MBBS IV Family Medicine – Seminar 1

Family Medicine - Consultation

 Consultation: a formalized interaction between a doctor and a patient (+/- family)
 Primary care:
o First contact: may not be ill (need something from doctor)
o Serving as point of entry for patients into the healthcare system
o Comprehensive, involving any discipline
o Continuity (in sickness/ in health)
o Coordinated
o Whole-person/personalized
o Time pressured (impatient – make sure questions are relevant!)

Types of primary care consultation

 Patient initiated – understand why they come
o Walk-in (more urgent)/booking
o Symptom or sign (mostly symptom): know why patient is at consultation -
limits of tolerance (need medications), anxiety (reassurance? further
investigations?)  can change management
o Administrative: review of condition, get prescription, sick leave, referral,
certificate, medical report, reassurance (worried – means that something is
wrong with the body), allowance (compassionate re-housing, financial
allowance, handicapped parking spots)
o Preventive care: body check, vaccination, travel advices, health advices (need
certain drugs for particular travels?)
o Problems with living/hidden agenda
 Doctor initiated – usually not first booking
o Subsequent scheduled appointment/followup/call back
o Call back for review of abnormal investigation results
o Review continuing conditions
o Minor procedures, wound management
o Preventive care: body check, vaccination

Potentials in each primary care consultation

 1. Management of presenting problems
o History of presenting illness
o Aetiology (risk factors)
o  Make diagnosis
 2. Management of continuing problems
o Past medical Hx, drug Hx, social Hx
 3. Modification of health seeking behaviour
o Health seeking behaviour: doctor shopping, frequent attendees, late
presentation
o Tell patients about certain red flags/when to seek help
 4. Opportunistic health promotion
o Health risks: smoking, alcohol, diet, physical activity (sedentary lifestyle),
mental and sexual health
o Education for certain illnesses
MBBS IV Family Medicine – Seminar 1

Focused history of presenting problems

 New symptoms
o Nature of presenting problems (OPQRST, associated +/- symptoms)
 Existing condition
o Disease control: e.g. blood pressure measurements, asthma – nocturnal
symptoms, walking up slope, frequency of inhaler use
o Presence of complications (acute or chronic)
o Compliance to treatment (drug and lifestyle)
 Administrative
o Reasons – justified? – signing particular forms? allowances?
 Ask why they need it – underlying condition/situation they have
o Details of conditions
 Health check (+/- due to fear of disease)
o Symptoms of feared disease
o Risk factors
o Indications and contraindications of tests (e.g. MRI – ask claustrophobia)
 Abnormal investigation results
o Possible/probable causes of abnormal results (e.g. electrolyte disturbances 
then followup with questions that may figure out why there are abnormal
results)

Top 30 presenting symptoms in primary care (first column)

MBBS IV Family Medicine – Seminar 1

Case study: insomnia

 Chief complaint: didn't sleep well yesterday night
 Risk factors: Age? Occupation? Socio-demographics? Personality?
 Idea: PMH, past experience, risk factors, culture (shape health belief)?
 Concerns/expectations: impact on daily living/work/family relations (psychosocial)

Models of consultation – 5 tasks (Pendleton)

 1. To define reason for patient’s attendance (presenting problem):
o Nature and history of problems
o Aetiology
o Patient’s ideas, concerns, and expectations
o Impact/effect of the problems
 2. To consider other issues (treat beyond the condition)
o Continuing problems
o Risk factors (modifiable vs non-modifiable)
 3. Choose appropriate action for each problem together with the patient
o Collect necessary information from the history – cover enough!
 4. Achieve shared understanding of problems with the patient
o Explain to patient what you have thought of
 5. Involve patient in the management and encourage
 *ICE: “Have you thought of why do you have these symptoms?” – at around 3 minutes
(can go back to history of presenting of illness after ICE since doc/patient discrepancy)

Patient centred diagnosis/consultation  biopsychosocial problem/ddx list!

 Psychosocial hallmarks (relevance)
o Patient as person (family, social aspect)
o Ideas, concerns, expectations

Ideas, concerns, expectations – based on health beliefs – allow patient to say WHY
 Ideas: own ideas about nature of problem and causes
 Concerns: importance and possible outcomes
 Expectations: aims of the consultation
  Exploring the ICE
o What do you really think deep down is the cause of problem?
o Do you have any particular concern about your health?
o “People with this symptom would worry about …., what about you?”

Effective consultation (example 76y/o lady with mechanical knee pain) - relevance
 HPI: joint swelling, redness, morning stiffness, hip pain
 Aetiology: past med Hx, drug Hx, obesity, gout, renal/stomach, analgesic choice
 Ideas: thinks she has osteoporosis (achy, lumbar spine/hip, asymptomatic till fracture)
 Concerns: osteoporosis leading to fracture
 Expectations
 Effects of problems of the illness on patient
 Continuing problems
 Psychosocial factors: mood, social, family, job
 Hidden agenda
 - ddx? - most likely dx? OA
o OA: weight bearing joints? occupation?
o Red flag: RA: morning stiffness, joint inflammation – heat/swelling
MBBS IV Family Medicine – Seminar 1

o Missed: referred pain (above and below)