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Patient Logs

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Patient Logs

Case 1: 78-Year-Old White Male

Client Information:

Diagnosis

Procedure:

Treatment Plan and Notes:

J.D. is a 78-year-old male presenting for follow-up care of chronic back pain, which has been ongoing since 1965 and has worsened post-lumbar fusion in 2022. He complains of continuous and daily limping pain (3/10), and it is worsened by standing and walking. No additional treatments were started during this visit, and pain management consists of gabapentin, Tylenol, and ibuprofen. J.D. walks with a walker and a cane, suggesting that he has a severe functional impairment.

The plan of treatment will be continuing with the present pain management, and the concentration will be on mobility help in the treatment, along with regular follow-ups. Since he is of advanced age, the treatment objective is to ensure he has a quality life and there is no further deterioration in his mobility.

Case 2: 52-Year-Old Black Female

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

K.M. presents with daily sciatica flare-ups and a history of emphysema, asthma, and prediabetes. She also reports a new lump behind her knee, which has prompted an MRI for further evaluation. The patient is treating her sciatica by resting and taking ibuprofen. The management schedule entails controlling the pain using anti-inflammatories and observing the lump based on the MRI report.

An appointment will be made following the checkup results of the MRI to determine the next course of action. Also, her chronic diseases, such as emphysema and asthma, should be monitored closely, and pulmonary testing should be done regularly to improve the situation.

Case 3: 84-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

G.T. is a long-term patient with COPD who is placed on continuous oxygen now and complains of back pain daily. His chest pain, which is relieved with nitroglycerin, raises concerns as to the possible cardiac involvement. Treatment plans entail additional oxygen supplementation and medicine against back pain, including referral to a cardiology unit, where chest pain will be investigated.

It is also suggested that the patient limit the physical exercises and stressors that may contribute to the development of symptoms of respiratory and cardiac conditions. Any suggestion of COPD exacerbation (especially worsened or more dyspnea and wheezing) is to be checked regularly, and the patient is to be educated on being warned about increased difficulties with the heart or lungs.

Case 4: 78-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

H.W. presents with ongoing shortness of breath, productive cough, and nasal congestion, which are likely linked to pleural effusion and chronic sinusitis. The patient is on Flonase and a saline nasal spray. The management course involves the maintenance of respiration, including Nasal saline irrigation and Flonase.

Pulmonology follow-up is also performed to monitor pleural fluid levels, and a smoking cessation regimen should also be advised to minimize further respiratory complications (Krishna & Rudrappa, 2024). The patient should be educated regarding potential alarming signs of worsening respiratory condition, that is, dyspnea and change in the production of sputum, and instructed to contact the issues as soon as they occur.

Case 5: 27-Year-Old Black Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

D.P. has carpal tunnel syndrome in both hands, which is worsened by excessive use of computers. The patient has been recommended to take some ibuprofen to ease pain and wear a wrist splint at night and during rest. In 2-3 weeks, a progress review will be conducted. The patient will also be encouraged to take a break when working to avoid any additional strain on his wrists and the use of heavy loads.

Physical therapy can be an option when symptoms do not resolve or become worse. As part of the treatment plan, ergonomic changes to his workstation will be implemented so as to minimize the wrist strain and any additional injury.

Case 6: 58-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

M.F. is in remission following the removal of his left kidney due to cancer. He denies any pain or urinary symptoms, and he is under follow-up regarding the possibility of recurrence. The treatment plan entails follow-up care, which involves lab work and imaging. The patient is advised to maintain periodic screening to identify any future likelihood of cancer and uphold healthy living to promote overall health. The patient is also advised to take preventive health measures like a balanced diet and regular exercise so as to sustain the functioning of the kidney and healthy living.

Case 7: 20-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

S.B. reports radiculopathy symptoms following a bulging disc in his lumbar region. He already had an epidural steroid injection and is now going through physical therapy. Sitting inflicts more pain on him. The management process will involve the continuation of physical therapy and medications such as nabumetone or Robaxin, which represses pain (Alexander & Varacallo, 2024).

His reaction to treatment will be monitored regularly, and the plan will be adjusted accordingly. Simple tasks such as bending, dashing, and heaving that can tax the back of the patient should also be discouraged, and the patient is encouraged to ensure his body posture in his daily routines is good.

Case 8: 45-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

L.W. is managing cervical strain due to tension headaches, with MRI results showing degenerative disc changes. The patient has episodic neck pain that occurs periodically, particularly when he looks up. Treatment involves physical therapy and application of stretching activities to ensure that muscle tension is reduced.

A second follow-up visit will then be scheduled to follow up on his progress and to discuss any new developing symptoms. The patient should also learn to shun neck-straining activities and learn to work using better ergonomics.

Case 9: 78-Year-Old White Male

Client Information:

Diagnosis:

Procedure:

Treatment Plan and Notes:

R.F. has undergone radiation therapy for prostate cancer and is currently receiving hormone therapy injections. He continues to experience erectile dysfunction and frequent nighttime urination. The management involves follow-up treatment with drugs such as Tamsulosin and Proscar.

Follow-up care with oncology is planned to track the possibility of the recurrence of the cancer, and additional treatment can be further changed depending on how he reacts to the ongoing medicines. The patient must also be advised on how to deal with the side effects of his treatment and how to deal with urinary and sexual dysfunction.

References

Alexander, C. E., & Varacallo, M. (2024, February 27). Lumbosacral radiculopathy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430837/

Donnally III, C. J., Hanna, A., & Varacallo, M. (2023). Lumbar degenerative disk disease. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448134/

Krishna, R., & Rudrappa, M. (2024). Pleural effusion. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448189/

Rosario, E., & Rosario, D. J. (2020). Localized prostate cancer. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK563248/

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Question 

Patient Log
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.

78 white male

52 black female

84 years old white male

78 years old white male

27 years old black male

58 white male

20 years old white male

45 years old white male

 

78 years old white male

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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