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PresentationsUpdated: 04-06-21
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Resume & CVUpdated: 04-06-21
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SkillsUpdated: 04-06-21
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified N63 | Unspecified lump in breast Z11.3 | Encntr screen for infections w sexl mode of transmiss Z12.31 | Encntr screen mammogram for malignant neoplasm of breast Z12.4 | Encounter for screening for malignant neoplasm of cervix |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | mk |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 34 y.o. female presenting today for pap Desires to be tested for STD's Living with some female room mates so she feels like her periods have changed No changes in medical history |
| Clinical Notes: | Pap -6/10/19 ASCUS/-HPV -cotesting done today>if nl repap 5 years Mammogram -4/10/18 L breast bx benign>recommend fu 6 mth US -breast US f/u scheduled STD check -urine GC/CT/trich -serum HIV, Hep C and RPR Annual -encouraged exercise, vitamin daily |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings Z12.4 | Encounter for screening for malignant neoplasm of cervix Z30.09 | Encounter for oth general cnsl and advice on contraception |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ef |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. female presenting today for well woman exam. IUD paragard fell out Does not desire pregnancy in the near future, not using anything for BC Would like another paragard-last IC 2 days ago Will replace with next period in 2 weeks Has lost 22lbs since Jan with exercise and diet Boys Dallas and Colton doing well |
| Clinical Notes: | pap -6/2017 NILM -pap done today>if normal next pap w HPV 3 yrs Birth control -desires paragard replaced -will place with period Annual -encouraged to continue exercise -PNV daily |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.33 | 33 weeks gestation of pregnancy |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Asian |
| Patient ID: | TN |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 21 y.o. G1P0 presents for NOB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid, contractions and endorses GFM No PNC, just moved from Arizona surprise pregnancy Employed: none Shane husband supportive FHT: 150 FH: 30 |
| Clinical Notes: | 21 y.o. G1P0 at 33w0d via LMP (Estimated Date of Delivery: 5/27/21) presents for NOB visit. Pregnancy c/b LTC FWB: -FHR reassuring via doppler -FH |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings Z31.69 | Encounter for oth general cnsl and advice on procreation |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | gc |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 34 y.o. female presenting today for well woman exam. Pt not using anything for BC-desires pregnancy but not really trying Son Glen is doing well Periods monthly but 30-40 days Not taking any PNV-encouraged to start |
| Clinical Notes: | Pap -11/5/19 NILM/-HPV -contesting 11/2024 Preconceptual counseling -encouraged PNV |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri O26.893 | Oth pregnancy related conditions, third trimester O34.21 | Maternal care for scar from previous cesarean delivery Z3A.30 | 30 weeks gestation of pregnancy |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | jt |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 25 y.o. G2P0101 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM Some heartburn at night-has not used any meds, needs to sleep propped up Unplanned pregnancy-happy Employed: Jimmy Johns Dae-Shawn supportive FHT: 145 FH: 36 leapolds vtx |
| Clinical Notes: | 25 y.o. G2P0101 at 37w4d via L=9w4d (Estimated Date of Delivery: 4/26/21) presents for ROB visit. Pregnancy c/b prior CD, PTD 32 wks for pre-e, trich+>TOC 11/16 neg, and fetal polydactyly FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/20/20 -harmony LR/ MQS LR -flu 10/20/20 -Tdap 2/5 -Discussed us, 3T discomforts Ultrasound -anatomy 12/15 post placenta, 3VC, polydactyly both Land R hand -extensive US The ultrasound findings suggest polydactyly. This supernumerary digit appears as an echogenic foci lateral to the pinky sugges ve of type A (bone). This is one of the most common limb anomalies (1:3000) and occur as an isolated finding or in associa on with other findings. On Extensive US today, there are no other findings suggestive of congenital malformations. Patent to undergo aneuploidy screening with primary OB though no other findings concerning for T13. If aneuploidy screening is normal, can consider this a normal variant and can undergo post partum neonatal evaluation. -growth US 3/8 Vtx, EFW 33%, AFI 10.8 Prior CD - 32wks for FGR with absent EDF - Op note reviewed in IHIE, routine low transverse CD -- NOT classical - VBAC success calculator 67.5% - Will start discussion of delivery planning RCD vs TOLAC. Reviewed the risk of uterine rupture with TOLAC is 0.5-0.7% with CDx1. Explained the risks of TOLAC are catastrophic and include emergent CD, hysterectomy, and neonatal death. Also emphasized risk of abnormal placentation, including placenta previa, morbidly adherent placenta, and abruption, in subsequent pregnancies with increasing number of CD. This is all in addition to increasing scarring and adhesions that can increase operating time and risk of damage to surrounding tissue. --She would like TOLAC but desires RCD at 39 week on 4/19 if does not go into labor prior to that. Case request and PAT appointment placed. Called scheduler. History of Pre-e w/ SF - G1 also c/b pre-E with SF diagnosed by plt <100k and mild range Bps. Delivery for fetal decelerations in the setting of FGR with absent EDF - BP today normotensive - Baseline labs9/25PC ratio 0.09, Cr 0.69, AST/ALT 10/15, plt 158, Hgb 10.8 - 24hUP 2/5 222 - Cont daily ASA Trich -pos initial labs -pt and partner treated -TOC 11/17 neg Postpartum Plans Breast PpBC: POP |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A60.9 | Anogenital herpesviral infection, unspecified Z3A.30 | 30 weeks gestation of pregnancy |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | kk |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 20 y.o. G1P0000 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM Planned pregnancy Employed: adaptative nursing Jason supportive FH: 29 FHR: 150 |
