--- module: 071-01 language: en chapter: 71 title: "Primary Care, Prevention, Multimorbidity, and Continuity" module_title: "Mechanistic foundations, classification, normal variation, and clinical presentation" source_sha256: c7bdee99a0101d0538971ce16f966cf561864a5359836f6c5f9fe1de9d794b3a --- # Primary care foundations and presentation ## Scope of primary care ### Undifferentiated symptoms, prevention, chronic disease ### Unit is a person, not a disease episode #### Family, work, community, changing risk ### Longitudinal observation shifts probability #### Reveals treatment effects, permits prevention ### Familiarity must not become complacency ## Continuity as a clinical intervention ### Relational: repeated care by clinician or team ### Informational: accurate story across records ### Management: plans aligned across professionals ### Personal baseline reveals subtle decline #### Values read as trajectories ### Time reduces uncertainty if follow-up is reliable ### Hazards: anchoring, normalising, weak boundaries #### Periodic diagnostic reset ## Biological and social systems ### Disease, illness, sickness ### Symptoms from tissue, brain, emotion, context #### Not real versus psychological ### Social determinants shape exposure and capacity ### Racism and exclusion act via stress and deprivation ### Inverse care law #### Unaffordable or unreachable plan is ineffective ## Multimorbidity ### Coexisting conditions without an index disease #### Shared causes, tradeoffs, burden, competing risks ### Concordant versus discordant conditions ### Treatments synergistic, neutral, or antagonistic #### Summed guidelines give impossible regimens ### Priority by danger, burden, goals, time to benefit #### Individualisation, not age-based denial ## Chronic trajectories and adaptation ### Stable, progressive, relapsing, episodic ### Test each flare against alternatives ### Self-management capacity varies #### Reduce workload rather than blame non-compliance ### Adaptation hides decline #### Ask concrete tasks, compare with prior ability ### Response shift alters quality-of-life ratings ## Prevention across the life course ### Primordial: change conditions creating risk ### Primary: reduce disease onset ### Secondary: detect presymptomatic disease ### Tertiary: limit complications ### Quaternary: reduce harm from unnecessary medicine ### Thresholds combine absolute risk, harm, preference #### Higher baseline risk, more absolute benefit #### Offset by treatment harm, competing mortality ### Avoid framing disease as moral failure ## Common presentations by pattern ### Fatigue: broad causes, staged testing #### Untargeted tests yield incidental findings ### Persistent unexplained symptoms #### Positive formulation and rehabilitation goals #### Repeated tests raise fear and iatrogenic harm ### Usually benign, occasionally catastrophic #### Red flags have low specificity, combine them ### Mental and physical disease coexist #### Neither psychologise nor ignore emotion ## Family and community context ### Family history: genetic and shared risk ### Household shapes diet, infection, safety #### Preserve confidentiality and autonomy ### Community epidemiology changes probability #### Detect clusters, link to public health ### Commercial determinants shape exposure #### Regulation, taxation, safer defaults ### Health literacy is relational #### Plain language, teach-back, interpreters ## Watchful waiting without neglect ### Active management with planned review #### Working diagnosis, warning signs, relief ### Safe when probability low, follow-up dependable ### Unsafe if rapid deterioration or no return ### Continuity needs curiosity, access, accountability