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I will be first (P3) describing the clinical investigations carried out and measurements made, to diagnose and monitor the disorder in each individual. I will then (M2) explain possible difficulties involved in making a diagnosis from the signs and symptoms displayed by the individuals and the results of their investigations.

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(P3) Mr. “X”, Diabetes type two.

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During a visit to his G.P. because of his depression, the doctor quickly ascertained that Mr. “X” may have additional problems, as he had all the classic signs of being diabetic, he arranged for Mr. “X” to have blood tests at his local clinic and gave him a further appointment for the following week to discuss the results and their possible implications.

On his return to the G.P. he was informed that he had type two diabetes, which is the most common type as 90% of all diagnosed diabetics are type two. He was informed that his condition was manageable with the correct medication and that he should look forward to leading a fit and healthy life provided he took more care of himself, as it is very much down to the individual to eat properly, avoiding the food stuffs which would only antagonize his condition and to exercise regularly.

The G.P. gave Mr. “X” a leaflet which contained ten steps to eating well, for patients diagnosed with type two diabetes. They are as followed- 1) Eat at least three meals a day, as in breakfast, lunch and evening meal, and these should be spread out accordingly. This not only helps to control your appetite, but also helps to control your blood glucose levels. 2) Each meal should also include starchy carbohydrates, such as bread, pasta, potatoes, rice and cereals etc. The foods which are more slowly absorbed (having a lower glycaemia index) will have less affect on your blood glucose levels. Also the high fibre varieties of starchy foods will also help to maintain the health of your digestive system and prevent such problems as constipation. 3) Cut down the fats you eat particularly saturated fats. A low fat diet is beneficial to everyone’s health.

Mr “X” was provided with a plan to help him choose unsaturated fats, especially “MONOUNSATURATED” fat (olive oil, rape-seed oil etc) as this is better for your heart, and as fat is one of the main sources of calories, then eating less fat will also help if for example you are overweight. It is necessary therefore to cut down on butter, margarine and cheese etc, eat only lean meat and fish. Use skimmed or semi-skimmed milk, low fat yoghurts, cheese etc. Cut out fried foods, creamy sauces and salad dressings etc. 4) eat more fruit and vegetables. 5) Try to include more beans and lentils. 6) try to eat oily fish (mackerel, sardines, pilchards and salmon) at least twice a week. 7) Reduce or limit the amount of sugar intake. 8) You must ingest no more than six grams of salt per day. 9) Moderate your alcohol intake. 10) Beware of diabetic foods and drinks as they offer no real benefits, may well have a laxative effect and are usually expensive.

Mr. “X” was informed by his G.P. that certain goals must be achieved, in order for him to have a happy healthy life and that these goals would involve a radical change in his outlook and lifestyle.

Firstly, the eliminations of the symptoms and stabilization of his blood glucose levels must be achieved. Then the ongoing goals are to prevent long-term complications thus prolonging his life. He was informed again that the primary treatment for type two diabetes is diet and exercise. There should be no “ifs and or buts” this is vital for the control of Mr. “X’s” condition.

Mr. “X” will need to learn, how to test for and record his blood glucose levels, what to eat and when, how to take medication if prescribed, how to recognise and treat both high and low blood sugars, how to cope with “bad days”. Obviously this will take time maybe even several months.

Mr. “X” will have to gradually become used to a totally different way of life. Once his condition has become stabilized, he must continue to take care of himself, and to keep up to date with current medical breakthroughs and treatments.

Self testing is achieved by checking the glucose levels of a small drop of blood taken by pricking the finger and with regular testing and recording you are able to control and live with diabetes, as these will tell you how well your diet, exercise and medication are working together. The meter used for this self-testing is called a “GLUCOMETER” and gives you results in 30-45 seconds.

Regular exercise is essential alongside diet, in the control of diabetes. It not only helps to control the amount of glucose in the blood, but also helps to burn off excess calories and fat to achieve optimal weight. Exercise will also improve the blood flow and your blood pressure. It will naturally decrease insulin resistance, even without weight loss. Exercise will also increase the body’s energy levels, lower tension and improve your ability to handle stress.

Obviously you should obtain medical approval before doing anything too physical, it being better to increase your physical activity gradually. If normal or near normal blood glucose levels cannot be achieved by diet and exercise your G.P. will prescribe insulin, which cannot be taken orally but must be injected under the skin. This may also apply if you have had a bad reaction to the oral medicine.

(M3) Mr. “X” was obviously very reassured by his diagnosis of diabetes as he knew this would make him feel much healthier. Emotionally Mr “X” has reconstructed his lifestyle as appropriate and cut out much of his alcohol intake, as advised by his G.P. Exercise would help control his stress, at first Mr. “X” ignored his advice to walk at least three times per week, however after many discussions with his G.P. Mr. “X” gradually walks and now even visits his local swimming pool. Cutting down on alcohol was also an issue but would help stabilize both his blood sugar levels and depression. This also was difficult and took him many weeks to actually cut down, he was already visiting a councillor and results have shown to be improved dramatically.

