answer for the question on pain management was obtained by 63.3% of trainees and 23.7% got a correct answer for the question on the use of a syringe driver. Concerns on managing dying patients in the community were raised by 40.9% of trainees. Trainees judged overall positively their STPFM. Conclusion: GP trainees need to be trained in PC in a manner that adequately addresses their future caseload. Changes need to be made in the PC teaching within the STPFM to address areas such as ethical issues in end-of-life; using a syringe driver; selfcare and managing patients in the community.peer-reviewe

Continuity of information and care : a pilot study in a health centre

Introduction: Family medicine is the first level of contact of individuals, the family and the community with the national health.1 Quality of continuity is the degree of which a series of discrete encounters with health care professionals is coherent, connected, and consistent with the patient's medical needs and personal context.2 Objective: The aim of this study was to assess continuity of care in patients attending for General Practitioner consultations in Floriana Health Centre (FHC). Method: The study focused on all the physician- patient encounters occurring in the GP consultation rooms between 8 a.m. and 5 p.m, which accounts for the overall majority of patient contacts in health centres over a 24 hour period. This was a pilot study and consequently the study was carried out in only one health centre. The field work was carried out on five working days, including a Sunday. The number of medical records which were given to patients was noted together with the total number of patients attending for a consultation. This data was then divided in morning (8a.m. – noon) and afternoon (noon – 5p.m) sessions. Medical records given to GPs were assessed to see whether an entry was actually made and the quality of the entry. Results: A total of 529 patient encounters were included in the study. There were 411 patients attending the FHC for a GP consultation between 8a.m. and 5p.m. in four weekdays and 118 patients attending a consultation on Sunday. 23% of patients attending for a GP consultation during weekdays were given a file while 77% were not. A higher percentage of medical records were not given in the afternoons. 75% of GPs wrote a note in the patient’s file when it was provided to them. Conclusion: Continuity of care is an important and essential element in delivering good quality healthcare service to the patient. Continuity of care is not occurring to the desired degree in FHC and is possibly leading to sub-optimal care being provided to our patients. The intention is that in the future, this pilot study will be implemented on a larger scale in other health centres for a greater representation of the work being done at primary care level.peer-reviewe

Evaluating a prescription clinic at a primary health centre

Introduction: One of the pillars of a good primary health system is the establishment of a good doctor- patients relation. Amongst other things, this will result in mutually accepted treatment plans, which are understood by all parties involved. This study aimed to describe and analyze one particular aspect of this care delivery, namely the repeat prescription clinic. In this clinic, which is run on an appointment basis, prescriptions are issued on a regular basis to patients and their relatives. Method: A piloted questionnaire describing patients' demographics, diseases and treatment knowledge, was filled in during three randomly chosen clinics in November 2011. Results: The clinic is attended by a relative majority of male clients, but both genders showed a peak attendance in the 60-69 age group. An average of 4 medications per person were prescribed and treatment in each patients was aimed at an average of 3 co-existent disease states. 56% of female attendees knew the complete list of their respective treatment as opposed to 45% of males attendees. Unfortunately, 73% of patients did not know the treatment they were on and did not have an up-to-date treatment list. Conclusion: This study highlights the lack of knowledge of patients with respect to their treatment. However it can also be argued that this is a reflection of inadequate care being provided by doctors in the various fields. The clinic takes care of a significant number of patients whose treatment is not accounted for. This raises issues of safe prescribing. There is a need that all patients have an up-to-date treatment card, and a need for improvement in communication between all health care workers is noted, so as to improve the safety of all prescription practices in the island. This will lead to better disease control, less treatment interactions, and prescription errors.peer-reviewe

Attitudes of family doctors, attached to the Department of Family Medicine, towards consulting and treating young people

Background: There is a perceived concern that there is no law which governs the right of young people (YP), defined as ages 15-18, to be treated by doctors and to have their privacy protected from their parents or legal guardians. On the other hand doctors seem not to be covered by a specific law which allows them to see and treat this age group, although the Medical Council has expressed itself once in this regard. Method: This study aimed to assess the perception of doctors to seeing young adults alone since they are considered vulnerable because of their age and may not express concerns and practices if in front of parents or guardians. In this regard a questionnaire was delivered to family doctors attached with the department of family medicine at the University of Malta. Results: the response rate was 72.5%. Most respondents were males. Most (89.6%) agreed that YP have a right toe speak to the family doctor alone. Doctors are happy to discuss various topics with YP alone, but in certain issues, find difficulty in providing treatment to YP alone. There seems to be a significant difference in attitude towards the sex of the doctor with respect to the sex of the patient. Conclusion: The study was meant to be a pilot study including those doctors attached to the Department of Family Medicine at the Medical School, with a future study planned on a larger number. The significance and importance of the results however merited previous publication of this study as a sentinel. Doctors are largely concerned about the law and are sometimes reluctant to see young adults alone even if they feel that they should be able to do so. The importance of having a clarification of the law by an amendment is discussed.peer-reviewe

The outcome of elderly patients following removal of indwelling urinary catheter

The objectives of this study were to examine the documented indications for the insertion of the indwelling urinary catheter in elderly patients before admission to Zammit Clapp Hospital, St. Julians and St Vincent de Paule Residence, Luqa and to study the outcome after attempting removal of the indwelling urinary catheter. 64 patients from Zammit Clapp Hospital and 61 patients from St. Vincent de Paule Residence were studied. In 34 patients (24%), no clear reason for catheterisation prior to admission could be identified. In 46 patients (32 %) catheterisation was performed for severe uncontrollable incontinence. In all, 66 patients had their indwelling urinary catheter removed at some stage. Of these a total of 49 patients were continent 15 days after the removal of the catheter, 33 patients were still continent after 3 months and 29 patients remained continent after one year. With regards’ to continence rate, a poorer outcome was noted in patients with a mental score of less than 5/10, when compared to patients with a mental score of more than 5/10. Continence rates were better in patients from Zammit Clapp Hospital than in patients from St. Vincent de Paule residence. In conclusion, attempts should be made to use long term indwelling urinary catheterisation only if other measures fail. This can be achieved by proper multi-disciplinary team assessment and education of the patient or his carers. Full support from social services and provision and advice about the use of continence aids is necessary.peer-reviewe

A case of acute low back pain

A forty-year old gentleman, walks into your clinic complaining of low back pain, which has been present for the past four days. The pain is quite severe and poorly localized, forcing the patient to abstain from work. The patient is not on any medication and has no relevant past medical history, except for an episode of back pain years back. He is annoyed by the pain and by the fact that he had to stop working. What would you do?peer-reviewe