1. Comprehensive, Holistic and Level of care Department of Community Health & Family Medicine Dr Samsul Bin Draman

2. A story from Perhentian Island

3. ”The plane…..the plane……”

6. Too fast too furious

10. A 27 years old woman G4P3 at 10/52 POA came at Health clinic for USG ( Unsure of date)

11. 3/12 later, at 22/52 POA c/o- unable to control micturition & a/w bowel incontinence for 1/12. Gradual weakness of both LL for 3/52 Unable to walk for 1/52. No trauma or fever

12. BP – 120/80 T-35.6 C CVS- DRNM, Lungs- clear P/A- Ut 24/52

13. NS

14. Impression ? Spinal cord compression ? Transverse myelitis Refer tertiary hospital

15. Tertiary Hospital Reclerking and rechecking MRI- normal Refused to repeat MRI and took AOR discharged, afraid of radiation to baby

16. 5 days later, went to tertiary Hospital

18. Weekly home visit by paramedic, monthly by medical team of Polyclinic

19. 2/12 after AOR D A 27yr old/ M/ lady , G4P3 at 34/52 POA c/o progressive bilateral lower limbs weakness for 6/12.Initially Lt proximal LL then to Rt proximal LL Associated numbness from midthoraxic region Urinary frequency and loose stool. Came w referral letter from a private hospital for readmission in tertiary Hospital. Husband – chronic cough, screening for PTB positive

20. Husband says W – Without I – Information F – Fighting E - Everytime

21. Wife says W – With I – Idiot F – For E - Ever

22. Wife referred for 2nd MRI Husband advised for admission to accompany wife and start anti TB

23. 2nd MRI-features are suggestive of an extramedullary intradural mass. Differentials are neurofibroma and schwannoma

24. Role of MRI in pregnancy MR 1

25. Introduction 2 MRIs performed. Thoracolumbar spine MRI on 23/12/03 (from T8-L5). MRI of the cervical spine on 14/02/2004.

26. Thoracolumbar spine MRI on 23/12/03 (from T8-L5). Reduction of intervertebral disc space of T12/L1 with evidence of spinal stenosis or cord involvement.

27. MRI of the cervical spine on 14/02/2004. No IV gadolinium. 27 y.o G4P3 @ 36 weeks with 4/12 history of bilateral lower limb weakness.

28. A well defined extramedullary, intradural mass at C7 level. It is isointense on T1, slight hyperintense on T2 Streaky hyperintensity of the cord on T2 , [superiorly till C5 level and inferiorly till above T2 level] - cord oedema. There is also cord expansion above and below the lesion

30. It extends laterally causing widening of both side exit foraminae at C7 level. Spinal cord is pushed posteriorly and to the right and severely compressed at C7 level. No verterbal body scalloping noted

31. SAFETY OF MRI IN PREGNANCY

33. A woman may fear radiation so much that she believes she should abort a fetus after exposure. Up to 25 % of exposed women - believe their infants are at risk for major malformation. Guidelines from ACOG : "Exposure to x-ray during pregnancy is not an indication for therapeutic abortion."

34. Most common foetal malformations caused by high-dose radiation : are of central nervous system, primarily microcephaly and mental retardation. Maximal limit of ionizing radiation to which the foetus should be exposed during pregnancy is a cumulative dose of 5 rad.

35. Laminectomy Laminectomy C7 T8 + tumour excision Posterior midline approach after delivery For LSCS under GA if induction fail

36. Full term SVD, a baby girl , weight 2.8kg

37. D6 post SVD They undecided for operation Discharge, TCA 2/52 Never turn up

38. Problems list Bio:Spinal cord compression, ? Neurofibroma .Husband:TB Psy:Anxiety:Undecided for operation. If operated, ? prognosis. Not operated, remain paraplegic Social: Low socioeconomic group . Poor understanding of illness

39. Social:care of newborn baby and others children. Lack continuity of care

40. Low socioeconomic group

41. National Health Welfare Fund ( Tabung Kebajikan Kesihatan Kebangsaan)

42. Criteria To Qualify For The Fund Malaysian citizens only People who are not government employees or government pensioners or relatives or government employees who enjoy medical benefits under Skim Saraubat JPA. The poor and underprivileged Patients must be referred from government hospitals The medical treatment sought must be found in Malaysia

43. Types of Assistance Considered Assistance in paying for the cost of medical treatment of indigent patients where such medical treatment is not available in hospitals under KKM. Assistance in the purchase of medicine which is not supplied by hospitals under KKM Assistance in payment for the purchase of medical instruments which are not supplied through government subsidies.

