ASSIGNMENT: WEEK 10 CLINICAL HOUR AND PATIENT LOGS

ASSIGNMENT: WEEK 10 CLINICAL HOUR AND PATIENT LOGS

ASSIGNMENT: WEEK 10 CLINICAL HOUR AND PATIENT LOGS

CLINICAL HOUR AND PATIENT LOGS

Clinical Hours

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.

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You may only log hours with preceptors that are approved in Meditrek. Students must complete a minimum of 160 hours of supervised clinical experience. All students must record at least 100 encounters with GYN patients. 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)

Notes/Comments

PATIENT LOG

Throughout this course, you will also keep a log of patient encounters using Meditrek. All students must record at least 100 encounters with GYN patients by the end of this practicum.

The patient log must include the following:

Course

Clinical Faculty

Approved Preceptor

Patient Number

Client Information

Visit Information

Practice Management

Diagnosis

Procedure (Note: Make sure that, as you perform procedures at your practicum site, you also note those on your printed-out Clinical Skills List.)

Treatment Plan and Notes

IV Medication

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

BY DAY 7

Record your clinical hours and patient encounters in Meditrek.

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Rubric

PRAC_6552_Week7_Assignment1_Rubric

PRAC_6552_Week7_Assignment1_Rubric
Criteria Ratings Pts

This criterion is linked to a Learning OutcomePart 1: Time logs and patient logs are completed within 48 hours of completing clinical time.

5 pts

Excellent

*Time logs are completed within 48 hours of completing clinical time. *Patient logs are completed within 48 hours of completing clinical time.

0 pts

Poor

*Time logs are completed more than 48 hours after completing clinical time. *Patient logs are completed more than 48 hours after completing clinical time.

5 pts

This criterion is linked to a Learning OutcomePart 2: Patient logs meet the minimum documentation requirements. *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

Excellent

*Patient logs include all of the required documentation elements.

0 pts

Poor

*Patient logs do NOT include all of the required documentation elements. There are some elements missing or the logs are incomplete. *Patient logs were submitted more than 48 hours after completion of the clinical time.

