Comprehensive, Holistic

and Level of care

Department of Community Health

& Family Medicine

Dr Samsul Bin Draman

A story from Perhentian Island

”The plane…..the plane……”

Too fast too furious

• A 27 years old woman G4P3 at 10/52

POA came at Health clinic for USG (

Unsure of date)

3/12 later, at 22/52 POA

c/o- unable to control

micturition & a/w bowel

incontinence for 1/12.

Gradual weakness of both

LL for 3/52

Unable to walk for 1/52.

No trauma or fever

• BP – 120/80

• T-35.6 C

• CVS- DRNM, Lungs- clear

• P/A- Ut 24/52

NSRt UL Lt UL Rt LL Lt LL

tone N N Increase

d

increase

d

Power 5/5 5/5 2/5 2/5

Reflexes 2+ 2+ 3+ 3+

Sensory deficit at level of T10-L4

Plantar up up

Impression

• ? Spinal cord

compression

• ? Transverse myelitis

• Refer tertiary hospital

Tertiary Hospital

• Reclerking and

rechecking

• MRI- normal

• Refused to repeat

MRI and took AOR

discharged, afraid of

radiation to baby

5 days later, went to

tertiary Hospital

• Weekly home visit by

paramedic, monthly

by medical team of

Polyclinic

2/12 after AOR D

• A 27yr old/ M/ lady , G4P3 at 34/52 POA

• c/o progressive bilateral lower limbs weakness for 6/12.Initially Lt proximal LL then to Rt proximal LL

• Associated numbness from midthoraxic region

• Urinary frequency and loose stool. Came w referral letter from a private hospital for readmission in tertiary Hospital.

• Husband – chronic cough, screening for PTB positive

Husband says

• W – Without

• I – Information

• F – Fighting

• E - Everytime

Wife says

• W – With

• I – Idiot

• F – For

• E - Ever

• Wife referred for 2nd

MRI

• Husband advised for

admission to

accompany wife and

start anti TB

• 2nd MRI-features are suggestive of an

extramedullary intradural mass.

Differentials are neurofibroma and

schwannoma

Role of MRI in pregnancy

MR 1

Introduction

• 2 MRIs performed.

• Thoracolumbar spine MRI on 23/12/03 (from T8-L5).

• MRI of the cervical spine on 14/02/2004.

• Thoracolumbar spine MRI on 23/12/03 (from T8-L5).

• Reduction of intervertebral disc space of T12/L1 with evidence of spinal stenosis or cord involvement.

• MRI of the cervical

spine on 14/02/2004.

• No IV gadolinium.

• 27 y.o G4P3 @ 36

weeks with 4/12

history of bilateral

lower limb weakness.

• A well defined extramedullary, intradural mass at C7 level.

• It is isointense on T1, slight hyperintense on T2

•

• Streaky hyperintensity of the cord on T2 , [superiorly till C5 level and inferiorly till above T2 level] - cord oedema. There is also cord expansion above and below the lesion

• It extends laterally causing widening of both side exit foraminae at C7 level.

• Spinal cord is pushed posteriorly and to the right and severely compressed at C7 level.

• No verterbal body scalloping noted

SAFETY OF

MRI

IN

PREGNANCY

X-ray imaging "No single diagnostic procedure results in a radiation dose

that threatens the well-being of the developing embryo and

fetus." – ACR.

"[Fetal] risk is considered to be negligible at 5 rad or less

when compared to the other risks of pregnancy, and the risk

of malformations is significantly increased above control

levels only at doses above 15 rad." -- National Council on

Radiation Protection (NRCP)."Women should be counseled

that x-ray exposure from a single diagnostic procedure does

not result in harmful fetal effects. Specifically, exposure to

less than 5 rad has not been associated with an increase in

fetal anomalies or pregnancy loss." -- ACOG

MRI "Although there have been no documented adverse fetal

effects reported, the National Radiological Protection

Board arbitrarily advises against its use in the first

trimester." -- ACOG and NRCP.

Ultrasound

imaging

There have been no reports of documented adverse fetal

effects for diagnostic ultrasound procedures, including

duplex Doppler imaging." "There are no

contraindications to ultrasound procedures during

pregnancy, and this modality has largely replaced x-ray

as the primary method of fetal imaging during

pregnancy." – ACOG

• A woman may fear radiation so much that she believes she should abort a fetus after exposure.

• Up to 25 % of exposed women - believe their infants are at risk for major malformation.

• Guidelines from ACOG : "Exposure to x-ray during pregnancy is not an indication for therapeutic abortion."

• Most common foetal malformations caused by high-dose radiation : are of central nervous system, primarily microcephaly and mental retardation.

• Maximal limit of ionizing radiation to which the foetus should be exposed during pregnancy is a cumulative dose of 5 rad.

Laminectomy

• Laminectomy C7 T8 +

tumour excision

• Posterior midline

approach after

delivery

• For LSCS under GA if

induction fail

• Full term SVD, a baby

girl , weight 2.8kg

D6 post SVD

• They undecided for

operation

• Discharge, TCA 2/52

• Never turn up

Problems list

• Bio:Spinal cord compression, ? Neurofibroma .Husband:TB

• Psy:Anxiety:Undecided for operation. If operated, ? prognosis. Not operated, remain paraplegic

• Social:

• Low socioeconomic group .

