PRAC 6531 Week 5 Clinical Hour and Patient Logs Paper

PRAC 6531 Week 5 Clinical Hour and Patient Logs Paper

PRAC 6531 Week 5 Clinical Hour and Patient Logs Paper

Osteoarthritis
Initials: G.L Age: 68 years
Sex: Male Race: White
Diagnosis: Osteoarthritis
S: G.L is a 68-year-old White male who came to the office with complaints of painful knee joints. He states that he began experiencing mild knee pain about 15 months ago after walking moderate to long distances. The pain advanced and started occurring when he walked, accompanied by stiffness that limited his movements. The severity of the joint pain has worsened over time from mild to moderate pain. He now experiences joint stiffness in the morning and during rest on some days. N.S describes the pain as deep and achy in both knee joints, lasting 10-15 minutes. The joint pain is aggravated by activities such as walking and alleviated to some degree by rest and Tylenol, but nothing relieves the joint stiffness. He denies using any other medication or measures to relieve the symptoms. He rates the pain at 5/10.
O: Vital Signs: Temp-98.96; BP- 132/80; HR-78; RR-16; SPO2-99%
Height- 5’5 Weight- 189, BMI-31.4
Musculoskeletal: ROM-3/5 (bilateral knee joints). Reduced ROM of bilateral knee joints with crepitus. On palpation, the knee joints are tender.

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Neurological: Muscle strength 4/5; Stable body balance; CNs are intact.
A: Diagnostic Results: Elevated erythrocyte sedimentation rate (ESR)- Normal
C-reactive protein (CRP)- Normal
WBC count- Normal
Rheumatoid factor-Negative
P: Meloxicam- 7.5 mg PO OD for 2 weeks. Occupational therapy; Heat and cold applications.
 
Preeclampsia
Initials: D.W Age: 34 years
Sex: Female Race: AA
Diagnosis: Preeclampsia
S: D.W is a 34-year-old AA female on her antenatal visit and she has complaints of swollen legs. The patient is a Para 1+0 gravida 2 and her gestation age is 28 weeks. She states that the leg swelling began six weeks ago and she assumed that it is the normal edema that occurs in pregnancy. However, the edema does not improve with an elevation of the lower limbs and is worsening over time. She also reports having occasional headaches in the occiput region which began around the same time as the edema. The headaches sometimes get severe to a point that she experiences blurred vision and confusion. K.W states that in her previous pregnancy she had mildly elevated gestational hypertension, which was managed by a low sodium diet and it abated after birth. However, she did not experience edema and headaches.
O: Vital Signs: Ht: 5’5 Wt.: 171 lbs. O2 Sat-98% P-114; T: 98.4 F RR: 22, BP: 150/94 (seated); 152/94 (lying).
Lower limb edema, bilaterally.
Diagnostic Results: Urinalysis-Pus cells (minimal); proteinuria 2+; Ketones-negative; RBCs- negative. Full hem: HB- 12.4; CBC- Normal RBCs, WBCs, and platelets.
A: High blood pressure, proteinuria 2+, new-onset edema, headaches, blurred vision, and confusion.
P: Nifedipine extended-release 30 mg orally once a day; Calcium supplementation
BP measurement every 4 hours at least 4 times a day; Ultrasound every two weeks; Daily fetal movement count; 24-hour examination of urine.
 