| Clinical Notes: | 20 y.o. G1P0000 at 30w4d via L=22w4d (Estimated Date of Delivery: 6/14/21) presents for ROB visit. Pregnancy c/b HSV, depression FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 12/4/20 -harmony LR -Tdap complete 3/26/2021 -Discussed PTL Ultrasound -anatomy 2/12 post placenta, 3VC, NL AFI, EFW 60%, NL anatomy but suboptimal -anatomy completion 3/16 AFI 19.3, EFW 58%, vtx, NL growth HSV -very few outbreaks -discussed suppressive treatment at 36wks Depression -referral to Dr Harris -appt in April Postpartum Plans Breast PpBC: Nexplanon |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N76.4 | Abscess of vulva |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JE |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 37 y.o. female presenting today for intermittent itching to the Rt labia that has been intermittent in the past, but then she noticed a cyst like area that became swollen and painful last month around 3/22. The swelling and pain has not decreased, but she still notices a painless hardened area. Location - Rt labia majora Quality - hardened, no hair growth to the area, but denies pain with palpation Severity - non-painful today Duration - 3 weeks Timing - started 3 weeks ago when she was on vacation after she shaved, does not normally shave pubic hair Associated s/s denies drainage, fever, chills |
| Clinical Notes: | Ext genitalia: Hardened area to Rt labia about 2cm by 0.5cm with lack of hair growth to that area, and some darkening of the skin, painless to palpation, no drainage or opening noted, does not appear to have drained, close to bend-may be irritation from shaving and underwear rubbing Labial Abscess -will treat with ATB -RTC if worsens -keflex 500 BID sent |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z30.09 | Encounter for oth general cnsl and advice on contraception |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 28 y.o. female presenting today for discussion of birth control She is currently taking ocp and doing well but would like a mode that she would not have to take a pill everyday She has no BTB or menorrhagia No vaginal discharge |
| Clinical Notes: | Pap -10/3/18 NILM -next pap due 10/2021 Birth control -all modes discussed -would like to proceed with liletta IUD -will place with next period |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri O26.10 | Low weight gain in pregnancy, unspecified trimester O99.810 | Abnormal glucose complicating pregnancy Z3A.30 | 30 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CBL |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM Doing well, no HA, visual disturbances or LOF, some nausea making it hard to eat but no chronic vomiting at this time Planned pregnancy Employed: EZ NP Ryan supportive FHT: 130 FH 29 |
| Clinical Notes: | 33 y.o. G2P1001 at 30w1d via L=14w1d (Estimated Date of Delivery: 6/17/21) presents for ROB visit. Pregnancy c/b prior pre-e w SF, BMI 38 FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/28/20 -harmony LR male -Tdap 3/26/21 -Discussed PTL, preeclamptic s/s, Ultrasound -dating 12/18 CRL cw LMP 14w1d -extensive anatomy US 2/18 post placenta, 3 VC, AFI NL, EFW 46%, NL anatomy -growth US 4/14 PNL WNL 3T labs 3/26 hgb 12, plt 238, 1hr GTT 171>3hr GTT 83,172,107,119 -GBS @ 36 weeks Prior pre-e w SF -normotensive today -baseline labs 10/30/20 PC ratio uncal, Cr 0.53, AST/ALT 13/30 -HELLP labs 2/3 in OBT PC ratio uncal, Cr 0.40, AST/ALT 10/12, LDH 177, UA 3.7 -24 HUP never collected -daily ASA 81 mg BMI 38 -HA1c 4.8 Chronic n/v -doing well will zofran, b6 and unison -total wt gain 1 LB Postpartum Plans Breast PpBC: will discuss |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.28 | 28 weeks gestation of pregnancy Z86.79 | Personal history of other diseases of the circulatory system |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G1P0000 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM Planned pregnancy Employed: WIC Chad supportive FHT: 155 FH: 30 |
| Clinical Notes: | 33 y.o. G1P0000 at 20w6d via LMP (Estimated Date of Delivery: 6/26/21) presents for ROB visit. Pregnancy c/b obesity, fibroid ut FWB: -FHR reassuring via doppler -FH>GA -Flu vac: 12/11/20 -harmony LR -Tdap 3/12/21 -Discussed PTL, US results, Ultrasound - anatomy 2/5 L=19w6d, post placenta, 3VC, AFI NL, EFW 69%, Fibroid post 44x51x140, ant 52x58x26, suboptimal view of heart - fu anatomy 3/29 AFI 16.5, EFW 79%, anatomy complete NL Fibroid Size 48 mm x 35 mm x 29 mm. Mean 37.3 mm. Vol 25.510 cm. BMI 39 -early 1hr GTT 115 Reports Hx of Heart Murmur -no murmur heard today -desires Echo, ordered Postpartum Plans Breast PpBC: POP |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.513 | Supervision of elderly primigravida, third trimester Z34.90 | Encntr for suprvsn of normal pregnancy, unsp, unsp trimester Z3A.39 | 39 weeks gestation of pregnancy |
| Patient Age: | 38 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 38 y.o. G1P0000 presents for ROB visit. Doing well. No complaints of: vaginal bleeding or pain, +FM Planned pregnancy Employed: EZ pharmacist Chris supportive FHT: 140 FH: 37 leapolds vtx |
| Clinical Notes: | 38 y.o. G1P0000 at 39w2d via L=21w2d US (Estimated Date of Delivery: 4/14/21) presents for ROB visit. Pregnancy c/b AMA FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 9/23/20 -Tdap 1/7/21 -s/p covid vaccine Ultrasound -extensive anatomy 12/3 anterior placenta, 3VC, NL AFI, EFW 54%, NL anatomy -growth 2/5 EFW 59%, AFI 14.3 -Pap: 5/3/2017 NILM/-HPV -3T labs hgb 14, plt 175, 1Hr GTT 95 -GBS 3/25 neg AMA -has seen GC -harmony testing LR female -extensive US NL -daily ASA 81 mg -growth US 30 wks - discussed option for IOL at 39wks, patient thinks she would like to go til 40+2 (4/16) but would like to discuss this with her husband prior to scheduling - plan to strip membranes at her next appt and schedule IOL for 4/16 if the patient desires Postpartum BC POP breast |
Case Log/Encounter
| Date: | 04/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings Z12.4 | Encounter for screening for malignant neoplasm of cervix |
| Patient Age: | 55 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TS |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 55 y.o. female presenting today for well woman exam. Doing well, no complaints She became SA with new partner, would like STD screen today No problems with dyspareunia No using HRT-the patch would not stay on and she didn't feel any different Has an IUD-Mirena, would like it removed and another placed for birth control Discussed she does not need birth control with her age, can remove and if another is needed for bleeding it can be replaced, the last IUD had to be placed in the OR 2/2 stenotic cervix and flexion of uterus Mother with hyst in 30's but sister is 3 years younger and has stopped having periods |
