Week 7 Assignment 1: Clinical Hour and Patient Logs/PRAC 6635
Week 7 Assignment 1: Clinical Hour and Patient Logs/PRAC 6635
PRAC 6635 WEEK 7 Clinical Hour and Patient Logs
- Depression
S: L.W. is a 37-year-old female who reports she has had a relapse of a constantly low depressed mood for the last month. She reports that the relapse was caused by the loss of her employment four months ago and is currently anxious she might not get employed again. She reports significant appetite loss and has lost over 15 pounds. Additionally, she reports feeling fatigued most of the day and sleeps over 12 hours. She also says she is experiencing anhedonia, is socially withdrawn, and feels worthless.
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O: Patient is alert, oriented, and well-groomed. She has a depressed mood, coherent thoughts, good judgment, and insight. There are no hallucinations or delusions.
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A: The patient has a relapse of depressive episodes. She currently feels anxious and hopeless.
P: Administer paroxetine 30mg orally once daily.
- Schizophrenia
S: M.O. is a 24-year-old male who presented with visual and auditory hallucinations that have been present for the last year. He reports that the hallucinations have progressively worsened as they occur more often. Additionally, he reports that people constantly talk about what he is thinking about, which makes him feel paranoid. He also has abnormal thoughts, disorganized speech, keeps on repeating the same answer to different questions, and bizarre behavior. He reports experiencing anhedonia, making him socially withdrawn, and he lacks the initiative to go to work.
O: Patient is alert, disoriented, improperly groomed, and agitated. He has apathy, flat affect, incoherent thoughts, circumstantiality, bizarre and paranoid delusions, and visual and auditory hallucinations. He has memory gaps, poor judgment, and lacks insight.
A: Neurocognitive disorder with hallucinations and delusions.
P: Administer olanzapine 10mg orally once daily.
- Bipolar Mood Disorder
S: S.P. is a 44-year-old male who presents with a constantly low mood. He reports that the low mood has followed a period where he describes he was experiencing a mania but reports medication noncompliance. He currently reports increased appetite, a 15-pound weight increase, excessive sleeping, anhedonia, and fatigue. He reports feeling worthless, is forgetful, and is no longer motivated to go to work.
O: Patient is alert, oriented, and inappropriately groomed. He has a depressed mood, gaps in his memory, poor judgment, and a lack of insight. He has no hallucinations or delusions.
A: Depressive episode in a patient who has previously experienced manic symptoms.
P: Administer Prozac 25mg and olanzapine 6mg orally once daily in the evening.
- Alcohol Use Disorder
S: P.N. is a 29-year-old male who is currently on detox following alcohol use for the last seven years. He reports that during this period, he has increased the amount he takes gradually due to excessive cravings and tolerance. He reports being unable to limit the amount of alcohol he takes and spends a lot of time drinking. Additionally, he reports that the use has led to separation from his wife, failed businesses, and has spent a lot of time in rehabilitation. He says he feels he needs to recover his failing life from chronic alcohol use.
O: Patient is alert, oriented, relaxed, and well-groomed. He has a coherent thought process and no hallucinations or delusions. Her memory and judgment are intact.
A: There has been marked improvement after initiation of treatment, and the patient is willing to be on treatment.
P: Continue on naltrexone 50mg orally once daily.
- Brief Psychotic Episode
S: G.L. is a 31-year-old female who presented scratching her skin after she reported feeling insects crawling on her skin. Additionally, she says she has been having auditory and visual hallucinations for the last 12 days. She has also had a delusional memory with abnormal thoughts and bizarre behavior. She reports having recurrent episodes every year that last about two weeks after she started using heroin three years ago.
O: The patient is alert, disoriented, inappropriately groomed, and agitated. He has an incoherent thought process, delusional memory, and visual, auditory, and tactile hallucinations.
A: The patient has hallucinations, delusions, and bizarre behavior following heroin use
P: Administer risperidone 4mg orally twice daily.
- Dementia
S: D.T. is a 77-year-old female who the son brought after he noticed she has had increased forgetfulness over the last six months. He reports she can no longer remember the names of her children, neighbors, and people or towns she previously knew and often gets lost when driving or walking towards or around her home and store. Additionally, he reports she is often confused about what time of the day and day it is. He also reports she has been having difficulties planning day-to-day activities and performing tasks she could previously do. He reports that the symptoms have made her more paranoid and anxious.
O: Patient is alert and well-groomed but disoriented. He is anxious with incoherent thoughts and has gaps in his memory.
A: Neurocognitive disorder noted with memory loss.
P: Administer Aricept 10mg orally at bedtime.
- Post-Traumatic Stress Disorder
S: B.T. is a 17-year-old female who was involved in a mass shooting at her school three months ago. She reports having recurrent distressing memories, flashbacks, and nightmares of the traumatic event. Additionally, she reports she has been easily frightened, is always on guard, and has trouble sleeping and concentrating. She says after the incident, she has never gone back to her previous schools, avoids going out, rarely watches the television to avoid having to see guns, and is socially withdrawn. She has also had negative thoughts about the world, memory problems regarding the event, and is constantly in a low mood.
