全科医学教学课件：第7讲 A Profile of Family Practice

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(Nov.7)一.BestChoice（Score1foreach,totally40）（）1.Whoareinanbestpositionforhelpingpatientstoimprovetheirhealth?A．Physicians B．GynecologistsC．Paediatricians D．GPs二.MultipleChoices（Score2foreach,totally40）（）1.Whichcanbelistastheminorproblems?A．CoughfortwodaysB．BackpainfortwodaysC．HighfeverfortwodaysD．TiredfeelingfortwodaysE．Redurinefortwodays三.Translation（Score10-15foreach,totally20）Whatisthetruepictureofthecontentoffamilypractice?Torecordthediagnosismadeateachdoctor-patientencounterdiseases(well-defined)symptomorcomplaintManyillnessepisodesseenbyfamilyphysicians,however,aremuchmoredifficulttodefineandlabelcase8.1Anelderlywomancomplainedofasuffocatingfeelinginthechest,occurringintheearlyhoursofthemorning,whichwasrelievedtosomeextentbysittingbyanopenwindow.Shefirstcameinthemiddleofabusyofficesessionwhentimewasshort.Giventheabovecues,thedoctorformedafirsthypothesisofnocturnalcardiacasthma,andafteraphysicalexaminationrevealednosignstosupportthediagnosis,sentthepatientforachestx-ray.Whenthistoowasnormal,heaskedthepatienttocomeinforalongerinterview.OnthisoccasiontheGPobtainedthefollowinghistory.Hermaincomplaintwasofveryactiveperistalsisandabdominaldiscomfortoccurringatnightandkeepingherawake.Afterlyingawakeforhoursshewouldgetmoreandmoretense,getasuffocatingfeeling,andhavetogetupandgotothewindow.Theabdominalsymptomshadbeenpresentfortwentyyears,buttheinsomniawasofmorerecentorigin.Manyyearspreviouslyshehadhadacholecystectomy,whichfailedtorelievehersymptoms,andamastectomyforcarcinoma.Shehadafearofsurgeryandondirectquestioningadmittedtoananxietythatherabdominalsymptomsmightbeduetocancer.Shehadbeenwidowedseveralyearsandlivedinanapartmentbyherself.Recentlyherlandlordhadraisedherrentwithoutgivingheranynotice.Hertwochildrenwerebothmarriedandlivingaway.Recently,herdaughterhadmovedneartoherafterlivingawayforsomeyears.Duringtheinterview,sheexpressedhostilitytowardherlandlord,who,shefelt,hadbeenveryunfairtoher.Howtodefineandlabelthecase8.1?diseases?anxietystateorinsomniaInsomniaischaracterizedbypersistentdifficultyfallingasleeporstayingasleepdespitetheopportunity.Itistypicallyfollowedbyfunctionalimpairmentwhileawake.symptominsomniaorgastrointestinalsymptomsWhicheverroutewetake,weprovideonlyapartialpictureTheresultWhicheverroutewetake,weprovideonlyapartialpictureequivalenttotakingatwo-dimensionalslicethroughathree-dimensionalobject.NoassurancethatanytwophysicianswillclassifythesameillnessinthesamewayappearinthestatisticsundertherubricofmentalillnessappearundertherubricgastrointestinaldiseasesGiventhesedifficultiesofnomenclatureandstandardization,itissmallwonderthattherearewidevariationsinsuchestimatesastheamountofpsychiatricillnessinfamilypractice.StandardizedcodingsystemsforprimarycareICPCUnitedStates,Britain,theNetherlands,Australia,Norway,WestGermany,Austria,andBarbadosUseMakecomparisonsbetweenpracticesorcountriesRelateprocessofcaretooutcomeFollowtrendsinillnessovertimeLearnfromourexperiencebyretrospectivelyreviewingourcasesindifferentdiseasecategories.ICPCVSICDItemICDICPCPurpose/definitionBasedonwell-defineddiseasecategoriesandmoresuitableforclassifyinghospitaldischargesandcausesofdeathFortheearliermanifesta­tionsofillnessseeninprimarycare:areasonforencounterclassification,aclassificationforprimarycareorgeneralpracticeClassificationstructureAbiaxialstructureandconsistsof17chapters,eachdividedinto7componentsCreationdate1850s1987LastdatechangeICD-10ICPC-2,2003OtherUnstructuredamalgamStructuredICPCClassifyingthreeelementsofanencounterbe­tweenpatientanddoctorthereasonforencounter(RFE)thediagnosisorprob­lemtheprocessofcare.Ratherthanbeingorganizedaroundendpointsofillness(definitivediagnosesorcausesofdeath),theICPCisbasedonepisodesofcaredefinedas“aproblemorillnessinapatientovertheentireperiodoftimefromitsonsettoitsresolution”StructureofICPCBiaxialstructure17chaptersonthehorizontalaxisbodysystemstakeprecedenceoveretiology7componentsontheverticaldealingwithsymptomsandcomplaints(comp.1),diagnostic,screeningandpreventiveprocedures(comp.2),medication,treatmentandprocedures(comp.3),testresults(comp.4),administrative(comp.5),referralsandotherreasonsforencounter(comp.6)anddiseases(comp.7).COMPONENTSCHAPTERSABDF-EyeH-EarK-L-MusculoskeletaN-P-R-S-T-U-W-X-Y-Z-1.Symptomsand complaints2. Diagnostic, screeningprevention3. Treatment,procedures,medication4.Testresults5.Administrative6. Other7.Diagnoses,diseaseCase8.1inICPCBerecordedasfollowsthereasonsforencounter,recordedundertherelevantchapterheading,areshortnessofbreath(R02),insomnia(P06)fearofabdominalcancer(D26).thechestx-rayresultisrecordedundercomponent4.Twodiagnosticcodesareentered:irritablebowelsyndrome(D93)andanxietydisorder(P74).NoteaboutICPCAsinallclassificationsystems,theaccuracyofICPCdependsontheskilloftherecordingphysician.TheRFEisnotnecessarilythesameasthepresentingcomplaint,andunderlyingreasonsmaynotemergeatthefirstencounter.Muchdependsonthephysician’sknowledgeofthepatientandconsultingskills.Consistencyinassigningdiagnosticlabelsisdifficulttoattaininthemanyillnessesthatcannotbedifferentiatedtomorethanlowlevelsofabstraction.Allclassificationsystemsaresimplificationsofcomplexprocesses.Wecannotexpectthemtofullyrepresentthecomplexityoffamilypractice.SymptomsWhatarethetwenty-fivemostcommonreasonsWhatarethetenmostcommonpresentingOrderMalesFemales1SymptomsreferabletothroatSymptomsreferabletothroat2Headcold,upperrespiratoryinfectionCough3CoughHeadcold,upperrespiratoryinfection4SkinrashGeneralmedicalexamination(excl.gyn.andprenatalexams)5FeverSkinrash6GeneralmedicalexaminationAbdominalpain7PhysicalexaminationforemploymentBacksymptoms8EaracheEarache9Chestpain(excl.heartpain)Headache(excl.migraineandsinusheadache)10NonarticularrheumatismFever11Headache(excl.migraineandsinusheadache)Chestpain(excl.heartpain)12AbdominalpainPapsmear13PhysicalexaminationforschoolVertigo,dizziness14LacerationsofupperextremityNecksymptoms15NecksymptomsShouldersymptoms16FootandtoesymptomsStomachpain,cramps,andspasms17PhysicalexamforextracurricularactivitiesNausea18Stomachpain,cramps,andspasmsLegsymptoms19ProphylacticinoculationsPain,sitenotreferabletospecificbodysystem20NasalcongestionDysuria21Shouldersymptoms（50肩）Prenatalexamination22Legsymptoms（七十不留宿，八十不留饭，九十不留坐，寿终正寝diepeacefullyinbed）Weightgain23HandandfingerinjuryPhysicalexaminationforschool24KneesymptomsAnxietyandnervousness25DiarrheaProphylacticinoculationsThetenmostcommonpresenting

