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·       Introduction:

On the afternoon of Tuesday, October 17, 2017, I went to my
first hospital visit as a medical student. The hospital’s atmosphere on that
specific day was greatly different than usual. I have visited King Fahd
Hospital of the University many times as a patient. But, being a part of the
medical team, observing the flow of the work in clinics and taking history from
patients was a unique experience, especially for a second-year medical student.
Taking a medical history from the patient is a crucial part in reaching a
diagnosis. Even the most intelligent doctors cannot identify the condition of
their patients without taking a medical history from them. In order to take a
proper medical history from the patient, doctors have to communicate appropriately
and assure privacy and comfortable environment so that patients can express themselves.

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·       Background
and 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 married
male, 39 years old, working at National Petroleum Services (NPS) and lives in
Saihat. WZ came to the fracture clinic 5 months ago with an unmovable leg as he
has been in Oman having a fishing trip there. WZ has a certificate in diving so
he is a good swimmer and knows what to do in water. WZ and his friends took a
jet-ski to have fun in their free time and while driving the jet-ski a young
boy 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, in
which 10 is the worst pain and 0 is no pain, he described the pain as 8 out of
10. So, he decided to go to a local hospital in Oman to have a look at his knee
and there they treated him temporarily and advised him to take some
over-the-counter medications to relieve his pain such as Tylenol, so he can go
back to Saudi Arabia and have a full treatment.

When WZ came back to Saudi Arabia he went to King Fahd
Hospital of the University so that he can get full treatment. The doctor had a
look at his knee and asked him about the aggravating and alleviating factors
and he said that movement makes it worse and ice makes it better. WZ had a long
thought about his injury and how it could impact his life. He wasn’t able to go
to work or even to go out. He was concerned that this injury will affect his
muscles and may cause muscle wasting. His expectations of the medical team were
high, and he thought that they could help him to feel better in time.

The patient’s parents are still alive they are cousins with
no chronic conditions. He has 2 brothers and 1 sister, but he has no sons or
daughters. He has a family history of osteoarthritis in his grandmother which
can be relieved by paracetamol.

He lives with his wife in an apartment and he is financially
stable. The patient has a strong relationship with his family and friends and
they have supported him and helped him whenever he needed anything. He is an
athlete guy as he jogs every day and swims occasionally. He has no regular
diet. He is a smoker, who smokes half pack of Marlboro Red daily. He is also a
binge-drinker and drinks beer with 4% Alcohol.

The patient undergone a CT scan and a physical examination. The
differential diagnosis after examining his both knees to see the difference and
looking at the CT scan has led to a Lateral Tibial Plateau Fracture.

The doctor advised him to alter some of his daily routine
lifestyle. WZ was advised to watch his diet as it is difficult for his knees to
carry too much weight. Furthermore, he was advised to continue exercising for a
minimum of 150 minutes per week.

WZ condition is controlled now and he has a regular
appointment every month to change the cast and to have an x-ray to see the
changes in his knee condition. Although he is concerned a lot about his
condition and how it could be worsened by any sudden unexpected event, WZ has
faith in the medical team.

·      
Biological aspects:

(description of the fracture, pathophysiological change and
classifications, causes, clinical presentation, treatment and outcome,
respectively)

A tibial plateau fracture is a break of the higher part
of 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 sustain
a tibial plateau fracture are aged 50 years or older” (Pitta et al., 2014). Tibial plateau fractures in younger patients are usually
the result of high-energy injuries. The symptoms of tibial plateau fracture include:
pain when weight is implemented, swelling, limited range of motion and in severe
cases there is numbness in the foot because of nerve damage.

“Tibial plateau fractures are classified according to the
Schatzker classification system into six types: Type I: lateral tibial plateau
fracture without depression. Type II: lateral tibial plateau fracture with
depression. Type III: compression fracture of the lateral (IIIa) or central
(IIIb) tibial plateau. Type IV: medial tibial plateau fracture. Type V: bicondylar
tibial plateau facture. Type VI: tibial plateau fracture with diaphyseal
discontinuity” (Physiopedia, 2016). And according to the physical
examination and radiography, it is obvious that WZ has a tibial plateau
fracture Type IIIa.

