Write a 500-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
- What went well in your assessment?
- What did not go so well? What will you change for your next assessment?
- What findings did you uncover?
- What questions yielded the most information? Why do you think these were effective?
- What diagnostic tests would you order based on your findings?
- What differential diagnoses are you currently considering?
- What patient teaching were you able to complete? What additional patient teaching is needed?
- Would you prescribe any medications at this point? Why or why not? If so, what?
- How did your assessment demonstrate sound critical thinking and clinical decision making?
Expert Answer and Explanation
What Went Well in the Assessment
Various things went well in the assessment. One of them is gathering information about the patient’s history of present illness. The patient was able to property describe was is impacting her health at the present. She says that her throat is itchy and sore. She also has a runny nose and itchy eyes. Another thing that went well is the physical examination. I examined the patient and observed that she is obese, oriented alert, and is in no acute distress. I was able to observe her neck and found that it has no infraclavicular lymphadenopathy and that her thyroid is smooth. In other words, data collection went well.
What Did Not Go Well
I did not include the patient’s vital signs in the physical assessment section. Vital signs are essential because they can be used to assess whether the patient has a normal temperature, blood glucose, and heart rate. I will ensure that I collect the patient’s vital signs in my next assessment. Another this that did not go well during the assessment is that I did not collect data about the patient’s lifestyle.
The assessment revealed a lot of findings. One of the findings is that the patient is allergic to cats and dust. However, she has no medication allergies. Another finding is that the patient’s symptoms might be a result of being infected by her sister. The assessment shows that the patient’s sister has hay fever. The findings have also uncovered that the patient might be suffering from an upper respiratory infection. One thing I have learned from this assessment is that assessing the entire patient’s body provides infection that can be used to understand what is ailing the patient.
I used both open-ended and close-ended questions to collect data during patient assessment. open-ended questions provided a lot of data compared to close-ended questions. According to Chen et al. (2020), open-ended questions are questions that cannot be answered only through a yes or no format. The questions need respondents to respond by elaborating their points. Therefore, I was able to collect a lot of information using open-ended questions because the patient had a chance to explain herself.
One of the tests I can order is the skin prick test. This test can show whether the patient has an allergy. Another test that can check for an allergy is an allergy blood test. A CBC test can be ordered to determine whether the patient has an infection in the blood. I should also order a chest X-Ray to investigate whether the patient has other infections in the respiratory system.
- Hay Fever: The patient is most likely to have hay fever. The symptoms of the disease include a runny nose, itchy eyes, fatigue, sneezing, and sore throat (Ferreira et al., 2017). The patient has most of the symptoms making the disease a primary diagnosis.
- Common Cold: The patient also has some signs of the common cold including itchy eyes, runny nose, and sore throat (Ran et al., 2018). However, she does not report shortness of breath making the disease a secondary choice.
- Sore Throat: Sore throat has been included because it causes pain in the throat (van der Velden et al., 2020). However, it has been excluded as a primary diagnosis because it does not cause a runny nose.
I would educate the patient to drink plenty of water and take enough rest. The patient should also avoid cats and dust because they can trigger allergic reactions.
The patient should continue taking Claritin 10 mg orally daily as prescribed. The medication can be used to treat allergic reactions (Chu et al., 2021).
Chen, A. H., Bakar, N. F. A., & Lam, C. S. Y. (2020). Comparison of open-ended and close-ended questions to determine signs and symptoms of eye problems among children. Journal of Optometry, 13(2), 81-87. https://www.sciencedirect.com/science/article/pii/S188842961930069X
Chu, D. K., Oykhman, P., & Sussman, G. L. (2021). How to use antihistamines. CMAJ, 193(14), E478-E479. https://doi.org/10.1080/0284186X.2020.1769185
Ferreira, M. A., Vonk, J. M., Baurecht, H., Marenholz, I., Tian, C., Hoffman, J. D., … & Paternoster, L. (2017). Shared genetic origin of asthma, hay fever and eczema elucidates allergic disease biology. Nature genetics, 49(12), 1752-1757. https://www.nature.com/articles/ng.3985
Ran, L., Zhao, W., Wang, J., Wang, H., Zhao, Y., Tseng, Y., & Bu, H. (2018). Extra dose of vitamin C based on a daily supplementation shortens the common cold: A meta-analysis of 9 randomized controlled trials. BioMed Research International, 2018. https://doi.org/10.1155/2018/1837634
van der Velden, A. W., Sessa, A., Altiner, A., Pignatari, A., & Shephard, A. (2020). Patients with Sore Throat: A Survey of Self-Management and Healthcare-Seeking Behavior in 13 Countries Worldwide. Pragmatic and Observational Research, 11, 91–102. https://doi.org/10.2147/POR.S255872
[ANSWERED] Create your own script for building a health history and use the Health History Template for guidance (consider the type of language you would use to help your patient be more comfortable).