After reading the leaflet given by his G.P. containing ten steps to eating well, for patients diagnosed with type two diabetes, Mr. “X” described the lifestyle change to his eating pattern very difficult, as obviously he is not used to a new routine. Living off “fry-ups” was obviously not helping to stabilize his blood glucose levels, and as he did not exercise regularly and became a “couch potato” steps needed to be taken gradually.

Mr. “X’s” diet became much more carbohydrate based as advised, he eats much more fish, and especially sardines as these are his favourite balanced with pasta.

He also uses semi-skimmed milk now, which again is another improvement, which was first a hard change, as he has always drunk blue full fat milk. He avoids cheese much more now than before and also full fat yoghurt, cheese for him was much harder to cut off than yoghurt.

He described the change to his diet to be working but also created much more stress as he felt like a child being told what to and what not, to eat.

Mr. “X’s” digestive system gradually improved soon after a new food intake and different food stuffs as advised, became much more regular, and he felt much less constipation. Also a less fatty diet and a gradual exercise routine i.e. walking to his local shops, to collect the newspaper helped shed excess weight. Mr. “X’s” routine is looking much more positive and his heath checkups show a distinct improvement.

Mr. “X” is not insulin dependent now as he has realised how much his diet needed to be improved. Although for two months Mr. “X” was being prescribed with oral medication, he found this hard to cope with. He has also handled “bad days” much better than was expected. His daughter often visits, and does Mr. “X’s” shopping to make sure he is buying the food stuffs as appropriate to his diet. This gave him much more determination, and also was able to see his grandchild much more regularly, which helped with his depression.

Mr. “X” found the “GLUCOMETRE” at first very difficult, as he does not like the sight of blood, although eventually it became a part of life. He adapted to it, and used it as appropriately advised. He completed many goals as was set by his G.P. and this was found to boost his confidence.

It is now two years after Mr. “X” was diagnosed with diabetes, and now has full control with his diabetic regime. He is now enjoying a full and active life.

(P3) Miss “Y”, breast cancer.

Miss “Y” had become increasingly aware of a change occurring in her right breast. It appeared on self examination that a lump was forming. She first of all spoke to her partner about this, who also said he felt the lump, but thought nothing of it. She made an appointment to see her G.P. who on closer examination and consultation with her decided to send her for a scan. Read why examinations should not be abolished

An appointment was made with the local hospital. On arrival for her appointment she was given a “fact sheet” with regards to her possible condition. Within this information pack was a list of possible questions she might like, or wish to ask G.P. these were- “how is it decided, which are the best tests for diagnosis” “am I able to see the results of scans” “will I be informed immediately if one of the scans shows that the cancer may have spread” “how long will it take for the results of tests” “how will I be informed of the results” “if results show that I have cancer and/or that it has spread, what happens next” “will I be able to see a breast cancer nurse at the clinic” “is emotional support available, if I am anxious or have any concerns whatsoever”.

After the appropriate tests were taken Miss “Y” was given an appointment to see her G.P. in order for him/her to analyse the results and discuss them with her. Miss “Y” was informed that she indeed did have some cancerous cells in her right breast, and after discussion it was decided that a course of chemotherapy was the best approach in her particular circumstances. As this treatment is used both as a solution on its own and as a way of making the cancerous mass smaller prior to possible surgery.

Chemotherapy simply means treatment with drugs but, in cancer treatment it means “CYTOTOXIC CHEMOTHERAPY” drugs which kill cancer cells. The drugs work by the disruption of the growth of cancer cells. As the drugs circulate in the blood they are able to reach cancer cells wherever they are in your body. These drugs cannot distinguish between healthy cells or cancerous cells, so affect them all, but healthy cells can easily cope with this and repair themselves, whereas the cancerous cells are far more likely to be irreparable.

Chemotherapy may be administered in the form of capsules or tablets taken orally and will probably be a combination of three or more drugs. In Miss “Y’s” case and more likely in most cases the drugs will be injected into a vein. The course of treatment will usually follow a set pattern, often you will have the drugs injected for between one and five days, then have a break from them for three to four weeks, this will be termed as “one cycle”. The cycle then begins again. You may have up to eight treatment cycles, so a complete course of treatment may take up to eight months. Whilst undergoing this treatment you will usually be an out-patient but may have to spend some time in hospital.

A list of a few of the most common drugs used in combination, in the fight against breast cancer- CYCLOPHOSPHAMIDE, EPIRUBICIN, FLUOROURACIL, METHOTREXATE etc. Side effects of chemotherapy are as followed. As we are all individuals the ingestion of drugs affect us all in varying degrees. Not all chemotherapy drugs cause the same side effects, indeed some people have very few side effects. Chemotherapy can also lower the number of healthy white blood cells, red blood cells and platelets that exist in your body at all times. This in turn means that you may become more likely to get infections (coughs, colds etc) feel more tired than usual or have bleeding problems. Tiredness and fatigue being the most common side effect of chemotherapy, that may even continue for some months after the treatment has ended. Other side effects may be feeling sick, or actually being sick, hair loss or the thinning of hair, sore mouth, diarrhoea, sore eyes and changes of your menstrual cycle.

