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Family medicine
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FAMILY MEDICINE
ORIENTATION
FAMILY MEDICINE
PROF DR M. A. BADR
Family medicine
Prevention & health promotion
WONCA
World organization of family doctors
Family medicine
• Provide: Primary care ethics
PERSONAL
COMPREHENSIVE
CONTINUING CARE
Primary care ethics
FAMILY PHYSICIAN
• Ability to evaluate new information and its relevance to the practice
• Knowledge & skill
• Appropriate use of medical records and or other information system
FAMILY PHYSICIAN
• Efficient management of the organization or business aspects of practice
• The ability to plan and implement policies screening and preventive care
BASIC COMPONENTS
• Access to care
• Continuity of care
• Comprehensive care
• Coordination of care
• Contextual care
• Community and family based
• Evidence based health care
FAMILY MEDICINE
• STRUCTURE Presence, access,continuity
• PROCESS EBM
• OUTCOME Prevention , health promotion
COMPETENCIES OF F.P.
• Acute health problem• Chronic health problem• Provide health promotion services• Emergency services• Counseling• Preventive• Terminal and palliative• Home care
COMPETENCIES IN FMWHAT KNOW
DOIN ORDER TO BE EFFECTIVE
ORGANIZATION AND CATEGORIZATION OF
COMPETENCIES• COMMUNITY BASED
• PATIENT- PHYSICIAN RELATIONSHIP
• SKILLED CLINICIAN
• RESOURCE TO A DEFINED POPULATION
ORGANIZATION AND CATEGORIZATION OF
COMPETENCIES FM EXPERT
• COMMUNICATOR
• COLLABORATOR
• MANAGER
• HEALTH ADVOCATE
• SCHOLAR
• PROFESSIONAL
Reception
• Identification
• Appointment –Reminder communication
• Interpersonal communication
• Waiting room Hand-out, pamphlets, media,
• Call for file ( confidential)
PreventionPrevention
Patient education includePatient education include::
•Careful selection of Careful selection of footwearfootwear..
•Daily inspection of the Daily inspection of the feetfeet..
•Daily foot hygieneDaily foot hygiene..•Avoidance of self-Avoidance of self-
treatmenttreatment..•Avoidance of high-risk Avoidance of high-risk
behaviorbehavior..•Consultation if an Consultation if an
abnormality arisesabnormality arises
Documentationdouble sward
• Personal data
• Date & Time
• Communication Mobile no/ address
• File revision
• Notification about ADR allergy
• Oral anticoagulant
• Hereditary disease, sickling, G-6-P def
Physician visit
• Complaint and history of recent c/o
• > of 70% of the diagnosis
• Try to be a good listener, no interfere, interest, concentrating
• VITAL IS VITAL Temp, pulse, Bp
• Examination in the presence of a nurse
• Rapid decision if emergency hypotension
Process
• Safe
• Effective guidelines
• Efficient
• Timely
• Patient centered
• Equity discrimination
Guidelines
• Consensus
• Guidelines National, International
• Evidence based care
• Use of Algorithm and chart
• Quantitative medicine, personalized, individualized medicine
Continuous performance improvement
• Safety limit transmission of infection , hand hygiene
• Guidelines
• Keep record for your error
SOAP
• Subjective
• Objective
• Assessment, analysis
• Plan
PLAN
• Life style modification• Diet• Exercise• Sick leave• Medication• Consultation• Reference health education• Revision and follow up
Medications
• Prescription, handwriting
• Pharmacological name, dose, frequency, route, initial dose, duration, ADR
• ADR avoidable , nonavoidable
• Wrong prescription
• Role of the pharmacist
Non avoidable
• Sensitivity test
• Anaphylaxis
• Severe reaction erthyma Multiformis,Steven Jonhson
Avoidable
• Personalized Medicine pharmacogenomic, genetic make up
• Can be predictable >25% of commonly used drug (array)
MAR medication administration record
COPE computerized physician order entry
• Computerized physician order entry (CPOE) is the process of entering medication orders or other physician instructions electronically instead of on paper charts. The use of a CPOE system can help reduce errors related to poor handwriting or transcription of medication orders. Physician assistance
Personalized medicine
• Right patient
• Right treatment
• Right time
• Right dose according genetic make up of patient
Quantitative medicine is the key to reducing healthcare costs and improving
