Introduction to Family Medicine

Dr Kristen FitzGeraldDepartment of Family Medicine

Universiti Malaysia Sarawak

Definitions – “CCP model”

• Medical discipline which provides community based, continuing, comprehensive, preventative primary care

Definitions - RACGP

General Practice is the provision of primary continuing comprehensive whole-patient care to individuals, families and their communities

Scope of Family Medicine

• Interface between medicine and the community – good communication is vital

• Defined by the doctor – patient relationship rather than by a disease process. The commitment to the patient as a person is prior to any particular health problem

• must take responsible action on any problem the patient presents – scope is unlimited

• Point of first contact, enable access to health care

Scope

• Management of many common conditions• Preventative care and health promotion• Early diagnosis• Acute illness and medical emergencies• Psychological care• Chronic disease management• Palliative care

Scope

• Health Care Coordination – make appropriate referral to other doctors as well as health and community services. Assist patient in accessing health care

Nature of Family Medicine

• Patients presenting in community settings have very different problems to patients referred to hospitals

• FP’s see well patients for health promotion and preventative management

• When patients are not well they often present with vague, undifferentiated symptoms

• Multiple pathologies

Nature of Family Medicine

• Role of Family Physician to identify serious and life threatening diseases early

• Also to allay anxiety and health fears when there is no serious pathology

• 25-50% of presentations have no disease specific diagnosis even after thorough investigation

• Family Physicians need to be able to work with uncertainty and diagnostic dilemma

Illness and Disease

• Illness is a personal experience of physical or psychological disturbance encompassing sensations, feelings, disabilities and effects on activities and relationships

• Disease is the biological process physicians use to categorise and define illness.

Different Agenda

• Patients present with problems or illnesses• Patients are looking for advice, reassurance,

solutions• Doctors are interested in diseases,

classifications, diagnoses and treatments• The role of the Family Physician is to respond

to illness and recognise disease

Doctor Centered Approach

• Where management occurs according to traditional medical models of disease

• Often seen in Tertiary hospitals where patients usually have a clearly defined disease and where full range of diagnostic and treatment options are located

Patient Centered Approach

• Understanding the patient first• Understanding the patient’s disease• Negotiating a management plan with the

patient

Patients presenting problem

Medical AgendaHisory

Examinationinvestigation

Meaning of Illness for

patientExpectations

FeelingsFears

Impact on life

Negotiated with

patient

Clinical Diagnosis

Management Plan

Undifferentiated Illness

• Tiredness / fatigue• Sleeping problems• Anxiety and stress• Dizziness• Headache• Anorexia / nausea• Weight loss or gain• Pain – abdominal, chest, musculoskeletal• Sexual dysfunction

Diagnostic Strategy

Family Physicians need to develop a strategy to deal with undifferentiated illness

• Address patient’s agenda • Early Recognition of disease state• Avoid mistakes and litigation• Reduce doctor stress

Patients Agenda

Important to explore what outcome the patient desires from bringing their complaint to the doctor. May be different to Doctors agenda of diagnosis and cure

• Someone to talk to• Fears and anxieties about meaning of symptoms• Concern about a particular disease• Conflict in interpersonal relationships (advocacy)

Diagnostic Model (Murtagh)

• Probability diagnosis• Serious Disorders not to miss• What is often missed – pitfalls• Masquerades• Hidden Agendas

Probability Diagnosis

• The most likely diagnosis, not necessarily disease state

• Based on epidemiological knowledge acquired within a particular community about common illnesses

• Requires experience in community medicine

Serious Disorders

particularly those where the prognosis is changed by early diagnosis

• Neoplasia, esp malignancies• Infections (HIV/AIDS, bacterial sepsis, infective

endocarditis, tuberculosis, malaria, dengue)• Coronary Disease• Imminent or potential suicide• Intracranial lesions – SAH, SDH• Ectopic pregnancy and endometritis

Pitfalls

Non life-threatening problems that are easily overlooked, learnt by experience

• UTI• Allergy• Drugs and alcohol• Menopausal symptoms• Early pregnancy• Faecal impaction• Depression, esp with somatisation

