PRAC 6541 WEEK 2 CLINICAL HOUR AND PATIENT LOGS

Clinical Hour and Patient Logs

Name: JL

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Migraine headache

S: JL is a 16-year-old male whose parents brought her to the facility with complaints of severe, throbbing headaches for the last eight hours. JL reported that the headache is one-sided and is associated with symptoms, including vomiting and light sensitivity. The parents gave him oral Tylenol but it had a mild effect on his headache. He has a previous history of similar headaches.

O: Vitals: T 99.5, RR 22, SPO2 98%, BP 118/64, P 80. JL’s examination revealed that his head was atraumatic, with no evidence of hair loss, rhinorrhea, nasal flaring, and pupil reacting well to light. There was light sensitivity, mild numbness, and no paralysis or loss of consciousness.

A: Migraine headache

P: JL was prescribed oral sumatriptan 25 mg for three days.

Name: RY

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Influenza

S: RY is a 5-year-old male client whose parents brought him to the facility with complaints of headaches for the past two days. The parents reported accompanying symptoms, including persistent cough, fatigue, runny nose, and a sore throat. RY denied vomiting and diarrhea. The parents denied using any treatments for symptom relief.

O: Vitals: RR 20, SPO2 98%, T 100.3. The child had rhinorrhea with no nasal flaring or septum deviation. Examination of the mouth revealed post-nasal drainage and erythema.

A: Influenza

P: RY was prescribed oral cetirizine 5 ml once daily and oral Tylenol 5 ml thrice daily.

Name: ED

Age: 0-17 years

Gender:  Female

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Allergic conjunctivitis

S: ED is a 27-day-old female newborn whose parents brought her to the facility for assessment. The presenting complaints included eye puffiness in the morning and watery eye drainage. The parents reported that their child has been experiencing these symptoms for the past two days.

O: Vitals: T 99.4, SPO2 98%, RR 36. Examination revealed red eyes bilaterally with watery drainage. The eyelids also appeared puffy with no evidence of trauma or purulent drainage.

A: Allergic conjunctivitis

P: ED was prescribed topical epinastine one drop daily.

Name: VC

Age: 0-17 years

Gender:  Female

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Otitis media

S: VC is an 8-month-old female client whose parents brought her to the facility for assessment with complaints of ear pulling. The parents also reported that VC had a decreased need for sleep and appetite and a low-grade fever.

O: Vitals: T 100.3, RR 26, SPO2 98%. Otoscopic examination revealed moderate tympanic membrane bulging and erythema.

A: Acute otitis media

P: Oral Tylenol 5 ml thrice daily and oral amoxicillin 5 ml thrice daily for ten days.

Name: OT

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Fractured fibula

S: OT is a 12-year-old male client whose parents brought him for assessment after sustaining a fall while playing at home. The presenting complaints included left lower limb pain, swelling, inability to walk, and bruising on the affected limb. The child was non-weight-bearing on the affected limb.

O: The left lower limb was swollen, and bruised, with evidence of some bone protrusion. The patient was non-weight-bearing on the affected limb. His self-reported pain was 9/10 on a pain rating scale. An x-ray was ordered, which revealed a fractured fibula.

A: Fractured fibula

P: OT was administered intramuscular tramadol 100 mg stat, splinting done, and admitted to the orthopedics ward for specialized management.

Name: TM

Age: 0-17 years

Gender:  Female

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Acute diarrhea

S: TM is a 1-year-old female client whose parents brought her to the facility with complaints of diarrhea for the past 12 hours. The parents reported that their daughter has had four episodes of watery diarrhea. The parents denied nausea and vomiting.

O: Vitals: T 100.4, RR 24, SPO2 96%. TM had dry skin and mucous membranes. She appeared weak. The capillary refill was <2 seconds. A stool test and a complete blood count were ordered for her.

A: Acute diarrhea

P: TM was administered with oral Tylenol 5 mg, intravenous ringer’s lactate, and intravenous metronidazole. TM was admitted for further management.

