Painful Urination in a 15 Yearly Old Patient - Essay Example

A Reflective Account Relating To a Patient With Painful Urination Painful Urination in a 15 Yearly Old Patient Last week, a 15 year old female patient came to the walk in clinic. She was feeling pain while urinating and was suffering for the past 24 hours. Her mother accompanied her to the clinic. In diagnosing, examining and treating Patient, the Flanagan’s Clinical Skills Assessment (CSA) consultation model (Flanagan, 2010) was followed. 1. Welcome The author, a trainee nurse and relatively new to walk-in clinic, welcomed the patient and received her with a smile. He tried to make her comfortable enough to speak openly and without hesitation. The nurse tried to develop rapport with her and tried to make her feel at home. He was genuinely concerned about the patient. The nurse introduced himself before proceeding further. 2. Open question The UK government expects care organizations to behave more like a business in terms of delivering consistent care and quality (Standing, 2010). Upon seeing the patient’s face it was obvious that she was in pain. He asked the open ended question ‘how can I help you?’ Her mother started explaining that she had been complaining about pain while urinating. The nurse had to ask specifically the kind of pain to correctly understand the symptoms. He wanted to get as much data as possible so he let the patient and her mother talk about how she was feeling. 3. Facilitating The nurse kept nodding and showing all signs that he was attentively listening. Muhrer (2014) states that attentively listening to patients helps retrieve full patient history, which is a time saver when comes to diagnosis. Patient explained to me that she had been feeling severe abdominal pain while urinating and it had been over 24 hours since she first felt the pain. I was keen to get the medical history but I did not want to bombard Patient or her mother with questions. Bridge S. (2011) writes in his article that taking medical history is effective but it is disempowering to the patient. It is an empowering experience for the patient when they take the initiative in making a behavioural change (Bridge, 2011). Therefore I did not give the impression of me being all in control. He cooperated with the patient and aimed for retrieving ‘competency history’. There are seven major symptoms necessary to observe and list while taking the patient’s history; location, quality, severity, timing, background, aggravating/relieving elements and any related characteristics (Bickley & Szilagyi, 2012). These symptoms pertain to the chief complaint of the patient. It is also imperative to clarify the attributes of each symptom according to its context (Bickley & Szilagyi, 2012). The patient was asked about these symptoms exactly according to this system. 4. Ruling out ICE/Psycho-social By this time the nurse was certain that this was not an ICE. He specifically asked the patient about the severity of pain. She said it did not constantly hurt but only when she passes urine. Moreover, this was also not Munchausen or psycho-social stunt. In my opinion the majority of fake patients come alone or come with friends similar friends. After a small inquiry he deduced that although the patient felt pain but it was not an ICE case. 5. Focused questions I had to decide how to approach the problem. The patient was 15 years old and a good guess is that she was not sexually active. The NICE guidelines (2013) specifically address the urinary tract infections (UTI) in people under 16 years of age. When Patient told me about the nature and location of pain I was inclined to think in terms of UTI problems. Patient’s history and the physical exam should be the foundation for choosing the right diagnostic test (Muhrer, 2014). The patient’s vitals were checked; pulse was 68 beats per minute. I checked her temperature and she had a slight fever (a little above 37 °C). Validating and checking findings with the patient is crucial in building a working relationship between patient and the practitioner (Hinchliff & Rogers, 2008). I confirmed if she vomited in the past 24 hours, she hadn’t. The patient had no significant medical history relevant to this case. She was not taking any regular medication and was not allergic to drugs either. The past medical history helps in diagnosing the current problem. The patient was a student at a private school and took ballet lessons in the evening at a local dance club. Douglas et al. (2009) suggests that a patient’s social history helps reveal risk factors. For instance, a patient living near an industrial area is exposed to heavy metal toxins and other pollutants. This patient’s social history did not reveal anything medically relevant. 