Case requirement prior to diagnosing a patient.Case requirement prior to diagnosing a patient.



Case commentary


ID :2170000174

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Medical history, in my opinion, is a crucial requirement prior to
diagnosing a patient. Collecting particular data and information from the
patient about his life and family history can significantly lead to better and
more effective diagnosis, whereas shortage of those personal data can mislead
the person in charge and make him misdiagnose the case which could result in
unfavorable consequences.



Background and history:

        For the sake of
patient confidentiality, I will call him patient X.

Patient X came to a follow up appointment with the Doctor in charge
in the cardiology clinic, when he finished his session, I asked him for his
consent to interview him after introducing myself, and he had no problem or
objection. Patient X is a 45 year old man. He is from Hufr Albatin, but lives
in Khobar with his wife and five children. He works as geologist on his own
after retiring from Aramco company.



Patient X presented to the hospital
several times seven months after feeling headache and nausea for one week
suddenly and repeatedly at sleeping time to the extent that he feels he is
about to faint and he declared that his pain scores six out of ten. Nausea and
headache were aggravated by drinking coffee, however nothing helped alleviating
and soothing his suffering, this deprived him from good sleeping and made him
worried and anxious. Based on this meeting I asked him about his believes and
expectations, but he answered that he had none.

After being checked for vital signs and
taking chest X-ray and ECG, he was diagnosed as hypertensive. Having the same
symptoms again, he came back for further check up and more accurate diagnosis.
He underwent stress treadmill test which revealed no chest pain and he passed
the stress test successfully. After sometimes, he came back to hospital again,
where he was admitted for further investigations. An interventional
cardiologist decided to go for angiogram after having patient’s written consent
and letting him be aware of possible probabilities. This procedure revealed
artery stenosis due to atherosclerosis in one or more of his coronary arteries
which made the Doctor in charge apply angioplasty (stent) to the affected


Past history:

Patient X has been diagnosed to have
pneumonia 1 year ago, he doesn’t have any past surgical procedures or past
traumas, he did not receive blood transfusion before, he takes his vaccinations


Family history (1st degree):

Patient X mother died when she was 37
years old due to heart attack.

Patient X father is alive. He is 85 years
old, he is hypertensive, diabetic, has a heart disease, he had an bypass
surgery  and high cholesterol


Social history:

Patient X lives in a house with his
family members and he has a good relationship with them, they support and
respect his decisions and appreciate him.

Patient X has a normal diet; he does not
exercise or do a physical activity.

Patient X is Muslim.


Drug history:

Patient X is a smoker, he smokes 10-15
cigars a day (dunhill) type he is not an addict and he has no problem in
quitting smoking.

Patient X has a past history with
alcohol, he was drinking when he was 17 years but he quit 25 years ago.

Patient X did not use any medications and
he does not have an allergy to food or drugs.


Biological aspects:

Coronary artery disease is a condition where
arteries that supply the heart with oxygen and nutrients became narrowed,
damaged or affected, it is caused by accumulation of fats or plaque inside the
arteries or inflammation of the arteries, that will affect the flow of blood to
the heart, which may cause sweating, vomiting, chest pain (angina), shortness
of breath, or in some cases when complete blockage occurs it might cause a myocardial

Some factors that may cause heart disease
are obesity, physical inactivity, high fat diets, smoking and genetic

Pathophysiology, Angina pectoris, which
results from the reduced oxygen supply and high demand of oxygen in heart
muscles, can happen because of mental and emotional stress, sexual activity,

“progression of coronary artery often causes acute
clinical manifestations, sudden cardiac death, acute myocardial infarction and
unstable coronary syndromes. “Recently, it has been shown that stenosis
progression, whether clinically “silent” or associated with acute
coronary events, is a strong predictor of cardiovascular risk” (JC, 2018).

Non-pharmacological treatment, weight management
if overweight, smoking cessation, physical activity and exercise, dietary
modification, all these procedures can prevent, reduce, or managing coronary
heart diseases.

Pharmacological treatment, antiplatelet therapy (aspirin),
anti-anginal therapy and antihypertensive therapy (metoprolol, propranolol), in
some situations statin or lipid lowering therapy (lovastatin), in acute angina symptoms
sublingual glyceryl trinitrate.

Some of these medications are prescribed for
Patient X for his case they are (Aspirin. Plavix,,concor, Lipitor).


  doctor observation was Patient X showed after
being treated with pharmacological treatment and being advised to follow a
certain diet, and lose weight, and practice exercise and change other aspect of
life style like stress control. Patient X case has improved significantly and
he got better off, and had less complains.  

