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Summary of Clinical Experience
Summary of Clinical Experience
Bayhealth Primary Care/Total Care - (Harrington, DE)
Atlantic Family Physicians (Georgetown, DE)
Sussex NP (Georgetown, DE)
For Practicum III I returned to both Bayhealth Primary Care, and Total Care Urgent Care as well as Atlantic Family Physicians and Sussex NP. Throughout my time this summer, I refined my skills in diagnosing and managing conditions such as hypertension, diabetes mellitus, migraines, and substance abuse. During this practicum, I focused on being as independent as possible through my chart reviews, planning my visits, and reporting my findings and differentials to my preceptor. I started to keep a small notebook to help collect information, diagnostic tips, lab interpretation, and CPT/ICD-10 codes to help me in successive practicums and my future practice as an FNP! I had more experience with pediatric patients this semester when I completed school sports physicals at Delmarva Christian High School. I felt that my rotation this semester was extremely well-rounded and I am excited to move forward into my final double practicum for the Fall 2025 semester.
(Schwedt & Garza, 2025, Algorithm 1).
Seminar Diabetes Certificate.pdfScientific Foundation
Scientific Foundation
Evidence of Achievement:
Translates research and other forms of knowledge to improve practice processes and outcomes.
Develops new practice approaches based on the integration of research, theory, and practice knowledge.
I saw a 21 year old female who presented for acute repeated migraines. During her visit, I obtained a thorough HPI and compared her symptoms with a primary evidence-based resource from the American Headache Society. Based on the information from the AHS's 2018 clincial practice guidelines and UpToDate, I compared her symptoms to the most recent treatment pathway. Based on my findings, she had infrequent headache episodes and failed outpatient NSAID and analgesic therapy. Based on the clinical practice guidelines, I then prescribed her Sumatriptan as needed. Sumatriptan is a serotonin 1b/1d antagonist that promotes vasoconstriction in the brain and blocks pain modulating pathways. I prescribed Sumatriptan 100 mg as needed orally for headache abortive therapy. I also instructed the patient that she can take a repeat dose after two hours if no improvement, but that the max dose would be 200 mg in 24-hours (Schwedt & Garza, 2025).
I attended a seminar this semester on three different topics, one of which pertained to limiting renal injury in persons with type 2 diabetes mellitus. From my experience, I learned that in persons with existing cardiac and renal issues, GLP-1 administration has multiple beneficial effects to protect the kidneys and heart. For one, these drugs improve renal excretion of water and sodium which impacts blood pressure regulation positively. It also has a role in inflammatory modulation as it decreases plasma levels of inflammatory mediators (Charytan & Green, 2024). As a result, I saw a patient in clinic who had an elevated A1C around 8%, obesity, and comorbid hypertension. I discussed with my preceptor that we should potentially switch his Metformin therapy to a GLP-1, such as Ozempic, as it can decrease his risk of developing renal disease. The prior authorization process was then started to see if the patient's insurance would cover injectable Ozempic for diabetes.
https://practicingclinicians.com/activity/ecase/55DFE5DE-11B1-4D3A-9CAF-BC563435387B/1
Practice Inquiry
Practice Inquiry
Evidence of Achievement:
Analyzes clinical guidelines to determine treatment pathway
1. I reviewed the clinical practice guidelines for asthma management when I saw a 50-year-old male for a routine follow up for chronic health conditions. The patient was complaining the he was using his anti-inflammatory rescue inhaler daily and had been waking up in the middle of the night coughing almost every night of the week. He was not prescribed a maintenance inhaler. I reviewed the recommendations from the Global Initiative for Asthma and UpToDate and moved the patient from step 2 to step 3 on the asthma management guidelines. On step 3, the patient needed to be on maintenance therapy with a long-acting beta 2 agonist/inhaled corticosteroid combination drug (Dixon & Carr, 2025). I reviewed the medications covered by his insurance and decided to start the patient on Symbicort for MART (maintenance AND reliever therapy). Therefore, the patient was educated that he would take 2 inhalations daily and then one inhalation as needed for acute bronchospasm symptoms. I also educated the patient on avoiding his triggers for his asthma and implored him to stop smoking. Finally, I ordered repeat pulmonary function testing and spirometry for this patient to assess his lung function.
