Functional Dyspepsia ROME IV dx criteria

 presence of atleast 1 of the ff

 postprandial fullness (3d per wk)
 early satiety (3d per wk)
 epigastric pain (1d per wk)) and No evidence of structural disease
 criteria must present for atleast the past 3 mos with sx starting at least 6 mo before dx

tx: upper endoscopy (indications)

 clinically significant wt loss(>5% usual body weight over 6 to 12 mo)
 overt gi bleeding
 >1 other alarm feature
 rapidly progressive alarm features

alarm: Alarm Features

 age of onset greater than 45
 significant unintended weight loss
 anemia
 hematemesis
 melena/hematochezia
 dysphagia/odynophagia
 persistent vomiting
 abdominal mass
 jaundice
 chronic NSAID use
 previous history of ulcer

Proton Pump Inhibitors

 Omeprazole 20 and 40mg OD
 Esomeprazole 20 and 40mg OD
 Pantoprazole 40mg OD
 Rabeprazole 20mg OD
 Lansoprazole 15 and 30 mg OD
 Prokinetic Therapy
 metoclopramide 5-10mg TID 30 mins before meals and at night
 domperidone 30mg (10mg TID) daily or less

TCA
 amitriptyline 10 mg at night
 desipramine 25 mg at night
 Helicobacter pylori eradication
 over 45 yrs of age
 history of chronic dyspepsia
 chronic NSAID use
 diagnostic test
 stool antigen test
 urea breath test

Helicobacter pylori eradication

 twice daily, seven-day regimen
 recommended first line therapy: PPI-based triple therapy
 omeprazole 20mg
 lansoprazole 30mg
 pantoprazole 40mg
 alternative: Bismuth-based quadruple therapy (ranitidine bismuth citrate
400mg)
PLUS
 clarithromycin 500mg and amoxicillin 1000mg or
 clarithromycin 500 or 250mg and metronidazole 500mg

Types

Postprandial Distress Syndrome (PDS)

 motility-related dyspepsia
 at least one of the following:
 bothersome postprandial fullness after ordinary sized meals occurring at least
several times a week
 early satiation that prevents finishing a regular meal at least several times a
Week

Epigastric Pain Syndrom (EPS)

 acid-related dyspepsia
 must include all of the following
 Epigastric pain or burning at least once a week
 Intermittent pain
 Not generalized or localized to other abdominal or chest regions
 Not relieved by defecation or passage of flatus
 Not related to gallbladder or sphincter of Oddi disorders
A complete genogram should include:
1.Names and ages of all family members
2.Exact dates of birth, marriage, divorce, separation, death and other significant life events
including causes of death
3.Information on three or more generations
4.Illnesses
5.First born of each family to the left with sibling sequential to the right
6.Name of two families
7.Informant/s
8.Date constructed

FAMILY APGAR
Is a tool that qualitatively measures family functioning
10-15 minute pencil and paper tool that elicits the person’s perception and level of satisfaction
on the current state of family relationships

Adaptation
-it is the family’s utilization of the resources available within and outside of the familial system
when significant life events pose a crisis
Partnership
-it is the sharing of the family members in decision-making and responsibilities
Growth
-it is the physical and emotional growth attained by each family member from the family’s
ability
Affection
-it is the loving or caring relationship of the family
Resolve
-it is the commitment of family members to devote time to support each other’s physical and
emotional growth.
-it also pertains to the sharing of wealth and space

SCREEM
Acronym that represents family resources

Tool where the physician helps the family identify and assess their resources to meet a crisis
situation
Can also be a pathologyat certain situations

S ocial
C ultural
R eligious
E conomic
E ducational
M edical

FAMILY LIFELINE
Summarizes the history of the family particularly individual’s or family’s significant events
over a period of time in a chronologically sequenced manner and how the family has coped
with these stressful life events.
Presentation of a family’s life events in a limited space which allows quick retrieval of
information that provides identification of factors that may affect health of the family

Uses:
In cases where long-term illness is anticipated, presence of difficulty in care giving and non-
compliance to treatment strategies
In cases where the doctor needs to “think family” such as abnormal behavior in a child,
inappropriate behavior in the antenatal and/or postpartum period, drug, or alcohol abuse and
evidence of sexual of physical abuse

Interpretation is based on most significant eventsthat probably affects the health of each
member or that may influence the health seeking behavior or perception of health of the
individual or family

HYPERTENSION

FIRST VISIT

HISTORY AND PHYSICAL EXAMINATION

-All adult patients consulting at the clinic should be screened for high blood pressure with
appropriate BP measurement.
-Make a thorough history focusing on symptoms, family history using genogram, smoking and
other lifestyle and co-existing chronic disease.
-Make a thorough PE focusing on the weight/BMI, W/H ratio, fundoscopy, neurological, cardiac,
renal, and peripheral arteries.

