A: Introduction:         When dealing with a patient it is important to be organized and understand patient’s feelings, concerns, and ideas. For that doctors ask about Medical History which is an organized method to understand and acquire patient’s complaints accurately. Medical History is critical because it involves the impact of environment, social life, and behavior on the patient not mainly the biological aspects. Satisfaction and happiness can result if doctors focus on understanding what really the patient needs. When seeing doctors taking the medical history in skilled ways you can feel patient comfort,this will make him more able to give correct and helpful answers that help in the diagnosis. B: Background:         For the maintenance of patient privacy, I will name him Mr.XX. He is 38 years old Pilipino male, married and have two children, Work as a nurse in the same hospital, and live in Dammam.          Mr.XX came to the ENT clinic before three months because of a severe headache. He evaluates the headache 8/10that means it is severe. He said the pain is only in the front of the face. Mr.XX said that the pain is most severe in the morning and afternoon. The pain gets worst when he works for a long time. He feels the headache is like pressure. There are no associated symptoms. After the consultant takes the medical history and CT scan he diagnosed Mr.XX with sinusitis.   ? Past medical and surgical History           No common diseases e.g. diabetes, hypertension ….etc. Previous surgery in his back called microdiscectomy L4-L5 in 2010. Mr.XX took two vaccines before coming to Saudi Arabia but he does not remember the names. And he did not had blood transfusion in the last six months and has no allergy. ? Family History         He has a family history of hypertension, his parents have it. And his grandparents also died because of hypertension. His mother was diagnosed with diabetes type-II two years ago. He has no brothers and his wife and children are healthy.? Social History           Mr.XX mentioned that he lives in a small apartment with his family. And he has a good communication with his family back in Philippine. He also communicates with his old friends, they support him also in addition to the family support. Mr.XX work in the same hospital as a nurse and he is happy with that job. His diet mostly contains chicken, vegetable, and bread. He only takes a walk for 10 minutes two times a week. Mr.XX do not drink alcohol or smoke, and he is Christian.  ? Drug History       Mr.XX take some medications prescribed by the doctor for his sinusitis:? Clarinase(Loratadine/Pseudoephedrine): which used to manage sinus and nasal congestion.? Nasal topical steroid: reduce swelling of the mucous membrane and help relive discomfort. He also takes some over-the-counter drugs such as paracetamol.  C: Biological aspects: ? Definition and overview:          Sinusitis(or rhinosinusitis) is an infection of the paranasal sinuses(called so because they are located around the nasal cavity). It has two types acute sinusitis and chronic sinusitis. Acute sinusitis which it is clinical symptoms is only last for 4 weeks or even less whereas the chronic sinusitis last for 12 weeks or more. The sinuses are four air-filled right and lift pairs located in the skull to decrease its weight. All sinuses are lined by a mucous membrane or mucous secreting cells which become inflamed in sinusitis. Mr.XX is diagnosed with chronic sinusitis for that we will focus on it.    ? Pathophysiology:         The obstruction of the osteomeatal complex(or OMC) that allows the emptying of the mucus from the sinuses to the nasal cavity cause sinusitis. When viral infection, allergy, or air pollution occur they induce inflammation in the sinonasal mucosa that causes the membrane to swell and cause obstruction of the OMC channel. This obstruction impairs mucus clearance via respiratory cilia, therefore, the secretion accumulates,  become thick and filled with microorganisms. Microorganisms role until now is controversial. “In a series of 94 endoscopically guided ethmoid sinus cultures from 50 adults with chronic sinusitis, the recovered organisms included Staphylococcus aureus (50%), gram-negative rods (20%), Haemophilus influenzae (4%), group A streptococcus (4%), Streptococcus pneumoniae (2%), and Corynebacterium diphtheriae (1%)” (BMJ,  2017). The OMC also can be blocked by anatomical abnormalities(e.g. concha bullosa, septal deviation, foreign bodies). ? Symptoms:         To confirm that the patient has sinusitis we have four primary signs and symptoms they are:  • pain and swelling in the location of the sinuses.• Reduce smell and taste sensation.• Nasal congestion which will cause breathing difficulty.• Discharge from the nose or in the back of the throat, the discharge is colorless and thick.and many other symptoms, for example, ear pain, sore throat, and nausea. And infections of the upper respiratory tract in general. ? causes:         It is caused by conditions that harm the mucociliary clearance. the conditions are:• Genetic/physiological: primary ciliary dyskinesia, cystic fibrosis, or HIV/AIDS.• Environmental: smoking or exposure to smoke.• Structural: sever mid-septal deviation.and may be caused by many viral infections(most common), Asthma, and rarely by fungal disease.? Risk factors:          We have many factors that increase the risk of getting sinusitis or recurrence of the disease and they include: Asthma, Aspirin sensitivity, immunity disorder(e.g. HIV/AIDS), and fever or allergic conditions.? Treatment:          There is not much that we can do to treat the disease but we can treat symptoms.• Pharmacologic:1. Antibiotics: most recommended is course between 3 to 4 weeks. But in case of sinusitis that caused by a virus or an irritation in the air, the antibiotics will not help. In this case better to leave the infections and they will become better with time. The fluoroquinolones are used only if there are no other options.2. Anti-inflammation: use topical intranasal corticosteroid(mimic corticosteroid that produced by the adrenal gland ) for example fluticasone propionate (as a spray) to minimize the swelling and improve ventilation.3. In allergies: antihistamines are useful.