UNDIFFERENTIATED PATIENT

Doç. Dr. Nurver Turfaner Department of Family Medicine

Problem Solving Strategies in Family Medicine

The patterns of disease we encounter resemble the patterns of disease in the whole population.

High incidence; acute, short-termed, self-limiting

High prevalance; ChronicWhen 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 undifferentiationThe illness may be transient, acute, self-

limiting; may be cured before any diagnosisThe illness may be borderline or in betweenThe 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 OrganizedThe 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.

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.

Reasons for not Being Organized

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 DiagnosesPlanning the treatment of diseasePredicting the prognosisUnderstanding the etiology, cause of

disease and risk factorsBeing able to anticipate atypical

situationsCooperation, communication and

unification of terminology with other clinicians

TWO PROCESSES IN CLINICAL DECISION MAKING GeneralizationIndividualization

No two patients are the sameNo two illnesses are the same

DECISION MAKINGDiagnosis (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 MAKINGThe 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 study62 family health centersCoughing and chest auscultation

signs in 163 patientsLaboratory and imaging procedures

have not been usedAntibiotics are prescribed to 153

(93%) patientsCONCLUSIONPhysicians use symptoms and signs

in diagnosis and treatment

UNDERSTANDING PATIENT BEHAVIORWhy 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 BEHAVIORWhat 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 CATEGORIESTolerance limit (pain, discomfort,

disability can not be tolerated)Anxiety limit (e.g: hemoptysia)Life problems appearing as

symptomsAdministrative reasons (reports,

documents)Preventive care

THE TWO FEATURES OF SYMPTOMIt’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

Monospot test

Positive

Negative

Present Absent

IMN

17

3

69

911

a

c

b

d

Sensitivity =a

a + c X 100

Specificity = d b + d

X 100

(%85)

(%93)

A Not A A B

Emergent

Not emerg

ent

Categorization Models Used in Family Medicine

Upper resp.tract.inf.

Lower resp.tract.inf.

Bacterialİnf.

Acute abdomen

Not acute

abdomen

Viralİnf.

Activerheumatism

Notactive

rheumatism

Psychogenic Organic

ATTENTION TO CATEGORIZATIONThe 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 SOLVINGThe clinician encounters with the problemForms at least one or at most, on the

average 2-5 hypothesisBegins investigation (history,

physical examination, laboratory, imaging, etc.)

THE PROCESS OF PROBLEM SOLVINGSearches for evidence that confirms

or not confirmsIf the data does not confirm the

HINTSInformation materials Single/MultipleSymptom (subjective)/ Sign (objective)

Definite/Approximate

Events that stir activity(clinical, behavoral)

Diagnostic Process Model

Hypothesis

Investigation

Decision of therapy

Follow-up

Re-evaluate

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