NRNP 6631 WEEK 3 CLINICAL HOUR AND PATIENT LOGS PAPER

NRNP 6631 WEEK 3 CLINICAL HOUR AND PATIENT LOGS PAPER

NRNP 6631 WEEK 3 CLINICAL HOUR AND PATIENT LOGS PAPER

Week 3 Clinical Hour and Patient Logs

Week 3 Clinical Hour and Patient Logs
Tension-Type Headache
Initials: K.K
Age: 60 years
Sex: Male
Race: White
Diagnosis: Tension-Type Headache
S: K.K is a 60-year-old male who presented with a chief complaint of headaches. He reported having about two headache episodes per day 4-5 days a week in the past month. The headache occurred in the frontal and occipital parts of the head. He reports that each headache episode lasts 30 minutes to 2 hours. The patient described the headache as diffuse, pressing, and non-pulsating, and its intensity varies from mild to moderate. He further stated that the headache occurred bilaterally. He denies experiencing nausea, vomiting, photophobia, or phonophobia. Besides, the headaches were not aggravated by activity.

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O: Vital signs: BP- 132/84 mm Hg; Resp- 18; PR- 90; Temp- 98.78 F. The patient was alert and in no distress. Physical exam findings included tenderness on the scalp and neck. The cardiovascular and respiratory exam was normal. Normal neurologic examination. No meningeal irritation.
A: Bilateral Tension headache, No prodrome.
P: The patient was prescribed 400 mg TDS to relieve headache. Patient education focused on Regular exercise, stretching exercises, a balanced diet, and adequate sleep.

Acute Gastritis
Initials: S.L Age: 72 years
Sex: Female Race: Asian
Diagnosis: Acute Gastritis
S: S.L is a 72-year-old Asian female who presented with a chief complaint of epigastric pain. The epigastric pain began two weeks ago and has worsened over time. She described the pain as burning but non-radiating. She also reported losing appetite, nausea, vomiting, belching, and bloating. However, she denied having regurgitation, heartburn, abdominal pain/discomfort, nausea, or vomiting. She rated the epigastric pain as 4/10. The patient used Motrin to alleviate an ankle injury she sustained a month ago.
O: Vital signs: HR-84; BP- 120/80; RR- 20; Temp-98.42; Sp02-100%. On general exam, the patient was alert and in no distress. The cardiovascular and respiratory exam was normal. GI exam findings were: Normoactive bowel sounds, mild epigastric tenderness, and no abdominal tenderness, masses, or organomegaly. H pylori stool antigen test was negative, and the complete blood cell (CBC) count was within the normal range.
A: Gastritis secondary to exposure to NSAIDs. Peptic ulcer disease was a differential diagnosis but ruled out as the primary diagnosis.
P: Treatment included Omeprazole 40 mg PO once daily for 4-8 weeks. Motrin was changed to Tylenol. The patient was educated on the importance of alcohol and smoking cessation. She was also advised to avoid anti-inflammatory drugs and spicy foods.
Tinea Barbae
Initials: O.K. Age: 72-years
Sex: Male Race: White
Diagnosis: Tinea Barbae
S: O.K. is a 72-year-old White male who presented with complaints of pimples on the lower beard filled with pus. The pimples first appeared a week ago, and they had progressively increased in number. He reported that the beard area is tender and has become red. The beard hair had lost luster, was brittle, and easily plucked. In addition, he reported having a mild itch, and the pustules were also mildly painful. The pain was felt when he scratched the beard. The patient reported that he applied an over-the-counter steroid cream to help relieve the pustules and redness, but he had not seen much change.
O: Vital signs: BP-124/84; HR- 74; RR- 20; Temp-98.42F Ht-5’5; Wt-165 lbs.; BMI-27.5. The patient was alert, oriented, and in no apparent distress. Cardiovascular and respiratory exam findings were normal. The skin was fair, warm, and dry. The skin around the lower beard was inflamed with red lumpy areas. There were red pustules and crusting around the beard hairs. Pus-filled white masses were present involving the hair root and follicle. Beard hairs on the red lumpy areas were broken.
A: Inflammatory red nodule with pustules and draining sinuses. Tinea Barbae.
P: Treatment prescribed includes- Terbinafine 250 mg PO once daily.
Common Cold
Initials: L.W Age: 64-years
Sex: Male Race: White
Diagnosis: Common Cold
S: L.W. is a 64-year-old White male who presented with chief complaints of sneezing and nasal discharge. He states that he started experiencing nasal dryness and throat irritation four days ago, which progressed to sneezing and nasal discharge. He reports that the symptoms are associated with nasal blockage, cough, mild headache, and loss of sense of smell. D.P denied having posttussive vomiting, hoarseness, irritability, or fever. The patient reported taking OTC antitussive syrup, but the symptoms had persisted.
O: Vital signs: BP-130/80; HR- 74; RR- 20; Temp-98.42F. The patient was alert, oriented, and in no distress. HEENT exams revealed a red nose with a profuse, dripping nasal discharge; Clear and watery nasal discharge; Glistening and erythematous nasal mucous membranes. Mildly enlarged, non-tender cervical lymph node. Rhonchi present on chest auscultation. Normal cardiovascular exam findings.
A: Rhonchi; Common Cold. Differential diagnoses include Allergic Rhinitis and Acute Sinusitis.
P: Medications include: Cetrizine 10 mg O.D for 5 days; Tylenol 500mg PO QID; Phenylephrine nasal 1-3 gtt intranasally every 2-4 hours of 0.125% solution PRN, for 3 days. Patient education provided include: Avoidance of finger-to-eyes or finger-to-nose contact; Appropriate hand washing; Using nasal tissue to avoid spread by hand-to-hand contact.
Allergic Rhinitis
Initials: N.M Age: 64 years
Sex: Male Race: African American
Diagnosis: Allergic Rhinitis
S: N.M is a 64-year-old AA male who presented to the clinic with complaints of a runny nose and sneezing. He stated that the symptoms began three days ago, and was concerned that he could have flu. He described the runny nose as thin clear and watery mucus. The patient also mentioned that the sneezing and runny nose occurred more frequently in the morning and night. He also reported that he had not taken any medication to alleviate the symptoms.
O: The patient’s vital signs were HR: 94, BP: 130/80, RR: 20 Temp: 98.6, Sp02: 98. On general assessment, the child was alert, active, and well-nourished. HEENT findings include:
White sclera; Injected conjunctiva with excess tear production; Red reflex present bilaterally; PERRLA; Patent tympanic membranes bilaterally; Thin, watery nasal secretions; Pale-blue nasal mucosa; Well-aligned nasal septum. No abnormal findings on cardiovascular and respiratory exam.
A: Allergic rhinitis was the primary diagnosis, and Common cold and acute sinusitis were the differential diagnoses. Skin-prick testing was recommended to identify the specific environmental allergen the patient is allergic to.
P: The patient was prescribed Cetrizine 10 mg OD. Health education included compliance with the treatment regimen to alleviate symptoms; Adequate hydration with warm fluids; Avoidance of allergens such as cold, pollen, and dust mites.
 
