SUMMARY ObjectiveTo review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care. Methods Systematic searches of PubMed and Embase. ResultsOf 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)]. ConclusionsThere has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.

Most hospital inpatients are at risk of deep vein thrombosis (DVT) and the associated complications of fatal or non-fatal pulmonary embolism and post-thrombotic syndrome. Recognised risk factors for DVT are generally related to one or more elements of Virchow's triad (stasis, vessel injury, and hypercoagulability), and include surgery, trauma, immobilisation, malignancy, use of oestrogens, heart or respiratory failure, and smoking (box 1).1 Surveillance studies have found that the absolute risk of DVT is 10%-20% among general medical patients and up to 40%-80% in patients having hip surgery, knee surgery, or major trauma ( What are the methods of DVT prophylaxis? Methods of DVT prophylaxis include general measures: the use of aspirin, mechanical prevention with graduated compression stockings, and intermittent pneumatic compression devices. Anticoagulants often used include unfractionated heparin (UFH) (usually given as 5000 units two or three times daily), low molecular weight heparins (LMWH) (usually enoxaparin or dalteparin), vitamin K antagonists (most often warfarin, but also acenocoumarol, phenindione, and dicoumarol), and fondaparinux (a selective factor Xa inhibitor) (box 2). 6How well do the mechanical methods of prophylaxis work? A Cochrane review found that graduated compression stockings were effective in reducing rates of DVT for general medical and surgical patients whether they were used alone or in addition to other DVT prophylaxis. In nine studies comparing graduated compression stockings with no prophylaxis, rates of DVT were reduced from 27% to 13%, and in seven studies the addition of the stockings to background prophylaxis further reduced DVT rates from 15% to 2%. 7Additionally, a recent randomised but non-blinded clinical trial found that the use of graduated compression stockings in patients with DVT reduced the risk of post-thrombotic syndrome from 49% to 26%.8 A metaanalysis of 57 studies found that intermittent pneumatic compression devices for the thigh and calf were effective in reducing rates of DVT when compared with placebo (from 29% to 11%) and with graduated compression stockings alone (from 15% to 8%).9 A recent systematic review found that graduated compression stockings, intermittent pneumatic compression devices, and foot pumps reduce the risk of DVT in surgical patients by two thirds when used as monotherapy and by an additional 50% when added to drug prophylaxis. 10 The review also found that mechanical prophylaxis in surgical patients may reduce the risk of pulmonary embolism by about two fifths.

This article focuses on the key clinical and investigatory features that help differentiate the multiple causes of chest pain in adults in assessment of patients with undifferentiated chest pain in primary care using history, physical examination, and basic initial investigations. The initial treatment of many of the causes is discussed. Some treatments not only relieve symptoms but also provide further diagnostic information based on the response to treatment. Guidance for referral for specialist assessment and further investigations is provided, but the diagnostic usefulness of these measures is not discussed.

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