Professional Development
- 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?
- this 28 you African pleasant female, presents with complaints of stomach pains that started a month ago. “feels like heartburn” Relieved with antacids, but is getting worse. Pain 1-2 right now, but a 5/10 after eating. Eating makes it worse. Sitting up helps. PMH: diabetes: no meds: Asthma: on proventil and albuterol: controlled Social hx: hx of THC use, none now. drinks 3-4 cans of soda in a day. ROS: heart burn normal form of stools, no diarrhea or constipation : Denies mental health issues: FMK PGF with colon cancer Diet: lots of fried and fast food: Exercise: limited Shadow Health
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HPI: Ms. Jones is a pleasant 28-year-old African American woma who presented to the clinic with complaints of upper stomach pa after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 time per week. Pain is a 5/10 and is located in her upper stomach. Sh describes it “kind of like heartburn” but states that it can be shar She notes it to increase with consumption of food and specifical fast food and spicy food make pain worse. She does notice that has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “ev few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recen but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chip dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink cola on a regular basis. She denies use of tobacco and illicit drug She drinks alcohol occasionally, last was 2 weeks ago, and was drink. She does not exercise. Review of Systems: General: Denies changes in weight and gene fatigue. She denies fevers, chills, and night sweats. • Cardiac: De a diagnosis of hypertension, but states that she has been told he blood pressure was high in the past. She denies known history o murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturna dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization wa age 16, last chest XR was age 16. • Gastrointestinal: States that general her appetite is unchanged, although she does note that s will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, a constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequenc Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen. Shadow Health
- Educate on lifestyle changes including weight loss, engagement daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcoh and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduc • Encourage to eat smaller meals and to avoid eating 2-3 hours before bedtime. • Educate on dietary reduction in fat to decrease symptoms. • Trial of ranitidine 150 mg by mouth daily for two we If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, consider testing for helicobacter pylori, trial o proton pump inhibitor, or upper endoscopy. • Educate on when t seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Retur clinic in two weeks for evaluation and follow up.Patients Spiritual Needs: Case Analysis