5 pts

Total Points: 10

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Clinical Hour and Patient Logs
Breast Lumps
Patient Number:
Client Information: 51 years old female
Visit Information: Joint care
Practice Management: New hospital.
Diagnosis: Breast lumps
Procedure: Breast Exam
Treatment Plan and Notes: The Caucasian woman, who has gone through menopause and has given birth twice, came to the clinic today for her regular health examination. She has a history of hypertension, high cholesterol, and gastroesophageal reflux disease. She just discovered a lump in her right breast. The patient reports no breast discomfort, nipple discharge, or nipple inversion in both breasts. A palpable lesion of roughly 2.0 cm is detected in the upper outer quadrant during the examination. There is no detectable swelling of the lymph nodes on both sides of the body. She used to smoke cigarettes, with a smoking history of 23 pack-years. Her maternal grandmother was diagnosed with breast cancer at the age of 70. her mother has been diagnosed with esophageal cancer. She was sent to a gynecologist and oncologist to have further assessment and investigation for her probable breast cancer.
Abdominal Pain
Patient Number:
Client Information: 22 years female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Abdominal Pain
Procedure: Pelvic Exam
Treatment Plan and Notes: The patient presented to the clinic today with severe abdominal pain and irregular menstruation, which she has been feeling as a dull ache for the last six months. She has documented two occurrences of menstruation in the last year, with her most recent menstrual cycle occurring four months ago. The patient lacked any familial predisposition to ovarian or cervical cancer and had the surgical removal of a non-malignant ovarian cyst at the age of 172. The abdominal region is characterized by its softness and sensitivity upon palpation, with no rebound pain or guarding. The patient’s test for uterine pregnancy yielded a negative result. A probable right ovarian cyst has been identified, and the gynecologist will request a transvaginal ultrasound to confirm the presence of the cyst. Analgesic activities and pain medicines such as Tylenol were prescribed. The patient was referred to a gynecologist for further evaluation and treatment of the ovarian cyst.
Preeclampsia
Patient Number:
Client Information: 34 years old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Preeclampsia
Procedure: Vaginal Exam
Treatment Plan and Notes: The patient presented at the clinic today with a medical history of migraine headaches. Her blood pressure fluctuates between 125/85 and 135/90. She has been experiencing symptoms that have hindered her ability to carry out her everyday activities. Her family lineage consists of a biological mother and father, five siblings, and a notable medical history of hypertension and migraines. The patient’s examination indicated typical vital signs, a healthy nutritional status, and normal cardiac and cervical conditions. The musculoskeletal status was satisfactory, with no signs of cyanosis. The vaginal examination indicated that the cervix was dilated to the extent of a fingertip and had undergone 75% effacement. The patient’s evaluation resulted in a referral to the Labor and Delivery unit to monitor the progression of preeclampsia or any potential complications.
Bacterial Vaginosis
Patient Number:
Client Information: 29-year-old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Bacterial Vaginosis
Procedure: Urinalysis
Treatment Plan and Notes: The patient presented at the clinic today with a complaint of a scanty, pale vaginal discharge accompanied by a malodorous fish-like scent and irritation in the vulvar area. Approximately one week ago, she first had symptoms and attempted to alleviate them by utilizing yeast treatments on her own. She engages in regular physical activity and is now in a committed relationship with a male partner. She has no previous record of STIs and acknowledges regularly using douching and bubble baths. The laboratory tests conducted in the office indicate that the urine hCG is negative, but the wet prep test shows positive findings for the sniff test, clue cells, and leukocytes. There is no presence of yeast. However, the vaginal pH is raised. She received a diagnosis of Bacterial vaginosis. The patient was administered a 7-day course of metronidazole at a dosage of 400mg three times daily. Additionally, she was instructed to refrain from using douching and bubble bath products.
Polycystic Ovarian Syndrome
Patient Number:
Client Information: 29-year-old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: PCOS
Procedure: Vaginal exam
Treatment Plan and Notes: The patient came to the clinic today with complaints of hirsutism and irregular menstrual periods. She has been having these symptoms since the onset of menstruation at the age of 12 and has had black, coarse facial hair since the age of 14. The symptoms deteriorated after her weight increased throughout her time in college. She has been attempting to conceive for the last two years without any success. The laboratory results indicate that the CMP, CBC, TSH, total testosterone, and glycated hemoglobin levels are within the normal range. The patient received a diagnosis of polycystic ovarian syndrome. A prescription for a combination of oral contraceptives was given to address issues about the management of the menstrual cycle, lowering testosterone levels, and improving symptoms such as acne and hirsutism. She was sent to a gynecologist for further assessment and medical care.
Pelvic Inflammatory Disease
Patient Number:
Client Information: 21-year-old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Pelvic Inflammatory Disease
Procedure: Pelvic Exam
Treatment Plan and Notes: The patient presented to the clinic today with a chief complaint of stomach discomfort, malodorous vaginal discharge, and fever persisting for the last four days. She has no symptoms of nausea, vomiting, or feces problems. Notwithstanding the administration of ibuprofen, the pain is intense and confined to her lower abdomen. The physical examination indicated mild abdominal discomfort, soft and non-tender upper quadrants, and reduced bowel sounds. The pelvic examination revealed positive adnexal discomfort, positive cervical motion tenderness, and a significant quantity of greenish-thick secretions. The patient received a diagnosis of pelvic inflammatory disease (PID). She was sent to a gynecologist for further assessment and medical care.
STI
Patient Number:
Client Information: 19-year-old female
Visit Information: Joint care.
Practice Management: New hospital.
Diagnosis: STI
Procedure: Pelvic Exam
Treatment Plan and Notes: The patient presented to the clinic today with a primary complaint of fluid-filled vesicles and severe vulvar pruritus. She disclosed a previous diagnosis of genital herpes. She attempted to treat herself with metronidazole, but her symptoms deteriorated. She had no significant medical history and was sexually active with several partners. During a pelvic examination, many cystic lesions were seen on the vulva and introitus, along with enlarged lymph nodes in the inguinal regions. The patient was diagnosed with herpes simplex virus type 2. The patient was instructed to take Acyclovir 800 mg orally twice daily for five days. A follow-up appointment was set for one week to assess the therapy results.
Trichomoniasis
Patient Number:
Client Information: 23-year-old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Trichomoniasis
Procedure: Pelvic Exam
Treatment Plan and Notes: The patient presented to the clinic today with symptoms of vaginal pruritus, dysuria, and a malodorous frothy, yellow-green vaginal discharge. The symptoms began about a week ago and have gradually deteriorated. She refutes experiencing any fever or stomach ache. She engages in sexual activity with one person and does not routinely use condoms. The Review of Systems indicated the presence of vaginal irritation, discharge, and dysuria—no fever, chills, stomach discomfort, or other systemic signs exist. A pelvic Examination revealed inflammation and swelling of the vulva and vaginal walls—observation of frothy, yellow-green discharge. Wet mount microscopy reveals the presence of mobile trichomonads. The pH level of vaginal fluid is more than 4.5. The patient was diagnosed with trichomoniasis. A single oral dosage of 2 grams of Metronidazole was recommended for her. She will report to the clinic after two weeks for a follow-up evaluation.
Chlamydia
Patient Number:
Client Information: 31 years old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: chlamydia
Procedure: Urinalysis
Treatment Plan and Notes: The patient presented at the clinic today with complaints of discomfort during urination and sexual intercourse. These symptoms arose following a recent sexual encounter with her new partner. The individual denies engaging in safe sexual practices or having multiple partners. They also mention experiencing symptoms such as yellowish, foul-smelling vaginal discharge, lower abdominal pain, and bleeding. The patient’s pregnancy test yielded negative results; urine analysis showed no presence of nitrites and leukocyte esterase, the cervical discharge swab indicated no signs of cervical inflammation, and the NAAT swab confirmed the presence of Chlamydia trachomatis. The patient’s treatment plan involved taking Doxycycline 100 mg orally twice a day for seven days.
Bacterial Vaginosis
Patient Number:
Client Information: 27-year-old female
Visit Information: Joint care
Practice Management: New hospital
Diagnosis: Bacterial Vaginosis
Procedure: Pelvic/Vaginal Exam
Treatment Plan and Notes: The patient presented at the clinic with symptoms including vaginal itching, thin, grey discharge, and a strong, foul, fishy odor following sexual activity for one week. In addition to experiencing burning during urination, she did not report any other symptoms, such as fever, chills, nausea, or vomiting. The individual sought medical assistance due to their inability to endure the smell, discomfort, and discharge. The patient presented with a malodorous discharge in their urine, prompting an examination of a vaginal swab. Microscopic tests revealed a positive KOH test for a fishy odor, a pH level of 5.2, and the presence of clue cells. The patient has been diagnosed with bacterial vaginosis. The patient was prescribed Metronidazole (Flagyl), 500 mg orally twice daily for seven days.