44. Types of Chronic Diseases Cancer Heart attack A) Replace or correct defective heart valves B) Heart artery / Coronary Angioplasty surgery Prosthetics ( Artificial Limbs, hands or legs)

45. Application procedure Forms from the Secretariat National Health Welfare Fund , PERKIM building, Ministry of health, Malaysia Any government hospital ( Unit Kerja Sosial Perubatan atau Unit Kebajikan Perubatan)

46. Supporting documents IC / Birth certificate Medical reports- diagnosis, treatment received, treatment recommended, the place and the estimated cost of treatment. A socio economic report prepared by the officer of social medicine in a Government Hospital A copy of the salary statement and the latest KWSP statement.

47. Lack continuity of care

48. The process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality and cost effective medical care. Continuity of Care

49. Starfield 1986 Continuity of care is associated with more indicated preventive care, identification of patients psychosocial problems, fewer emergency hospitalizations, shorter lengths of stay, compliance appointments, taking of medication and more timely care for problems

50. Shear et al (1983) Utilizing a retrospective cohort study design 2 groups of pregnant women – 1) Group A under family practice centers 2) Group B under obstetric clinics Newborn infants of women in the familypractice, had much higher birth weight even after controlling for race, income, education and parity of their mothers.

51. Wasson et al (1984) A double blind randomized trial elderly men to either a “ provider continuity group” or a “ provider discontinuity group”. Found that patients in the continuity group had fewer emergency admissions & shorter hospital stays than those in the discontinuity group.

52. Continuity of care Increased patient and provider satisfaction (Starfield,1986) Increased compliance Enhanced disclosure of psychosocial problems Scheduled, rather than unscheduled, contact allows for preventive health maintenance (Billings ,1990) Reduced morbidity ( not mortality ) Enhanced clinical decision making (Parchman , 2002) Reduced costs ( ↓ tests, visits, hospitalizations ) (O’Conner et al, 1998)

53. Strategies to enhance continuity of care 1) A philosophical commitment A caring , friendly and approachable practitioner who is competent, available and trusted friend is “like gold” to his or her patient.

54. 2) Medical record efficient medical record system is fundamental. Information about a pt’s history , visit, tests , allergy , medications , and preferences

55. 3) Checklist use of checklist to assemble information on presenting problems will enhance knowledge and to diagnose disease.

56. 4) Home visits Information about intrafamily dynamics they should cement the dr- pt relationship if used appropriately and discreetly.

57. 5) Anticipatory guidance pts do not usually perceive the doctor as a counselor, but opportunity should be taken to advise about anticipated problems such as premarital visit, antenatal care and pre adolescent contact

58. 6) Patient education pt should be given insight to the nature of their illness and reason for the treatment and prognosis pamphlets, published in journals can be used as a starting point to ensure treatment compliance. This will improve dr-pt relationship.

59. 7) Personal Health Records Wallets which are handed to parents of newborn babies. Place an important role on ongoing care of children. Supply an outline of preventive health care beginning from birth. Provide a complete record of healthcare throughout pt’s life.

60. 8) Patient register age and sex registration of patient is very important. The main strategy is to find out who are the pt, what are their basic characteristic, and who suffers from chronic illnesses.

61. 9) Recall lists significantly improve health care delivery. Can remind pts that preventive items e.g. immunization schedule and cancer smear test are due.