Anterior Epistaxis
Initials: Y.G Age: 58 years
Sex: Male Race: African American
Diagnosis: Anterior Epistaxis
S: Y.G is a 58-year-old AA male brought to the ED with a complaint of nose bleeding. The nosebleed occurs on the left side. He reports that he woke up with a nosebleed, and it has not stopped despite applying pressure by pinching it. The patient has no history of nosebleeds. He denies trauma to the nose. He also denies headache or history of head trauma
O: Vital Signs: BP 124/7; P 84; R 14; T 97.8; Pulse ox 99%. Nose: No bruises or petechiae noted. Nasal septum is well-aligned. Anterior bleeds from the nasal septum were observed on the nasal speculum. Cardiovascular- Regular heart rate and rhythm; S1 and S2 present. No gallop sounds or bruits. Direct visualization using a nasal speculum- bleeding from the anterior nasal septum.
A: Anterior epistaxis was established as the diagnosis due to the patient’s history of nose bleed with no trauma and bleeding from the anterior nasal septum on nasal speculum exam. Posterior epistaxis was ruled out since bleeding occurred in the anterior nasal septum. Nasal foreign bodies was a differential diagnosis but ruled out since the patient had no history of inserting foreign bodies in the nose or trauma.
P: Topical saline sprays on the nasal mucosa to promote moisturization of the nasal mucosa and prevent recurrent epistaxis. Silver nitrate: This is a cauterizing agent that coagulates cellular proteins, which in turn reduce bleeding. Anterior packing to manage nose bleed if it does not respond to cauterization with Silver nitrate. The patient was advised to avoid strenuous activity, blowing nose, hot foods, or digital manipulation of the nose upon discharge. Referral to a hematologist and an otolaryngologist if the nose bleed persists.

