WCS13 Introduction To Clinical Problem Solving In Primary Care

Question 1

Problem solving general principles

Answer 1

Symptoms / Problems (clinical, behavioural, contextual)
—> Hypothesis (based on probability, payoff, personal knowledge)
—> Search (History, Examination, Investigation)
—> Management decisions
—> Follow up
—> Revise hypothesis

Conditions encountered in primary care is different from hospital / secondary care e.g. chest tightness

Each discipline has its own way of applying them due to problems encountered and roles in health care system e.g. blurred vision

Appropriate clinical interviewing skills esp. for psycho-social problems

Question 2

Primary care problems

Answer 2

1. ***Undifferentiated problem (vs Specialists)
   - vague (e.g. tiredness)
   - multiple
2. ***Bio/psycho/social causes (e.g. headache)
3. Often ***self-limiting but can be serious (e.g. influenza)
4. ***Not limited to the presenting complaint (e.g. neck pain leading to insomnia)

Question 3

Primary care model (Murtagh)

Answer 3

1. Probability diagnosis?
   - Primary care epidemiology
2. Serious disorder must not be missed?
3. Conditions often missed?
4. Masquerades (Diverse presentation)?
   - anaemia, depression, DM, drugs, thyroid
5. Patient trying to tell me something else? Problems other than physical?
   - Bio-psycho-social approach

Question 4

Example case: Knee pain

Answer 4

1. Probability diagnosis?
   - OA
   - Injury
2. Serious disorder must not be missed?
   - Septic arthritis
   - Neoplastic
3. Conditions often missed?
   - Referred pain: back / hip
   - Intra-articular loose bodies
   - Fractures around knee
4. Masquerades (Diverse presentation)?
   - Depression
   - DM
   - Spinal dysfunction
5. Patient trying to tell me something else? Problems other than physical?
   - Psychological factor / Psychosocial problems
   —> cannot go to restaurant
   —> cannot do shopping

Question 5

Patient centred approach

Answer 5

1. Nature and Course of illness
2. Effects of illness on the patient
3. Patient’s reasons for consultation
4. Patient’s expectation
5. Patient’s idea and concern

Question 6

Patient’s reason for consultation

Answer 6

1. Intolerance of symptoms
2. Intolerance of anxiety
3. Review of chronic condition
4. Administrative
5. Preventive
6. Problems of living presenting as symptoms

Question 7

Approach to psychosocial problems

Answer 7

• Somatic complaints
• Routine follow up consultation
• Interviewing skills

Question 8

Clinical interviewing skills

Answer 8

1. Puts patient at ease
2. Allows patient to elaborate presenting problem fully
3. Listens attentively
4. Uses silence appropriately
5. Recognise patient’s verbal / non-verbal cues
6. Consider psycho-social problems