PRAC 6665 Week 1 Assignment: Clinical Hour and Patient Logs
PRAC 6665 Week 1 Assignment: Clinical Hour and Patient Logs
Clinical Hour and Patient Logs
Age: 5-12 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Autism spectrum disorder
S: The patient is a 9-year-old whose parents brought him to the facility for psychiatric assessment. The parents complained that their son has challenges in communication and social interactions. He also shows some repetitive behaviors and sensory deficiencies.
O: The patient was dressed appropriately for the clinical visit. He appeared of appropriate weight for his age. He avoided eye contact during the assessment and had rocking motions. The patient’s communication skills were inadequate, as evidenced by his difficulties in sustaining conversations. He also lacked interest in social interaction and covered his ears because of loud noises.
A: Autism spectrum disorder
P: The patient was referred to a speech-language pathologist, pediatrician, and occupational therapist. The patient was prescribed oral risperidone 0.25 mg once daily. A follow-up visit was scheduled after four weeks.
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Age: 5-12 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Attention-deficit hyperactivity disorder (ADHD)
S: The patient is a 10-year-old female whose parents have brought her to the facility for her follow-up visit. The patient was diagnosed with ADHD at the age of nine years old and has been undergoing regular checkups in the facility.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented. Her weight was appropriate for her age. The patient remained fairly attentive during the assessment. She did not show any symptoms of impulsivity or avoidance of eye contact. She denied a depressed mood, illusions, delusions, hallucinations, or suicidality. A teacher’s report showed improved social and academic performance.
A: ADHD responsive to treatment
P: A decision to continue with oral risperidone 2.5 mg was made. A follow-up visit was scheduled after four weeks.
Age: 5-12 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Conduct disorder
S: The patient is a 12-year-old male whose parents brought him to the facility for assessment and treatment. The presenting complaints included defiance, disruptive behaviors, and aggression toward others at school. The parents also reported that their son argues with adults, experiences emotional outbursts in most cases, and has difficulties relating with his peers.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented to himself, others, time, and events. The patient argued with the provider during the assessment. He demonstrated evidence of emotional outbursts during the assessment. The patient reported frequent conflicts and aggression toward his peers at school. He denied anxiety, depressed mood, illusions, delusions, hallucinations, or suicidality.
A: Conduct disorder
P: The patient was prescribed oral clonidine 0.05 mg daily. He was also started on cognitive behavioral therapy and parent training. A follow-up visit was scheduled after four weeks.
Age: 13-17 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Anorexia nervosa
S: The patient is a 16-year-old female whose parents brought her to the facility for assessment and treatment. The presenting complaints included intentional weight loss, fear of weight gain, avoidance of food, and being overly concerned with body image. The patient reported engaging in restrictive eating behaviors, including self-induced vomiting to prevent weight gain.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. The patient was malnourished with dry skin and brittle air. She expressed low self-esteem. The patient denied a depressed mood, illusions, delusions, anxiety, or suicidality.
A: Anorexia nervosa
P: The patient was prescribed oral fluoxetine 10 mg once daily, increased fluid intake, and dietary changes. Psychotherapy will be initiated once she is stable.
Age: 13-17 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Panic disorder
S: The patient is a 16-year-old male whose parents brought him to the facility for assessment and treatment. The presenting complaints included frequent episodes of intense panic episodes accompanied by chest pains, palpitations, and trembling. The patient reported that the symptoms have affected his ability to concentrate on his academics. He denied substance use or abuse.
O: The patient was dressed well for the clinical visit. He was alert and oriented to himself, others, time, and events. He appeared anxious, restless, and tense. The patient expressed that he often fears impending doom. He denied a depressed mood, illusions, delusions, hallucinations, or suicidality.
A: Panic disorder, rule out generalized anxiety disorder.
P: The patient was prescribed oral sertraline 25 mg once daily. He also started individual psychotherapy. A follow-up visit was scheduled after four weeks.
Age: 13-17 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Premenstrual dysphoric syndrome
S: The patient is a 17-year-old female who presented to the facility for her follow-up visit. She was diagnosed with premenstrual dysphoric syndrome a month ago and started treatment. Today, the patient denies a depressed mood or physical symptoms before her menstrual cycle.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. She was of the appropriate weight for her age. The patient denied irritability, restlessness, a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidality.
A: Premenstrual dysphoric syndrome that is responsive to treatment.
P: Oral sertraline 25 mg was stopped. She was advised to take oral ibuprofen 800 mg two days to, throughout, and two days after her menses. She was scheduled for a follow-up visit after four weeks.
Age: 13-17 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Generalized anxiety disorder
S: The patient is a 16-year-old female whose parents brought her to the facility for assessment and treatment. The presenting complaints included excessive worry and anxiety most days. The patient reported accompanying symptoms, including difficulty concentrating, controlling worry and anxiety, restlessness, and feeling on edge. She denied substance use, abuse, or a history of mental health problems. She reported that the problem has affected her ability to concentrate in class.
