Diagnosis holistic in

Comprehensive Care
at
Primary Health Centre
Yudhi Wibowo, MD

NUMBER OF PERSONS EXPERIENCING AN ILLNESS

DURING AN AVERAGE MONTH, PER 1000 POPULATIONS
1000 people

800 have symptoms

327 consider seeking
medical care
217 physician office
113 visit primary care
65 CAM provider
21 hospital outpatient
clinic
14 home health
13 emergency
department
8 are in hospital
< 1 in an academic
health centre
Green LA,Fryer GE Jr,Yawn BP, Lanier D,Dovey SM. The ecology of medical care revisited.N Eng
j Med 2001;344:2021-2025
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What are the attributes of

community physician?

The attributes as follows .

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The community physician

(included occupational physician &
family physician) give services with:
1. Comprehensive care
2. Family & community oriented
3. Continuous care
4. Working in team

Comprehensive
Integrated; health promotion, disease prevention,
curative care, rehabilitation, not only physical,but also
psychosocial problems
To individuals, in the context of family circumstances at
their live and work
Addresses the unselected health complaint or problems
Any kind of age, sex, social class, race and religions

Family & community oriented

The patients problems should be seen in the context of
his/her life in the family/ local community
Should be aware of the family /community health needs
Collaborate with other professionals, agencies from other
sectors
Initiate positive changes in family/ local health problems

Continuous care
Person center
Long-standing personal relationship between
patient and doctor
Not limited in certain time of illness episode

Primary health care teams

Basic team
Physicians, nurses, medical assistants,
midwives, social workers, community
health workers and family member as
caregiver

Supportive members
Receptionist,secretaries,administrators,
health educators, laboratory, pharmacy and
radiologist
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Characteristic of primary health care

1. Personal
2. First contact
3. Continuous
4. Comprehensive
5. Coordinated with specialists and other health professionals
6. Cost effective
7. High quality
8. Equitable distributed
9. Community, family oriented, partnerships
10. Accountable
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Characteristic of family medicine

approach
The medical care which:
1. Holistic and comprehensive
2. Continuum
3. Prevention care priority
4. Coordinative and collaborative
5. Personal care as integral member of a family
6. Concern to the family, work environment, and
living environment
7. Ethical and law concern
8. Finance and quality control
9. Auditable

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Primary health care practitioners

Holistic, comprehensive approach

professional value

(Multidisciplinary approach )

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due to the

The principles of practice, based on:

Epidemiological health services aspect,
Investigation on :

signs and symptoms,

the internal risk and external risk factors
the social background
in purpose for health promotion, disease prevention,cure,care and rehabilitation

Management health services aspect,

Provide the effective ,efficient and quality health service to achieve optimal health
outcome

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Diagnosis in primary health care

services
The act of determining the nature of disease
Diagnosis involves interviewing, observing patients and
physical examination and any kind supporting tests over a
period of time.

Diagnosis is a sequence of actions rather then single

investigations.

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Diagnosis

Physical diagnosis

Laboratory diagnosis

Microscopical diagnosis

Clinical diagnosis

Working Diagnosis

Differential diagnosis

Holistic diagnosis
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WHOLE PERSON
APPROACH

Another dimension
(psychosocial
hallmark):
The patient as a
person
Emotional reactions to
the illness
The family
The effect on
relationship
Work
Lifestyle
The environment

Emphasis on
making dx &
treating the
disease
Etiology of
disease
History
Exam
Special inves

The diseasecentred dx

The patient centred dx

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How the diagnostic process could focus on the implemented

holistic patient daily life ?
1.Interview; complains, reasons of encounter, hopes, and worries
2.Clinical Observation; physical examination findings, supporting tests
3.Analysis; clinical data, individual & family health problems & risk factors

What kind of diseases

Who gets the disease
Why it happened (confounding & determinant factor)
What the functional status (based on physical disability)
What is the decision (based on evidence)
4.Diagnosis Holistic
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Holistic diagnosis
(multi aspects& multidisciplinary approach)

1st aspect:
Chief complain
Fear
Wishes/ hope

2nd aspect:
Clinical diagnosis & differential diagnosis

3rd aspect:
Health behavior & perception (internal risk/confounding
fs)

4th aspect:
Familys psychosocial & economy problems, occupation &
environment factors (external risk factors/determinant)

5th aspect:
Social function scale
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Example
case: Mr.A.36 yo, security in Kelurahan Office, unmarried, live with his
sister who married with 3 children

I: - Productive cough no blood-tinged since 1 month

- going to be worst condition
- possible to cure
II: - Pulmonum tuberculosis with acid-fast bacili (+), broad lesion & left lung fibrosis
- Obesity
- Suspect Diabetes Mellitus
III: - drop out from anti-tuberculosis treatment after 1 month
- lack motivation and supporting behavior
- unmarried & dependent
IV: - less harmony interpersonal relationship with brother in law
- no family participation in patient management
- high risk transmitted in the family
- un-comfort living for patient and family
V: functional scale: 2 (partly willingness, provider dependency)

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

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comprehensive
planning
A. Patient-centered:

Therapy of PTB by long term 3 combinations drug therapy

(package 2)
Special diet with adjusting of family capacity (lower
calorie, high protein & zinc)
Supportive therapy by vitamin B6
Special attention on blood glucose
Special attention on PTB complication and drug
compliance per 2 weeks in 2 month, and monthly on 3rd
-6th months after.
Chest exercise after treatment when necessary
Regular exercise
B.......
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

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comprehensive
B. Family-focused:
planning

Assigned possible caregiver in the family

PTB guidance of treatment to his caregivers
Active screening of PTB of all family member to find the
contact source and in purpose of early detection
Nutrition guidance for all family member with adjusting of
family resources
Preventive care guidance for all family member
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

C. Community-oriented:

Circulation and ventilation guidance at house

Case infectious disease report to local government to be
active screening for PTB in the living area of the patient

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Sources
1.

Charles Boelen, Cynthia Haq, Vincent Hunt, Marc Rivo & Edward
Shahady, Improving Health Systems ; The contribution of Family
Medicine, Family Doctors in Health systems; Wonca 2002 :37-47

2.

Bruce E.Johnson, Osteoartritis, Current Diagnosis and Treatment in

Family Medicine , International Ed. Lange Medical Books /Mc GrawHill USA; copyright 2004: 265-271

3.

Robert E Rakel, Essentials of Family Mediicne, 3rd ed.Saunders

elseviers, 2006

4.

Robert E Rakel, Textbook of Family Medicine, 7th ed.Saunders

elseviers, 2007

5.

Nitra Nirwani , Diagnosis Holistik pada Pelayanan Kesehatan Primer,

IKK FKUI;2008

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Thank you for

your kind
attention

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