Patient Diagnosis: Lack of Energy Presentation
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This dissertation is based on two patients who presented to medical services with a presenting complaint of a lack of energy?. My first patient, Mrs W, 61 years, has Diabetes Mellitus, type 2 and my second patient, Mr H, 59 years, has severe anaemia from unknown lower
Gastrointestinal blood loss.
I shall begin by focusing on the clinical aspects and basic medical sciences of their diseases and then go on to discuss psychosocial aspects, management, investigations and the role of professionals involved in their health care. I will then look at research and evidence based trials to explore the scope of their conditions and look at any current research that is being carried out.
Throughout my dissertation I aim to reflect and convey what I have learnt and how I felt about my experiences.
From writing this report I have developed as an individual and have gained personal advancements that I didnt expect to achieve. I have been able to widen my understanding of diseases and patients experience of their disease.
Furthermore, I have gained an appreciation for research and evidence based medicine and developed a respect for other health care professionals. I have learnt the vital importance of taking on a holistic approach when dealing with a patient, rather than just looking at the basic science behind a disease.
All in all, writing this dissertation has enabled me to truly understand how a disease can affect a patient and I now appreciate that it is not always about curing a patient, but about treating, advising and working towards a better quality of life for the patient and their family.
In my dissertation I aim to explain, explore and reflect on my experience of the People and Disease course. In particular I will focus on my experience of meeting with two individual patients with the same presenting complaint a lack of energy?.
Both patients seem to be concerned with the prognosis of their disease but from very different points of view. My first patient wants to overcome her diabetes and not let it worsen; whereas, my second patient does not wish to know the cause of his anaemia, but is worried about the associated symptoms of his condition and how they will progress.
Before contacting my first patient, Mrs. W, I felt apprehensive and quite anxious about the idea of having my own patient. I was worried about what she would think of me, how we would be able to build a rapport and what sort of questions I would ask her. In all honesty, I had naturally stereotyped her as a typical old lady?, but on meeting her, my initial thoughts were soon corrected. From this I have learnt that when given details about a patient you shouldnt necessarily stereotype and categorise them into a certain group in society.
When asking her the initial questions that I had prepared I felt that it made the conversation very informal, so to adapt to the situation I just literally let her speak and tell me whatever she wanted to. This was very helpful to me as she had a lot of things she wanted to tell me and talk about. However, I do realise from communication skills seminars that not all patients will be as open as this in the future and therefore I do need to have the ability to speak to patients that are perhaps a bit more reluctant and unwilling to share their problems and thoughts. For example, you can use a lot of open questions to allow the patient to answer what they feel is comfortable for them and just gradually develop the conversation from what they say, rather than chit chatting?, which is what I found with my first patient.
After asking Mrs.W about her recently diagnosed diabetes she seemed very unsure how to explain to me what she thought was wrong with her, she seemed to resent the fact she has a disease and questioned what she had done to deserve becoming ill. She said that even though the Doctor had explained everything to her, she was unsure of what to expect in the future and seemed quite worried about the aspect of not being able to care for herself. From telling me all of this, I felt quite overwhelmed and unsure of how to reassure her. Even though I wanted to help, I found myself in a situation where I physically couldnt, which was very frustrating. On my second and third visits I asked a bit more about her family situation, her social activities and her thoughts, ideas and feelings (psychological factors). From taking on this broader approach, I began to realise the true picture of Mrs Ws life and how it contributed to the worries of her illness. She told me about her husband leaving her and her daughter and son becoming quite distant, she explained that she often felt lonely and at times it made her feel quite depressed. This seemed to be more of a concern to her than her actual illness, but it demonstrated why she is concerned about her diabetes worsening because she has very little family support and would have to cope by herself.
From the meetings with Mrs W, I have learnt the vital importance of taking on a holistic approach when speaking to a patient. I have learnt that its not just a biological illness that contributes to the wellbeing of a patient; you have to take into consideration the home/family environment and the social and psychological factors. Not only have I had the opportunity to see an illness in the context of real life but I have greatly improved my confidence and patient communication skills by being able to gather information, take family history and cope in a one-to-one based home environment.
However, my experience from meeting my first patient contrasted completely with my second patient experience. Initially I had some difficulties finding my second patient, as the consultant I had contacted only ran morning clinics; so I took the initiative to go into the hospital and find a suitable patient myself. Even though I felt quite nervous, I went onto the haematology ward and simply explained to one of the nurses about my course and what had happened so far with trying to find a patient. She was extremely helpful and understanding, which put me at ease and she more or less found me a patient right there and then (which I hadnt expected). However, even though I hadnt really prepared anything I already felt that I had developed some good skills and awareness of communicating appropriately with patients, both from my first patient and communication skills seminars, to be able to build up a good report with my second patient.
Mr. H (my second patient) was very different to my first patient in the sense that he wasnt as open when talking about his illness. He is suffering from severe anaemia and has to have blood transfusions every week (so like my first patient, had the presenting symptom of no energy). However, he didnt seem to recall any dates of his illness and didnt want to explain what had caused the anaemia. However, after reading his medical records and meeting with his consultant, I came to realise that Mr. H had had a bad experience with a doctor and had adamantly refused further investigation, so his severe/worsening anaemia remains an unknown cause.
Also, in comparison to my first patient, he had a much more considerable loss of energy, so even though he gave consent for me to talk to him, I felt at times he needed a break so I ensured that I did not stay too long and trouble him during my visits. Nevertheless, I found that meeting a patient in a hospital environment is completely different to meeting them in a home environment. In a hospital environment you need to be very aware of everything around you, how you are acting towards other staff and patients and there is a real need to realise certain cues from the patient (as they are in a more severe situation than a patient in a home environment).
Overall, the People and Disease course has been a really enjoyable learning curve. Ive been able to put my communication skills to practice and see how to adapt to different situations, which has boosted my confidence enormously. Even though there is much more to learn, I really look forward to doing so and I hope that I will develop the skills needed to become a good doctor in todays society.
