Medical Assessment

  • 10 Pages
  • Published On: 11-12-2023

Case study 1

Patient X was suffering from Hypertension and has been ailing from the condition for 6 years now, a male patient aged 64. He has regularly been attending the clinic to check on progress and asses the current state of his illness. I regularly check his vitals on his every visit, his weight, blood pressure recorded and his temperatures taken. Patients X’s condition seems to be unstable lately and I have scheduled a plan to commence his treatment. Patient x has a drinking history and was smoking three packets of cigarettes a week during his lunch breaks before the diagnosis. He works in a production and distribution company, a Muslim who goes to the mosque on Friday morning and evening, Tuesday and Wednesday morning hours before work. The patient has no known allergies and has been responding well to the treatments, only a few adjustments are needed in the treatment plan to ensure efficiency.

Treatment plan

Patient X treatment plan will include are range of lifetime adjustments and standard are based on treating hypertension. The first step will include moderate intensity aerobic exercise (Smith & Friedman, 2017) for my patient every week. Since my client is a Muslim and works all the five days of the week ill schedule the walks from 5:30 pm every evening after his working hours excluding Friday as he will visit the mosque after his work. Since Saturday is not a working day for X, the walking and jogging hours will be in the early morning hours and will last for two hours unlike the other days where it lasts an hour.

Patient x works for long hours which may during the week which might have contributed to hypertension due to work stress. Meditation and yoga classes are scheduled every Thursday and Monday morning hours before the patient goes to work. This will help them reduce stress related to work and hence controlling the blood pressure levels. The patient has been prescribed medications such as beta-blockers and alpha blockers, vasodilators, central agonists and thiazides to help regulate the intensity of the blood pressure (Kaplan, 2010). The patient has no known allergies and these prescribed medications will be effective as the patient’s condition has not advanced any further.


Patient doctor dialogue

Patient X: good morning doctor I don’t feel well, I have been having severe headaches, blurred vision, chest pains that have increased in intensity.

Doctor: good morning to you too X, for how long have you been experiencing these symptoms,?

Patient X: since our last meeting last week.

Doctor: did you skip your drugs? Are you maintaining a healthy diet?

Patient X: yes doctor I have been taking all my meals on time and my medicines too.

Doctor: Well then I have to put in a new plan in place to help you and ensure that these symptoms and side effects reduce. First of all will have moderate- intense aerobic for every week, meditation and yoga will be done every Monday and Thursday morning before you leave for work and then I will improve the medication prescribed to use to ensure they work effectively, am looking forward to meet you and discuss your plan treatment plan on detail.

Patient X: thank you doctor

Case study 2

Patient Y is a type 2 diabetes patient that was diagnosed 2 years ago. It is a female patient aged 56 and married with two kids and has been attending the clinic for regular checkups. The patient’s vitals have been taken and sugar levels assessed every time she visits the clinic. The patient works at lecturer in a local university and has no drinking or smocking history. She is leader at their local church which they have meetings on Wednesdays and Fridays and a main church service on Sunday. The patient has no cultural and social norms that may hinder her treatment and seems to comply with the medication and treatment plan in place. The patient has no known allergies; however the patient has lately shown advanced symptoms that have called for a more integrated plan to ensure that the condition is kept under check.

Treatment plan

Healthy lifestyle choices will help patient Y prevent the type 2 diabetes and avoid complications resulting from the illness. These healthy lifestyle include,

Eating a healthy and a balanced diet, the patient was recommended a balanced diet that had low fats and calories (El-Sappagh et al, 2018). Only foods with vitamins and high fiber content are recommended for patient Y. frits vegetables and grains are part of a recommendation plan for the patient. This will help to build the iron content and build the body’s resistance against other opportunistic diseases that may arise as a result of the condition.

Physical exercise and getting active (Simos et al., 2020), patient Y has been recommended a moderate to rigorous physical activity for about 150 minutes a week, this is scheduled on Monday, Tuesday and Thursdays of every week as the patient has free time on evenings of these days. This will help to reduce weight which delays further progression of the disease.

