reflect on pattern recognition in diagnoses.
reflect on pattern recognition in diagnoses. Explain how pattern recognition of patient symptoms might help lead
to a diagnosis hypertension
Nurs6531 clinical
Practcum Journal EnTryVarnie STevensonVarnie.sTevenson@waldenu.eduIndiana DeparTmenT of HealThDr. Moye317-221-3400MMoye@MarionHealTh.orgDay one of week #1:My first day of clinical I have the opportunity to do a head to toeassessment on a 28 years- old male that came to the clinic today complaining of Coughing forabout two days, and he states it is not getting better. He also says he experience chills and sweata lot. He did not have any past medical history.During my assessment, I noticed that his abdomen was soft and not distended he had hypoactivebowel sounds. His last bowel movement was on Feb 28th; I saw 3/1/ The only abnormality withhis assessment was a diminished lung sound in his lower base.His pain was mostly felt aboveand below his eyes as well as behind his nose.The entire day was full of teaching and fun. The patient was very receptive to learning. Base onhis assessment my preceptor determines that the patient had a sinus infection. We discussed hisdietary options, and hydration because due to him sweating at night, he can quickly becomedehydrated. He was advice to take over the counter Zyrtec 10 mg Po. Once for two. He was alsoadvised if he chooses to used nasal decongestant continuously for periods of 10 to 14 days it willcause rebounds.Day Two of week #2:I was assigned a 26-year-old female who came in complaining of itchingof her vagina and discharge. She past medical history of the same issue. Since she was a female,Dr. Moye had advised me to always have a female nurse with me when I’m doing my head toassessment. After the assessment, she consented to a wet mouth swap, a vagina swap for yeastinfection done. Pelvic exam was also done. I had two patients on this day, but we saw eightpatients. With these two patients, I had to do some prioritizing before I can do anything else. Mypatient lab result came back positive for yeast.My preceptor was made aware. She claims tohave multiple sexual partners. She was educated on safe sex. The clinic regularly gives patient abrown paper bag that contains pamphlet for safe sex and condom. Over the counter, Monistatwas recommended before her discharge.Day Three: of week#3I was a little nervous on this morning when I enter the room, where 21years female was sitting waiting to see a doctor. She kept saying “I have had a pain in the lowerride side of my stomach for two days. I have been vomiting, and I continue to be nausea duringthese few days.”
The patient was a 21years- old soft spoken female presents to the clinic by her mother and fathercomplaining of sharp stabbing right lower quadrant pain for the past two days.She states thePain started in her periumbilical area and moved to the right lower quadrant. She states all theyhave done has not made the pain better or worse. The pain is persistent.She has a fever lastnight high of 100.4. Patient has been nausea since 5 am that morning, with two episodes ofvomiting early this morning. She has had three loose diarrheas since late night. She has not eatenin two days. The last meal she ate was last night, chicken noodle soup. After a head to toeassessment, Dr. Moye decided to send her to our affiliate hospital for further assessment.My clinical experience has been great so far.TimelinePractcumTimelinePracticum to betaken in byVarnieStevensonSubmit NP Clinical Skillsand Procedures ChecklistDr. MoyeContinue to see patientswith Dr. Moyeandcontinue to train on thecomputer system and startto write soap note.Finish allrequirements byApril 7thand startseeing patients anddoing a head toassessmentindependentlyCompletion of e-portfoliodocumentsFebruary28th March 1-28 continue clinicalMarch 24thconTnueto see paTents withmy precetor.April 7thApril 7thhave aconference callwith Dr. COLEMarch 27-28computertraining andpaTentassignment April 11-26AprilMay conTnueto see paTentand wriTngnoteMay 1-10conTnueprocedureschecklist.
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