COPD Exacerbation
Initials: P.K Age: 58 years
Sex: Female Race: AA
Diagnosis: COPD Exacerbation
S: P.K is a 58-year-old female patient who was admitted to the medical wards after presenting with dyspnea, chest tightness, and constant cough with sputum production. She has a history of COPD diagnosed two years ago. The symptoms began three days ago and had worsened over time to a point that they limited her daily activities.
O: The patient is alert and has no signs of acute respiratory distress. She is oriented to person, place, and time. Vital signs include: BP-132/86; HR-94; RR-20; Temp-98.6; SPO2-99%.COPD exacerbation symptoms have abated, and she reports improved respiration with no dyspnea, cough, or purulent sputum. On respiratory exam, respirations are smooth with no use of accessory muscles, the chest rises in uniform, and breath sounds are clear bilaterally. Cardiovascular exam reveals regular heart rate and rhythm.
Spirometry: FEV1/FVC- 80%.
ABGs- pH- 7.38; PaCo2- 40 mmHg; PaO2-90; HCO3-24;O2 Sat- 99%; CBC: WBC- 6,000/microliters
A: COPD Exacerbation; Bacterial pneumonia ; Acute Respiratory Acidosis; Hypertension
P: Non-invasive positive-pressure ventilation by face mask; Nebulization with Albuterol 2.5 mg every 2 hours; IV administration of Lactate solution.
 
COPD
Initials: F.P Age: 65 years
Sex: Male Race: White
Diagnosis: COPD
S: F.P is a 65-year-old White male who presented with shortness of breath and chest tightness. He has a history of COPD diagnosed at 60 years and has been managed on Ipatropium. The symptoms began five days ago and have worsened over time to a point where they impair his daily activities. He reports producing a ‘whistling’ sound, especially when breathing out. The SOB has also interfered with eating. The patient’s reports that he has had a prolonged cough with colorless sputum production in the past two weeks.
O: Vital signs: BP-136/84; RR-28b/min; HR-88; Temp-99.2; SPO2- 92%. On general exam, the patient was in mild respiratory distress. To evaluate the cause of the SOB and chest tightness, we performed a cardiovascular physical exam and a respiratory assessment including a physical exam and a pulmonary function test before and after administering Albuterol. The cardiovascular exam revealed distant heart sounds. Chest exam findings include a barrel chest; use of pursed-lip breathing and accessory respiratory muscles; prolonged expiration; bilateral wheezes on forced and unforced expiration; diffusely decreased breath sounds; Hyperresonance on percussion. Before Albuterol, the FEV1- 50%; FEV1/FVC- 60%; after administering Albuterol: FEV1- 50%; FEV1/FVC- 60%.
A: The pulmonary function test exam confirmed COPD exacerbation as the diagnosis.
P: Prescribed medications include: Salmeterol 1 inhalation (50 mcg) BD; Ipratropium inhaler 2 actuations (34 mcg) every 6 hours.  
COPD
Initials: A.L Age: 75 years
Sex: Male Race: AA
Diagnosis: COPD
S: A.L. is a 75-year-old AA male with a chief complaint of shortness of breath and chest tightness. The symptoms began ten weeks ago during the fall and have worsened over time to a point where the SOB and chest tightness impair his daily activities. Besides, the SOB has interfered with eating resulting in significant weight loss. He reports having a prolonged cough with colorless sputum production in the past 15 months. He has repeatedly been to the community clinic and administered cough suppressants and antibiotics for the cough and sputum, but they only offered temporary relief. He reports that the symptoms have significantly affected his daily activities, including his work at his farm.
O: Barrel chest. Use of pursed-lip breathing and accessory respiratory muscles. Prolonged expiration. Bilateral wheezes on forced and unforced expiration. Diffusely decreased breath sounds bilaterally. Hyperresonance on percussion
A: The patient’s symptoms suggested a restrictive respiratory disease, Asthma or COPD. To differentiate the two, the clinician performed pulmonary function testing before and after administering Albuterol. Before administering Albuterol: FEV1- 50%; FEV1/FVC- 60%; After administering Albuterol: FEV1- 50%; FEV1/FVC- 60%.
Asthma ruled out.
P: Nebulization with Albuterol 2.5 mg every 2 hours. Albuterol 2 to 4 puffs (100 mcg/puff) by metered-dose inhaler. Prednisone 40 mg orally OD for 5 days.
Non-purulent Cellulitis
Initials: W.G Age: 58 years
Sex: Male Race: Mexican
Diagnosis: Non-purulent Cellulitis
S: W.G is a 58-year-old Mexican male who presents with a chief complaint of having a swollen leg that was painful. He reports that the swelling and pain started after he stumbled and fell when working on the farm three days ago. He sustained a laceration on the left leg after being pricked by a twig, which he cleaned using an antiseptic. The area around the laceration started swelling and there was pain, which has progressed over time. He states that the swollen area is hot to touch and red than other parts of the leg. The symptoms are only on the left leg and the right leg is just fine. He also reports having some degree of fever in the last 12 hours. The patient reports taking OTC Motrin 400 mg twice daily to relieve the pain but he did not notice any significant impact. He rates the leg pain as 6/10.
O: Vital Signs: Temp-100.22F; BP-, BP-118/76 (sitting position); HR-88; RR-16; SPO2- 99%.
Edema of the left leg on the lower posterior aspect. Erythema, tenderness, and warmth on a poorly demarcated posterior part of the left leg.
CBC- Elevated WBCs.
A: Inflammation, Mild fever, and leukocytosis.
P: Blood culture; Levofloxacin 500 mg PO once a day; Immobilization and elevation of the affected leg.
 
