The Role of Structured Consultation and History Taking - Essay Example

A Reflective Account Relating To a 14 Year Old Female Patient (Complaining Of Painful Urination/ UTI) Focusing On a Patient Centred Structured Consultation/History Taking Examination Prior to the inspection, the nurse introduced herself, as well as explained her role in the examination. The patient was asked her name, and as a minor, the parent, was noted to have accompanied the patient. The patient details, such as age, address and preferences were recorded in the assessment. The patient was prepped for examination by a doctor and the readiness, comfort and privacy of the patient were addressed by the nurse and the patients mother. The nurse engaged the patient and companion to ensure comfort and mental ease. This was done by eliciting a comment on the personal quality of the patient to elicit rapport from the patient (Prabhu et al. 2007, p. 17). The second phase of the examination was obtaining the patients agenda as well as the main concerns. The time available for the patient was indicated in the examination while the patient was asked to indicate the need for doctor’s intervention. This was done with the assistance from the mother. The patients full concerns regarding her condition and the procedures involved were tackled. The evaluation of the concerns was followed by a summary of the agenda, and negotiations of the procedure specifics on the agenda were addressed (Nicole 2013, p. 67). The third phase of the examination involved collection of information based on the specifics identified in the agenda. The questions that were asked were simplified and did not include any medical jargon to avoid any confusion by the patient. The structure of the questions was both open and close ended. The patient was allowed to explain herself in the open-ended questions while the close ended questions required a yes or no answer. These questions were designed not to lead the patient towards eliciting different reactions. The mother as also asked not to participate in the questioning, to avoid leading from the mother. The patient was also asked to participate in the analysis of the concern, by being asked if they had any idea of the cause of the concern. The nurse also used transitional statements to expound on the different types of questions and sections in the inspection. The nurse finalized with a summary of the patient responses, and asked for any feedback from the patient while eliciting any further information from the patient, without any form of judgment (Macleod and Fiona 2006, p. 62). The fourth phase of the inspection involved collecting information on the history of the present illness (HPI) of the patient. The information that was collected was structured. The first assessment was on the characteristics of the concern, which meant the quality as well as the severity of the symptoms. The location or source of the discomfort was also asked in the assessment. The onset and duration of the symptom were also recorded in the evaluation. The patient was asked of any unmentioned symptoms that were being experienced, as well as the exacerbating and relieving factors associated with the illness. This information was recorded without the participation of the mother in the answering since it did not involve any experience by the companion (Saks 2008, p.6). The fifth phase of the analysis involved record of the past medical history of the patient. The patient was asked of any allergies and reactions to any drugs. In this question, the mother was asked for input since the patient was a minor. The patient was also asked if they were taking any medication for an illness, this question covered any medicine that was recently or currently prescribed, bought over the counter, and herbal or alternative methods of medication. A history of the patient covered the major diseases, treatments, toxins and/or industrial grade exposures, and doctoral visit in the past year (Taylor et al. 2012, p. 12). The patient was also asked if they had been involved in any form of surgery and the surgical procedures for the inpatient and outpatient dates were recorded, where applicable. The patient was also asked of any hospitalization and the respective date. The gynaecologic/obstetric information was also gathered since the patient was female. The menstrual cycle history was recorded which included the onset, cycle duration, discharge quantity and characteristics of the menses. The patient was also asked of any history with pregnancy as well as childbearing, and if there were any complications in pregnancy (Bickley 2012, p.90). The patient was also asked of the use of contraceptive methods, a history of sexually transmitted diseases, a mammogram as well as the last Pap smear that was conducted on the patient. The patients immunization history was also recorded, such as tetanus-diphtheria while information about the patients diet was incorporated in the analysis. This analysis of diet includes questions on the last meal and any history of diabetes in the family. Trauma history was also assessed in the examination, both history and in the treatment while any childhood diseases through growth were also incorporated in the report. Through this phase, the mother was asked to participate actively through various questions since the teenager may not have had all the answers to the asked questions (Macleod and