PATHWAY DECISIONS
-If BP is >140/90 mmHg with signs and symptoms of acute end-organ damage, consider referral
to hospital.
-If the initial BP is >180/110 mmHg consider hypertension and start medication.
-If BP is >140/90 mmHg and with previous history of high BP taken by another health
professional within the month, consider hypertension and start medication.
-If BP is >140/90 mmHg and first time high BP, confirm with home BP measurements or second
visit within 4 weeks.

LABORATORY
12-L ECG
URINALYSIS
FBS
CREATININE
SERUM K
LIPID PROFILE

PHARMACOLOGIC INTERVENTIONS

-DIAGNOSED HYPERTENSION
-Start/continue medications with either or a combination of thiazide-type diuretic, calcium
channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blocker
depending on co-morbidities or side effects.
-NEED TO CONFIRM HYPERTENSION
-No medications are warranted.
-PATIENTS FOR EMERGENCY REFERRAL
-Consider giving a single dose of anti-hypertensive prior to transport.

NON-PHARMACOLOGIC INTERVENTIONS
-PATIENT INTERVENTIONS
Educate the patient about hypertension, risk factors, and complications.
If medications were prescribed, explain the dose, frequency, intended effect, possible side
effects and importance of medication adherence.
Lifestyle modifications focusing on weight control, exercise and smoking cessation.
-FAMILY INTERVENTIONS
Inquire and recommend family members’ lifestyle activities.
-COMMUNITY INTERVENTIONS
Inquire for community lifestyle activities.
-CONTINUING CARE
Follow-up after 1-2 weeks.
Offer family wellness package.

First visit
PATIENT OUTCOMES
Aware of initial diagnosis.
Aware of risk factors and complications.
Aware of importance of adherence to diagnostics and interventions.

SECOND VISIT
HISTORY AND PHYSICAL EXAMINATION
-Review and note any change in history focusing on symptoms, family history using the
genogram, smoking and other lifestyle and co-existing chronic disease.
-Repeat and note any change in PE focusing on the weight/BMI, W/H ratio, fundoscopy,
neurological, cardiac, renal and peripheral arteries.
-Review BP monitoring if available.
-Review laboratory results and establish the presence of other risk factors and co-morbidities.

PATHWAY DECISIONS
-If home BP and/or second visit BP are >140/90 mmHg, diagnose hypertension.
-If home BP and/or second visit BP are <140/90 mmHg, rule out hypertension but monitor after
6-12 months.

LABORATORY
12-L ECG
URINALYSIS
FBS
CREATININE
SERUM K
LIPID PROFILE

PHARMACOLOGIC INTERVENTIONS

-DIAGNOSED HYPERTENSION
-Start/continue medications with either or a combination of thiazide-type diuretic, calcium
channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blocker
depending on co-morbidities or side effects.

NON-PHARMACOLOGIC INTERVENTIONS
-PATIENT INTERVENTIONS
Enhance education about hypertension, risk factors, and complications.
If medications were prescribed, repeat explanation about the dose, frequency, intended effect,
possible side effects and importance of medication adherence.
Enhance advise on lifestyle modifications focusing on weight control, exercise and smoking
cessation.
-FAMILY INTERVENTIONS
Enhance recommendation for family members’ appropriate lifestyle activities.
-COMMUNITY INTERVENTIONS
Recommend participation in appropriate community lifestyle activities.
-CONTINUING CARE
Follow-up after 1 month until BP target is achieved and every 3-6 months if BP is already
achieved.

