Introduction: months ago and had caused him much

 

Introduction:

There is no denying the importance of a correct diagnosis and treatment in achieving the goal of every physician, which is to cure, treat, or at least improve the quality of their patient’s life. This cannot be done without the most important clinical skill, taking proper medical history.

Medical history is an account of all medical events and problems a person has experienced which may contain relevant information concerning their past, present, and future health. By mastering this skill, we will hopefully cross our first milestone in our career, and be one step closer to becoming competent doctors who offer the care that our patients deserve.

Background and history:

By the time I arrived at the neurosurgery ward, the patient had just been called into the clinic. I gently knocked on the door and politely asked to observe. The patient, as well as the physician on duty, agreed so I sat down and watched. As the physician was wrapping up his consultation with his patient, I asked whether I could interview him. He was happy to oblige. For the sake of patient confidentiality, the patient will be addressed as “patient X” from here on out.

Patient X is a forty-five year old Saudi male. He currently lives with his wife and children in Khobar working as a professional instructor. He was born and raised in Hufoof.

·        Present history (current situation)

The consultation I attended was a follow-up of another visit where he presented with back pain and what he described as a burning sensation in his left shin. He states that it had started 4 months ago and had caused him much pain, rating it at 8 out of 10 (0 being no pain and 10 being extreme pain). These symptoms would be alleviated by using hot packs and would become worst when sleeping at night. Also, some improper sitting positions caused pain, especially when sitting for long periods of time. Furthermore, he felt numbness, heat and stiffness in his entire leg. Later, he developed neck pain and stiffness along the right arm all the way to his thumb. Also, he found it difficult to carry heavy objects in front of his body. He suspects that he has brought this upon himself due to his sleeping habits and bad posture. He seemed afraid and was concerned that he may never get to have a good night’s rest again, but the physician did well to reassure him. After a couple of tests, the patient was diagnosed with having cervical disc prolapse, specifically, a disc between section C5 and C6 of his spinal column which has herniated and is now pushing onto the neighboring nerve root. His doctor prescribed Neurontin (Gabapentin) 400mg as well as twelve sessions of physical therapy and scheduled a follow-up one month later to check his progress.

·        Past history:

Other than his current state, patient X has led a healthy life so far. He has taken all his vaccines as a child, he is not suffering from chronic diseases, and hasn’t needed a blood transfusion within the last ten years.

The only time he was ever hospitalized was when he needed surgery for an inguinal hernia, and after consulting the physician, I was told that this is not relevant to the case.

·        Family history:

Patient X’s mother is alive and well. According to the patient, “she is 91 years old and doesn’t suffer from chronic illnesses except those common with age (diabetes and hypertension). His father had passed away several years ago but has not died of any disease.

Patient X once wanted to donate blood but was denied because he carried a blood borne disease (I asked what it was but he could not remember). Because of this, he was asked to never donate blood.

·        Social history:

Patient X is living happily with his family in a villa that he inherited from his father. He categorizes himself as being average in terms of income and lifestyle. He has strong bonds with both distant and close relatives and they offer great emotional support especially in his time of need. Patient X reports ample amounts of exercise and a wholesome diet.

·        Drug and allergy history:

Patient X is not allergic to any food or drugs (or any that he knows of). Lately, he’s been taking painkillers because of increased pain but not too much, only two pills a day.

Smoking (shisha) is not accepted by his family but Patient X used to smoke with his friends occasionally. He started smoking two years ago and claims to have stopped last year.

Biological aspects:

A prolapsed (herniated) cervical disc occurs when the outer wall of a disc ruptures and allows the inner gel-like material to ooze out (or herniate), causing it to press against a nearby nerve root. If a cervical disc herniates, it can press onto or cause irritation near one of the cervical nerves, causing pain, muscle weakness and other symptoms to all areas it innervates along its path.

Discs usually herniate laterally, causing inflammation to a nerve root on one side. The two most common levels in the cervical spine to herniate are the C5-C6 level (Patient X’s condition) and the C6-C7 level.

·        Causes:

Disc herniation is usually caused by disc degeneration due to progressive wear and tear and aging. As a person gets older, discs lose some of their water content, making them less flexible more susceptible to rupture, releasing the gel-like nucleus inside. Trauma can also cause disc prolapse.

Factors that increase the risk of developing disc prolapse:

–       Obesity, although this usually causes the disc to herniate in the lumbar section.

–       Occupation and sports: physically taxing jobs and extreme sports such as heavy weight lifting can increase the risk of a herniated disc. Patient X reported that before his current job, he used to work in a workshop where he worked with blocks of steel, carrying them around often.

–       Genetics: some studies show a correlation between people having herniated discs and their children also developing it.