| Clinical Notes: | Pap -3/2/18 NILM/-HPV -next cotesting 3/2023 Mmg -NL 7/3/2020>ordered for 7/4/2021 Wet prep -BV>rx sent for cleocin vag STD screening -urine GC/CT/trich -HIV,RPR and Hepc Colonoscopy screening - done in 2016, reports she had some polyps, but otherwise normal, done at St. Francis IUD -removed today -if bleeding will consider reinsertion in OR |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J45.41 | Moderate persistent asthma with (acute) exacerbation |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ad |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G3P2002 at 21w3d (Estimated Date of Delivery: 8/16/21) Presents for chest tightness, shortness of breath, and dry cough, gradually worsening over last 3 weeks. Hx of asthma but has been out of her Dulera inhaler x 3 weeks. She states she has been using her albuterol inhaler several times a day as well as duoneb breathing treatments a few times per day, but only gets relief for a few hours. She denies any abdominal pain, vaginal bleeding, or LOF. Endorses GFM. |
| Clinical Notes: | 29 y.o. G3P2002 at 21w3d via L=17 (Estimated Date of Delivery: 8/16/21) Pregnancy cb asthma and obesity. Asthma -Duoneb given and assessment per RT -sent ER per advice from RT |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N94.9 | Unsp cond assoc w female genital organs and menstrual cycle |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | pzg |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 22 y.o. G2P1001 at 34w4d (Estimated Date of Delivery: 5/16/21) Presents for lower abdominal pain on Rt and Left side, on and off for the past week. This AM, she states she felt a heavy middle lower pelvic pressure that only lasted a few minutes and then went away. Denies any dysuria, increased frequency, or blood in the urine. Denies vaginal bleeding or LOF. Endorses GFM. |
| Clinical Notes: | Leopold's: vtx SVE: c/l/h FHT: Baseline: 130 Accels >15 beats per min, peaks at 155 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: Quiet 22 y.o. G2P1001 at 34w4d via 18w5d US (Estimated Date of Delivery: 5/16/21) Pregnancy uncomplicated RLP -abdominal pain consistent with RLP -Toco quiet -Cvx c/l/h -FHR reactive -discussed return precautions for PTL -back brace for support Disp home |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O28.8 | Other abnormal findings on antenatal screening of mother O47.9 | False labor, unspecified |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | GAO |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 36 y.o. G4P2012 at 34w3d (Estimated Date of Delivery: 5/17/21) Presents from clinic for NR NST for BMI. Denies feeling any contractions or pain. Denies dysuria or hematuria, nausea, vomiting, or diarrhea. Endorses GFM. Denies any vaginal bleeding or LOF. |
| Clinical Notes: | 36 y.o. G4P2012 at 34w3d via L=23w3d (Estimated Date of Delivery: 5/17/21) Pregnancy cb AMA, BMI (41.16), and LTC. NR NST -FHR reactive -cervix 1/75%/h posterior AMA -harmony LR Leopold's: vtx SVE: 1/75%/h posterior FHT: Baseline: 130 Accels >15 beats per min, peaks at 155 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: Irregular |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O60.03 | Preterm labor without delivery, third trimester |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | LRJ |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 20 y.o. G1P0 at 30w2d (Estimated Date of Delivery: 6/15/21) Presents for lower abdominal pain on and off for the last week, but pain more constant and severe since this AM, rated 8/10. Denies any LOF or vaginal bleeding. Denies any dysuria or increased urinary frequency. Denis any n/v/d. She has not been getting any prenatal care thus far, but states her LMP was 9/18/2020. Endorses GFM, but states it causes pelvic pain. |
| Clinical Notes: | Leopold's: vtx SVE: 1/75/-3 posterior FHT: Baseline: 120 Accels >15 beats per min, peaks at 160 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: irrit Preterm contractions -cx 1/75/-3 post @ 1545>recheck 3/75/-3 post>1745 -FHR reactive/toco 2-4 -urine for culture, GC/CT/trich -IV hydrate/morphine No PNC -initial labs done today PpPlans: Breast/Nexplanon Due to language barrier, an interpreter was present during the entire visit with this patient. Disp: admit to labor for PTL |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O47.9 | False labor, unspecified |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G3P2002 at 34w1d (Estimated Date of Delivery: 5/19/21) Presents for intermittent contractions and constant lower back pain and pressure starting today around 5am waking her from sleep. Reports the abdominal pain is coming and going every 5 minutes, rated 7/10. Denies vaginal bleeding, LOF, dysuria, increased frequency, vomiting or diarrhea. Reports some mild nausea all day today. She was seen last at OCC in 12/2020 around 17 weeks gestation. Endorses GFM. |
| Clinical Notes: | SVE: c/l/h anterior FHT: Baseline: 150 Accels >15 beats per min, peaks at 170 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: irregular Pre-term contractions -c/l/h anterior -Toco irregular -urine cx, gc, ct, trich FWB -FHR reactive -Toco irregular LTC -3T labs drawn -GBS collected -message sent to OCC5 pool to schedule ROB appt Disp to home with PTL return precautions and to f/u with clinic visit |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O47.9 | False labor, unspecified |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ab |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 40 y.o. G6P0414 at 35w2d (Estimated Date of Delivery: 5/11/21) Presents for intermittent contractions, increased vaginal discharge, and diarrhea for the last 2 weeks. Denies vaginal bleeding or leakage of fluid, endorses GFM. |
| Clinical Notes: | Leopold's: vtx BSUS SVE: 3/50/-2 @ II Care today>4/50/-2 FHT: Baseline: 120 Accels >15 beats per min, peaks at 150 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: Q 7-9 40 y.o. G6P0414 at 35w2d via 9wk US(Estimated Date of Delivery: 5/11/21) Pregnancy c/b obesity,T2DM, AMA, depression, hx of gHTN, UTI x1. Pre-term contractions -3/50/-2 @ II Care today -recheck @ 1300 4/50/-2 -will admit for 23 hr obs for labor -Toco 4-6 -GBS pending from clinic 4/8/2021 -Vtx per BSUS T2DM -A1c 6.0 on NOB labs - Extensive US on 1/7/21 - ECG normal 10/12 - TSH 0.8 10/12 - Pre-pregnancy regimen: metformin1000mg XR daily. (no longer taking). - s/p diabetes education - Baseline HELLP labs (9/18): Hgb 13.3, plt 217, Cr .63, AST/ALT 10/24, p:c 0.05 -currently on ASA - 24 hr urine collection with 164 mg protein - Current regimen: - NPH: 22 am, 30 pm - Lispro: 10/10/18 (or less depending on intake) - Blood sugars reviewed today. Testing and BG log seem to be inconsistent in timing and BG levels, but tend to be globally eleaveted. Discussed with patient that she would benefit from increasing insulin doses. She again does not want to make any changes to her regimen. She feels like her blood sugars are better controlled than what is reflected in her log. I recommended that she consistently take her current regimen of insulin without decreasing her doses. - continue antenatal testing - HbA1c 6.1 (2/25) FWB -reactive tracing/toco q 4-8 -BSUS vtx Hx of gHTN -hx in chart, but patient denies -BP normotensive today -ASA 81 mg daily Disp: Admit for contractions |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O47.9 | False labor, unspecified |
