The patient is a 9-year-old boy, who visited the general practitioner with his 37-year-old mother. The general practitioner reviewed the patient’s medical history and conducted an interview with the patient’s mother to learn more about the boy’s family history, as well as the history of the boy’s chronic cough. The mother reported having seasonal allergies, especially during springtime when plants release their pollen. However, the boy had no known allergies or respiratory problems according to his mother and his medical history.
The physical examination included the assessment of the patient’s vital signs, nasal canals, auditory canals, and the respiratory assessment. The patient displayed wheezing during inhalation and exhalation. Because the patient’s mother reported that the boy’s coughing increased after physical activity and that the cough was usually productive, asthma was the suspected diagnosis. Pulmonary function testing was performed, and the test results confirmed that the patient has asthma.
The asthma was mild, so the patient was prescribed short-acting bronchodilatators, and the mother was informed to return if the boy had to use the bronchodilatators more than twice per week. Over the period of 6 months, the patient and his mother returned only once because the boy started using the bronchodilatators three or four times per week. A two-week therapy of low-dose inhaled corticosteroids was used and a follow-up showed that the patient’s condition was stable without corticosteroids.
reflections On the process of diagnosis
Clinical reasoning skills. Clinical reasoning skills need to be applied in all stages of healthcare delivery, but their first application is during the diagnosis. The clinical reasoning skills observed during the diagnosis in this case included communication and critical thinking skills. The physician must communicate effectively to collect all of the facts relevant to the diagnosis, whereas critical thinking is necessary to ask relevant follow-up questions about the patient’s history and narrow the list of possible diagnoses.
The most important insight I learned from this case is that the same patient must be reviewed thoroughly and objectively each time they visit because patients and their environments change every time. The medical history review and physical examination were performed at the beginning of every visit to determine if any new directions in management therapy are warranted.
Clinical skills to diagnose many problems. Although this particular patient did not have multiple problems once the definitive diagnosis was determined, that is not something a family doctor can conclude immediately after the examination. In order to determine that the chronic cough was a symptom of asthma, the family doctor had to conduct an interview and examination to perform a differential diagnosis and eliminate other possibilities, such as bronchiectasis or post-nasal drip.
Personally, I found the interview the most complex and demanding clinical skill because an individual approach is necessary for each patient. Although the Calgary-Cambridge Guide to the Medical Interview provides a general framework, there are no structured questions because each patient brings unique problems and has a unique personal history that determines which questions the family doctor will ask.
reflections On the process of consultation
The consultation process. According to the Calgary-Cambridge Process Guide, the consultation must have a structure, but I observed that a conversation that flows in a logical sequence is not always possible in clinical practice. The only consistent parts of the patient interview were the introduction, in which the goal was to build rapport before starting the questions, and the closing of the session, in which the physician would summarize everything that was said and check if the patient understood everything. Otherwise, the interviewer must be able to stay flexible and break the sequence if necessary to ensure that the interview helps diagnose the correct problem.
I also observed that structuring consultations with patients is secondary to using a patient-centered approach. As long as the doctor focuses on what the patient is saying, shows the patients that their input is important in the healthcare delivery process, and explains everything to the patient using simple language, the patient will feel respected and valued. I believe that the use of the patient centered-approach in this case was the key reason why the doctor received few complaints and why the mother had few concerns.
Ideas, concerns, and expectations. The social integration was main concern of the patient’s mother because she believed that physical activity is an important part of social and physical development in childhood. Overprotective behavior was one of the risks because of the mother’s concerns about the child’s safety, so the family doctor provided various recommendations. For example, one recommendation was to engage in supervised physical activities to ensure that the boy will receive help if something happens. That would also serve as an opportunity to determine the boy’s acceptable physical activity levels. Although the pharmacological management of asthma follows a similar stepwise management plan for all patients, this case illustrates how the doctor’s involvement can reach beyond treating symptoms and contribute to the patient’s social and psychological well-being by offering support.
Dealing with complaints. In this case, the majority of complaints were received from the patient’s mother immediately after the diagnosis. I believe that those complaints were caused by the grieving process, which starts with shock and continues with denial and bargaining (Kavanaugh 107). The mother asked the doctor to order more tests because she could not accept the diagnosis at first, but the physician guided her through the denial effectively. Of course, the fact that the asthma was only mild was helpful because the boy required minimal pharmacological treatment and could still stay physically active without risk for acute exacerbations. However, I believe that it takes patience, understanding, and skill to guide patients through denial regardless of the disorder severity, especially if we consider that this case was only one of many a family doctor deals with every single day.
Management program negotiation. Negotiation was not a part of this case because the disorder was mild, so the program was simple straightforward. The patient only had to take bronchodilatators when necessary. When the patient used the inhaler too frequently, stronger corticosteroids were used instead of bronchodilatators until the severity of the condition reduced. Although the mother was concerned about the side-effects of corticosteroids at first because her son is still a young child, the family doctor ensured her that the prescribed medication was selected because it is safe for children to use.
reflections On the process of management
Condition information. Asthma is a complex chronic pulmonary disorder that is associated with various pathophysiological changes, such as thickened lamina reticularis, increased mucus excretion, or edema located in the airways (Lemanske and Busse S95). Those changes contribute to airway inflammation and intermittent airflow obstruction.
The main patient safety risk in asthma is acute exacerbation, which accounts for high mortality and morbidity rates. Although children are the lowest risk age group with approximately 37 asthma-related deaths per year (Tsai et al. 1252), Therefore, the patient must continuously manage the condition to prevent further complications.
Continuity of care and compliance. The continuity of care and record keeping in this case is of utmost importance because of the chronic nature of the disease, and recording everything allows the family doctor to review the current management plan. In order to determine if the patient is compliant with the medication, the physician must build a strong relationship with the patient based on trust. The patients must understand that honest answers are important and that they will not be judged regardless of what they say. In my observations, the non-judgmental attitude of the family doctor in this case was probably the reason why the patient and his mother disclosed many things with the doctor, including that the child forgot to take corticosteroids when the condition slightly worsened.
Effects of the illness. The patient’s illness in this case had a significant effect on the family medicine practitioner and the family. The physician had the responsibility of disclosing bad news to the patient and his mother, and the patient and his mother had to adapt to the fact that he will have to manage his chronic condition continuously. Although no significant problems were encountered throughout the case in the doctor-patient relationship, both sides have responsibilities they can fulfill only if they build a strong relationship in which both parties collaborate in healthcare delivery.
Works Cited
Kavanaugh, Robert. Facing death. New York, NY: Penguin Books, 1974. Print.
Lemanske, Robert F., and William W. Busse. "Asthma: clinical expression and molecular mechanisms." Journal of Allergy and Clinical Immunology 125.2 (2010): S95-S102. Web. 18 May 2016.
Tsai, Chu-Lin, et al. "Age-related differences in clinical outcomes for acute asthma in the United States, 2006-2008." Journal of Allergy and Clinical Immunology 129.5 (2012): 1252-1258.
