Sixteen diseases not to miss in the office

In the daily routine of primary care there are several conditions that have significantly reduced morbidity and mortality if they are diagnosed early. The volume of information that crosses our desks daily makes it difficult to keep these diseases in clear focus.

1) Non-valvular atrial fibrillation
Undiagnosed and untreated atrial fibrillation has an associated 6% annual rate of stroke, 20% of which are fatal. Treatment with warfarin to an INR between 2 and 3 reduces this risk by 68% per year.

2) Diabetes mellitus
Undiagnosed and untreated diabetes (type 2 being by far the most common) inevitably results in significant cardiovascular, ocular, neurological, and renal complications. Treatment with glycemic control, ASA, ACE inhibitors, and statins dramatically reduces the associated severe morbidity and mortality.

3) Hypertension
Undiagnosed and untreated hypertension inevitably results in significant cardiovascular, neurological, and renal complications. Treatment with ACE inhibitors, diuretics, calcium channel blockers, and beta-blockers, dramatically reduces the associated morbidity and mortality.

4) Ulcerative colitis
Ulcerative colitis is associated with a 5% annual incidence of cancer of the colon. Confirming the diagnosis on pathology is critical to assigning the patient to a high-risk category. Diagnostic colonoscopy initially and on a 5-year term virtually eliminates the risk of death from colon cancer. Air contrast barium enema is my preferred diagnostic test because of cost and availability. Colonoscopy has a 97% detection rate, barium enema has an 86% detection rate, and stool for occult blood has a 41% detection rate.

5) Prostate cancer
Detecting and diagnosing prostate cancer in men between the ages of 40 and 60 can result in a cure for this aggressive malignancy. Annual digital rectal examination and PSA determination will diagnose the vast majority of these cancers in the curative stage. Follow-up with free PSA and then ultrasound-guided prostate biopsy clinches the diagnosis.

6) Hypercholesterolemia
Undiagnosed and untreated elevated cholesterol and/or triglycerides results in significant cardiovascular complications. The death rate for a first myocardial infarction can be as high as 30%. Treatment of this condition with statins, fibrates; or bile acid sequesterants dramatically reduces mobility and mortality.

7) Acute myocardial infarction
Any patient presenting to the office with unstable angina or preinfarction angina or myocardial infarction needs treatment and intensive supervision. Immediate transfer to an emergency department is necessary. The death rate and infarction size can be dramatically reduced by aggressive treatment.

8) Congestive heart failure
Left ventricular failure secondary to coronary artery disease and/or prior myocardial infarction has an extremely poor prognosis (50% 5-year survival) unless detected and treated. Treatment with ASA, ACE inhibitors, beta-blockers, and spironolactone dramatically reduces morbidity and mortality.

9) Epilepsy
An undiagnosed seizure disorder can cause death or severe injury if the seizure occurs while the patient is driving, bathing, swimming, or in some other precarious situation. Advice, treatment, and withdrawal of driving dramatically reduce these risks.

10) Breast cancer
Breast cancer is a common and serious malignancy of women (9% to 11% lifetime risk) that causes very significant morbidity and mortality. Early diagnosis and treatment with mastectomy can result in cure. Annual breast examination and mammography for all women between the ages of 40 and 60 can result in a significantly increased cure rate.

11) Malignant melanoma
This relatively uncommon but extremely serious form of cutaneous malignancy is most common in patients in the 40 to 60 year age group. Excisional biopsy with pathological evaluation often results in cure. An absence of treatment may result in death within 5 years. If you are not sure that the cutaneous lesion or spot is benign, remove it and send it for pathological analysis.

12) Acute lymphocytic leukemia
This condition is rare but easily diagnosed with a CBC. It is considered a medical emergency and generally treatment is initiated within 24 hours of diagnosis.

13) Asthma
Sudden death occurs in patients with asthma who are overusing rapid acting beta-agonists. Detecting this overuse and initiating more effective treatment with inhaled corticosteroids, oral corticosteroids, antibiotics, and long-acting beta-agonists will save lives.

14) Bacterial vaginitis/cervicitis and acute pelvic inflammatory disease
Untreated PID can result in pelvic abscesses and permanent infertility. Early diagnosis and effective empiric treatment can prevent these unfortunate outcomes.

15) Acute appendicitis
This condition is generally easy to diagnose (RLQ pain and tenderness) and surgical treatment offers rapid cure. There is significant potential morbidity and mortality if missed.

16) Ectopic pregnancy
The combination of a late or missed period, vaginal spotting or bleeding, and abdominal pain is an ectopic pregnancy until proven otherwise. Undiagnosed this condition can cause death. Pelvic tenderness, a positive pregnancy test, and/or an urgent pelvic ultrasound or CT scan make the diagnosis.

—Ian L. Mitchell, MD
Delta