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
|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.
|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.
|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.
|G.A./72/M||Presents with memory loss and cognitive impairment.||H/o progressive deterioration of cognitive function.||Alzheimer’s Dementia||(i) Activities
|(i) Stimulating activities, physical activities, and adequate sleep.
|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.