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Background and history

I have met a patient in
the primary health care center who came to general clinic complaining of
headache, and concerns about hypertension, I have started interviewing him
after presenting myself as a second-year medical student, and after having the
consent, I started to have his medical history, firstly I asked about personal
information, and for confidentiality purposes I will name him Patient.MSH as a
pseudonyms, Patient.MSH is Saudi male citizen, he is 30 year, married, work as a
teacher, he lives in Dammam.

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Presenting complaints

Patient.MSH present to
the primary health care center with a headache, the headache starts about 2
weeks ago, the pain effect more in the lower part of the head, the quality of
the pain was like if there is a pressure on the head, asking the patient to
grade the pain out of 10 (when 0 is no pain at all and 10 the most severe
pain), the grade of pain was 4 to 5, Panadol can reduce the pain sometimes, and
being in stress can make the pain worse, asking about what the patient believes
he answers that he is concern about hypertension because he had some blood
pressure reading at home , and lastly, Patient.MSH adds that sometimes he have a
pain in his chest.

Patient.MSH had some
blood pressure reading at home, and they were slightly high, 138/89, 136/88


Past history

Patient.MSH didn’t suffer from any dangerous disease,
but, in the last few months he got some common cold for few days, he has no
surgical procedure history, and he didn’t have blood transfusion, for immunization and vaccination he
had vaccinated for meningitis and for the seasonal flu.

Patient.MSH is not a
smoker, and he don’t drink

Family history

Patient.MSH fathers are
alive, both have chronic disease, his father is diabetic patient, and his
mother have hypertension.

Social history

Patient.MSH live with
his wife in a nice home in ad Dammam, his relationship is very good, and he is
friendly person, he is will educated, religious person, financially good and







Drug and allergy history

Patient.MSH don’t use prescribed drugs, and no
recreational drugs.

Sometimes he uses over
counter drug such as:

Panadol: he uses it for
the headache, and t can relive the pain for a while.

He doesn’t have allergy for drugs or food



Examination and diagnosing

The doctor had a lock
over Patient.MSH vital signs:

O2 saturation was: 99

Temperature was: 37.4

Respiratory rate was: 16

Blood pressure: 145/91, 138/87

The doctor listened to
heart and chest sound found it normal.

The doctor registered Patient.MSH
to have an ECG, CBC, and more blood test

And the plan was to
monitor the blood pressure of the patient, by a device to record the blood
pressure for several days, then he made an appointment after tow weeks to follow
up the situation, because at this time its too early to say if he has

Biological aspects:

The definition of
headache is pain
in any region of the head. Headaches may occur on one or both sides of the
head, be isolated to a certain location, radiate across the head from one
point, or have a viselike quality (Mayo Clinic, 2018).

The international
headache society classified headache into three categories:

primary headache: in which the headache itself is the
disorder, like migraine.


secondary headache: headaches caused by inflammatory,
metabolic, or structural problems, like the headache associated with fever, and
it may be associated with hypertension.


cranial neuralgias: pain related to a nerve of the
head, like trigeminal neuralgia.



Headache associated with hypertension:

Headache, often
bilateral and pulsating, caused by hypertension (arterial hypertension),
usually happen in acute rise in systolic and/or diastolic blood pressure, (in
acute rise of blood pressure reading will be close to, ? 180 mmHg for systolic, and ? 120 mmHg for diastolic).

Mild and moderate
chronic hypertension does not appear to cause headache.


Pharmacological treatment:

Pain relievers are the first drugs recommended by doctors for migraine
and headaches, many of them are over-the-counter drugs, Drugs for relief of
migraine or headache symptoms include drugs used for pain relief such as
Acetaminophen, and Aspirin, another drug are Ibuprofen, and Diclofenac used for
Treatment of tension headache, and migraines. (WebMD, 2018)


Non-pharmacologic treatment:

Referring to the treatment without using drugs, using techniques like
Acupuncture, and Relaxation Techniques, reducing the stress can reduce the
headache, also Diet Changes can be done, like reducing the Caffeine, lastly
Many people find that putting gentle pressure on the head, face, and neck
during a migraine can help ease the pain. (WebMD, 2018)

Ethical issues:

Doctor patient relationship:

In fact, the doctor established very good rapport with Patient.MSH, he
was fully concentrating with the patient, giving him time to talk about
himself, telling
the patient before asking him about the history if he need anything, but,
sometimes the doctor was crossing his leg Unintentionally, other than that
Patient.MSH was fully satisfied and felt comfortable.