• Poor understanding of illness

• Social:care of

newborn baby and

others children.

• Lack continuity of

care

Low socioeconomic group

National Health Welfare Fund

( Tabung Kebajikan

Kesihatan Kebangsaan)

Criteria To Qualify For The Fund

• Malaysian citizens only

• People who are not government employees or government pensioners or relatives or government employees who enjoy medical benefits under Skim Saraubat JPA.

• The poor and underprivileged

• Patients must be referred from government hospitals

• The medical treatment sought must be found in Malaysia

Types of Assistance Considered

• Assistance in paying for the cost of medical

treatment of indigent patients where such

medical treatment is not available in hospitals

under KKM.

• Assistance in the purchase of medicine which is

not supplied by hospitals under KKM

• Assistance in payment for the purchase of

medical instruments which are not supplied

through government subsidies.

Types of Chronic Diseases

• Cancer

• Heart attack

• A) Replace or correct

defective heart valves

• B) Heart artery / Coronary

Angioplasty surgery

• Prosthetics

• ( Artificial Limbs, hands or

legs)

Application procedure

• Forms from the

Secretariat National

Health Welfare Fund ,

PERKIM building,

Ministry of health,

Malaysia

• Any government

hospital ( Unit Kerja

Sosial Perubatan atau

Unit Kebajikan

Perubatan)

Supporting documents

• IC / Birth certificate

• Medical reports- diagnosis, treatment received, treatment recommended, the place and the estimated cost of treatment.

• A socio economic report prepared by the officer of social medicine in a Government Hospital

• A copy of the salary statement and the latest KWSP statement.

Lack continuity of care

The process by which the patient and

the physician are cooperatively involved

in ongoing health care management

toward the goal of highquality and cost

effective medical care.

Continuity of Care

Starfield 1986

• Continuity of care is

associated with more

indicated preventive care,

identification of patients

psychosocial problems,

fewer emergency

hospitalizations, shorter

lengths of stay,

compliance

appointments, taking of

medication and more

timely care for problems

Shear et al (1983)

• Utilizing a retrospective cohort

study design 2 groups of pregnant

women –

• 1) Group A under family practice

centers

• 2) Group B under obstetric clinics

• Newborn infants of women in the

family practice, had much higher

birth weight even after controlling

for race, income, education and

parity of their mothers.

Wasson et al (1984)• A double blind

randomized trial elderly

men to either a “ provider

continuity group” or a “

provider discontinuity

group”.

• Found that patients in the

continuity group had

fewer emergency

admissions & shorter

hospital stays than those

in the discontinuity group.

Continuity of care

• Increased patient and provider satisfaction (Starfield,1986)

• Increased compliance

• Enhanced disclosure of psychosocial problems

• Scheduled, rather than unscheduled, contact– allows for preventive health maintenance (Billings ,1990)

• Reduced morbidity ( not mortality )

• Enhanced clinical decision making (Parchman , 2002)

• Reduced costs ( ↓ tests, visits, hospitalizations )(O‟Conner et al, 1998)

Strategies to enhance continuity of

care

• 1) A philosophical commitment– A caring , friendly and

approachable practitioner who is competent, available and trusted friend is “like gold” to his or her patient.

2) Medical record

• efficient medical

record system is

fundamental.

– Information about a

pt‟s history , visit, tests

, allergy , medications

, and preferences

3) Checklist

– use of checklist to

assemble

information on

presenting problems

will enhance

knowledge and to

diagnose disease.

4) Home visits

Information about

intrafamily dynamics

they should cement

the dr- pt relationship

if used appropriately

and discreetly.

5) Anticipatory guidance

– pts do not usually

perceive the doctor as

a counselor, but

opportunity should be

taken to advise about

anticipated problems

such as premarital

visit, antenatal care

and pre adolescent

contact

6) Patient education

– pt should be given

insight to the nature of

their illness and

reason for the

treatment and

prognosis

– pamphlets, published

in journals can be

used as a starting

point to ensure

treatment compliance.

– This will improve dr-pt

relationship.

7) Personal Health Records

– Wallets which are handed to parents of newborn babies. Place an important role on ongoing care of children.

– Supply an outline of preventive health care beginning from birth.

– Provide a complete record of healthcare throughout pt‟s life.

8) Patient register

• age and sex

registration of patient

is very important.

– The main strategy is to

find out who are the pt,

what are their basic

characteristic, and

who suffers from

chronic illnesses.

9) Recall lists

– significantly improve

health care delivery.

– Can remind pts that

preventive items e.g.

immunization schedule

and cancer smear test

are due.

10) Computer

• have simplified and streamlined the design

and use of practice registers and pts recall

systems in addition to their use for

accounting purposes.

– Potential for pt education and dr education.

Other measures

• Other measures:

– special clinics for group of pts with same

diagnosis/problems.