2. Clinical Features
In this section I aim to discuss clinical features of my patients diseases and differential diagnoses.
My first patient was diagnosed with Type 2 Diabetes Mellitus and my second patient suffers from severe anaemia; both of these conditions have similar clinical features and the same presenting complaint of a lack of energy and fatigue. Both of my patients recorded symptoms of lethargy, dizziness, fainting and shortness of breath; exploring these similar symptoms demonstrates the importance and accuracy needed for a diagnosis, as these symptoms could be indicative of a variety of other diseases. It is also vital to have a correct diagnosis, as a misdiagnosis would lead to unnecessary grievance, treatments or investigations which would cause a patient a lot of stress.
Fatigue is the common presenting complaint in both of my patients and is clinically difficult to define; it is related to tiredness, exhaustion and a general lack of energy. Fatigue is a very common health complaint and around 20% of people in the United Kingdom claim to have fatigue intense enough to interfere with them having a normal life. Physical causes are estimated at 20-60%, and emotional causes are the other 40-80% (1).The fact that fatigue alone can disrupt ones life so severely indicates the important role of a doctor to be able to make a correct diagnosis for the cause of it.
However, my individual patients described their fatigue in very different ways. Mrs W described her lack of energy in relation to feeling lethargic and very tired all the time, whereas Mr Hs fatigue was very much to do with a sudden onset of shortness of breath and chest pain.
The symptoms that patients with anaemia normally present with are highlighted in the image below: (2)
Mr. H has anaemia with haemoglobin levels often as low as 3.2gm/dL; with the normal range being 13 - 18 gm/dL for a male and 12 - 16 gm/dL for a female (2); indicating that his anaemia is very severe and therefore explains why he would experience fainting, chest pain and angina as shown in the image above. And in comparison to Mrs. W, highlights the difference in their experience of their clinical presentation of a lack of energy.
Type 2 diabetes was previously referred to as adult onset diabetes and is related to insulin resistance and a relative, rather than an absolute, deficiency of insulin secretion (3). Due to the fact that this type of diabetes is concerned with gradual insulin resistance/deficiency means that individuals do not always (or initially) require insulin to achieve satisfactory diabetic control.
The common symptoms associated with Type 2 Diabetes are (4):
- Polyuria: the need to urinate more often due to the body trying to excrete the extra glucose that is in the blood and in turn creating an osmotic gradient resulting in more urine production.
- Polydipsia: feeling thirsty more often than usual, due to the loss of fluids (increased urine production).
- Weight loss: this is due to the fact that glucose is not being taken up by cells due to insulin deficiency/resistance, so the body starts to burn up fat instead, which results in weight loss due to fat storage depletion.
The majority of diabetic patients experience lack of energy because the cells in the body are not getting the glucose that they need, resulting in lethargy and tiredness. As type 2 diabetes progresses, patients may also experience blurred vision, yeast infections and prolonged time for wound healing.
Mrs W was diagnosed with type 2 diabetes in February 2007; initially only experiencing a lack of energy. Over the months that I met with her she also started to experience polyuria and polydipsia. She was concerned as to how much her diabetes would progress and worsen because it had not been made very clear by her Doctor. This demonstrates the important need for a Doctor to be aware of patients concerns and level of understanding of their disease process.
However, when speaking to Mr H about his clinical presentation and symptoms he had a very nonchalant attitude towards the cause of his disease. I later discovered that his anaemia was in fact due to unknown lower Gastro-intestinal (GI) blood loss and on questioning Mr H about this; he explained that he refused investigation to find the cause of the blood loss due to dissatisfaction with the way he was treated. He explained that during a scheduled procedure for a colonoscopy, the doctor carrying out the investigation was extremely rough and caused him a lot of distress and discomfort. And even though Mr H asked for the procedure to be stopped, the doctor proceeded against the patients wishes; this aggravated Mr H and led to violent behaviour towards the doctor and the dispute was later taken to court.
I was very shocked to hear of his experience and also felt deeply concerned that he refused future investigations as his symptoms and anemia are very severe and have lead to angina and disabling conditions; with him being unable to walk and get out of bed unassisted due to such severe lack of energy. This emphasizes the crucial need for a good doctor-patient relationship, as shown in this case, without it, a doctor may be unable to make a proper diagnosis and prescribe ideal treatment.
The process of looking at a differential diagnosis involves weighing the probability of one disease against the possibility of other diseases accounting for a patients illness. For example, Mrs W presented with a lack of energy for her diabetes mellitus, but this complaint could have been diagnosed as any other kind of condition such as, hypothyroidism or Cushings disease as they can also present with fatigue.
Differential diagnosis to Diabetes Type II:-
Why is the condition considered to be a differential diagnosis
How to make the correct diagnosis:-
Also results in a lack of energy and fatigue.
Often diagnosed via a blood test, examining the levels of T3,T4 and TSH in the blood.
Polyuria (and associated polydipsia); insulin resistance (especially common in ectopic ACTH production) (5)which can lead to hyperglycaemia (high blood sugar levels), which can in fact lead to diabetes mellitus.
Dexamethasone suppression test or/and a 24hour urinary measurement of cortisol(6).
High circulating blood glucose levels this is a symptom of diabetes, but could also be due to physiological stress, critical illness or certain drugs.
Blood test which indicates a glucose level of 10+ mmol/L (180mg/dl) also a test for diabetes, therefore, need drug/medical history.
The differential diagnosis of anaemia would be any condition relating to the presenting complaint of a lack of energy?, or any other condition relating to the symptoms of anaemia, as discussed in the clinical features section. In particular relation to Mr Hs lower gastrointestinal bleeding the differential diagnoses are as follows:
Differential diagnosis for lower GI bleeding:-
Why is the condition considered to be a differential diagnosis?
How to make the correct diagnosis:-
Swelling/inflammation of veins in the rectum commonly due to straining in constipation. These can often rupture and bleed.
Physical examination of external haemorrhoids, digital rectal examination for internal haemorrhoids.
Cancerous growths in the colon (thought to be adenomatous polyps) can rupture, thus causing a bleed.
