Introduction: As a medical student, communications skills and dealingappropriately with others are considered one of the most important things you have to learn andpractice, because they will facilitate your task in dealing with your patients and taking theperfect medical history in the future.
The medical history is a routine process happens every dayat every medical clinic. It helps the physicians to take the correct information from theirpatients, which consider an important key in identifying the right diagnosis and the optimaltreatments for the patients. So, as students the practice on taking a medical history was the mostimportant thing we have focused on in the first visiting for us to the educationalhospital. 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 femalepatient with 62 years old from Ras Tnora. A widow retiredteacher. She is a diabetic patient; X is a patient suffers from diabetes type2.
Presented tothe diabetes clinic in king fahad university hospital with irregular blood glucose level and problem in her eyes for fivedays ago. she said that there was an abnormal increase in her blood glucose level thoughshe doesn’t eat large amount of sugar. The main X’s aim from the visit was to identifythe 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. Xdoesn’t suffer from any chronic disease except diabetes. X did three surgeries in the past, thefirst one was thyroid gland removal (thyroidectomy), the second was in her heel because ofdiabetic ulcers, and the last one was in her eye because of Diabeticretinopathy. Patient hasn’t done a blood transfusion. X is takingsome medications that are insulin glargine ( Lantus), and aspirin for the stomach.
X has suffered from a little increase blood pressureand balance problem in the last days, and increase in cholesterol level. X a widow has 3 daughters and 6 sons, the husband andthe eldest son suffered from diabetes type 1, while her parents and other kids were healthydidn’t suffered from any chronic disease. X lives with her sons in the same house allof them are employees and spend most of their time in their workplaces, but she said thatthey 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’tregular in which she eats her meals at a random time.
Andon 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 toany drugs or substances.
After taking the medical history the doctor suggeststhe main causes of that irregular blood glucose level is the unhealthy diet and the amount ofthe medication dose. So he advised her to increase the dose of her medication, and alter her lifestyle by changing her diet. Biologicalaspects: Diabetes is a disease related withincreasing in blood glucose level. The sugar (glucose) in your blood which comes from your diet you needto transport it from your blood stream to your cells which they use it as asource of energy. So the glucose need a hormonal assistance which provided by an essentialhormone called insulin that play a role in entering the glucose into the cells, especiallyskeletal muscles cells. In diabetic patients they have problem with their insulin, but it is differentdepending on the type of the diabetes. There are two types of diabetes, in diabetes type 1 thebody can’t make an insulin, while in diabetes type 2 which is more common the body doesn’tproduce enough insulin or your cell becomes resistance to the insulin, so you will have increase in yourblood glucose level.
Diabetes is a common disease especially here in SaudiArabia although it is a dangerous disease can damage your kidneys, eyes, and nerves. And cancauses heart disease. There are a lot of symptoms show in the diabetic patients some ofthese, weight loss, increased thirst, increasing the ketones bodies in urine, fatigue, andother symptoms. Therefore, when you notice these signs you have to visit the hospital tocheck up and ensure that you don’t have any problems. The factors that have a role indiabetes are unclear enough until now, but in diabetes type 1 your immune system has an effects onyour pancreas cells which lead to reduces or inhibit the production of the insulin andusually caused by genetic and environmental factors, where obesity and prediabetes areconsidered factors that may cause diabetes type 2, also genetic and environmental factors have arole in development of type 2. There are some pathophysiologicalchanges related with diabetes disease, one of these is the retinopathy which is acomplication happened in diabetic patients affects eyes by damaging the blood vessels of the eyeretina that lead to vision problems and sometimes can cause blindness, it is developed in thetwo 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 toskip the cellular resistance, and theremany other changes related with diabetes disease.
