Anonymised Patient records

      Complete a case study of a single patient. This must be from first contact with the clinic, consultation, delivery of treatment and follow up.. The patient must have been treated for at least 4 weeks. All identifiable data must be anonymised but may be required, at source, for external verification by the Awarding Organisation for Audit purposes. Minimum 2,500 word count. Task Guidance 1. Your answer should include, anonymised Patient records; and a full refection on your own practice Reflective account. Guidance notes; 1. Patient records; initial enquiry, consultation, imagery pre and post treatment, you may like to add a perceived final outcome for comparison. You must include your initial treatment plan with ongoing amendments if changes have been made, any test results you have carried out, consent form, any contemporaneous notes you have made, any issues elucidated at consultation, your preferred treatment and the outcomes plus any post treatment advice/products. If any adverse or side effects were felt these should also be noted in your patient notes. MS X presented as young lady being mother of two young children. She reports looking tired and was looking for a way to enhance her look by giving a bit of definition to her lips. She stated had the treatment in past few years but never had her lips done recently. Prior to the procedure , steps of the treatment was explained thoroughly and patient consented to have the treatment. I went through the juvederm questioners and consent form (see appendix ) I treated Ms X with Volbella juvederm 0.5 ml. The patient was happy with the look and the possible side effect (such and such) was explained. Alternative ways to enhance lip (such as make up technique, such and such) was explained however the patient was insisting to have the lip filler. The area was cleaned to make sure there where no make up. The cost and possible side effect (Bruise and swelling) was explained as well as after care was explained. MS X consented to have the treatment. With her consent photo was taken both for clinical and educational purposes.) Her lip was treated with 0.5 ml of volbella across the lips. (Talk about which point injected far end and vlomillion border as well as the body of the lip also talk about the teqnich was use: linear treading) The patient had opportunity to hold the mirror and watch the whole procedure and comment on areas she wanted more or less improvement. She was happy with the final look and did not show any signs concerns. The patient was so easy to communicate with very friendly individual and the whole treatment was straightforward. After care was explained again and the patient gave two weeks of follow up. Unfollowup day the patient was still happy with the overall look however she reported that she noticed a lump in her inner upper lip in wet area. Patient was made confortable on the coach and the area was cleaned and made sure there where no makeup. with Ms X’s consent the area which was concerning her was checked. We noticed there was a tiny sack full with derma filler lacetd in her inner wet area of upper lip. My supervisor tried to verbally calm the patient and Ms X was informed dermalfiller has travelled very close to her skin surface thereby the lump has formed and its notable to touch. The options was given to inject hyaluronidase to dissolve the filler however the squeezing method was also explained . Ms X preferred to try the squeezing method first and my supervisor then squeezed the filler out of her inner lips by applying a gentle pressure. The filler was the started oozing out and the sack gone flat. The area was cleaned and after care was explained. Ms X was happy of the outcome of the procedure and she was given opportunity to contct the clinic if any further issues concerning her. 2. Reflective account; In your reflective account you should make reference to the patient, gender, age, mental wellbeing, skin type/colour any anomalies, an account of the treatment delivered and the outcome. Your assessor will be looking to ensure this is a true reflection so it is essential to say what you did, why you did it, how you did it, what went well, what didn’t go so well and given the same circumstance what you would do differently. Your assessor will also be looking to see that other parts of the qualification have been included e.g. Skin Anatomy, Consultation skills, Procedure followed, Health and Safety, Critical Literary Review and Values, ethics, and professionalism