Digital rectal examination, Fecal occult blood test (testing for blood in the stool), endoscopy (7).
A form of Inflammatory Bowel Disease, includes ulcers and open sores which lead to constant diarrhoea mixed with blood.
Endoscopy; involving both colonoscopy and sigmoidoscopy.
From exploring the differential diagnosis of my patients conditions it has made me more aware of the vital importance of making the correct diagnosis; as there are a number of conditions that certain symptoms could be caused by. Furthermore, considering Mr Hs anaemia it does highlight the fact that his condition could be a number of quite serious conditions, which shocks me even more as he has chosen not to find out the cause of his worsening anaemia due to his troubled experience with a doctor.
It is quite complex to discuss the aetiology of both my patients conditions as the exact cause of type 2 diabetes is not fully understood, although clear risk factors have been identified. Furthermore, Mr H refused investigation into his GI bleeding, which results in the cause of his anaemia remaining ambiguous.
Diabetes Mellitus Type 2:-
Diabetes Mellitus is a group of metabolic disorders characterised by chronic hyperglycaemia (high blood glucose concentration), due to insulin deficiency, insulin resistance, or both. There are two main types of diabetes; type 1 and type 2. They can clearly be distinguished by their epidemiology and probable causation, but not always so easily separated clinically.
Type 1 diabetes is due to autoimmune destruction of insulin-producing beta cells of the pancreas therefore, causing an increase in fasting blood glucose. However, diabetes type 2 is a disorder that is characterised by high blood glucose due to insulin resistance and relative insulin deficiency (8).
Since diabetes is a disease that affects your bodys ability to utilize glucose, it is important to understand what glucose is and how your body would normally control it. Glucose is a monosaccharide (simple) sugar that comes from the food we eat, cells take in glucose from the blood and break it down for energy; brain cells and red blood cells rely solely on glucose for fuel.
The pancreas (where Insulin is synthesised) has both endocrine and exocrine functions. The exocrine function involves the secretion of digestive enzymes that are secreted from acinar cells and released into the small intestine via a system of ducts.
Additionally, the endocrine part of the pancreas consists of millions of clusters of cells called Islets of Langerhans that produce hormones. Within the islets there are four main cell types; cells secrete glucagon, cells secrete insulin, cells secrete somatostatin, and PP cells secrete pancreatic polypeptide (9).
Glucagon and Insulin are hormones secreted from the pancreas that work concomitantly to control the level of glucose in our blood. Glucagon is released when blood glucose levels fall, therefore resulting in stored glycogen being converted to glucose and thus increasing blood glucose levels, preventing a hypoglycaemic state.
Insulin is a hormone that causes cells to take up glucose from the blood and store it as glycogen, thus a deficiency or resistance of this hormone will result in a high concentration of glucose in the blood.
Beta cells release insulin via the following process;
- The glucose uptake takes place through a specific transporter protein called GLUT-2. The pancreatic ?-cell membrane contains several K+ channels, and two of them are directly involved, the K+-ATP channel and the maxi-K+ channel.
- The hyperglycaemia (high blood sugar level) accelerates the glucose uptake and metabolism and thus increases the ATP/ADP ratio.
- Increased ATP closes the K+-ATP channels, so the cell depolarises. During deploarisation from the normal resting membrane potential of -70 mV, a threshold is reached at - 50 mV, resulting in the opening of Ca2+ channels.
- The Ca2+ influx triggers exocytosis of insulin and C-peptide containing granules following vesicular fusion with the cell membrane. ne.
This process is demonstrated in the diagram below (10):
However, in an insulin resistant individual normal levels of insulin that are released (via the process described above), do not have the same effect on muscle, adipose and liver cells, therefore resulting in glucose levels staying higher than normal.
Increased levels of glucose in the bloodstream over a sustained length of time result in damage to blood vessels. Poorly controlled glucose levels can lead to complications such as nephropathy, retinopathy, neuropathy and cardiovascular diseases. Even though these complications may take a while to develop, it is important to realise that type 2 diabetes is often diagnosed at a relatively late stage.
From looking at the pathophysiology of diabetes, Mrs Ws main symptom of lack of energy/tiredness can be explained. Due to her slow progression of insulin resistance means that more glucose remains in the blood and is not utilised by certain cells, such as muscle cells. Therefore, due to the fact that her cells are not able to use the glucose, she experiences weakness and tiredness. This lack of energy will progressively become worse and she may develop other complications if her diabetes is not controlled appropriately.
Anaemia occurs when there is a decrease in the level of haemoglobin in the blood and occurs when the production rate of red blood cells does not match the loss rate.
It is a common condition in which all forms can be defined on the basis of physiological mechanisms. There are three broad categories: decreased/defective red blood cell production; increased destruction of red blood cells; and a mixture where both mechanisms operate simultaneously (11).
Haemoglobin is a substance contained within red blood cells and is responsible for their colour. It is composed of haem (an iron-containing porphyrin) linked to a protein, globin (12). Adult haemglobin consists of two and two globin chains. The iron containing porphyrin in the haem group is bound to each globin chain and a ferrous atom that can reversibly bind one oxygen molecule (as shown below (13).
The biconcave shape of red blood cells enables a large surface area for the uptake and release of both oxygen and carbon dioxide. Haemoglobin becomes saturated with oxygen in the pulmonary capillaries where the partial pressure of oxygen is high and haemoglobin has a low affinity for oxygen (therefore, binds easily). Oxygen is then released in the tissues where the partial pressure of oxygen is low and haemoglobin has a low affinity for oxygen (therefore, oxygen offloads easily).
The haemoglobin molecule itself exists in two conformations, relaxed (R) and tense (T). The tense state is characterized by the globin units being tightly held together by electrostatic bonds; when oxygen binds to the haemoglobin these bonds are weakened and broken, resulting in the relaxed conformation. The binding of one oxygen molecule leads to an increased affinity for the remaining binding sites, this is known as co-operativity, and is the reason for the sigmoid shape of the oxygen dissociation curve (below (14)).