(Global Initiative for Asthma, 2024).
2. I saw a 24-year-old female during my clinical rotation who presented with congestion, rhinorrhea, headache, and sinus tenderness. Based on her presentation and length of symptoms, I diagnosed her with acute bacterial rhinosinusitis. Upon ordering her an antibiotic, I saw that she had an allergy to penicillins. I reviewed the clinical practice guidelines from UpToDate to decide an alternative antibiotic regimen. Based on their recommendations, I prescribed Doxycycline 200 mg by mouth daily for 7 days (Patel, 2025).
Empiric antimicrobial therapy uncomplicated ABRS (adults) - UpToDate.pdf(Patel, 2025).
Technology & Information Literacy
Technology & Information Literacy
Evidence of Achievement:
Uses technology systems that capture data to provide care and assist in decision-making
Uses technology systems that capture data to provide care and assist in decision-making
One resource that I used more frequently this semester was 5-Minute Clinical Consult (5-MCC). 5-MCC is a phone application that allows the user to input clinical information and provides differential diagnoses and resources to help guide decision-making. I recently saw a 35-year-old male who presented to the office with acute headache and disrupted sleep. Prior to entering the room, I used 5-MCC to guide my review of systems questions and my exam. When stepping out of the room, I discussed the case with my preceptor. I found that because he reported frequent morning headaches, this led me to asking if his partner noticed him snoring in his sleep. Due to his daytime sleepiness, snoring habits, and comorbid obesity, I kept Obstructive Sleep Apnea as one of my differential diagnoses. As a result, I ordered a sleep study for the patient to rule out this condition.
2. During each patient encounter, the EPIC electronic medical record stores data from the medical assistant (e.g. vital signs, weight and height, medication reconciliation) that I use during each visit. I was seeing a 45-year-old female patient for weight loss medication follow up. The patient states that she was not seeing any improvement in her weight at home, even though she was eating better and exercising. Upon review of her lab work, I saw that her triglycerides had increased from 251 to 272 mg/dL as well as her weight increased from 258 lbs to 265 lbs from our last visit. Due to my knowledge of triglycerides and how they are affected by a high calorie diet consisting of fats and sugar, I took this opportunity to educate the patient on the importance of proper diet while on GLP-1 medication (Rosenson & Eckel, 2025). I explained that she would ultimately hit a peak and would no longer lose weight as efficiently than she did when she started therapy. Later in our visit, she admitted that she was not entirely truthful with her diet and that she had an opportunity to improve. Instead of increasing her dose of Wegovy, we planned to repeat her lab work and weight in 3 months to assess for improvement before adjusting her medication dose.
Ethics
Ethics
Evidence of Achievement:
Involves system-based resources to guide ethical decision-making.
Integrates ethical principles in decision-making.
Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care.
Maintaining Confidentiality and Autonomy:
I saw a 15 year old patient in clinic for an annual physical. The patient was accompanied by her mother who was filling out her paperwork. The patient had mentioned that she was having extremely difficult menstrual cycles due to pain and irregular frequencies. The patient had expressed her interest in hormonal contraceptives to help regulate her cycles. Her mother interrupted during our visit and had expressed her concern about her daughter being on birth control. I had asked the patient's mother to step out of the room and my preceptor was present as an adult chaperone. I explained some options for hormonal therapy and notified that the patient was of age to seek confidential sexual health services. The patient explained that she wanted to think about starting this medication and was worried that her parents would find out she was taking contraceptives. I explained that there are more invasive therapy methods that are discreet and that should she wish to begin therapy, she could reach out to the office or go to her high school's wellness center for guidance in starting this process.
Del. Code. Ann. tit. 13, § 710 provides that a minor age 12 or older who professes to be pregnant, or who professes to be exposed to the chance of becoming pregnant, may give written consent for any diagnostic, preventive, lawful therapeutic procedures, medical care and treatment, except to an abortion, by any licensed physician, hospital, or public clinic (English & Guderman, 2024).
