Diagnosis holistic in

Comprehensive Care
at
Primary Health Centre

Dhanasari VT & Nitra Nirwani R

University Indonesia
Faculty of Medicine
Community, Occupation and Family Medicine Department

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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

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 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

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 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

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 Continuous care

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

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 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 due to the

professional value

(Multidisciplinary approach )

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 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
Microscopic diagnosis
Clinical diagnosis
Working Diagnosis
Differential diagnosis
Holistic diagnosis

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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

1.Who gets the disease
2.Why it happened (confounding & determinant factor)
3.What the functional status (based on physical disability)
4.What is the decision (based on evidence)

4.Diagnosis Holistic

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 Natural history of diseases

The process by which diseases

occur and progress in the human
(host).

This process is an interaction of

different kind of factors: a biology
variability (internal risk factor) & the
multi-factors which are predispose
the diseases (external risk factor)

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Clinical Decision Making
are based on

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

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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.......

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 comprehensive
planning
B. Family-focused:
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

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 Graw-
Hill 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

Nitra Nirwani
Dhanasari Vidiawati

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