family medicine

FAMILY MEDICINE

ORIENTATION

FAMILY MEDICINE

PROF DR M. A. BADR

Family medicine

Prevention & health promotion

WONCA

World organization of family doctors

Family medicine

• Provide: Primary care ethics

PERSONAL

COMPREHENSIVE

CONTINUING CARE

Primary care ethics

FAMILY PHYSICIAN

• Ability to evaluate new information and its relevance to the practice

• Knowledge & skill

• Appropriate use of medical records and or other information system

FAMILY PHYSICIAN

• Efficient management of the organization or business aspects of practice

• The ability to plan and implement policies screening and preventive care

BASIC COMPONENTS

• Access to care

• Continuity of care

• Comprehensive care

• Coordination of care

• Contextual care

• Community and family based

• Evidence based health care

FAMILY MEDICINE

• STRUCTURE Presence, access,continuity

• PROCESS EBM

• OUTCOME Prevention , health promotion

COMPETENCIES OF F.P.

• Acute health problem• Chronic health problem• Provide health promotion services• Emergency services• Counseling• Preventive• Terminal and palliative• Home care

COMPETENCIES IN FMWHAT KNOW

DOIN ORDER TO BE EFFECTIVE

ORGANIZATION AND CATEGORIZATION OF

COMPETENCIES• COMMUNITY BASED

• PATIENT- PHYSICIAN RELATIONSHIP

• SKILLED CLINICIAN

• RESOURCE TO A DEFINED POPULATION

ORGANIZATION AND CATEGORIZATION OF

COMPETENCIES FM EXPERT

• COMMUNICATOR

• COLLABORATOR

• MANAGER

• HEALTH ADVOCATE

• SCHOLAR

• PROFESSIONAL

Reception

• Identification

• Appointment –Reminder communication

• Interpersonal communication

• Waiting room Hand-out, pamphlets, media,

• Call for file ( confidential)

PreventionPrevention

Patient education includePatient education include::

•Careful selection of Careful selection of footwearfootwear..

•Daily inspection of the Daily inspection of the feetfeet..

•Daily foot hygieneDaily foot hygiene..•Avoidance of self-Avoidance of self-

treatmenttreatment..•Avoidance of high-risk Avoidance of high-risk

behaviorbehavior..•Consultation if an Consultation if an

abnormality arisesabnormality arises

Documentationdouble sward

• Personal data

• Date & Time

• Communication Mobile no/ address

• File revision

• Notification about ADR allergy

• Oral anticoagulant

• Hereditary disease, sickling, G-6-P def

Physician visit

• Complaint and history of recent c/o

• > of 70% of the diagnosis

• Try to be a good listener, no interfere, interest, concentrating

• VITAL IS VITAL Temp, pulse, Bp

• Examination in the presence of a nurse

• Rapid decision if emergency hypotension

Process

• Safe

• Effective guidelines

• Efficient

• Timely

• Patient centered

• Equity discrimination

Guidelines

• Consensus

• Guidelines National, International

• Evidence based care

• Use of Algorithm and chart

• Quantitative medicine, personalized, individualized medicine

Continuous performance improvement

• Safety limit transmission of infection , hand hygiene

• Guidelines

• Keep record for your error

SOAP

• Subjective

• Objective

• Assessment, analysis

• Plan

PLAN

• Life style modification• Diet• Exercise• Sick leave• Medication• Consultation• Reference health education• Revision and follow up

Medications

• Prescription, handwriting

• Pharmacological name, dose, frequency, route, initial dose, duration, ADR

• ADR avoidable , nonavoidable

• Wrong prescription

• Role of the pharmacist

Non avoidable

• Sensitivity test

• Anaphylaxis

• Severe reaction erthyma Multiformis,Steven Jonhson

Avoidable

• Personalized Medicine pharmacogenomic, genetic make up

• Can be predictable >25% of commonly used drug (array)

MAR medication administration record

COPE computerized physician order entry

• Computerized physician order entry (CPOE) is the process of entering medication orders or other physician instructions electronically instead of on paper charts. The use of a CPOE system can help reduce errors related to poor handwriting or transcription of medication orders. Physician assistance

