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UNDIFFERENTIATED PATIENT

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

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UNDIFFERENTIATED PATIENT

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  1. UNDIFFERENTIATED PATIENT Doç. Dr. NurverTurfaner Department of Family Medicine

  2. Problem SolvingStrategies in FamilyMedicine

  3. The patterns of disease we encounter resemble the patterns of disease in the whole population. • High incidence; acute, short-termed, self-limiting • High prevalance; Chronic • When 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)

  4. 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)

  5. Undifferentiated Clinical Picture • A clinical situation which is not formerly evaluated, categorized or named by a physician.

  6. Reasonsforundifferentiation • Theillnessmay be transient, acute, self-limiting; may be curedbeforeanydiagnosis • Theillnessmay be borderlineor in between • Thenature of thediseasemay be that it does not differentiatefor a longperiod; e.g (transientblurring of visionandmultiplesclerosis) • Thediseasemay be associatedwithpersonalitytraits, agingandstages of the life cycle; e.g: chronicpain

  7. 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.

  8. Reasonsfor not BeingOrganized • The 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.

  9. Reasonsfor not BeingOrganized • The most critical problemmaybe 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.

  10. 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.

  11. FamilyPhysicianshavetwogoalswhensolvingclinicalproblems • Differentiating serious major and life-threatening situations from minor ones in the early period. • Handling the patients problems with a biopsychosocial approach.

  12. Process of Diagnosis • Gettinginformationfromthepatient • Adding his/her experiencetothisinformation • Associatingthisinformationandexperiencewithformerspecifieddiseasepatterns

  13. Purpose of Diagnoses • Planning the treatment of disease • Predicting the prognosis • Understanding the etiology, cause of disease and risk factors • Being able to anticipate atypical situations • Cooperation, communication and unification of terminology with other clinicians

  14. TWO PROCESSES IN CLINICAL DECISION MAKING • Generalization • Individualization • No two patients are the same • No two illnesses are the same

  15. DECISION MAKING • Diagnosis (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

  16. DECISION MAKING • The clinician should be able to handle together personal and environmental conditions • The clinician should be able to involve the patient in decision making process • Intheprimaryhealthcare, only 50% of patients can be diagnosedwiththeconventionalclassificationsystem(e.g: ICD 10)

  17. Foreign study • 62 family health centers • Coughing and chest auscultation signs in 163 patients • Laboratory and imaging procedures have not been used • Antibiotics are prescribed to 153 (93%) patients • CONCLUSION • Physicians use symptoms and signs in diagnosis and treatment

  18. UNDERSTANDING PATIENT BEHAVIOR • Why 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?

  19. UNDERSTANDING PATIENT BEHAVIOR • What 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?

  20. PATIENT BEHAVIOR CATEGORIES • Tolerance limit (pain, discomfort, disability can not be tolerated) • Anxiety limit (e.g: hemoptysia) • Life problemsappearing as symptoms • Administrativereasons (reports, documents) • Preventivecare

  21. THE TWO FEATURES OF SYMPTOM • It’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.

  22. InfectiousMononucleozis-Monospot test IMN Present Monospot test Absent Positive 17 69 a b c d 3 911 Negative a a + c X 100 Sensitivity= (%85) d b + d Specificity = X 100 (%93)

  23. Categorization Models Used in Family Medicine A B A Not A Not emerg ent Emer gent Lower resp. tract.inf. Upper resp. tract.inf.

  24. Not acute abdomen Viral İnf. Acute abdomen Bacterial İnf. Psychogenic Organic Active rheumatism Not active rheumatism

  25. ATTENTION TO CATEGORIZATION • The 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

  26. The eliminative diagnosis of Crombie: To decide which diagnosis does not exist in the patient

  27. THE PROCESS OF PROBLEM SOLVING • The clinician encounters with the problem • Forms at least one or at most, on the average 2-5 hypothesis • Begins investigation (history, physical examination, laboratory, imaging, etc.)

  28. THE PROCESS OF PROBLEM SOLVING • Searches for evidence that confirms or not confirms • If the data does not confirm the

  29. HINTS • Information materials • Single/Multiple • Symptom (subjective)/ Sign (objective) • Definite/Approximate

  30. Diagnostic Process Model Events that stir activity (clinical, behavoral) Hypothesis Re-evaluate Investigation Decision of therapy Follow-up

  31. Since thepatientsapply in theearlyperiod in FamilyMedicine, ‘Symptoms’ aremoreimportantfordiagnosis • Evenifthefamilyphysicianseesonecase in 10 years,(lowprevalanceclinician), he must not miss a subarachnoidalbleeding in a patientapplyingwith a headache.

  32. THANK YOU FOR YOUR ATTENTION

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