Patient Y and doctor dialogue

Patient Y: good afternoon doctor?

Doctor: good afternoon Y? How are feeling today?

Patient Y: am not feeling ok doctor, lately I have been urinating frequently, increased hunger and I have a blurred vision.

Doctor: for how long have been experiencing these symptoms? Are you taking good care of yourself as instructed in the last visit?

Patient Y: Yes doctor I have been taking all my prescriptions and I have been having all my meals on time.

Doctor: ok, then we have a new plan in plan in place to ensure that these symptoms are regulated. This will include regular physical exercise, improved medication and eating a balanced diet. Please visit the clinic so that we can discuss this plan in detail.

Patient Y: thank you doctor I will visit as soon as possible.

Case study 3

Patient Z is a 60 year old male patient suffering from a heart attack. He has three children, lost his wife 10 years ago before he retired as a coach. Z has been ailing from the condition for more than 8 years now. He used to work as a football coach in a local team and was diagnosed 2 years after he retired as the coach. His grandfather was diagnosed with the same illness years ago and died of the same. The patient has been taking medications and physical activities that are moderate to reduce the impact of the illness. The patient has no drinking history and has never smoked. He has no allergies to the medications given, however recently the patient has had multiple episodes of heart failure which has called for a new treatment plan to help regulate the occurrence of these attacks.

About the illness

When blood circulation to the heart is blocked, heart attacks occur. This blockage arises from fat build up and cholesterol in the human body (Greenwood, Carnahan & Huang, 2018). In some instances, these plagues re capture and form clots that block blood flow to the heart hence heart failure. The major symptoms of heart failure include, pain or aching sensational in the chest, nausea, heartburns, shortness of breath, cold sweat and fatigue. These symptoms of these infections vary some have mild pain, while in others the pain is severe.

Treatment plan

Every attack that happens deteriorates heart tissues and a muscle, however restoring blood flow quickly helps to prevent heart attack damage. There are several medications that will be included for prevention and treatment plan for patient Z. these include:

Aspirin, this will be used every time the episode occurs in patient z in order to maintain the flow of blood in the body. Clot busters will also be used to dissolve a blood clot that has blocked blood from flowing into the patient’s heart (Levenson, Herrera & Wilson, 2020). Receiving these drugs early enough after the attack has occurred increases survival chances and less damage of heart tissues. Pain relievers such as morphine will be used to relieve pain and Statins are used to control blood cholesterol levels. A cardiac rehabilitation program has been put in place to ensure that patient Z condition is under check. Changes in life styles and emotional distress are part of the rehabilitation process that will help reduce these episodes of attack. These rehabs will be scheduled right after these episodes occur, these can be anytime of the week and has no specific set dates as the attacks cannot be predicted either.

Patient Z and doctor’s dialogue

Doctor: hello Z. how are you feeling I recall in your last visit to the clinic you complained of nausea, shortness of breath and fatigue. Are these symptoms still persistent?

Patient Z: hello doctor am feeling a little better the nausea is gone but am still feeling fatigue and I lose my breath at times

Doctor: well I have a new plan that we should put to action soon, this will help relieve you of these symptoms. These will require you to pass by the clinic so that we can discuss when to start. I will prescribe a new range of drugs for you that will help you during the heart attack episodes, and cardiac rehabilitation programs that you will have to attend every once in a week or immediately after the episodes to help you recover quickly.

Patient Z: thank you doctor I will be in touch

Doctor: you are welcome Z your physical health is our concern.

