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Patient Log

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Patient Log

70-Year-Old Hawaiian Male

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H.K. is a 70-year-old male with uncontrolled hypertension and chronic nasal congestion associated with purulent drainage and facial pressure. He failed the whisper test and has impaction of earwax in both ears, which indicates hearing problems. The patient is a smoker and unemployed, which can potentially be an obstacle in the context of care compliance.

A referral to an ENT specialist was made to determine the hearing and condition of the sinus. Quitting smoking was advised. Blood pressure is to be monitored and controlled. The resumption of nasal corticosteroid treatment can also be reevaluated and supervised in the case of toleration.

45-Year-Old White Male

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R.B. is a 45-year-old male presenting with persistent nasal congestion, purulent drainage, post-nasal drip, nasal crusting, and sinus pressure localized to the frontal and maxillary regions. He also complains about daily headaches and mouth breathing. His past medical history is characterized by allergic rhinitis and sinusitis, which occurred back in 2015. His previous prescription was with Flonase, which he abandoned because it was not alleviating his symptoms, and he complained of headaches.

He denies having undergone a surgical procedure and has asked to be referred to ENT to have the case further investigated. The patient is unemployed, having quit his job as a basketball coach. The plan consists of ENT consultation, such as sinus assessment, examination of other nasal treatments, and referral to an allergist. Future management is recommended in terms of supportive care measures and symptom following.

72-Year-Old Black Male

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L.W. is a 72-year-old male with a history of chronic low back pain dating to 1978. He describes daily tender, cramping, and sharp pain of 8/10 with occasional flares of 9/10 that last several hours with motion or standing still. He has typical numbness and tingling sensations in both legs and wears a back brace over time. There is bilateral edema (2+) with no use of compression socks.

He had undergone physical therapy before but did not undergo back surgery. The existing prescriptions involve Metformin, Tramadol, Hydrochlorothiazide, and Lidocaine patch 5%. The plan entails pain management, lower extremity sensation monitoring, reassessment to resume compression therapy, and reassessment of the effectiveness of the medication.

73-Year-Old Black Male

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D.T. is a 73-year-old male with chronic recurring fungal toenail infections since 1972. He has a previous history of diabetes, peripheral neuropathy, tinea pedis, and flat foot. He has orthotic footwear and ambulates with a stick. He has dull, painful pains along the toes with a rating of 7/10, where he has flare-ups five times weekly, with several minutes of duration, which is worsened by standing up or walking.

He is physically active through yoga and tai chi. He denies any history of surgery. The drug regimen is Gabapentin 600 mg TID, Metformin, and triamcinolone acetonide 0.1% cream (Yasaei et al., 2024). His movements are restricted, and he is no longer able to swim or run. Continued podiatry care, neuropathic pain management, and support of foot hygiene and protective footwear are recommended.

60-Year-Old Latina Female

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M.A. is a 60-year-old Latina woman with a distant history of right lateral thigh muscle strain dated 1981. At the time, she did not seek any medical attention. At the present time, she does not experience any pain, weakness, or restrictions and is fully mobile and functional daily. No residual impairment is evidenced.

No imaging, medication, or treatment is required. It was recommended that she continue to exercise and be informed about any musculoskeletal complaints in the future. Prevention education was undertaken, and she will give subsequent wellness check-ups. There is currently no active treatment required.

60-Year-Old White Male

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R.C. is a 60-year-old White male with a longstanding history of chronic rhinosinusitis since 2010. He is having continuous nasal congestion, sneezing during physical activities, and transparent nasal secretions following chilling showers. He does not complain about headaches, and he has not had imaging or an ENT assessment. Management of the existing symptoms involves Flonase and Claritin, yet symptoms remain despite the current symptom control measures.

He further has a comorbidity of systemic lupus erythematosus, and it could be a factor that leads to persistent mucosal inflammation and immune dysregulation. At night, he sleeps with a CPAP nasal unit, which is possibly contributing to nasal dryness and/or irritation. His signs and symptoms have a tremendous impact on daily comfort and quality of life, which cannot be overcome by pharmacologic interventions.

