PRAC 6665 Week 4 Assignment: Clinical Hour and Patient Logs

PRAC 6665 Week 4 Assignment: Clinical Hour and Patient Logs

PRAC 6665 Week 4 Assignment: Clinical Hour and Patient Logs

Clinical Hour and Patient Logs
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 an 8-year-old female client whose parents brought her to the facility for her follow-up visit. The patient was diagnosed with ADHD four months ago and started treatment. The parents and the child’s teacher report improved attention span and social and academic functioning.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. She appeared mildly restless. She did not fidget or show difficulties remaining seated during the assessment. The attention span was grossly intact. The patient interrupted the conversation. The teacher reports improved academic and social performance. She denied a depressed mood, anxiety, illusions, delusions, or hallucinations.
A: ADHD responsive to treatment
P: Based on the diagnosis, the plan was that the patient continues with the current oral methylphenidate 2.5 mg once daily and incorporate modifications into her social and school activities. The patient’s follow-up was scheduled after four weeks.

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Age: 5-12 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Autism spectrum disorder (ASD)
S: The patient is a 10-year-old male whose parents brought him to the facility for a follow-up visit. The patient was diagnosed with ASD three months ago and started treatment. The parents report improved social engagement and sensory sensitivities. They expressed the child’s difficulties maintaining his peer relationships.
O: The patient was dressed appropriately for the occasion. The child demonstrated limited eye contact and mild repetitive movements. There was evidence of routine adherence that made it difficult for him to adjust to new environments. The child demonstrated echolalia and sensitivity to loud noises. He denied a depressed mood, anxiety, illusions, delusions, hallucinations, or suicidality.
A: ASD
P: Based on the diagnosis as per DSM-V, the parents were advised to continue with oral risperidone 0.25 mg daily and behavioral interventions targeting communication and social skills. The patient was scheduled for a follow-up visit after four weeks.

Age: 65 years and above
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Dementia
S: The patient is a 66-year-old male whose daughter brought him to the facility for assessment. The presenting complaints included forgetfulness, getting lost in familiar places, difficulties in completing activities of daily living, and episodes of confusion and irritability.
O: The patient was dressed appropriately for the clinical visit. He was alert and grossly disoriented to space, time, and events. The patient had mild hand tremors, speech preservation, and difficulty recalling recent events. He denied a depressed mood, anxiety, illusions, delusions, or hallucinations.
A: Dementia, rule out Alzheimer’s disease
P: The patient was referred for a neurologist review

Age: 5-12 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Social anxiety disorder
S: The patient is an 11-year-old female whose parents brought her to the facility for assessment. The presenting complaints included distress in social situations where others scrutinized her. The parents noted that their daughter is usually anxious when exposed to such situations and often avoids them. The symptoms have affected her academic performance and self-esteem.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. The patient was anxious and nervous during the assessment. She avoided eye contact. She was reluctant to express herself. She did not show any signs of distress or aggression.
A: Social anxiety disorder
P: Based on the diagnosis as per DSM-V, the patient was prescribed oral sertraline 25 mg once daily. A follow-up visit was scheduled after four weeks.

Age: 13-17 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Oppositional defiant disorder
S: The patient is a 15-year-old male whose parents brought him to the facility for assessment. The presenting complaints included a history of temper outbursts, violating school and social norms, arguing with adults, and vindictiveness. The symptoms have persisted for more than six months. They impair the patient’s academic and social functioning.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented to himself, others, time, and events. The patient was restless, argumentative with the healthcare provider, and had a limited attention span. He also demonstrated argumentative behaviors during the assessment. There were no signs of distress, depressed mood, anxiety, or suicidality.
A: Opposition defiant disorder, rule out intermittent explosive disorder
P: Based on the diagnosis as per DSM-V, the patient was prescribed oral risperidone 0.25 mg daily and started cognitive behavioral therapy. 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: Post-traumatic stress disorder (PTSD)
S: The patient is a 16-year-old female whose parents brought her to the facility for her follow-up visit. She was diagnosed with PTSD a month ago and started treatment. Today, the patient reports improved mood, social and academic activity.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. She denied a depressed mood, anxiety, insomnia, avoidance behaviors, or changes in her appetite. The patient denied suicidality, illusions, delusions, or hallucinations.
A: PTSD responsive to treatment.
P: Based on the patient’s response to the treatment, the patient was advised to continue with oral sertraline 25 mg daily. A follow-up visit was scheduled after four weeks.