The binding of oxygen to haemoglobin can also be influenced by secondary effectors (as seen in the above image) i.e. hydrogen ions, carbon dioxide, and 2-3 diphosphoglycerate. The binding of 2, 3 DPG stabilizes the tense state and therefore, reduces haemoglobins affinity for oxygen (15). In conditions with lowered haemoglobin/oxygen levels, such as anaemia or hypoxia the concentration of 2, 3 DPG increases to raise oxygen availability for tissues.
Haemoglobin is synthesised in a series of complex steps, it takes place in the mitochondria of the developing red blood cells. The major rate limiting step is the conversion of glycine and succinic acid to ?-aminolaevulinic acid (ALA), this occurs via ALA synthetase. Two molecules of ?-ALA condense to form a pyrrole ring, called porphobilinogen. The pyrrole rings are then grouped together in fours, to form protoporphyrins. Iron is then inserted into the rings to form haem and then finally, haem is attached to the globin chains to form haemoglobin.
Production and removal of red blood cells:-
Red blood cells are formed and develop in the red bone marrow of large bones; the process by which they are produced is called erythropoiesis. The organ responsible for "turning on the faucet" of red blood cell production is the kidney. The kidneys can detect low levels of oxygen in the blood. When this happens, the kidneys respond by releasing a hormone called erythropoietin, which then travels to the red bone marrow to stimulate the marrow to begin red blood cell production. Within the bone marrow there are many stem cells from which red blood cells can be formed. As these cells mature, they extrude their nucleus and fill with haemoglobin, forming reticulocytes which can circulate around the body. After 3/4 months, approx 120 days, red blood cells begin to weaken and their cell membranes become very fragile. The red pulp of the spleen allows mechanical filtration and removal of red blood cells, and any leftover components i.e. iron from the haemoglobin are recycled to form new red blood cells (16).
There are several different types of anaemia such as B12 deficiency, iron deficiency, diseases of the bone marrow and in relation to Mr H, chronic loss of blood. His severe loss of blood has subsequently led to his anaemia as there is a mismatch in production of red blood cells and loss of blood. Due to his deficiency in circulating reticulocytes, oxygen, via haemoglobin is insufficiently supplied to his body, resulting in severe lack of energy. Complications of his condition have led to shortness of breath and angina.
Angina pectoris literally means a choking sensation in the chest?. It is an episodic pain that is usually felt in the centre of the chest, often radiating to the neck and left arm. Angina occurs because myocardial oxygen requirement is greater than what it is supplied with. This results in a buildup of metabolites, causing pain (17). Classic angina occurs after exertion, excitation or emotion and is caused by insufficient oxygen supply to meet its demand; however, the pain normally subsides with rest. Due to Mr Hs chronic blood loss, there is insufficient blood supply to the heart and subsequent stress is placed on the organ which has led to his angina.
4. Psychosocial aspects of Illness and Disease
The impact of chronic illness and disability is far reaching, extending beyond the patient to all those whom the individual has contact. Illness and disability affects all aspects of life, including social and family relationships, economic status, activities of daily living, and recreational activities. Even though several factors influence the extent of impact, every illness or disability requires some adjustment to everyday life. The extent of the impact can depend on (18):
- The nature of the condition
- Individuals pre illness/disability personality
- The meaning of the illness to the individual
- Individuals current life circumstances
- The degree of family/social support
With reference to my patients, they each had different outlooks on their illnesses as mentioned previously. However, they do have certain similarities when considering the psychological aspect of their diseases. Both patients were shocked to find out their conditions as neither of them had expected to be diagnosed with a lifelong illness. This is known as biographical disruption, which is a key sociological concept as it identifies severe illness or disease as a major disruptive and unexpected experience.
The illness/disease leads to a biographical shift from a perceived normal trajectory to an abnormal one, with the development of a new consciousness of the body, fragility of self and grief for a former life. For instance, Mrs W had future intentions to look after and care for her grandchildren and Mr H wanted to carry on working as a HGV driver; but due to their conditions they cannot achieve these former life plans and now have to adapt to a new ones.
Additionally, they both explained to me how they experienced the feeling of facing stigma. Stigma refers to the identification and recognition of a negatively defined condition, attribute, trait or behaviour in a person or group of persons (19) . There are different types of stigma, such as enacted or felt. Mr H explained how he felt shunned from his friends and some relatives which refers to enacted stigma; the real experience of prejudice, discrimination and disadvantage as the consequence of his illness. Whereas, Mrs W spoke about her fear of being discriminated against and what people would think/say, which falls under a felt stigma; a fear of enacted stigma, also encompasses a feeling of shame associated with being diabetic?.
I feel that this notion of facing stigma is perhaps underestimated in health care because it is not necessarily something a Doctor would automatically think about and therefore, perhaps wouldnt advise the patient on how to deal with such feelings. However, from talking to my patients about how they feel about having an illness they both stressed how psychologically disruptive it is, and how the feeling of being categorised as an ill individual has often led to depressive moods and anxiety. Therefore, from this experience I have learnt the importance of considering the patients thoughts and feelings rather than just focusing on how to treat their disease.
Biological-psychosocial Model (Engel, 1977):-
This is a model that incorporates psychological, sociological and biological factors in contribution to well being and health of an individual (20). It suggests that all three of these factors together and individually play an important role in relation to health and emphasises the importance of taking on a holistic approach when caring for a patient.
The obvious factor of health is the biological factors of disease, the process of the disease and the individuals genetic make-up. Sociological factors include individuals family and friend support network as well as financial status and social class. Psychological factors include peoples disposition, their emotional status, whether they are stressed, depressed or anxious all contribute to ill health. From learning about this model it is important to note what factors affect a patient and how to deal with them accordingly when it comes to management and treatment of their disease.
Both of my patients spoke of their psychological and social aspects and how they thought these factors had affected their illness. Mrs W, for example often felt quite depressed and lonely as she recently divorced her husband, and due to her illness often felt too tired to see her grandchildren. She also explained how she felt useless?, as she would get tired grocery shopping and house cleaning and she would get frustrated with herself, which often made her feel worse. This highlights how illness can be affected by more than just a biological aspect, and as a Doctor it is important to recognize other factors that affect a patients life.