Delirium
Initials: G.W Age: 76years
Sex: Female Race: Asian
Diagnosis: Delirium
S: G.W is a 76-year-old Asian female accompanied by her son, who reported that her mother has confusion, agitation, and restlessness. He describes the confusion as acute and more than usual and the agitation and restlessness as occurring to some degree. The son states that she started to be more confused than usual and very easily agitated two days ago. He also reports that the previous day, his mother could not remember where she was in her own home. MP has a known history of dementia, managed with Aricept 10 mg. daily. Last MMSE score was 18/30 with primary deficits in orientation, registration, attention, calculation, and recall at the previous visit. The patient medical history is positive for Hypertension, Diabetes, Osteoporosis, and Chronic Allergic Rhinitis.
O: Vital signs: Temp- 98.1F; HR- 72; RR- 20; BP- 120/64.
Neurological exam: Alert and obeys motor commands. Impaired coordination and balance.
MMSE- The patient is alert but easily distracted, occasionally, during the clinical interview. She maintains fair eye contact; the speech is clear and coherent but tangential at times. The patient makes no unusual motor movements and has no tics. She denies any visual or auditory hallucinations and denies any suicidal thoughts or ideations. She is alert but disoriented to place and time.
CT head—diffuse Cerebral Atrophy; Hemoglobin A1C-7.2%; Potassium- 3.4
A: MMSE score- 18/30, points to moderate dementia. Primary deficits in orientation, registration, attention, calculation, and recall note
P: Risperidone- 0.5 mg PO daily.
Health education: Healthy diet and optimal hydration; Medication adherence; Caregiver support. Follow-up after four weeks to monitor progress and assess for complications. 
Allergic Rhinitis
Initials: P.T Age: 55 years
Sex: Male Race: White
Diagnosis: Allergic Rhinitis
S: P.T is a 55-year-old White male presenting with a chief complaint of itchy nose, eyes, palate, and ears. He reported that the symptoms began five days ago. In addition to this complaint, he reported having nasal congestion, sneezing, rhinorrhea, and postnasal drainage. He describes the postnasal drainage as thin, watery nasal secretions. The symptoms have no associated aggravating factors. He reported using OTC Mucinex in the past two nights to help him breathe while he sleeps. However, he stated that the Mucinex has had only minimal improvement in the symptoms. He is allergic to pollen and dust mites.
O: Vital Signs: BP- 128/76, HR- 86, RR-20, Temp-98.42F, HT- 5’5, Wt- 158 pounds.
HEENT: Head: Normocephalic and atraumatic. Eyes: Dark circles around the eyes. Positive for excessive lacrimation. The sclera is white; the conjunctiva is pink, and PERRLA. Ears: No ear discharge, Tympanic membranes are shiny and intact. Mastoid bone is non-tender. Nose: Pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates obstructing airway flow. Throat: Positive for throat clearing. The throat is mildly erythematous, but the tonsils are not enlarged. Anterior rhinoscopy revealed swelling of the nasal mucosa and thin, clear secretions with boggy nasal turbinates.
A: Allergic rhinitis was the clinical impression based on pertinent positive subjective findings of itchy nose, eyes, palate, and ears, nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Besides, the patient was allergic to pollen and dust mites which are documented triggers of Allergic rhinitis.
P: Cetrizine PO 10 mg once daily; Pseudoephedrine 120 mg PO twice daily. The patient was educated on Environmental control measures and allergen avoidance, including minimizing exposure to allergens such as dust mites, pollen, smoke, and mold. Educated on hand hygiene through hand washing and using alcohol-based hand sanitizers. Follow-up after two weeks to monitor response to antihistamines and decongestants.
 
Urinary Tract Infection
Initials: F.K Age: 53 years
Sex: Female Race: White
Diagnosis: UTI
S: F.K is a 53-year-old White female presenting with a chief complaint of increased urinary frequency, burning, and pain when passing urine. The client states that the urinary symptoms are similar to previous UTIs. The symptoms began about two days ago. She also reports increased lower abdominal pain and vaginal discharge in the past week. She describes the abdominal pain as severe, constant, and has no aggravating or relieving factors. ROS: Positive for increased brown, foul-smelling P.V discharge. Positive for dark urine, increased frequency, and burning and pain on urination. Denied vaginal itchiness.
O: Vital Signs: BP -120/80, P- 80; R: 16; T: 99.7 F; Wt. 140 lbs.; Ht.5’3; BMI 23.4.
Abdomen exam: Soft and tender on palpation with suprapubic tenderness. Genital/Pelvic exam: Cervical motion tenderness, adnexal tenderness, foul-smelling vaginal drainage.
Lab results: 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. Positive monoclonal A.B. for Chlamydia, KOH preparation, Wet preparation, and VDRL negative.
A: UTI was the differential diagnosis based on pertinent positive findings of pain and burning sensation during urination, increased urinary frequency, suprapubic tenderness, and dark urine. PID and Cervicitis were ruled out.
P: Nitrofurantoin 100 mg orally twice daily for 7 days. The patient was advised to complete the antibiotic dose to prevent recurrent UTIs. Adequate fluid consumption at least 8 glasses a day to flush pus cells from the urinary tract. Counseling on hygiene interventions to prevent UTIs, including wiping front to back. Follow up after one week.
 