Age: 13-17 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Anorexia nervosa
S: The patient is a 17-year-old female client whose parents brought her to the facility for assessment. The presenting complaints included restrictive eating behaviors and considerable weight loss. The parents reported that they daughter has been engaging in restrictive eating habits for the past eight months. The patient reported fear of weight gain, preoccupation with food, and being dissatisfied wither body shape.
O: The patient was dressed appropriately for the clinical visit. She was underweight for her age. The mucus membranes were dry with a decreased capillary refill and poor skin texture. Hypotension and bradycardia were observed. The patient did not show any signs of acute distress.
A: Anorexia nervosa, rule out major depressive disorder
P: Based on the clinical findings and psychiatric assessment, the patient was administered intravenous normal saline 0.9% 1L was administered before the patient was admitted for stabilization, nutritional, psychologist, and psychiatric review.

Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Major depression
S: The patient is a 28-year-old female who came to the facility for assessment. The presenting complaints included a depressed mood most days, lack of energy, insomnia, lack of interest, changes in her appetite, and hopelessness. The patient reported that the symptoms started two months after she broke up with her fiancé. The patient reported that the symptoms have affected her occupational and social functioning.
O: The patient was dressed appropriately for the visit. She was alert and oriented to herself, others, time, and events. She reported a depressed mood, insomnia, and avolition. The patient demonstrated preserved speech. There were no abnormal body movements, illusions, delusions, hallucinations, illusions, or suicidality.
A: Major depression
P: The patient was prescribed oral sertraline 50 mg once daily and started cognitive behavioral therapy. A follow-up visit was scheduled 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: Panic disorder
S: The patient is a 22-year-old male who came to the facility for assessment. The presenting complaints included recurrent panic attacks whenever distressed. The patient reported symptoms, including sweating, chest pains, difficulty breathing, and trembling. He reports that the symptoms affect his social and academic functioning.
O: The patient was dressed appropriately for the clinical visit. He appeared tense and guarded during the assessment. He also demonstrated a limited attention span with difficulties concentrating.
A: Panic disorder
P: Based on the diagnosis, the patient was prescribed oral risperidone 2 mg once daily. A follow-up visit was scheduled after four weeks.

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Age: 18-64 years
Gender: Female
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Obsessive-compulsive disorder
S: The patient is a 26-year-old female who came to the facility for her follow-up visit. The patient was diagnosed with obsessive-compulsive disorder a month ago and started treatment. Today, the patient reports reduced intrusive thoughts and compulsive behaviors. She also reports improved social and occupational functioning.
O: The patient was dressed appropriately for the clinical visit. She was alert and oriented to herself, others, time, and events. She demonstrated mild anxiety. There was no evidence of compulsive behaviors.
A: Obsessive-compulsive disorder that is responsive to treatment
P: Based on the diagnosis and findings, the patient was advised to continue with oral risperidone 2.5 mg daily and reassess after a month

Age: 18-64 years
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Generalized anxiety disorder
S: The patient is a 29-year-old male who presented to the facility for assessment. The presenting complaints included excessive fear and anxiety beyond his control. The patient reported accompanying signs such as tension, muscle pain, fatigue, and difficulty concentrating. The symptoms have affected his interpersonal relationships.
O: The patient was dressed appropriately for the clinical visit. He was alert and oriented. He appeared anxious, tense, guarded and had difficulty concentrating. The patient denied a depressed mood, illusions, delusions, hallucinations, or suicidality.
A: Generalized anxiety disorder, rule out panic disorder
P: Based on the diagnosis, the patient was prescribed oral sertraline 25 mg daily and started psychotherapy. A follow-up visit was scheduled after four weeks.

Age: 65 years and above
Gender: Male
Site: Hospital
Student Level of Function: Joint Care
Practice Management: Assessment
Diagnosis: Alzheimer’s disease
S: The patient is a 65-year-old male whose son brought him to the facility for his follow-up visit. The patient was diagnosed with Alzheimer’s disease two months ago and started treatment. Today, the son reports improved memory, orientation, and execution of daily activities.
O: The patient was dressed appropriately for the clinical visit. He was aware of the improved symptoms. He interacted moderately with the healthcare provider during the assessment. The patient demonstrated mild impairment in his short-term memory. His language comprehension was appropriate. He did not show any distress or impaired insight.
A: Alzheimer’s disease that is responsive to treatment
P: Based on the clinical response findings, the patient was advised to continue with oral memantine 7 mg once daily and cognitive behavioral therapy. 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 4

Record your clinical hours and patient encounters in Meditrek.

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