| Patient Age: | 35 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | jn |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 35 y.o. G4P3003 at 33w1d (Estimated Date of Delivery: 5/26/21) Presents for lower back and lower abdominal pain for 1 week intermittently, every 30 minutes, rated 9/10, lasting approx 1 hour. Denies dysuria or increased frequency. Denies any LOF or vaginal bleeding. Reports acid reflux and vomtiing every time after she eats x 2 weeks, denies diarrhea. Endorses good fetal movement. |
| Clinical Notes: | G4P3003 at 33w1d via L=16 (Estimated Date of Delivery: 5/26/21) Pregnancy cb obesity, T2DM on insulin. Pre-term contractions -urine cx, GC, CT, trich -IV fluids, pain control -2/50/-2 @ 1052 -recheck unchanged @1252 -Admit for PTL to Ante FWB -reactive NST -Toco Q 4-6 T2DM -Admitted 12/12 - 12/13, but patient left on HD2 due to issues with child care issues -discharged on regimen of NPH 35U BID and Lispro 10U with meals. Patient lost her prescriptions and has not taken insulin since her discharge. After being seen in OBT on 12/29 with a random accucheck of 312, she was re-sent prescriptions to St. Margaret's Pharmacy. She was unable to stay due to childcare. -Strongly recommended patient stay to be monitored in house on 12/31, but she declined due to child care -HbA1c 9.6 on 12/12 -HELLP 12/12: Hgb 13.4, Plt 332, Cr 0.31, AST/ALT 8/12, P:C 0.18 ○ 24HUP Pending - jug previously provided ○ TSH 0.821 ○ EKG NSR ○ Plan eye referral - placed 1/11/21 -Long discussion about risks of pregnancy and diabetes, including malformations, worsening maternal health, eye changes, preeclampsia, growth abnormalities, still birth, neonatal hypoglycemia, and cesarean section Obesity in Pregnancy -BMI >30 -Counseled on risks of pregnancy including fetal malformations, growth abnormalities, still birth, cesarean section, preeclampsia, and preterm delivery -S/p extensive US -Delivery timing dependent on glucose control AMA -Will be 35 at time of delivery -MQS low risk -Extensive US 2/17: variable, posterior placenta, 3VC, nml CI, MVP 5.8, EFW 900g (58%), normal anatomy but incomplete-unable to visualize fetal profile. F/u US ordered Hx of CD -Cesarean section in 3rd pregnancy -Done in Florida - states was induced for poorly controlled diabetes, but nothing happened after 4 hours and then had section -Discussed TOLAC vs RCD. Strongly desires RCD -Discussed the risks of each subsequent cesarean section Disp: Admit for 23 hr obs for PTL |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O47.9 | False labor, unspecified |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | km |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 21 y.o. G1P0 at 35w4d (Estimated Date of Delivery: 5/9/21) Presents for lower abdominal pain for the last few days, intermittently, lasting less than 10 minutes, occurring 4 times per day. States the pain got worse today, more severe, and happening more often. States she has been feeling less fetal movement for the past few days, but now in OBT she is feeling normal movement. Reports 1 episode vomiting this AM, nausea now subsiding. Denies dysuria, but reports increased frequency. Denies vaginal bleeding. Reports 1 episode of fluid yesterday and had to change pad and underwear. |
| Clinical Notes: | 21 y.o. G1P0 at 35w4d via L=20w3d US (Estimated Date of Delivery: 5/9/21) Pregnancy c/b +THC, UTIx1, GBS+, PTL (this pregnancy) Pre-term contractions -toco irregular, no ctx after IV hydration and meds -3/100%/-1 @1141 > 3/100%/-1 @ 1430 FWB -FHR reactive Dispo to home with return precautions |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R10.9 | Unspecified abdominal pain |
| Patient Age: | 38 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | JM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 38 y.o.G2P2002 s/p RCD on 3/22 here for follow-up on abdominal pain and concern for possible intra-abdominal abscess. JM was seen in OBT on 3/29 for abdominal pain and a HA. She rated the pain a 10/10 at that time. She had a CT A/P that showed "asymmetry in the right inferior rectus abdominis with developing intramuscular fluid collection with small foci of air concerning for abscess". Patient left before the CT A/P results came back. She was asked to come back to OBT to be evaluated for a possible abscess. JM states that her pain has significantly improved since she was last seen in OBT. She is taking Ibuprofen/Tylenol q 6-8hrs. She denies any fevers or chills at home. Also denies any redness or drainage. No additional concerns at this time. |
| Clinical Notes: | 38 y.o.G2P2002 s/p RCD on 3/22 here for follow-up on abdominal pain and concern for possible intra-abdominal abscess. Abdominal Pain: - CT A/P 3/29:Asymmetry in the right inferior rectus abdominis with developing intramuscular fluid collection with small foci of air concerning for abscess - VSS, afebrile - WBC: 6.3 (3/29) -> 5.9 today - No signs of infection on physical exam - Patient reports improvement in pain - Reviewed imaging with staff physician. Two separate small foci concerning for abscess versus possible fibroids - As patient is afebrile with no signs of infection or leukocytosis, will continue expectant management at this time - Continue Tylenol/Ibuprofen at home - Discussed strict return precautions Dispo: Will discharge to home with return precautions |
collaborative agreement sample cover sheet
210406092535_Sample_Collaborative_Practice_Agreement_Cover_Sheet.pdf (.pdf) 0.15mb
Collaborative practice agreement Sample
210406092506_Sample_Collaborative_Practice_Agreement.pdf (.pdf) 0.17mb Case logs provide a record to show a list of actions taken with a patient, facility of encounter, and date of service.
The entries below are the case logs I've submitted for during my academic career.
The entries below are the case logs I've submitted for during my academic career.
