Strategies for diagnosing leg oedema in primary care: a qualitative study of GPs' approaches

[The swollen leg and clarification of bilateral leg swelling : Practical procedure in general practice]

Swelling of soft parts of the lower extremities, whether uni- or bilateral, is a common reason for consulting a general practitioner (GP). Complex interactions mean that GPs are faced with a wide range of differential diagnoses during clarification of such findings. Of enormous importance is the prevention of a dangerous course, e.g., by initiating weight-adapted calculated antibiotic treatment, antithrombotic therapy, or even initial inpatient treatment and acute diagnostic workup in case of impending compartment syndrome or extensive venous thrombosis of the leg with or without suspicion of pulmonary embolism. Sometimes an acute venous thrombosis of the leg unmasks malignant disease. A swollen leg/swollen legs are frequently a leading symptom of decompensating heart or renal failure. Another possible cause are drug side effects, which may be exacerbated in a warm environment. An endocrine cause must also be considered in some cases. The GP is the appropriate physician for patients to contact and to initiate and coordinate diagnostics and treatment. In addition to coordination of specialist examinations, it is not infrequent that nurses and physiotherapists have to be involved in treatment, to ensure successful outpatient care.

Individual utilisation thresholds and exploring how GPs' knowledge of their patients affects diagnosis: a qualitative study in primary care

BACKGROUND

One of the tenets of general practice is that continuity of care has a beneficial effect on patient care. However, little is known about how continuity can have an impact on the diagnostic reasoning of GPs.

AIM

To explore GPs' diagnostic strategies by examining GPs' reflections on their patients' individual thresholds for seeking medical attention, how they arrive at their estimations, and which conclusions they draw.

DESIGN AND SETTING

Qualitative study with 12 GPs in urban and rural practices in Germany.

METHOD

After each patient consultation GPs were asked to reflect on their diagnostic reasoning for that particular case. Qualitative and quantitative analyses of consultations and interview content were undertaken.

RESULTS

A total of 295 primary care consultations were recorded, 134 of which contained at least one diagnostic episode. When elaborating on known patients, GPs frequently commented on how 'early' or 'late' in an illness progression a patient tended to consult. The probability of serious disease was accordingly regarded as high or low. This influenced GPs' behaviour regarding further investigations or referrals, as well as reassurance and watchful waiting. GPs' explanations for a patient's utilisation threshold comprised medical history, the patient's characteristics, family background, the media, and external circumstances.

CONCLUSION

The concept of an individual threshold for the utilisation of primary care would explain how GPs use their knowledge of individual patients and their previous help-seeking behaviour for their diagnostic decision making. Whether the assumption behind this concept is valid, and whether its use improves diagnostic accuracy, remains to be investigated.

Diagnosing skin disease in primary care: a qualitative study of GPs' approaches

BACKGROUND

Skin diseases are a common reason for consulting a GP. This regular occurrence happens despite most GPs' lack of knowledge and training in skin disease.

OBJECTIVES

We aimed to explore different diagnostic approaches of GPs in patients presenting with a dermatological problem. In addition, we aimed to identify strategies used by GPs to handle diagnostic uncertainty in these patients.

METHODS

We conducted interviews (20-40 minutes) with 14 GPs using a semi-structured guideline. Recalling encounters with patients with skin disease, GPs described their individual diagnostic strategies. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters using a deductive-inductive approach.

RESULTS

We identified several aspects of a complex decision-making process in GPs' diagnostic management of patients with dermatological problems. In the general diagnostic workup, GPs used a broad spectrum of different strategies such as spot diagnosis, stepwise refinement, pattern recognition trigger or test of treatment. GPs reduced diagnostic uncertainty through the identification of red flags, the application of the test of time, therapeutic trials and asking for further advice, including patient referral.

CONCLUSIONS

GPs encounter a broad range of dermatological problems in their daily work using a variety of strategies in the workup of these patients. However, in a significant number of patients, there remains diagnostic uncertainty that is mainly reduced by specialist referral. Regular training in the diagnosis and treatment of common dermatological diseases should be offered to all GPs.