Introduction: this irregular blood glucose level and to change




As a medical student, communications skills and dealing
appropriately with others are

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considered one of the most important things you have to learn and
practice, because they will


facilitate your task in dealing with your patients and taking the
perfect medical history in the


future. The medical history is a routine process happens every day
at every medical clinic.


It helps the physicians to take the correct information from their
patients, which consider


an important key in identifying the right diagnosis and the optimal
treatments for the patients.


So, as students the practice on taking a medical history was the most
important thing we have


focused on in the first visiting for us to the educational
hospital. In this case commentary will


discuss the details of the visit and the medical history.





Background and history:


X patient (X the nick name for the patient) is a Saudi female
patient with 62 years old from


 Ras Tnora. A widow retired
teacher. She is a diabetic patient; X is a patient suffers from


 diabetes type2. Presented to
the diabetes clinic in king fahad university hospital


with irregular blood glucose level and problem in her eyes for five
days ago. she said that


there was an abnormal increase in her blood glucose level though
she doesn’t eat large


amount of sugar. The main X’s aim from the visit was to identify
the main cause of this


irregular blood glucose level and to change her medications.


Diabetes type 2 started with X since she was 37 years old. X
doesn’t suffer from any chronic


disease except diabetes. X did three surgeries in the past, the
first one was thyroid gland


removal (thyroidectomy), the second was in her heel because of
diabetic ulcers, and the last


one was in her eye because of Diabetic
retinopathy. Patient hasn’t done a blood transfusion.


 X is taking
some medications that are insulin glargine ( Lantus), and aspirin for


the stomach.  X has suffered from a little increase blood pressure
and balance problem in the


last days, and increase in cholesterol level.


X a widow has 3 daughters and 6 sons, the husband and
the eldest son suffered from diabetes


type 1, while her parents and other kids were healthy
didn’t suffered from any chronic


disease. X lives with her sons in the same house all
of them are employees and spend most of


their time in their workplaces, but she said that
they give her all kinds of support regarding


her situation. X is a retired kindergarten teacher,
now she spends most of her time at home


without any physical activities, and her diet wasn’t
regular in which she eats her meals at a


random time.  And
on the hand of religious and believes, X believes that this is the life and


should accept what the god has written for us.


X doesn’t smoke and live at home free from smoking,
and doesn’t drink alcohol. She doesn’t


use any over the counter drugs and hasn’t allergic to
any drugs or substances.


After taking the medical history the doctor suggests
the main causes of that irregular blood


glucose level is the unhealthy diet and the amount of
the medication dose. So he advised her


to increase the dose of her medication, and alter her lifestyle by changing her diet.





Diabetes is a disease related with
increasing in blood glucose level. The sugar (glucose) in


 your blood which comes from your diet you need
to transport it from your blood stream to


your cells which they use it as a
source of energy. So the glucose need a hormonal assistance


which provided by an essential
hormone called insulin that play a role in entering the glucose


into the cells, especially
skeletal muscles cells. In diabetic patients they have problem with


their insulin, but it is different
depending on the type of the diabetes. There are two types of


diabetes, in diabetes type 1 the
body can’t make an insulin, while in diabetes type 2 which is


more common the body doesn’t
produce enough insulin or your cell becomes resistance to


 the insulin, so you will have increase in your
blood glucose level. Diabetes is a common


disease especially here in Saudi
Arabia although it is a dangerous disease can damage your


kidneys, eyes, and nerves. And can
causes heart disease. There are a lot of symptoms show in


the diabetic patients some of
these, weight loss, increased thirst, increasing the ketones


bodies in urine, fatigue, and
other symptoms. Therefore, when you notice these signs you


have to visit the hospital to
check up and ensure that you don’t have any problems. The


factors that have a role in
diabetes are unclear enough until now, but in diabetes type 1 your


immune system has an effects on
your pancreas cells which lead to reduces or inhibit the


production of the insulin and
usually caused by genetic and environmental factors, where


obesity and prediabetes are
considered factors that may cause diabetes type 2, also genetic


and environmental factors have a
role in development of type 2.


There are some pathophysiological
changes related with diabetes disease, one of these is the


retinopathy which is a
complication happened in diabetic patients affects eyes by damaging


the blood vessels of the eye
retina that lead to vision problems and sometimes can cause


blindness, it is developed in the
two types of diabetes. Also alteration T cells mediated


particularly in helper T cell
(CD4+) is a pathophysiological change, Beta cells failure is


one of these changes when B pancreatic cell fails to produce the adequate insulin to
skip the


cellular resistance, and there
many other changes related with diabetes disease.


