Carelli Francesco , Professor e and elective courses in Family Medicine , University of Milan

Censabella  Federica , internship student in FM, University of Milan

Colosimo Valentina , internship student  in FM ,  of GP clinic

If family doctor and patient develop a good relationship over time, the doctor becomes the key person in many critical and complex situations, both before and after pathologies.

As an example, we can present the case of an 81 year old patient presenting at our practice because of an episodic chest pain the day before and spontaneously disappeared in about 30 minutes.  The patient was soon well and no pain had followed.  Without alarming the old patient, we ask him to contact us soon if pain would reappear.  In two days time, the patient contacted us complaining of a severe chest pain.  Arrived at his home, we found hypertension and tachycardia.  We called the emergency services as a case of suspected heart attack.

 

In the emergency room , electrocardiogram confirmed our diagnosis with extensive myocardial attack, ST over lined laterally,  With heparin, nitro-glycerine  and morphine, patient was hospitalised in cardiac unit. Coronarography indicated 3 vessel disease and this was followed by coronary angioplasty and 2 stent ( interventricular antero-proximal artery and median-circunflex artery ) with good results and angiography and partial re-vascularisation. 

 

On admission to hospital, there were high Troponine and CPK, with  slow decrease during following 2 weeks.  The patient refused a proposal for entering a rehabilitation department and was soon discharged home.  So, the patient was carefully monitored by his family doctor with frequent controls and periodic exams at home and in the practice. The same for monitoring therapy, as well as modifying and controlling side effects.

 

From this case we see how family doctor would be frequently of key importance to rapidly make diagnosis so to act, as in follow up. This because he/ she knows personal behaviours and family substrate, can improve compliance to therapies and evaluate in real time problems on taking therapies or exams.  Family doctor can be a bridge between patient and hospital doctor, with benefits on adequacy and care completeness. 

 

Also, considering many community’s studies, one month mortality after heart attack is about 50 % , half of this during first  2-3 hours, mainly before doctor’s arrival.  A prompt and early approach is key to reduce these percentages,  when a delay precludes some possible therapies.  In this sense, family doctor occupies a key position being the first doctor usually called in such situations. 

Family doctor should analyse the situation, advise patient, reduce delays, identify dangerous situations. It is important doctor knows all differential diagnoses so to recognise urgency and ensure  fast access to therapies, towards so frequent muscle- skeletal pains in  daily practice.  

To be remembered prevention possibly incisive of main part of risk factors.  Smoking, sedentary lifestyle, blood hypertension, diabetes, hypercholesterolemia can be controlled with a good relationship and partnership with family doctors.