A Female Patient

Per grandmother, the client’s pregnancy, and delivery were normal. The grandmother recalls that Keisha’s developmental milestones were reached appropriately, including basic motor skills such as crawling, walking and fine motor skills such as writing. According to the client, she experienced an accident when she was nine years old. The accident affected her brain causing her to experience a coma for more than a month. It took her several months of rehabilitation to be able to return back to school. Keisha reports fatigue and/or loss of energy very often. Even after sleeping for more than twelve hours per day she feels tired every morning. She has been feeling this way for more than three years. Furthermore, the client reports that she has poor appetite, eating one or two meals per day. Due to her decrease in appetite the client reports that she lost about ten pounds since last year. Keisha mentions that her appetite has decreased since she started high school. Per client, her father abused drugs when he was younger, which included heroin and crack. She is unaware if father continues abusing drugs. Per client, her mother did not abuse any drugs while she was alive. The client reports no allergies, traumas or chronic diseases affecting her

At some point in all of our practicing careers, we will encounter a challenging patient. It is critical for practitioners to devise ways to work with difficult patient. The patient may be “difficult” for different reasons. It is rare that he or she is difficult for no reason. Finding the root of the cause may assist in caring for this patient in future visits. This root cause may be related to culture, communication, or autonomy of care.

Within this case study I am going to use two of the Chapelhow et al. (2005) enablers to discuss and reflect on the care of a patient I have been involved with on placement over a period of 5 weeks. ‘Enablers are the essential and underpinning skills that come together to provide expert professional practice’ (Chapelhow, C et al. 2005, p.2). These include; assessment, communication, documentation, risk, professional decision making and managing uncertainty. The enablers work together to provide a holistic approach to the care of patients in health care settings. I am going to focus on and discuss two of the enablers, linking them both together, which will be assessment and communication as I believe these two enablers can be related most to my patient.

D.W. is a 23-year-old married woman with 3 children under 5 years old. She came to her physician 2

The patient tells me that she is unsure when her last menstrual cycle was. Her periods are very irregular and she had not been keeping track of it. She and her husband have been attempting pregnancy for the last year and a half and she tells me that as of Thursday, August 27th, she and her husband had gone through the procedures for adoption. She said that she knows she ovulated on August 18th. She was using an ovulation kit. She took a home pregnancy test on the 28th, which was positive, repeated with a different brand of test on the 29th and that was also positive. She has a regular gynecologist with York Gynecology, Robert Cervenka, MD, that she uses regularly, and she already has an appointment with him

The individual interviewed was a medical folk from Promedica Fostoria Community Hospital. They work in the surgery department for sterile processing and have been there for over 16 years. The interviewee was asked multiple questions about the professional group they represent, their code of conduct, and their mission as a facility. They answered the questions to the best of their ability and gave much insight about the facility itself and the staff within the hospital.

Sharon is a 17 year old young women, her mother noticed that Sharon had lost a significant amount of weight, and she looked pale and had dark circles under her eyes. Sharon was complaining of severe diarrhea, stomach cramps, and after battling this for weeks she was extremely tired. Her doctor conducted a standard physical exam, and interviewed Sharon about her general health, diet, family history, and environment.

VG is a thirty-one-year-old female who comes in for a routine follow-up. She reports that she has been feeling excessive fatigue over the last month. She also notes that she is having some problems at work, not only because of her fatigue but also because of difficulty concentrating. She also notes that she has gained 10 pounds over the last month, and she is unable to identify the cause of the weight gain. She also notes that her periods are a little heavier and more irregular. She is currently taking daily ferrous sulfate and over-the-counter calcium. According to VG’s medical record, she had a TSH level of 4.2 mIL/L about a year ago. Although, Her previous blood levels were slightly elevated, VG’s previous medical provider did not schedule retesting as, no further follow-up lab was deemed necessary at the time. Repeat blood work today reveals a TSH level of 9.8 mIL/L and a free T4 of 0.72 ng/dL.

She reports a history of back pain, ovarian cysts excision, and breast tumor. She denies chest pain, shortness of breath, or palpitations. Patient reports that her immunizations and preventive care are up to

Client reported no known allergies to food or drugs. Client reported that she has 8 years daughter. Client indicated her physical health "average". Client reported that she does not have a current primary care physician at the time of assessment. Client reported that she is not currently pregnant and does not taking medication for medical purpose. Client denied any issues in this dimension. Indicated no current condition or medications that would interfere with treatment. Client exhibited adequate ability to tolerate and cope with physical discomfort. No immediate biomedical services are needed at the time of assessment.

Janet receives her medical care from Dr. John Lee in Milton, Florida, for $100.00 each visit. She has used him twice in the last year. Janet uses Bridgeway for her psychiatric medications, and for emergencies, she goes to Twin Cities Hospital in Niceville, Florida, because they do not ask her for money up front. Janet has not seen a dentist in more than 20

Case 1: a 57-year-old female patient presented with a pinkish small nodule 3 x 3 mm in diameter on right palatal area near teeth 14. Overall clinical examination revealed benign epithelial lesion with the similar nodule in the right index finger of the patient. The final diagnosis was papilloma. High intensity diode laser (810 nm, 3 w and 1.5 w) was used to ablate lesion and stop bleeding. Post irradiated area was healed normally and no recurrence was observed.

Thank you for sharing your experience. What you did was right in educating the patient about the risk and referring her to a genetic counsellor.

HPI: 24-year-old Caucasian female, domiciled, presents today for her annual wellness visit. Patient also complains of experiencing her first abnormal heavy menstrual flow last month.