The Hands-on Experience of Working with Patients - Essay Example

DATA BASE ive Demographic data: Reyna is a 33 y/o full-time surgery scheduler Hispanic female presents to the ER. She is married and has three children. She resides in Richmond, TX. She provides her phone number as (281) 999-9999. Chief Complaint: “Abdominal pain.” History of Present Illness: Ms. Garcia presents with sudden abdominal pain. She denies trauma. She states the pain started today and has gradually got worst. Food or liquids do not make a difference in abdominal pain. Pain 1/10. Patient appears in no acute distress. Denies fever, chills, n/v/c/d. Denies history of recent travels. ROS: Constitutional: Denies fever, chills. Eyes: Glasses and contact lenses since 1996. Denies change in vision, eye pain, discharge, excessive tearing, itching. Ear/Nose/Throat: Denies ear pain, drainage from ear, epistaxis, obstruction, sinus problems, bleeding gums, sore throat, hoarseness. Cardiovascular: Denies chest pain. Respiratory: Denies SOB, cough. Gastrointestinal: Abdominal pain. Denies nausea, vomiting, constipation, diarrhea. Genitourinary: Pelvic pain. Denies vaginal bleeding. Musculoskeletal: Denies any joint swelling, loss of ROM. Skin: Denies redness, swelling. Neurological: Denies slurred speech, unable to speak. Hematologic: Denies bleeding. Endocrine: Denies polyuria, polydipsia, polyphagia, temperature intolerance, changes in hair or skin texture. Allergies: Denies seasonal allergies. Psychiatric: Denies anxiety, depression, suicide ideation and/or homicidal ideation. All systems reviewed & negative except as marked. Patient Explanatory Model: Patient states not sure what is the cause, but states “my friend had the same problem, and her appendix was taken out.” Past Medical History: Reports none. Family History: Reports none. Social History: Reports good social support, local resident. Allergies: No Known Allergies (03/24/15) Meds: Reports none. Objective General: Alert, oriented X 3, no acute distress. Vital Signs: Temp 98.4 oral; Heart Rate 83; BP 140/65; Respiratory Rate 18: O2 saturation 100% RA; Height 5’2; Weight 172lbs. HENT: Head normacephalic, atraumatic. Neck: Trachea noted to be midline. Respiratory/Chest: Atraumatic, no distress, no tenderness, normal breath sounds, no accessory muscle use. Cardiovascular: Regular rate and rhythm, normal heart sounds, normal capillary refill, BP & pulses = bilaterally. Abdominal: Atraumatic, soft, no guarding, no rebound, no distention, normal bowel sounds, no mass/organomegaly, no pulsatile mass, no hernia, tenderness (mild RLQ). Back: Atraumatic, normal inspection, full range of motion, painless range of motion, no midline vertebral tenderness, no CVA tenderness. Skin: Intact, no lesions, no rashes, no cyanosis, pallor, or jaundice. Ext: Full ROM all extremities. No joint swelling or erythema. Neuro: Alert and oriented x 3, cooperative. CN II-XII grossly intact. Assessment Diagnosis: 1 Finding suggestive of Ovarian cyst (620.2), diagnosis supported by /confirmed by radiographic imaging of . Ovarian cyst(s) occur mostly in young women and produce adnexal pain. The cysts may be palpable, late cycle (corpus luteum) cysts. Ovarian cysts can become quite large before producing symptoms (Dains, Baumann and Scheibel, 2012). Differential Diagnosis 2 Ectopic pregnancy: signs of hemorrhage, shock, and lower abdominal peritoneal irritation that can be lateralized; enlarged uterus; CMT; tender adnexal mass (Dains, Baumann and Scheibel, 2012). 3 Appendicitis: patient lying still; involuntary guarding; tenderness in RLQ; other tests for peritoneal irritation positive; rebound tenderness; variation in presentation common, particularly with infants, children, and elderly (Dains, Baumann and Scheibel, 2012). 4 Pelvic inflammatory disease (PID): Abdominal tenderness, CMT and adnexal tenderness (usually bilateral); with peritonitis can also have guarding and rebound tenderness; fever and vaginal discharge common (Dains, Baumann and Scheibel, 2012). Plan Diagnostic 1 CT abd/pelvis w/cont. a Rationale: an abdomen or pelvis CT scan is done to diagnose the causes of abdominal pain which is often unexplained or infections (Corwin et al, 2014). Some causes of abdominal pain include infections such as appendicitis. 2 US transvaginal. a Rationale: the transvaginal ultrasound test looks at the reproductive organs of a woman, including the cervix, ovaries and the uterus. The test is conducted when there is an ectopic pregnancy or pelvic pain (Saccardi et al, 2012). 