O: Patient is alert, oriented, well-groomed, and hyper-vigilant. She has a depressed mood, a coherent thought process, and a trance when asked about the event. She has memory gaps but lacks hallucinations or delusions.
A: The patient is anxious, hyper-vigilant, and exhibits a trance.
P: Initiate paroxetine 30mg orally once daily.
- Generalized Anxiety Disorder
S: B.K. is a 23-year-old female who presented with increased restlessness and persistent worrying over her upcoming medical examinations. She reports that she is an excellent student and fears that she may fail in her final examinations. She reports that recently, she has been overthinking plans and creating solutions if she fails. Additionally, she has been anxious about whether she is ready to become a doctor and cannot set the worry aside as she fears causing more harm. She reports she has been having difficulties concentrating and sleeping, further worsening her anxiety.
O: Patient is alert, oriented, and well-groomed. She is anxious, has coherent thoughts, no hallucinations or delusions, and has an intact memory.
A: The patient is experiencing generalized anxiety coupled with insomnia and difficulty concentrating.
P: Administer paroxetine 20mg orally once daily.
- Anorexia Nervosa
S: P.L. is a 17-year-old female whose mother brought in after noticing she has had massive weight loss over the last four months. The patient reports that she has been feeling the need to lose weight to allow her to fit in amongst her friends. She reports that she has been dieting, fasting, denying hunger, making excuses to avoid eating, eating foods low in fat and calories, and lying about how much she has eaten to reduce food intake. She also reports self-induced vomiting to get rid of food and exercising excessively to ensure weight loss. She also reports that she will not fit in with her friend group if she gains weight.
O: She is alert, oriented, appropriately groomed, and anxious. She reports a low mood but with a coherent thought process. However, she lacks insight.
A: The patient lacks insight into how chronic starvation impacts her nutritional status.
P: Initiate the patient on nutritional supplements, fluids, and glucose.
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- Attention-Deficit Hyperactive Disorder
S: J.P. is a four-year-old boy brought to the clinic after the mother noticed he has difficulty concentrating on one activity. She says she first noticed the symptoms when the son was two years old, and the symptoms have been worsening. She reports that the son can no longer stay seated in a class, frequently fidgets and squirms in a seat, and talks too much. She says he constantly needs to move in inappropriate situations, interrupts others while playing or talking, and is very impatient.
O: The child is alert, agitated, and fidgets on the seat. He keeps running up and down the room and repetitively interrupts the mother during the whole session.
A: The child is hyperactive, easily distractible, and has a reduced attention span.
P: Administer methylphenidate 20mg orally once daily.
- Substance-Use Disorder
S:A.J. is a 25-year-old male who is currently being rehabilitated due to cocaine use. He reports that in the last two years, he has been feeling the need to use the drug regularly, making him use it several times a day. Additionally, he gets intense urges for the drug that block out any other thoughts and uses more significant amounts for a longer period to get a similar effect. He reports that the use has made him lose friends, fail to concentrate on his studies and work, and steal to maintain his supply. He says he has had withdrawal symptoms whenever he tries to stop using the drug, making him fail to stop using. He feels he needs treatment to get his life together.
O: Patient is alert, oriented, relaxed, and inappropriately groomed. He has an intact thought process, memory, and judgment. He does not have hallucinations and delusions.
A: The patient is willing to have a successful rehabilitation.
P: Administer naltrexone 50mg orally once daily.
- Delirium
S: P.Y. is a 44-year-old female who presented with confusion and was disoriented. She reports she is currently on alcohol withdrawal. She has a poor memory of recent events, difficulty talking and recalling words, says incomprehensible words and does not understand when spoken to. In addition, she is easily distracted, withdrawn, inattentive, irritable, and restless.
O: Patient is confused, disoriented, and agitated. She has incoherent thoughts, poor recent memory, and poor judgment, and is irritable but has no hallucinations or delusions.
A: Confusion, disorientation, and memory loss have been noted in this patient.
P: Administer risperidone 4mg twice daily and lorazepam 4mg orally twice daily.
Clinical Hour and Patient Logs
Clinical Hour Log
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 to earn the points associated with this assignment. You may only log hours with Preceptors that are approved in Meditrek.
Students must complete a minimum of 160 practicum hours.
You may not complete your hours sooner than 8 weeks. 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 RESOURCE
Patient Log
Throughout this course, you will also keep a log of patient encounters using Meditrek. You must record at least 80 patients by the end of this practicum. You must record at least 80 patients by the end of this practicum. You must see at least 5 pediatric/adolescent patients and 5 adult/older adult patients.
The patient log must include the following:
Student Notes—Students must include a brief summary/synopsis of the patient visit—this does not need to be a SOAP note; however, the note needs to be sufficient to remember your patient encounter
By Day 7 of Week 7
Record your clinical hours and patient encounters in Meditrek.
Rubric
PRAC_6635_Week7_Assignment1_Rubric
| Criteria | Ratings | Pts | ||
|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Part 1: Time logs and patient logs are completed within 48 hours of completing clinical time. |
|
5 pts | ||
| This criterion is linked to a Learning Outcome Part 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 | ||
| Total Points: 10 | ||||
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