PRAC 6531 WEEK 6 CLINICAL HOUR AND PATIENT LOGS PAPER

PRAC 6531 WEEK 6 CLINICAL HOUR AND PATIENT LOGS PAPER

PRAC 6531 WEEK 6 CLINICAL HOUR AND PATIENT LOGS PAPER

UTI

S: F.G is a 58-year-old female presenting with a chief complaint of increased urinary frequency, burning and pain when passing urine. The client stated that the urinary symptoms were similar to previous UTIs. The symptoms begun about two days ago. She also had increased lower abdominal pain and vaginal discharge in the past week. She described the abdominal pain as severe, constant and has no aggravating or relieving factors.

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O: Vital Signs:  BP -100/80, P- 80; R: 16; T: 99.7 F; Wt. 120 lbs.; Ht.5’0; BMI 23.4.

Abdomen: Soft and tender on palpation with suprapubic tenderness.

Genital/Pelvic: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage.

Leukocyte differential: Neutrophils 68%, Lymphs 13%, Bands 7%, Monos 8%, EOS 2%.

Urinalysis: Straw colored. Specific gravity- 1.015; pH- 8.0; Protein-negative; Glucose- negative, Ketones- negative; Bacteria – numerous, Leukocytes: 10-15; RBCs 0-1.

Urine gram stain – Gram-negative rods.
A: PID and Cervicitis were ruled out. 

P: Nitrofurantoin 100 mg oral twice daily for 7 days. Counseling on hygiene interventions to prevent UTIs including wiping front to back.

GERD

S: J.L. is a 36-year-old female who presented to the office complaining of food regurgitation and heartburn. She reported symptoms began about six days ago when she noticed food regurgitating, especially the evening meals. This mostly occurs when she goes to sleep and feels a bitter substance in her mouth. She describes the heartburn as occurring on the non-radiating and has a duration of roughly 5-10 minutes. She also reports occasional epigastric pain, belching, and swallowing difficulty. The patient had been taking antacid tablets to relieve the heartburn, which was effective, but she is worried about the regurgitation.

O: The abdomen is round and soft with no distension or scars. Bowel sounds are normoactive. No epigastric or abdominal tenderness on palpation. No abdominal masses or organomegaly.

A: Heartburn, regurgitation, epigastric pain, swallowing pain, and belching.

P: Omeprazole 20 mg orally once daily for 4 weeks.

Gastroenteritis

S: C.V is a 64-year-old A.A female patient presented to the clinic with complaints of abdominal pain and diarrhea. She reported that the abdominal pain was generalized to the entire abdomen. The abdominal pain began three days ago. She described the pain as crampy, non-radiating, and intermittent, but it had no specific timing. The diarrhea also began three days ago and was characterized by loose, watery stools occurring about seven times a day. The patient reported that the abdominal pain and diarrhea were accompanied by nausea, vomiting, and mild fever. He denied experiencing epigastric pain, abdominal distension, or bloody stools. The abdominal pain has no aggravating factors, but it is temporarily relieved by taking Antacid gel. The patient rated the abdominal pain as 5/10. He denied having traveled in the past week.

O:  Flat abdomen with smooth movements on respirations. Hyperactive bowel sounds in all quadrants. Mild, diffuse abdominal tenderness. No palpable masses or muscle guarding. No hepatomegaly or splenomegaly. In the rectum, the anal sphincter was intact and no rectal fissures were present. Stool microscopy was negative for ova and cyst, and the Complete blood count revealed mild elevated WBCs.

A: Viral gastroenteritis was identified since the patient had a low-grade fever. Bacterial gastroenteritis and food poisoning were ruled out.

P: Treatment included Loperamide 4 mg initially, then 2 mg after every loose stool.

S: A.M is a 27-year-old White female who presented with a chief complaint of frequent headaches. She began experiencing headaches five days ago. The headaches are intermittent and last 10-20 minutes. She described the headache as diffuse, occurring all over the head, but the greatest intensity and pressure occurred above the eyes and spread through the nose, cheekbones, and jaw. She denied experiencing any associated symptoms. The headache is worsened by bending over and activity, which interferes with her job activities. She reported taking Aspirin to relieve the headache and resting, which lessened the intensity of the headache. She rated the headache as 5/10.