Cellulitis
Initials: L.S Age: 63 years
Sex: Female Race: White
Diagnosis: Cellulitis
L.S is a 63-year-old female who presented with chief complaints of having a painful and swollen leg. She states that the symptoms started after she fell and sustained a minor injury 5 days ago when hiking in the woods. She got pricked on the left leg by a stick, but she did not think it would result in a severe outcome. The patient states that the pain in the leg had gradually increased, and the swelling progressed every day. In addition, to the pain and swelling, she reports that the affected leg area is red and warmer than the other leg. The client also states that she has been having a mild fever in the past two days and is unsure whether it is associated with the leg injury. She has taken Tylenol in the past two days, but it has not been effective in alleviating the pain. She rates the pain as 5/10.
O: Vital signs: BP-114/72; HR-82; RR-16; Temp- 100.22F.
Erythema, tenderness, and warmth on the anterior lower part of the left leg. Leg swelling.
CBC- Elevated WBCs.
A: Cellulitis; Necrotizing fasciitis; Erysipelas.
P: Levofloxacin 500 mg PO once a day. Use cool, wet dressings on the affected part of the left leg.

Generalized Anxiety Disorder
Initials: P.T Age: 65-years
Sex: Female Race: White
Diagnosis: Generalized Anxiety Disorder
S: P.T is a White female who presented with excessive anxiety and worries about her job. She had started a restaurant business and was ever-concern about meeting client’s expectations and making profits. She reported that the excessive anxiety was difficult to control even when resting which caused difficulties in initiating and maintaining sleep. The anxiety symptoms begun about five months ago after starting into business. P.T also mentioned that she felt keyed up and had her mind would often go blank. She easily got fatigued and had become easily irritable at work and home.
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 was ‘anxious’ and affect was congruent. Speech was clear with normal rate and volume. Coherent, linear, and goal-directed thought process. 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; Insomnia.
P: Paroxetine 20 mg orally. Refer for psychotherapy.

Major Depressive Disorder
Initials: J.K Age: 52-years
Sex: Female Race: White
Diagnosis: Major Depressive Disorder
S: J.K is a 52-year-old White female client who reports that in the past 6 weeks, she had lost interest in most activities including her family. She was feeling sad and empty most of the day and nearly every day. Besides, she reported that he was fatigued most of the day and had little energy to work. She felt sleepy during the day, although she slept for more hours than usual. The client also reports that her appetite had reduced in the past weeks. She reports that the symptoms have significantly affected his work due to a diminished ability to concentrate and make decisions on her own. She admits taking alcohol 3-4 beers on weekends but denies tobacco or other drug substance use.
O: The client is neat and dressed appropriately for the weather. She is alert but maintains minimal eye-contact. Her self-reported mood is “sad” and affect is constricted. Speech is clear but she speaks in low tones. She has a coherent thought process. No delusions, hallucinations, or suicidal/homicidal ideations were noted. Her short-term and long-term memory is grossly intact. Judgment, abstract thought, and insight are intact.
A: Depressed mood; Disturbed sleep pattern; Nutrition imbalance less than body’s requirements. No risk of self- injurious behavior. PHQ-9 score- 12.
P: Citalopram 20mg once a day.

