Sue denied any of these symptoms which made it less likely boston college application essay topics a diagnosis ultimately. On enquiry Sue told me that she used Depo- Provera injections for contraception and dysmenorrhoea and consequently did not menstruate.

I auscilated for bowel sounds in the four quadrants and as these were heard and of normal tone I was able to rule out an acute abdominal problem. I then percussed her abdomen and found no change to expected tympani. When I palpated her suprapubic region Sue complained of discomfort, this tenderness is indicative of bladder inflammation.

Bowel history and examinations were normal so constipation was also discounted. As Sue had a record of in date contraceptive cover with an injectable contraceptive and denied sexual intercourse I discounted pregnancy. Although I was aware that Pelvic inflammatory disease could account for her symptoms, examination findings had not supported these hypotheses and were all negative at this stage.

Sue confirmed that she had no side effects from this medication and that she was willing to take it. This is in line with prodigy guidance and local prescribing policy. As this was the treatment plan Sue had originally requested I was confident of concordance. I discussed with Sue some steps she could take to try and prevent reoccurrence of infection. These includes toilet hygiene front to back wipingpost-coital micturation, regular voiding and reiterated early symptom self help measures with increased fluid intake and OTC cystitis remedies.

I am a non medical prescriber and generate prescriptions for patients. I work autonomously within my agreed scope of practice and am supported by the structure of a small organisation of professional clinical and administrative staff, boston college application essay topics.

Boston college application essay topics will discuss the consultation and show how I used the problem solving consultation style detailed by Alison Crumbie. Focused questioning and clinical examination and investigations will then be used to eliminate some of the initial hypotheses. I provide first contact appointments for patients registered with the practice each morning on a walk-in basis.

She said that her abdominal pain reduced after taking paracetamol but reoccurred after a few hours. She requested a prescription of the same antibiotics she had last time she had this problem. Forming the initial conceptMy first impression of Sue was that she was smartly dressed, of normal weight, looked physically well and did not appear to be distressed.

Reflection in and on practiceI felt that this was a satisfactory consultation for both the patient and me. It began with the patient stating that she thought she knew what was wrong with her and what action needed to be taken to resolve the problem. Proceeding with focused inquiry and utilizing clinical examination skills enabled me to discount some of these hypotheses, and by using structure, reminded me of hypotheses I had originally forgotten to include.

Developing the problem synthesisWhen I considered the presenting problem, my history and examination findings, and compared them with my original hypotheses I found that I was able to eliminate some at this stage. As Sue had no fever, nausea, haematuria or costovertebral pain I discounted pylonephritis, boston college application essay topics.

She appeared systemically well to me but possibly had cystitis, boston college application essay topics. It is important to think as widely as possible about potential causes to generate broad hypotheses which can then be narrowed down with focused enquiry and investigations Crumbie et all The quality of hypotheses is dependent on the practitioners experience in eliciting information from the patient and in translating this information into boston college application essay topics number of potential scenarios.

She attended alone and I could see from her patient record that she was 25 years old. I try not to interrupt the patient as they respond and so give them the opportunity to relate what they think the problem is and what it is they think I can do to help them manage this problem.

On reflection I need to be able to balance the quality of the consultation with the quantity of patients requiring attention during a session, boston college application essay topics.

The patientwhom I will call Sue, boston college application essay topics, presented in the walk-in Surgery and told me she had had three days of stinging pain on passing urine, increased frequency of passing water and intermittent low abdominal discomfort, boston college application essay topics. She also said that she had a water infection three months previously and that she thought that she now had the same problem. She had tried over the counter OTC medications and had increased the amount of fluids she drank with little effect.

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Sue declined an internal exam at this time. I noted from records that Sue had not had a smear test so I offered to do this at this time. After explanation Sue agreed to this. I asked Sue to undress from the waist down and to lie on the examination coach. I ensured that she was comfortable screened and relaxed before commencing the exam.

Genital herpes causes ulcerated areas and scratching can cause minor skin lacerations. This external exam was normal. I continued with the vaginal examination. If there is infection in the uterus this test can elicit pain. Sue did not have any pain on testing, boston college application essay topics. I then inserted the speculum and examined the vaginal walls for signs of injury or discharge.

boston college application essay topics

It is important that the information offered by the patient is understood boston college application essay topics and not translated badly by the practitioner. For example a patient may say they felt sick and the practitioner understands this as feeling nauseated whilst the patient meant they felt generally unwell.

Sue told me that she got a burning pain on passing urine and thought that she had cystitis. She told me that last time she had a similar problem she was given antibiotics tablets.

Sue told me that she had tried to self manage with OTC medications for pain relief and for cystitis for the past 2 days but had had no lasting relief from symptoms. She said that a few hours after taking paracetamol her pain returned. My boston college application essay topics concept was of an articulate, boston college application essay topics, well dressed woman, who had decided that she was experiencing a urinary tract infection UTIwho had tried unsuccessfully to manage her symptoms her self and was now requesting assistance from a health care professional.