Headache

S: W.F is a 47-year-old White female who presented with a chief complaint of frequent headaches. She began experiencing headaches five days ago. The headaches are intermittent and last 10-20 minutes. She described the headache as diffuse, occurring all over the head, but the greatest intensity and pressure occurred above the eyes and spread through the nose, cheekbones, and jaw. She denied experiencing any associated symptoms. The headache is worsened by bending over and activity, which interferes with her job activities. She reported taking Aspirin to relieve the headache and resting, which lessened the intensity of the headache. She rated the headache as 5/10.

O: Vital Signs: BP- 118/76; Resp- 20; HR- 88; Temp- 98.78 F; Weight- 137 lbs.; Height- 5’5; BMI- 22.8. Tenderness on the cheekbones and jawline and on the orbital area, and the frontal sinus was palpable. Respiratory and cardiovascular exam findings were normal.

A: Bilateral diffuse headache; Sinus headache.

P: Phenylephrine nasal 0.25% PRN to offer symptomatic relief by shrinking the inflamed and swollen nasal mucosa. Tylenol to relieve headache. Advised to perform warm compresses on the painful facial areas to relieve pain.

Anemia

S: D.B. is a 61-year-old female patient who presented to the clinic with complaints of feeling tired all the time. She reported that feeling tired all the time, and now, more recently, she feels weak and cannot catch her breath at times. The patient has been healthy except for high cholesterol, managed by Lipitor. She attributes the fatigue to dealing with her husband’s death, who died nine months ago. However, she admits that she is feeling worse and not better as time passes. Positive findings on ROS: Weight loss, fatigue, body weakness, and dyspnea.

O: Vital Signs: BP-106/70 mm Hg; HR-66; Temp-98.0 F; Resp-18; BMI- 22.

Conjunctiva pale. Heart tachyarrhythmia with regular rate; Soft mid-systolic murmur.

Hb- Low, RBCs-Low, MCHC-Low-, MCV-Low

Urine dipstick- Negative.

A: Anemia identified as the diagnosis.

P: Peripheral smear; Ferrous sulfate (Extended-release) 160 mg orally, once daily; Folic Acid 400 mcg orally, once daily. Nutritional counseling.  Follow-up after four weeks.

Osteoporosis

S: A.D is a 68-year-old White female with a complaint of pain in the right thigh. She states that the pain began four months ago and has worsened over time, causing discomfort in ambulation. The patient has a history of a right hip fracture which she sustained a year ago. She states that the pain occurs when she is walking and is worse when she is carrying a load. F.L reports that the hip joint has limited motion, and the right thigh rotates externally when in a resting position. She mentions that the thigh pain is associated with low back pain, which began almost four months ago. F.L has taken OTC Tylenol to relieve the pain. She rates the pain at 4/10.

O: Neurological- Poor balance; Abnormal gait.

Musculoskeletal- Muscle strength at 4/5. Reduced hip range of motion reduced internal rotation and flexion of the hip joint.

DXA Scan: Low bone mass density (BMD).

A: Low bone mass density. Ruled out Hyperparathyroidism and Page Disease.

P: Plain x-ray of the right femur. Lab testing for serum magnesium, calcium, and phosphorus.

Meds: Alendronate 10 mg OD; Calciferol 600 units OD; Calcium Citrate 250 mg BD.

Physical and Occupational therapy.

Type 2 Diabetes

S: S.T is a 75-year-old White male on his diabetes follow-up. He stated that he is fine with no health concerns. The client is currently on his seventh routine diabetic check-up today. He was in the diabetic clinic two days ago for fasting labs. He reported taking his medications as prescribed but often has low blood sugars, making him feel shaky and weak. He takes cookies, 3-4 candy bars, and ice cream to improve his low blood sugar when hypoglycemic. The patient’s blood sugar is not well-controlled and has not achieved the target HbA1c levels. He has a history of Type 2 DM and HTN. He is currently on Metformin 2000 mg OD; Glyburide 4 mg OD; HCTZ/Losartan 12.5/100 mgs; Amlodipine 5 mg for HTN; Fetorbostatin 40 mg.

O: CVS- Some degree of peripheral edema. Dorsalis pedis and posterior tibialis pulses are slightly diminished +1.

Neurological: Positive sensation on monofilament testing. Reduced vibration sensation on tuning fork testing. Very diminished DTRs on the ankles bilaterally. 

HbA1c- Above the normal range; FBS-140 mg/dL.

