PRAC 6531 Clinical Hour and Patient Logs Essay

PRAC 6531 Clinical Hour and Patient Logs Essay

PRAC 6531 Clinical Hour and Patient Logs Essay

 PRAC 6531 Clinical Hour and Patient Logs

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Tonsillitis

Initials: K.K                           

Age: 54 years

Sex: Male                               

Race: White                  

Diagnosis: Tonsillitis

S: K.K is a 54-year-old male that came to the clinic with complaints of painful swallowing. The patient reports that the symptoms started yesterday as a sore throat. The pain worsens with swallowing. He reports that he was fatigued. He had taken over-the-counter Motrin, which helped in managing fever and not sore throat. The client states that symptoms worsen during nighttime. The assessment showed enlarge tonsils (2+), erythematous, with tonsil stones on the right side. He also has white patches on his tongue.

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O:  Vital Signs: BP- 128/80, RR-16, Temp- 99.4, HR-80

Throat: There is no lymphadenopathy. Tonsils appear erythematous, inflamed (+2), with the presence of tonsil stones on the right side. There are white patches on the tongue. There is no halitosis.

A: Throat cultures were requested to identify the cause of the sore throat. Rapid antigen detection testing was also ordered to establish the accurate diagnosis due to its high specificity. Tonsillitis was the clinical impression.

P: Penicillin V 500 mg BD orally. Supportive treatment includes analgesia, hydration, and rest.  Follow-up after one week.

Pelvic Inflammatory Disease (PID)

Initials: T.D                

Age: 45 years

Sex: Female                            

Race: White           

Diagnosis: PID

T.D is a 45-year-old White female who presented with complaints of abdominal pains and awful-smelling vaginal discharge. The patient reports that the abdominal pain began six days ago after cessation of her menstrual periods. She states that the pain is located on lower abdomen bilaterally and lasts for about 5-10 minutes. She describes the pain as a constant dull cramping pain. Reports that the pain is triggered by movement, exercise, and sexual activity. States that she has been taking Aspirin to lower the pain but had a minimal temporary effect. Rates the pain as 3/10.

O: Vital Signs: Ht: 5’3 Wt.: 130 lbs. BMI: 23.0; P-78; T: 101.48 F RR: 22, BP: 124/78 O2 Sat-99%.

Abdomen: Abdominal tenderness on the lower right and left quadrants. Rebound abdominal tenderness.

Genital and Rectal: Mucopurulent vaginal discharge. Uterine tenderness and cervical motion

tenderness. Tender adnexal mass. No rectal ulcers or fissures. WBC count: 11000/uL.

A: Cervicitis, Endometriosis, and UTI were ruled out.

P: The patient was managed as an outpatient with: Ceftriaxone 250 mg IM STAT; Doxycycline 100 mg BD × 14 days; Oral Metronidazole 400 mg BD × 14 days. Follow-up after 2 weeks.

Tinea Capitis

Initials: E.K                

Age: 50 years

Sex: Male                               

Race: African American                    

Diagnosis: Tinea Capitis             

S: E.K is a 50-year-old A.A man who presented with complaints of round white patches on his scalp. The symptom began 2 weeks ago when he noticed small red spots developing on the scalp, on the root of the hair strands. After about five days from when the red papules developed, they started turning pale and appeared like scales. The hair started discoloring and became brittle and lusterless. The hair began shedding off in patches, and white patches began appearing in a ring pattern. EK says that he had moderate itching that would, at times, become intense. The itching had no triggering factors, but cleaning the scalp with soap would relieve the pruritus to some extent. He had applied an OTC Hydrocortisone cream to relieve itching.

O:  Presence of white patches on the scalp. Five patches present with a diameter of about 2-3 cm. Hair is black but with areas of Alopecia present. Black dots present in areas of broken hair fibers. Lesions present on the scalp with red papules and bright –yellow areas. Erythematous papules present with areas of alopecia.

Microscopic examination of infected hair samples revealed the presence of endothrix large-spores within the hair shaft.

A: Alopecia Areata and Seborrheic dermatitis were ruled out.

P: Griseofulvin 250 mg OD PO for 6 weeks. 2% Nizoral shampoo and 2.5% Selsun shampoo 3 times a week.

UTI

Initials: B.B                

Age: 48 years

Sex: Female                            

Race: White               

Diagnosis: UTI          

S: B.B is a 48-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.

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.  Subjective, objective, and lab results indicated UTI.

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

Type 2 Diabetes Mellitus

Initials: M.L               

Age: 56 years

Sex: Male                               

Race: White                

Diagnosis: Type 2 DM

S: M.L is a 56-year-old White male who presented with complaints of experiencing abnormally excessive hunger and thirst despite taking plenty of water. The patient reports that he began experiencing unusual excessive hunger 6 months ago with a feeling of thirst despite taking plenty of water. The feeling of hunger progressed over time and he started noticing that he was having weight loss. The acute thirst persisted despite taking lots of water and even carrying a bottle of water every time. He also states that due to the excessive intake of water he has been experiencing excessive urine production. Denies using any medications to manage the symptoms.

