The Initial History-Taking and Assessment - Essay Example

? Health Sciences and Medicine Question Critically discuss the initial history taking and assessment of Mr. Markantonakis. Medical history taking and assessment of Mr. Markantonakis was either not done well or no conclusive response could be gotten from the family members. When Chrisoula was asked about the medical history for Mr. Markantonakis she did not have a detailed response. She was unable to recollect about a motor vehicle accident he was involved in 2002 where he got neck and shoulder injuries. When Mrs. Markantonakis (Eleni) was asked same question, she said, the accident injuries were not serious though could not a certain about physiotherapist process since the process was undertaken by Mr. Markantonakis and details was with him. Eleni could not confirm whether he suffered sciatica only said he was seeing Dr. Switajewski for regular blood pressure review. These inconsistencies indicate that medical history for the late was not well documented or family members we not well acquainted. Jennifer Bell (Ambulance officer) was not professional on her approach to collect history and assess the state of the patient. This is evident as Eleni says could not recollect being questioned by the officer about the medical history of the patient, or patient discussing his medical history of the lower back pain by the officer. Negligence is portrayed during the assessment process of the patient during first visit by ambulance officers. This conclusion is derived from the fact that officer Bell did not take the blood pressure of the patient even though was requested by the patient’s wife. This is further seconded by Dr. Walsh response during cross examination when he confirmed a good radial pulse alone was not sufficient. However; he agreed that initial assumptions or lack of conclusive medical history make it difficult to judge conduct of the officers. It is reasonable to say that lack of proper medical history information made the officer miss diagnose the patient. However; as a trained paramedic initial assessment and documentation of patient condition should be a key thing before taking any action. Question 2: Potential diagnoses and clinical decisions would be if you were attending Mr. Markantonakis and provide your rationale. Diagnosis and clinical decisions regarding Mr. Markantonakis case could have been challenging following poor history records. However: As a paramedic, I would have taken basic diagnosis steps to measure blood pressure as requested by the patient’s wife to give confidence and reassurance on our services. In addition, would have taken further assessment to provide a good medical record and take necessary actions in regards to diagnosis. Different patients react differently to pain, writhing of the patient may prompted further probing of the condition either by questioning patient or relatives. As stated by relatives and attending officer no substantial medical assessment was carried out and I think that was improper. I agree with Miss Moore that a different approach should have been taken on clinical decision. The patient should have been encouraged to go to the hospital rather than discouraged. This is evident since Ms Bell concentrating on telling patient about longer hours he will take waiting at Flinders Medical Centre. Even though she gave alternative suggestion of going to Royal Adelaide Hospital, she was not convincing about taking him to hospital. Clinical decisions of a paramedic should be to administer proper medical assistance to a patient and provide better environment for treatment. The conditional change that en route to the hospital of suprapubic and epigastric pain should be documented and triage nurse advised properly of the condition. Handing over at the triage was poor and I think this slimed chance of the patient being given correct reception attendance. Patients in pain in most cases require instant relief. Having been told that patient had taken penthrane forte and vomited, a different approach should have been sought instead of saying additional same reliever be administered. This was careless and unprofessional in my rationale judgement. Diagnosis and clinical decisions should be properly documented so as to properly attend to a patient. This was not in the case of Mr. Markantonakis and it was an act of negligence which deteriorated patient’s condition instead of proving it. Question 3: Discuss the style of communication used by Ms Bell when interacting with Mr. Markantonakis and his family. Communication style used by Ms Bell when interacting with Mr. Markantonakis and family was aggressive. She portrayed this by disregarding most requests and responses from the family. For instance, when requested by Eleni to test blood pressure she ignores just claim radial pulse was normal. This is a characteristic of aggressive communication where one thinks she knows all and disregards other person’s point of view. She had I do no care attitude as illustrated in her utterances and lack of concern also was reported to have shouted to the patient in the ambulance. Ms Bell should have employed assertive communication style while communicating with the patient and family members. This is effective and employs good listening skills; making others know they are valued (Sherman, 2012, pg 1-2). Question 4: Discuss how the handover to the triage staff at the hospital could have been improved. Provide rationales for your answers. Handover to the triage staff at the hospital was very poor since no patient card was presented. In addition, Ms Bell gave an implication that was only suffering from pain back which was not serious. She did not disclose the conditional changes that occurred and made the problem seem less critical. This is acknowledged by triage nurse; who acknowledge that if suprapubic and epigastric pain information was given, she would have rated his condition as much critical. However; triage nurse should have insisted of getting further information on the condition of the patient. Either by probing the handling over officer or doing diagnosis at the reception. The judgement was questionable; triage nurse should have not relied on the officer verbal reports as conclusive (Bruce & Suserud. 2005, pg 1-2). Question 5: Discuss the assessment and decisions made regarding Mr. Markantonakis’s pain. At the first visit, the officer assumed that Mr. Markantonakis was suffering from musculoskeletal pain or simple back pain. This was reasonable assumption following the information the officer gathered from the wife. However; the officers should have done their on assessment and diagnosis to determine the condition and make better judgement. Ms Bell assess the pain as mild and claimed it was an exaggeration or “a poor me condition” this blinded their immediate due response and further jeopardize the patient’s condition (Chevan, 2011, p 1-19). A pain management approach or plan that I would have used would involve: Painkiller had been ministered and the patient vomited it out. Administration of pain reliever using a different mode i.e. injection would be considered. Hot or cold treatment. As ice pack was place at the lower back would be appropriate, however; in some case hot compression pack could be used to relieve pain for other patient. Alternating hot and cold treatment would have been considered (Nadivelu, 2011, pg 20-25). Suggesting alternative sleeping position or relaxation position if the two approaches yield no substantial results. If the above mentioned approaches could not assist. Then manual therapy would be considered and applied to manage the pain. If all fails then, antidepressants could be administered and further surgical approach employed for treatment. References Vadivelu N. (2011) Essential Pain Management! Yale University School of Medicine 333 Cedar Street. New Haven,USA. Page 20-25. Sherman R. (2012) Understanding Your Communication Style: retrieve on 26th March 2013 from http://www.au.af.mil/au/awc/awcgate/sba/comm_style.htm page 1-2 Bruce K. Suserud B. (2005) the handover process and triage of ambulance-borne patients: the experiences of emergency nurses. Emergency Department, Southern Alvsborgs Hospital, Boras, Sweden, retrieve on 26th March 2013 from http://www.ncbi.nlm.nih.gov/pubmed/15997974 page 1-2. SULTAN QUBOOS UNIVERSITY (2013) Triage Policy, Department of Family medicine and Public health. Retrieve on 26th March 2013 from http://www.squ.edu.om/tabid/4535/language/en-US/Default.aspx Chevan J. (2011) Physical Therapy Management of Low Back Pain: A Case-Based Approach, publisher; Jones & Bartlett Publishers, 2011. Page 1-19. Read More