AGPCNP Clinical Practinum Paper
AGPCNP Clinical Practinum Paper
CLINICAL CASE LOG AND TIME DOCUMENTATION
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: ___________________
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| 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
hours (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.
