Thomas Jefferson University Jefferson School of Nursing Nurse Practitioner Program 10/30/11 see comments.TYeo Clinical og NU !"# $ NU !

31 Stu%ent Name& oretta Cavaliere Clinical Site/Prece'tor(s)& *on +oenigs,erg *- an% +eith *usch. C/NP Clinical 0ee1 *ates at Clinical Site& 10/12 10/33

ist 343 s'ecific measura,le goal/s for 5ee1. *iscuss the goals 5ith your 'rece'tor. Goal #1 Goal #2 Goal #3 Perform Physical Exams Perform patient education Orient to The Minute Clinic site

Summary num,er of 'atients seen& 6%olescents 13412 3 Young 6%ults 304#0 30 ist of Patient <ncounters 7i%%le 6ge 6%ults #14!8 9 -l%er 6%ults !!498 9 -l%est -l% 9!4 an% ol%er 0 0omen:s ;ealth 0

*ate

*emogra'hic *ata&

Patient =nitials. 6ge. >en%er. /ace

Su,?ective *ata& (/eason for @isit) 4 Chief Com'laint (CC). 4 ;istory of 'resent illness (;P=). 4 /evie5 of systems (/-S) (only those a''lica,le to the CC) 4 7e%s. allergies

-,?ective *ata& Significant Physical <Aam (P<) Bin%ings& P<& vital signs. 5t/ht >eneral& S+=N& ;<<NT& /<SP& C6/*& >=& >U& 7S& Neuro& 4 inclu%es CNs 4 ma?or muscle grou's (intact or not) 4 *T/s T ". '/ 00 ,P 13!*0. PE# GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect6 $ 3ouldn7t really call this a neuro exam8 do

6ssessment/=m'ression & *ifferential *iagnosis& ** is %evelo'e% relate% to a s'ecific 'ro,lem. ie. Cac1 'ain& **& S %isc 'ro,lem. in?ury. musculos1eletal 'ain. etc. Shoul% inclu%e ,rief rationale for ** =f 'atient has an esta,lishe% 'ro,lem. *74 there may not ,e a **. ?ust a Pro,lem ist or a %iagnosis 5ith an im'ression e.g. *A& <uglycemia4 *7 5ell4controlle% 559# :;y M/$< '1P C!6=60 -nresol%ed 3ith conser%ati%e treatment

Plan/=nterventions (e.g.. la, stu%ies. me%ications. referrals. 'atient e%ucation) Ce s'ecific a,out 5hich la,s or%ere% an% 5hy. names of me%s an% %ose4 if ne5 me% /ecor% as& a,s& 7e%s& /eferrals&

Patient Bollo54 u' (e.g.. return to clinic)

10/12 J !" M

CC# $ ha%e nec& pain 'P$# Chronic nec& and ri(ht shoulder pain 1)*1)+ associated radiatin( pain ,-E PM'# ,e(an . months a(o+ s*p

/efer to sur(ery

>ollo3 up as neede

Cer%ical transforaminal epidural in?ections + usin( TE1 unit++ Cer%ical M/$ '1P /O # M- @# 1ec& and ;*l shoulder pain and pain to fin(ers ,-E ME5 # 4mitryptilline 1)) m( Ahs+ $;uprofen .)) m( T$5+ >lector patch A 12 hrs+ Percocet 162 ta;s A ! hrs 4BBE/GC# 1@54 10/12 C, 3" M CC# ,ac& and le( pain s*p transforaminal epidural #2*3 3ith impro%ement in ;aseline pain 'P$# Chronic

you e%er chec& cranial ner%es or 5T/s on these patientsD C4/# ///6 not an appropriate cardiac exam for an 1PE 'eart sounds are either normal or not8 so state normal 1 28 no 38! or m8 (8rE /E P# CT4 M- @# :F< pain on palpation ;ilateral nec&8 trapeGius+ 5ec /OM nec&+ :F< resistance on /OM+ 1) de(ree rotation B*/+ una;le to touch chin to chest+ 2) de(ree extension+ F=*= motor stren(th ,-E neuro examD Hitals# T "IE!+ '/ I2 ,P 120*0. GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect C4/# /// /E P# CT4

