Assignment: PRAC 6531 Week 4 Clinical Hour and Patient Logs

Assignment: PRAC 6531 Week 4 Clinical Hour and Patient Logs

Assignment: PRAC 6531 Week 4 Clinical Hour and Patient Logs

 

Clinical Hours

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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

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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.

Rubric

PRAC_6531_Week4_Assignment_Rubric

PRAC_6531_Week4_Assignment_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 ptsExcellent

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

0 ptsPoor

*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 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 ptsExcellent

*Patient logs include all of the required documentation elements.

0 ptsPoor

*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

PRAC 6531 Week 4 Clinical Hour and Patient Logs

Pseudofolliculitis barbae (PFB)

Initials: T.J                              Age: 47-years

Sex: Male                                Race: White

S: T.J is a 47-year-old Asian male with complains of painful pimples that have erupted on his beard. He states that the pimple erupted after shaving 12 days ago in a barbershop. The eruption has occurred multiple times in the past two years. He reports that the acne occurs with itchiness and tenderness on the beard area. The patient reports that the acne usually discharges pus. He reports that he often uses post shave balm but it does not prevent the eruption of the acne.  He has also used OTC Hydrocortisone which alleviates the itchiness to some degree but it does not prevent future pimple eruption after shaving.

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O: Vital signs: BP- 120/74; HR- 74; RR-16; Temp-98.4; HT- 5’7; WT- 163 lb;

BMI- 25.5

The beard area has red erythematous patches. Red follicular papules. Multiple perifollicular pustules in the beard area. Broken beards hairs on the erythematous patches.

Diagnostic tests- Pustule swab.

A: Red follicular papules, multiple perifollicular pustules in the beard area and erythematous patches align with Pseudofolliculitis barbae.

P: Topical hydrocortisone 1%; Oral doxycycline 100 mg BD. Warm compresses and retraction and release of ingrown hair tips.

Herpes Zoster

Initials: O.M                           Age: 23-years

Sex: Male                                Race: White

Diagnosis: Herpes Zoster

O.M is a 23-year-old White patient who presented with a chief complaint of painful blisters on the skin that caused pruritus. The blisters are located on one side of the back. The symptoms started six days ago when he experienced an abnormal skin sensation with mild pain on the affected part. The symptoms were accompanied by malaise and mild headaches. Two days later, he noted some red spots, which quickly progressed into painful blisters that occurred in a cluster. He described the pain as burning, severe and constant, which caused a lot of itching. O.M also mentioned that some of the blisters ruptured, forming ulcers that develop into crusts. He states that pain has no triggering or relieving factors. The patient tried using OTC Hydrocortisone cream to relieve the itching, but it had no significant impact. He rates the pain as 5/10.

O: Vital signs: RR- 16; HR-82; BP-112/76; Temp- 99.14F; Ht. – 5’4; Wt. -132 pounds. No abnormal cardiovascular or respiratory findings. Skin exam reveals Dermatomal clusters of swollen red vesicles on the superficial layer of the left lower back. Elevated vesicles about 0.5 cm filled with purulent fluid. Lesions occur in a linear pattern. Crusts are present on parts of the dermatome.

A: Unilateral distribution of lesions within a single dermatome; Varicella infection.

P: The patient was prescribed Acyclovir 800 mg PO every 4 hours for 10 days Tylenol 500 mg TDS for pain relief. The patient was advised to avoid direct skin contact with immunocompromised persons, pregnant women, and infants since he is contagious.

Constipation

Initials: D.P                             Age: 63-years

Sex: Male                                Race: White

Diagnosis: Constipation

S: Patient reports that she has been having fewer bowel movements and inability to pass flatus in the past three weeks. Reports that she spends about 10 minutes in the toilet when passing stools. She at times stays for 5 days with no bowel movements and strains a lot when defecating. She is forced to apply manual maneuver when defecating and passes hard stools which she causes slight rectal bleeding. She reports a sensation of obstruction in her rectum and a feeling of incomplete evacuation after passing stools. The symptoms were gradual in onset and began with missing a bowel movement in a day and progressed to two, three and five days. Denies using any non-pharmacological measures to relieve the constipation. Used Magcaps tablets TDS to relieve abdominal pain and bloating which had minimal relief.