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.522 | Supervision of elderly multigravida, second trimester O99.212 | Obesity complicating pregnancy, second trimester Z3A.27 | 27 weeks gestation of pregnancy |
| Patient Age: | 38 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JH |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 38 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid, contractions and endorses GFM Has been off work since end Jan-wants FMLA papers signed. Discussed no reason to be off at this time-aware that not as much Planned pregnancy Employed: no gets support from friend-not happy in marriage FHT: 150 FH: 29 |
| Clinical Notes: | 38 y.o. G2P1001 at 27w0d via 20w2d US (Estimated Date of Delivery: 6/22/21) presents for ROB visit. Pregnancy c/b Asthma, AMA, obesity (BMI 45) FWB: -FHR reassuring via doppler -FH=GA -Flu vac: declined -harmony LR male -Tdap 3/23 -Discussed birth control, 3T labs today Ultrasound -anatomy 2/4 dating based on US 20w4d, 3VC, AFI nl, MVP 4.5, EFW 56%, Nl anatomy -extensive US growth 4/23 PNL Lab Results Component Value Date ABO O 12/16/2020 RH POS 12/16/2020 LABANTI NEG 12/16/2020 RUBELLAIGGQT Reactive 12/16/2020 -PNL: ○ Hgb 13.3 ○ Plt 255 ○ Hep C neg ○ hep B neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ UDS neg ○ Sickle cell neg -Pap: Lab Results Component Value Date GYNPAPDX Negative for intraepithelial lesion or malignancy 01/16/2020 HPV neg -3T labs 3/23 -GBS @ 36 weeks AMA -harmony LR male -extensive US Obesity -early 1hr GTT 121 -dietician in to talk with pt 2/23 -allergic to ASA -NST 2 x weekly at 32 wks -discussed wt gain Asthma -never hospitalized -rarely using inhaler |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O91.219 | Nonpurulent mastitis associated w pregnancy, unsp trimester Z39.2 | Encounter for routine postpartum follow-up |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | kh |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PO-Postpartum Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. G1P1001 is in for her postpartum visit. Pregnancy was cb asthma, BMI 32 and resolved low lying placenta She delivered on 2/22/21 by SVD Breast feeding, denies mastitis Infant: ○ Female Apgars8,8at 1 and 5 min Weight3460 g denies pp blues Blake supportative No co bowel or bladder problems Bleeding has stopped Intercourse not resumed |
| Clinical Notes: | 31 y.o. female presents for postpartum Contraception -none at this time but will start OCP in the future -discussed POP vs OCP Mastitis -much better on dicloxacillin -will call if reappears PAP NILM 2020 |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O41.00X0 | Oligohydramnios, unsp trimester, not applicable or unsp Z3A.34 | 34 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | JC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G2P0010 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions, endorse good fetal movement. Having some RLP after grocery shopping this week, surprise pregnancy Employed: no Cesar supportive FHT: 150 FH: 35 |
| Clinical Notes: | 33 y.o. G2P0010 at 34w2d via L=22w1d (Estimated Date of Delivery: 5/2/21) presents for ROB visit. Pregnancy c/b scant care-went to Brazil FWB: -FHR reassuring via doppler -FH=GA -Flu vac:2020 -horizon LR -Tdap 2/12 -Discussed discomforts 3T, GBS next visit Ultrasound -anatomy 12/28/20 L=22w1d, anterior placenta, 3VC, EFW 25%, NL AFI, NL anatomy -growth ultrasound 3/11 vtx, MVP 5.5, AFI 8.3, EFW 45%, repeat us 4 wks PNL ○ Hgb 13.8 ○ Plt 283 ○ Hep C neg ○ hep B neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ UDS neg ○ Sickle cell neg -Pap: NILM/HPV- (9/25/2020) -3T labs 2/12/21 1hr GTT 107, hgb 11, plt 261 -GBS @ 36 weeks Poor weight gain -discussed with pt to increase protein -will check US -pt states she is eating appropriately |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G44.029 | Chronic cluster headache, not intractable N93.8 | Other specified abnormal uterine and vaginal bleeding |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | DD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. female presenting today for irreg bleeding Fu visit from 10/2020>seen for amenorrhea Decided to start depo as she has use in the past Had a BTL for birth control Depo worked well until last mth Started bleeding 2 weeks before last depo>and has continued Last depo was 3/8 No vaginal discharge-no reason for STD check |
| Clinical Notes: | DUB -2/2 depo for amenorrhea -will move depo to 10-12 wks -add premarin 0.625 for 14 days Headaches -will add flonase and zyrtec-maybe some sinus/allergies |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.15 | 15 weeks gestation of pregnancy |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AL |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32 y.o. G3P1011 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions Planned pregnancy Employed: EZ interpreter Husband Rodrigo supportive |
| Clinical Notes: | 32 y.o. G3P1011 at 15w2d via LMP (Estimated Date of Delivery: 9/13/21) presents for ROB visit. Pregnancy uncomplicated FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 9/15/20 -MQS today -Tdap @ 28wks -Discussed genetic testing Ultrasound -anatomy 4/26 Postpartum Plans Breast PpBC: will discuss |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z34.90 | Encntr for suprvsn of normal pregnancy, unsp, unsp trimester Z3A.39 | 39 weeks gestation of pregnancy |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | db |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G3P1011 presents for ROB visit. No LOF or vaginal bleeding, endorses GFM Some irreg ctx FHT: 140 FH: 38 leapolds vtx Pregnancy c/b BMI 33.6, PTL 12/28>pos GBS |
| Clinical Notes: | FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 11/10/20 -harmony LR-male -Tdap 1/19/21 -Discussed labor, IOL shceduled for 3/31 @ 10pm, covid testing done 3/30 Ultrasound -anatomy 11/17 L=20w4d, ant placenta, NL AFI, EFW 19%, anatomy suboptimal -fu anatomy 2/12 AFI 8.9, MVP 2.9, EFW 23%, vtx PNL -Blood type:Opos, rubella immune, antibody neg -PNL: ○ Hgb 12.7 ○ Hct 38 ○ Plt 296 ○ hep B neg ○ Hep C neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: 5/21/18 NILM -3T labs 1/5 1hr GTT 98, hgb 12, plt 258 -GBS 12/28 pos Asthma -using albuterol inhaler as needed, states rarely -never been hospitalized or on ventilator for asthma -referral pulmonary -add zytrec, flonase>much better BMI 33 -HA1c 5.1 PTL 12/28 -admitted to Methodist -cx 2-3/25/h -s/p Betamethasone 12/28-29 -infection w/u labs NL -GBS pos -strict PTL precautions to return to OBT -works in warehouse for home depot-off work Postpartum Plans Both PpBC: None |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D06.9 | Carcinoma in situ of cervix, unspecified N92.1 | Excessive and frequent menstruation with irregular cycle |