Tibial plateau fractures are caused by a force driving the
lower end of the femur (thigh bone) into the soft bone of the tibial plateau. The
reason of tibial plateau fractures is primarily car- or motor accidents and
sometimes sport accidents, mostly sports with a high velocity such as horse
riding and specific water sports, such as jet-ski which was the cause of WZ
injury.

Full clinical assessment is required, including evaluation of
the soft tissues to determine if a compartment syndrome is present and whether
the patient has maintained a neurovascular injury. Gentle stress testing can be
done with the leg in extension to evaluate the stability of the ligaments and
to assess any sign of fracture displacement. As it was done in each follow-up
appointment that WZ came to.

Not all fractures of the tibial plateau require surgical
intervention. The first challenge in the management of tibial plateau fractures
is to decide between nonoperative and surgical treatment. And
according to WZ situation he was treated nonoperatively by having a physiotherapy
session 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 have
been noted in cases treated both operatively and nonoperatively. Complex tibial plateau fractures are realted to nonunion and
malunion, 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 very
important in the process of treating a patient. A good relationship will make
it easier for the physician to take an appropriate history from the patient and
eventually will lead to a more accurate diagnosis. And I saw this impact of the
physician-patient relationship when I was in the clinic that day. The doctor
stood when WZ entered the clinic and greeted him with a big smile and he has
shaken WZ’s hands. This action of greeting the patient has lead to making WZ
very comfort and happy about the healthcare team.

Morally, we all know that a doctor can’t force patients to do
or accept something they don’t want to. For instance, a male doctor can’t
coerce a female to let him examine her breast to see whether she has a breast
cancer or not. And that’s what happened in the clinic when the physician asked
our patient WZ if the presence of us as second-year medical students will
bother him or not. Furthermore, the doctor asked him if he doesn’t mind if we
as students took a detailed history from him.

In our practice, confidentiality means keeping the
information of the patient as a secret between the doctor and his own patient
and 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 when
expressing themselves. When we were in the clinic the doctor asked us to kindly
leave him and the patient for some time as he felt the patient is a bit shy and
he is not comfortable. And when WZ left the clinic, the doctor told us that he
asked us to leave so that he ensures the patient’s comfort and to tell WZ that
any information will remain confidential.

·      
Legal issues:

(consent and confidentiality, respectively)

In any healthcare setting, a set of rules and obligations
govern healthcare workers and they must follow them. These rules may differ in
the way they are applied from one situation to another and between different
countries. But in the end, they aim to reinforce the autonomy of the patient,
non-malpractice, beneficence as well as social justice and equity. This is
considered as the legal aspect of medical practice in which healthcare
providers can be sued if they break these laws intentionally. And most of the
lawsuits are because of break in the laws of consent or confidentiality.

When we look at how sensitive the goals of these laws are, we
realize 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 to
examine his knees. Also, the doctor asked WZ if there’s any discomfort when we observe
the doctor while examining him and WZ accepted it immediately. It’s the
patient’s right to be asked if our presence while examining his knees is
bothering him or not. By gaining consent, practitioner has avoided any legal
accountability that he might experience in the future.

The consequences of breaching confidentiality are severe if
the patient decided to sue the practitioner. That’s why physicians do their
best to keep patient’s information as a secret. We recognized this thing when
we asked the doctor about what happened with WZ when we were asked to leave the
room and the doctor refused to tell us what happened back then. But, in some
situations such as communicable diseases or child abuse the doctor can breach
confidentiality and disclose the information to appropriate authorities.

·      
Sociological aspect:

(political, economic, cultural, social, respectively)

Accessibility and government policies to healthcare services
differ when we look at different countries. Thankfully, here in Saudi Arabia
government give access to wide range of healthcare services for citizens and
residents without any discrimination between them. In addition, we have a large
distributed healthcare centers in many different areas to help in enhancing the
overall health. As we’ve seen here with WZ when he was in Oman he took the
minimum health care needed just to come back to Saudi Arabia and complete
treatment in here.

