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Report: Patient Case Study

Name: Muhammad Aiman Bin Zainal Matric. No.: 0808-0866 Year: Year 3, MBBS 2008 Posting: Public Health & Community Medicine Dates of visit: 16.3.2011, 24.3.2011, 31.3.2011

Table of contents

No 1. 2. 3. 4. Patient details


Page No 1 2 24 5

Introduction: Case Summary Clinical History Evaluation of physical & psychosocial environment Belief and understanding of illness Impact of illness and family Evaluation on patients need Evaluation on communication Evaluation on patient need for community care and support

5. 6. 7. 8. 9.

6 67 7 8 8 89 10 11 12 12

10. Wellness diagnosis 11. Wellness intervention 12. Discussion 13. References

1. Patient Details Patients name: Pn. Siti Khadijah Abdul Malik Age: 58 Date of Birth: 19th December 1953 Occupation: Factory canteen food provider Address: Jln. Pinang Muda, Kg.Bukit Bangkong. Race: Malay Religion: Islam Marital status: Married Family members: 3 sons and 3 daughters (from age: 41 years old to 15 years old) Height: 154 cm Weight: 80kg

Diagram 1: Me and my patient.

2. Introduction / Case Summary Pn. Siti Khadijah a 58 years old women was diagnosed with hypertension since 5 years ago. However, she does not develop any complication of hypertension.

3. Clinical history

Chief complaint: Pn Siti Khadijah has hypertension.

History of presenting illnesses: She was apparently well until 5 years ago where she had a headache and a syncopal attack. The headache was sudden onset and was felt at the occipital area. It was triggered by stressful activity throughout her daughters wedding ceremony. By the end of the tiring day, she had a severe headache and fainted. She was brought to clinic Banting by her family members and noted her blood pressure was very high which is 200/110 mmHg. She was referred to Banting hospital after that and was admitted for 3 days. After her condition was stabilized, the doctor also set an appointment for follow-up in a week time. After a week, the headache has disappeared. However, Pn.Siti blood pressure was still at an alarming level. So, she registered herself at health clinic and began her monthly follow up. She was given anti-hypertensive medication and was advised by the doctor to control her salt intake as well as maintain a regular exercise.

Past medical history: Pn. Siti has never been hospitalized. She has no other past chronic illness and no past surgical history.

Family history: Her father and mother have no history of hypertension. There are no other chronic illnesses.

Social history: Pn. Siti works as a factory canteen food provider at a factory near her house. Due to the low income, she did multiple jobs like body massage and selling cakes which is upon demand. So, her monthly income now is about RM 1000 to RM 1500. Since she is very busy with her job and role as a mother to take care of her children, she has no time to exercise. Currently, she lives in her own house with her son and two daughters. She is not a smoker or an alcoholic drinker. She is a regular motorcycle rider.

Drug history: She took medication prescribed by the doctor and traditional medication like Misai kucing. She does not have any allergies to the medication given.

Physical examination: Weight: 80 kg Height 154 cm BMI: 33.7 (obese) Pulse rate: 75 beats per min No signs of pallor or jaundice No tachypnea or dyspnea No signs of dehydration No ulcers on extremities

Provisional and differential diagnosis: Primary hypertension

Investigations: (January to February 2011) Blood pressure: 150/85 mmHg Blood test: Test Haemoglobin Hematocrit MCV MCH MCHC Platelet WBC Renal profile: Test BUN Sodium Pottasium Chloride Creatinine Uric acid Lipid profile: Test Cholesterol Triglyceride HDL Cholesterol LDL Cholesterol Final diagnosis: Uncontrolled primary hypertension Management: Perindopril : 4mg ( once a day) Acetylsalicylic acid: 300mg ( once a day) Lovastatin: 20mg ( once a day) Metoprolol tartrate 100mg ( twice daily ) Amlodipine: 5mg ( twice daily ) Result 4.0 0.7 1.3 3.1 Unit mmol/L mmol/L mmol/L mmol/L Ref Range 0.0---6.0 0.34---2.0 Result 4.8 140 3.8 109 54 352 Unit Mmol/L Mmol/L Mmol/L Mmol/L Mmol/L umol/L Ref Range 2.5---6.4 135---145 3.5---5.0 98---106 53---115 155---428 Result 14.4 42.0 85.7 29.4 34.3 295 6.9 Unit g/dL % fL pg g/dL
*109 *103

Ref Range 13.0-18.0 40-50 83-100 27-32 33-37 150-450 4-11.0

Doctor advice: Control salt intake and exercise regularly.


4. Evaluation on physical, psychological environment, behavior and lifestyle Pn. Siti Khadijah lives in her own house which is a single-storey terrace house in Kg.Bukit Bangkong. The outside environment of the house was clean and spacious which suitable for gardening and landscaping. The inside of the house was neat, tidy and complete with necessities like furniture, carpet, television and many more. Overall, it is a peaceful neighborhood and most of her neighbor is her family relatives.