On later reflection I realized I could have though about interstitial cystitis, boston college application essay topics, appendicitis and renal calculi. My multiple hypotheses for this patient are presented in Table 1. Formulating an Inquiry StrategySue had told me that she had pain on passing urine and as I focused my questioning she told me her urine appeared darker in colour than normal and smelled different than usual.

This was also normal, inspection of the cervix and of the os showed no discharge and this combined with a negative chandelier sign now made the diagnosis of pelvic inflammatory disease less likely. I performed a smear test and took samples for HVS and Chlamydia testing. My initial hypotheses of cystitis now seemed most likely as the cause of symptoms. During this examination sequence I was reminded to consider appendicitis as a hypothesis in the future with this set of presenting symptoms.


I then asked her about her sexual history. Sue told me that she was currently celibate and had not had a sexual relationship for one year. I enquired about her bowel habits and Sue told me that she had passed a soft stool that morning as was her normal routine and that there had been no recent change to bowel actions. This enabled me to focus my questions and to analyse symptoms and Sues responses. It is especially useful when assessing symptoms of pain and enabled me to detail a focused history of her complaint.

Palpation of the costovertebral angles induced no pain response from Sue and as I recalled her vital signs and presenting history I felt able to exclude pylonephritis also. Inflammation and discharge are common with Candida and other vaginal infections, boston college application essay topics.


boston college application essay topics

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Diagnostic decision makingMy differential diagnosis was cystitis. She wanted her health care provider to facilitate this request. She had tried self management and used OTC preparations before presenting in surgery. This showed me that she was motivated in trying to achieve resolution of her problem.

I also provided Sue with a printed Patient Information Leaflet about self help measure for women with cystitis. I advised Sue that she should find her symptoms improving within the next 24 hours and asked to return to either the practice or the NHS Walk in Centre depending on hours of opening if she had no improvement in 48 hours or if her symptoms changed and she became feverish or pain increased.


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I have used this technique extensively since commencing Nurse Practitioner training and have found it easy to remember and that it adds a structure to my questioning that was previously lacking. Incorporating the patients perspectiveFollowing the above questioning, I went on to discuss with Sue her own concept and concerns regarding her presenting complaint.

As these measures had not been successful in this instance we could agree a short course of oral antibiotics would be an appropriate treatment plan. As I had access to Sues health record I could see that she had been prescribed trimethoprin previously.

I asked Sue what she thought was causing her problem, what she thought was required to rectify the problems and what could help prevent reoccurrence. She told me that she was sure that she had another episode of cystitis and that she needed antibiotics.

I explained that these could be signs that the infection was moving up towards her kidneys and that this would require urgent review.


I explained that I had given her an antibiotic which would work for the majority of infections but that on some occasions is not effective and a different antibiotic is necessary. I provided her with this information so that she could make sense of any change in symptoms and would be more likely to present earlier for a consultation with a health care professional if there was treatment failure.

I recorded her vital signs. She was apyrexial These results are within normal limits for a person of her age. I performed near patient testing in the surgery with urine dip stick testing. This showed a positive response to nitrates and leukocytes. I did not have facilities for near patient pregnancy testing, and on reflection would not have performed one at this time in this case due to her contraceptive history. I chose not to send a test off to the laboratory for pregnancy testing for the same rational.

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Following on from this I was able to reach a diagnostic decision and make therapeutic interventions, boston college application essay topics. Throughout I was communicating with the patient, boston college application essay topics, offering education and involving her in her care which should translate to better concordance with boston college application essay topics plans and improved patient satisfaction with the consultation. This consultation took me 18 minutes to conclude and although I feel that I covered a wide range of potential hypotheses concerning the initial complaint and responded effectively to boston college application essay topics patients concerns, I did feel time pressured.

I noted her abdomen was of normal appearance with what appeared to be an appendicectomy scar. Boston college application essay topics confirmed that she had had her appendix removed as a child.

She described the pain as stinging and said that it was provoked by micturating and relieved a minute or so after she stopped boston college application essay topics. I asked her to point to where the pain was in her abdomen and she indicated the suprapubic region. She gauged the pain to be level 6 on a pain scale of without analgesia but did say it was relieved by analgesia and resolved to a feeling of pressure rather than pain at that time.

She also denied any spotting of blood. Her last injection was given in practice 40 days previously and by reviewing her notes I could see her history showed timely attendance for these injections. Although I knew that both dysuria and suprapubic pain can be experience in both normal early pregnancy and in eptopic pregnancy, and that cystitis is more common in pregnant women, I felt I could now discount pregnancy as a cause of her symptoms due to her contraceptive history.


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