Introduction to Family Medicine

Dr Kristen FitzGerald
Department of Family Medicine
Universiti Malaysia Sarawak
 Definitions – “CCP model”
• Medical discipline which provides community
based, continuing, comprehensive,
preventative primary care
 Definitions - RACGP
General Practice is the provision of primary
continuing comprehensive whole-patient care
to individuals, families and their communities
 Scope of Family Medicine
• Interface between medicine and the community
– good communication is vital
• Defined by the doctor – patient relationship
rather than by a disease process. The
commitment to the patient as a person is prior to
any particular health problem
• must take responsible action on any problem the
patient presents – scope is unlimited
• Point of first contact, enable access to health care
 Scope
• Management of many common conditions
• Preventative care and health promotion
• Early diagnosis
• Acute illness and medical emergencies
• Psychological care
• Chronic disease management
• Palliative care
 Scope
• Health Care Coordination – make appropriate
referral to other doctors as well as health and
community services. Assist patient in
accessing health care
 Nature of Family Medicine
• Patients presenting in community settings
have very different problems to patients
referred to hospitals
• FP’s see well patients for health promotion
and preventative management
• When patients are not well they often present
with vague, undifferentiated symptoms
• Multiple pathologies
 Nature of Family Medicine
• Role of Family Physician to identify serious and
life threatening diseases early
• Also to allay anxiety and health fears when there
is no serious pathology
• 25-50% of presentations have no disease specific
diagnosis even after thorough investigation
• Family Physicians need to be able to work with
uncertainty and diagnostic dilemma
 Illness and Disease
• Illness is a personal experience of physical or
psychological disturbance encompassing
sensations, feelings, disabilities and effects on
activities and relationships
• Disease is the biological process physicians use
to categorise and define illness.
 Different Agenda
• Patients present with problems or illnesses
• Patients are looking for advice, reassurance,
solutions
• Doctors are interested in diseases,
classifications, diagnoses and treatments
• The role of the Family Physician is to respond
to illness and recognise disease
 Doctor Centered Approach
• Where management occurs according to
traditional medical models of disease
• Often seen in Tertiary hospitals where patients
usually have a clearly defined disease and
where full range of diagnostic and treatment
options are located
 Patient Centered Approach
• Understanding the patient first
• Understanding the patient’s disease
• Negotiating a management plan with the
patient
 Patients presenting
problem

Medical Agenda
Meaning of Hisory
Illness for Examination
investigation
patient
Expectations
Feelings
Fears
Impact on life
Clinical
Diagnosis
Management
Plan