In comparison to Mrs W, who quite openly spoke about her psychological and social problems, Mr H was much more reluctant to tell me how he felt about his illness and how it was affecting him. However, over time I felt that he became much more comfortable talking to me and we were able to build a good rapport. He later went on to explain how he felt he had to keep a bravado about himself, being an ex army sergeant and that he was embarrassed that he often felt severely depressed and stressed about his worsening condition, but felt that by standing his ground and refusing investigation he was able to stay in control of his life.
I found it very hard to understand his thought process, because surely by having investigations he would know more about his condition and be able to get appropriate treatment. Never the less, from this I have learnt that every patient is different and you cant always expect them to openly explain what is wrong and how they are feeling. I feel that from meeting with my patients I have greatly improved my communication skills and ability to understand a patients point of view of a disease.
Furthermore, with regards to the bio-psychosocial model, Mr H also explained how on days when he felt rather down and anxious he found that he would lose more blood in comparison to other days. This clearly demonstrates how psychological factors can affect ones disease. Due to his worsening condition, Mr H applied for a Disability Facility Grant from Leicester City Council. From this he was hoping that the council would agree to make a wheelchair ramp to enable easy access into his house, as he now finds it almost impossible to get out of his wheelchair without feeling faint and dizzy. However, he was initially refused this grant as the council didnt consider his illness to be severe enough which consequently made Mr H extremely frustrated and angry. Ironically, he then developed angina, which he felt was due to this extra stress caused by the council, but was then given the grant. I think this encompasses the core idea of the bio-psycho social factors and is a real example of how not only a patients health can be affected but also the psychological thought process of the individual.
The Transactional Model of Stress (Lazarus and Folkman, 1984):-
Both my patients said that their conditions induced stress and made them feel unable to cope with their simple daily routines. The model below summarises why and how individuals may become stressed (21) .
By taking the situation/event to be an illness, the primary appraisal involves the patient deciding if the illness will cause them stress. If yes, they would then decide if they are able to cope with the illness via a secondary appraisal. The inability to cope means there would be an imbalance between the way the patient understands/sees the disease and the way they see themselves coping with the disease; this imbalance leads to stress. With regards to my patients, both of them at times would feeling that their primary and secondary appraisals were negative, and they felt that they couldnt quite cope and thus lead to stress.
Health locus of control (Rotter, 1954):-
The idea of coping with stress of an illness, as explained above, also relates to the health locus of control. This is a theory suggesting the extent to which an individual believes that they control their health depends on either an internal or external belief (loci) (22). If the individual has an internal locus then they are more likely to engage with the concept of having a disease and try to overcome it or cope to the best of their ability. However, an external locus is when the patient believes that their health is very much to do with luck, and if they overcome or can cope with their illness is a matter of chance beyond their control.
Both my patients have an internal locus of control as they do, to certain extents, understand what is happening to their bodies, and most of the time feel that they are able to cope to a certain degree, due to their understanding and explanations from certain health professionals and health promotion. Mr H expressed that even though he did not know the cause of his anaemia, he has been told about the associated symptoms that he may develop and as a consequence what will happen to him; so to a certain degree feels he is in control?. Moreover, with Mrs W, although she explained that she did not fully understand what diabetes is, she still felt that her health was not due to chance and she wants to try and have a healthy diet and exercise to try and feel more in control. And perhaps, with further understanding of her disease she may realise the real need to do so. These factors of health promotion, education and understanding therefore can influence whether a patient may become stressed and feel an inability to cope, thus demonstrating their importance in coping and managing disease.
Overall, if there is an imbalance with the ability to cope with a disease leading to stress, and an external belief of control over ones health, this can lead to detrimental effects of the patients wellbeing both physically and mentally. Again, this emphasises the importance of the doctors need to be aware of these psychological aspects of health, so that they can be addressed appropriately when dealing with patient illness.
?A mental state characterized by a pessimistic sense of inadequacy and a despondent lack of activity (23)
Even though neither of my patients are clinically depressed, both of them expressed feelings of depression and seem quite troubled by it. However, they seem to view depression as a normal consequence of illness and not as separate condition that can be treated; which is perhaps why neither of them have brought it up in consultation with their doctor. Not only does this demonstrate the need for a doctor to ask about depression or any other mood disorder, but also highlights the concept of lay beliefs.
Davidson et al (1991) suggested that people may use a combination of personal, familial and social sources of knowledge to form beliefs about their illness or disease. Lay beliefs also relate to the lay referral system which is the chain of advice seeking contacts which the sick make with other lay people prior to, or instead of, seeking help from health care professionals (24).
Mr H spoke of his depression as an embarrassment?; he explained that he felt ashamed that he sometimes let an illness affect him psychologically and often felt unable to deal with it appropriately. Even though he lives at home with his wife and son, he feels that he doesnt want to burden them further as they already have to deal with the stress of looking after him. Mr H spoke fondly of his wife but was very concerned that their relationship had been hindered by his disabling condition and he explained how he was frustrated that he couldnt love her properly.
A study comparing those with anaemia and those without suggests that those with the disease have more cognitive impairment and depressive symptoms. It also goes on to suggest that Anaemia in elderly people appears to be associated with an increased risk of death, independent of comorbidity (25). This implies that with anaemia a patient is more likely to suffer from depression and is at a higher risk of death; it is important for a doctor to be aware of these studies and be able to provide the patient with correct and accurate information about their condition.
Mrs W also explained that she experienced depressive moods and said that they had become more frequent than usual. Similar results from studies show that patients with diabetes also have a higher incidence of depression.
Results from a study confirm that neuropathy and weakness are risk factors for depressive symptoms because it generates unsteadiness and fatigue. Fatigue (lack of energy) is the symptom with the strongest association with depression, and is linked to depressive symptoms by perceptions of diminished self-worth as a result of inability to perform social and physical roles (26).