559# :;y M/$< '1P B= 3ith lum;ar radiculopathy ,BE 559# 5M8 3ell controlled

/9# Bum;ar Transforaminal epidural steroid in?ection #3*3

/eturn tomorro3 for in?ection

lo3er ;ac& pain M- @# :F< pain on 3ith increase in palpation lum;ar ;*l+ se%erity .*1) :F< pain on le( past 0 3ee&s+ strai(htenin( ,BE ne3 / anterior thi(h pain+ 1e3 B le( ;urnin( pain radiatin( posterior and lateral from thi(h to toes+ 1e3 episodic Jelectric shoc&Kpain sole of left foot+ ne3 M/$ B= '1P PM'# Microdiscectomy 3ith foraminotomies 2))"+ PT 39 monthly+ s*p lum;ar epidural in?ections 5r Collier+ 5M8 type $$ 3ell controlled Meds# Metformin 4ller(y# 1@54 10/12 JC !" M CC# On(oin( ti(htness lo3er ;ac& 3ith pain Hitals# T "IE!+ '/ I2 559# ;y M/$ ,P 120*0. GE1# 5isc ;ul(e B!B= 3ith 2ell de%eloped*3ell ner%e root compression /9# Transforaminal epidural in?ection /eturn on >riday for in?ection

10/12 ME I" >

2*1) 'P$# e%ere flare of chronic lum;ar pain for ! 3ee& period related to stress+ mana(ed 3ith chiropracty+ no3 3ith lin(erin( ti(htness PM'# Episodic lum;ar pain 9 ! years Meds# 1one 1@54 CC# 1a((in( / hip and ri(ht le( pain 'P$# harp (luteal pain ;e(an . 3ee&s a(o 3ithout precipitatin( e%ent+ sa3 PCP 3ith no relief PM'# -nremar&a;le /O # M @# harp (luteal pain exacer;ated 3ith mo%ement+

nourished*145 1E-/O# 44Ox3 1ormal affect C4/# /// /E P# CT4 M- @# :F< pain on palpation lum;ar ;*l+ :F< pain on le( strai(htenin( ,BE

T# ".E0 '/ II ,P 130*00 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 M @# /i(ht lum;ar ;ac& pain 1)*1) 3ith palpation radiatin( from (luteal muscle to &nee+ F=*= muscle stren(th ,BE

559# /*O '1P 559# /*O Transforaminal narro3in( 559# /*O lum;ar facet ?oint arthropathy

/9# O;tain Bum;ar M/$

/eturn 3ith scans

10/12 J/ 3! M

;urnin( pain radiatin( to left le( from hip to &nee Meds# $;uprofen+ -ltram 1@54 CC# ,ac& pain flare 'P$# Episodic ;ac& pain s*p MH4 2 years a(o Treated ;y Transforaminal in?ections PM'# -nremar&a;le Meds# 1one 1@54

T# ".E0 '/ II ,P 130*00 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 M- @# Thoracic pain "*1) on palpation T# ".E0 '/ "! ,P 13)*I2 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 M- @# Beft sacroiliac ?oint pain

559# ;y M/$ 5isc ;ul(e T!T=

/9# Transforaminal in?ection thoracic

/eturn on >riday for in?ection

10/12 2H =" M

CC# Beft ;utt pain x 2 3ee&s 'P$# Pain ;e(an 3hile 3or&in( as auto mechanic PM'# Multiple epidural in?ections for chronic ;ac& pain Meds#

559# acrroiliitis left 559# '1P B!B=

/9# teroid in?ection B sacroiliac ?oint

/eturn as needed

10/12 JM 0" M

10/12 JC =" M

im%astatin 2)m( daily+ Bisinopril 2) m( daily 4ller(y# PC1 CC# $ am here for refills 'P$# Chronic lum;ar ;ac& pain x ! years 3ithout in?ection relief PM'# C45+ 'T1+ PE Meds# Coumadin 1) m( daily+ 5io%an 2= m( daily+ Lestril 2)*2= $ ta; daily+ Oxycontin 1) m( ,$5+ Percocet =*32= A 0 hours prn 1@54 CC# Bo3er ;ac& pain 3ith radiatin( le( pain s*p &itchen reconstruction 'P$# ;ac& and le( pain x ! 3ee&s PM'# Episodic