62. 10) Computer have simplified and streamlined the design and use of practice registers and pts recall systems in addition to their use for accounting purposes. Potential for pt education and dr education.

63. Other measures Other measures: special clinics for group of pts with same diagnosis/problems. Imparting caring skills to caregivers Group education of pts and their families. Decentralization of services Integrations of care into primary health care.

64. Patient’s progress Paraplegic Pampers Pressure sore Primary care

65. Whole Person Approach Holistic Health Care approach or Comprehensive Health Care approach An important approach to patient care in modern medicine Determine whether there is a ‘hidden agenda’ in the presentation & whether there is stressors including interpersonal conflicts are significant factors in the illness.

69. HuluTembeling

70. HuluTembeling

81. Compliance?

82. What is compliance Compliance is defined as the extent to which a persons behaviors coincide with medical advice

83. Forms of non compliance Failure to keep follow up appointment Drop out from treatment program Failure to have prescriptions filled Failure to take enough medicines Failure to observe the correct interval between doses Failure to observes correct duration of treatment Failure to follow advice on healthy life style Refuse treatment or admission

84. Factors associated with poor compliance Psychiatric disease Duration of treatment Duration of disease- hypertension, diabetes, schizophrenia Complexity of treatment- more evident in the older age and the less educated. Greater number of drugs Greater behavior demand

85. Improving compliance Used patient centered approached 1) explore patient belief about vulnerability 2) seriousness of illness and efficacy of treatment Direct attention of patient and staff to the problems of noncompliance Special pamphlets regarding disease and treatment

86. Improving compliance Detect and reduce missed appointment Make appointment convenient Give specific appointment date Avoid long clinic waiting time Titrate frequency of visit to compliance Follow up of non attendees

87. Improving compliance Contracting with patients Help patient appreciate the benefit of compliance- use feedback and positive reinforcement Enlist the aids of patients family and friends Group discussion Visit patients home

88. Improving compliance Simplify treatment regime Eliminate unnecessary medication Reduce the frequency of dose Prescribe the least amount of drugs to achieve the desired goals

90. Controlled study of patient compliance to 2 regimens of oral Voltaren therapy The present study was designed to check extent patient compliance could be improved by reducing the daily tablet intake from qid to od without changing the total daily dosage of active drug.

91. Tablets & quantities of active drug omitted in each treatment goup

92. Results – therapeutic efficacy

93. Patients' preferences

94. Conclusion Single daily dose regimen: compliance is better Quantity of drug omitted is smaller Patients prefer this kind of regimen

95. D:ld my documentiarah Muslim.ppt

97. Fuller (1993) stated On a daily basis I assess the disease process and adjust the medical management as needed, but my joy comes from listening carefully, helping people to identify their stressors, providing my best advice when I think appropriate , but always offering my caring and understanding. I am both rewarded and fascinated to observe that people feel better just by recognizing that I CARE

98. One of his patients said it best: “ No one care how much you know, until they know how much you care”

101. Conclusions

103. DAN…INGAAATLAAAH!!! … Sesungguhnya orang yang paling mulia di antara kamu di sisi Allah ialah orang yang paling takwa di antara kamu… (al-Hujuraat 49 :13) Bertakwalah kamu kepada Allah,maka Allah akan mengajarmu. Al Baqarah:282

104. Godfearing will prevent u from doing this

105. Think of your parent

107. Sabda Nabi Muhd SAW Ubatilah penyakitmu dengan sedekah . Belilah semua kesulitanmu dengan sedekah . Bersegeralah bersedekah, sebab yang namanya bala tidak pernah mendahului sedekah.

108. Orphans The poor The needy

109. Respect Security Officers Cleaners AVA Technicians Librarians

110. Don’t stick to the old ways of doing thingThank you Find alternative

111. Nobody is perfect

112. Teamwork

113. Discharge letter contain 1)Diagnosis 2) Summary of symptoms & PE 3)Management plan 4)Information given to patient and relatives 5)Follow up arrangements.

115. No one care how much you know until they know how much you care. Understand money is not everything

117. Charge them