Graham, 2007, p. 61). The Family medical history was another subject of examination. The patient and immediate family member ages were recorded, while their existence was also recorded. The family members health, physical and meant, was also analyzed while focusing on elements such as depression and substance abuse (Bickley, 2008). The patient was asked of the possibility of other members of the family who had recorded similar symptoms and signs. Family relationships, as well as the history of chronic ailments, were also incorporated in the family history assessment. The mother was also asked to be active through this section of the examination as she could answer the questions posed to the patient in a better way (Playfer and John 2008, p. 90). A history of the patient; personal and social was also incorporated in the examination. The patient was asked of the presence of any relationships as well as their outcome such as the marital status, and sexual partners involved. An analysis of the home environment was another question that was posed to the patient, such as with whom the patient lived. The financial, ethnical, personal background and directives of care subjects were also covered in the examination (Bickley et al. 2009, p. 67). The preventive or risk factors were also assessed. The nurse asked of any preventative measures, past and present (i) Tobacco use, (ii) Alcohol use, (iii) Recreational drug use, (iv) Sexual history, participation, and orientation, (v) Occupational hazards, and (vi) Violent risks. Since the concern was a UTI, the active sexual partners segment was pressing, and the nurse asked for details with regards to partners, safe sex, and past medical history on STDs. The mother was asked not to be present in this analysis since the patient did not feel comfortable revealing such information in the presence of the mother (Kamerow 2007, p. 54). The patient was also subjected to a general review of systems, where the weight, pressure, and heart rate were recorded. This led to the urinary review of systems. The questions that were asked in the section included the frequency, urgency (need to), sensation (burning or dysuria), frequency at night (nocturia), lack of control (incontinence), presence of pebbles or gravel (renal stones), and a slow start (hesitancy) of urinating. This information was essential towards the treatment of the patient with respect to their symptoms as well as the extent of the illness. This data would be useful through the diagnosis as well as the treatment phase since the history of the patient would influence the approach towards treatment of the condition (Bickley et al. 2007, p. 89). Reflection The approach towards the UTI and patient diagnosis and treatment was lengthy and involved amassing of large data quantities from the patient as well as companion. The nature of the examination was attributed to the patient having no prior records with the facility, which meant that information on the patients health had to be acquired manually. This process could benefit from the sharing of patient databases by registered medical facilities, which would easily simply the data collection process and minimize it to a minimal current systems review. With records shared between facilities, all that the patient would need to do is engage in an examination that focused on the symptoms and current concerns since the medical institution could access the patients information from a collective database. Such a system would minimize the chances of cheating and hesitancy (Nice Guidelines 2008, p. 78). Reference List Bickley, M.D. (2008). Bates Guide to Physical Examination. Lippincott Williams & Wilkins. Bickley, Lynn S., Peter G. Szilagyi, and Barbara Bates. (2007). Bates Guide to Physical Examination and History Taking. Philadelphia: Lippincott Williams & Wilkins. Bickley, L.S., Peter, G. and Barbara, B. (2009). Bates Guide to Physical Examination and History Taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Bickley, Z. (2012). Zui Xin Beishi Shen Ti Jian Cha Zhi Yin = Bates Guide to Physical Examination and History Taking. Drug Misuse: Psychosocial Interventions: The NICE Guidelines. (2008). London: British Psychological Society & Royal College of Psychiatrists. Hopcroft, K. and Vincent, F. (2010). Symptom Sorter. Abingdon, U.K.: Radcliffe Medical. Kamerow, D. (2007). Morals and Ethics and Medicine. Bmj 334. Macleod, J. and Graham, D. (2007). Macleods Clinical Examination. Edinburgh: Elsevier Churchill Livingstone. Macleod, J. and Graham, D. (2010). Badanie Kliniczne Macleoda. Wrocław: Elsevier Urban & Partner. Macleod, J., Graham, D. and Fiona, E. (2006). Nicol and Colin Robertson. Macleods Clinical Examination. Edinburgh: Elsevier Churchill Livingstone. Nicolle, L. (2013). Urinary Tract Infection in Long-term Care Facilities. Healthcare Infection. Playfer, J. R. and John, V. (2008). Parkinsons Disease in the Older Patient. Oxford: Radcliffe, 2008. Prabhu, F. R., Lynn S. Bickley, and Barbara, B. (2007). Case Studies to Accompany Bates Guide to Physical Examination and History Taking, Ninth Edition. Philadelphia, PA: Lippincott Williams & Wilkins. Saks, M. (2008). When Is a Urinary Tract Infection Really a Urinary Tract Infection? Emergency Medicine News 30(11), pp. 6. Taylor, D., Carol, P. and David, T. (2012). The Maudsley Prescribing Guidelines in Psychiatry. Chichester, West Sussex, UK: Wiley-Blackwell. Read More