Diagnosis holistic in Comprehensive Care

at Primary Health Centre

Yudhi Wibowo, MD

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NUMBER OF PERSONS EXPERIENCING AN ILLNESS DURING AN AVERAGE MONTH, PER 1000 POPULATIONS1000 people

800 have symptoms327 consider seeking medical care217 physician’ office113 visit primary care

65 CAM provider21 hospital outpatient clinic

14 home health13 emergency department

8 are in hospital< 1 in an academic health centre

Green LA,Fryer GE Jr,Yawn BP, Lanier D,Dovey SM. The ecology of medical care revisited.N Eng j Med 2001;344:2021-2025

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What are the attributes ofcommunity physician?

The attributes as follows ………….

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The community physician (included occupational physician & family physician) give services with:

1. Comprehensive care2. Family & community oriented3. Continuous care4. Working in team

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Comprehensive • Integrated; health promotion, disease prevention,

curative care, rehabilitation, not only physical,but also psychosocial problems

• To individuals, in the context of family circumstances at their live and work

• Addresses the unselected health complaint or problems

• Any kind of age, sex, social class, race and religions

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Family & community oriented • The patient’s problems should be seen in the context of

his/her life in the family/ local community

• Should be aware of the family /community health needs

• Collaborate with other professionals, agencies from other sectors

• Initiate positive changes in family/ local health problems

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Continuous care • Person center

• Long-standing personal relationship between patient and doctor

• Not limited in certain time of illness episode

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Primary health care teams •Basic team

Physicians, nurses, medical assistants, midwives, social workers, community health workers and family member as caregiver

•Supportive members Receptionist,secretaries,administrators, health educators, laboratory, pharmacy and radiologist

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Characteristic of primary health care 1. Personal

2. First contact

3. Continuous

4. Comprehensive

5. Coordinated with specialists and other health professionals

6. Cost effective

7. High quality

8. Equitable distributed

9. Community, family oriented, partnerships

10. Accountable

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Characteristic of family medicine approach

The medical care which:1. Holistic and comprehensive2. Continuum3. Prevention care priority4. Coordinative and collaborative5. Personal care as integral member of a family6. Concern to the family, work environment, and

living environment 7. Ethical and law concern8. Finance and quality control9. Auditable

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Primary health care practitioners

•Holistic, comprehensive approach due to the professional value

(Multidisciplinary approach )

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The principles of practice, based on:

•Epidemiological health services aspect,Investigation on : •signs and symptoms, •the internal risk and external risk factors •the social backgroundin purpose for health promotion, disease prevention,cure,care and rehabilitation

•Management health services aspect,•Provide the effective ,efficient and quality health service to achieve optimal health outcome

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Diagnosis in primary health care services

• The act of determining the nature of disease

• Diagnosis involves interviewing, observing patients and physical examination and any kind supporting tests over a period of time.

• Diagnosis is a sequence of actions rather then single investigations.

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Diagnosis• Physical diagnosis

• Laboratory diagnosis

• Microscopical diagnosis

• Clinical diagnosis

• Working Diagnosis

• Differential diagnosis

• Holistic diagnosis

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The disease-centred dx

HistoryExam

Special inves

Emphasis on making dx & treating the

disease

Etiology of disease

Another dimension (psychosocial hallmark):•The patient as a person•Emotional reactions to the illness•The family•The effect on relationship•Work•Lifestyle•The environment

The patient centred dx

WHOLE PERSON APPROACH

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How the diagnostic process could focus on the implemented holistic patient daily life ?

1.Interview; complains, reasons of encounter, hopes, and worries

2.Clinical Observation; physical examination findings, supporting tests

3.Analysis; clinical data, individual & family health problems & risk factors

• What kind of diseases • Who gets the disease• Why it happened (confounding & determinant factor)• What the functional status (based on physical disability)• What is the decision (based on evidence)

4.Diagnosis Holistic

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Holistic diagnosis(multi aspects& multidisciplinary approach)

• 1st aspect: • Chief complain• Fear• Wishes/ hope

• 2nd aspect:• Clinical diagnosis & differential diagnosis

• 3rd aspect:• Health behavior & perception (internal risk/confounding

fs)• 4th aspect:

• Family’s psychosocial & economy problems, occupation & environment factors (external risk factors/determinant)

• 5th aspect:• Social function scale

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Examplecase: Mr.A.36 yo, security in Kelurahan Office, unmarried, live with his sister who married with 3 children

I: - Productive cough no blood-tinged since 1 month - going to be worst condition - possible to cure II: - Pulmonum tuberculosis with acid-fast bacili (+), broad lesion & left lung fibrosis - Obesity - Suspect Diabetes MellitusIII: - drop out from anti-tuberculosis treatment after 1 month - lack motivation and supporting behavior - unmarried & dependentIV: - less harmony interpersonal relationship with brother in law - no family participation in patient management - high risk transmitted in the family - un-comfort living for patient and familyV: functional scale: 2 (partly willingness, provider dependency)

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comprehensive planning• A. Patient-centered:

– Therapy of PTB by long term 3 combinations drug therapy (package 2)

– Special diet with adjusting of family capacity (lower calorie, high protein & zinc)

– Supportive therapy by vitamin B6 – Special attention on blood glucose– Special attention on PTB complication and drug

compliance per 2 weeks in 2 month, and monthly on 3rd -6th months after.

– Chest exercise after treatment when necessary– Regular exercise

– B.......QuickTime™ and a

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comprehensive planning• B. Family-focused:

– Assigned possible caregiver in the family– PTB guidance of treatment to his caregivers– Active screening of PTB of all family member to find the

contact source and in purpose of early detection– Nutrition guidance for all family member with adjusting of

family resources– Preventive care guidance for all family member

• C. Community-oriented:– Circulation and ventilation guidance at house– Case infectious disease report to local government to be

active screening for PTB in the living area of the patient

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Sources

1. Charles Boelen, Cynthia Haq, Vincent Hunt, Marc Rivo & Edward Shahady, Improving Health Systems ; The contribution of Family Medicine, Family Doctors in Health systems; Wonca 2002 :37-47

2. Bruce E.Johnson, Osteoartritis, Current Diagnosis and Treatment in Family Medicine , International Ed. Lange Medical Books /Mc Graw-Hill USA; copyright 2004: 265-271

3. Robert E Rakel, Essentials of Family Mediicne, 3rd ed.Saunders elseviers, 2006

4. Robert E Rakel, Textbook of Family Medicine, 7th ed.Saunders elseviers, 2007

5. Nitra Nirwani , Diagnosis Holistik pada Pelayanan Kesehatan Primer, IKK FKUI;2008

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Thank you for your kind attention