AGPCNP Clinical Practinum Paper

AGPCNP Clinical Practinum Paper


Filled in electronically using Word, no hand-written documents will be accepted.


Student Name: _____________________________________ Clinical site and location: ___________________________________

Preceptor Name: _________________________________________

Date: ________________ Hours completed today: ___5.1 hours____ Total Hours completed: ___________________



Date of Visit Patient Initials, Age, and gender HPI/CC Assessment

H & P

Primary dx and/or differential diagnoses Plan of Care summary Specific Plan of Care related to preventative

& psychosocial

Prescriptions (OTC & by Prescription) w/ patient instructions ICD-10 diagnosis code(s) Direct care estimated


(in increments of .5=30 minutes)

  A.N./22/F Painless genital lesions that are rough and bumpy.AGPCNP Clinical Practinum Paper. Has multiple partners and sexually active with both. O/E pos for round, elevated but painless lesions on external labia. Lymphogranuloma venereum (LGV).


Prescription of antibiotic, health education/ promotion for safer sex. Counseling and education about STIs and their prevention. Doxycycline 100 mg orally twice daily for 21 days.

Must not get pregnant during the treatment.

A55 20 min
  V.M.V./42/F Routine Pap smear Koilocytic atypia Low-grade squamous intraepithelial lesion (SIL) or CIN 1. Advice on safe sex and education on the importance of doing another Pap smear & HPV test within a year. Education on safe sex and an appointment for the next Pap smear and HPV test in less than 12 months time. NIL N87 24 min
  A.J./24/F C/o diarrhea, abdominal cramps, and nausea. H/o p.r. bleeding 3 years ago. O/E soft abdomen with hyperactive bowel sounds. (i) Gastroenteritis (ii) PID Antibiotics and health education on proper sanitation. Health education, prescription, and reassurance. Ciprofloxacin 500 mg po twice daily for 3 days. A09 21 min
  D.N./36/M C/o heart burn/ retrosternal chest pain. H/o chest pain after meals with regurgitation. Reflux esophagitis Prevention of erosion of the mucus membrane of the esophagus. H2 blockers and proton pump inhibitors. Prescription of medications and dietary education. K21.0 22 min
  S.N.M./35/M C/o difficulty breathing while sleep and loss of sexual drive. H/o sleep apnea. O/E, BMI = 32.6 kg/m2. Obesity Nonpharmacologic management and education on lifestyle changes. (i) Isotonic aerobic exercise (ii) dietary modifications (less fatty foods and more fresh fruits & vegetables) Isotonic aerobic exercise (walking) for 30 minutes every day. E66 20 min
  L.W.L/65/M C/o LLQ pain, fever, and constipation. H/o of constipation. O/E has rebound tenderness, fever, tachycardia, and guarding. Diverticulitis (diverticular disease) Colonoscopy, antibiotics, and dietary advice. (i) Colonoscopy (ii) liquid diet for two weeks (iii) Ciprofloxacin and metronidazole. (i) Ciprofloxacin 750 mg PO BID (ii) Metronidazole 500 mg PO QID. K57.92 25 min
  J.A./18/F C/o “feeling sad”. H/o social isolation and self blame. Major Depressive Disorder (MDD) Psychotherapy, medication, and psychoeducation. (i) CBT (ii) Antidepressant. Fluoxetine (Prozac) 10 mg PO OD. F32.9 22 min
  E.L.M./52/M C/o chest pain and difficulty in breathing. H/o HTN and hypercholesterolemia. Acute Coronary Syndrome (ACS) Health education on behavioral change and medication. (i) Health education (ii) Statin Atorvastatin 40 mg PO OD. 124.9 19 min
  M.R./42/F Presents with “headache” for three days. O/E has a BP of 145/85 mmHg. Primary HTN (i) Education on medication compliance and dietary discretion (ii) medication (i) H/E on the need for strict medication adherence (ii) Low salt diet, and (iii) Antihypertensives. 1. Nifedipine 20 mg OD

2. Losartan 50 mg OD.

I10 22 min
  T.R./21/M Presents with a c/o nightmares and flashback. AGPCNP Clinical Practinum Paper. Reports a h/o molestation and abuse as a child. PTSD Psychoeducation/ psychotherapy. CBT N/A F43.11 24 min
  E.R.T/18/F C/o left knee pain (dull) H/o trauma during soccer. O/E, pain on applied force. Collateral ligament sprain left knee (i) Conservative management (ii) analgesic Tylenol Tylenol 1g PRN (OTC) S83.4.2A 19 min
  J.J.L/63/M Presents with dyspnea, hemoptysis, fatigue, and weight loss. Has a h/o smoking and COPD. O/E, decreased breath sounds and tachypnea. COPD exacerbation Health education and medication (i) To stop smoking (ii) long-acting anticholinergic. Spiriva 18 mcg (2 inhalations) OD orally. J44.1 20 min
  A.A.C./28/F  A lactating mother presenting with sudden hostility to the baby. O/E has blunted affect but insight and judgment intact. Postpartum Depression Educational intervention and pharmacotherapy. (i) Psychotherapy (ii) SSRI (i) CBT

(ii) Celexa 20 mg PO OD.

F53.0 22 min
  G.A./72/M Presents with memory loss and cognitive impairment. H/o progressive deterioration of cognitive function. Alzheimer’s Dementia (i) Activities

(ii) Medication.

(i) Stimulating activities, physical activities, and adequate sleep.

(ii) Donepezil

Aricept 5 mg HS. G30.9 25 min


Signature of Student: _________________________________________________ Date: __________________________________


Signature of Preceptor: _______________________________________________ Date: __________________________________

(signature by preceptor and student is required upon completion of hours) AGPCNP Clinical Practinum Paper.