O: No use of abdominal muscles during respiration. The abdomen is round and distended. No scars present. Bowel sounds are inactive in all 4 quadrants. Abdomen tender, and hard on palpation. Mass palpable on the left lower quadrant. No hepatosplenomegaly present. CVA tenderness absent. No abdominal guarding or rebound tenderness. No anal fissures or hemorrhoids noted. Lacerations noted long the anus.

A: Abdominal distension, abdominal mass in the LLQ, inactive bowel sounds, and anal lacerations.

P:  Barium enema within 8 hours, to assess for a rectal or colon obstruction, or colonic stricture. Senna concentrate/ Docusate 2 tabs (8.5/50 mg) BD.  Manual dis-impaction or Transrectal enema.

Bipolar Disorder

Initials: J.O                             Age: 55-years

Sex: Male                                Race: AA

Diagnosis: Bipolar Disorder

S: J.O is a 55-year-old AA male who reports having episodes of severely elevated mood, which alternates with intense depressed mood. The client mentions that he gets into high moods for some months, but this rapidly changes to a low mood and a reduced interest in most pleasurable activities. He reports currently having episodes of severely elevated mood and excitement. He rarely sleeps since he has many plans that he needs to execute. He also reported doing things without thinking of the consequences when he is in an elated mood.

O: The client is well-groomed but inappropriately dressed for the event. He is alert and oriented but restless and distracted. The self-reported mood is “excited,” and the affect is expansive. An incoherent thought process with a pressure of speech and flight of ideas and. The client is very talkative with a high volume and rate of speech. Delusions of grandeur are present, with the client having an elevated sense of self-worth. Hallucinations are absent, and he denies suicidal or homicidal thoughts. Recent and long-term memory is intact. Judgment is impaired, and insight is lacking. Young Mania Rating Scale score- 12.

A: Severe mania; Poor judgment; Client was less engaged and interested in psychotherapy sessions.

P:  Lithium 300 mg oral dose twice a day. Weekly Interpersonal therapy alongside treatment with Lithium.

Alcohol Use Disorder

Initials: S.K                             Age: 63-years

Sex: Male                                Race: White

Diagnosis: Alcohol Use Disorder

S: S.K is a 63-year-old White male brought to the clinic by his brother with reports of alcoholism. The client has been taking alcohol since he was 18 years. In the past year he has been taking 5-7 glasses of whiskey per day and states that he could not stay without it. The excessive drinking has contributed to social and interpersonal problems. His alcohol consumption has led to an inability to fulfill major role obligations at work and home. He states that he started struggling with alcohol since he was 45 years and has attended Alcoholics Anonymous severally, but he keeps on relapsing. He also smokes tobacco 1PPD but states that tobacco is not a problem like alcohol. He has no history of psychiatric admission or medical condition attributed to Alcohol use.

O: The client is well-groomed and appropriately dressed for the weather. He is alert, maintains eye contact, relaxed, and cooperative throughout the session. The self-reported mood is good, and affect is appropriate. Speech is clear with normal rate and volume and an appropriate length of answers. Coherent and goal-directed thought process. No delusions, hallucinations, or suicidal/homicidal ideations were noted.  The short-and long-term memory is intact. Attention and concentration levels are somewhat affected.

A: Improved mood, behavior, and cooperation. He demonstrates more interest in the psychotherapy session. Exhibits determination in fighting off the alcohol craving. Increased attention and concentration levels compared to the previous session.

P: Naltrexone 50 mg orally once/day. Continue with Group therapy such as AA to help him learn social skills and coping mechanisms to avoid relapse.

Generalized Anxiety Disorder

Initials: F.L                             Age: 55-years

Sex: Female                            Race: AA

Diagnosis: Generalized Anxiety Disorder

S: F.L is a 55-year-old AA female on psychotherapy for anxiety disorder. The client has excessive anxiety and worries about her business. She started a new business as a plan for her upcoming retirement and is ever-concerned about meeting clients’ expectations. The excessive anxiety is difficult to control and has caused difficulties in initiating and maintaining sleep.  The anxiety symptoms began about four months ago after shortly after being employed. She reports feeling keyed up and her mind often going blank. She easily gets fatigued and easily irritable.

O: The client is well-groomed and appropriately dressed for the weather. She is alert but maintained minimal eye contact and was a bit uneasy during the interview. Her self-reported mood is nervous,’ and her affect was congruent. The speech was clear with normal rate and volume. Coherent, linear, and goal-directed thought process. The client expressed worries about her job and was preoccupied with thoughts about the job. No Delusions, hallucinations, or suicidal/homicidal ideations were noted. Memory, abstract thought, judgment, and insight were grossly intact.

