Itching for a diagnosis

doi:10.1136/bmj.329.7464.501-a

BMJ 2004;329:501-502 (28 August), doi:10.1136/bmj.329.7464.501-a

Commentary

Itching for a diagnosis

William R Phillips, clinical professor of family medicine¹

¹ Department of Family Medicine, Box 356390, University of Washington, Seattle, WA 98195-6390, USA wphllps@u.washngton.edu

The first 150 words of the full text of this article appear below.

This real patient illustrates real challenges of general practice:incomplete information, evolution of illness, clinical uncertainty,and providing good care in an imperfect system.¹

Mrs Prior caught the attention of her general practitioner duringher husband's scheduled consultation. Caring for the "secondarypatient" is part of general practice, occurring in up to 18%of encounters.² This initial evaluation was necessarily brief,yet dealt with three problems: itch, rash, and cystitis.

Blood tests are sometimes used as a temporising tactic, butin this case they identified cholestatic liver disease beforejaundice became evident. By the time Mrs Prior returned fora consultation of her own, she was frankly jaundiced and herliver tests results were very high.³

Painless jaundice made some respondents on bmj.com predict cancer.Itching made many put primary biliary cirrhosis at the top oftheir list. Macro-cytic anaemia suggested chronic disease, includingalcohol misuse. The rapid rise in . . . [Full text of this article]

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