O: The patient was dressed appropriately for the occasion. She appeared tense, anxious, and on edge. She reported that her thoughts overwhelm her. She denied a depressed mood, illusions, delusions, hallucinations, or suicidality.
A: Generalized anxiety disorder
P: The patient was prescribed oral sertraline 25 mg once daily. She was scheduled for a follow-up visit after four weeks.
Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Major depression
S: The patient is a 45-year-old male whose spouse brought him to the facility for assessment. The presenting complaints included feeling sad almost every day, lack of interest or pleasure, insomnia, easy irritability, and changes in the patient’s eating habits. The patient reported decreased productivity in his occupational roles. He denied substance use, abuse, or suicidal thoughts.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented to himself, others, and events. The patient’s mood was moderately depressed. He expressed hopelessness. His speech and thought process were intact. The patient demonstrated avolition. He did not show tremors, tics, or eye avoidance. He denied illusions, delusions, hallucinations, or suicidality.
A: Major depression
P: The patient was prescribed oral sertraline 50 mg once daily. He was scheduled for a follow-up visit after four weeks.
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Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Post-traumatic stress disorder
S: The patient is a 38-year-old male who came to the facility for assessment and treatment. The patient complained of nightmares, flashbacks, and avoidance of cues related to an accident he was involved. The patient also reported being hyper-vigilant and experiencing a depressed mood over the last two weeks. He denied substance use, abuse, or a history of mental health problems.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented. His mood was moderately depressed. His speech and thought process were intact. The patient reported intrusive thoughts, nightmares, and flashbacks about the accident. He denied illusions, delusions, hallucinations, or suicidality.
A: Post-traumatic stress disorder
P: The patient was prescribed oral sertraline 50 mg once daily. He was scheduled for a follow-up visit after four weeks.
Age: Above 65 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Insomnia
S: The patient is a 66-year-old male who presented to the facility for assessment and treatment. The patient complained of difficulty initiating and maintaining sleep. He reported that he sleeps less than four hours every night. He also experiences daytime sleepiness, frequent awakenings, and impairment in his daily routines.
O: The patient was dressed appropriately for the clinical visit. He was lethargic and fatigued. He denied any medical condition that could be associated with his sleep problem. He denied anxiety, depression, illusions, delusions, or hallucinations.
A: Insomnia
P: The patient was prescribed oral zolpidem 6.25 mg at night. He was scheduled for a follow-up visit after two weeks.
Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Bipolar disorder
S: The patient is a 35-year-old female who presented to the facility for assessment and treatment. The presenting complaints included fluctuations in her mood, activity, and energy levels for the past four months. The patient reported that she usually has cycling periods of a depressed mood and an expansive mood. The fluctuations last about two weeks. She notes that she is unable to focus on her work and academics during these periods. She denied substance use, abuse, or any medical condition that could be attributed to her complaints.
O: The patient was dressed appropriately for the occasion. The patient was easily irritable, restless, and had speech pressure. She reported a depressed mood, a flight of ideas, and an intense urge to engage in goal-directed activities. The patient denied anxiety, illusions, delusions, hallucinations, or suicidality.
A: Bipolar disorder
P: The patient was prescribed oral lithium 600 mg twice daily. She was scheduled for a follow-up visit after four weeks.
Age: Above 65 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Substance use disorder
S: The patient is a 66-year-old male who presented to the facility for his follow-up visit. He was diagnosed with alcohol use disorder four months ago and started oral naltrexone 50 mg once daily treatment. Today, the patient denied consuming alcohol over the last three months. He also denied alcohol withdrawal symptoms.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented to himself, others, time, and events. The patient had mild hand tremors. He denied a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidality. The patient’s thought process was intact. He had mild speech incoherence.
A: Substance use disorder
P: The patient was advised to continue with oral naltrexone 50 mg once daily. He was linked with an Alcoholics Anonymous group. A follow-up visit was scheduled after four weeks.
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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 in order to earn the points associated with this assignment. You may only log hours with Preceptors that are approved in Meditrek.
Students 2018 must complete a minimum of 160 hours of supervised clinical experience. 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)
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 will also keep a log of patient encounters using Meditrek. You must record at least 80 encounters with patients by the end of this practicum (40 children/adolescents and 40 adult/older adult).
The patient log must include the following:
Date
Course
Clinical Faculty
Preceptor
Patient Number
Client Information
Visit Information
Practice Management
Diagnosis
Treatment Plan and Notes: You 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 1
Record your clinical hours and patient encounters in Meditrek.
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Rubric
PRAC_6665_Week1_Assignment3_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 *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 | ||||