Pn. Siti Khadijah has six children. She is a single mother who lives with two daughters and one son at home. Her son that is at home is 30 years old and he has Down syndrome. Moreover, her daughter who also lives with her is 28 years old and she has mental retardation. Her youngest daughter is a form three student and Pn. Siti has to fetch her from school every evening. Her eldest and second sons are both working and they are at good health. Every weekend, her children will come and visit her.

According to Pn. Siti Khadijah, since she got hypertension, she has to make some adjustment at home. She has changed her lifestyle especially in her diets as she claims that she has reduced the usage of salt in her meal. However, she still did not exercise even though the doctor had advised her.

For her diet pattern, she usually consumes a bowl of oatmeal for breakfast. Sometimes she will skip her breakfast. As for lunch, she eats one and a half bowl of rice and fried vegetable. She also did take chicken and fish but only once every two days. The fish and chicken are mostly fried. As for dinner, she will eat one bowl of rice with vegetable, fried eggs and salty fish sometimes. She drinks approximately eight glasses of water every day.

From her last follow up, her blood pressure was 150/80 mmHg which is high. At home, her child who is Down syndrome really irritated her sometimes and he love to test Pn. Sitis patient. This has eventually creates a stressful environment at home as she has to get angry and scold her children.

5. Belief and understanding of illness Belief: Pn. Siti Khadijah belief that her illness come from Allah and it is not a supernatural causes. She also belief in the usage of traditional medication like misai kucing. According to her, the traditional medication will improve her blood circulation, lower her blood pressure in the fastest way and give her an extra energy for working.

Understanding: Pn. Siti Khadijah knows that hypertension can be caused by stress and high salt intake. She also knows that getting angry can trigger the increase of her blood pressure. For example, she will easily get angry if her children did not listen to her at home. Beside headache, she does not aware of other complication from her illnesses. Furthermore, she knows that for hypertension management, she has to control her diet, follow regular follow up and prescribe the medication given by the doctor. Even though she is very observant with her follow up, but she did not comply well with her medication as she took her medication only when there is symptoms. She never visits other traditional medicine practitioner like bomoh beside her doctor.

6. Impact of illness on patient and family

Pn. Siti Khadijah illness does give an impact in her life especially in term of financial. There is no physical impact as she does not develop any complications from her illness. Since she has hypertension, she keeps on feeling headache and dizziness sometimes. With the illness that she has, she never felt depress and her illness does not affect her relationship with her neighbors. However, she does felt that taking medication every day is a burden to her as there are many types of medication to take. Besides that, the challenges to take her medication rises when there is no one around her that can truly remind of her medication every day. She also felt that it is harder to control her illnesses with her special children at home. Her illness does affect her monthly income. That is why she did multiple jobs to compensate the loss as well as to support her children at home.

Her illness does not give much impact to her family in term of physical. She claims that out of three working children, only her second son supported her financial. Overall, she was taken good care by her family and her children did visit because they are worried of her illness. 7. Evaluation on patients need

In term of physical need, she felt that it is easier for her if she have a maid at home to take care of her children while she is working. If she has a maid, the maid can always remind of her medication as well as doing daily chores to lessen Pn.Siti Khadijah burden. If possible, she thinks of having a personal blood pressure machine at home and the knowledge to use it so that she is aware of her current blood pressure all the time. As for her, she felt that house modification and furniture arrangement is unnecessary because her house is complete will all necessities.

In term of emotional needs, she felt that it is best if her children can come back more frequent and have a family gathering together. Even though she does not feel depress or lonely, but sometimes she want some entertainment once in a while or somebody to talk to about her problem to relief her stress. So, she requires counseling and she also need the motivation to exercise.

Basically, she got all her social need because since she is working with multiple jobs, she does interact with people around her. She never had any problem with her neighbor and she socializes well.

8. Evaluation on communication

Throughout her follow up, she does not have any communication problem with health personnel. She was able to understand their explanations regarding her illness. After hearing a clear explanation, she was able to fully accept her condition and understand the importance of the treatment and follow up meeting. So, there is no problem in communication between medical/health personnel.

She communicates well with her family and there are no miscommunications. All her family member understood the explanation given by the medical personnel. Since she is working in the factory, she builds up a good relationship with her employers and there is no misunderstanding.

9. Evaluation on patient need for community care and support

Pn. Siti Khadijah always seeks for the primary health care support at the local health clinic. She also requires home visit so that it is easier to check her condition instead of travelling long way with motorcycle. In term of financial need, she requires a consistent financial support like ZAKAT or MUIZ. With a good financial, she can take care of her illness better. It is well recommended if she register with a nongovernment organization (NGO) for hypertension as the organization will provide her with thorough and well-researched information and updates on her disease. 10. Wellness diagnosis Based on my patients, below are the contributing factors to her illness:

10.1 Biological Factor Since she is 58 years old, increasing in age is known risk factor for hypertension. As we grow older, our blood vessels will be narrower and more rigid, due to the atherosclerosis, and this will affect the regulatory process during the systolic and diastolic period which will cause higher resistance to the flow of the blood. Since Pn. Siti is obesity, obesity is also another well-recognized risk factor for both hypertensions.


