· Introduction:On the afternoon of Tuesday, October 17, 2017, I went to myfirst hospital visit as a medical student. The hospital’s atmosphere on thatspecific day was greatly different than usual. I have visited King FahdHospital of the University many times as a patient. But, being a part of themedical team, observing the flow of the work in clinics and taking history frompatients was a unique experience, especially for a second-year medical student.Taking a medical history from the patient is a crucial part in reaching adiagnosis.
Even the most intelligent doctors cannot identify the condition oftheir patients without taking a medical history from them. In order to take aproper medical history from the patient, doctors have to communicate appropriatelyand assure privacy and comfortable environment so that patients can express themselves. · Backgroundand history:(presenting complaint and initial treatment, family history,social history, diagnostic process, advices, current situation, respectively)WZ (the name of the patient de-identified) is a Saudi marriedmale, 39 years old, working at National Petroleum Services (NPS) and lives inSaihat.
WZ came to the fracture clinic 5 months ago with an unmovable leg as hehas been in Oman having a fishing trip there. WZ has a certificate in diving sohe is a good swimmer and knows what to do in water. WZ and his friends took ajet-ski to have fun in their free time and while driving the jet-ski a youngboy riding another jet-ski wasn’t focusing and came to him and crashed into WZ.WZ was feeling an extreme pain in his knee that he couldn’t move it. Moreover,his knee was swelled and red with excessive heat and in a scale out of 10, inwhich 10 is the worst pain and 0 is no pain, he described the pain as 8 out of10.
So, he decided to go to a local hospital in Oman to have a look at his kneeand there they treated him temporarily and advised him to take someover-the-counter medications to relieve his pain such as Tylenol, so he can goback to Saudi Arabia and have a full treatment. When WZ came back to Saudi Arabia he went to King FahdHospital of the University so that he can get full treatment. The doctor had alook at his knee and asked him about the aggravating and alleviating factorsand he said that movement makes it worse and ice makes it better. WZ had a longthought about his injury and how it could impact his life. He wasn’t able to goto work or even to go out. He was concerned that this injury will affect hismuscles and may cause muscle wasting. His expectations of the medical team werehigh, and he thought that they could help him to feel better in time.
The patient’s parents are still alive they are cousins withno chronic conditions. He has 2 brothers and 1 sister, but he has no sons ordaughters. He has a family history of osteoarthritis in his grandmother whichcan be relieved by paracetamol.He lives with his wife in an apartment and he is financiallystable. The patient has a strong relationship with his family and friends andthey have supported him and helped him whenever he needed anything.
He is anathlete guy as he jogs every day and swims occasionally. He has no regulardiet. He is a smoker, who smokes half pack of Marlboro Red daily. He is also abinge-drinker and drinks beer with 4% Alcohol.
The patient undergone a CT scan and a physical examination. Thedifferential diagnosis after examining his both knees to see the difference andlooking at the CT scan has led to a Lateral Tibial Plateau Fracture.The doctor advised him to alter some of his daily routinelifestyle. WZ was advised to watch his diet as it is difficult for his knees tocarry too much weight. Furthermore, he was advised to continue exercising for aminimum of 150 minutes per week.
WZ condition is controlled now and he has a regularappointment every month to change the cast and to have an x-ray to see thechanges in his knee condition. Although he is concerned a lot about hiscondition and how it could be worsened by any sudden unexpected event, WZ hasfaith in the medical team.· Biological aspects:(description of the fracture, pathophysiological change andclassifications, causes, clinical presentation, treatment and outcome,respectively)A tibial plateau fracture is a break of the higher partof the tibia (shinbone) that includes the knee joint. “Fractures of the tibial plateau are quite uncommon,representing around 1.2% of all fractures. More than 50% of patients who sustaina tibial plateau fracture are aged 50 years or older” (Pitta et al., 2014). Tibial plateau fractures in younger patients are usuallythe result of high-energy injuries.
The symptoms of tibial plateau fracture include:pain when weight is implemented, swelling, limited range of motion and in severecases there is numbness in the foot because of nerve damage.”Tibial plateau fractures are classified according to theSchatzker classification system into six types: Type I: lateral tibial plateaufracture without depression. Type II: lateral tibial plateau fracture withdepression. Type III: compression fracture of the lateral (IIIa) or central(IIIb) tibial plateau. Type IV: medial tibial plateau fracture. Type V: bicondylartibial plateau facture. Type VI: tibial plateau fracture with diaphysealdiscontinuity” (Physiopedia, 2016). And according to the physicalexamination and radiography, it is obvious that WZ has a tibial plateaufracture Type IIIa.