The plan consists of referring him to ENT to get diagnostic imaging and potentially changing his sinus regimen (Dai et al., 2025). Rheumatology coordination is advised to help maximize the control of SLE, which can also mitigate nasal inflammation. CPAP treatment should be continued, and the nebulizer should be integrated for dryness.

55-Year-Old Black Male

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T.J. is a 55-year-old Black male presenting with a history of chronic lower back pain and previously reported right-sided sciatica. MRI showed some mild degree of degenerative changes and a slightly protruding disc. He underwent physical therapy, which helped mildly. He was initially on Ibuprofen without much effect.

Nevertheless, on switching to meloxicam, his pain level dropped considerably and is currently reported as 3/10 with no experienced sciatica symptoms. He notes that he has better operations in everyday life. The structural results, along with the ongoing nature of his pain, conspired to result in a referral to pain management and a spine specialist to be evaluated further and a long-term treatment strategy.

Meloxicam should be continued, and gastrointestinal tolerance should be monitored. Lifestyle changes such as back support, posture correction, and shunning high-impact exercises are recommended to avoid exacerbation of symptoms (Farley et al., 2024).

39-Year-Old White Male

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C.L. is a 39-year-old homeless White male with a complex psychiatric and neurologic history following a traumatic brain injury from a motor vehicle accident. He is oriented and alert yet exhibits degraded short- and long-term memory, recurrent intrusive thoughts, insomnia, irritability, and hypersensitivity to any sensory input, such as light and sound. Other symptoms include tinnitus, blurred vision, and headaches. He has PTSD comorbidity, anxiety, depression, chronic adjustment disorder, and ADHD.

He speaks grossly and is demotivated in an impulsive nature. He does not have a job and used to work as a paramedic. He is under the treatment of a psychologist. Further mental health treatment, cognitive rehabilitation, and social services outreach are suggested. Multidisciplinary coordination is needed to address his mental health and homeless instability.

47-Year-Old White Male

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B.S. is a 47-year-old White male diagnosed with prostate cancer in the summer of 2024. He completed five sessions of radiation therapy and has had no surgical intervention. He denies any acute urinary symptoms, such as incontinence, urgency, frequency, erectile dysfunction, and urinary tract infection. He has a job and runs his own business.

He continues to be functional and has minimal disturbances in his daily life. He uses Tamsulosin 0.4 mg once a day to facilitate urinary flow and prostate conditions. His last follow-up with his urologist was in January 2025. The patient will also have regular urology check-ups to monitor progress.

Despite being asymptomatic, it is important to regularly measure PSA and follow up on recommendations as an early method of recurrence. There must be no immediate alteration of treatment. Modification of lifestyle involves ensuring the consumption of healthy, balanced diets, regular physical activities, and immediate reporting of new changes in urinary and sexual health. Psychosocial support and survivor education can be useful in the future.

46-Year-Old Black Male

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M.C. is a 46-year-old Black male with a medical history notable for a left-sided hydrocele (greater than right), recent incarceration, and current smoking status. He was returning as a follow-up due to right shoulder pain with a negative X-ray, two weeks of sore throat, a few painful bumps on the skin, and a wet spot on his back. Physical examination showed nasal erythema on both sides, swollen tonsils on the right, and a tender lymph node. He had slightly elevated blood pressure figures.

He asked to be refilled with vitamin D and to increase Cialis, but it was not permitted because of hypertension. He was referred to dermatology for skin lesions, ENT for pharyngitis, and urology for the management of hydrocele.

An MRI and physical therapy of his shoulder was ordered. Smoking cessation was highly recommended, and he was prescribed nicotine patches (Huzaifa & Moreno, 2023). Further blood pressure checks, as well as smoking habits, would be encouraged. 

51-Year-Old Black Female

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L.N. is a 51-year-old Black female who presented for follow-up after a workplace-related needlestick injury. She is a housekeeper in a healthcare institution where she accidentally hurt her gloved finger, stabbing a bed using a butterfly needle. The location bled instantaneously, and she was rushed to emergency care, where work found her to be HIV HIV-negative, not susceptible to Hepatitis B. She is physically stable but indicates great anxiety, such as neck pain, headaches, and palpitations, claiming that this is a result of the stressful event.