A:  Uncontrolled diabetes; Hyperglycemia;   Occasional hypoglycemia

P:  Continue with Metformin 2000 mg OD; Glyburide 4 mg OD; HCTZ/Losartan 12.5/100 mgs; Amlodipine 5 mg for HTN; Fetorbostatin 40 mg. Nutritional counseling.

Major Depressive Disorder

S: T.R is a 62-year-old AA female client on follow-up for MDD. She previously presented with symptoms of a prolonged sad mood and loss of interest in her work and social interactions. She reported having lost interest in hanging out with her friends and avoided social gatherings, yet she previously found them pleasurable. She was sad and felt empty most of the time for most days. In addition, the client mentioned that she was constantly tired and had low energy to work which negatively affected her productivity at work. Besides, she slept for more hours than usual but still felt the need to sleep after. She had also noted a reduced ability to make decisions and concentrate in her job.

O: The self-reported mood is sad and affect is constricted. Her speech is clear but the volume and rate varies from normal to low. Coherent and logical thought process. No phobias, delusions, hallucinations, or suicidal/homicidal ideations were noted.  She is oriented to person, place, and time. Her short-term and long-term memory is intact.  Judgment, abstract thought, and insight are grossly intact.

A: Depressed mood. Disturbed sleep pattern. No risk of self- mutilating behavior. PHQ-9 score- 15.

P:  Continue with Zoloft 50 mg/day.

Alcohol Use Disorder

S: A.L is a 57-year-old Hispanic male patient with a habit of excessive alcohol consumption. He admitted to excessive alcohol intake for the past five years and has been on rehab twice. The client reported that he began taking alcohol when he was 19 years. In the first four years, alcohol intake was occasional mostly on weekends and during parties. However, the consumption increased progressively to a point that he could not go a day without a glass of whiskey. Besides, he would begin the day with two shots of alcohol to help him last the day and prevent being restless.  The client admitted using a large percentage of his salary to buy alcohol. He has also been fired twice because of coming to work drunk.  He reported drinking 4-6 glasses of whiskey or Tequila daily.

O: The client is well-groomed and appropriately dressed. He is alert, oriented, and maintains eye contact throughout the session. The self-reported mood is okay and affect is congruent. His speech is clear with normal rate and volume. Thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal/homicidal ideations were noted. The client is preoccupied with thoughts of reducing alcohol craving and changing his drinking habits. Short-and long-term memory is intact. Attention and concentration span is somewhat limited. Abstract thought, judgment, and insight are intact.

A: Alcohol Use Disorder.

P: IM Naltrexone 380 mg every 4 weeks.

Generalized Anxiety Disorder

S: D.M is a 47-year-old White female who expressed excessive worries about her job and whether she would have enough sales to get commissions. She is a real estate agent and her job entailed showing houses on sales to potential clients and negotiating a deal on behalf of the owners. Her income depended on the number of houses she sold. The client stated that her work was overwhelming since she had to convince clients to purchase houses and if she failed to, she would not make an income. The fear of not making enough money from commissions to sustain her family led to excessive and uncontrollable worries, which left her restless. She stated that the restlessness affected her concentration levels and would often go blank when showcasing houses or negotiating deals. Besides, she reported being easily fatigued, having insomnia, and constant headaches and muscle tension. 

O: Alert and cooperative, but maintained minimal eye contact. She appeared uneasy and occasionally fidgeted. Her speech was clear but the volume and rate varied from normal to low. Coherent and logical thought process. The client had a preoccupation about her work. No obsessions, compulsions, delusions, hallucinations, or suicidal/homicidal thoughts were noted. Her short and long-term memory was intact. She demonstrated good judgment.

A: GAD score-12.

P: Lorazepam 3 mg twice daily and weekly CBT sessions.

Post-Traumatic Stress Disorder

S: T.Y is a 46-year-old White ex-military officer who reported re-experiencing traumatic events that occurred when he was in combat. He stated that he experienced a persistent high level of anxiety when he re-experienced the combat events. The client also reported experiencing intrusive recollections and nightmares of his worst experience in the combat when he witnessed his colleague being shot by terrorists. The intrusive memories often resulted in intense psychological distress and the client reported that he avoided thoughts and feelings associated with the shooting of his colleague. In addition, he reported having an increased arousal which was not present before the combat event such as difficulty initiating and maintaining asleep, outbursts of anger, and difficulty concentrating. The symptoms had caused significant impairment in social and occupational functioning.