Negotiated
with
patient
 Undifferentiated Illness
• Tiredness / fatigue
• Sleeping problems
• Anxiety and stress
• Dizziness
• Headache
• Anorexia / nausea
• Weight loss or gain
• Pain – abdominal, chest, musculoskeletal
• Sexual dysfunction
 Diagnostic Strategy
Family Physicians need to develop a strategy to
deal with undifferentiated illness
• Address patient’s agenda
• Early Recognition of disease state
• Avoid mistakes and litigation
• Reduce doctor stress
 Patients Agenda
Important to explore what outcome the patient
desires from bringing their complaint to the
doctor. May be different to Doctors agenda of
diagnosis and cure
• Someone to talk to
• Fears and anxieties about meaning of symptoms
• Concern about a particular disease
• Conflict in interpersonal relationships (advocacy)
 Diagnostic Model (Murtagh)
• Probability diagnosis
• Serious Disorders not to miss
• What is often missed – pitfalls
• Masquerades
• Hidden Agendas
 Probability Diagnosis
• The most likely diagnosis, not necessarily
disease state
• Based on epidemiological knowledge acquired
within a particular community about common
illnesses
• Requires experience in community medicine
 Serious Disorders
particularly those where the prognosis is changed by
early diagnosis
• Neoplasia, esp malignancies
• Infections (HIV/AIDS, bacterial sepsis, infective
endocarditis, tuberculosis, malaria, dengue)
• Coronary Disease
• Imminent or potential suicide
• Intracranial lesions – SAH, SDH
• Ectopic pregnancy and endometritis
 Pitfalls
Non life-threatening problems that are easily
overlooked, learnt by experience
• UTI
• Allergy
• Drugs and alcohol
• Menopausal symptoms
• Early pregnancy
• Faecal impaction
• Depression, esp with somatisation
 Masquerades
Conditions which cause a non-specific “shopping list” of symptoms,
sometimes with a normal physical examination
• Anaemia
• UTI
• Depression
• Diabetes
• Hypothyroidism
• Chronic Renal Failure
• Infections eg CMV, hepatitis, EBV
• Neurological d/o – Parkinson’s, Guilliain- Barre, MS
• Connective Tissue Disorders - SLE
 Masquerades
• Ward Tests
-Urinalysis, pregnancy test, blood sugar, Hb
• Consider pathology screen
-Full blood count, iron, electrolytes, urea,
creatinine, TSH, relevant antibodies
 Hidden Agendas
• “ticket of entry” where a symptom justifies
attendance
• Patient may or may not have insight into this
• Plea for help
• Doctors need to provide an opportunity for
patients to communicate freely – listening,
being non -judgmental, empathising
Case Study
 Case Study
• 28 yo married woman, 3 children under 5,
brings 6 month old baby for routine
immunisation. In response to the Doctors
question “How are you feeling?” she mentions
she is very tired and has been having
headaches
 What to do?
In the middle of a busy clinic when the baby is
the patient
• Dismiss / Reassure?
• Address concerns immediately?
• Return for further appointment?
 How to decide
• Is this a medical emergency?
• What is the patient’s agenda?
 History of Presenting Complaint
• Always tired, hasn’t really recovered from the birth
• doesn’t feel like getting up in the morning
• Often woken by children during night
• Not managing to complete daily chores
• Loss of fitness and strength, doesn’t like to carry 2
year old around, requires frequent rests
• Weaned baby 2 months ago but symptoms not
improved
• Headache usually there, dull, makes thoughts foggy
 Systems Enquiry
• Occasional dizziness and shortness of breath
on exertion. No chest pain
• Weight gain
• Epigastric discomfort, especially after meals
• No urinary or genital system complaints
• Mood – stressed, so much to do, mood a bit
low, feels overwhelmed
 Examination
• Looks tired and run down
• BMI 28
• Afebrile and PR, BP, RR and Sa02 all within
normal range
• Thyroid palpable, mild soft diffuse enlargement
• 2/6 systolic murmur at lower L sternal border
• Chest clear
• Mild epigastric tenderness
Probability Diagnosis?
• Exhaustion
• Post natal depression
Serious Conditions?
 Serious Conditions
• Potential Suicide
• Neoplasms
• Infections
Pitfalls?
• UTI
• Early pregnancy
• Drugs and alcohol
• depression
Masquerades?
• Anaemia
• Hypothyroidism
• Diabetes
• UTI
• Depression
• Chronic Renal Failure
• Infections eg CMV, hepatitis, EBV
• Neurological d/o – Parkinson’s, Guilliain- Barre, MS
• Connective Tissue Disorders - SLE
Hidden Agendas?
 Maybe
Maybe
• Relationship issues, sexual difficulties
• contraception
What now?
 Ward Tests
• Urinalysis normal
• Pregnancy test negative
• BSL 5.1
 Options
• Depression Scale
• Lifestyle and Nutritional Assessment
• Blood Tests
• Refer to hospital or specialist?
• Review?
 Blood Results
• Initial Laboratory Profile
Hb 12.2gm/ dL (12-16)
WBC 10.0 X10 9/L (4.8-19)mm3
Plt 420 X10 9/L (150-450)

MCV 76 fl.( 78-96)

RBC 5. 0 X10 12/L (4.2-5.4)
MCH 24 pg (27-31)
MCHC 34 %(32-36)
Hct 40 % (37-47)
• Peripheral smear morphology shows:
microcytic, hypochromic erythrocytes,
poikilocytosis, occasional target and banana
shaped cells. The white blood cells(WBC’s)
had fairly normal morphology, and the platelet
distribution was slightly increased.
Diagnosis?
• Iron deficiency Anaemia
• Are other differentials excluded?
What is the likely cause?
Absorption /Use / Loss
• Nutritional
• Recent Pregnancy
• Blood Loss from delivery
What shouldn’t you miss?
Malabsoprtion
GIT loss
Management from here?
• Iron replacement therapy and review
• FOB
• Gastroscopy
• Colonoscopy
 Comprehensive Ongoing Care
• Hallmark of Family Medicine
• Follow up and Review
• Always be open to possibility of mixed and
new pathology