Critical reflection on your growth and development during your practicum experience in a clinical setting has the benefit of helping you identify opportunities for improvement in your clinical skills while also recognizing your clinical strengths and successes.
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JOURNAL ENTRY #1
Critical reflection on your growth and development during your practicum experience in a clinical setting has the benefit of helping you identify opportunities for improvement in your clinical skills while also recognizing your clinical strengths and successes.
This week, you will write a Journal Entry reflecting on your clinical strengths and opportunities for improvement.
JOURNAL ENTRY (3 PAGES):
Based on your experience, write a 3-page journal entry discussing an interesting case or a case that you have never encountered before (Case below).
1. What did you find challenging?
2. Were there any cultural differences that you found challenging?
3. What treatment plan did you implement?
4. What did you learn from this experience?
5. What references did you use for the assessment and treatment plan?
Use at least 3 resources in your response. Make sure you cite the sources using APA format (7th edition).
Interesting case or a case that you have never encountered before.
S:
A 13-month-old female, coming in for a follow-up of a 1-month left upper arm rash without itchiness. Transitioning from breast milk to formula milk. Feeding well, regular BM, and good urine output. No fever/chills, nausea/vomiting, diarrhea, and no history of insect bites.
ROS are all negative except those mentioned in the HPI.
Past Medical History: No, specialty or emergency care since the last visit.
Family History: No new health condition in the family, and no one died.
Social History: No one smokes tobacco in the house or around the house. Car seats use regularly. No pesticide is used around the house/yard.
O:
Generally well-appearing. Awake, alert, and interactive; not in active distress. Normal pink color.
Weight: 10.5 kg. (88th percentile), Height: 68 cm. (25th percentile), Head circumference: 46.2 cm. (75th percentile),
VS: Temp 99.1’F, RR 26, HR 102
GEN: Normal general appearance. NAD.
HEENT
-Head: NC/AT.
-Eyes: No redness or discharge.
-Ears: Normal external ears.
-Nose: Normal nares.
-Mouth and Throat: MMM. Normal gums, mucosa, and palate. Good dentition.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: N/A
SKIN: Warm & well-perfused. Left upper arm (lateral) with + multiple, nonpruritic, small spiny keratotic papules with erythema.
MSK: Normal gait. No clubbing, cyanosis, or edema. Normal extremities. No deformities.
NEURO: No focal deficits.
A:
• 2023 ICD-10-CM Diagnosis Code L11.0. Acquired keratosis follicularis.
Diagnostics: None
Pharmacological: Hydrocortisone base (2% cream) tube. Apply a thin film to the affected area 2 times daily x 7 days.
Immunization: UTD
Anticipatory guidance:
• Social determinants of health (risks [living situation and food security; tobacco, alcohol, and drugs], strengths and protective factors [social connections with family, friends, childcare and home visitation program staff, and others])
• Establishing routines (adjustment to the child’s developmental changes and behavior; family time; bedtime, naptime, and teeth brushing; media)
• Feeding and appetite changes (self-feeding, continued breastfeeding/formula-feeding, and transition to family meals, and nutritious foods)
• Establishing a dental home (first dental checkup and dental hygiene)
• Safety (car safety seats, falls, drowning prevention and water safety, sun protection, pets, safe home environment: poisoning)
Referral/Follow-up:
• Patient can follow up in 7 days if conditions worsen/no improvement.
• Next appointment is in 2 months (well-child check-up)
References:
https://www.uptodate.com/contents/keratosis-pilaris?source=bookmarks_widget
SUMMARY AND RECOMMENDATIONS
●Clinical presentation – Keratosis pilaris (KP) is a common disorder of follicular keratinization. It typically appears during childhood or adolescence with spiny, keratotic papules (picture 1C) predominantly involving the extensor aspects of proximal arms and thighs (picture 1A). The face, trunk, buttocks, and distal extremities may also be affected. Variants with prominent background erythema have been described (picture 5A-B). KP is often seen in association with atopic dermatitis and ichthyosis vulgaris. (See ‘Clinical manifestations’ above and ‘Clinical variants’ above and ‘Associated conditions’ above.)