There may be some long term side effects such as your ability to become pregnant, your periods may stop and in some cases never start again, giving you early menopause. In most cases your periods will resume 6-12 months after treatment has ended. One or two examples of less dramatic effects of the drug are that your skin may become darker and be more sensitive to the sun and that depending on the actual colour of the drug, your urine may well change to that colour.

It is recommended that you are put in touch with other women that have had breast cancer treatment, in order to chat about how they have been affected. There are also many organisations you can get in touch with, including the “online cancer chat forum” or “my wave length”. These are free services, aiming to put women in touch with other women, experiencing similar problems.

Obviously the earlier breast cancer is diagnosed, the better the chances of complete recovery. For most women with a normal risk of developing this disorder, self examination, clinical examination and mammography (usually carried out from the age of 40) are all that is necessary for the screening of breast cancer.

High risk women, e.g. those with a family history of breast cancer, may need much earlier screening or additional tests. Self examination is a proactive method in helping to take care of yourself. While some cancers are too small for you to notice and most lumps found may not be cancerous, it is vital for the woman to know her own body, particularly her breasts, as any change in the “feel of her breasts” or the shape, may be an early indication of problems to come.

Clinical breast examinations are performed by health care professionals, usually inaugurated from around the age of 20, and are a basic part of women’s checkups.

Mammograms are a special type of x-ray and are used for the detection of changes in breast tissue or abnormal growths. Most growths and body tissue changes do not turn out to be cancerous, but are an early indication of what may be occurring. These tests could lead to ultra sound images being taken which will give an indication as to whether any breast lump found is a cyst (a fluid filled sac that is not cancerous) or a solid mass which may well turn out to be cancer.

MRI (magnetic resonance imaging) is another method used in the early detection of breast cancer. If any of these tests indicate that cancerous tissue may be developing, then there are other tests which can be performed such as breast biopsy. This involves the removal of cells from a suspected area or mass of tissue and performing further clinical tests on the matter removed. The same applies to the sentinel node biopsies, this involves doctors checking a few lymph nodes under the arm in order to ascertain whether the cancer has spread into the lymph system. The sentinel node biopsy will usually be carried out in conjunction with the ductal lavage tests, which checks cells from the milk ducts for precancerous cells.

Monitoring and treatment of breast cancer. Modern medicine is a major reason for the high number of women who now survive what was once considered to be a fatal condition.

The treatments for breast cancer have come a long way and part of the treatment process involves the patient’s preferences, which if at all possible are taken into consideration in the decision making. There is now a wide range of treatments available including surgery, which is performed to remove the cancer while still in the breast. Chemotherapy which is often the treatment chosen to both eradicate the cancer and prevent its return. Radiation therapy (herceptin being a prime example of this) aims to use the body’s own immune system to curb cancer. If breast cancer does return it strangely does not always re occur in the breast, therefore its location will determine the type of treatment necessary.

(M2) After Miss “Y” felt the lump she was extremely anxious and scared, as of course any person in her situation would be. Although after discussing this with her partner who also said he had felt the lump, she described this as making her feel somewhat “embarrassed” and “worried”. When someone else also feels a change, she knew there was a problem. After the examination the G.P. referred her to the hospital to have a scan which then she became a “nervous wreck” and highly emotional, complications also occurred during the scan as many photographs had to be taken of the breast but Miss “Y” became much ashamed and kept hesitating whilst during her scan, this took much longer than deemed necessary. After Miss “Y” had a scan she reportedly had many arguments and conflicts with her partner, this affected her self confidence and self-esteem.

On arrival for her appointment with her G.P. she was given the news that she indeed did have some cancerous cells in her right breast and that chemotherapy was the best approach in order to treat the cancer. Although Miss “Y” is a midwife and already has much knowledge of chemotherapy, she, as any women would, thought the worse of the situation. After breaking the news to her partner they both became emotional, but decided would not tell other family members about this. Miss “Y” also described this to have brought herself and her partner much closer together and their relationship to be on the up, which was much unexpected. Although still, she considered her body to be “abnormal” and won’t get undressed without hesitation or feeling “ugly”, less confident and also because of the chemotherapy Miss “Y’s” hair did become much thinner, but she was also quite lucky as she has not experienced much hair loss. This for her she explained, would be very traumatic and make her even less confident.

It is now 2 years since she was diagnosed with cancer and is still in remission.

Miss “Y” after having “one cycle” of treatment which was injected, explained this too, made her feel tired and fatigued, her skin did indeed gradually become much darker, and more sensitive towards the sun. She continued to feel this way through the full course of her treatment which lasted for 8 months. Miss “Y” has also only just recently begun having a menstrual cycle again, although is still very much on/off.

Miss “Y” ignored advice about becoming in touch with others who also have, or had breast cancer, as she felt this was unnecessary and would make her feel much worse. However, her life has become much more relaxed and her chemotherapy is thought to be working correctly, and with not many symptoms, Miss “Y” is coping much better than before.

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