Masquerades

Conditions which cause a non-specific “shopping list” of symptoms, sometimes with a normal physical examination

• Anaemia• UTI• Depression• Diabetes• Hypothyroidism• Chronic Renal Failure• Infections eg CMV, hepatitis, EBV• Neurological d/o – Parkinson’s, Guilliain- Barre, MS• Connective Tissue Disorders - SLE

Masquerades

• Ward Tests-Urinalysis, pregnancy test, blood sugar,

Hb• Consider pathology screen

-Full blood count, iron, electrolytes, urea, creatinine, TSH, relevant antibodies

Hidden Agendas

• “ticket of entry” where a symptom justifies attendance

• Patient may or may not have insight into this• Plea for help• Doctors need to provide an opportunity for

patients to communicate freely – listening, being non -judgmental, empathising

Case Study

Case Study

• 28 yo married woman, 3 children under 5, brings 6 month old baby for routine immunisation. In response to the Doctors question “How are you feeling?” she mentions she is very tired and has been having headaches

What to do?

In the middle of a busy clinic when the baby is the patient

• Dismiss / Reassure?• Address concerns immediately?• Return for further appointment?

How to decide

• Is this a medical emergency?• What is the patient’s agenda?

History of Presenting Complaint

• Always tired, hasn’t really recovered from the birth• doesn’t feel like getting up in the morning• Often woken by children during night• Not managing to complete daily chores• Loss of fitness and strength, doesn’t like to carry 2

year old around, requires frequent rests• Weaned baby 2 months ago but symptoms not

improved• Headache usually there, dull, makes thoughts foggy

Systems Enquiry

• Occasional dizziness and shortness of breath on exertion. No chest pain

• Weight gain• Epigastric discomfort, especially after meals• No urinary or genital system complaints• Mood – stressed, so much to do, mood a bit

low, feels overwhelmed

Examination

• Looks tired and run down• BMI 28• Afebrile and PR, BP, RR and Sa02 all within

normal range• Thyroid palpable, mild soft diffuse enlargement• 2/6 systolic murmur at lower L sternal border• Chest clear• Mild epigastric tenderness

Probability Diagnosis?

• Exhaustion• Post natal depression

Serious Conditions?

Serious Conditions

• Potential Suicide• Neoplasms• Infections

Pitfalls?

• UTI• Early pregnancy• Drugs and alcohol• depression

Masquerades?

• Anaemia• Hypothyroidism• Diabetes• UTI• Depression• Chronic Renal Failure• Infections eg CMV, hepatitis, EBV• Neurological d/o – Parkinson’s, Guilliain- Barre, MS• Connective Tissue Disorders - SLE

Hidden Agendas?

Maybe

Maybe• Relationship issues, sexual difficulties• contraception

What now?

Ward Tests

• Urinalysis normal• Pregnancy test negative• BSL 5.1

Options

• Depression Scale• Lifestyle and Nutritional Assessment• Blood Tests• Refer to hospital or specialist?• Review?

Blood Results

• Initial Laboratory ProfileHb 12.2gm/ dL (12-16) WBC 10.0 X10 9/L (4.8-19)mm3Plt 420 X10 9/L (150-450)

MCV 76 fl.( 78-96)RBC 5. 0 X10 12/L (4.2-5.4)MCH 24 pg (27-31)MCHC 34 %(32-36)Hct 40 % (37-47)

• Peripheral smear morphology shows: microcytic, hypochromic erythrocytes, poikilocytosis, occasional target and banana shaped cells. The white blood cells(WBC’s) had fairly normal morphology, and the platelet distribution was slightly increased.

Diagnosis?

• Iron deficiency Anaemia• Are other differentials excluded?

What is the likely cause?

Absorption /Use / Loss• Nutritional• Recent Pregnancy• Blood Loss from delivery

What shouldn’t you miss?

MalabsoprtionGIT loss

Management from here?

• Iron replacement therapy and review• FOB• Gastroscopy• Colonoscopy

Comprehensive Ongoing Care

• Hallmark of Family Medicine• Follow up and Review• Always be open to possibility of mixed and

new pathology