• Non-pharmacologic:1. Surgery: in case of a patient with a serious condition and in risk of developing further complication the doctor advice Functional endoscopic sinus surgery(or FESS) it is used to improve ventilation and drainage of the sinuses by making sinus drainage openings(such as OMC) wider. The main process in that procedure is removing part of the bone or foreign bodies that block the sinuses openings. The surgery is performed when the patient is under general anesthesia. The sugary may induce complications such as infection, bleeding, brine injury, or CSF leak. ? Outcome:         Generally, it depends on the patient’s condition to decide which treatment option should be applied. The surgery will end the problem but it may have severe complications. On the other hand, the pharmacologic management will not end the problem but may reduce the symptoms effect with fewer complications. In the case of Mr.XX the consultant advised him to undergo the surgery because of his severe condition and the fear of further complications.  D:Ethical issues:            In healthcare system it is important to take into consideration the Ethical issues when dealing with the patient because of its strong effect in the therapeutic relationship which will eventually affect patient health. ? Doctor-patient relationship:         “The competence of a physician to benefit the patient by his or her medical knowledge, skill and compassion, as well as the expectation and desire of the patient to be benefited by this competence are the key components of a therapeutic relationship”(Prof. Jonsen, 2015). The consultant and Mr.XX relationship is constant because Mr.XX work as a nurse in the same hospital. At the start of  Mr.XX visit the doctor shake Mr.XX hand and ask him how he is doing as a form of greeting. The consultantmaintained eye contact and was sitting in an angle to the patient and using verbal and non-verbal communication. The consultant was asking the patient whether he want to do the surgery or not and was explaining the benefits and side-effects of the surgery in a very convincing way to direct Mr.XX into the appropriate choice this is called respecting patient autonomy.         Mr.XX have a good relationship with the staff also and one of them was his cousin.  ? Consent:           Consent is the process by which doctor explain to the patient what he will do, how he will do it and why is it important then the patient decide whether accept or refuse. After greeting the consultant kindly ask Mr.XX whether he agree to us to take his medical history or not and explain to him that we are a medical student and we will only ask some questions. Mr.XX with big smile agree to us. ? Confidentiality:          Mr.XX examination requires the use of an endoscope to see his sinuses from inside. before the consultant start, he asks Mr.XX if he agrees to us to stay in the room and Mr.XX agreed. After the examination, Mr.XX ask the consultant to tell us to go outside the room and the doctor ask us to do it. At first, we did not understand why Mr.XX did that then the consultant explains to us that the patient wants to tell him a private information. E: Legal issues:         To avoid being in a legal problem the medical professionals have to have enough Knowledge about the medical laws. Ignoring them in consent phase or confidentiality can lead to big issues. ? Consent:         From the legal aspect taking consent is not an extra thing that doctor do but it is essential to start the history taking and we cannot start any medical process without it. In the clinic I was in the consultant was taking consent before start with all patient, he takes it before history taking by us or examination by himself. ? Confidentiality:         An integral part of gaining information from the patient is privacy or confidentiality because patient usually have private information to share with his consultant and if the patient does not feel the privacy he will never disclose anysensitive information. In another aspect, if the doctor discloses any private information without patient consent that will put him in a legal problem. As I said before the consultant in ENT clinic that I was in response to the patient request to ask us to leave the room because Mr.XX want to tell private information.F: Sociological aspects:? Political aspect:         Healthcare system is an area of interest for all countries in the world. In Saudi Arabia, the government provides the primary, secondary, and tertiary health care for all citizen for free. Saudi Arabian government spend a large amount of money in the health care system, for example, the healthcare budget for 2016 is 58.899.190.000 S.R which is less than that of 2015 by 3.443.349.000 S.R. ? Economic aspect:          In the economic side Mr.XX who is a resident in KSA has no problem with the healthcare because he is under the system of the hospital, he works in. For residents who are work in private companies the government provides the care only for the emergency cases but for other cases the government represented by the ministry of health put a compulsory insurance provided from privet companies to all companies employees.? Cultural aspect:         Some knowledge of the cultural difference between patients helps in avoiding the misunderstanding between doctor and patient. It is not only treating the patient with respect that matter but also knowing the patient culture is an integral part of the healthcare process. Mr.XX is a nurse and because of his Knowledge of medicine he is not a strong believer in the herbal medicine but some time his wife insist on to take some herbal medications but as he said it have no obvious side-effects on him. Doctor reaction when the patient tells him about the herbal medications has an important effect in healthcare process because of that college of medicine include the cultural aspect in their curriculum to graduate culturally competent doctors.? Social aspect:          Mr.XX is social person even if he lives far away from his