Medical Case Study

This is a reflective practice, medical case study essay using Gibbs framework. This reflective essay is based on the situation that happened whilst working in the Medical Assessment Unit (MAU) at Selly Oak Hospital, Birmingham when I was asked to attend a patient brought in complaining of severe exacerbation of psoriasis. In order to help me with my reflection I have chosen to use Gibbs model (Gibbs, 1988) in my reflective process. Gibbs model of reflection includes Description, what happened?, Feelings, what were your feelings and thoughts at that time, Evaluation, what was good or bad about the experienced?, Analysis, what can you learn from the event? and  Conclusion, as to what could you have done differently or in addition? (Gibbs,1988) . The model will be applied to the essay to facilitate critical thought, relating theory to practice where the model allows.

The areas of reflection on this essay mainly is about the causes of psoriasis, whether lifestyle, smoking or excessive alcohol intake can exacerbate psoriasis and the difference between attending this patient in the home and in the hospital.

The first stage of Gibbs (1988) model of reflection requires description of the events. The incident happened whilst working on placement in the Medical Assessment  Unit (MAU) at Selly Oak Hospital, Birmingham. I was asked to attend a 48 year-old male patient who had been transferred to MAU via the Accident and Emergency Department (A&E). The patient had been brought to the A&E  by way of  a 999 emergency call via ambulance service complaining of severe exacerbation of  psoriasis. On this occasion, I had to do a history taking and general examination on a patient I didn’t know very well.

The second stage of Gibbs (1988) model of reflection is a discussion of my thoughts and feelings. At that moment, my first worry is that before undertaking the training in patient assessment I would not have either the skills or the inclination to properly assess and examine the patient. Secondly, If  I were first to have seen the patient in his own home it would be all to easy to dismiss this particular patient along the lines of “ alcoholic with self-neglect”  but to label him as such would have been an injustice without  taking a thorough history of the patient first. Thirdly, I asked myself, what cause his psoriasis to be at that state? Whether if lifestyle, smoking and excessive alcohol intake exacerbated his condition? And lastly, would there be a difference between attending the patient in the home and in the hospital given his condition?

The third stage of Gibbs (1988) model of reflection is Evaluation wherein the reflector is required to state what was good and bad about the event. As I started to interview and examine the patient, I felt increasingly at ease and somehow felt empathy towards the patient. He was cooperative. It also allowed me both the time and opportunity to build rapport with the patient and discover for myself just how severe his condition was. It would appear that various factors which had affected this patient’s life in the past six months, i.e. stress, increased alcoholic intake and heavy smoking had all contributed to the worsening of his chronic condition. He had even reached the stage of not taking the medications prescribed to alleviate his depression preferring instead to resort to alcohol.

The patient had suffered with mild bouts of localized plaque psoriasis since his late teens and is usually treated with Betnovate creams which he applied to affected area and normally affording relief.

On further questioning the patient, he told me that he had been drinking heavily and neglected himself for the past six months following a very stressful incident which had resulted in him losing contact with his family and having nowhere to live.

The fourth stage of Gibbs (1988) is an analysis of the event where the reflector is encourage to make sense of the situation. On this incident I have learn that I need to be more confident when conducting an interview and general examination to the patient. Believing on my capability to do such task may promote a good conversing environment thereby easily establishing rapport to the patient and getting the necessary information needed to assess the patient thoroughly.

I also learn through this situation that is indeed fair not to judge a patient prematurely (as to a “ alcoholic with self-neglect” in this case) as I found out in the patient’s history and later discover for myself how severe his condition was.

With regards to the medical case, I have learn and became more familiar about the psoriasis condition. Psoriasis  is one of the most common dermatologic diseases affecting up to 1-2 percent of the world population (Swerlick and Lawley, 1998). This chronic inflammatory skin condition is clinically characterized by erythematous, sharply demarcated papules and rounded plaques covered by silvery scales. The lesions are variably pruritic. Additionally , other external factors like infections, stress and medications( lithium, beta-blockers and anti-malarials) may exacerbate psoriasis (Swerlick and Lawley, 1998).

The etiology of psoriasis is still poorly understood, but there is clearly a genetic component. Studies report that over 50 percent of patient with psoriasis report a positive family history and a report on twin studies revealed a 65-72 percent concordance among monozygotic twins. There is also accumulated evidence that T-cells have a role in the pathophysiology of psoriasis, meaning it is immune-mediated (Swerlick and Lawley, 1998).

Researchers are studying how lifestyles affect psoriasis so as to provide patients with effective care and treatment. Recent findings shows that  people with psoriasis are more likely than the general population to be overweight, to smoke, and to lead a sedentary lifestyle. People with psoriasis also tend to drink more alcohol (Raychaudhuri, 2000).