A: Anxiety related to job concerns; Insomnia.

P: Paroxetine 20 mg orally to alleviate anxiety.

Major Depressive Disorder

Initials: W.P                            Age: 58-years

Sex: Female                            Race: White

Diagnosis: MDD

S: W.P is a 58-year-old White female who presented with complaints of a sad, empty mood that occurred most of the day and nearly every day. She reported losing interest in her work and other previously pleasurable activities. Besides, she reported having an increased appetite that had contributed to a significant weight gain. She also reported having sleeping disturbances and would get easily fatigued with low energy levels during the day. The low energy levels have affected her work as she is less productive and makes fewer sales.  She reported having a diminished ability to concentrate at work and make decisions independently, which led to a significant impairment in occupational functioning.  The patient takes alcohol and stated that in the past few weeks, her consumption has increased since it helps to relieve stress. However, she denied using other drug substances or having suicidal/homicidal ideations.

O: The patient is well-groomed and appropriately dressed. She is alert and oriented. The self-reported mood is ‘sad,’ and affect is constricted. Coherent thought process. Speech is clear, but the tone varies throughout the interview. Long-term and short-term memory is intact. No delusions, hallucinations, or obsessions were noted. Judgment is good, and insight is present.

A: Stress overload; Disturbed sleep pattern; Sleep deprivation; Activity intolerance.

P: Prozac 20 mg Orally OD. Refer to a counselor for psychotherapy.

Sciatica

Initials: A.M                           Age: 52-years

Sex: Male                                Race: White

Diagnosis: Sciatica

S: A.M. is a 52-year-old man who presents with a complaint of pain in the lower back. The back pain started a month ago. It radiates to the left leg, and he describes it as stabbing pain. The left leg pain is associated with weakness and numbness. The low back pain is aggravated by activity, bending, and sitting for long hours. He reports using OTC Tylenol, which alleviates the pain temporarily. He is concerned since the back pain interferes with his work which requires him to sit for prolonged periods. The patient rates the low back pain at 5/10 on the pain rating scale.

O: Vital Signs: BP- 128/86; HR- 76; RR-16; Temp-98.4; SPO2- 99%; HT-5’5; WT-164; BMI-27.6.

The patient ambulates independently; Symmetrical relationship among the limbs, torso, and pelvis; Upright head and torso; Walks smoothly and remains erect and balanced when walking and standing. The client complains of pain radiating down the left leg on raising the right leg.

A: Negative Straight leg raising and Reverse straight leg raising.

P:  Oral gabapentin 200 mg at bedtime. 24 to 48 hours of bed rest in a recumbent position

Respiratory Failure with SIRS

Initials: S.K                             Age: 80-years

Sex: Female                            Race: AA

Diagnosis: Respiratory Failure with SIRS

S: S.K. is an 80-year-old AA female who presented to the ED with a complaint of shortness of breath. The SOB began about four days ago when she started feeling a need to catch her breath, and this worsened when she was walking or doing her normal house chores. The patient also reported an increased breathing rate, and her body was unusually hot. However, the dyspnea with exertion rapidly progressed to severe dyspnea at rest, accompanied by a high respiratory rate. On arrival at the ED, the patient was anxious and agitated. She was immediately administered a high concentration of inspired oxygen.

O: VITAL SIGNS: BP- 110/70; HR-128;RR-26; Temp- 100.7; SPO2- 88; HT; 5’2; WT- 132; BMI- 24.1

The patient is restless, anxious, and confused.

Asymmetrical chest expansion. Labored breathing with the use of accessory muscles. Faint heart sounds; Dullness to percussion; Rales present; No wheezing or rhonchi.

Diagnostic results: ABG: PaO2-54 mmHg; PaCO2-38 mmHg, WBC- 12,500 µL, FEV1 -to-FVC ratio- decreased.

A: Meets criteria for SIRS with tachycardia, tachypnea, fever, and elevated WBC count of 12,500 µL.

P: Low-molecular-weight heparin; IV Hydrocortisone 200 mg OD; Salmeterol 1 inhalation BD. Oxygen supplementation via nasal cannula.