– Imparting caring skills to caregivers

– Group education of pts and their families.

– Decentralization of services

– Integrations of care into primary health care.

Patient‟s progress

Paraplegic

Pampers

Pressure sore

Primary care

Whole Person Approach

• Holistic Health Care approach or

Comprehensive Health Care approach

• An important approach to patient care in modern

medicine

• Determine whether there is a „hidden agenda‟ in

the presentation & whether there is stressors

including interpersonal conflicts are significant

factors in the illness.

Whole person approach is based on 2

components:

1. The disease-centred diagnosis- Traditional medical consultation model based on the

Hx, Ex and special Ix, with the emphasis on making a Dx & treating the disease

- Typical of hospital-based medicine, is defined in terms of pathology & does not focus significantly on the feelings.

2. The patient-centred diagnosis- Has been developed in the last two decades of

family medicine thinking

Patient-Centered Method

• Accounted for the diagnosed disease, its management & psychosocial hallmarks including details about

– The patient as a person

– The family

– The effects on relationships

– Work & leisure

– Lifestyle

– The environment

• The doctor has a better understanding of the patient and his disease

Hulu Tembeling

Hulu Tembeling

Compliance?

What is compliance

• Compliance is defined

as the extent to which

a persons behaviors

coincide with medical

advice

Forms of non compliance

• Failure to keep follow up appointment

• Drop out from treatment program

• Failure to have prescriptions filled

• Failure to take enough medicines

• Failure to observe the correct interval between doses

• Failure to observes correct duration of treatment

• Failure to follow advice on healthy life style

• Refuse treatment or

admission

Factors associated with poor

compliance• Psychiatric disease

• Duration of treatment

• Duration of disease-

hypertension, diabetes,

schizophrenia

• Complexity of treatment-

more evident in the older

age and the less

educated.

• Greater number of drugs

• Greater behavior demand

Improving compliance

• Used patient centered approached

• 1) explore patient belief about vulnerability

• 2) seriousness of illness and efficacy of

treatment

• Direct attention of patient and staff to the

problems of noncompliance

• Special pamphlets regarding disease and

treatment

Improving compliance

• Detect and reduce missed appointment

• Make appointment convenient

• Give specific appointment date

• Avoid long clinic waiting time

• Titrate frequency of visit to compliance

• Follow up of non attendees

Improving compliance

• Contracting with patients

• Help patient appreciate the benefit of

compliance- use feedback and positive

reinforcement

• Enlist the aids of patients family and friends

• Group discussion

• Visit patients home

Improving compliance

• Simplify treatment

regime

• Eliminate

unnecessary

medication

• Reduce the frequency

of dose

• Prescribe the least

amount of drugs to

achieve the desired

goals

•Give clear instruction for complex

treatment regimen

Maintain compliance intervention as

long as desirable

Controlled study of patient

compliance to 2 regimens of oral

Voltaren therapy

• The present study was designed to check

extent patient compliance could be

improved by reducing the daily tablet

intake from qid to od without changing the

total daily dosage of active drug.

Tablets & quantities of active drug

omitted in each treatment goup

Voltaren Dosage

per

tablet

Daily

number

of

tablets

Doses

omitted

Total

quantity

of drug

omitted

Enteric

coated

25mg 4 83 2075mg

Slow

release

100mg 1 12 1200mg

Results – therapeutic efficacy

Voltaren Excellent Good Fair Nil

Enteric

coated

10 19 8 5

Slow

release

18 13 6 4

Patients' preferences

Preference Regimen Efficacy Tolerability

Enteric

coated

2 6 0

Slow

release

25 15 17

Conclusion

• Single daily dose regimen: compliance is

better

• Quantity of drug omitted is smaller

• Patients prefer this kind of regimen

• D:\old my document\Ziarah Muslim.ppt

One of his patients said it

best: “ No one care how

much you know, until they

know how much you care”

Conclusions

D A N … I N G A A AT L A A A H ! ! !

… Sesungguhnya orang

yang paling mulia di

antara kamu di sisi Allah

ialah orang yang paling

takwa di antara kamu…

(al-Hujuraat 49 :13)

Bertakwalah kamu

kepada Allah,maka Allah

akan mengajarmu.

Al Baqarah:282

Godfearing will prevent u from

doing this

Think of your parent

Sabda Nabi Muhd SAW

• Ubatilah penyakitmu dengan sedekah .

• Belilah semua kesulitanmu dengan

sedekah .

• Bersegeralah bersedekah, sebab yang

namanya bala tidak pernah mendahului

sedekah .

• Orphans

• The poor

• The needy

Respect

• Security Officers

• Cleaners

• AVA Technicians

• Librarians

Don‟t stick to the old ways

of doing thing

Thank you

Find alternative

Nobody is perfect

Teamwork

Discharge letter contain

1)Diagnosis

2) Summary of

symptoms & PE

3)Management

plan

4)Information

given to patient

and relatives

5)Follow up

arrangements.

No one care how

much you know until

they know how much

you care.

Understand money is

not everything

Charge them