inmales

CanadianPracticeBritishPracticeCoughCoughSorethroatRashColdsSorethroatAbdominal/pelvicpainAbdominalpainRashBowelsymptomsFever/chillsChestpainEaracheBackpainBackproblemsSpots,sores,ulcersSkininflammationHeadacheChestpainJointpainThetenmostcommonpresenting

infemalesCanadianBritishAbdominal/pelvicpain CoughCough RashSorethroatSorethroatMenstrualdisorders Spots,sores,ulcersColds AbdominalpainRash BowelsymptomsDepression BackpainVaginaldischarge ChestpainAnxiety GastricsymptomsHeadacheHeadacheDiagnosesDiagnosticcategoriesfromtheICDandICHPPCaregroupedintoclustersthatbringtogetherdiscreteconditionsthatareclinicallyrelated.367rubricsofICHPPC-2arecondensedintoasmallernumberofclusterssuitableforcompara­tiveanalysis.OtherFeaturesofGeneralPracticeWomenconsultfamilyphysiciansmoreoftenthanmales,evenafterallowingforattendancesduringpregnancy.Thereasonsforthisdifferencearenotknown.Between70percentand80percentofmembersofapracticeconsultatleastonceayear.Theaveragenumberofvisitspermemberisbetweenthreeandfive.RankingorderofdiagnosticchaptersforprincipaldiagnosesinpatientsvisitingGPICD-9ChaptersPercentageDistributionRespiratory20.9Preventiveandadministrative(supplementaryclassification)12.1Circulation9.3Injuriesandpoison8.9Nervoussystemandsenseorgans7.0Musculoskeletalandconnectivetissue6.9Symptoms,signs,andill-defineddisorders5.1Ge