Medical history in clinical medicine is the previous
and current data of a patient taken by asking the patient about his past and
present history of his case of disease.
Taking history correctly is a very
important step to get an optimal diagnosis of the patient. Since we need to
give the patient the best health care service, we should be able to do the
procedures in a respectful and skillful way.
In order to get a good history to diagnose a
disease, you have to consider the mental, social, psychological, and physical
health to cover everything that is possible to be relevant to the patient’s
Background and history:
The patient X, the actual name was not
mentioned to save the patient’s confidentiality, is a 65 year-old married male.
The patient came to the clinic of diabetes in
King Fahad University Hospital, follow-up patient, complaining of swelling in
his both feet. He noticed the swelling with high
blood glucose level three days before coming to the clinic. The patient was
unable to walk and even stand on his feet. In addition, the blood glucose was
high as seemed in the test of glycated hemoglobin. After the present doctor
took the history and did a physical examination, he diagnosed the disease as a
diabetes associated condition called edema.
The patient has a history of diabetes type
2, which was diagnosed 23 years ago. In addition to that, as an associated
condition, he has hypertension after four years of getting diabetes.
The patient has undergone only one
operation during his life. He had a vitrectomy, which is removal of the
vitreous gel from diabetic retinopathy patients who have vitreous
The patient had a heart attack ten
years ago because of smoking.
The patient did not take any vaccination.
The patient’s parent both are dead his father was 72 year-old and his
mother was 44 year-old, both had diabetes and hypertension. The patient has
three sisters and one brother, and two of his sisters have diabetes. The
patient has 9 daughters and 4 sons with no chronic diseases.
The patient X lives in a house with his wife and
children. He feels very happy and comfortable with his family. He does not do
any kind of exercising. In addition, he is careless with his diet.
Drug and allergy
patient does not have any allergy toward any kind of food. The
patient’s father was a smoker. His mother did not use any kind of smoking or
alcohol. He used medications including:
Tobrex eye drops against eye
infections: are used as antibiotic.
Respirator Solution: used
in some respiratory conditions like asthma,
Finely, the doctor arranged
an appointment for furthermore investigations as Patient.HS’s statue was
somehow controlled and relieved by using some eye’s droplets.
Edema is swelling due to accumulation of fluids in the body’s
tissues. It can affect any part of the body. It usually occurs within the
hands, arms, feet, ankles, and legs.
-Pathophysiology of Edema:
“Edema occurs when tiny blood vessels in your
body (capillaries) leak fluid. The fluid builds up in surrounding tissues,
leading to swelling.”
-Causes and risk factors of Edema:
edema could be a result of one of the following:
-Sitting in one
positing for a long period time
some medications can cause edema, as a side effect:
medications called thiazolidinediones
can be a cause of several disease:
deficiency of protien
The main symptom of edema is swelling. There
are other symptoms associated with the swelling including weight gain, skin
discoloration, stiff joints, painful limbs, and hypertension
possibility of skin infections
Often, history taking
and physical examination by doctor is enough to diagnose the disease and know
the reason underlying it. In some cases, X-rays, ultrasound exams, magnetic resonance
imaging, blood tests or urine analysis may be necessary.
The sever edema is treated by drugs that
help the body to expel it within the urine called diuretics. Furosemide,
also called Lasix, is a common diuretic used for edema. Your doctor may
alter your medication to avoid giving you a drug that causes edema.
The mild edema usually goes
away on its own. It is advised to rise the affected limb above the heart to heal
is a diuretic that reduces salt absorption to expel within the urine, which
lead to decrease fluid accumulation, and thus, the cure of edema.
There could be some side
effects including diarrhea, constipation, dizziness, breathing difficulty, and
– Doctor-patient relationship:
I saw a wonderful
relationship between the doctor and patient. The doctor was paying attention
very well with the patient. The patient had been a little bit worried, but the
doctor 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 doctor
because of what he said. I can say the doctor absolutely did as best as could
The doctor was careful
not 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 understand
that there may be some sensitive questions that should be asked to have the diagnosed
done well. Also, he was very careful during the physical examination and asked
the patient to permit him to do it. In addition to that, he was telling the
patient during the physical examination what he was going to do to make him
feel safe and comfortable.
Confidentiality is when the
information given by the patient kept restricted and not shared to anyone
unless some certain cases. The doctor was concentrating on that we, the
students, do not tell anyone the patient’s information. When the patient had
come and before his family members came, the doctor ask the patient whether
someone is with him and if he would like to have someone of them with him or not.