family and old friends (because he is from the Philippines and works in Saudi Arabia ) he still communicates with them as if he is home. Mr.XX take half hour of his day for calling his diabetic mother and he also calls his best friend back in the Philippines once a week. Here in Saudi Arabia, he lives with his life and two children a happy life.G: Self-care and lifestyle:      ? Education:         Mr.XX finished his primary, intermediate, and high school then he moved to the nursing college in the Philippines. Because of his specialization as a nurse he knows about the disease and its symptoms really well. When I was asking him in the history taking process he was answering my questions in a good medical language. ? Stress management:           In the times when Mr.XX is under stress, he usually tends to manage it by walking around his neighborhood or sometimes he listen to the music. His family support also helps in managing the stress.? spirituality:         As we mentioned before Mr.XX is Christian and he has a strong belief in god. He thinks that his disease is from the god and anything from the god is great. ? Exercise:         His disease is not preventing him from the physical activity. Mr.XX  take 10 minutes walk twice a week and he prefers to walk around his neighborhood or on the beach. ? nutrition:         Each morning Mr.XX take two apples for breakfast and drink water with it. Then in the afternoon he usually tends to eat chicken with bread and also drink water or apple juice. Mr.XX consider his diet as a healthy one.? Connectedness:         As we mention before Mr.XX has great communication with his mother in the Philippines and his old friends there. He also has happy life with his wife and two children. Mr.XX also have a good relationship with his coworker in the hospital. ? Environment:         Mr.XX live in an apartment with his wife and two children. The apartment is in Dammam in a good neighborhood and he describes it as small one but it is enough for him and his family.  H: Patient perspective:? Attitude to the condition:         He totally understands the disease and its effects without and denial. And he is not annoyed by the repeated visits to the clinic. ? Feeling about support:          Mr.XX think that his condition and his recovery progression is more when he is supported by family and friends. And he feels the love between his family when they talk to him with supportive language. ? Affect in self-image and lifestyle:           He mentioned that the disease has nothing to do with his integrity as human it is only an abnormality in part of the body. And he is only worried that the disease will affect his job.  ? comment on health care received:         When I ware asking him about the health care quality the doctor was in the room Mr.XX looks at the doctor and the doctor looks back with a big smile then they both start laughing. This reflects the high quality of healthcare and satisfaction of Mr.XX.? future Expectation:         Mr.XX expect a large improvement in his condition with doctor help and family support. He also expects that he will enjoy his life more soon without the disease. I: My own perspective:? Reflect on the interview:             The interview was really a simulation of what we have learned throughout the semester. Even if there are some small mistakes I really think it is a good interview. Although the patient was not Arabic speaker everything was going smoothly.? Impact of meeting and talking with the patient:         When Mr.XX start sharing his concerns and feelings with me as if I am his best friend I have feel the greatness of becoming a doctor in the future because people do not usually share their feelings with anyone. And I also feel the burden of taking the responsibility of being a doctor and patient tall you private things.  ? Reflect in doctor/patient interaction:         After the visit, I have made the consultant as my role model when dealing with a patient. From his eye- contact, position, fluency, and verbal and non-verbal communication to his relationship with Mr.XX the consultant was really good. ? Awareness of disease:         When Mr.XX finish and go outside the consultant start explaining to us about the disease and I have learned some information that I will not forget in my whole life. ? Thoughts as a future doctor:         I believe that medical profession is not a regular job but it is a mixture of knowledge, competent, feelings, and interaction that eventually can lead to a healthy patient. J: Conclusion:           Mr.XX was diagnosed with sinusitis which is inflammation of the sinus in the skull. The visit was to the ENT clinic. Mr.XX had decided to continue with the steroid for some time then thinking about the surgery.       Total words according to ward counter2650                    (excluding references list, headings, and subheadings)              K: References:? Kumar, P. and Clark, M. (2012). Kumar and Clark’s Clinical Medicine E-Book. London: Elsevier Health Sciences, p.1052.? Jonsen, A.R., Siegler, M. & Winslade, W.J. 2015, Clinical ethics: a practical approach to ethical decisions in clinical medicine, 8th edn, McGraw-Hill Education LLC, New York, N.Y.? Bestpractice.bmj.com. (2017). overview – Chronic sinusitis – Bmj best practice. online Available at: http://www.bestpractice.bmj.com /topics/en-gb/15Accessed 25 Jan. 2017.   ? Moh.gov. (2017). Ministry of health portal – Kingdom of Saudi Arabia. onlineAvailable at: https://www.moh.gov.sa/en/Pages/Default.aspxAccessed 25 Jan. 2017.? Mayoclinic.org. (2017). symptoms and causes – Chronic sinusitis – Mayo clinic. online Available at: https://www.mayoclinic.org/diseases-conditions/chronic-sinusitis/symptoms-causes/syc-20351661Accessed 25 Jan. 2017. ? PubMed Health. (n.d.). Consent. online Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109754/Accessed 25 Jan. 2017.? Cdc.gov.(2017). sign and symptoms – chronic sinusitis – Cdc. online Available at: https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sinus-infection.htmlAccessed 25 Jan. 2017.                     


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