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Clinical Experience: Week 2

During clinical this week I saw several patients with a variety of different ailments. I believe a challenge that I did face was that several of the patients I worked with at the clinic needed to be referred to the emergency room for further treatment. Although I was able to complete their patient interview and assessment, I don’t feel like I was able to see their whole case through due to them being sent to the emergency room. I am hoping when I return to my clinical site I am able to discuss their cases with my preceptor based on the follow up they performed. A large success for this week at clinical was my charting. The first week was challenging learning a new system, and I often felt that I was asking too many questions! Now I feel more comfortable, and have learned a lot about different diagnosis codes.

During this week one patient that stands out was a 62 year old male who presented to the clinic with a chief complaint of “I think I have a blood clot”. Prior to seeing this patient my preceptor and I were immediately concerned that this man should have sought emergency care if he believed he had a possible clot. The patient presented with a large painful, fixed bruise just below his left knee. He reported that the bruise popped up approximately one week prior, and he does not recall any trauma to that area of his body. The patient states the bruise is painful to the touch, and has a “pulling” feeling when he twists or moves his leg. He informed us the bruise has not gotten any better, and he was concerned it may be a blood clot. Deep vein thrombosis, or DVT, generally present with asymmetrical swelling, warmth, or pain in an extremity (Stone et al., 2017).

The patient’s vital signs were stable and he denied any shortness of breath. On assessment the patient was in no acute distress and had no abnormalities other than the nodule. Skin assessment revealed firm, fixed half dollar sized nodule to his medial left lower leg, just below left posterior knee, mild edema, warm to touch, with surrounding tissue discoloration, and pain with palpation. Due to being unable to complete scans in the clinic the patient was referred to the emergency room for an ultrasound and further treatment. As discussed by Stevens et al. (2020), compression ultrasonography, or CUS, has become the most common imaging method to evaluate suspected deep vein thrombosis of the leg. The patient was educated on the risks of DVT including the development of a pulmonary embolism, which may occur in one third of DVT cases and is a primary contributor to mortality (Stone et al., 2017).

Differential diagnosis for this patient may include a hematoma, cyst, or sarcoma. Hematomas are defined as a blood collection outside of the blood vessels, these are often plainly called bruises. Generally, hematomas resolve on their own by being reabsorbed. Cysts are pockets within the membrane which can consist of fluid and other substances. Majority of cysts are benign, and do not need further investigation. Finally, sarcomas may often masquerade as hematomas or DVTs, but actually represent malignant soft tissue tumors which arise from the connective tissue (Valverde et al., 2016).

I believe my clinical experience this week will allow me to be open to exploring differential diagnoses for patients. As practitioners I believe we often get set on certain diagnoses and sometimes disregard the possibility of others. An additional benefit I will take with me into my practice as an advanced practice nurse is the importance of following up with patients. I believe it is necessary to see a patient through to resolution, although sometimes this can be difficult when the need for referral arises.

References

Stevens, S., Fazili, M., & Woller, S. (2020). Choosing ultrasound technique for suspected deep vein thrombosis: Which is best?. Quantitative Imaging in Medicine and Surgery, 10(6), 1418–1421. https://doi.org/10.21037/qims-2020-18

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: Pathogenesis, diagnosis, and medical management. Cardiovascular Diagnosis and Therapy, 7(3), S276–S284. https://doi.org/10.21037/cdt.2017.09.01

Valverde, J., Vinagreiro, M., Gouveia, P., Koch, P., Soares, V., & Gomes, T. (2016). Sarcoma the great “masquerader” hematoma/deep vein thrombosis manifestation. International Journal of Surgery Case Reports, 28, 348–351. https://doi.org/10.1016/j.ijscr.2016.10.041