NCYLMinorConsentCompendium2024-Delaware.pdf2. Upholding Autonomy:
I saw a 87-year-old patient who presented for follow up of chronic health conditions: cervical radiculopathy and essential tremor. The patient was extremely frustrated that she lived with constant back pain and felt that her tremors were getting worse. Her son accompanied her to the visit and he vented his frustrations that no one was helping to fix his mom's issues. When I explained the process of what was triggering her tremors, the patient began to say that she was ready to seek quality of life measures and, "did not want any more tests or medications." I educated the patient on palliative care when her son interjected and detested this option. After letting him speak, I asked for him to step out of the room so I could discuss this with the patient privately. Ultimately, the patient was interested in hearing what palliative care could help her with and wanted a referral for their services. I upheld the patient's wishes and consulted Bayhealth Palliative care to contact the patient.
By upholding the patient's right to decision-making due to being of sound mind, I followed the ANA's Code of Ethics by allowing her to prioritize quality of life during her illness and respecting her right to autonomy, so long as she is adequately educated on all treatment options (American Nurses Association [ANA], 2025).
Code of ethics.pdfPolicy
Policy
Evidence of Achievement:
Analyzes the implications of health policy across disciplines
Demonstrates an understanding of the interdependence of policy and practice
DELVAX is an online resource for reporting vaccinations of children and adults. Per law, DELVAX is required in Delaware with no ability for parents to opt their child out of vaccine reporting. I recently saw an 18-year-old patient who was establishing care from a pediatric office to our office. I used the DELVAX portal to verify her vaccine records because EPIC was not up to date with her vaccine reports and showed that she was overdue for her MMR and meningococcal vaccinations. As a result of this law, healthcare service is much safer because I have access to vaccine records for all patients in Delaware that I treat. Per Delaware Code, children and adults are required to participate and vaccine reporting by healthcare agencies is mandatory (Delaware Department of Health and Social Services, Division of Public Health, 2025, § 4202-2.0). Therefore, I assured the patient I could use this database to obtain her records if she did not have them on-hand.
2. I saw a 35-year-old male patient for an annual physical just over three years since his last visit in office. CMS guidelines state that patients are new if they have not received healthcare services from the clinical provider or provider from the same medical group within 3 years (Centers for Medicare and Medicaid Services [CMS], 2017). Since the patient presented for his annual physical, this visit had to be coded as if he were establishing care because he did not receive any medical care from the practice. Therefore, when documenting his visit's E/M code, he was billed as a 99385, which is the corresponding code for 18-39 year old new patient preventative visits.
Leadership
Leadership
Evidence of Achievement:
Self-reflection of leadership style and identification of personal merits.
Inter-professional leadership and collaboration
Demonstrates leadership that uses critical and reflective thinking.
I was conducting a visit for a 68-year-old married couple who presented for their annual physical. During their visit, they described that they were experiencing some stress due to the wife's mother who recently fell and had a stroke and returned to live at home. They were having financial difficulties and caregiver role strain due to having to hire a 24-hour caregiver that cost $25,000 per month. I inquired if they would be interested in a skilled nursing facility instead to help conserve some of their funds. I researched some pricing during their visit and provided them the information for Country Rest Home, which is approximately $9,500 per month for a resident bed. The patients were both elated and planned to go home and research not only that facility but other local nursing homes to compare amenities and prices for their family member.
I was conducting a follow up visit for a 55-year-old male who had a history of hypertension on an ACE inhibitor. While reviewing his lab work, I found that his potassium was elevated on his lab work at 5.6 mEq/L and he had a previous trend of hyperkalemia. I reveiwed his medication list and found that his Lisinopril was started prior to his potassium becoming elevated consistently. I inquired about his diet to ensure that he was not eating any potassium-based supplements or seasonings and explained that I would need to discontinue his ACE inhibitor (Townsend, 2024). I started the patient on 5mg of Amlodipine daily and reordered a follow up comprehensive metabolic panel to reassess his electrolytes. I shared my findings and plan of care with my preceptor and led this entire patient encounter.