Tibial plateau fractures are caused by a force driving thelower end of the femur (thigh bone) into the soft bone of the tibial plateau. Thereason of tibial plateau fractures is primarily car- or motor accidents andsometimes sport accidents, mostly sports with a high velocity such as horseriding and specific water sports, such as jet-ski which was the cause of WZinjury.Full clinical assessment is required, including evaluation ofthe soft tissues to determine if a compartment syndrome is present and whetherthe patient has maintained a neurovascular injury. Gentle stress testing can bedone with the leg in extension to evaluate the stability of the ligaments andto assess any sign of fracture displacement. As it was done in each follow-upappointment that WZ came to.Not all fractures of the tibial plateau require surgicalintervention. The first challenge in the management of tibial plateau fracturesis to decide between nonoperative and surgical treatment. Andaccording to WZ situation he was treated nonoperatively by having a physiotherapysession twice a week.
Outcome”The average time to union for the fracture is 13 weeks(range 8–36)” (NCBI, 2010). No significant differences regarding time to union havebeen noted in cases treated both operatively and nonoperatively. Complex tibial plateau fractures are realted to nonunion andmalunion, because of comminution, unstable fixation, failure to bone graft,infection or combination of these factors.· Ethical issues:(Doctor-patient relationship, consent and confidentiality,respectively)The relationship between the doctor and the patient is veryimportant in the process of treating a patient. A good relationship will makeit easier for the physician to take an appropriate history from the patient andeventually will lead to a more accurate diagnosis. And I saw this impact of thephysician-patient relationship when I was in the clinic that day. The doctorstood when WZ entered the clinic and greeted him with a big smile and he hasshaken WZ’s hands.
This action of greeting the patient has lead to making WZvery comfort and happy about the healthcare team.Morally, we all know that a doctor can’t force patients to door accept something they don’t want to. For instance, a male doctor can’tcoerce a female to let him examine her breast to see whether she has a breastcancer or not. And that’s what happened in the clinic when the physician askedour patient WZ if the presence of us as second-year medical students willbother him or not. Furthermore, the doctor asked him if he doesn’t mind if weas students took a detailed history from him.In our practice, confidentiality means keeping theinformation of the patient as a secret between the doctor and his own patientand not disclosing it with any third party unless there’s a need to do so.
Confidentiality is very important to ensure that patients feel comfortable whenexpressing themselves. When we were in the clinic the doctor asked us to kindlyleave him and the patient for some time as he felt the patient is a bit shy andhe is not comfortable. And when WZ left the clinic, the doctor told us that heasked us to leave so that he ensures the patient’s comfort and to tell WZ thatany information will remain confidential.· Legal issues:(consent and confidentiality, respectively)In any healthcare setting, a set of rules and obligationsgovern healthcare workers and they must follow them. These rules may differ inthe way they are applied from one situation to another and between differentcountries. But in the end, they aim to reinforce the autonomy of the patient,non-malpractice, beneficence as well as social justice and equity. This isconsidered as the legal aspect of medical practice in which healthcareproviders can be sued if they break these laws intentionally.
And most of thelawsuits are because of break in the laws of consent or confidentiality.When we look at how sensitive the goals of these laws are, werealize that it is important to minimize the errors when practicing medicine.And that’s what the doctor did when he obtained verbal consent from WZ toexamine his knees. Also, the doctor asked WZ if there’s any discomfort when we observethe doctor while examining him and WZ accepted it immediately. It’s thepatient’s right to be asked if our presence while examining his knees isbothering him or not.
By gaining consent, practitioner has avoided any legalaccountability that he might experience in the future.The consequences of breaching confidentiality are severe ifthe patient decided to sue the practitioner. That’s why physicians do theirbest to keep patient’s information as a secret. We recognized this thing whenwe asked the doctor about what happened with WZ when we were asked to leave theroom and the doctor refused to tell us what happened back then. But, in somesituations such as communicable diseases or child abuse the doctor can breachconfidentiality and disclose the information to appropriate authorities. · Sociological aspect:(political, economic, cultural, social, respectively)Accessibility and government policies to healthcare servicesdiffer when we look at different countries. Thankfully, here in Saudi Arabiagovernment give access to wide range of healthcare services for citizens andresidents without any discrimination between them. In addition, we have a largedistributed healthcare centers in many different areas to help in enhancing theoverall health.
As we’ve seen here with WZ when he was in Oman he took theminimum health care needed just to come back to Saudi Arabia and completetreatment in here.Economically, the Saudi government expenditure on healthservices reached “58.899.190.000 SR in 2016″(MOH, 2016).
This large budget is customized to improve the quality of healthcareservices provided to people who live in Saudi Arabia. Moreover, most of thehealth services provided by the government is for free. When we consider WZ case, we note that he was first treatedin Oman where he must pay for treatment in there. In this case costs might be aheavy burden for people with limited or low income. But, fortunately WZ has aninsurance that works in all gulf countries, so he didn’t have to pay for histreatment.Recognizing the patients cultural and religious believes willimpact the relationship between the physician and the patient. For instance, ifdoctors criticized patients’ believes about how to treat a disease, patientswill distrust doctors as they will think doctors are close minded.