●Diagnosis – The diagnosis of KP is clinical, based on clinical features. Involvement of the eyebrows, marked inflammation, and atrophic scarring with alopecia suggest the diagnosis of keratosis pilaris atrophicans (picture 8A-C). (See ‘Diagnosis’ above and ‘Differential diagnosis’ above and “Keratosis pilaris atrophicans”.)
●Management – KP typically improves with age without treatment. However, for patients with widespread KP who have cosmetic concerns, treatment with emollients and topical keratolytics can provide symptomatic relief. Topical retinoids (eg, tretinoin 0.05% cream, adapalene 0.1% cream, or tazarotene 0.05% cream) are a second-line therapy for patients who fail to respond to emollients and keratolytics. (See ‘Treatment’ above.)
Medline ® Abstracts for References 5,6 of ‘Keratosis pilaris’
5
PubMed
TI
Sebaceous gland, hair shaft, and epidermal barrier abnormalities in keratosis pilaris with and without filaggrin deficiency.
AU
Gruber R, Sugarman JL, Crumrine D, Hupe M, Mauro TM, Mauldin EA, Thyssen JP, Brandner JM, Hennies HC, Schmuth M, Elias PM
SO
Am J Pathol. 2015;185(4):1012. Epub 2015 Feb 7.
Although keratosis pilaris (KP) is common, its etiopathogenesis remains unknown. KP is associated clinically with ichthyosis vulgaris and atopic dermatitis and molecular genetically with filaggrin-null mutations. In 20 KP patients and 20 matched controls, we assessed the filaggrin and claudin 1 genotypes, the phenotypes by dermatoscopy, and the morphology by light and transmission electron microscopy. Thirty-five percent of KP patients displayed filaggrin mutations, demonstrating that filaggrin mutations only partially account for the KP phenotype. Major histologic and dermatoscopic findings of KP were hyperkeratosis, hypergranulosis, mild T helper cell type 1-dominant lymphocytic inflammation, plugging of follicular orifices, striking absence of sebaceous glands, and hair shaft abnormalities in KP lesions but not in unaffected skin sites. Changes in barrier function and abnormal paracellular permeability were found in both interfollicular and follicular stratum corneum of lesional KP, which correlated ultrastructurally with impaired extracellular lamellar bilayer maturation and organization. All these features were independent of filaggrin genotype. Moreover, ultrastructure of corneodesmosomes and tight junctions appeared normal, immunohistochemistry for claudin 1 showed no reduction in protein amounts, and molecular analysis of claudin 1 was unremarkable. Our findings suggest that absence of sebaceous glands is an early step in KP pathogenesis, resulting in downstream hair shaft and epithelial barrier abnormalities.
AD
PMID
25660180
6
PubMed
TI
Genotype-phenotype associations in filaggrin loss-of-function mutation carriers.
AU
Landeck L, Visser M, Kezic S, John SM
SO
Contact Dermatitis. 2013;68(3):149.
BACKGROUNDLoss-of-function mutations in the filaggrin gene (FLG) have been reported to be associated with specific phenotypic characteristics such as hyperlinearity and keratosis pilaris.
OBJECTIVESTo study phenotypic features in patients with occupational irritant contact eczema of the hands in relation to FLG loss-of-function mutations.
MATERIALS AND METHODSIn a prospective cohort study, genotype was determined for 459 study subjects for four FLG null alleles, and investigated for selected history, clinical and laboratory features.
RESULTSOverall, 68 patients showed a mutation in the FLG alleles R501X, R2447X, S3247X, and/or 2282del4. Flexural eczema, xerosis cutis, pityriasis alba, dirty neck, pulpitis sicca, hyperlinear palms, keratosis pilaris and family history of eczema were positively associated with FLG mutations (p<0.05). Although we observed a statistically significant correlation with higher serum IgE in FLG mutation carriers, allergic rhinoconjunctivitis and allergic asthma were not over-represented in this group.
CONCLUSIONThis study shows further genotype-phenotype correlations in patients with occupational irritant contact eczema and FLG mutation carrier status. These features may help to identify those with FLG mutations on a specific phenotype basis.