10.2 Behavioral Factor Pn. Siti is very positive toward her follow up and monthly medical check-up. Unfortunately, she is not living in an active life. Due to multiple jobs and responsibility to take care of her children, she does not exercise.

10.3 Environmental Factor She lives in a peaceful neighborhood with accessible services and support. However, her stressful environment at home with her naughty children may be the contributing factor to her uncontrolled hypertension.

10.4 Nutritional Factor Since Pn. Siti is a food provider, she might as well consume a high cholesterol food. Besides that, she did take salty fish in her meal. Based on her diet, she loves to cook fried meal which is high in oil and fats.

10.5 Occupational Factor Besides becoming a factory food provider, she also did multiple jobs in one day like body massage and selling cakes. Just to support her financial, she push herself to the limit and this will eventually increases the stress on her body. To prepare the food early in the morning, she has lack of efficient time to sleep and she easily use to feel tired and stress throughout the day.


11. Holistic management Intervention







Contributing Factors Biological factor

Intervention Take her meals in smaller portions up to 6 times per day. Exercise regularly at least three times a week so that she can lose weight and have an ideal BMI.

Behavioral Factor

She can do light exercise every evening or do activities that burn calories like gardening at her house yard.

Environmental Factor

She can hire a maid to take care of her children while she is away to work. Counseling to relief stress Instead of fried meal, she can change into boiled or steamed meal to reduce the oil & fats.

Nutritional Factor

Occupational Factor

Financial help may boost her self-esteem to take care of her illness better. With good financial help, she may not have to do multiple jobs and reduce the amount of stress towards her body.


12. Discussion Pn. Siti Khadijah, 58 years old women, has been diagnosed with primary hypertension since 5 years ago. She has risk of hypertension such as age and obesity. Lack of exercise, stress, nutrition and occupation is her contributing factor to her hypertension. She is not well compliance to her anti-hypertensive medication with uncontrolled blood pressure. According to A Mohd Yunus, hypertension was most prevalent in respondents aged 50-59 years (53.3%) and 60 years and above (57.3%). Hypertension, namely systolic hypertension has been shown to increase steeply with age. Based on my patients age, she falls under this category. According to Hejar Abdul Rahman, there were 35 obese female and 17 obese male in health clinic Sepang, sixteen of the obese were in 50-59 years old. This shows that women have high chances to get obese more than men. The author also stated that, availability of high caloric density foods and socially influence personal choice are some of the many environmental forces that contribute to the development of obesity. Based on my patient, high calories intake of food in her diet is what lead to her obesity and obesity is a risk factor for hypertension. According to Zaiton Ahmad, moderate physical activity can reduce substantially the risk of developing or dying from heart disease, diabetes, colon cancer and hypertension. As for my patient, that is why doing light exercise like gardening as part of the wellness intervention is very important for her. This is because physical activity is postulated to protect against coronary disease by reducing blood pressure, raising high density lipoprotein cholesterol and protect against other harmful risk factors. According to Haizal Haron Kamar, exposure to job strain was also associated with an increase left ventricular mass, which would be consistent with the effect of sustained elevation of blood pressure from regularly occurring stress. Based on my patient, since she did multiple job in one day, that itself might has increase the stress and affect her blood pressure.

A studied done by Chua SS in a hypertension clinic have shown that, the most common form of noncompliance was underuse (81%), followed by overuse (17%) and misuse (2%). Additionally, 54% of all noncompliance was reported as being intentional and 46% as being unintentional. Based on my patient, she is also not compliance to her anti-hypertensive medication intentionally and therefore she is underuse of her medication. The study result also showed that, only 16.9% of the respondents had their blood pressure under control although these respondents were on anti-hypertensive agents. As for my patient, she has uncontrolled blood pressure due to not compliance to her anti-hypertensive medications. 13. References

1. Hejar Abdul Rahman, Shaza Wahieda Mohd Shaffie, Junainah Sabirin, Zaiton Ahmad and Long She Chin. The Prevalence of Physical Activity, Smoking and Obesity among the Attendees of Health Clinic in Sepang District. 2003. Malaysian Journal of Public Health Medicine Vol 3(1); 23-28.

2. A Mohd Yunus, MS Sherina, MZ Nor Afiah, L.Rampal & KH Tiew. The Prevalence of Hypertension and Smoking in the Subdistrict of Dengkil, Selangor. 2003. Malaysian Journal of Public Health Medicine Vol 3(2); 5-8.

3. Haizal Haron Kamar, Wan Azman, Tan Kim Heung, Anna Maria Choy. Stress and Hypertension. 2000. JUMMEC Vol 5(1); 3-8

4. Chua SS, YK Lee, CT Chua and Abdullah MS. Compliance To Antihypertensive Therapies Among Outpatient in a Hypertension Clinic. 2002. JUMMEC Vol 7( 2);100-104.