Peer Response – Ranveet – Reflection
Peer Responses:
For the SOAP notes, I completed HEENT for Adults >= 18 years, annual exam or wellness SOAP for Adults >= 18 years, annual exam or wellness SOAP for >= 65, Cardiovascular for Adults> 18, Endocrine Type 2 DM for Adults >= 18, Gastrointestinal for Adult>=18 years. For program completion, I will prioritize pediatric cases for infants, children, and teens. I should be able to complete all my pediatric cases and SOAP notes when I do my pediatric rotation in my third clinical rotation. We do not see my pediatric cases in the family practice clinic where I work. Therefore, I plan to do my third rotation at a pediatric clinic to get my required experience in pediatrics. My priority for my next clinical rotation is completing my women’s health case documentation. During this rotation, I saw women’s health cases, but I still need to make SOAP notes.
- Reflection of a Patient Encounter
During this course, encountering a 59-year-old female with a right arm swelling post-thyroid surgery was a memorable patient interaction. She came to the clinic for right arm swelling. She had her thyroid surgery done two weeks ago, and swelling happened to her right arm where they inserted an IV; it did not work and was removed. Several aspects of this encounter stood out and provided valuable learning opportunities. Firstly, the patient’s medical history was crucial in guiding the diagnostic and treatment decisions. Her history of deep vein thrombosis (DVT) and the recent cessation of Xarelto prior to surgery highlighted the importance of vigilant monitoring for thrombotic events in postoperative patients, especially those with a predisposition to clotting disorders.
The decision to order a venous ultrasound to assess for DVT was pivotal in this case. The positive results indicating a clot involving almost the entire right cephalic vein with no blood flow underscored the significance of timely diagnostic interventions. This emphasizes the importance of recognizing and investigating new or worsening symptoms, especially in patients with a history of thrombotic events. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the arms and the mesenteric and cerebral veins (Waheed et al., 2023). Collaboration with specialists, such as the hematologist, was instrumental in developing an appropriate management plan tailored to the patient’s needs. Deep-vein thrombosis can occur in many settings and almost every medical specialty; failing to diagnose DVT can result in a pulmonary embolism, which can be fatal (Waheed et al., 2023). Initiating Xarelto 15 mg BID and Aspirin 81 mg daily, in consultation with the hematologist, demonstrated the importance of interdisciplinary communication and shared decision-making in patient care.
Additionally, the follow-up referral to the hematologist for further investigation into the underlying causes of the patient’s recurrent DVTs reflects a commitment to comprehensive patient management and addressing potential contributing factors beyond the immediate thrombotic event.
If faced with a similar patient scenario, I would ensure thorough documentation of the rationale behind diagnostic and treatment decisions, including discussions with specialists and the patient. Additionally, I would prioritize patient education regarding the importance of medication adherence, signs and symptoms of thrombotic events, and the need for regular follow-up appointments for ongoing monitoring and management.
Overall, this patient encounter reinforced the significance of a holistic approach to patient care, integrating medical history, diagnostic assessments, interdisciplinary collaboration, and patient education to optimize outcomes and ensure patient safety.
References
Waheed, S., Kudaravalli, P., & Hotwagner, D. (2023, January 19). Deep vein thrombosis. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK507708/
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