A recent study revealed that developing psoriasis was significantly higher among current and former smokers. Another study, found out that 78 percent of patients who smoke said they began smoking before onset of their psoriasis  The patient in this medical case was known to have smoked for the past 35 years and began to develop psoriasis on his late teens which only further support  the said study.

In a study among  818 adults with psoriasis, it was found out that patients who smoke more than a pack of cigarettes per day were 50 percent more likely to have severe psoriasis than patients who smoked 10 cigarettes or fewer per day (Fortes,2005)

There is also evidence that smoking has  shown to reduce improvement rates among patients with psoriasis, both men and women as researchers who reviewed studies at the relationship between smoking and psoriasis found out  (Behnam,2005).

As to whether alcoholic drinking increases the severity of psoriasis, an analysis of several studies that looked at the relationship between drinking and plaque psoriasis found that drinking may indeed increase severity in both men and women (Behnam,2005). This finding confirms an earlier study conducted in Finland that found once a person develops psoriasis, the amount of skin affected increases as alcohol consumption rises (Eriksson,1998).

The findings from these studies suggest that lifestyle  really has a great impact on patients suffering on psoriasis and indeed excessive alcohol intake and smoking really can exacerbate the said skin disease.

The patient on this case was brought due to pain (on his feet) and limited mobility. This probably is a manifestation of psoriatic arthritis. This condition is a chronic inflammatory arthritis that affects 5-42 percent of people with psoriasis (Shur,1998).

As to the issue on the difference between attending the patient in the home and in the hospital, I believe that the patient in this case really needs inpatient hospitalization for his case is a severe exacerbation of psoriasis. It is a fact that majority of patients can be treated in an outpatient basis but still there continues to be a small number of patients who experience severe, acute exacerbations needing intensive inpatient care. Such hospitalizations result in significant improvement in patient’s quality of life and patient’s morbidity and mortality (Nelson et al, 2005). Given the condition of  our patient, treating him in the home will not suffice and management options will be limited. Also, knowing the patient, his compliance to management will probably poor especially  that no one will be there with him at home to make sure he will follow whatever recommended management will be instructed on him. At least on the hospital, there will always be a hospital staff available to look after him and make sure that he received the necessary treatment he needs.

In conclusion, stage five of Gibbs( 1988) model, this incident made me aware how important to be more prepared and confident to conduct a history taking and general examination on the patient. Next time, I need to read more about certain medical cases in advance while in placement in the Medical Assessment unit so as I will know more or less how to handle or approach whatever case will be assign to me.

Also through this experienced, I became more familiar with the disease known as psoriasis and in this particular case made me aware and witness first hand that indeed lifestyle, smoking and excessive alcohol intake exacerbate psoriasis as also supported by the patient’s medical history and other related literature.

Furthermore, I do believe that the patient needs medical treatment and if I had  attended this patient firsthand on his home, I would have no hesitation referring him to the Medical Assessment unit for inpatient treatment. However, I do no feel that attendance at the Accident and Emergency Department would be warranted.

Overall, through the production of this essay my reflection skills have been developed. Using this model of reflection helped me to structure my thoughts and feelings. Through the use of  critical reflection, my level of awareness concerning evidence-based practice has been enhanced. My competence in dealing and approaching patients has been further developed and my knowledge regarding this medical case (psoriasis) has been broadened.

References:

Benham SM et al. “Alcohol as a Risk Factor for Plaque-Type Psoriasis.” Cutis. 2005 September;76(3)181-5.

Behnam SM et al. “Smoking and psoriasis.” SKINmed. 2005 May-June;4(3):174-6.

Eriksson MO et al. “Palmoplantar pustulosis: A clinical and immunohistological study.” British Journal of Dermatology. 1998. March;138(3):390-8.

Fortes C et al. “Relationship between Smoking and the Clinical Severity of Psoriasis.” Archives of Dermatology. 2005. December;141(12):1580-84.

Naldi L et al. “Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study.” Journal of Investigative Dermatology. 2005. July;125(1):61-7.

Nelson A et al “ Inpatient management of severe psoriasis.” Journal of Drugs in Dermatology. 2005 Sept-Oct.

Raychaudhuri SP et al. “Psoriasis Risk Factors: Role of Lifestyle Practices.” Cutis. 2000. November;66(5)348-52.
Swerlick R and Lawley, T “Eczema, Psoriasis, Cutaneous  infections, Acne and other common skin disorders.” Harrison’s Principle of internal Medicine 14^th ed. 1998 Vol. 1, 300-301

Schur P “ Psoriatic Arthritis and Arthritis associated with  Gastrointestinal disease.” Harrison’s Principle of internal Medicine 14^th ed. 1998 Vol. 2, 1949

Reflection Cycle… Retrieved August 6, 2006 from www.trainer.org.uk/members/theory/process/reflective_cycle.htm