6. Summarising A nurse has to be fully aware of the importance of time. The nurse did not want patient’s mother to go on explaining about irrelevant things. About four minute into the consultation, he summarised the patient’s problem back to her and her mother to make sure that he had understood it accurately. It was also necessary to make them listen to their own problem so that they could add to or correct my understanding. He reiterated what he had learnt from the talk that the patient had been feeling abdominal pain while urinating for the past 24hours. She had a slight fever but did not have a history of this pain. 7. Examination The nurse explained that he would need to take the full medical history of the patient followed by a physical examination, so that a clear diagnosis could be reached. It was the nurses’ primary motive to make the patient and her mother feel relaxed and comfortable. Anxiety may impair a patient’s cognitive abilities (Ralph & Taylor, 2005). Bickley and Szilagyi (2012) mention that a full physical exam should accompany the patient’s medical history in order to accurately diagnose a problem. Genital examination is crucial to check for labial adhesions, epididymo-orchitis, vulvitis and phimosis (patient.co.uk). In adolescents and older children the symptoms suggestive of UTI make it straightforward to perform test to investigate UTI (Rothrock & Brennan, 2010). The nurse explained that a urine sample will be needed. Since the patient was 15, a clean catch urine sample was easy to get. This type of urine testing in older children is suggested by NICE Guidelines (patient.co.uk). The patient also had no history of infection or a risk of serious illness, there was no need for sending the urine sample for culture (patient.co.uk). The lab results disclosed that the patient’s leukocyte esterase and nitrite were positive. From the urine test it was obvious that patient had a mild case of UTI. The doctor confirmed the lab test results and prescribed the antibiotics for the patient. When there is no vaginal discharge or irritation and the urine test is 90% positive empirical antibiotic treatment is the recommended way to go (Health Protection Agency, 2011). I explained the dosage to the patient again. Research suggests that prophylactic antibiotics reduce the frequency of bacteruria and other makers of UTI (RCN, 2013). In such cases a small course (2-4 days) of oral antibiotics is sufficient (Burge et al., 2005). The patient was given antibiotics for two days and asked to visit the clinic on the third day for a follow up. 8. Shared Opinion Involving the patient in the diagnosis and decision making helps the patient understand and comply with the clinician’s instructions (Bickley & Szilagyi, 2012). The patient was diligently explained about the whole procedure; diagnosis, management and treatment. She was also explained that how to properly take care of herself along with other useful medical advice. The patient and her mother were given all the opportunities to ask questions and give opinions about the process. The purpose of spending time on explaining all this to the patient was necessary as it cleared any doubts and hesitation in the patient’s mind. 9. Closure The nurse was experienced in his field but he had been recently transferred to a walk in clinic, which was his first experience. During the consultation the nurse looked overly concerned about the patient. There was absolutely nothing wrong with his professional conduct. It only indicated that the nurse was a little nervous facing a new situation. It makes more sense why consultation models like Flanagan’s Clinical Skills Assessment (CSA) exist. It is not only for assessing the skills of a nurse but the nurses can also prepare their approach to a situation according to such models. In this particular case the nurse checked all the critical areas of consultation, especially taking patient history. The nurse’s experience showed in developing rapport with the patient, it made the patient comfortable. It is important for patients to be comfortable with their clinicians; otherwise they might withhold something when being asked about medical questions. The author successfully took the patient history through effective communication and will continue to do so in the future. His approach was effective and with more practice he will overcome the nervousness too. References 1. Bickley L. & Szilagyi, P. G., 2012. Bate’s guide to physical examination and history-taking. Lippincott Williams & Wilkins. 2. Bridge, S., 2011. A competency history- an additional model of history taking. Aust Fam Physician. Sep 40(9): 735-8. 3. Burge et al., 2005. Paediatric surgery, 2nd edition. CRC Press. 4. Douglas et al. 2009. Macleod clinical exam. Elsevier Health Sciences. 5. Flanagan. 2010. Flanagan’s consultation model. Pennine GP Training. [Accessed online] 6 July 2014 http://www.pennine-gp-training.com/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm 6. Health Protection Agency, 2011. Diagnosis of UTI- Quick reference guide for primary care. British Infection Association. [Accessed online] 6 July 2014 http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1194947404720 7. Hinchliff, S. & Rogers, R. (2008) Competencies for advanced nursing practice. CRC Press. 8. Muhrer, J. C., 2014. The importance of the history and physical in diagnosis. The Nurse Practitioner. Apr 13; 39(4):30-5. 9. NICE. 2013. Urinary tract infection in children: Diagnosis treatment and long term management. National Institute for Healthcare and Excellence. [Accessed online] 6 July 2014 http://www.nice.org.uk/guidance/CG54 10. N.d. Childhood urinary tract infection. Patient.Co.UK. [Accessed online] 6 July 2014 http://www.patient.co.uk/doctor/childhood-urinary-tract-infection 11. Ralph, S. S. & Taylor. C. M., 2005. Nursing diagnosis reference manual. Lippincott Williams & Wilkins. 12. RCN. 2013. Antibiotic Prophylaxis for Short-term Catheter Bladder Drainage in adults. University of South Wales Prifysgol De Cymru. [Accessed online] 6 July 2014 http://www.rcn.org.uk/__data/assets/pdf_file/0010/569152/2014_RCN_research_2.9.2.pdf 13. Rothrock, S. G. & Brennan, J. A. 2010. Paediatric emergency medicine. Elsevier Health Sciences. 14. Standing, M., 2010. Clinical Judgement and Decision- Making in Nursing and Interprofessional Healthcare. Open University Press. Read More