Somepatients have strong belief in herbal remedy as a way of treating illness insteadof taking pointless medications. Although their belief might be wrong, doctorsmust persuade them without criticizing their beliefs. Also, because WZ is aMuslim, he believes that death stage is the destiny for every living creature.
So, this will hopefully impact the way he accepts treatment and diseases.The social conditions of patients will always affect the waythey are treated. As we have mentioned WZ is a 39-year-old male, he lives withhis wife and they have no children yet.
His parents are still alive and in goodhealth. He has 2 brothers and 1 sister. WZ is well supported by his family andfriends and according to his words he says that they do whatever it takes tomake him feel better.· Self-care and lifestyle:(ESSENCE, respectively)As I mentioned before WZ works in NPS and specifically he isa petroleum engineer who graduated from KFUPM with a certificate of excellence.
This means that he is a well-educated person and this will help in the way heis treated. As an educated person, he will follow the doctor orders and hewon’t miss any physiotherapy session as he recognizes how important they are.Every person feels stressed at some point in life. But, ifthis stress isn’t totally managed this may lead to depression and other physicaland psychological diseases. The way people manage stress differs greatlyaccording to their culture, personal traits and manners.
When I asked WZ aboutthe way he handles his stress he responded immediately that he is an athleteguy, so whenever he is stressed he goes out and runs until he feels that thestress is relieved. Also, as he is an expert diver, he sometimes swims insteadof running. He said that sports always help him in managing stress.As a Muslim person, WZ always attends to prayer and hecelebrates every religious festival. He says that spirituality and meditationcalm him down whenever he is mad. Like we said before, WZ is an athlete guy sodespite the doctor’s advice of keeping a lower limit for exercising of 150minutes per week, WZ jogs almost every day and he swims occasionally. Moreover,he follows the diet advices given to him by the doctor.
He is trying his bestto keep his weight in the normal range.WZ is a social person and he doesn’t like to spend much timealone. He always attends family and friends’ gatherings. He believes that thisgood relationship with people is the reason he feels satisfied and happy abouthimself.
He’s surrounded by a supporting environment which encourage him inevery step he makes in his social or academic life. This thing was obvious whenhe first got the injury as the people around him did their best to cheer him up.· Patient’s perspective:(attitude to the condition, support, self-management and lifestyle,health care received, future expectation. Respectively)WZ is accepting his condition as he believes in predestination.Furthermore, he is a curious patient as he wants to know more about hiscondition to enhance the outcome of treatment. He is well-supported andencouraged by the people surrounding him.
Also, he takes the doctor’s advices aboutchanging his daily routine lifestyle. WZ tries his best to self-manage hiscondition as he depends on himself totally to get things done.When he left the clinic, WZ was completely satisfied with thehealth care he received. I saw him smiling and I asked him why.
He answered meand said here I feel treated the way a patient should be treated unlike Omanwhere they wanted to finish as fast as they could just because I’m not Omani. Finally,when I thanked him for his cooperation and his precious time he smiled at meand said that he sees a bright future for medicine as we learn that we aredealing with human beings and not with machines. He also praised the role ofuniversity in engaging students in hospital visits from the beginning to getused to the hospital environment.· My own perspective:(reflection on interview, impact of meeting, reflection ondoctor-patient interaction, respectively)The experience of visiting the hospital and interviewing patientsfor the first time is one of the milestones that will have an effect in myfuture career.
It was like the transition from the theoretical part to thepractical part of medicine. This meeting has changed my thoughts of injuries andtaught me how to appreciate the confidentiality of patients as what the doctordid when he asked us to leave him alone with WZ. Moreover, I learned howimportant it is to take the history appropriately because any mistake may leadto wrong diagnosis. In addition, this visit has broadened my horizon. It taughtabout conditions I didn’t ever thought of and this is important for the future.
The doctor-patient relationship is known to be the key for reachingan accurate diagnosis. It’s used to be paternalistic in the past in which thedoctor act as a parent and guide the patient without considering his feelings.Thankfully, this model has changed to become mutualistic in which the doctorasks open ended questions to let the patient express himself. This changed wasseen clearly in the visit as the doctor let the patient express himself freely.· Conclusion:WZ came to the clinic with pain in his knee,which then was discovered to be lateral tibial plateau fracture. At first, thepatient was concerned of his condition but with time he became relieved. Thecondition of WZ’s knee is controlled now and he has a follow-up appointmentevery month. The hospital visit will always stay in my mind as it was my firstone.