healthcare outcomes
Patients with same diagnosis
Misdiagnosed
Non-responders,toxic responders
Non-toxic responders
Asthma Drugs 40-70%Beta-2-agonists
Hypertension Drugs 10-30%ACE Inhibitors
Heart Failure Drugs 15-25% Beta Blockers
Anti Depressants 20-50%SSRIs
Cholesterol Drugs 30-70% Statins
Major drugs ineffective for many…
Source: Amy Miller, Personalized Medicine Coalition
The PromiseImagine when doctors can…
• Prevent Disease by identifying risks, early interventions
• Diagnose Conditions less Predict Disease pre-symptomatically with simple testing
• invasively, more accurately
• Select Drugs that maximize benefits and minimize risks
• Calibrate Treatments to heighten efficacy and recovery
• Treat/Cure Disease using our own genes
Take five
• BE with us
Common clinical diagnosis
• Hypertension• Chest pain , chest infection, asthma• Diabetes• GIT, jaundice ,Diarrhea• Coma & syncope• Stroke• Trauma• fever
Office BP Measurement
§ Use auscultatory method with a properly calibrated and validated instrument.
§ Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.
§ Appropriate-sized cuff should be used to ensure accuracy.
§ At least two measurements should be made.
§ Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.
BP Measurement Techniques
MethodBrief Description
In-officeTwo readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.
Ambulatory BP monitoringIndicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.
Self-measurementProvides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.
Blood Pressure Classification
Normal<120and<80
Prehypertension120–139or80–89
Stage 1 Hypertension140–159or90–99
Stage 2 Hypertension>160or>100
BP ClassificationSBP mmHgDBP mmHg
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
Laboratory Tests
Routine Tests• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
Hassan age 50 years
• Presented to you with severe throbbing headache, chills, epig pain and vomit once Past history of hypertension,dyslipidemia
• Pulse full, Bp 200/120, lung showed bilateral basal fine crepitation
• Ask the patient about important symptoms
• What you will do if you are in OPD
Hilal 18 years old known type1
• c/o of epig pain vomiting, fever , diarrhea
• He miss last night insulin dose
• He ring you this morning at 10:00
• What is your advise to Hilal
• You propose what?
Mr Hamdi 45 ys old
• Vomit this morning brown colouration vomitus after an overnight severe nausea
• Several days before he seeked the advise of the orthopedic surgeon for a low backache and girdle pain
• Ask him few question
• Decide what to do if you examine him home
Amira young female 22 years old
• C/o of vertigo, vomiting , unsteady gait associated with severe headache, she was on antibiotic because of an upper respiratory tract infection few days before
• Your examination revealed afebrile, nystagmus , brisky reflex on both LL.
• Is it serious, what you will do
Soad pregnant in her last trimest
• Referred by her obstetrician because her last urine analysis showed + sugar ,FBS is 90, her PP is 116mg%
• Is she gest diabetes
• What you will recommend
Ali young asthmatic patient
• c/o since yesterday something giving way in his rt lower chest after cough
• Today his respiration not at ease and suffer from stitching pain on the same side during walking
• Examination revealed only mild degree of fever 37.4
• Decision
60 ys old lady
• Fever, rigor, bilateral loin pain and scanty urine
• Past history of renal stones, gout, HTN,osteoathrosis
• What you will do as investigations
Ahmed 34 year old
• c/o of lower left pricking sensation in the chest
• Few day later rash appear in the same area and extend , associated with general illhealth
• What you will ask him ?
• DD
50 years old male
• C/o progressive loss of wt, anorexia, night fever
• No cough • Examination revealed significant loss wt• Few L node enlargement deep cervical
group, shotty ,rubbery not fixed • CBC lymphopenia, normocytic ,
normochromic anaemia and shooting ESR• Discuss the case and make a plan
40 years old patient
• Irregular palpitation since last night
• Past history of similar condition
• Pulse completely irregular and rapid
• Bp 120/80
• ECG AF
• Discuss the case and manage