0*1) on palpation

T# ".E0 '/ .! ,P 13.*0. GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 M- @# .*1) lum;ar pain :F< palpation

559# ;y M/$ '1P B!B=

/9# /efill oral pain meds

/eturn in one month

T "IE0 '/ .. ,P 132*00 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4

559# ;y M/$ 5isc ;ul(e B162B263B36 !B!6= 3ith foraminal narro3in( C45 3ith recent stent placement

/9# Transforaminal in?ection recommended ;ut contraindicated ;y Pla%ix dosin(+ una;le to interrupt Pla%ix for one year s*p stent placement

/eturn as appropriate

10/12 5T 3! >

10/12 MT 0" M

;ac& pain mana(ed 3ith transforaminal epidural in?ections Cardiac stents =*2)11 Meds# Pla%ix+ 5io%an 1@54 CC # 1ec& pain 'P$# Chronic nec& pain 9 3 years s*p 3or& in?ury PM'# >reAuent epidural in?ections 3ith pain relief /O # M @#.*1) chronic nec& pain Meds# 4le%e+ Percocet =*32= 1 ta; A 0 hours 1@54 CC# 1e3 onset lo3er ;ac& pain 'P$# imilar B,P resol%ed 0

M- @# .*1) lum;ar pain :F< palpation+ :F< pain le( strai(htenin( ;*l+ le( pain radiatin( from (lut to cal%es ;*l

T# ".E. '/ 00 ,P 1)!*=0 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 M @# 1ec& pain 1)*1) on palpation 3ith shoulder pain + /OMM!= extension*flexion nec&+ shootin( pains ,-E+ F!*= motor stren(th T ".E0 '/ .1 ,P 12.*I. GE1# 2ell de%eloped*3ell

59# :;y M/$< '1P C!6= 3ith cer%ical radiculopathy

/9# Cer%ical transforaminal Epidural $n?ection

/eturn on >riday for in?ection

55x# /9# Transforaminal Bum;ar pain r*t B= '1P lum;ar epidural in?ection

/eturn on >riday for in?ection

10/33 J 1" >

months a(o after treatment 3ith Epidural+ no3 recurs 3ith acti%ity PM'# @nee arthroscopy /O # M- @# Bo3er ;ac& pain Meds# $;uprofen .)) m( T$5 4ller(y# 1@54 CC# $ 3ant a flu shot PM'# 1o recent fe%ers8 no aller(y to e((sE

nourished*145 1E-/O# 44Ox3 1ormal affect C4/# /// /E P# CT4 M- @# lo3er ;ac& pain 0*1) on palpation+ :F< pain on le( strai(htenin(

Hitals# 15

559# >lu shot

/9# >lu shot

$nstructed to mana(e flu li&e symptoms 3ith acetaminophen $nstructed to mana(e flu li&e symptoms 3ith acetaminophen $nstructed to mana(e flu li&e symptoms 3ith acetaminophen

10/33 G !" >

CC# $ 3ant a flu Hitals# 15 shot PM'# 1o recent fe%ers8 no aller(y to e((sE CC# $ 3ant a flu Hitals# 15 shot PM'# 1o recent fe%ers8 no aller(y to e((sE

559# >lu shot

/9# >lu shot

10/33 J !3 >

559# >lu shot

/9# >lu shot

"

10/33 J 21 M

CC# 2ound follo3 up 'P$# /ecent fall 3ith facial laceration+ sutured in E5 PM'# -nremar&a;le /O # Gen# 5enies fe%er*chills Meds# none 1@54 CC# /ash 'P$# $tchy rash ;e(an ! 3ee&s a(o PM'# -nremar&a;le Meds# 1one 1@54

10/33 J !" M

10/33 P 2! >

CC# ore throat 'P$# ore throat

T "" '/ 0" ,P 1)2*00 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 'EE1T# 'ealin( laceration ri(ht chee&+ erythema8 3armth8 edema ri(ht chee&+ non drainin(+ pain!*= T ". '/ I! ,P 13.*00 GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 &in# /ed macular rash 3ith deeper toned external ;order co%ers =N of trun& on anterior and posterior chect T ""E" '/ I0 ,P 12.*0!