However, a contradicting study suggests that there is no correlation between depression and type 2 diabetes. The study found no association between anxiety or depression and the metabolic syndrome (insulin resistance). (27). These contradictory findings convey the need for a doctor to be aware of both strong and weak correlations and up to date with current research. It shows that it is necessary for a doctor to see their patient as an individual; not as part of a sample study, because different findings from studies apply to different confounding factors and situations and therefore cannot easily be generalised to the rest of the population.
However, in contrast to Mr H, Mrs W said that her feelings of depression were due to her feeling lonely rather than due to the actual illness itself. She explained that both her son and daughter seemed to have drifted away since she was diagnosed with diabetes as she is no longer capable of babysitting her grandchildren. She said living alone is even worse when you havent got the energy to look after yourself?.
From speaking to both my patients about their depression it made me feel quite upset that I was unable to help them in anyway. However, I was able to empathise with them and they both said how helpful it was to talk to someone about how they feel for a change, rather than just being treated for their disease. This demonstrates and highlights the need for a doctor to take on a holistic approach to patient care and recognize that a patient is often more troubled psychologically than physically when it comes to their illness. Furthermore, from this I have also realised that it is important not to get emotionally attached to patients and there is the need to maintain a professional barrier, as becoming too attached in the future is likely to cloud judgment.
Transtheoretical Model of Change (Prochaska and DiClemente, 1977):-
This model suggests that change is a "process involving progress through a series of six stages?:
- Precontemplation - "people are not intending to take action in the foreseeable future, usually measured as the next 6 months"
- Contemplation - "people are intending to change in the next 6 months"
- Preparation - "people are intending to take action in the immediate future, usually measured as the next month"
- Action - "people have made specific overt modifications in their life styles within the past 6 months"
- Maintenance - "people are working to prevent relapse," a stage which is estimated to last "from 6 months to about 5 years"
- Termination - "individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping" / Relapse is also considered to be a stage where the individual returns from maintenance or action to an earlier stage. (28)
This model relates to the likelihood of an individuals behavior change, such as giving up smoking. Both of my patients are smokers but have different attitudes towards smoking. For example, when Mrs W was diagnosed with diabetes and advised to give up smoking, she did so immediately and her biggest concern is her disease progressing beyond her control. On the other hand, Mr H described smoking as a comfort and de-stressor and therefore, when advised to try and quit, it took him a long time to come to terms with why and how. Even now he says he is in the action stage but often feels that he is likely to relapse. This model is an explanation to why individuals may relapse and is reassuring for patients in the sense that it is not the be all and end all. Furthermore, the model is helpful for doctors to reassure and advise patients on giving up smoking and enables them to explain the process and stages they may go through.
From exploring and discussing psychosocial aspects, it is clear to see how important it is to recognise how patients are affected by an illness physically, socially and psychologically. I feel quite strongly about this, as both of my patients seem to dwell on the fact that they have feelings of depression and anxiety and dont know how to deal with it. In my future career I will aim to speak to patients about the factors included in the bio-psychosocial model and about their ideas, concerns and expectations of their illness to ensure that I can advise, manage and treat them appropriately.
5. Roles of health and social care professionals
Both patients were happy with their health care in general and explained that without the professionals involved they would not be able to cope with their disease. Mr H especially emphasised how grateful he was that his consultant respected his decision not to undergo further investigations and explained that apart from the one incident with a previous doctor he has always been impressed with the health care provided by the NHS. This demonstrates the importance of putting a patient central to their care; it is essential that a patients wishes are respected and that their management of disease is set accordingly.
Mrs W was also pleased with the healthcare provided but had a desire for more knowledge as to what her medication was for, the disease process and future prospects as she sometimes felt in the dark about it all. From speaking to my patients about their healthcare I noticed how important they perceive effective communication to be and how highly they value a good doctor patient relationship.
Also, from discussing my patients healthcare and the professionals involved in their wellbeing, it is key to note the need for a doctor to recognise and work with other health and social care professionals and the vital need for a coherent multidisciplinary team.
Some professionals involved in Mrs Ws health:-
Diabetic Nurse - advises patients on issues of diet, exercise, lifestyle, blood glucose monitoring, insulin regimes, eye care and foot care (29). Mrs W expressed that her diabetic nurse was extremely helpful in explaining the need for her management of her diabetes and was very reassuring about any worries that she had.
Dietician develop modified diets, participate in research, and educate individuals and groups on good nutritional habits. They fulfil both a therapeutic and preventative role. Mrs Ws dietician advised her on what to eat and asked her to keep a food chart to record her day-to-day intake; she found this quite difficult as she was used to her old eating habits and she felt that she needed more motivation and reassurance that changing her diet would make a difference.
General Practitioner - provides primary care and specializes in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. Mrs W expressed her appreciation for the care and advice her GP had given her over the years, but explained that she felt let down by the fact he didnt educate her enough about diabetes, the disease process and the consequences that may occur due to the disease.
Professionals involved in Mr Hs care:-
Haematology Nurse - provide support and information for patients and families with a haematology condition from investigation through to diagnosis, treatment and long term support (30). The nurses work as part of a multidisciplinary team with colleagues in clinical haematology and others in the hospital and community. Mr H requires a blood transfusion for his severe anaemia, therefore is admitted to hospital once a week; he expressed his immense satisfaction with the nurses on the haematology ward; they check his Hb levels, give him a blood transfusion and generally look after him for the day, he said he couldnt ask for better care?.
General Nurse - responsible for the treatment, safety, and recovery of acutely or chronically ill or injured people; health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings. The general nurses on the hospital ward would also give Mr H his blood transfusions and would also look over and check the rest of his health and medications.
Social Worker - assess a service user's situation; agreeing with the service user what he or she needs; organising the support needed; developing a relationship with the service user and his or her family and often continuing to offer support, information and advice (31). Social workers were involved in assessing Mr Hs disability needs and arranging with the council the need for appropriate facilities to be fixed for him at home.