| Patient Age: | 49 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ss |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 49 y.o. female presenting today for fu abnl pap and irreg bleeding Monthly periods Depo helped to lessen periods, stopped depo 2/2 covid restrictions Pap Hx: - 10/8/08: NILM - 11/16/10: Unsatisfactory - 1/10/11: Unsatisfactory - 5/4/12: NILM - 12/14/15: Unsatisfactory - 12/21/18: NILM/HPV+ - 4/10/20: HSIL/HRHPV+ (neg 16/18/45) colpo 9/9/20 A. Endocervix, curettage: Endocervical mucosa with no histologic abnormality. No evidence of dysplasia. B. Cervix, 12:00, biopsy: Endocervical and squamous mucosa with focal high grade squamous intraepithelial lesion (severe squamous dysplasia/cervical intraepithelial neoplasia 3). C. Cervix, 6:00, biopsy: Squamous mucosa with no histologic abnormality Dr Schiedel in to discuss procedure for biopsy results, pre-op and surgery scheduled, all questions were answered |
| Clinical Notes: | Menorrhagia -depo provera has helped -no longer feels that she needs depo abnl pap -LEEP cone scheduled with Dr Shiedeil |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.513 | Supervision of elderly primigravida, third trimester O13.3 | Gestational htn w/o significant proteinuria, third trimester Z3A.38 | 38 weeks gestation of pregnancy |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 36 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM She did have a headache yesterday and minor contractions but no HA, visual disturbances or epigastric pain today Planned pregnancy Employed: Blackburn WIC Will supportive FHT: 150 FH: 36 leapolds vtx cx 1/l/-2 |
| Clinical Notes: | 36 y.o. G1P0 at 38w6d via L=19w3d US (Estimated Date of Delivery: 3/27/21) presents for ROB visit. Pregnancy c/b AMA, +CT w neg TOC, gHTN FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/12/20 -Tdap 1/5/21 -Discussed IOL Ultrasound -anatomy 10/6 anterior placenta, 3VC, NL AFI, EFW 55%, unable to visualize hands and feet-will scheduled next US extensive -extensive US 2/4 AFI 17.8, MVP 5.8, EFW 46%, NL anatomy PNL -Blood type:Apos, rubella immune, antibody neg -PNL: ○ Hgb 11.8 ○ Hct 35.3 ○ Plt 192 ○ hep B neg ○ Hep C neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: 10/6/20 NILM/-HPV -3T labs 1/5 1hr GTT 94, hgb 11.3, plt 189 -GBS @ 36 weeks Chlamydia -pos on initial labs -TOC 10/6/20 neg AMA primigravid -GC appt 11/6 -extensive US ordered -harmony 10/6/20 LR -AFP discussed/declined -ASA 81mg daily gHTN -elevated BP>4hrs apart -severe range BP today 174/99 with repeat 165/97 -will send to OB for labs and IOL -cx 1/l/-2 -vtx per leapold Postpartum Breast PpBC: unsure |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O24.419 | Gestational diabetes mellitus in pregnancy, unsp control Z39.2 | Encounter for routine postpartum follow-up |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | at |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PO-Postpartum Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 28 y.o. G4P2022 is in for her postpartum visit. Pregnancy was cb COVID + on 2/9, gDM-dc, CT+ this pregnancy. She delivered on 2/22/21 by SVD Breast/bottle feeding, bring baby to breast 3x day, sts low milk supply, educated to increase breastfeeding to increase supply ,denies mastitis Baby boy is doing well Edinburg score 2 ,denies pp blues FOB supportative>now in US No co bowel or bladder problems Bleeding stopped 2 weeks ago Intercourse 3 days |
| Clinical Notes: | Contraception -all modes discussed --desires OCP>POP until done BF -BUM discussed PAP -done today -will NL pap>next pap 3/2024 STD check -FOB now in US -CT during pregnancy GDM -2hr GTT -scheduled nurse visit |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N93.9 | Abnormal uterine and vaginal bleeding, unspecified Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RL |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 25 y.o. female presenting today for fu DUB Initial appt with me 1/17/20 -OCP started, GC/CT, trich NL, TSH NL, HCG neg, CBC and A1C NL -pap was unsat 2/2 bleeding F/U appt 2/14/20 -still irreg bleeding but forgot some pills -TVUS 2/10/20 NL Today pt has been off OCP since last May 2020, periods were regular while on OCP and for 2 mths after then have become irreg again Getting married in 5/2021-does not desire pregnancy in the near future Would like to begin OCP again, last IC in February |
| Clinical Notes: | Menorrhagia -restart OCP -discussed BUM -will start with neg UPT Pap -unsat 1/17/20 2/2 bleeding -repeat today>if NL then pap in 3/2024 |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A30.0 | Indeterminate leprosy P05.10 | Newborn small for gestational age, unspecified weight Z87.59 | Personal history of comp of preg, chldbrth and the puerp |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions , endorses GFM Doing well today Planned pregnancy Employed: EZ physical therapist Husband Collin supportive FHT:140 FH: 28 |
| Clinical Notes: | 29 y.o. G2P1001 at 30w4d via L=21w4d (Estimated Date of Delivery: 6/4/21) presents for ROB visit. Pregnancy c/b hereditary hemochromatosis,prior gHTN, SGA, anxiety FWB: -FHR reassuring via doppler -FH |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.23 | 23 weeks gestation of pregnancy |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | tj |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 19 y.o. G1P0 at 23w6d (Estimated Date of Delivery: 7/23/21) Presents stating that she went into the kitchen today to clean and suddenly felt a gush of fluid and then started having lower middle pelvic pain lasting 5 minutes. She is now having dull intermittent pelvic pain. She denies leaking any more fluid since 12:19pm today. Denies vaginal bleeding, endorses GFM. She has been getting her prenatal care at community health but would like to switch to Eskenazi North Arlington. |