Diabetes treatment is divided into
non-pharmacological and pharmacological treatments each


type has an important role in the
treatment process.  Non-pharmacological
treatment which is


mean that the patient doesn’t
depend on the drugs, it depends on the patient life style, in


which the patients have to take in
their consideration the importance of their life style on their


situation. So patients should aim
on their diet, in which most of researches say that eating


three main meals with the five main
food groups every day essential component of diabetes


management, also snacks have a role
to prevent hypoglycemia after multiple insulin


 injections. Physical activities also are a
non-pharmacological treatment, adults advised to do


an aerobic exercises a minimum 150
min/week. Exercises work on reducing the insulin


resistance and lower the blood
glucose level, also helping in maintaining body weight,


because overweighting affect
negatively in diabetic patients. 


Pharmacological treatments vary
depending on the type of diabetes. In which diabetes type1


medications are insulin either
short acting insulin e.g. regular insulin (Humulin) or long


acting insulin e.g. insulin glargine
(Lantus). Amylinomimetic drug is a medication for


diabetes type 1
e.g.(pramlintide), it is a drug used before meals acts on the stomach by


delaying the time to empty
itself, and reduces glucagon secretion that lead to decrease


glucose level in the blood. There different types of
diabetes type 2 medications, some of them


Alpha-glucosidase inhibitors these type of drugs work in helping your body to


down starchy foods and table sugar this decrease
blood glucose levels for examples: Miglitol


and Acarbose.


Biguanides is a type of medication for diabetes type
2 works by decreasing production of


glucose in the liver and sugar absorption in
intestines, increase the body sensitivity to insulin,


and help muscles in the absorption of glucose. e.g. Metformin.


Sulfonylureas those type of medications work by
enhancing the pancreas’s cells to make


more insulin e.g. Tolazamide (Tolinase).


Outcome: diabetes is a manageable
chronic disease in which until now there are no fully cure


for it. But there many treatments
are used to control diabetes and decrease or inhibit its


Symptoms. So diabetic patients
must care about their lifestyle all the time. because the


lifestyle of the patient helps in
management of the disease.






Ethical issues:


The relationship between the
doctor and the patients has a big role in diagnostic and


treatment processes. So the
doctors have to try to build good relations with their patients.


Generally, the keys in making a
good relationship with another person you need to show the


respect and interest to this
person and these come in several things.


And that’s what I have noticed in
our case (the relationship between the doctor and X


patient). Which there was a good
relationship between them, and this good relation showed


up in many things, firstly when X
entered the clinic the doctor stood up and welcomed her in


respectful way and she responded
in the same way. Also thing that showed the good relation


the eyes contact between them,
though the patient (X) is a female but the male doctor use the


proper way to keep eye contact. In
addition to that the doctor was giving X the enough time


to say her concerns and opinions
which helps to build a nice relation.


The consent from the ethical
aspect is an important thing that the doctors have to take it from


the patients, because through it
the doctors show the respect and freedom to the patients. This


what exactly happened between X
and the doctor in which he took a consent from X before


start taking her medical history.


Patient’s confidentiality, is a
thing doctors have to take in their considerations. Because, from


the ethical perspective the patients
have the right to keep their information secrecy, so


ethically as a doctor you need to
respect the patients demands. In our case the confidentiality


 appeared in several things one of them when
the doctor took the consent from X for us as


medical students to be present
during the interview, also the doctor respected X


confidentiality through inhibiting
any person out of the medical staff to enters the clinic


during the interview.






Legal issues:


 A legal consent which means a consent is taken
by doctors in aspect of protecting


themselves legally in case of any
complications after any decision or operation they do.


Almost it is taken in before
surgeries or chemotherapies.


usually be a written consent in
order to be shown in the in the future if it is needed. Doctors


usually are careful about taking an
accurate consent because any misunderstanding in the


consent can enter them in law
problems. The doctor in our case took a legal consent when he


took consent from X to change her medication
dosage. This can protect him in case of any


complications related with that


Confidentiality in the legal
aspect. The persons have the legally rights to save their


information in security. So as
doctors you must protect your patient’s privacy and don’t tell


 any other persons about their results or
information. Because if you break the patient


 confidentiality, you expose yourself to legal
accountability, so you should to respect the


patient’s decisions and privacies







1-Political aspects: Kingdome of
Saudi Arabia is living a state of development and changing


in all fields and one of these
fields the health sector. In which the Saudi government is doing


the best it could through provide
all kinds of support to the health system to improve the


 quality of the health field and provide
services to all citizens and residents in a fair way


trying to make the health system
here in Saudi Arabia in the best situation.