AD
PMID
23421459
Medline ® Abstract for Reference 14 of ‘Keratosis pilaris’
14
PubMed
TI
Papular, profuse, and precocious keratosis pilaris.
AU
Castela E, Chiaverini C, Boralevi F, Hugues R, Lacour JP
SO
Pediatr Dermatol. 2012 May;29(3):285-8. Epub 2011 Dec 6.
Keratosis pilaris (KP) is a frequent and benign condition in children characterized by the presence of rough, follicular papules and varying degrees of erythema. Different variants have been described, including simple KP and red KP. Between September 2007 and October 2010, 11 children with profuse and precocious KP seen at the department of pediatric dermatology were included. They defined an underemphasized clinical variant of childhood KP: the papular, profuse, and precocious KP characterized by early age of onset (<18 mos), extensive involvement of the limbs and cheeks, and papular nature of lesions. No clinical association has been found. The main complication was episodes of folliculitis. Diagnosis was delayed for all patients. Treatment is difficult, but association between emollient and keratolytic agents can provide some help.
AD
Department of Dermatology, Academic Hospital of Nice, Nice, France.
PMID
22141376
Medline ® Abstract for Reference 30 of ‘Keratosis pilaris’
30
PubMed
TI
Practical management of widespread, atypical keratosis pilaris.
AU
Novick NL
SO
J Am Acad Dermatol. 1984 Aug;11(2 Pt 1):305-6.
AD
PMID
6480934
Rubric
PRAC_6810_Week5_Assignment2_Rubric
PRAC_6810_Week5_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeAssimilation and Synthesis: Content Reflection 50 to >44.0 pts
Excellent
Reflection demonstrates a high level of critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or discussions. Insightful and relevant connections are made through contextual explanations and examples. 44 to >39.0 pts
Good
Reflection demonstrates a moderate level of critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or discussions. Connections are made through explanations and/or examples. 39 to >34.0 pts
Fair
Reflection demonstrates minimal critical thinking in applying and integrating key course concepts and theories from readings, lectures, and/or discussions. Minimal connections are made through explanations and/or examples. 34 to >0 pts
Poor
Reflection lacks critical thinking. Superficial connections are made with key course concepts and resources, and/or assignments
50 pts
This criterion is linked to a Learning OutcomeAssimilation and Synthesis: Personal Growth 30 to >27.0 pts
Excellent
Expresses solid evidence of reflection on own work. Demonstrates substantial personal growth and awareness of deeper meaning through inferences, well-developed insights, and significant depth in awareness and challenges. Synthesizes current experience into future implications. 27 to >23.0 pts
Good
Expresses moderate evidence of reflection on own work. Demonstrates satisfactory personal growth and awareness through some inferences, insights, and challenges. There is mention of the future implications of student’s current experience. 23 to >20.0 pts
Fair
Expresses minimal evidence of reflection on own work. Demonstrates less than adequate personal growth and awareness through limited or simplistic inferences made, insights, and/or challenges that are not well developed. Minimal thought of future implications of student’s current experience. 20 to >0 pts
Poor
Expresses inadequate evidence of reflection on own work. Personal growth and awareness are not evident and/or demonstrate an impersonal experience. Lacks personal insights, challenges, inferences, and/or future implications are overlooked.
30 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting 15 to >13.0 pts
Excellent
Well written and clearly organized using standard English, characterized by elements of a strong writing style and basically free from grammar, punctuation, usage, and spelling errors. 13 to >11.0 pts
Good
Above average writing style and logically organized using standard English with minor errors in grammar, punctuation, usage, and spelling. 11 to >10.0 pts
Fair
Average writing style that is sometimes unclear and/or with some errors in grammar, punctuation, usage, and spelling. 10 to >0 pts
Poor
Poor writing style lacking in standard English, clarity, language used, and/or frequent errors in grammar, punctuation, usage, and spelling. Needs work.
15 pts
This criterion is linked to a Learning OutcomeAPA 5 to >4.0 pts
Excellent
No APA errors 4 to >3.5 pts
Good
Contains 1-2 APA errors 3.5 to >3.0 pts
Fair
Contains 3-5 APA errors 3 to >0 pts
Poor
Contains > 5 APA errors
5 pts
Total Points: 100
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