There is no affective cure so far for coronary
artery disease but some procedures like angioplasty ( stent) and some
medications like anticoagulants can reduces the impact of coronary artery disease
symptoms like angina and short breath


Ethical issue:

The doctor and patient relationship, I was
waiting  at the clinic when Patient X
entered the doctors room, I observed a very good relationship between Patient X
and the doctor, the doctor welcomed and shacked hands with Patient X, the
doctor asked  Patient X how is he doing
in his life and he was smiling all the time, however the eye contact was not
perfect because the doctor need to write some important notes while asking
Patient X, the doctor was listening to Patient X carefully, Patient X was too
comfortable talking to the doctor, and asking 
question for any doubts, the overall atmosphere was lovely and peaceful,
after the appointment ended the doctor shacked hands again and he wished to see
Patient X with a better and good health.


Taking consent is an important ethical step before
ending the appointment the doctor asked Patient X for a consent so that I can
take a medical history, this made me relaxed and made the communication easier
and to the point, as he put trust in me after the doctor told him about our



usually patients information are kept confidential for the sake of continuing
treatment without fear of disclosing patient information to other parties,
thus, Patient X came to the clinic with personal information that he was afraid
of being released. we assured him that such information is usually kept between
doctor and patient which made him be frank and honest in telling his history.


Legal issues:


Every country and every hospital has its own
rules and regulations that doctors should be aware of, which will keep the
doctor safe from legal sewing, it is imperative that doctors obtain a written
consent from the patient before taking any procedural step or surgery, thus in
this case after the doctor described to Patient X his condition and what is the
procedure that he is going to have and what are the possibilities to have
complications during procedure, the doctor took a written consent from Patient
X .


Some people have some worries towards some
legality of some practices like drinking alcohol or using narcotics and they
feel afraid to reveal their confidential information to the doctor however, reassuring
them and pledging to them that their information will be kept secret and no one
other than medical staff will see their information, can encourage them to
share their information, if any breach happens responsible people can be
severely punished, with Patient X after assuring him that his information are
secretly kept he did not hastate telling me that he was using alcohol.

In some cases, doctors are allowed to breach
patient confidentiality to the responsible authorities in (Child abuse,
communicable diseases like AIDS)






Sociological aspects:


Every government has its own rules and policies,
one of the most demands governments face is health care and how to distribute resources
in a good way to those who need it.

 In Saudi
Arabia, health care is a high priority, that’s why it is free for all citizens
and residents, having a primary health care centers in almost every village and
having general hospitals in every city and some specialized hospitals
facilitate the use of health care system, even private health support companies
can participate in some health care services to help provide a high quality
services to people.



Some governments set huge budgets for health care
which represent their commitment to health care providing, Saudi Arabia for
example has allocated (totaling SR 58.899.190.000)   riyals for Ministry of health (MOH) YEAR
(1436/1437) H. In patient X case an angioplasty ( stent ) would usually cost
him more than (70-100) thousands riyals if it is done in a private hospital which
is too costly for ordinary people specially for those who don’t have major



Different people tend to believe in different
methods of treatment due to their culture, some like to use herbs, some use
alternative medicine which make them turn away from going to the right paths
like clinics and hospitals, which may cause their health to deteriorate or
postpone the cure for some cases. Some patients have religious believes that
might make them refuse being physically examined or they neither use certain
medications, though, doctors need to respect patients believes and give
alternatives for patients in such cases to avoid conflict.



 Since we
live in a conservative society, many problems arise from social point of view,
problems like having a female checked by a male doctor is considered a taboo to
some people, while many educated people find such practice a normal procedure
and would not refuse that male or female be seen by a different gender doctor.

People who come from industrial and busy cities
tend to be more flexible in different procedures than those who come from
villages or small towns.

After all it is noticed that educated people tend
to accept different procedures and tend to visit clinic upon feeling sick
before their situation worsen. Patient X comes from Alkhobar which makes him
easier to deal with as mentioned above

Social limitations can affect patient’s health,
in Patient X case stress is a major factor that contributes to worsening the



Self-care and life style



Education is a major factor that contributes to
the understanding of the patient since educated people usually get exposed to
different meeting and conferences with other nationalities and multi-cultural
personnel which help widen horizon
of educated patients, thus, Patient X who is a geologist and will educated
showed a positive attitude and response to the doctor when trying to assess his
case and provide treatment to him after final diagnosis.