55x# $nfection 3ound 55x# /*O maxillary fracture

/9# @eflex =))m( !9 daily+ facial xray+ refer to PCP if no impro%ement 3 days

>ollo3 up 3ith PCP

55x# /in(3orm 55x# 4topic dermatitis 559# Byme disease

/x# Medrol dose pac&

/efer to 5ermatolo(y

559# trep pharyn(itis 559# Post nasal drip

/9# 4lle(ra 5 1 ta; daily+ $;uprofen 0))

trep :F<# 4dd Pennicillin H@

1)

9 I days PM'# -nremar&a;le Meds# 1one 1@54

GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect 'EE1T# Tonsillar edema ;*l 3ith redness8 Prurulent post nasal drip and co;;lestonin( of pharynx8 no cer%ical lymphadenopathy CH# /// P-BM# CT4 T "" '/ 0) ,P 1))*=" GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect CH# /// P-BM# CT4 T "0E1 '/ 0) ,P 1).*=! GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 559# -T$

m( T$5+ /apid strep test

=)) m( ,$5 x1) days

10/33 4 2) >

CC# $ ha%e a -T$ 'P$# -rinary freAuency and ;urnin( 9 3 days PM'# >reAuent -T$ Meds# 4LO 1@54

/9# -rine dipstic& >ollo3 up 3ith :F< 3;c8 protein8 PCP as needed ;lood /9# ,actrim 5 ,$5 x 3 days+ Pyridium 2))m( T$5 for 3 days

10/33 4 1" >

CC# $ can7t hear out of my ri(ht ear 'P$# Ear con(estion ;e(an 3 days a(o

559# Cerumen impaction 559# 3immers ear

/9# Cerumen remo%al HisualiGed ri(ht TM normal

ee PCP if recurs

11

PM'# -nremar&a;le Meds# C4L ;irth control 1@54

1ormal affect 'EE1T# 1asal polyp /i(ht nare+ / ear cerumen o;scures TM for exam+ CH# /// P-BM# CT4 T ".E1 '/ I) ,P 120*0) GE1# 2ell de%eloped*3ell nourished*145 1E-/O# 44Ox3 1ormal affect 'EE1T# 5ar&ened s&in under ;oth eyes+ Oropharynx reddened ;*l 3ith prurulent P15+ Pallor nares ;*l+ TM pin& CH# /// P-BM# CT4 Hitals 15 55x# trep pharyn(itis 559# Hiral pharyn(itis 55x# 4ller(y 3ith con(estion trep and %iral pharyn(itis ruled out r*t a;sence of fe%er and PE oropharynx /x for aller(ies# >lonase 1 spray each nostril once daily 4lle(ra 5 once daily /efer to 4ller(y testin(

10/33 M 1" >

CC# ore throat 'P$# ore throat ;e(an 2 3ee&s a(o8 cou(h at ni(ht PM'# -nremar&a;le Meds# 1one 1@54

10/33 C 1" >

CC#$ am here for a PP5 placement reAuired for school PM'# Pre% PP5 1e(ati%e Meds# 1one 1@54

59# PP5 placement

/9# PP5 placement

/eturn !. to I2 hours for assessment

12

<valuation 0here you a,le to meet your s'ecific measura,le goals for the 5ee1D =f yes. ho5D =f not. 5hy not an% ho5 5ill you meet it in the futureD Goal #1 yes*no Goal #2 yes*no Goal #3 yes*no Ces Ces Ces

2hat e%idence* references did you utiliGe for clinical decision6ma&in( this 3ee&D The Minute Clinic Clinical Guidelines+ Epocrates+ -p to 5ate

13