Multidisciplinary Team This involves a group of health care and social care professionals who provide different services for patients in a co-ordinated way. Members of the team may vary and will depend on the patient's needs and the condition or disease being treated (31). From speaking to Mr Hs consultant he emphasised the importance of an MDT, especially in a hospital environment because so many things could go wrong. And it is vital that all the staff work together and coherently to provide the best health care for the patient.
Both of my patients felt pleased with the health professionals involved in their care as they did not aim to just treat their diseases but were also health promoters. Health promotion is the process of enabling people to exert control over the determinants of health and thereby improve their health (32). However, not all patients perceive health promotion as beneficial; this is due to their health beliefs.
Health Belief Model (Becker, 1974):-
This model demonstrates the factors that affect health actions in the population and indicate why health promotion is often not effective. For example, if a patient believes that they are not susceptible to a disease and see the barriers to change as too great then they are unlikely to take action. Mrs W appreciated how severe her Diabetes could become and thus she aimed to change her diet, exercise more and stop smoking which demonstrates how health beliefs can lead to health promoting behavior. In contrast, Mr H understood the severity of his disease and the associated symptoms, but felt that due to his condition being chronic that the perceived barrier was too high to always lead to health promoting behaviour. This is an example of how the health belief model can sometimes deter health promoting behaviour.
One of the important roles of a doctor is to identify a patients ideas, concerns and expectations (ICE). Identification of patients ICE has been shown to improve compliance of treatment, adherence to medical advice and increase patient satisfaction (34). However, even though my patients expressed their gratitude towards their healthcare, when asked about their ICE and how it had been addressed they both felt the concept had not been addressed in much depth.
My patients ideas, concerns and expectations are as follows:-
- Initially had no clue as to why she was feeling tired all the time
- Thought it may just be because she is getting old
- Very worried as to how the disease may progress, she wants to be able to look after herself
- Expects to try and control her diabetes with appropriate medication
- Thought initial bleed may have been due to stress
- Has no clue what it could be, and does not wish to find out
- Nonchalant attitude towards condition itself, but concerned with the associated/worsening symptoms
- Shows concern for his wife and the stress he is causing her
* Has no expectations and expresses that he is ready to die
From discussing my patients ICE I have learnt how important it is in relation to healthcare. Before putting it into practice with my patients, I always thought it seemed pointless and unnecessary, but I have now realised that it is very important to the patient and enables a health professional to not only have a full insight into a patients view on their illness, but also to appropriately identify what areas to focus on in the management of their patient.
Along with health promotion/beliefs and a patients ICE, health policies are also an important part of health care today.
National Service Frameworks (NSFs) set national healthcare standards and policies. They are designed to improve the quality of health services, ensure that everyone gets the same level of care and also provide an excellent framework for clinicians to manage their patients appropriately.
The two main roles of NSFs are:
- setting clear quality requirements for care based on the best available evidence, and
- offering strategies and support to help health organisations achieve these standards. (35)
Some policies that apply to my patients include:-
The New NHS-Modern, Dependable aims to provide comprehensive and high quality care regardless of where they live.
Choosing Health making healthier choices easier promotes need for information and practical support to get people motivated and provides access to services to make healthy lifestyle choices
Improving the life chances of disabled people - to improve quality of life by focusing on giving disabled people independence, vocational opportunities and supporting their family.
The Diagnostic Process
Before 1979 diagnosing diabetes was quite complex, with their being at least six different criteria used for the diagnostic process; thus this would lead to the confusion of patients having diabetes according to one set of criteria and not having the disease when looking at a different set of criteria. However, after many large studies the gold standard diagnosis is as follows (36) :
- A random venous plasma glucose concentration > 11.1mmol.l-1
- A fasting plasma glucose concentration > 7.0mmol.l-1
- Plasma glucose concentration > 11.1mmol.l-1 two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)
A patient with symptoms of diabetes can be given a finger prick blood glucose test, but it is not accurate to use for diagnosis alone, and is more useful for screening purposes. Often patients who are symptomatic can be diagnosed with a confirmatory random plasma glucose level of > 11.1mmol.l-1
In asymptomatic patients whose random serum glucose level suggests diabetes, a fasting plasma glucose concentration should be measured. The oral glucose tolerance test is no longer recommended for the routine diagnosis of diabetes. With regards to Mrs W, when she presented to the medical services via her GP with her presenting complaint of a lack of energy, she was sent for a random venous plasma glucose test and later had a fasting glucose test, both which indicated a positive result for diabetes.
The diagnosis of diabetes has both medical and legal implications for the patient and it is therefore essential that a correct and accurate diagnosis is made; it is also imperative that the plasma glucose measurement is undertaken by an appropriate laboratory to ensure the correct results.
It is quite difficult to discuss the diagnostic process with respect to Mr H, as his anaemia is due to unknown GI blood loss. However, when normally examining a patient for anaemia it can be noted by both physical and biological tests. Anaemia can be suspected with a patient who has conjunctival pallor?, this is a classic sign of anaemia and refers to the vasculature on the inner surface of the eyelid; therefore, if it is pale can indicate anaemia. A classic sign of any patient with anaemia can also often be seen by their appearance; Mr H was extremely pale and did tend to joke about him looking like a ghost?. However, he did mention that due to his anaemia he experienced extremely cold hands and feet which often became numb which seemed to trouble him a lot.
I found it quite difficult to understand Mr Hs thoughts about his condition as he often complained about the symptoms that the disease results in, yet had refused investigation and possible treatment for his anaemia. However, his experience of inappropriate behavior from a doctor really made me realise the importance of a good doctor-patient relationship.
A diagnostic test for anaemia is to examine a blood smear for red blood cell morphology. For example, different shapes of the red blood cells can indicate different types of anaemia. If the anaemia is microcytic, then the doctor would consider iron deficiency, chronic blood loss, pernicious anaemia or folate deficiency (37) .