Diabetes treatment is divided intonon-pharmacological and pharmacological treatments each type has an important role in thetreatment process. Non-pharmacologicaltreatment which is mean that the patient doesn’tdepend on the drugs, it depends on the patient life style, in which the patients have to take intheir consideration the importance of their life style on their situation. So patients should aimon their diet, in which most of researches say that eating three main meals with the five mainfood groups every day essential component of diabetes management, also snacks have a roleto prevent hypoglycemia after multiple insulin injections. Physical activities also are anon-pharmacological treatment, adults advised to do an aerobic exercises a minimum 150min/week.
Exercises work on reducing the insulin resistance and lower the bloodglucose level, also helping in maintaining body weight, because overweighting affectnegatively in diabetic patients. Pharmacological treatments varydepending on the type of diabetes. In which diabetes type1 medications are insulin eithershort acting insulin e.g. regular insulin (Humulin) or long acting insulin e.
g. insulin glargine(Lantus). Amylinomimetic drug is a medication for diabetes type 1e.g.
(pramlintide), it is a drug used before meals acts on the stomach by delaying the time to emptyitself, and reduces glucagon secretion that lead to decrease glucose level in the blood. There different types ofdiabetes type 2 medications, some of them areAlpha-glucosidase inhibitors these type of drugs work in helping your body tobreak down starchy foods and table sugar this decreaseblood glucose levels for examples: Miglitol and Acarbose. Biguanides is a type of medication for diabetes type2 works by decreasing production of glucose in the liver and sugar absorption inintestines, increase the body sensitivity to insulin, and help muscles in the absorption of glucose. e.g.
Metformin. Sulfonylureas those type of medications work byenhancing the pancreas’s cells to make more insulin e.g. Tolazamide (Tolinase). Outcome: diabetes is a manageablechronic disease in which until now there are no fully cure for it. But there many treatmentsare used to control diabetes and decrease or inhibit its Symptoms. So diabetic patientsmust care about their lifestyle all the time.
because the lifestyle of the patient helps inmanagement of the disease. Ethical issues: The relationship between thedoctor and the patients has a big role in diagnostic and treatment processes. So thedoctors have to try to build good relations with their patients. Generally, the keys in making agood relationship with another person you need to show the respect and interest to thisperson and these come in several things. And that’s what I have noticed inour case (the relationship between the doctor and X patient). Which there was a goodrelationship between them, and this good relation showed up in many things, firstly when Xentered the clinic the doctor stood up and welcomed her in respectful way and she respondedin 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. Inaddition to that the doctor was giving X the enough time to say her concerns and opinionswhich helps to build a nice relation. The consent from the ethicalaspect is an important thing that the doctors have to take it from the patients, because through itthe doctors show the respect and freedom to the patients. This what exactly happened between Xand the doctor in which he took a consent from X before start taking her medical history. Patient’s confidentiality, is athing doctors have to take in their considerations. Because, from the ethical perspective the patientshave the right to keep their information secrecy, so ethically as a doctor you need torespect the patients demands.
In our case the confidentiality appeared in several things one of them whenthe doctor took the consent from X for us as medical students to be presentduring the interview, also the doctor respected X confidentiality through inhibitingany person out of the medical staff to enters the clinic during the interview. Legal issues: A legal consent which means a consent is takenby doctors in aspect of protecting themselves legally in case of anycomplications after any decision or operation they do. Almost it is taken in beforesurgeries or chemotherapies. usually be a written consent inorder to be shown in the in the future if it is needed.
Doctors usually are careful about taking anaccurate consent because any misunderstanding in the consent can enter them in lawproblems. The doctor in our case took a legal consent when he took consent from X to change her medicationdosage. This can protect him in case of any complications related with thatchange. Confidentiality in the legalaspect. The persons have the legally rights to save their information in security. So asdoctors you must protect your patient’s privacy and don’t tell any other persons about their results orinformation. Because if you break the patient confidentiality, you expose yourself to legalaccountability, so you should to respect the patient’s decisions and privacies sociologicalaspects: 1-Political aspects: Kingdome ofSaudi Arabia is living a state of development and changing in all fields and one of thesefields the health sector. In which the Saudi government is doing the best it could through provideall kinds of support to the health system to improve the quality of the health field and provideservices to all citizens and residents in a fair way trying to make the health systemhere in Saudi Arabia in the best situation.
