Three-stage assessment

in Family Medicine
By
Dr. Jude Tadeo Onyango
Lecturer, Dep’t. Family Medicine,
Sch. Medicine, Mak CHS
 Introduction

• Pursue excellence in patient care in Family Practice

• Excellence in care by taking the person as a whole

• Looking at systems and their interrelationships

• Use a Holistic, patient centred clinical method

• A practical tool used to assess patients holistically (Fehrsen
& Henbest, 1993)
• Referred to as an assessment rather than a diagnosis
• In Family Practice very often patients present ;
- early during disease process, no physical signs, no organic
pathology
- psychosocial problems
- physical signs that have an emotional or psychosocial basis
• Patient and physician deal holistically with the problem
• Biological, psychological and environmental systems &
their interrelationships. Impact on health & illness
• Arrive at a 'best-fit' understanding of a person's problem, by
the doctor and the patient together
• Individualize assessment and management
• Excellence in care and better health outcomes more likely if
care is given in an individualized way within a systems
understanding
 Three-stage assessment process

• Takes place at two levels: Assessment and

Management
Assessment Management plan
• Framework:
Clinical
(Biological/Biomed
ical)
Individual
(Psychosocial/psyc
hological)
Contextual (micro
& macro
environment)
 Clinical component

• Biomedical: Symptoms, signs and investigations

relating to the patient’s disease
• Recorded at highest level of certainty e.g. , a
patient could be assessed initially as ‘jaundice-
cause?’ or with more certainty as ‘hepato cellular
jaundice’ or with complete diagnostic certainty as
‘acute viral hepatitis B’
 Individual component

• Patient’s experience of illness. His or her

perception of the problem
• Includes ideas, fears, expectations, feelings,
concerns, beliefs, loss of function, and any other
important emotions or reactions
 Contextual component

• How patient’s environment affects the patient &

• How patient’s illness impacts on his or her
environment
• Includes; social system- person’s family
(genogram), life stage, work, community (ecomap),
physical environment, etc
 Case I
• A 56/F housewife presents with head ache & failure to sleep. Head
ache has been present for 4 weeks and feels like a pressure band
around her head. She also feels tired. Her documents show that she
was previously treated with Amitriptyline which relieved the pain.
She would prefer to be given the same treatment again. She is
married with four adult children who live in the same home. Her
husband consumes a lot of alcohol on a regular basis and is un able
to provide for the home. Non of her children has made it beyond
ordinary level secondary education or is gainfully employed. She
believes her symptoms are due to her husband’s behavior. Her
husband is a graduate mechanic who owns a mechanical work shop
in town where he works.
 Three stage assessment for case
I
Assessment Management plan
Clinical Chronic tension headache Tab Amitriptyline – 25mg at
Insomnia night
Tab Paracetamol as needed
Address sleep problem

Individual Believes that her symptoms Refer to social worker to

have a direct relationship to
husband’s drinking habits
Concerned about financial
position
Wants the same medication
as before
discuss husband’s drinking
problem
Explain that medication
gives only symptomatic
relief and that other
problems will have be
addressed

Contextual Lives with husband and adult Discuss the possibility of her
children in a two roomed seeking employment
house Return for follow up visit
Housewife with no income
of her own
 Case II
•A 34 year old male, single, secondary school teacher in Mbale district and a
Japadhola originating from Tororo district both located in the eastern part of Uganda
was brought by a relative who is a second year undergraduate medical student at
MakCHS to the Family medicine department for consultation about his health
problems. His concern was his progressive loss of weight which was initially noticed
by relatives, friends and work mates. Over the last 12 months, his weight has gone
down from 86 kgs when he last measured to a current weight of 60 kgs and he has
failed to understand why. When probed further, he said currently he needs to drink
about 6 Tampico cups of water through the night and has had some numb feeling in
his limbs for a period he could not specify. He has been on various medications both
traditional and modern medicines without much change in his symptoms. He is
convinced that his condition arises from problems he has had with his extended
family members over land issues and only came because his relative convinced him
to try Kampala for a solution.
 Case III
•A 25 year old female from Namuwongo presented to the Kisugu health center III
with a h/o fever and diarrhea for 2/52, associated with vomiting, dizziness,
dyspnea on exertion, productive cough, significant weight loss and myalgia. She
makes and sells chapatti and fresh juice at the road side for a living next to her
one roomed house. She lives alone with two children who are three and one year
old respectively, both from different fathers. In her ‘past medical history’, she
had a C/S two years ago and a surgical termination of pregnancy one month
prior to becoming ill. She was not on any medications before the visit to the
health center. She denies any use of cigarettes, illicit drugs or alcohol. She had
never had an HIV test before. O/E, she appeared fatigued, but in no distress. Her
temperature was 38.5 oC, blood pressure 100/70 mmHg, heart rate 100/min and
respiratory rate 18/min.
 
 Case IV
• A 36 year old man presents with an six day history of
productive cough. The sputum is greenish in color. He felt
feverish as well. He fears he has contracted TB. Further more
his previous problem of backache has started to disable and
worry him again. He wants medicine that can cure the back
problem once and for all. He thinks he might be retrenched
because of his illness. He has been a widower for one year now
with four dependent children living with him in a one bed
roomed house. He works in Kakira sugar factory located in
Jinja district in eastern Uganda where he lifts sacks of sugar on
to tracks for transportation to the capital city Kampala.
• THANK YOU FOR LISTENING