· Introduction: Medical history in clinical medicine is the previousand current data of a patient taken by asking the patient about his past andpresent history of his case of disease.
Taking history correctly is a veryimportant step to get an optimal diagnosis of the patient. Since we need togive the patient the best health care service, we should be able to do theprocedures in a respectful and skillful way.. In order to get a good history to diagnose adisease, you have to consider the mental, social, psychological, and physicalhealth to cover everything that is possible to be relevant to the patient’sstatus.
· Background and history:The patient X, the actual name was notmentioned to save the patient’s confidentiality, is a 65 year-old married male. · Present history: The patient came to the clinic of diabetes inKing Fahad University Hospital, follow-up patient, complaining of swelling inhis both feet. He noticed the swelling with highblood glucose level three days before coming to the clinic. The patient wasunable to walk and even stand on his feet. In addition, the blood glucose washigh as seemed in the test of glycated hemoglobin. After the present doctortook the history and did a physical examination, he diagnosed the disease as adiabetes associated condition called edema. · Past history: The patient has a history of diabetes type2, which was diagnosed 23 years ago.
In addition to that, as an associatedcondition, he has hypertension after four years of getting diabetes. The patient has undergone only oneoperation during his life. He had a vitrectomy, which is removal of thevitreous gel from diabetic retinopathy patients who have vitreoushemorrhage. The patient had a heart attack tenyears ago because of smoking. The patient did not take any vaccination.· Familyhistory: The patient’s parent both are dead his father was 72 year-old and hismother was 44 year-old, both had diabetes and hypertension. The patient hasthree sisters and one brother, and two of his sisters have diabetes. Thepatient has 9 daughters and 4 sons with no chronic diseases.
· Social history: The patient X lives in a house with his wife andchildren. He feels very happy and comfortable with his family. He does not doany kind of exercising. In addition, he is careless with his diet.
· Drug and allergyhistory: Thepatient does not have any allergy toward any kind of food. Thepatient’s father was a smoker. His mother did not use any kind of smoking oralcohol. He used medications including:1- Tobrex eye drops against eyeinfections: are used as antibiotic.
2-VentolinRespirator Solution: usedin some respiratory conditions like asthma, Finely, the doctor arrangedan appointment for furthermore investigations as Patient.HS’s statue wassomehow controlled and relieved by using some eye’s droplets. · Biological aspects: Edema is swelling due to accumulation of fluids in the body’stissues. It can affect any part of the body. It usually occurs within thehands, arms, feet, ankles, and legs. -Pathophysiology of Edema: “Edema occurs when tiny blood vessels in yourbody (capillaries) leak fluid. The fluid builds up in surrounding tissues,leading to swelling.
“-Causes and risk factors of Edema:v Mildedema could be a result of one of the following:-Sitting in onepositing for a long period time-Eating muchsalts-Pregnancyv Also,some medications can cause edema, as a side effect:-Hypertensionmedications-Non-steroidalanti-inflammatory drugs-Steroid drugs-Some diabetesmedications called thiazolidinedionesv Edemacan be a cause of several disease:-Cirrhosis-Heart failure-Long-termdeficiency of protien -Edema symptoms: The main symptom of edema is swelling. Thereare other symptoms associated with the swelling including weight gain, skindiscoloration, stiff joints, painful limbs, and hypertension-Edema complications:· Increasing theswelling pain· Stiffness· Itchiness· Increasedpossibility of skin infections· Walking difficulty· Decreased bloodcirculation -Edema diagnosis: Often, history takingand physical examination by doctor is enough to diagnose the disease and knowthe reason underlying it. In some cases, X-rays, ultrasound exams, magnetic resonanceimaging, blood tests or urine analysis may be necessary.-Edema treatment: · Pharmacologicaltreatment: The sever edema is treated by drugs thathelp the body to expel it within the urine called diuretics. Furosemide,also called Lasix, is a common diuretic used for edema. Your doctor mayalter your medication to avoid giving you a drug that causes edema.
· Non-pharmacologicaltreatment: The mild edema usually goesaway on its own. It is advised to rise the affected limb above the heart to healmore quickly. -The outcome: Furosemideis a diuretic that reduces salt absorption to expel within the urine, whichlead to decrease fluid accumulation, and thus, the cure of edema. There could be some sideeffects including diarrhea, constipation, dizziness, breathing difficulty, anditchiness. · Ethical issues: – Doctor-patient relationship: I saw a wonderfulrelationship between the doctor and patient.
The doctor was paying attentionvery well with the patient. The patient had been a little bit worried, but thedoctor did well with him by explaining the disease and how it is going to be cured.The patient changed and clearly got comfortable and cooperative with the doctorbecause of what he said. I can say the doctor absolutely did as best as couldbe. -The consent: The doctor was carefulnot to disturb or bother the patient X.
After the patient came into the clinic,the doctor introduced himself and then told the family member to understandthat there may be some sensitive questions that should be asked to have the diagnoseddone well. Also, he was very careful during the physical examination and askedthe patient to permit him to do it. In addition to that, he was telling thepatient during the physical examination what he was going to do to make himfeel safe and comfortable.-Confidentiality: Confidentiality is when theinformation given by the patient kept restricted and not shared to anyoneunless some certain cases. The doctor was concentrating on that we, thestudents, do not tell anyone the patient’s information.
When the patient hadcome and before his family members came, the doctor ask the patient whethersomeone is with him and if he would like to have someone of them with him or not.