Independent Practice
Independent Practice
Evidence of Achievement:
Clinical decision-making based on evidence and shared decision-making
Functions as a licensed independent practitioner
I had a 44-year-old patient come in for a sick visit with complaints of indigestion and chest pain for 2 weeks. During this time, I completed a thorough HPI and developed three differentials for his pain: costochondritis, anxiety, and GERD. The patient explained that he ate meals close to his bedtime, had a stressful job as a police officer, and frequently consumed caffeinated beverages. Based on this information, I diagnosed the patient with gastro-esophageal reflux disease. Using UpToDate, I started the patient on an 8-week trial of 40 mg of oral Pantoprazole and counseled him on eating smaller, more frequent meals, identifying trigger foods that cause this pain, elevating the head of bed during sleep, and avoiding carbonated beverages (Winter, 2024). I instructed the patient to follow up if no improvement after 2 months of therapy. To aid my diagnosis, I also ordered an ultrasound of his abdomen to rule out any additional disease processes, such as acute cholecystitis. I presented my plan of care to my preceptor and I required no assistance during this clinical encounter.
I saw a 35-year-old female who presented for her annual physical. I completed a full mental health exam by having the patient fill out a PHQ-9 and GAD-7. Based on her results, I found that she had moderate anxiety as her GAD-7 score was a 14 (Sapra et al., 2020). Afterwards, I discussed what triggers the patient can identify for her anxiety and offered therapy services and medication therapy. I discussed a couple options for anxiety management and through shared decision-making, the patient and I agreed to start her on Lexapro and follow up in 1 month to reevaluate her anxiety. I discussed my findings and shared my plan of care with my preceptor after completing this patient encounter.
Health Delivery Systems
Health Delivery Systems
Evidence of Achievement:
Inter-professional collaborative relationships
Evaluates the impact of healthcare delivery systems on patients, providers, stakeholders, and the environment
During a follow-up visit with a 64-year-old female for chronic health conditions, I noticed she looked depressed and probed further with gentle questioning. The patient then stated that she was dealing with "a lot mentally" and was having a difficult time with her ex-husband who kept trying to enter her life repeatedly. The woman had a poor socioeconomic and social support system and had existing caregiver burden from caring from her elderly mother. I identified her struggles and completed a PHQ-9 and GAD-7 during our visit and diagnosed her with anxiety and depression. I discussed the benefits of psychotherapy and offered to schedule services. The patient agreed and while she waited, I consulted the licensed professional counselor for mental health that works at Bayhealth Primary Care. At the end of our visit, the mental health provider took some time to discuss therapy and scheduled an upcoming appointment with her.
https://www.bayhealth.org/locations/primary-care-harrington - Caitlin Pepper, LPCMH
During a visit with a 21-year-old male with existing anxiety, depression, and OCD, he discussed wanted to start on medication to "fix" these issues. I explained that while medications can assist with mental health management, therapy has been found to be beneficial for some persons to help develop coping strategies for dealing with mental health crises. The patient stated that he was willing to talk to someone, but he had attempted multiple times to find a pyschiatrist and he could not. Due to the multiple comorbid mental health conditions, I felt that it would be best that any additional medications be managed by a mental health provider. Therefore, I referred the patient to a colleague of mine who is a mental health nurse pracittioner who specializes in these conditions. Before leaving the visit, I ensured that the patient had set up an appointment for psychotherapy sessions and medication management.
https://toriiwellness.com/ - David Torres, PMHNP
Quality and Safety
Quality and Safety
Evidence of Achievement:
Uses best available evidence to continuously improve clincial practice
Evaluates relationships among access, cost, quality, and safety, and their influence on healthcare
I saw an 87-year-old patient who presented with an essential tremor and chronic back pain. The patient was frustrated because she was on multiple medications (Pramipexole, Gabapentin, Lyrica, etc.) for her pain and tremor and was having difficulty managing her medications. The patient stated that she stopped taking some of her medications due to how drowsy she felt from their side-effects. Due to her extensive medication list and comorbidities, I consulted the in-practice clinical pharmacist to review the patient's medication list with her to see if any medications could be removed, altered, or re-timed to more appropriate hours of the day to increase compliance and prevent adverse events.
