Short and simple guide in approaching cases in primary care clinics

1. Brief Guide to the Approach to
Primary Care Consultations
Dr Tan Chai Eng
Dept of Family Medicine
29 Sept 2015
FF5115 Family Medicine posting, UKM

2. Pendleton’s 7 Tasks of Consultation
1. To define reasons for the patient’s attendance, including the nature
and history of the problems, their etiology, patient’s ideas, concerns
and expectations, and the effect of their problems.
2. To consider other factors including continuing problems, risk
factors.
3. To choose with the patient an appropriate action for each problem.
4. To achieve a shared understanding of the problem with the patient.
5. To involve the patient in the management and to encourage
him/her to accept appropriate responsibility

3. Pendleton’s 7 Tasks of Consultation
6. To use time and resources appropriately
7. To establish and maintain a relationship with the patient which
helps to achieve other tasks.
• Ref : The Consultation. Pendleton, Schofield, Tate and Havelock
(1984) Oxford University Press.

4. Types of consultations you may encounter
• Walk-in for an acute undifferentiated problem
• Follow up for a chronic disease
• Specialised settings:
• Maternal and child health = antenatal clinic, postnatal clinic, family planning
clinic, child health follow up
• Specialised clinics = quit smoking clinic, methadone replacement, long-term
stroke clinic

5. Acute undifferentiated problem
• Identify the diagnosis
• Take a good history of presenting illness – open ended questions first,
followed by close ended to obtain additional details.
• Formulate differentials as you are taking history – specifically ask questions to
rule in or rule out the differentials
• Assess the severity
• Symptom severity, acute complications eg dehydration, disability, work/
school absenteeism
• Identify risk factors / precipitating / aggravating factors
• Can help to support likely diagnosis, may also be removed and thus
preventing further problems

6. Acute undifferentiated problem
• Physical examination and investigations (where appropriate) to help
confirm/exclude your provisional / differential diagnosis
• Formulate a problem list
• Management plan
• Pharmacological vs non-pharmacological
• Acute vs long-term
• Comprehensive – taking into account the biopsychosocial issues

7. Chronic diseases – follow up
• Assess for any acute problems – whether related or unrelated to
chronic disease
• Assess for symptoms of acute complications e.g. diabetes –
hypoglycaemia, hyperglycaemia.
• Assess for symptoms of chronic complications e.g. diabetes –
neuropathy, peripheral vascular disease
• Assess adherence to medications, any side effects
• Any self-monitoring at home?

8. Chronic diseases – follow up
• Assess lifestyle – diet, exercise
• Assess impact of the disease on patient – depression? Functional
limitations?
• Explore patient’s concerns regarding his current health status –
satisfied, worried, lost hope?
• Physical examination and investigations as appropriate to:
• Objectively measure control
• Screen for complications
• Formulate problem list, including control/uncontrolled, and reasons if
poorly controlled.

9. Chronic diseases – follow up
• Management
• Pharmacological vs non-pharmacological
• Short term and long term
• Involvement of other healthcare professionals e.g. diabetes educator,
pharmacist, nutritionist or dietician

10. Problem list
• Is NOT the individual symptoms e.g. fever, rash, pain
• Is the final analysis and synthesis of the information obtained via
history taking and physical examination
• E.g. A 50-year old woman with the following problems
• 1. Provisional diagnosis: Dengue fever day 4, with no alarming signs.
Differentials: Chikugunya, Epstein-Barr virus, Measles
• 2. Underlying type 2 diabetes mellitus, poorly controlled due to non-
adherence to medications and diet
• 3. Anxiety due to symptoms and inability to care for children because sick
• 4. Unable to do work as part time cleaner and no income.

11. Hope this helps to guide you
during your clinic sessions and
miniCEX.
All the best! Dr Tan CE 