Doç. Dr. Nurver Turfaner Department of 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; Chronic When 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 undifferentiation The illness may be transient, acute, self- limiting; may be cured before any diagnosis The illness may be borderline or in between The 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 T hat 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 Organized The 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 Diagnoses Planning the treatment of disease Predicting the prognosis Understanding the etiology, cause of disease and risk factors Being able to anticipate atypical situations Cooperation, communication and unification of terminology with other clinicians

TWO PROCESSES IN CLINICAL DECISION MAKING Generalization Individualization No two patients are the same No two illnesses are the same

DECISION MAKING Diagnosis (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 MAKING The 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 study 62 family health centers Coughing and chest auscultation signs in 163 patients Laboratory and imaging procedures have not been used Antibiotics are prescribed to 153 (93%) patients CONCLUSION Physicians use symptoms and signs in diagnosis and treatment

UNDERSTANDING PATIENT BEHAVIOR Why 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 BEHAVIOR What 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 CATEGORIES Tolerance limit (pain, discomfort, disability can not be tolerated) Anxiety limit (e.g: hemoptysia) Life problems appearing as symptoms Administrative reasons (reports, documents) Preventive care

THE TWO FEATURES OF SYMPTOM It’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 a c b d Sensitivity = a a + c X 100 Specificity = d b + d X 100 (%85) (%93)

ANot A AB Emer gen t Not emerg ent Categorization Models Used in Family Medicine Upper resp. tract.inf. Lower resp. tract.inf.

Bacterial İnf. Acute abdomen Not acute abdomen Viral İnf. Active rheumatism Not active rheumatism Psychogenic Organic

ATTENTION TO CATEGORIZATION The 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 SOLVING The clinician encounters with the problem Forms at least one or at most, on the average 2-5 hypothesis Begins investigation (history, physical examination, laboratory, imaging, etc.)

THE PROCESS OF PROBLEM SOLVING Searches for evidence that confirms or not confirms If the data does not confirm the

HINTS Information materials Single/Multiple Symptom (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