Personalized medicine

• Right patient

• Right treatment

• Right time

• Right dose according genetic make up of patient

Quantitative medicine is the key to reducing healthcare costs and improving

healthcare outcomes

Patients with same diagnosis

Misdiagnosed

Non-responders,toxic responders

Non-toxic responders

Asthma Drugs 40-70%Beta-2-agonists

Hypertension Drugs 10-30%ACE Inhibitors

Heart Failure Drugs 15-25% Beta Blockers

Anti Depressants 20-50%SSRIs

Cholesterol Drugs 30-70% Statins

Major drugs ineffective for many…

Source: Amy Miller, Personalized Medicine Coalition

The PromiseImagine when doctors can…

• Prevent Disease by identifying risks, early interventions

• Diagnose Conditions less Predict Disease pre-symptomatically with simple testing

• invasively, more accurately

• Select Drugs that maximize benefits and minimize risks

• Calibrate Treatments to heighten efficacy and recovery

• Treat/Cure Disease using our own genes

Take five

• BE with us

Common clinical diagnosis

• Hypertension• Chest pain , chest infection, asthma• Diabetes• GIT, jaundice ,Diarrhea• Coma & syncope• Stroke• Trauma• fever

Office BP Measurement

§ Use auscultatory method with a properly calibrated and validated instrument.

§ Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.

§ Appropriate-sized cuff should be used to ensure accuracy.

§ At least two measurements should be made.

§ Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

BP Measurement Techniques

MethodBrief Description

In-officeTwo readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoringIndicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

Self-measurementProvides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.

Blood Pressure Classification

Normal<120and<80

Prehypertension120–139or80–89

Stage 1 Hypertension140–159or90–99

Stage 2 Hypertension>160or>100

BP ClassificationSBP mmHgDBP mmHg

Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Laboratory Tests

Routine Tests• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,

and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and

low-density lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Hassan age 50 years

• Presented to you with severe throbbing headache, chills, epig pain and vomit once Past history of hypertension,dyslipidemia

• Pulse full, Bp 200/120, lung showed bilateral basal fine crepitation

• Ask the patient about important symptoms

• What you will do if you are in OPD

Hilal 18 years old known type1

• c/o of epig pain vomiting, fever , diarrhea

• He miss last night insulin dose

• He ring you this morning at 10:00

• What is your advise to Hilal

• You propose what?

Mr Hamdi 45 ys old

• Vomit this morning brown colouration vomitus after an overnight severe nausea

• Several days before he seeked the advise of the orthopedic surgeon for a low backache and girdle pain

• Ask him few question

• Decide what to do if you examine him home

Amira young female 22 years old

• C/o of vertigo, vomiting , unsteady gait associated with severe headache, she was on antibiotic because of an upper respiratory tract infection few days before

• Your examination revealed afebrile, nystagmus , brisky reflex on both LL.

• Is it serious, what you will do

Soad pregnant in her last trimest

• Referred by her obstetrician because her last urine analysis showed + sugar ,FBS is 90, her PP is 116mg%

• Is she gest diabetes

• What you will recommend

Ali young asthmatic patient

• c/o since yesterday something giving way in his rt lower chest after cough

• Today his respiration not at ease and suffer from stitching pain on the same side during walking

• Examination revealed only mild degree of fever 37.4

• Decision

60 ys old lady

• Fever, rigor, bilateral loin pain and scanty urine

• Past history of renal stones, gout, HTN,osteoathrosis

• What you will do as investigations

Ahmed 34 year old

• c/o of lower left pricking sensation in the chest

• Few day later rash appear in the same area and extend , associated with general illhealth

• What you will ask him ?

• DD

50 years old male

• C/o progressive loss of wt, anorexia, night fever

• No cough • Examination revealed significant loss wt• Few L node enlargement deep cervical

group, shotty ,rubbery not fixed • CBC lymphopenia, normocytic ,

normochromic anaemia and shooting ESR• Discuss the case and make a plan

40 years old patient

• Irregular palpitation since last night

• Past history of similar condition

• Pulse completely irregular and rapid

• Bp 120/80

• ECG AF

• Discuss the case and manage