Ethically having a permission before doing any action is important.

The doctor toke the consent from Patient.MSH for us as students to be in
the clinic to see this case, and before he takes the consent, he explained to
the patient why there are students with him, Patient.MSH was more than welcome
to keep us in the clinic, and then before the physical examination doctor
explained the examination and had the consent to do the physical examination.


Confidentiality is ‘the practice of keeping harmful, shameful, or embarrassing
patient information within proper bounds (Purtilo and Doherty, 2013).

During the physical examination doctor closed the door and ensure the
patient privacy, and he did not tell anyone about the result without the
consent from patient to share that information, and he did not disclose any
information that can harm the patient.

Legal issues:


We must remember that having the consent is not just for ethical purposes,
legally it is one of the patient rights, not something we offer it for the patient,
so, to avoid the Accountability doctors should ask for the consent, and they
can take it in tow ways depending on the situation:

Verbally: e.g. before starting the medical interview.

Non-verbally: e.g. before doing a surgical procedure.


In the clinic I saw good example of confidentiality, after the patient left
the clinic, the doctor refused to let us see the patient file, and before he
let us to know more about the patient, he kindly asked the patient if he allow
the students to write some information about him.

Sociological aspects:

Political aspects:

The public health sector is overwhelmingly financed, operated,
controlled, supervised and managed by the ministry of health, from my own perspective,
our government made the health care easy to access, even for the foreign people,
Patient.MSH did not find it hard to come to the clinic it was easy for him to
access to the health care he required.


The MOH Approved Budget for the Fiscal Year 1437/1438H was totaling SR
58.899.190.000 (MOH, 2017).
And the government made
the health care free to access in the governmental hospital, even if Patient.MSH
went to a private sector he will not have problem financially, his financial
state is good, and he did not have problem.


Understanding the cultural differences can help doctors to establish better
relationship between patient and doctor, some patients refuse to have test
because of cultural or religious Customs and traditions, or as in a simple
example, when the patient is women, usually in our community men do not shake
hands with women.


As we mentioned earlier, Patient.MSH is Saudi male, he is 30 years old,
married, he live and work in Dammam, he live in his own house with his wife, he
complete his academic learning, he have the master degree, he have a good
relationship with his wife, and his family.



Self-care and lifestyle:

In this part I will use the ESSENCE model

Ø  Education:

 very will educated have a master


Ø  Stress management:

Patient.MSH live in lovely environment, away from family and social problems
and that kept him out of stress for most of his day, but, when he finds out
that after he take blood pressure readings and found it high, he started to
become more worry about his health and that made him under stress in some ways.


Ø  spirituality

Patient.MSH is religious man, and he is not in fear from illness, he thinks
that god (Allah) made him sick for a reason, and I respect his opinion.


Ø  Exercise

Patient.MSH has just started to exercise about 3 weeks now, he started by
walking and jogging for an hour per day.


Ø  Nutrition

He did not have a specific diet, but he said that he is trying to start one,
the one want to start he will try to avoid junk food, and soft drinks.  


Ø  Connectedness

Patient.MSH have very good relation ship with his family and the friends,
he feels that this connectedness is making him better if he is sick, and he
think that he has a very solid relation between him and people surrounding him.


Ø  Environment

Patient.MSH live in a peaceful environment, away from the pollution and
the factories, his work environment also free of pollution and away from chemicals.

Patient perspective:

Patient.MSH think about his condition and says that it may not effect on
his life and job, but he will try to change his life style to achieve the best
health level he can reach, Patient.MSH fells supported by his family, and that
give him hope that he can live and be healthier person,







































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