Epilepsy Patient Clinical log

General: She has weight loss of 6kg, but no fatigue, body weakness, malaise, pain, no episode of

fever, has normal activity.

Head and neck: She have no headache, dizziness, seizure, neck stiffness, no thyroid issues.

Vision: She has short sightedness and wearing glasses. There is no cataract, glaucoma, redness,

burning, and discharge of eyes.

Ear: She have no hearing issues, ear pain, discharge. She has never undergone any hearing

assessment before.

Nose and sinus: She has good ability of smell. There is no running nose, no colds, nose blockage,

voice change and epistaxis.

Mouth and throat: No history of mouth or throat cancer, bleeding and swollen gums. Never done

dental assessment before

Cardiovascular: No chest pain, palpitations, did ECG last year and results were normal.

Respiratory: No wheezing, sputum production, cough, no TB contact.

GIT: No loss of appetite, nausea, constipation, diarrhoea, change in stool colour.

Genitourinary: No pain and change in urination, nocturia, incontinence, urgency

Hematology: No bleeding disorders, regular blood transfusions, easy bruising

Neurological: No tremor, loss of sensation and coordination, numbness, and no stroke or brain injury

Endocrine: No polydipsia, polyuria, no changes in body hair and body fat distribution

Musculoskeletal: No deformity, change in strength, history of muscle injury

Peripheral vascular: Mrs Y has no peripheral oedema, claudication, ulcer, and peripheral vascular

disease.

Skin & hair: No history of skin, hair, and nail disease. There is no itching, pigmentation change,

no thick or yellow nails, and no hair loss.

O&G: Attained menopause 15 years ago, no uterine or ovarian cancer. Had 2 pregnancies and 2

children. Never done pap smear before.

Anus and rectum: No history of haemorrhoids, and rectal cancer.

Mental health: Has no history of having psychiatric illness and no psychiatric symptoms.

Breast examination

Inspection:

I asked patient to sit on bed with arms at her side, then hands clasped overhead and tensed, then I asked her

to put hands on hips and then lean forward.

Breast

Left and right breasts are same size, pendular shape, and symmetrical. The colour of left and right

breast was normal, and visible lump was seen in the upper outer quadrant of right breast, with no overlying

skin lesion, no oedema, dilated veins, dimpling, no orange peel skin, surgical scars, retraction, and bruises.

Nipple and areola

The left and right nipple looks pink, symmetrical both nipple in same direction, no retraction, inversion,

no nipple lump noted, no supernumerary nipples. There is presence of bloody nipple discharge of right

breast.

Axilla

Right and left axilla looks normal colour, no lesions, equal hair distribution.

Palpation:

I asked patient to lie in supine position and I first examined the non-affected left breast. I did light, medium,

and deep palpation in a circular motion. I palpate the breast in overlapping vertical strips and continue until

covered the entire breast including the axillary. I palpated around areola by pressing nipple gently between

thumb and index finger. I then lowered patient’s arm and palpate for axillary lymph nodes.

Breasts

Left breast has normal texture, soft consistency, no tenderness, and no mass were palpated. The right breast

has a normal texture, firm consistency, non-tender, and mass was palpated in the upper outer quadrant of

right breast. Mass is oval shape, 3x3cm, asymmetrical surface, hard consistency, irregular border, non-tender

and immobile.

Nipple and areola

The left nipple and areola have normal elasticity, no tenderness, and no discharge. The right nipple has

reduced elasticity, non-tender and has bloody nipple discharge.

Lymph nodes

I examined the lymph nodes assessing their size, shape, symmetry, consistency, mobility, borders, and

tenderness. The anterior cervical, supraclavicular, infraclavicular, axillary, and epitrochlear lymph nodes are

not palpable.

· Reflection–on-action and clinical learning:

a) Describe 2 ways your nursing health assessment skills expanded during this experience

· I am more well versed now to perform breast examination on patients as I have the skills and experience. Moreover, by practicing this assessment I able to plan a proper nursing care for my patient.

· I have improved my communication skills, since now I can enquire deeper personal details of patient in a proper way.

b) Name 2 things you might do differently if you encounter this kind of situation again

· I will advise female patients to do regular breast examination by themselves at home, and if they discovered a lump, I would ask them to get it checked by a doctor immediately so that we can intervene at an early stage to prevent widespread of disease.

· I will ask patient’s female family members such as her niece and cousins to get screened, as this breast cancer is a genetic disease running in her family.

c) What additional knowledge, information and skills do you need when encountering this kind of situation or similar situation in the future?

· I should learn about different examination techniques, positions, and ways to check patients of different ages, body habitus, and body types. I must know about the differential diagnosis of breast swelling to correctly diagnose patient.

d) Describe any changes in your values or feelings as a result of this experience.

· I learnt about the importance of always keeping our health in check, anyone is predisposed to all kinds of diseases, hence I realized that we must always check our body, pay attention to it, and try to keep ourself healthy by doing regular checkups.