O: The client is neat, alert, but appears anxious and maintains minimal eye-contact. Self-reported mood is ‘Anxious,’ and affect is congruent. Speech is clear, but rate and volume escalates when the client talks about the combat event. He also becomes agitated and develops tremors when discussing the shooting event. Thought-process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were noted. Orientation, memory, abstract thought, judgment, and insight are intact.

A: Vigilance and startle response. Emotional distress when reminded of the combat events. Improved range of positive emotions.

P: Zoloft 50 mg/day. Continue with weekly sessions of Trauma-Focused CBT.

Cellulitis

S: G.W is a 57-year-old male who reported that he started having pain on the left middle finger three days ago after he was poked with a hook while fishing. The pain and tenderness began on the distal side of the middle finger and progressed to the proximal side. He describes the pain as severe and rates it at 7/10. Reports pain is slightly relieved by applying ice on the finger and aggravated more performing tasks. He has taken OTC Ibuprofen 400 mg to alleviate pain and reports slight relief. Reports the symptom have interfered with his daily activities. Reports having an ulcer on the finger with pus. Denies blue discoloration of the finger. Reports the finger is red, hot, and swollen.

O: Temp-101.48, BP-120/74, Pulse-86, Resp-24.

Left middle finger skin is red, hot, and tender on touch. Lesion noted with pus on left finger. No necrosis noted. No generalized skin rash, lesions or moles.

A: Culture of needle aspiration within 6 hours.

P: Doxycycline 100 mg BD for 10 days; Tylenol 500 mg TDS for 3 days; Tetanus toxoid vaccine 0.5 ml IM STAT.

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CLINICAL HOUR AND PATIENT LOGS

Clinical Hours

For this course, all practicum activity hours are logged within the Meditrek system. Hours completed must be logged in Meditrek within 48 hours of completion in order to earn the points allocated for this assignment. You may only log hours with preceptors that are approved in Meditrek.

Students must complete a minimum of 160 hours of supervised direct patient clinical experience. You will enter your approved preceptor and clinical faculty as part of each time and patient encounter you log.

Your clinical hour log must include the following:

Dates

Course

Clinical Faculty

Approved Preceptor

Total Time (for the day)

Notes/Comments

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

PATIENT LOG

Throughout this course, you must keep a log of every patient that you encounter in clinical using Meditrek. You must record at least 120 patients by the end of this practicum.

The patient log must include the following:

Date

Course

Clinical Faculty

Approved Preceptor

Patient Number

Client Information

Visit Information

Practice Management

Diagnosis

Procedure (Note: Make sure that, as you perform procedures at your practicum site, you also note those on your printed-out Clinical Skills List.)

Treatment Plan and Notes

BY DAY 7

Record your clinical hours and patient encounters in Meditrek.

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Rubric

PRAC_6531_Week6_Assignment1_Rubric

PRAC_6531_Week6_Assignment1_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning OutcomePart 1: Time logs and patient logs are completed within 48 hours of completing clinical time.

5 pts

Excellent

*Time logs are completed within 48 hours of completing clinical time. *Patient logs are completed within 48 hours of completing clinical time.

0 pts

Poor

*Time logs are completed more than 48 hours after completing clinical time. *Patient logs are completed more than 48 hours after completing clinical time.

5 pts

This criterion is linked to a Learning OutcomeThis criterion is linked to a Learning OutcomePart 2: Patient logs meet the minimum documentation requirements. *Each entry includes Date, Course, Clinical Instructor, Preceptor, Patient number, Client information, Visit information, Practice management, Diagnosis, Procedures (if applicable), Treatment plan and notes, Notes section (Students must include a brief summary/synopsis of the patient visit—this must include enough information to understand how the patient presnted and the student intervention. Do NOT include EMR SOAP notes. *LOGS MUST BE SUBMITTED WITHIN 48 HOURS TO BE ELIGIBLE FOR ANY POINTS

5 pts

Excellent

*Patient logs include all of the required documentation elements.

0 pts

Poor

*Patient logs do NOT include all of the required documentation elements. There are some elements missing or the logs are incomplete. *Patient logs were submitted more than 48 hours after completion of the clinical time.

5 pts

Total Points: 10

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