Issues raised outside work place

Patient Y, who is al lecturer at the local university, complained of the excess work load. She complains that recently here work load has increased which has been brought up by the Covid 19 pandemic that has driven all learning processes to be online oriented. It is hard to supervise and monitor each student’s progress online, unlike in one single classroom setting where student’s response could be gathered by physical observation. This has increased her working hours and she barely has time for herself. She has been missing physical therapy sessions as she needed extra time to manage her class and give out assignments. Group online assignments have been difficult to manage and hence she is forced to assign and asses work given to each and every student. It is an issue that is outside my work jurisdiction as a doctor there is little I could do to ensure she makes it to her physicals on time.

Reflection Questions

Describe any social, cultural, emotional, spiritual and psychological wellbeing issues encountered by the clients.

Patient X who is a Muslim has been influenced by the cultural aspect of the Ramadan fasting during the day and having a light meal during the evening. The medications prescribed to the require that they have a proper and well balanced diet all thought the day this hindered the patient’s ability to show change. The patient is stressed due to the current workload as he works in a production and distribution company that requires taking inventory of all the products and services undertaken during the day. The cultural aspect of patient Z was a hindrance to treatment, she only preferred to be handled by female doctors. She claimed that in her physical therapy sessions she had trouble reconnecting with male doctors and could not open up entirely. The patient was a Christian and believed in receiving divine healing, she would go to pray and fast in sacred places which was not good for her health despite the condition. The pressure from the workload at the university made her mind switch and was having psychological issues due to work load. Patient Z had psychological issues that resulted from the death of his wife; he stopped coaching football right after his wife died in order to take care of their three children. He has not been working out ever since and this emotional distress might have brought about the trauma and hence heart attack. His condition might have been genetically inherited from his grandfather who died from a similar illness.

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Describe how you encouraged the clients to draw on their strengths and improve their sense of self esteem and confidence

In attempt to strengthen patients self esteem and confidence, one must be able to ensure that they religious and cultural beliefs are not harmed (Bajaj, Gupta & Senguta, 2019). I encouraged patient X to maintain her balance diet and take her medicines on time despite this Ramadan time as it will enhance his healing process. The patient was also advised to enroll in therapy classes for two sessions a week to ensure that the work load stress is reduced. In order to improve and strengthen her confidentiality, patient Y was advised to see a professional therapist that could help her deal with emotional and psychological stress that emanated from work and taking care of her family. The patient was also advised to maintain a healthy diet of fruits and vitamins that could help build her defense mechanism against opportunistic diseases Patient Z has been advised to see a therapist who might helps with his condition at the moment. Aside from receiving medications on heart attack, the patient is a lot advised to indulge in physical therapy that might helps relieve the stress and hence reduce the impact of heart failure. The patient has been advised to be around family and loved ones to avoid boredom and loneliness that may lead to stress.

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Kaplan, N. M. (2010). Kaplan's clinical hypertension. Lippincott Williams & Wilkins.

Smith, S. V., & Friedman, D. I. (2017). The idiopathic intracranial hypertension treatment trial: a review of the outcomes. Headache: The Journal of Head and Face Pain, 57(8), 1303-1310.

El-Sappagh, S., Kwak, D., Ali, F., & Kwak, K. S. (2018). DMTO: a realistic ontology for standard diabetes mellitus treatment. Journal of biomedical semantics, 9(1), 1-30.

Simos, Y. V., Spyrou, K., Patila, M., Karouta, N., Stamatis, H., Gournis, D., ... & Peschos, D. (2020). Trends of nanotechnology in type 2 diabetes mellitus treatment. Asian Journal of Pharmaceutical Sciences.

Greenwood, B. N., Carnahan, S., & Huang, L. (2018). Patient–physician gender concordance and increased mortality among female heart attack patients. Proceedings of the National Academy of Sciences, 115(34), 8569-8574.

Levenson, B., Herrera, C., & Wilson, B. H. (2020). New ACC Global Heart Attack Treatment Initiative: Improving STEMI Care Worldwide.

Bajaj, B., Gupta, R., & Sengupta, S. (2019). Emotional stability and self-esteem as mediators between mindfulness and happiness. Journal of Happiness Studies, 20(7), 2211-2226.

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