| Clinical Notes: | SSE: no pooling, no valsalve, Nitrazine neg and Fern neg Wet prep neg for mobile trich, pos lactobacilli SVE: c/l/h FHT: Baseline: 140 19 y.o. G1P0 at 23w6d via 9w0d US (Estimated Date of Delivery: 7/23/21) Pregnancy cb THC, obesity, UTI x1, RPL Prenatal labs from CHN: O-positive Rubella immune Hgb 10.7, platelets 405 HIV neg Hep BsAg neg RPR neg Varicella nonimmune-vaccinate postpartum Panorama screen Low Risk, Horizon neg UDS 12/8/20 THC UTIx1 -pos urine cx 1/5/2021, TOC 2/5/21 WNL RPL -ASA 81mg started at 13 weeks THC -denies current use Vaginal discharge -cultures sent for urine, GC, CT, trich -SSE neg for SROM -cvx c/l/h -wet prep neg FHR -reassuring per EFM |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A02.20 | Localized salmonella infection, unspecified M54.5 | Low back pain |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | DMB |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32 y.o. G3P1102 at 20w0d (Estimated Date of Delivery: 8/19/21) Presents for pain in her lower back for 1 week that comes and goes and is worse with bending and sitting down. Also reports lower abdominal pain for 1 day, that comes and goes and is not brought on or worsened by anything. Also reports Rt knee pain and swelling for 3 years, wiith no known injury, but has gotten more swollen and hurting more in the last few days |
| Clinical Notes: | SVE: c/l/h FHT: 140 32 y.o. G3P1102 at 20w0d via L=8w1d (Estimated Date of Delivery: 8/19/21) Pregnancy cb CD, PTD @ 34wk, prior pre-e Prior pre-e/cHTN -stated takes meds when she feels bad-unsure what med -baseline HELLP labs -ordered 24HUP -ASA daily Prior PTD at 34wks -inducted for pre-e Prior CD -fetal intolerance Back pain -flexeril -back brace sent in Abdominal pain -FHR doppler 140 -urine culture, GC, trich sent Rt knee pain -tylenol OTC -apply ice for swelling at home Due to language barrier, an interpreter was present during the entire visit with this patient. |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O36.80X0 | Pregnancy w inconclusive fetal viability, unsp Z3A.35 | 35 weeks gestation of pregnancy |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | AD |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. G5P2113 at 35w1d (Estimated Date of Delivery: 5/5/21) Presents for non-reactive NST in clinic today. She is feeling mild contractions, denies LOF, vaginal bleeding, vaginal discharge, fever, dysuria. Endorses GFM. |
| Clinical Notes: | BSUS: vtx SVE: c/l/h, cerclage intact FHT: Baseline: 130 Accels >15 beats per min, peaks at 170 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: variable decel noted with contraction down to 100 x 1 minute @1230 Toco: Q5-10 31 y.o. G5P2113 at 35w1d via 17 week US (Estimated Date of Delivery: 5/5/21) Pregnancy cb cerclage PTD @ 32 weeks, CD x3, T2DM, UTI x1 Non-reactive NST -23 hour obs for extended monitoring -betamethasone initiated -GBS pending -cultures for urine, gcct, trich -FHR variable with decel with contraction down to 100 x 1 minute @1230 -cervix c/l/h @ 1315 -vtx per BSUS CDx3 T2DM -metformin 1000mg BID -last A1c 11/12/2020 = 6.8 -accu check UTI x1 -culture sent today -tx with macrobid 11/2020 -neg urine culture TOC on 1/7/2021 |
Case Log/Encounter
| Date: | 04/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.15 | 15 weeks gestation of pregnancy |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ZC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 20 y.o. G3P2002 at 15w2d (Estimated Date of Delivery: 9/21/21) Presents for pelvic cramping x 2 weeks constantly 7/10 and sometimes 10/10, bilateral white nipple discharge x 2 weeks, vaginal leaking clear fluid, had big gush of fluid 2 days ago and continues to have small amount of leaking daily. Denies dysuria but has increased urinary frequency in last 3 weeks, feels like she is always peeing on her self. |
| Clinical Notes: | SSE: no pooling, nitrazine negative, ferning negative SVE: c/l/h FHT: 145 20 y.o. G3P2002 at 15w2d via 8w3d US (Estimated Date of Delivery: 9/21/21) Pregnancy cb asthma, HSV, obesity, hx of preE w/SF, anxiety, and depression Vaginal discharge -Nitrazine negative, small amount white thin vaginal discharge noted -GC labs sent -patient refused to provide urine sample for urine culture Nipple discharge -no discharge noted -nipples are normal in appearance, no erythema or cracking Prenatal Care -patient prefers W 38th St -message sent to pool to schedule for OB reg |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O42.90 | Prem ROM, 7th0 betw rupt & onst labr, unsp weeks of gest |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | bg |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 18 y.o. G1P0 at 38w1d (Estimated Date of Delivery: 4/13/21) Presents stating this AM she was having contractions less than a minute apart. She states then she and her partner had intercourse and then she felt a big gush of fluids and then passed some mucous. She states she is not feeling the baby move as much today. She has eaten today at 11 am. She reports currently having constant lower middle abdominal pain. She reports increased urinary frequency but denies dysuria. |
| Clinical Notes: | General: Alert,oriented x 3. Pleasant and cooperative. Answers questions appropriately. No acute distress. Respiratory: Respirations even and unlabored; no distress Heart: well perfused peripherally GI: Abdomen soft and non-tender, no rebound or guarding Extremities: NT, no edema Leopold's: vertex SSE: Nitrazine negative and Fern negative SVE: fingertip/50%/-2 Call to room after going to bathroom with constant leaking-nitrazine pos, clear fluid on towel FHT: Baseline: 130 Accels >15 beats per min, peaks at 170 with duration >15 beats Variability: moderate (6-25 beats per min) Decels: none Toco: every 4 minutes 18 y.o. G1P0 at 38w1d via 5wk US (Estimated Date of Delivery: 4/13/21) Pregnancy cb anemia &COVID this pregnancy SROM -clear fluid @ 1430 -cx ft/50/-2 @ 1245 -BSUS vtx -FHR reactive/toco q 3-5 Covid -11/21/20 positive Anemia -2/10/21 hgb 9.5 PpPlans: Both/unsure * Labor / Induction: - Indication for IOL: SROM - BSUS on admission: vtx presentation - EFW 3200gms - Cervix FT, favorable / unfavorable - Membrane status: SROM @ 1445 - Will start IOL/augment with * - Plan for analgesia: unsure - Recheck cervix in 4 hours or sooner prn Admit for delivery and postpartum care |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A18.13 | Tuberculosis of other urinary organs O21.9 | Vomiting of pregnancy, unspecified |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | bj |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. G5P3023 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods monthly Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx no HTN or GDM G1 2010 FTSVD G2 2014 FTSVD G3 2016 SAB G4 2019 SAB 6 wk G5 2020 FTSVD G6 current STI none Pap all NL meds PNV |
| Clinical Notes: | 31 y.o. G5P3023 at 13wk via LMP (Estimated Date of Delivery: 10/6/21.) presents for OB Reg visit. Pregnancy cb short interval pregnancy Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 26 Headaches -rx tylenol -discussed hydration, sleep, caffeine N/V -rx sent unison, B6, zofran Anatomy US ordered |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.22 | 22 weeks gestation of pregnancy |