Bell’s palsy
Initials: D.K Age: 57 years
Sex: Female Race: White
Diagnosis: Bell ’s palsy
D.K is a 57-year-old White female who reported with a chief complaint of her right side of the face drooping. She reports that the onset of the face drooping was in the morning. The face drooping was accompanied by other symptoms including excessive lacrimation and drooling on the right side. She states that the face drooping had no associated triggers.
ROS: HEENT- Positive face drooping on right-side, excessive lacrimation on the right eye, and right-sided drooling. Denied loss of vision, hearing loss, nasal discharge/congestion, or swallowing difficulties.
NEUROLOGICAL: Positive right-sided facial drooping, muscle paralysis, facial numbness, and right-sided drooling. Negative for headaches, burning sensations on lower limbs, or black spells.
O: Vital Signs: BP-112/72, HR- 94, RR- 20, TEMP- 98.42F, HT-5’4, WT-147 pounds.
The right-side of the face sags and has a mask-like appearance. Flattened nasolabial fold. The patient cannot smile, grimace or crease the forehead on the right side. Eyes: Right eyebrow is in a low position and the right lower eyelid sags. Client cannot shut the right eye completely. Excessive tearing noted on the right eye. Normal gait and posture. Intact facial sensation and taste sensation is normal. Right-sided facial muscle paralysis.
A: Acute stroke and Guillain-Barré Syndrome were ruled out. The rapid onset unilateral facial drooping and muscle paralysis, excessive lacrimation on the right eye, right-sided drooling was consistent with Bell’s palsy.
P: Prednisone 30 mg OD. Teaching the patient to manually close the eyelid at intervals and to instill artificial tears during the day. Encouraged the patient to eat and drink using the unaffected side of the mouth. Frequent, small meals were recommended since they are better tolerated.
 
Trigeminal neuralgia
Initials: R.I Age: 60 years
Sex: Female Race: White
Diagnosis: Trigeminal neuralgia
S: R.I is a 60-year-old White female who presented with complaints of abrupt, intense face pain episodes. The pain occurred on the left side of the face and the right side was unaffected. She explained that the pain attacks lasted 15-40 seconds. The pain attacks occurred one after the other in cycles that lasted up to two hours. The pain was worsened by chewing, brushing the teeth, or smiling. Besides, sleeping on the left side of the face was intolerable.
O: Vital Signs: BP-122/70; HR-88; Temp-98.0 F; Resp-18; SPO2- 98%.
Normal neurologic examination. No sensory or motor deficits were found on examination,
A: Differential diagnoses that were ruled out include: Chronic paroxysmal hemicranias, Postherpetic pain, migraine, Sinusitis, and odontogenic pain,
P: Carbamazepine 100 mg orally twice a day. Increase the dose by 100 to 200 mg/day until pain is controlled (maximum daily dose 1200 mg).
Referral to a neurosurgeon or neurovascular surgeon if the patient does not respond to medication therapy to determine whether microvascular decompression and other surgical procedures are necessary.

Alzheimer’s Disease
Initials: F.G Age: 77-year-old
Sex: Female Race: African American
S: F.G. is a 77-year-old A.A female accompanied by her daughter. The daughter reports that her mother is becoming increasingly forgetful of more recent events. However, she easily recalls historical moments and events. She also reports that F.G encounters difficulties finding the right words in a conversation and shifts to an entirely different conversation line. Besides, the mother laughs off things when she forgets important appointments or becomes upset or critical of others when they point these things out. The daughter reports that her mother asks the same questions even after being answered, and she even gets lost.
Medical history- Hypertension, Hyperlipidemia, and Osteoporosis.
O: Vital signs: Temp- 98.06F; PR- 92; RR- 20; BP- 136/88.
Neurological: Alert and obeys motor commands. Normal balance and posture. CN I-XII intact. Muscle strength 5/5.
MMSE: Alert, cooperative, and eye contact is fair. Clear and coherent speech but occasionally tangential. No abnormal motor movements or tics. Denies any visual or auditory hallucinations. She also denies any suicidal thoughts or ideations. Alert and oriented to person, partially oriented to place but is disoriented to time. The patient laughs off at her disorientation to place. She denies any history of falls or pain.
A: MMSE score- 18/30, pointing to moderate dementia. Frontotemporal Dementia and Vascular dementia were ruled out.
P: Aricept (Donepezil) 5 mg P.O. every bedtime.
The patient was recommended to engage in mild exercises such as walking and jogging to reduce the progression of dementia by boosting brain health. The patient and primary caregiver were educated on taking a healthy diet to promote blood pressure control, healthy weight, and boost brain health. Follow-up after four weeks.

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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_Week3_Assignment1_Rubric

PRAC_6531_Week3_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 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