2-Economic aspect: The Saudigovernment paid huge budgets to provide health accessibility in all regions to all papulationfairly. 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 payfor the health services or who can’t. 3-Cultural aspect: the differencein cultures is natures of the humans. So you need to respect this differences in the believesand concerns to build good relations with other. Doctors encounter all sects from differentcountries with different religions and believes which they have to respect them. Because, not respectingand accepting these differences can be a difficult factor in buildingrelations with the patients. 4-Social aspect: social aspects have effects on the patientstate either the diagnosis or treatment processes.
In our casepatient X is a Saudi widow 62 female lives in Ras Tnora she is a retired kindergartenteacher since 15-year, the level of her education abachelor’s degree. As I mentioned before X has 3 daughters and 6 sons.And lives with her sons in the same home. Self-care andlifestyle (ESSENCE model): 1- Education: Patient X has a large backgroundabout her condition which is diabetes type 1 disease. Her backgroundinformation about her condition based the experience and as an academic person she read a lotabout her disease from different reliable resources. 2- Stress management: Stress hasimpact on patient’s treatment progression. In which in case of high stress the affect yourstate negatively. Patient X live in lovely and supported environment from her family, whichhelp her to skip psychological effects related with her condition.
3- Spirituality: X believe that herdisease is inherited and that what the god written for her. So she accepted it and try to live togetherwith it. 4- Exercises: Physical activitiesand exercises affect the patient health positively in different factors like lose weight, maintenance normalblood glucose level. X unfortunately is not capable to do any physicalactivities resulted from various factors some of them are the old age and overweight also thesurgery in her heel affects her. 5- Nutrition: The healthy food anddrinks have a big role in making a healthy body, also in the treatment of some disease. InX condition which is diabetes. the healthy diet is essential factor in controlling the bloodglucose level. X eats a healthy type of food but unfortunately she is not committed to eat thethree main meals in the proper time, that can affects her healthy diet.
6- Connectedness: The family andsociety support and the good relationships help the patient situation psychologically, byproviding all kinds of support. 7- Environment: X’s around environmentis considered a healthy environment in all environmental aspects. Also theirgood financial state helps in making the healthy environment. Patientperspective: X accepts her disease and try tolive together with it, but she still has a little worried about her eyes condition in which X thinks that ifshe can loss her vision.
From different aspect X finds the enough support from herfamily and society that helps her in skipping any complications. Actually X’scondition especially in overweight and not capable of doing physical activities affect herlife from different perspectives either her social life or personal life. After exiting from thehospital X was happy about the services and good dealing from the hospital staff. X expectsafter the interview with the doctor her condition will better if she follows the doctor advises. My ownperspective: The interview was in aprofessional way started from the doctor who welcomed us in respectfully way and allow us toenter the clinic and interview the patients, then when the doctor take the consent for usfrom the patients. In addition, the cooperation from the patients with us.
So I think it was awonderful interview from all aspects. Interviewing the patients had aneffect on me in breaking the barriers to deal with patients. Also apply what we have studiedabout dealing and communicating with patients. So it was having a big role in entering theatmosphere of hospitals. Although there are some factorswhich can relatively affect the patient-doctor relationship, such the crowded and a low light, theinteraction between the doctor and X was almost in perfect way, in which the doctorwas dealing with X in professional and respectful way, also X was cooperative either with thedoctor or with us (medical students).
I think as medical students weshould focus on studying and practicing in dealing with patients as same as focusing inthe study of medical and scientific stuff. Conclusion: In our interview we have met a diabetic patient (X) suffers fromdiabetes type for 25 years, she came to the clinic toknow the cause of her irregular blood glucose level. The doctor advised her to change her diet and he increased her medicationdose. Then we (medical students) took themedical history from X and discussed here in our case commentary project.