Download undifferentiated patient

Doç. Dr. Nurver Turfaner
Department of Family Medicine
 The patterns of disease we encounter
resemble the patterns of disease in the
whole population.
 High incidence; acute, short-termed, selflimiting
 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)
 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 undifferentiation
 The illness may be transient, acute, selflimiting; may be cured before any diagnosis
 The illness may be borderline or in between
 The 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
Organized
 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.
Reasons for not Being
Organized
 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.
 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 Diagnosis
 Getting information from the
patient
 Adding his/her experience to this
information
 Associating this information and
experience with former specified
disease patterns
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
TWO PROCESSES IN
CLINICAL DECISION
MAKING
Generalization
 Individualization

 No two patients are the same
 No two illnesses are the same
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
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
 In the primary healthcare, only 50% of
patients can be diagnosed with the
conventional classification system(e.g:
ICD 10)
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
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?
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?
PATIENT BEHAVIOR
CATEGORIES
 Tolerance limit (pain, discomfort,
disability can not be tolerated)
 Anxiety limit (e.g: hemoptysia)
 Life problems appearing as symptoms
 Administrative reasons (reports,
documents)
 Preventive care
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.
Infectious Mononucleozis-Monospot test
IMN
Monospot test
Absent
Present
Positive
17
Negative
3
Sensitivity =
a
a+c
X 100
(%85)
Specificity =
d
b+d
X 100
(%93)
a
b
c
d
69
911
Categorization Models Used in Family
Medicine
A
Emer
gent
Not A
Not
emerg
ent
A
Upper resp.
tract.inf.
B
Lower resp.
tract.inf.
Acute
abdomen
Active
rheumatism
Not
acute
abdomen
Bacterial
İnf.
Not
Psychogenic
active
rheumatism
Viral
İnf.
Organic
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
 The eliminative diagnosis of
Crombie:
To decide which diagnosis does not
exist in the patient
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.)
THE PROCESS OF PROBLEM
SOLVING
 Searches for evidence that confirms or
not confirms
 If the data does not confirm the
HINTS
 Information materials
 Single/Multiple
 Symptom (subjective)/ Sign
(objective)
 Definite/Approximate
Diagnostic Process Model
Events that stir activity
(clinical, behavoral)
Hypothesis
Re-evaluate
Investigation
Decision of
therapy
Follow-up
 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