Name: ZP

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Peptic ulcer disease

S: ZP is a 12-year-old male client whose parents brought him to the hospital for assessment. The presenting complaints included epigastric pain, indigestion, and burning sensations in his throat for the last week. ZP also reported a loss of appetite, belching, and feeling bloated most time. He denied nausea and vomiting.

O: Vitals: T 99.5, RR 20, SPO2 98%. Normoactive bowel sounds were heard in all the quadrants. There was no organomegaly or signs of altered nutritional status.

A: Peptic ulcer disease

P: ZP was prescribed oral omeprazole 20 mg once daily.

Name: MO

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Type 1 diabetes mellitus

S: Mo is a 14-year-old male client whose parents brought him to the facility for his follow-up visit. He was diagnosed with type 1 diabetes mellitus a month ago and started treatment. MO denied oliguria, polyuria, polydipsia, or polyphagia for the past three weeks. He tolerates insulin treatment well.

O: Vitals: T 99.4, RR 22, SPO2 98%, HbA1c 6.8.

A: Controlled type 1 diabetes mellitus

P: MO and his parents were advised to continue with the current subcutaneous insulin injection 12 i.u. thrice daily and self-monitoring of blood glucose levels. They were scheduled for a follow-up visit after four weeks.

Name: GG

Age: 0-17 years

Gender:  Female

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Meningitis

S: GG is a 3-year-old female client whose parents brought her to the facility for her follow-up visit. She was hospitalized for meningitis three weeks ago. Today, GG denied headaches, light and noise sensitivity, vomiting, or nuchal rigidity. She has completed her prescribed treatments.

O: Vitals: T 99.5, RR 22, SPO2 96%. GG was alert and oriented to herself, others, time, and events. There were no headaches, nuchal rigidity, loss of bowel or bladder movements, and negative Kernig and Brudzinskis’s signs.

A: Resolved meningitis

P: Treatment was terminated since the desired outcomes had been achieved.

Name: KR

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Strep throat

S: KR is a 3-year-old male client whose parents brought him to the facility with complaints of a painful throat. The parents reported that their son has been complaining of throat pain and painful swallowing. They also reported a fever in the morning and denied nausea or vomiting.

O: Vitals: T 100.5, RR 24, SPO2 98%. KR did not have rhinorrhea, nasal flaring, or skin rash. The tonsils were red and edematous. There were swollen lymph nodes with no post-nasal drainage. A throat culture was taken for analysis, which confirmed a diagnosis of Strep throat.

A: Strep throat

P: KR was prescribed oral Tylenol 5 ml thrice daily and oral amoxicillin 5 ml twice daily for five days.

Name: DS

Age: 0-17 years

Gender:  Female

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Tinea corporis

S: DS is a 5-year-old female client whose parents brought her to the facility for assessment. The presenting complaints included red, itchy, circular patches on the abdomen. The parents reported that the patch appeared three days ago and is not associated with the production of pus.

O: Vitals: T 99.3, RR 22, SPO2 98. Abdominal skin examination revealed a red, circular patch, which raised scales on its edge with no production of pus. The patch had symmetrical edges.

A: Tinea corporis

P: DS was prescribed topical terbinafine 1% twice daily for two weeks.

Name: HL

Age: 0-17 years

Gender:  Male

Site: Hospital

Student Level of Function: Joint Care

Practice Management: Assessment

Diagnosis: Abscess

S: HL is a 21-day-old male client whose parents brought him to the facility with complaints of swelling in his cheek. The parents reported red swelling in his cheek for the past two days. They noted that the swelling is tender to the touch, warm, and is associated with some low-grade fever.

O: T 99.8, RR 20, SPO2 98%. HL had a small swelling on his right cheek. The swelling was warm and tender to the touch. There was a visible buildup of pus in the swelling. Incision and drainage of the pus were done.

A: skin abscess

P: HL was prescribed oral Tylenol 5 ml thrice daily for pain relief and oral amoxicillin 5 ml thrice daily.