3. US pelvis complete a. Rationale: this is an ultrasound that focuses on the female pelvis. It examines a woman’s pelvic organs including the cervix, ovaries, uterus and the uterus lining (endometrium). A pelvic ultrasound is vital in diagnosing symptoms which are often felt by females such as pelvic pain. Also, a pelvic ultrasound is vital in monitoring the development and health of a fetus or embryo during pregnancy (Durham et al, 1997). Pharmacological 1 Motrin 600 mg tab for pain. Take with food. Education 1 Diagnosis, lab results, imaging studies, prescriptions, need for follow up (GYN), when to return to ER. Follow-up 1 Follow up with primary care provider in two days. 2 Follow up with OB/GYN at first available. 3 If symptoms do not improve or worsen return to ER. Summary: (EXAMPLE GIVEN) I found this case particularly interesting because it allows me to utilize what I’ve learned during our health assessment workshop on campus I learned to evaluate the patient. By observing patient’s gait and performing test such as the Tinel’s sign test and Varus/Valgus stress test I was able to rule out possible sprain and/or tunnel syndrome (Graham & Uphold, 2003). I learned from my preceptor how to order test like x-ray and how to refer patients to other interdisciplinary teams for consultation. This case was vital to me because I had the opportunity to examine a real person. As such, I learnt what to look for while conducting rectal or vaginal exams. Thus, I acquired the needed hands on experience. Additionally, by communicating professionally with the patient, I was able to make them feel at ease and appreciated. But of most significance is the hands on experience I gained from the whole experience. Having hands on experience is vital for all health care professionals. Self-Reflection My experience at the Standardized Patient (SP) Center was educational. The most significant aspect I learned/gained during this rewarding undertaking was the hands-on experience of working with patients. The SP Center provided me with the opportunity to practice on a real person, specifically by conducting a pelvic exam on both a male and female patient. This experience has taught me what to expect, feel, or look for in vaginal and rectal exams. Gaining or having hands on experience is a crucial aspect among healthcare professionals. My experimental learning was further by receiving a copy of the recorded sessions. These videos allow me to deduce and view my strengths or weaknesses, enabling me to identify the areas where I need improvement. I made a connection between coaching exams at the SP center and the textbook / video via the hands on experience. The textbook readings were applicable when I had to practice and work on a real person. As a result, I had to apply the theoretical perspective outlined in the book to a real life experience. While treating and interacting with the patient, I confidently connected and communicated professionally. Further, I was able to express my compassion in a respectful manner while undertaking the exam followed by a conversation after the whole process. To make the patient feel appreciated, I thanked them for allowing me the opportunity to examine them. For this reason, am greatly pleased with how I treated and interacted with the patient. From the video, it is evident that I performed well in the heart, lung and abdomen exams. I learned these skills from undertaking repetitive ER MD observations. Nevertheless, there are some aspects I would prefer to do differently after watching the video. For instance, I feel that the patient’s experience would be improved by me being more confident and comfortable. During patient interactions, and (3) gain experience during the course duration. To build this confidence, I will face encounters in the ER practice instead of just observing them. Overall, the video information showed me that I must strive to achieve three primary objectives during this course: (1) be more confident during patient interactions, (2) be more comfortable References Corwin, M. T., Sheen, L., Kuramoto, A., Lamba, R., Parthasarathy, S., & Holmes, J. F. (2014). Utilization of a clinical prediction rule for abdominal–pelvic CT scans in patients with blunt abdominal trauma. Emergency radiology, 21(6), 571-576. Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advance health assessment and clinical diagnosis in primary care. (4th ed.). St. Louis, MO: Elsevier. Durham, B., Lane, B., Burbridge, L., & Balasubramaniam, S. (1997). Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Annals of emergency medicine, 29(3), 338-347. Saccardi, C., Cosmi, E., Borghero, A., Tregnaghi, A., Dessole, S., & Litta, P. (2012). Comparison between transvaginal ultrasound, sonovaginography and magnetic resonance imaging in the diagnosis of posterior deep infiltrating endometriosis. Ultrasound in Obstetrics & Ginecology, 40(4), 464-469. Read More