2-Economic aspect: The Saudi
government paid huge budgets to provide health accessibility


in all regions to all papulation
fairly. In which the citizens here have the right in the free


health services in government hospitals.
This facilitate accessibility to all papulation sects


either who owns the cost to pay
for the health services or who can’t.


3-Cultural aspect: the difference
in cultures is natures of the humans. So you need to respect


this differences in the believes
and concerns to build good relations with other. Doctors


encounter all sects from different
countries with different religions and believes which they


 have to respect them. Because, not respecting
and accepting these differences can be a


difficult factor in building
relations with the patients.


4-Social aspect:  social aspects have effects on the patient
state either the diagnosis or


treatment processes. In our case
patient X is a Saudi widow 62 female lives in Ras Tnora she


is a retired kindergarten
teacher since 15-year, the level of her education a
bachelor’s degree.


As I mentioned before X has 3 daughters and 6 sons.
And lives with her sons in the same





Self-care and
lifestyle (ESSENCE model):


 1- Education: Patient X has a large background
about her condition which is diabetes type 1


disease. Her background
information about her condition based the experience and as an


academic person she read a lot
about her disease from different reliable resources.


2- Stress management: Stress has
impact on patient’s treatment progression. In which in case


of high stress the affect your
state negatively. Patient X live in lovely and supported


environment from her family, which
help her to skip psychological effects related with her




3- Spirituality: X believe that her
disease is inherited and that what the god written for her. So


she accepted it and try to live together
with it.


4- Exercises: Physical activities
and exercises affect the patient health positively in different


 factors like lose weight, maintenance normal
blood glucose level. X unfortunately is not


capable to do any physical
activities resulted from various factors some of them are the old


age and overweight also the
surgery in her heel affects her.


5- Nutrition: The healthy food and
drinks have a big role in making a healthy body, also in


the treatment of some disease. In
X condition which is diabetes. the healthy diet is essential


factor in controlling the blood
glucose level. X eats a healthy type of food but unfortunately


she is not committed to eat the
three main meals in the proper time, that can affects her


healthy diet.


6- Connectedness: The family and
society support and the good relationships help the patient


situation psychologically, by
providing all kinds of support.


7- Environment: X’s around environment
is considered a healthy environment in all


environmental aspects. Also their
good financial state helps in making the healthy









X accepts her disease and try to
live together with it, but she still has a little worried about


 her eyes condition in which X thinks that if
she can loss her vision. From different aspect X


finds the enough support from her
family and society that helps her in skipping any


complications. Actually X’s
condition especially in overweight and not capable of doing


physical activities affect her
life from different perspectives either her social life or personal


life. After exiting from the
hospital X was happy about the services and good dealing from


the hospital staff. X expects
after the interview with the doctor her condition will better if she


follows the doctor advises.





My own


The interview was in a
professional way started from the doctor who welcomed us in


respectfully way and allow us to
enter the clinic and interview the patients, then when the


doctor take the consent for us
from the patients. In addition, the cooperation from the patients


with us. So I think it was a
wonderful interview from all aspects.


Interviewing the patients had an
effect on me in breaking the barriers to deal with patients.


Also apply what we have studied
about dealing and communicating with patients. So it was


having a big role in entering the
atmosphere of hospitals.


Although there are some factors
which can relatively affect the patient-doctor relationship,


 such the crowded and a low light, the
interaction between the doctor and X was almost in


perfect way, in which the doctor
was dealing with X in professional and respectful way, also


X was cooperative either with the
doctor or with us (medical students). 


I think as medical students we
should focus on studying and practicing in dealing with


patients as same as focusing in
the study of medical and scientific stuff.






In our interview we have met a diabetic patient (X) suffers from
diabetes type for 25 years,


 she came to the clinic to
know the cause of her irregular blood glucose level. The doctor


advised her to change her diet and he increased her medication
dose. Then we


 (medical students) took the
medical history from X and discussed here in our case


commentary project.