Rational test ordering in family medicine.

A 54-year-old man, P.H., presented to his GP for a “health check.” He was well, with no relevant past medical history or family history. The GP examined him and requested “routine screening bloods” from the computer software program: full blood count; electrolyte, urea, and creatinine levels; liver function tests (LFTs); blood glucose level; lipid levels; thyroid-stimulating hormone level; iron studies; prostate-specific antigen level; and vitamin B12, folate, and vitamin D levels. The test results were all normal apart from mildly elevated transaminase levels. The GP telephoned P.H. and suggested repeating the LFTs in 1 month. The repeat test results were abnormal and P.H. was referred for hepatitis serology and an antinuclear antibody test (the results of both were normal), and for an upper abdominal ultrasound scan. The ultrasound results were normal apart from an incidental 3.5-cm lesion in the right kidney suggestive of an angiomyolipoma (AML), with a recommendation for further investigation. The patient was recalled, causing him great anxiety about a possible malignant cause. A computed tomography (CT) scan confirmed the AML, although it led to a further recommendation for followup in 12 months to monitor size. Repeat LFT results were normal.