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Principles of Family Medicine The Patient Centered Clinical Method Saudi Diploma in Family Medicine Center of Post Graduate Studies in Family Medicine Presented by: Dr. Zekeriya Aktürk [email protected] www.aile.net 1 / 17 Scenario • An old lady comes early in the morning complaining of dyspnea. She feels better after opening the window and sitting in front. You have a busy day and she is without appointment. • What is the first diagnosis you would think of? • Physical exam: normal. • What do you think now? • PA chest X-ray: normal • Did you change the order of your differential diagnoses? McWhinney, 1997 2 / 17 Nex day: you invite the patient with appointment • Detailled history – – – – – – – Main complaint: increased bowel movements Awaking at night and feeling suffocating Relieves in front of the window Intestinal symptoms present since 20 years Insomnia recently starded Underwent cholecystectomy years ago: symptoms remained Mastectomy due to breast CA • What is your first differential diagnosis ? 3 / 17 • More detailed history: – – – – – Fear of CA. Widowed since severeal years; living alone Landlord increased the rent without notice Feels anger with the landlord Two children married, living away • What will be your clinical approach? 4 / 17 Objectives • At the end of this session, the participants will have knowledge on the patient centered clinical method – Defend the importance of patient centered clinical metnod in family practice – Express Levenstein’s patient centered clinical method principles – Discuss the diagnostic process • Method: interactice presentation, 15 minutes 5 / 17 Levenstein’s model (1984) 1. Evaluating both the disease and the illness experience – – Differential diagnosis Extent of disease (effect on the feelings, expectations, ideas and functions of the patient) 6 / 17 Disease Illness “Differentiated” “Unique personal experience” • Signs and symptoms • Feelings • Abnormal tests • Expectations • A “classification” • Fuctions… • Illness is a personal perception Doctor waves back and forth 7 / 17 Example: increased cholesterol • Disease – – – – CAD, past MI Obesity Hypercholesterolemia Rule out depresssion • Illness – Ideas: no longer a healthy man – Feelings: fear of inability to participate family activities or even a second MI – Expectations: co-operation with doctor regarding diet – Functions: walks 6 km per day. Returned to work. Sexual activity needs to be explored 8 / 17 2. Understanding the whole person – – “as a person” (life story, personal and developmental conditions) Context (anybody being effected from the patients condition, physical environment) 9 / 17 Disease Person Illness Environment 10 / 17 3. Finding common ground with the patient about the problem and its management – – – Problems and priorities Treatment goals Roles of doctor and patient in the treatment 11 / 17 4. Incorporating prevention and health promotion – – – – Health promotion Risk reduction Early diagnosis Decreasing complications 12 / 17 5. Enhancing the doctor-patient relationship – – – – – Features of the therapeutic relationship Sharing of power Care and cure Self awareness Transference and countertransference 13 / 17 6. Being realistic – – – Time Resources Team 14 / 17 15 / 17 The diagnostic process Clues Hypothesis Review Unexpected clues Investigation Finding commmon ground Management decision Follow up 16 / 17 Clue: nocturnal dyspnea Hypothesis: cardiac asthma No Clue : abdominal discomfort, sleep disorder Hypothesis : organic disease leading to sleep disorder No Hypothesis : functional abdominal symptoms. Disease triggered by personal factors. Clue : recent sleep problem Hypothesis : insomnia decreased the tolerance for abdominal symptoms. Insomnia is related with personal problems Clue : children living away Hypothesis : personal problems with children No Clue : landlord increased the rent Hypothesis : main problem increase of the rent Yes Clue : cancer history Hypothesis : cancer and op. anxiety 17 / 17Yes