The flow diagram below demonstrates how anaemia can be investigated using the reticulocyte production index, this value can be misleading in patients with anaemia. The reticulocyte count is often referred to as a percentage of the number of red blood cells, and in patients with anaemia red blood cells are depleted, which would therefore suggest an inaccurate increased reticulocyte count (31).
Further diagnostic tests could be carried out, such as, stool for occult blood, liver function tests, and platelet counts. For a definitive diagnosis a hematologist may perform a bone marrow examination.
7. Management of Disease
The primary aim of management is to allow the patient to maintain a good Quality of life; achieving this necessitates the use of a holistic approach, placing an emphasis on each prong of the Bio-psycho-social triad. Physicians have often used health-related quality of life (HRQOL) to measure the effects of chronic illness in their patients to better understand how an illness interferes with a person's day-to-day life (38).
Management of Diabetes:-
Dietary Management it is important to modify diet to limit and control glucose in the blood. It is also important to control diet in relation to weight loss, as this is recommended for those suffering from type 2 diabetes. Mrs W modified her diet and aimed to eat less sugary foods, more fruits, vegetables, and more whole grain foods. She was also advised to keep a daily food diary to help her and her Doctor check and record what she was eating, and where she might need to change her habits.
Exercise exercise reduces the body's need for insulin by keeping weight down. It also increases the body's sensitivity to insulin, so glucose is used more effectively. As long as there is enough insulin in the body, muscles burn glucose during exercise which naturally reduces blood sugar level. Regular exercise is said to reduce insulin resistance which is the root cause of type 2 diabetes. Mrs W aimed to walk to the grocery store and local shops instead of getting the bus, but she did say at times she often felt too tired and weak to walk; so found it quite difficult to do exercise at times.
When talking to Mrs W about managing her diabetes she explained that she found controlling her diet and especially exercise very difficult, but she said it was due to the fact she didnt understand how it would benefit her or prevent further progress of the disease; this insufficient understanding would lead to her having a sub-optimal satisfaction with her care and lead to an increase in non-compliance as illustrated in Leys cognitive model of compliance:
Leys Cognitive Model of Compliance (1988):-
This model demonstrates why patients may not comply with treatment or advice given and consequently fail at managing their condition (31).
Diabetes and Metformin:-
Due to Mrs Ws progression of her condition, her insulin resistance and deficiency became too great so she was started on the first line anti-diabetic drug, metformin. Mrs W said that even though being put on metformin means that her disease is getting worse, she felt happier that she was taking tablets for her disease as it made her feel like she was actually treating the disease by physically taking medication.
Metformin helps diabetics to respond normally to insulin. It helps to lower blood sugar levels to normal and maintain them at this level. To prevent the diabetes progressing further (to insulin dependence) it is advised that patients continue to maintain a healthy diet and participate in regular exercise.
Metformin acts on the hyperglycaemia of the patient by suppressing hepatic glucose production. This is successful in combating type 2 diabetes as individuals with the disease have approximately three times the normal rate of gluconeogenesis; and metformin reduces this by over one third (39).
Management of Anaemia:-
Mr H requires a blood transfusion of 1-2 units of blood per week; this is the only management for his severe anaemia and he refuses investigation to find out the cause. There are many different treatments for anaemia depending on the cause and the severity and blood transfusions are usually only given in emergency situations such as in a trauma incident. Treatment for chronic loss of blood anaemia entails restoring blood volume through intravenous (IV) administration of saline, dextran, albumin, or plasma. For large blood losses, transfusion of fresh whole blood is the treatment of choice (as in Mr Hs case) (40). The anemia itself does not require specific therapy unless it is associated with iron, folate, or cobalamin (B12) deficiency.
8. Scope of the problem
Anaemia is the most common disorder of the blood. It has a number of types due to various underlying causes and therefore, the scope of anaemia varies tremendously worldwide.
A rise in the aging population has been predicted, and, as a result, it is expected that the incidence of age-related health conditions will also increase. Although common in the elderly, anemia is often mild and asymptomatic and rarely requires hospitalization. However, untreated anemia can be detrimental, because it is associated with increased mortality, poor health, fatigue, and functional dependence and can lead to cardiovascular and neurological complications. Several factors have been suggested to cause anemia in this population, for example, blood loss or chronic disease and in some cases, like Mr H, the cause is unknown. It has been suggested that this is a result of the presence of comorbid conditions that can mask the symptoms of anemia. Therefore, appropriate diagnosis and management strategies of anemia in the elderly need to be identified, particularly because anemia may indicate the presence of other serious diseases (41).
A further study suggests the incidence of anemia among older people is 4 to 6 times greater than that suspected clinically, rises with age, and is higher in men than in women. The apparent cause in half the cases is blood loss. Even mild anemia is associated with reduced survival, especially during the first year, but again this could relate to underlying comorbid conditions (42).
Type 2 Diabetes:-
Type 2 diabetes is said to be common amongst populations with an affluent and rich lifestyle. However, large differences in prevalence exist, which is said to be due to differences in genetic susceptibility between ethnic groups. For example, type 2 diabetes is said to be three to four times more prevalent in people of African and Caribbean ancestry and four to seven times more likely in people of Hispanic American origin and in those from South Asia and Arabia living in Western lifestyles compared to white Europeans. From the WHO criteria it has been estimated that there is an overall prevalence of 2% of type 2 diabetes in the United Kingdom (36).
Preventing Type 2 diabetes is an active area of research, particularly because of the increasing number of people who are developing the disease. Recent studies have found evidence that two drugs used to lower cholesterol levels statins and ACE inhibitors may have the added benefit of lowering a person's risk of developing diabetes. However, these trials both need to be repeated in a larger group of people for better results and there is also no suggestion of the drug aiding those already with the disease. Another study is looking at whether a drug used to treat Type 2 diabetes (metformin) might also be able to prevent the disease. This drug is being tested in people who have already begun to show signs of insulin resistance, but have not yet developed diabetes. But, it will be several years before results from this trial are available (43).
Further research has looked at pancreatic stem cells and the possibility of them producing insulin secreting cells. This concept has been tested on mice and results suggested that those mice that had pancreatic stem cells transpla
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