Hemorrhagic Stroke

Initials: R.G                            Age: 82-years

Sex: Male                                Race: AA

Diagnosis: Hemorrhagic Stroke

S: R.G. is an 82-year-old AA male brought to the ED by the paramedical team in the company of his wife. The patient’s wife reports that the patient suddenly developed left-sided weakness and could not lift objects with his left head or move his left leg. The left side of his face also became weak, and his vision declined drastically. On noting this, she asked the husband how he felt, but he denied his problems. His level of consciousness started deteriorating and the wife feared that he would get into a coma if he was not rushed to the ED. Before the ambulance arrived, the patient complained of a headache and had one episode of vomiting.

O: VITAL SIGNS: BP- 188/118; HR- 102; RR-20; Temp: 98.42 F; Sp02-97; Wt-220; Ht-5’5; BMI- 36.6

He is disoriented to time, place, and person and is unaware of neurologic deficits. Abnormal findings include: Right gaze preference; Left visual field cut; Abnormal left eye movement; Altered muscle tone and reflexes in left upper and lower limbs; Ataxic gait; dysarthria; left facial, arm, and leg paresis.

A: Acute onset of neurological deficits with altered consciousness. Hemorrhagic stroke, Hypertension, and Obesity.

P: Initially, Labetalol 20 mg IV over 2 minutes, then as a continuous infusion at 2 mg/min.

Hydralazine 20 mg IV. Switch Enalapril from oral IV to 1.25 mg/dose over 5 minutes QID.

Continue HCTZ 25 mg OD; Continue Simvastatin 40 mg QHS.

 

Appendicitis

Initials: M.L                            Age: 74-years

Sex: Female                            Race: Hispanic

Diagnosis: Appendicitis

S: M.L. is a 74-year-old Hispanic American female who presented to the ED with complaints of lower abdominal pain and eating difficulties due to nausea, vomiting and loss of appetite. She reported that the pain began 2 days ago and had been worsening over time. She stated that the pain had a rapid onset beginning in the epigastric region and radiates to the right side of the lower abdomen. Described the pain as sharp with a pain scale of 8/10 and lasts for more than 10 minutes. The pain is worsened by vomiting and is relieved by rest and sitting in a tripod position. She reported taking Ibuprofen tablets to relieve the pain which had a temporary and had to take after every 4 hours. The patient further stated that the pain had interfered with her daily routine.

O: Vital Signs: Ht: 5’4, Wt: 143 lbs, BMI: 24.5, P-112; O2 Sat-97%, RR: 24, BP: 134/86

The patient is in moderate distress and bends forward when seated. Abdomen, flat, and smooth. BS active in all quadrants. Tenderness on percussion.  Right lower quadrant tenderness. Rebound tenderness and abdominal muscle guarding noted. No hepatosplenomegaly. Extension and flexion of the right hip against resistance elicited pain in the right lower quadrant.

A: CBC: WBC- 15000 cells/uL; neutrophilia; C-reactive protein: 1.5 mg/dl

Abdominal CT scan- revealed an inflamed, non- perforated appendix.

P: The patient was scheduled for laparatomy the following day. She was started on IV Cefotan1g and Cefoxitin 1g for prophylaxis.100 mg Tramadol was administered IM QID, to relieve pain.

Cerumen Impaction

Initials: Z.N                            Age: 64-years

Sex: Male                                Race: White

Diagnosis: Cerumen Impaction

S: Z.N. is a 64-year-old White male who presented with complaints of ear pain and itching. He reported that the symptoms are in the right ear and the left one was okay. The symptoms started four days ago and have become discomforting over time. He reported partial hearing loss in the right ear but normal hearing in the left ear. Other associated symptoms include tinnitus and a feeling of fullness in the right ear. He had tried using OTC ear drops but was not effective in relieving the symptoms. He rated the ear pain at 2/10.

O: Vital Signs: BP- 134/82; HR-90; RR-16; Temp-98.4; HT-5’5; WT-171; BMI- 28.5

Ear: Unable to examine the right ear by otoscopy because of accumulation of excessive cerumen. Left ear- TMs are shiny and intact.

A: Right ear cerumen impaction. Rules out Acute Otitis Media and Otitis Externa.
P: The right ear was washed out with a colace and water mixture. Patient education on ear hygiene. Cerumen-softening drops and home irrigation kits were recommended when cerumen is visible.

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