Then, she was recommended to repeat H/HIV and Hepatitis C after six months, according to the protocol. Referral to mental facilities was also advised, owing to escalated anxiety symptoms. She was advised to find supportive counsel and apply mechanisms for managing stress.

There has been a notification to the employer about workplace follow-up. Further reassurance and examination will be necessary as she finishes the surveillance time frame.

32-Year-Old White Male

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J.P. is a 32-year-old right-handed White male presenting with bilateral knee pain and post-operative right wrist discomfort. In 2024, he injured his right knee in a hyperextension case, and this resulted in partial tears of the ligament that have since healed. He has developed compensatory pain in his left knee. He explains the pain in his knees as sharp and shooting, with a pain scale of 5/10 per day, escalating to 7/10 thrice a week with long walks or sitting positions.

Temporary relief is enabled by Ibuprofen and rest. He also complains of chronic pain in the right wrist (4/10), which is mostly in the mornings or when he is applying pressure. This discomfort followed carpal tunnel release surgery in 2025, which was preceded by an EMG in 2024. Treatment options consist of conservative procedures with NSAIDs, joint protection strategies, and ongoing physical therapy. Surveillance of residual neuropathy and joint instability is recommended, and imaging or orthopedic evaluation can be considered for the worsening of symptoms.

77-Year-Old White Male

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E.W., a 77-year-old male, was diagnosed with prostate cancer in 2009. He preferred watchful waiting and has not undergone any surgery or radiation. He does not report urinary problems or kidney infections. His final visit to a urologist was normal, and he refused a PSA laboratory and urine test.

He is a homeless man, and he denies having suicidal thoughts. Further surveillance and patient education regarding the necessity of lab screening are advised. Referral to social services can be helpful in stabilizing the situation and getting access to services.

75-Year-Old White Male

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G.H. is a 75-year-old male with chronic pain dating back to a cervical strain in 1980 and lumbar disc degeneration diagnosed in 1969. He denies any injury, surgery, or physical therapy. His daily neck pain is 7/10, and flare-ups are 10/10 two to three times a week, and the pain is aggravated by looking up. He also claims moderate intermittent paresthesia of both the upper extremities.

On his lower back, he scores pain experienced daily as 7/10 and flare as 10/10 on a daily basis, which increases with prolonged standing or bending. He has already experienced four spinal ablations; the last one was in December 2024, and it gave some relief. Tylenol is utilized as a pain medication.

He denies bowel or bladder dysfunction and notes that he has limited mobility, so, in some instances, he uses a cane. His condition has had a major impact on his daily life—he no longer hunts, fishes, or camps. Further conservative treatment, such as referral to physical therapy and imaging, could be helpful.

References

Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Dai, X., Fan, Y., & Zhao, X. (2025). Systemic lupus erythematosus: Updated insights on the pathogenesis, diagnosis, prevention, and therapeutics. Signal Transduction and Targeted Therapy, 10(1). https://doi.org/10.1038/s41392-025-02168-0

Donnally, C. J., III, Hanna, A., & Varacallo, M. A. (2023, August 4). Lumbar degenerative disk Disease. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK448134/

Fanai, M., & Khan, M. A. (2023, July 10). Acute stress disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK560815/

Farley, T., Stokke, J., Goyal, K., & DeMicco, R. (2024). Chronic low back pain: History, symptoms, pain mechanisms, and treatment. Life, 14(7), 812. https://doi.org/10.3390/life14070812

Hammi, C., & Yeung, B. (2022, October 15). Neuropathy. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK542220/

Huzaifa, M., & Moreno, M. A. (2023, July 3). Hydrocele. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559125/

Yasaei, R., Katta, S., & Saadabadi, A. (2024, February 21). Gabapentin. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK493228/

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Question 

Throughout this course, you will also keep a log of patient encounters using Meditrek. AGPCNP students must record at least 100 encounters with GYN patients; FNP students must record at least 125 encounters with patients (100 GYN and 25 OB patients) by the end of this practicum.

The patient log must include the following:

Please see attached.

70 Hawaiian make

45 years old white male

72 years black male

73 years old black male

Latina female 60

55 black make

39 years old white male

47 years old white male

46 black male

51 black female

32 white male

77 years old white male

75 years old white male

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