·        Symptoms:

A herniated disc in the cervical area can cause a range of symptoms in the neck, shoulder, arm, and hand all the way to the fingers. Clinical manifestations are dependent upon the location of the hernia. For example, if a hernia occurred at the C4-C5 level, it may cause shoulder pain and weakness in the deltoid muscle, but would not usually cause numbness or tingling.

In Patient X’s case, a C5-C6 herniation occurred. This can cause weakness in the biceps muscle and wrist extensor muscles. This explains why he cannot lift heavy objects in front of his body and therefore must rely on his shoulder and triceps. Other symptoms include numbness, tingling and pain that radiate all the way to the thumb side of the hand. This is also consistent with our patient.

·        Diagnosis:

After the initial clinical examination, a choice of diagnostic imaging tests may be required to reach a diagnosis:

–       Magnetic resonance imaging (MRI): The best test to diagnose a herniated disc and the one which was ordered for Patient X.

–       Computerized tomography (CT) scan with myelogram: Although this test is more sensitive, it is slightly invasive. That is why it is not the first test to be ordered.

–       Electromyography (EMG): This test helps to confirm the diagnosis by ruling out other conditions causing similar symptoms.

·        Treatment:

Treatment for a herniated disc may include non-invasive options to manage the symptoms or surgical intervention to remove the herniated portion of the disc. To understand when to use which, we must understand what causes pain in disc herniation. Pain caused by a herniated disc is associated with two mechanisms, compression of the nerve root and inflammation due to the disc material itself, which contains many pro-inflammatory substances.

Initial nonsurgical treatment involves reducing the inflammation and pain by using anti-inflammatory drugs such as ibuprofen and COX-2 inhibitors. Alongside this treatment, non-pharmaceutical treatment options can also help alleviate pain such as physical therapy, exercise, chiropractic manipulation and some lifestyle changes (Patient X is still at this stage). If there is little to no response, we move on to the next stage, steroid injections. Epidural steroid injections in conjunction with one or more of the above options can help enhance their effect.

If the symptoms subside it is acceptable to continue these nonsurgical treatments. However, if the symptoms are persistent despite physical therapy and exercise or if the symptoms hinder the patient’s ability take part in physical therapy or their quality of life, surgery is typically the last option. Discectomy is a relatively small surgery in which the excess disc is removed to decompress the nerve root and mitigate symptoms.

·        Outcome:

As discussed above, treatment for a herniated disc is progressive. We first start with managing symptoms with drugs and correcting the biomechanics involved using physical therapy. If the patient doesn’t respond or starts to deteriorate, surgical intervention may be required before any further complications. Such complications include: Bladder/bowel dysfunction (if the hernia is in a lumbar disc) or worsening of symptoms until they interfere with daily activities.

Ethical issues:

·        Doctor-patient relationship

The doctor-patient relationship is one of the most important factors ensuring that the patient will give a complete and truthful history as well as cooperate during the clinical examination and comply with doctors’ advice.

In this particular case, the physician demonstrated perfect behavior for building rapport with the patient; he greeted the patient when he entered and shook his hand, smiling throughout the interview, but only when appropriate. When Patient X showed signs of concern and worry, the physician did well to reassure him and put his mind at ease. In my opinion, this has helped bolster their relationship and made the consultation go more smoothly, ensuring patient satisfaction. Finally, the physician made sure to include the patient in planning treatment and managing his condition, further deepening their relationship and likelihood of compliance.

·        Consent

Both the code of our professionalism and the teachings of Islam stress the importance of respecting people’s rights. That includes not acting towards them without consent and not disclosing their information without their permission.

The physician made sure to ask patient permission at every stage of the interview; he requested permission to ask some personal questions, asked for consent to perform the clinical examination, and to order the tests he needed. I wasn’t present in the first consultation but the patient confessed to this.

·        Confidentiality

Maintaining confidentiality is a trait of all competent doctors. It establishes trust and rapport between the patient and doctor, increasing the likelihood of reaching the right diagnosis as well as patient compliance with treatment.

In this case, patient X had nothing to hide from us. In fact, he was happy to help to answer any question we, or the doctor, asked. This means it is our duty to keep his information secret and not disclose it to anyone.

Legal issues:

As I have stressed before, not only should we respect people’s right because that’s what we are taught in medicine, but also because this is what Islam teaches us. However, taking consent and maintaining confidentiality aren’t done merely for ethical reasons, but have legal consequences as well.

·        Consent

Consent is not a privilege but a right. As future practitioners, we must understand this concept to avoid being legally held accountable in the future.

Since I only attended the follow-up, I haven’t witnessed consent being taking but Patient X admitted that his doctor made sure to take informed consent for all procedures and tests he needed. For example, the physician kept balance between optimism, and transparency and realism when informing him that one of the possible treatments is surgery, telling him of all the pros, cons and statistics of the procedure.