Stress management:  


Stress management represents one of the main
elements to reduce consequences of stress like hypertension and heart
arrhythmia and heart disease, insomnia, in Patient X situation stress relief
and management could reduce the possibility of getting angina pectoris, and
getting enough sleep.



Spirituality helps people being hopeful,
optimistic, and comfort, and this enhance the state of wellbeing, it may not be
the cure, but feeling better is the goal. Patient X had a good spiritual belief
in Allah, thus, he is thankful for god’s gifts, and
feeling satisfied about his situation.



physical exercising is a bodily activity
that help maintain and enhance fitness and health, it can help reducing aging,
and weight loss, it also helps strengthen cardiovascular system which can
prevent some morbid illness like coronary artery disease and hypertension, even
stress can be released by exercising, Patient X does not exercise and he is
physically inactive, he is a bet over weight, so doctor recommended him to do
some exercises and he promised to start soon and that will help his heart
pumping blood more efficient.








Food is the material that gives our body
the energy to metabolic processes, an error during these process may cause a lot
of health issues, so diet is directly related to health, what we eat determines
our health state, there are a lot of health problems related to diet like
obesity, hypertension, cardiovascular disease, Patient X is not having a
healthy diet he eats to much carbs and fats , but he does not consume fast food,
soft drinks, thus, doctor asked Patient X to make some modifications in his
diet to improve his health.


A person’s relationship with family, friend’s
neighbors, and participation in volunteer activities, all of them play a role
in enhancing wellbeing, which can influence health directly or indirectly,
Patient X fortunately have a good relationship with his siblings and family,
they support him to take care of his health, this helped him to be happier
which is reflected on his health.


Environment affects our health by different
ways directly or indirectly, dealing with factors such as population, air and water
pollution, weather, can reflect on people’s health, for example Patient X is living
in Alkhobar which is too crowded and this pots stress on him, which indirectly affects
his coronary artery disease case negatively.


Patient’s perspective:

Patient X accepted the fact that he is
sick, and this did not have a negative impact on his psychological situation,
no depression was observed.

Patient X understood his situation
clearly he could explain what is his condition easily, Patient X was satisfied
with services introduced by the hospital in general and was thankful in
particular to the staff.

He was happy and the system was up to Patient
X expectations, Patient X family was supporting him to get better and they
provided enough at home and they accompanied him at the hospital all the time
and showed emotional support by reassuring him and praying for him to get will

Patient X case hindered him from playing
football and exercising severely, eating fatty foods, like old days, he expects
to gradually raise his fitness and go back to almost a normal life and in a
better health.

My own perspective:

studying this case in my early study
years made me more self-confidant when dealing with patients with serious
diseases, it had a good impact on my communication skills as well as my medical

Doctor showed great passion toward Patient
X because Patient X was hopeful and optimistic and he was interacting with the
doctor positively which made the doctor happy for the patient, this made me
able to intervene and ask both doctor and Patient X more questions in this
positive atmosphere, which helped me understand the case deeply and be aware of
the aetiology and how to diagnose coronary artery disease and what are the
possible treatments.

future expectations, primarily cardiology seems to be one of my top interests
as I find myself able to go further step in understanding and dealing with such
a case, I hope that I become a distinguished doctor by increasing my skills and
studying hard.



Patient X came to the hospital with a
headache and nausea, after having him cheeked up he was diagnosed with coronary
artery disease, he underwent angioplasty (stent) and he went on medications for
life long, his situation is controlled and he is doing well, the visit was
fruitful and useful, it was an unforgettable experience.   



















– (2018). Stable
ischaemic heart disease – Symptoms, diagnosis and treatment | BMJ Best Practice.
online Available at: Accessed 28 Jan.


–        JC, K. (2018). Rapid coronary
artery disease progression and angiographic stenosis morphology. PubMed – NCBI.
online Available at: Accessed 28 Jan. 2018.



–       Mayo Clinic. (2018). Coronary artery disease –
Symptoms and causes. online
Available at:
Accessed 28 Jan. 2018.



 Anon, (2018).
online Available at: –
Accessed 28 Jan. 2018.


–       Anon, (2018). online Available at: – Accessed 28 Jan. 2018.


(2018). online Available at: –
Accessed 28 Jan. 2018.



 Anon, (2018).
online Available at: –
Accessed 28 Jan. 2018.