Second visit
PATIENT OUTCOMES
Improved BP control (Age 18 to 59: <140/90 mmHg; Age 60: <150/90 mmHg
BMI between 18.5-24.9 kg/km2
Modification of risk factors i.e. diet, lifestyle, smoking and exercise.
Absence of new complications.
Adherence to diagnostics and interventions.
Agreed plan for family intervention.
Agreed plan for community involvement.

CONTINUING VISIT

HISTORY AND PHYSICAL EXAMINATION

-Review and note any change in history focusing on symptoms, family history using the
genogram, smoking and other lifestyle and co-existing chronic disease.
-Repeat and note any change in PE focusing on the weight/BMI, W/H ratio, fundoscopy,
neurological, cardiac, renal and peripheral arteries.
-Review laboratory results and establish the presence of other risk factors and co-morbidities.

PATHWAY DECISIONS
-Enhance/revise pharmacologic and non-pharmacologic interventions until BP control is
achieved (Age 18 to 59: <140/90 mmHg; Age >60: <150/90 mmHg)

LABORATORY
-After 6-12 months, repeat for:
12-L ECG
URINALYSIS
FBS
CREATININE
SERUM K
LIPID PROFILE

PHARMACOLOGIC INTERVENTIONS

-DIAGNOSED HYPERTENSION
-Continue/revise medications with either or a combination of thiazide-type diuretic, calcium
channel blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blocker
depending on co-morbidities or side effects.

NON-PHARMACOLOGIC INTERVENTIONS
-PATIENT INTERVENTIONS
Enhance education about hypertension, risk factors, and complications.
If medications were prescribed, repeat explanation about the dose, frequency, intended effect,
possible side effects and importance of medication adherence.
Enhance advise on lifestyle modifications focusing on weight control, exercise and smoking
cessation.
-FAMILY INTERVENTIONS
Enhance recommendation for family members’ appropriate lifestyle activities.
-COMMUNITY INTERVENTIONS
Recommend participation in appropriate community lifestyle activities.
-CONTINUING CARE
Follow-up after 1 month until BP target is achieved and every 3-6 months if BP is already
achieved.

Continuing Visit
PATIENT OUTCOMES
Improved BP control (Age 18 to 59: <140/90 mmHg; Age 60: <150/90 mmHg
BMI between 18.5-24.9 mg/kg2
Modification of risk factors i.e. diet, lifestyle, smoking and exercise
Absence of new complications.
Adherence to diagnostics and interventions.
Agreed plan for family intervention.
Agreed plan for community involvement.
5 star physician

Health care provider

Counselor
Teacher/Educator
Reasearcher
Manager/leader
Social Mobilizer

Health care providers – Family physicians facilitate entry to the health system as primary care /
first contact physicians.They see patients with undifferentiated problems and provide continuing
comprehensive, cost-effective, and high quality care.
They know their limitations and refer patients appropriately and promptly.
They provide patient-centered, family-focused and community-oriented care.

Counselors – they apply active listening skills, empathize with patients and families, provide
alternatives, clarify issues, reassure patients and families and give support.

Educators – they promote healthy lifestyles through effective explanations and advocacies,
thereby empowering individuals and groups to enhance and protect their health, disseminate info
to patients and families and provide professional knowledge and skills that are community and
family-centered. As teachers to students and residents they act as role models and trainers
They also act as tutors/ facilitators in quality assurance circles involving practice based trainees
and family practitioners,

Researchers – they document experiences and conduct researches in practice; appraise and apply
research to clinical decision making, manage information about patients and the community
through record keeping with reporting, analyze health statistics and data; and use an evidence-
based approach to care by adhering to clinical practice guidelines. As lifelong learners, they
maintain continuing professional development by using electronic technology, practicing quality
assurance, updating knowledge and skills through journals, attending conferences surfing the
internet, and maintaining a practice portfolio.

Community leaders – they establish a trusting relationship with the people they work with,
reconcile individual and community health requirements, advice citizen groups and initiate
action on behalf of the community
As manager, they work harmoniously with individuals and organizations both within and outside
the health system to meet their needs and make appropriate use of available health data.
Social Mobilizers – they lead and actively participate in health policy-making, advocate patients’
rights and safety mobilize communities towards worthy projects which will improve their quality
of life and promote quality health care development and progress among colleagues.