Patient ecords

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 anonymized but may be required, at source, for external verification by the
Awarding Organisation for Audit purposes. Minimum 2,500-word count. Patient records:
Task Guidance
1. Your answer should include, anonymized Patient records;  and a full reflection on your own
practice Reflective account.
Guidance notes;
1. Patient records; initial inquiry, 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,
a consent form,  any contemporaneous notes you have made, and 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 a young lady the 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 the past few years but never
had her lips done recently. Prior to the procedure, the steps of the treatment were
explained thoroughly and the patient consented to have the treatment.

I went
through the Juvederm questionnaires 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
the lip (such as makeup technique, such and such) were explained however the
patient insisted to have the lip filler. The area was cleaned to make sure
there was no makeup.

The cost and possible side effects (Bruises and swelling) were explained as well as
aftercare 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 volvelle across the lips. (Talk about which
point injected far end and vermillion border as well as the body of the lip also
talk about the technic was used: linear treading)

The patient had the 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 of concern. The patient was so easy
to communicate with a very friendly individual and the whole treatment was
straightforward. After care was explained again and the patient gave two weeks
of follow-up.

On Unfollow day the patient was still happy with the overall look however she
reported that she noticed a lump in her inner upper lip in a wet area. The patient was
made comfortable on the couch and the area was cleaned and made sure there
was no makeup. with Ms. X’s consent, the area which was concerning her was

checked. We noticed there was a tiny sack full of derma filler placed in the
inner wet area of her upper lip. My supervisor tried to verbally calm the patient and
Ms. X was informed dermal filler has traveled very close to her skin surface
thereby the lump has formed and it’s notable to the touch.

The option 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 gentle pressure. The filler started oozing out and the sack
went flat. The area was cleaned and aftercare was explained. Ms. X was happy with
the outcome of the procedure and she was given the opportunity to contact 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 well-being,  skin type/color 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

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