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Principles of Family Medicine The Patient Centered Clinical Method. Saudi Diploma in Family Medicine Center of Post Graduate Studies i n F amily M edicine. Presented by: Dr. Zekeriya Aktürk zekeriya.akturk@gmail.com www.aile.net. Scenario.

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slide1

Principles of Family Medicine

The Patient Centered Clinical Method

Saudi Diploma in Family Medicine

Center of Post Graduate Studies in Family Medicine

Presented by: Dr. Zekeriya Aktürk

zekeriya.akturk@gmail.com

www.aile.net

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scenario
Scenario
  • An old lady comes early in the morning complaining of dyspnea. She feels better after opening the window and sitting in front. You have a busy day and she is without appointment.
  • What is the first diagnosis you would think of?
  • Physical exam: normal.
  • What do you think now?
  • PA chest X-ray: normal
  • Did you change the order of your differential diagnoses?

McWhinney, 1997

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nex day you invite the patient with appointment
Nex day: you invite the patient with appointment
  • Detailled history
    • Main complaint: increased bowel movements
    • Awaking at night and feeling suffocating
    • Relieves in front of the window
    • Intestinal symptoms present since 20 years
    • Insomnia recently starded
    • Underwent cholecystectomy years ago: symptoms remained
    • Mastectomy due to breast CA
  • What is your first differential diagnosis ?

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slide4
More detailed history:
    • Fear of CA.
    • Widowed since severeal years; living alone
    • Landlord increased the rent without notice
    • Feels anger with the landlord
    • Two children married, living away
  • What will be your clinical approach?

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objectives
Objectives
  • At the end of this session, the participants will have knowledge on the patient centered clinical method
    • Defend the importance of patient centered clinical metnod in family practice
    • Express Levenstein’s patient centered clinical method principles
    • Discuss the diagnostic process
  • Method: interactice presentation, 15 minutes

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levenstein s model 1984
Levenstein’s model (1984)
  • Evaluating both the disease and the illness experience
    • Differential diagnosis
    • Extent of disease (effect on the feelings, expectations, ideas and functions of the patient)

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slide7

Disease

Illness

  • “Differentiated”
  • Signs and symptoms
  • Abnormal tests
  • A “classification”
  • “Unique personal experience”
  • Feelings
  • Expectations
  • Fuctions…
  • Illness is a personal perception

Doctor waves back and forth

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example increased cholesterol
Example: increased cholesterol
  • Illness
    • Ideas: no longer a healthy man
    • Feelings: fear of inability to participate family activities or even a second MI
    • Expectations: co-operation with doctor regarding diet
    • Functions: walks 6 km per day. Returned to work. Sexual activity needs to be explored
  • Disease
    • CAD, past MI
    • Obesity
    • Hypercholesterolemia
    • Rule out depresssion

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slide9
Understanding the whole person
    • “as a person” (life story, personal and developmental conditions)
    • Context (anybody being effected from the patients condition, physical environment)

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slide10

Disease

Person

Illness

Environment

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slide11
Finding common ground with the patient about the problem and its management
    • Problems and priorities
    • Treatment goals
    • Roles of doctor and patient in the treatment

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slide12
Incorporating prevention and health promotion
    • Health promotion
    • Risk reduction
    • Early diagnosis
    • Decreasing complications

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slide13
Enhancing the doctor-patient relationship
    • Features of the therapeutic relationship
    • Sharing of power
    • Care and cure
    • Self awareness
    • Transference and countertransference

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slide14
Being realistic
    • Time
    • Resources
    • Team

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the diagnostic process
The diagnostic process

Clues

Hypothesis

Unexpected clues

Review

Investigation

Finding commmon ground

Management decision

Follow up

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slide17

Clue: nocturnal dyspnea

Hypothesis: cardiac asthma

No

Hypothesis: organic disease leading to sleep disorder

Clue : abdominal discomfort, sleep disorder

No

Hypothesis: functional abdominal symptoms. Disease triggered by personal factors.

Clue : recent sleep problem

Hypothesis: insomnia decreased the tolerance for abdominal symptoms. Insomnia is related with personal problems

Clue : children living away

Hypothesis: personal problems with children

No

Clue : landlord increased the rent

Hypothesis: main problem increase of the rent

Yes

Yes

Hypothesis: cancer and op. anxiety

Clue : cancer history

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