Practicum Experience Time Log and Journal Template Assignment

Practicum Experience Time Log and Journal Template Assignment

Student Name:
E-mail Address:
Practicum Placement Agency's Name:
Preceptor’s Name:
Preceptor’s Telephone:
Preceptor’s E-mail Address:

 (Continued next page)

Patient: A , S

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Unit #: L000297016

Room/bed:

Age: 62

Sex: M

 

Adm DT:

Rep srv DT: 08/21/18

Rep srv Tm: 0633

History of Present Illness

Chief Compliant: Abnormal Behavior

Pcp: No Primary or family physician

 

Hpi: 62 yo CM who presented on a 1013 for abnormal, behavior, homicidal ideations, danger to self and others was consulted for admission for elevated lipase. Pt was unable to be placed by psych, 2/2 lipase elevation-therefore medicine was consulted for admission. Patient is bizarre on examination, consistent with patient narration of cocaine use and utox positive multiple drugs. Apparently, on previous admission the patient acted inappropriately with staff and would require a 1-1 ratio when admitted to this facility. He is a very poor historian, mumbling something or another, rather than answering any of the questions. Practicum Experience Time Log and Journal Template Assignment

History

Past medical history: reports: COPD, schizophrenia

Additional medical history: cocaine use disorder

Additional surgical history: denies any past surgical history

Additional family history: denies any FH of mental illness

alcohol use: alcohol use

drug use: cocaine

Smoking status for patients 13 years old or older: current every day smoker

Medications/allergy-vaccine HX

Practicum Experience Time Log and Journal Template Assignment

Medications: haloperidol 2 mg po daily

Haloperidol 5mg po bedtime

Quetiapine (seroquel) 50 mg po bid 9a 5p

Quetiapine (seroquel) 400 mg po bedtime

Trazodone pamoate (vistaril) 50 mg po q6h prn prn agitation pr anxiety

Cyanocobalamin (vitamin b-12) 1000 mcg po qam

Allergies:

Coded allergies:

No known drug allergies (08/20/18)

Review or systems

Additional notes:

12 pt ROS was attempted, however he didnt answer

Practicum Experience Time Log and Journal Template Assignment

Physical Exam

VS/i&O

General appearance: agitated, chronically ill appearing, alert, awake

head/eyes: A BNL conjunctiva/sclera, a traumatic

ENT: Dry mucosal membrane

Neck: no JVD

Cardiovascular: normal heart sounds respiratory: clear to auscultation , no distress

Abdomen/G.I.: active bowel sounds, soft , non-tender

Extremities: moves all

musculoskeletal: normal inspection

Neuron/CNS: abnormal speech (pressured) , Altered mental status, alert

Skin: dry, intact

Psychiatry: aBNL judgment/insights, auditory hallucinations, unable to evaluate.

Practicum Experience Time Log and Journal Template Assignment