Post-Traumatic Stress Disorder
Initials: T.E Age: 64-years
Sex: Female Race: AA
Diagnosis: Post-Traumatic Stress Disorder.
S: T.E is a 64-year-old female client who was involved in a fatal RTA four months ago where she witnessed two people succumb to severe injuries. The client reported that six after the accident she started re-experiencing intrusive thoughts about the RTA. She reported experiencing distressing dreams and nightmares about the RTA. Besides, she experiences recurrent memories and flashbacks of the screams and wails during the incident. The constant nightmares have disrupted her sleeping pattern and she now has difficulties maintaining sleep. She also reports that her stress levels have increased significantly.
O: The client is well-groomed and appropriately dressed for the weather. She is alert, but appears anxious and maintains minimal eye-contact. The self-reported mood is ‘nervous,’ and affect is congruent. Her speech is clear, but rate and volume reduces when the client talks about the RTA. She also develops tremors when discussing the sight of the dead passengers. Thought-process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations noted. Orientation, memory, abstract thought, judgment, and insight are intact.
A: Reduced vigilance and startle response. Emotional distress when discussing the RTA.
P: Zoloft 50 mg once a day.

Insomnia
Initials: C.G
Age: 74-years
Diagnosis: Insomnia
S: C.G is a 74-year-old A.A male client who reported experiencing difficulties initiating and maintaining sleep and he barely sleeps for 4 hours. The sleeping disturbances began 6 months ago and have worsened over time. He states that he stays on his bed for 1-2 hours before falling asleep. Besides, he rolls a lot on the bed as he waits to sleep. The client also reported waking up often in the middle of the night and takes about 2 hours before he can find sleep. The sleeping difficulties have affected his work since he mostly feels fatigued during the day. He reports taking about 4 cups of coffee per day because it stimulates him during the day. He has been taking OTC sleeping pills to induce sleep, but they have had minimal impact.
O: The client is neat and dressed appropriately for the weather. The self-reported mood is ‘tired,’ and affect is appropriate. He appears somewhat bored during the psychotherapy session. His speech is clear, and thought process is coherent and goal-directed. No delusions, hallucinations, or suicidal ideations were noted. He is oriented to person, place, and time. His memory and judgment are grossly intact and insight is present.
A: Impaired interpersonal and social functioning.
P: Sleep hygiene education emphasizing on modification of lifestyle habits that influence sleep, such as drinking too much caffeine late in the day or not getting regular exercises.

Pelvic Inflammatory Disease
Initials: D.L
Age: 44-years
Diagnosis: PID
S: Patient reports that the abdominal pain began 6 days ago after cessation of her menstrual periods. She reports 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 OTC Tylenol to lower the pain and it had a minimal temporary effect. Rates the pain as 3/10. Reports abnormal vaginal discharge began 4 days ago accompanied by some slight pain during urination. Describes the discharge as having mucus and pus and white-cream in color. Reports pain during sexual intercourse and bleeding after intercourse.
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%
Abdominal tenderness on lower right and left quadrants. Rebound abdominal tenderness. No masses or organomegaly
Genital and Rectal:Mucopurulent vaginal discharge. Uterine tenderness and cervical motion tenderness. Tender adnexal mass.
WBC count: 11000/Ul
A: Lower abdominal pain, dyspareunia, , abnormal vaginal discharge, and dysuria.
P: Oral Ofloxacin 400 mg BD × 14 days; Oral Metronidazole 400 mg BD × 14 days.

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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_Week5_Assignment2_Rubric

PRAC_6531_Week5_Assignment2_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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