I was seeing a 66-year-old patient who presented to the office for follow up for her rheumatoid arthritis and COPD. While reviewing her health maintenance, I saw that she was on chronic steroids and had never had a DEXA scan. I had ordered her for a DEXA scan because she was within the age range for this screening and chronic steroid use can lead to osteoporosis. Prior to her leaving, I also used a clincial risk calculator, the FRAX score, to assess for her risk of major osteoporotic fracture (21%) and hip fracture (5.1%) (United States Preventative Services Task Force [USPSTF], 2025). Based on these results, I implored the patient to complete her scan and we would review the results at an upcoming visit to potentially start medication for osteoporosis, if her T score was -2.5 or less.
References
American Nurses Association. (2025). 2025 code of ethics for nurses. Retrieved August 15, 2025, from https://codeofethics.ana.org/home
Centers for Medicare and Medicaid Services. (2017, March 9). 0043 - new patient visits: Incorrect coding. CMS.gov. Retrieved August 15, 2025, from https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0043-new-patient-visits
Charytan, D. M., & Green, J. B. (2024, December 23). Navigating the latest evidence and strategies for renal risk reduction in T2D. Practicing Clinicians. Retrieved August 15, 2025, from https://practicingclinicians.com/activity/ecase/55DFE5DE-11B1-4D3A-9CAF-BC563435387B/1
Delaware Department of Health and Social Services, Division of Public Health. (2025). Control of communicable and other disease conditions (16 Del. Admin. Code § 4202) [Regulation]. Delaware Administrative Code. https://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Public%20Health/Health%20Promotion%20and%20Disease%20Prevention/4202.shtml
Dixon, A. E., & Carr, T. F. (2025). Ongoing monitoring and titration of asthma therapies in adolescents and adults (B. S. Bochner & P. Dieffenbach, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/ongoing-monitoring-and-titration-of-asthma-therapies-in-adolescents-and-adults?search=gina%20asthma%20guidelines%26source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H577170696
English, A., & Guderman, R. (2024, August). Minor consent and confidentiality: A compendium of state and federal laws Delaware - August 2024 [PDF]. National Center for Youth Law. Retrieved August 15, 2025, from https://youthlaw.org/sites/default/files/2024-10/NCYLMinorConsentCompendium2024-Delaware.pdf
Global Initiative for Asthma. (2024). Global initiative for asthma - global initiative for asthma - gina. Global Initiative for Asthma - GINA. Retrieved August 15, 2025, from https://ginasthma.org
Patel, Z. M. (2025). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment (D. G. Deschler, T. M. File, & Z. Hussain, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-in-adults-treatment?search=bacterial%20rhinosinusitis%20treatment%26source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H1796329932
Rosenson, R. S., & Eckel, R. H. (2025). Hypertriglyceridemia in adults: Approach to evaluation (M. W. Freeman, N. F. Botkin, & S. Swenson, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/hypertriglyceridemia-in-adults-approach-to-evaluation?search=triglycerides%26source=search_result&selectedTitle=5~150&usage_type=default&display_rank=4#H3455109711
Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (gad-2) and gad-7 in a primary care setting. Cureus, 12(5). Retrieved August 15, 2025, from https://doi.org/10.7759/cureus.8224
Schwedt, T. J., & Garza, I. (2025). Acute treatment of migraine in adults (J. W. Swanson, R. P. Goddeau, & K. Law, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine%20treatment%20adult%26source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Townsend, R. R. (2024). Major side effects of angiotensin-converting enzyme inhibitors and angiotensin ii receptor blockers (W. J. Elliott & J. P. Forman, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/major-side-effects-of-angiotensin-converting-enzyme-inhibitors-and-angiotensin-ii-receptor-blockers?search=hyperkalemia%20ace%20inhibitor%26source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
United States Preventative Services Task Force. (2025, January 14). Recommendation: Osteoporosis to prevent fractures: Screening. Retrieved August 15, 2025, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening
Winter, H. S. (2024). Gastroesophageal reflux disease in children and adolescents: Management (B. U. Li & A. G. Hoppin, Eds.). UpToDate. Retrieved August 15, 2025, from https://www.uptodate.com/contents/gastroesophageal-reflux-disease-in-children-and-adolescents-management?search=gerd%26source=search_result&selectedTitle=4~150&usage_type=default&display_rank=3
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