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Gathering Patient Information History And Physical Examination Essay

Gathering Patient Information History And Physical Examination Essay

I-Human Reflection

Part A: Gathering Patient Information History and Physical Examination

Gathering a patient’s medical history and physical examination are significant aspects of diagnosis and treatment processes. Most medical diagnoses can be achieved through a patient’s health history and physical examination alone. Health history consists of various elements contributing to the presented clinical manifestations, including chief complaint, history of the presented illness, medical history, surgeries, immunizations, current medications, known allergies, social history, family history, and reproductive history. Additionally, physical examination allows a healthcare provider to collect a patient’s general information and review various body systems based on the presented health history to conform to health-related information provided by the client. Thus, the effectiveness of diagnosis and treatment offered to the client presented with hyperthyroidism with Graves’ disease significantly influenced the patient’s medical history Gathering Patient Information History And Physical Examination Essay.

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Regarding gathering patient information history and physical examination, I realized that I have strengths and areas that require growth. My most significant strength involves having effective communication skills. I apply verbal and non-verbal communication skills, gathering a wealth of information on the patient’s medical history, including symptoms of the presented illness and past medical history. However, I need to improve my physical examination skills. Despite collecting a detailed health history, I fail to examine a patient effectively, which is required to conform to health-related information provided by the patient. I will improve my physical examination competencies by enrolling in a 2-years’ experience program in an acute-based hospital. Experience programs equip nursing learners with skills and competencies to provide safe, effective, high-quality, patient-centered care to their clients. Leslie et al. (2021) states that nurses practicing in the U.S are expected to apply standard evidence-based practices and core competencies in their clinical practice to provide quality patient care.  Nursing competency enables nurses to combine knowledge, values, skills, beliefs, and experience acquired while providing healthcare services to patients in various clinical settings. Therefore, I will use physical examination competencies acquired during the program to examine patients presenting to the practice with different clinical manifestations, resulting in the most appropriate diagnosis and treatment plan.

Part B: Changing the Treatment Plan

The treatment plan for this client should be changed if the client does not have insurance. The client was diagnosed with hyperthyroidism with Graves’ disease. The management plan used in treating the client’s condition involved a discussion with the patient about potential treatment options, including PTU or Methimazole, thyroid ablation with radioactive iodine, and surgical resection. This discussion included the risk and benefits of each treatment approach. Thyroid ablation with radioactive iodine should be used in treating the patient who presented with hyperthyroidism with Graves’ disease if the client did not have an insurance cover. This treatment intervention is preferred since it is cost-effective for Graves’ disease. Kahaly et al. (2018) reported superior results among patients with Graves’ disease treated using radioiodine. Consequently, thyroid ablation with radioactive iodine is the most preferred treatment therapy for Graves’ disease in the United States. Additionally, Europe and Asia recommend radioiodine as the second-line treatment intervention for patients with relapse after initially being treated with ethionamide treatment (Kahaly, et al., 2018). The Graves’ disease and Thyroid Foundation support individuals diagnosed with the infection in our area. It provides them with required resources, up-to-date information on evidence-based treatment interventions, and referrals, resulting in the provision of holistic healthcare.

References

Kahaly, G. J., Bartalena, L., Hegedüs, L., Leenhardt, L., Poppe, K., & Pearce, S. H. (2018). 2018 European Thyroid Association guideline for the management of Graves’ hyperthyroidism. European thyroid journal, 7(4), 167-186. Doi: 10.1159/000490384

Leslie, K., Moore, J., Robertson, C., Bilton, D., Hirschkorn, K., Langelier, M. H., & Bourgeault, I. L. (2021). Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia and the UK. Human Resources for Health, 19(1), 1-12. https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00550-3

Reflection: In a Microsoft Word document, respond to the self-reflection questions below. Include a title page in APA format using the title iHuman Reflection Week 2. In 2-3 paragraphs, respond substantively to all required reflection questions. Analyze your personal strengths and areas for growth Gathering Patient Information History And Physical Examination Essay.

  1. Select ONE of the following topics and discuss your performance in 2-3 paragraphs. Analyze your strengths and opportunities for growth. Include at least ONE evidence-based improvement strategy to improve your performance in your next virtual patient encounter.
    • gathering patient information (history and physical examination)
    • organization and interpreting information to synthesize the problem
    • identifying differential diagnosis
    • ranking differential diagnosis and identifying must not miss diagnoses
    • developing the treatment plan and selecting appropriate diagnostic tests, medications, or other treatments
  2. Both the diagnostic testing and treatments available for this client’s diagnosis can be very expensive. How would your treatment plan change if your client did not have insurance? What resources are available in your area to support a client with these diagnostic and treatment needs?
  1. APA 7th edition reference
  2. Reference to use only Evidenced- practice within 5 years from U.S. Europe or Canada allowed
  3. Evidenced-based practice (EBP) to support reflection
  4. Put DOI number for references
  5. Stat pearls resources are not unacceptable sources
  6. Intext citation required

 Guide

Diagnosis: Diagnosis: Hyperthyroidism with Graves’ disease

Management plan used:

Discussed with the patient about the following treatment options:

PTU or Methimazole

Thyroid ablation with radioactive iodine or

Surgical resection

Discuss the risk and benefits of each approach

Support the patient’s choice and schedule the appropriate follow- up Gathering Patient Information History And Physical Examination Essay