O: Vital signs: BP- 132/88, HR-86; RR-16; Temp-98.6; BMI-32.4

RBS- 10.5 mmol/L; Urine glucose- positive.

A: Obesity; Hyperglycemia. Type 2 DM was confirmed as the diagnosis.

P: Metformin 850 mg OD orally. Health education on lifestyle modification to help in weight management. Two-weekly follow-up in the diabetic clinic.

Constipation

Initials: S.Y                

Age: 67 years

Sex: Female                            

Race: White                

Diagnosis: Constipation

S: S.Y reports that she has been having fewer bowel movements and inability to pass flatus in the past three weeks. 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. Reports pain on defecation. Reports abdominal bloating and diffuse mild abdominal pain with a scale rate of 3/10.

O: Weight -172 pounds, Height5’0, BMI-33.6; Temp-98.7F; BP-128/86; Pulse-80; Resp-18-

GI: The abdomen is round and distended. Bowel sounds are inactive in all 4 quadrants. Abdomen is tender, and hard on palpation. Mass palpable on the left lower quadrant. No hepatosplenomegaly, CVA tenderness, abdominal guarding, or rebound tenderness. Lacerations noted long the anus.

Fecal occult blood- negative.

A: Irritable Bowel Syndrome and Diverticulitis ruled out. 

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 and Transrectal enema.

Cellulitis

Initials: P.J                 

Age: 63 years

Sex: Male                               

Race: White               

Diagnosis: Cellulitis

S: The patient reports that he started having pain on the left middle finger three days ago after he was poked with a hook while fishing in a freshwater lake. 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, Wt -135 pounds, HT-5’5, BMI-24.7

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: Ruled out Necrotizing fasciitis, Erythema Multiforme, and Gas Gangrene.

P: Culture of needle aspiration within 6 hours.

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

Surgical incision and drainage of the lesion. Cleaning and dressing the incised finger with normal saline and sterile gauze.

Urinary Tract Infection

Initials- R.B.

Age- 95 years

Sex- Male

Race- White

Diagnosis: UTI

S: R.B is a 95-year-old White male, accompanied to the clinic by his son. The patient presented with complaints of his urine appearing to be bright red. He has a psychiatric history of moderate vascular dementia and Hives due to Penicillin. The patient currently lives in a skilled nursing facility (SNF). His dietary patterns include a regular diet, pureed texture, and honey-thickened liquids.

O: Vital Signs: BP-122/70; HR-66; Temp-98.0 F; Resp-18-Pulse oximetry- 98%.

Diagnostic results:

RBC- Low; Hemoglobin- Low

WBC UA-High; RBC UA- High; Epithelial cells and Hyaline casts- WNL

Urinalysis results:

Color-Red; Ketones- Trace; Specific gravity- Normal range; Blood-Large; Leukocytes- Small; Nitrites- Positive

A: Hemorrhagic Cystitis and Bladder cancer were ruled out.

P: Urine Culture and sensitivity. Ciprofloxacin (Cipro) 500 mg PO BID for 14 days.

Referral to an urologist if there is a suspected underlying anatomic abnormality or acute scrotum.

Anemia

Initials- M. L

Age- 68 years

Sex- Female   

Race- White

S: M.L. is a 68-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.

Sinus Headache

Initials: H.K.

Age: 70 years

Sex: Male

Race: White

S: H.K is a 70-year-old White male presenting with a chief complaint of headaches. He began experiencing headaches five days ago. The headache episodes last 10-20 minutes. He describes the headache as diffuse, occurring all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. No associated symptoms were reported. The patient states that the headaches are intermittent. The headache is aggravated by bending over and activity, which interferes with his routines activities. He reports that Aspirin relieves the headache to some degree and also resting lessens the intensity. The patient rates the headache as 6/10 on the pain scale.

O: Vital Signs: BP- 138/86 mm Hg; Resp- 20; HR- 78; Temp- 98.78 F

HEENT: Tenderness on the cheekbones and jaw line. Tenderness on the orbital area and frontal sinus are palpable. Tenderness on the bridge of the nose.

A: Headache, facial pain, and facial pressure. Ruled out Migraine, Tension-type headache, and Cluster headache.

P: Decongestant and Saline nasal spray.  Warm compressions over the tender areas of the face.

Osteoporosis

Initials: F.L    

Age: 65 years

Sex: Female       

Race- White

S: F.L is a 65-year-old White female who presented with a chief 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: Vital Signs: Temp: 98.96F, BP: 134/88, Pulse: 88, RR- 20, SPO2: 98%

Height:            5’4, Weight: 184, BMI: 31.6

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.

Chronic Type 2 Diabetes

Initials: M.J

Age: 78 years

Sex: Male       

Race- White

M.J is a 78-year-old White male who has came for his diabetes check-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. Referral to an ophthalmologist for annual eye exam and to a podiatrist for an annual foot exam.

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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_Week2_Assignment_Rubric

PRAC_6531_Week2_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 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

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