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UNDIFFERENTIATED PATIENT. Doç. Dr. Nurver Turfaner Department of Family Medicine. Problem Solving Strategies in Family Medicine. The patterns of disease we encounter resemble the patterns of disease in the whole population. High incidence ; acute, short-termed, self-limiting - PowerPoint PPT Presentation
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UNDIFFERENTIATED PATIENT
Doç. Dr. Nurver Turfaner Department of Family Medicine
Problem Solving Strategies in Family Medicine
The patterns of disease we encounter resemble the patterns of disease in the whole population.
High incidence; acute, short-termed, self-limiting
High prevalance; ChronicWhen the patient admits to the family
physician, the clinical problem is not differentiated and organized.
All the problems should be considered without any limitations (Stipulation)
Incidence: Number of new diagnosed patients over a given period of time /Whole population X 100
Prevalance: Patients who have a defined disease at a given point in time (sum of new and old cases)
Undifferentiated Clinical Picture
A clinical situation which is not formerly evaluated, categorized or named by a physician.
Reasons for undifferentiationThe illness may be transient, acute, self-
limiting; may be cured before any diagnosisThe illness may be borderline or in betweenThe nature of the disease may be that it
does not differentiate for a long period; e.g (transient blurring of vision and multiple sclerosis)
The disease may be associated with personality traits, aging and stages of the life cycle; e.g: chronic pain
A Clinical Picture That is not Organized
Patient does not know the cause and effect relations of his complaints when
he applies to the doctor for the first time.
Reasons for not Being OrganizedThe patient talks about different
kinds of problems at the same time. There is no priority in the sequence
of the problems.The most important problem may be
presented as the last one.
The most critical problem may be expressed in an indirect or metaphoric way.
The problem of the patient may not be associated with the real disease.
The patient may give needless information.
Reasons for not Being Organized
Physicians should be able to make a correct diagnosis at the early stages of diseases.
As physicians have continious relations with patients, they have sufficient time for correct diagnosis.
Physicians have the opportunity for observing the accuracy of their preliminary diagnosis.
Physicians should be able to find the primary problem and be able to solve it.
Family Physicians have two goals when solving clinical problems
Differentiating serious major and life-threatening situations from minor ones in the early period.
Handling the patients problems with a biopsychosocial approach.
Process of DiagnosisGetting information from the patient
Adding his/her experience to this information
Associating this information and experience with former specified disease patterns
Purpose of DiagnosesPlanning the treatment of diseasePredicting the prognosisUnderstanding the etiology, cause of
disease and risk factorsBeing able to anticipate atypical
situationsCooperation, communication and
unification of terminology with other clinicians
TWO PROCESSES IN CLINICAL DECISION MAKING GeneralizationIndividualization
No two patients are the sameNo two illnesses are the same
DECISION MAKINGDiagnosis (categorization and naming) is an important component of problem solving
The clinician should be able to make complicated and difficult decisions which include concepts like risk, benefit, prognosis and ethics
DECISION MAKINGThe clinician should be able to handle
together personal and environmental conditions
The clinician should be able to involve the patient in decision making process
In the primary healthcare, only 50% of patients can be diagnosed with the conventional classification system(e.g: ICD 10)
Foreign study62 family health centersCoughing and chest auscultation
signs in 163 patientsLaboratory and imaging procedures
have not been usedAntibiotics are prescribed to 153
(93%) patientsCONCLUSIONPhysicians use symptoms and signs
in diagnosis and treatment
UNDERSTANDING PATIENT BEHAVIORWhy did the patient come? The real reason for coming?(secret agenda)(the hand on the door knocker syndrome)
Why did the patient come on this day and at this time?
What does the patient want to tell with his complaints?
UNDERSTANDING PATIENT BEHAVIORWhat kind of language and expression does the patient use?
How does the patient perceive the problems?
The real problem?The relationship of problems with life-stages and conditions?
PATIENT BEHAVIOR CATEGORIESTolerance limit (pain, discomfort,
disability can not be tolerated)Anxiety limit (e.g: hemoptysia)Life problems appearing as
symptomsAdministrative reasons (reports,
documents)Preventive care
THE TWO FEATURES OF SYMPTOMIt’s capacity to bring the patient to the doctor; (it’s importance for the patient) (iatrophic stimulus) (e.g:hemoptysia-coughing)
The sensitivity, specificity,and positive and negative predictive values of the symptom, sign or test.
Infectious Mononucleozis-Monospot test
Monospot test
Positive
Negative
Present Absent
IMN
17
3
69
911
a
c
b
d
Sensitivity =a
a + c X 100
Specificity = d b + d X 100
(%85)
(%93)
A Not A A B
Emergent
Not emerg
ent
Categorization Models Used in Family Medicine
Upper resp.tract.inf.
Lower resp.tract.inf.
Bacterialİnf.
Acute abdomen
Not acute
abdomen Viralİnf.
Activerheumatism
Notactive
rheumatismPsychogenic Organic
ATTENTION TO CATEGORIZATIONThe problem of the patient may be present in two categories at the same time (e.g: both psychogenic and organic or both upper and lower respiratory tract infections)
The category may change with time
The eliminative diagnosis of Crombie:
To decide which diagnosis does not exist in the patient
THE PROCESS OF PROBLEM SOLVINGThe clinician encounters with the problemForms at least one or at most, on the
average 2-5 hypothesisBegins investigation (history,
physical examination, laboratory, imaging, etc.)
THE PROCESS OF PROBLEM SOLVINGSearches for evidence that confirms
or not confirmsIf the data does not confirm the
HINTSInformation materials Single/MultipleSymptom (subjective)/ Sign (objective)
Definite/Approximate
Events that stir activity(clinical, behavoral)
Diagnostic Process Model
Hypothesis
Investigation
Decision of therapy
Follow-up
Re-evaluate
Since the patients apply in the early period in Family Medicine, ‘Symptoms’ are more important for diagnosis
Even if the family physician sees one case in 10 years,(low prevalance clinician), he must not miss a subarachnoidal bleeding in a patient applying with a headache.
THANK YOU FOR YOUR ATTENTION