·        Confidentiality

I have seen how confidentiality is practiced during my visit. The doctor prepared a private environment for the patient, had the door closed behind him and refused to disclose any information to me without his consent.

Although confidentiality must be maintained, there are some situations when it can be breached, such as cases of child abuse, breach of public health, communicable disease, etc.

Sociological aspects:

o   Political:

We cannot deny the government’s efforts in providing healthcare to all citizens and residents living in Saudi Arabia. By providing and distributing healthcare centers across the country, they have done well to control many common diseases, allowing more focus towards the more advanced stages of prevention (secondary and tertiary prevention). Indeed, Saudi Arabia is being transformed from a high-birth high-mortality rate country with many communicable diseases to a country with low-birth low-mortality rates.

Of course, no system is without its flaws. Studies have shown misdistribution in manpower as well as health centers, but these will hopefully be resolved soon.

Patient X is content with his experience so far; he is happy with the way he has been treated but complains of long appointment dates.

o   Economic:

Treatment for disc herniation can be quite expensive. Luckily, the Saudi government has allotted over 60 billion Saudi riyals in funding to establish free healthcare to its citizens and ease of access, though this idea is starting to shift recently towards having all citizens and residents be insured. Patient X is insured but believes he has the financial capacity to cover his medical expenses anyway.

o   Cultural:

Understanding the cultural differences of different patients is crucial for patient respect as well as treatment and management. Some patient may refuse to take certain drugs or undergo some procedure because of their beliefs. It is the physicians’ duty to respect patient autonomy and provide alternatives for such patients whenever possible.

Patient X did not have a problem with the doctor’s advice in this case but, without telling his doctor, took garden cress seeds as a kind of complementary medicine because he thought it may improve his condition. It did not help him much so he stopped one week later.

o   Social:

Patient X is a 45 year-old Saudi man, meaning he is almost at the age where disc prolapse is common. While it is not common in Saudi, disc herniation is starting to emerge in this day and age due to the advent of technological assistance. Patient X lives in Khobar with his wife and two daughters. He has a humble education and, overall, is satisfied with his current situation.

·        Self-care and lifestyle:

Patient X is a curious man. He is fairly familiar with his condition by know but continues to ask questions. This behavior may be a result of anxiousness but it is more likely due to curiosity since his queries are mostly about scientific matters as opposed to ones about prognosis. Patient X has dependable family members who provide him with the support he needs and remind him of his creator. He turns to Allah, praying that one day he will be cured. When the pain was at its peak he confessed to praying all night, repenting, worrying that this is punishment for a sin he may have committed. To take his mind off of it, Patient X wakes up every day at Fajr, prays and walks at a moderate pace as a form of exercise (except for weekends). Otherwise, he believes his work is enough exercise for him. To quote him: “I have to walk around at least three hours a day at work.” Patient X says his family is not like most Saudi families; their diet is very nutritious and he takes care of himself very well. Patient X has a good connection with his family; he visits his siblings and even distant relatives on a weekly basis. He lives with his family in a villa which he inherited from his father. His house is in a quiet neighborhood so he is content in that regard.

·        Patient’s perspective:

At first, patient X was worried that his condition could affect his life forever but his doctor showed empathy and optimism when consulting him. He will continue with his treatment while praying for his recovery.

·        My perspective:

First of all, the overall vibe I got from the waiting area was gloomy. The waiting area felt crowded even though there were only two people waiting. This is probably because the chairs were so close to each other. Everything else was decent; the lighting was adequate, the temperature was moderate and there was a TV to pass time. But because of the claustrophobic environment, everything else fell apart.

My experience with the doctor, however, was quite the opposite. He was polite, respectful and very considerate of the patient’s feeling. He also did well in explaining his condition to him in a way he’ll understand, and to us in a way we will understand as medical students. He was a role model to us; reflecting everything we learned so far perfectly and without mistake.

·        References:

Snell, R. (2007). Clinical anatomy by systems. Philadelphia: Lippincott Williams & Wilkins.

https://www.medicinenet.com/script/main/art.asp?articlekey=3768

https://academic.oup.com/bjaed/article/14/2/52/271401

https://www.moh.gov.sa/en/ministry/statistics/pages/budget.aspx

https://www.spine-health.com/video/cervical-herniated-disc-video

https://www.spine-health.com/video/video-can-herniated-discs-heal-their-own

https://www.spine-health.com/conditions/herniated-disc/cervical-herniated-disc-symptoms-and-treatment-options

https://www.webmd.com/a-to-z-guides/tc/cervical-disc-herniation-topic-overview#1

https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/syc-20354095

 

http://onlinelibrary.wiley.com/doi/10.1002/1529-0131(199902)42:2<366::AID-ANR20>3.0.CO;2-6/full

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.918.3464=rep1=pdf