Economically, the Saudi government expenditure on health
services reached “58.899.190.000 SR in 2016”
(MOH, 2016). This large budget is customized to improve the quality of healthcare
services provided to people who live in Saudi Arabia. Moreover, most of the
health services provided by the government is for free.

When we consider WZ case, we note that he was first treated
in Oman where he must pay for treatment in there. In this case costs might be a
heavy burden for people with limited or low income. But, fortunately WZ has an
insurance that works in all gulf countries, so he didn’t have to pay for his
treatment.

Recognizing the patients cultural and religious believes will
impact the relationship between the physician and the patient. For instance, if
doctors criticized patients’ believes about how to treat a disease, patients
will distrust doctors as they will think doctors are close minded. Some
patients have strong belief in herbal remedy as a way of treating illness instead
of taking pointless medications. Although their belief might be wrong, doctors
must persuade them without criticizing their beliefs. Also, because WZ is a
Muslim, 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 way
they are treated. As we have mentioned WZ is a 39-year-old male, he lives with
his wife and they have no children yet. His parents are still alive and in good
health. He has 2 brothers and 1 sister. WZ is well supported by his family and
friends and according to his words he says that they do whatever it takes to
make him feel better.

·      
Self-care and lifestyle:

(ESSENCE, respectively)

As I mentioned before WZ works in NPS and specifically he is
a 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 he
is treated. As an educated person, he will follow the doctor orders and he
won’t miss any physiotherapy session as he recognizes how important they are.

Every person feels stressed at some point in life. But, if
this stress isn’t totally managed this may lead to depression and other physical
and psychological diseases. The way people manage stress differs greatly
according to their culture, personal traits and manners. When I asked WZ about
the way he handles his stress he responded immediately that he is an athlete
guy, so whenever he is stressed he goes out and runs until he feels that the
stress is relieved. Also, as he is an expert diver, he sometimes swims instead
of running. He said that sports always help him in managing stress.

As a Muslim person, WZ always attends to prayer and he
celebrates every religious festival. He says that spirituality and meditation
calm him down whenever he is mad. Like we said before, WZ is an athlete guy so
despite the doctor’s advice of keeping a lower limit for exercising of 150
minutes 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 best
to keep his weight in the normal range.

WZ is a social person and he doesn’t like to spend much time
alone. He always attends family and friends’ gatherings. He believes that this
good relationship with people is the reason he feels satisfied and happy about
himself. He’s surrounded by a supporting environment which encourage him in
every step he makes in his social or academic life. This thing was obvious when
he 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 his
condition to enhance the outcome of treatment. He is well-supported and
encouraged by the people surrounding him. Also, he takes the doctor’s advices about
changing his daily routine lifestyle. WZ tries his best to self-manage his
condition as he depends on himself totally to get things done.

When he left the clinic, WZ was completely satisfied with the
health care he received. I saw him smiling and I asked him why. He answered me
and said here I feel treated the way a patient should be treated unlike Oman
where 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 me
and said that he sees a bright future for medicine as we learn that we are
dealing with human beings and not with machines. He also praised the role of
university in engaging students in hospital visits from the beginning to get
used to the hospital environment.

·      
My own perspective:

(reflection on interview, impact of meeting, reflection on
doctor-patient interaction, respectively)

The experience of visiting the hospital and interviewing patients
for the first time is one of the milestones that will have an effect in my
future career. It was like the transition from the theoretical part to the
practical part of medicine. This meeting has changed my thoughts of injuries and
taught me how to appreciate the confidentiality of patients as what the doctor
did when he asked us to leave him alone with WZ. Moreover, I learned how
important it is to take the history appropriately because any mistake may lead
to wrong diagnosis. In addition, this visit has broadened my horizon. It taught
about 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 reaching
an accurate diagnosis. It’s used to be paternalistic in the past in which the
doctor act as a parent and guide the patient without considering his feelings.
Thankfully, this model has changed to become mutualistic in which the doctor
asks open ended questions to let the patient express himself. This changed was
seen 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, the
patient was concerned of his condition but with time he became relieved. The
condition of WZ’s knee is controlled now and he has a follow-up appointment
every month. The hospital visit will always stay in my mind as it was my first
one.

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