ELIZABETH

B. ARCHIBALD
CLINICAL W/ KAREN MORROW

05/09/2017

Patient #1 Baylee and I assisted Dr. Harris with a circumcision today. The baby was 7
days old. Intake consisted of taking baby vitals, measuring the circumference of the head,
assessing overall body condition, and taking a height and weight. It is very important to
take a height and weight that are accurate to the ounce and centimeter, because a small
deviation for patient could be detrimental. (EX: A loss of one ounce overnight for a baby
is very bad). The doctor took the time to educated the parents about why it is a good
decision to circumcise their baby, including: decreased chances of UTIs, STDs, and AIDS.
He also stated that, although it is always a possibility, he has done this procedure
thousands of times and has never had an infection or an accidental trauma. For the
sterile procedure, the baby is placed in a plastic tray. The baby must be restrained with
soft straps. Overall, the baby reacted the most to the restraints. The doctor thoroughly
scrubbed penis, testicles, and surrounding area with betadine, then infused area with 0.1
ML Bicarbonate and 0.9 ML Lidocaine. Foreskin was clamped with two Kelly hemostats
and extended. Mayo scissors were used to bluntly dissect the adhesions connecting the
foreskin from the penis. Next, the Mogen clamp was applied just distal to tip of penis for
30 seconds. A scalpel was used to remove foreskin. This completed the procedure, and
there was only bleeding from the infusion of the local block. Once patient was removed
from restraints he stopped crying. Patient monitored for 15 minutes to ensure that
bleeding does not start. Parents are to apply Vaseline to area of foreskin removal, until
the normal discharge has subsided, and to keep it from adhering to the diaper. The
discharge normally subsides within 4 days.

Diagnosis: Healthy baby circumcision

Date: 05/09/2017 /// 0900
D: Patient present for removal of foreskin.
A: Nursing student stood at head of table while patient had procedure performed.
Patient cried, and nurse held binky/pacifier in patients mouth while stroking head,
and talking softly to patient.
Response: Patient settled down at times, but fussed throughout most of procedure.
Signature: Liz, RN Student
Patient #2: Male, 73 y/o, present to have INR checked. His insurance will not pay for it
unless it is attached to his PCP. Patient has a blood clotting disorder R/T agent orange
exposure in Vietnam. Goal INR= 2.5-4.5 Patients measurement today= 4.1. Patient
has prescription for Oxycodone refilled today. He has a history of back pain, and has had
spinal surgery in the past.

Patient #3 Male, 39 y/o, present to have genital warts removed. Two raised, non-
erythemic masses located to right side distal shaft, and one raised, non-erythemic mass
located in crack of buttocks. Patient has a long history of diabetes, and a history of being
non-compliant. In February, patients A1C was 11.9% and his fasting capillary blood
glucose was 303. Patient also has a history of high cholesterol. Patient states that he has
only been taking his Metformin and discontinued all his other medications. Nurse
Practitioner Karen is not willing to have warts removed due to long history of
uncontrolled diabetes. There is too high of a risk of removal not healing, and an infection
occurring. Additionally, Karen looked at the formulary for Western or Advanced Health
(patients current insurance provider), and determined that the topical medications she
wanted to send were not covered under his insurance plan. Because the medication is
not covered, and because the skin condition is only cosmetic at this point, no action will
be taken regarding the warts. Upon further discussion with patient, it is determined that
patient is being non-compliant, not because he is unwilling, but because most of the
supplies and medications he need are not covered by insurance, and additionally, his ex-
wife handled his health care and he no longer has that support system. Karen researched
what the insurance will cover, and determined the best course of action based on this
information. Patient is sent with an RX of a glucometer, test strips, insulin/syringes,
metformin, and atorvastatin. All of this should be covered by insurance. Patient is to
start at 10 units SQ BID. He is to check his CBG TID (in AM, before dinner, and before
bedtime). If his CBG is above 110 after one week, he is to increase his insulin by 2 units
to 12 units BID. After the second week, if CBG is still above 110, he is to increase insulin
by another 2 units to 14 units BID. Patient will continue this regimen until CBG is great
than or equal to 110.

Side note: Patient has lost a lot of weight. Karen mentions that this is not a good thing
to patient, because she states that the body is compensating because it cannot get the
glucose into the cells (patient is insulin dependent). Later, I asked her if this could be a
risk for a possible DKA. She says that it is not because DKA is normally something that
happens in Type 1 Diabetes, and that patients diagnosis is Type 2 DM.

2
Patient #4 Female, 50 y/o, obtained dog bite to left front shin bone 10 days ago. Patient
attempted to resolve on her own at home, and did not report incident to the police.
Patient has been warm compressing wound, dressing wound, and applying triple
antibacterial ointment to wound. Within the last couple of days, the wound has gotten
redder and more painful. It is determined that patient has a localized infection. Research
states that the PCP should place patient on an antibiotic to treat the canine oral flora that
could have gotten into the wound, as well as the flora from the humans skin that could
have gotten into the wound (Clindamycin and Septra). Karen decided that both
antibiotics were not necessary, and she is afraid that giving both will lead to CDIFF.
Patient is sent with Septra only, and is instructed to come back for a recheck in 7 days.
Culture not obtained because of scab.