| Patient Age: | 24 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | MA |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 24 y.o. G3P2002 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, OBT visit 2/11 for headache LMP / sure Periods monthly Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx FOB nephew>dandy walkers syndrome, no bleeding or clotting d/o OBhx-no HTN or GDM G1 2018 FTSVD G2 2019 FTSVD G3 current STI none Pap all NL meds PNV |
| Clinical Notes: | 24 y.o. G3P2002 at 22w3d via L=15wk US (Estimated Date of Delivery: 7/30/21) presents for OB Reg visit. Pregnancy cb LTC Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 28 -HA1c Dating -2/11/21 TAUS with IUP measuring 15w5d by CRL cw LMP -anatomy US ordered |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O10.919 | Unsp pre-existing htn comp pregnancy, unsp trimester O21.9 | Vomiting of pregnancy, unspecified Z3A.11 | 11 weeks gestation of pregnancy Z68.43 | Body mass index (BMI) 50-59.9 , adult |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | cj |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 27 y.o. G4P3013 at 16w3d via LMP (Estimated Date of Delivery: 9/12/21.) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 28 Anatomy US ordered |
| Clinical Notes: | 22 y.o. G1P0 at 11w2d via LMP (Estimated Date of Delivery: 10/16/21) presents for OB Reg visit. Pregnancy cb class III obesity, asthma, and cHTN. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 58.04 -A1C added today cHTN - Procardia 30xL daily started 2/19 - Baseline HELLP labs 2/19/21 PC ratio 0.061, hgb 12, plt 522, Cr 0.81, ALT/AST 11/16, UA 5.5, LDH 224 - ordered 24HUP - Will need ASA at 12 weeks - taking wrist pressures at home daily, running 137-140/90-98 - mild range BP today -discussed s/s pre-e Asthma -has not had to use rescue inhaler in over 6 months GERD -rx pepsid |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.16 | 16 weeks gestation of pregnancy |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | etp |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 27 y.o. G4P3013 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods monthly Mhx none Shx 2/2020 1,Hysteroscopy - attempt at IUD removal 2. Laparoscopic IUD removal Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx no GDM or HTN G1 2013 FTSVD G2 2015 SAB 8 wk G3 2016 FTSVD G4 2018 FTSVD G5 current STI none Pap all NL meds PNV |
| Clinical Notes: | 27 y.o. G4P3013 at 16w3d via LMP (Estimated Date of Delivery: 9/12/21.) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 28 Anatomy US ordered |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O21.9 | Vomiting of pregnancy, unspecified Z3A.01 | Less than 8 weeks gestation of pregnancy |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | SB |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 21 y.o. G2P0010 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, OBT visit 3/13 for pain, BHCG appropriate rise LMP / sure Periods - regular, monthly PMH: none Surgeries: miscarriage S&C Meds: PNV, Doxylamine/B6 Allergies: NKDA Ob hx: Denies Tobacco, etoh, drug use. G1 SAB 3 months, S&C G2 current Gyn hx: reports pap done 1 mo ago, unsure results, she will try to bring them to be scanned in next appt STI - denies |
| Clinical Notes: | 21 y.o. G2P0010 at 6w6d via LMP (Estimated Date of Delivery: 11/16/21) presents for OB Reg visit. Pregnancy uncomplicated. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 25.73 Nausea -prescription from OBT for doxylamine/B6, she will start taking now |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.33 | 33 weeks gestation of pregnancy |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | or |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G2P0010 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, endorses GFM LMP / sure Periods monthly Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx -G1 2017 eab STI none Pap all NL meds PNV, Fe |
| Clinical Notes: | 26 y.o. G2P0010 at 33w1d via LMP (Estimated Date of Delivery: 5/18/21) presents for OB Reg visit. Pregnancy cb LTC Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Transfer of care -transfer from IU south -will send for records |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.3 | Candidiasis of vulva and vagina O21.9 | Vomiting of pregnancy, unspecified Z3A.08 | 8 weeks gestation of pregnancy Z68.35 | Body mass index (BMI) 35.0-35.9, adult |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | js |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 27 y.o. G8P1061 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Was seen in OBT and had BSUS at 6w5d on 3/16/2021 Has been also having vaginal itching and malodorous discharge, tested pos for yeast in OBT and used suppository and it has not improved. LMP 1/3/21 unsure Periods - irregular, was taking OCPs Mhx - lower esophageal tear, f/u with GI @ I.U. on 3/19/21, no longer vomiting any blood or abd pain Shx - wisdom teeth, 2 surgeries on Rt knee from injury at age 8 and then in 2019 for dislocation Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o Maternal grandmothers x2 breast CA OBhx SAB x5 w/ FTSVD following-pph STI none Pap all NL Meds - Epi-pen PRN, ProAir PRN, Sumatriptan PRN migraines (needing to use it once every 3-4 months) |
| Clinical Notes: | 27 y.o. G8P1061 at 8w4d via 6w5d US (Estimated Date of Delivery: 11/4/21) presents for OB Reg visit. Pregnancy cb RPL Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 35 -A1C Nausea -states unisom, b6, zofran do not help -has reglan and phenergan from previous pregnancy -refill Reglan Vaginal itching -Terazol sent in dating -3/16/21TVUS showing viable SIUP with CRL measuring 6+5wks |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.16 | 16 weeks gestation of pregnancy |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | OS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 19 y.o. G2P0 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Went to OBT in Jan 2021 for cramping, had normal TVUS LMP / unsure Periods - monthly, regular Mhx - denies Shx - denies Social quit smoking 1/2ppd in Jan 2021, denies ETOH/history of THC, not using currently Genetic hx denies, no bleeding or clotting d/o OBhx G1 5/2020 ectopic, tx with methotrexate G2 current STI GC 3 years ago Pap NA Meds - none |
| Clinical Notes: | 19 y.o. G2P0 at 16w6d via 6 wk US (Estimated Date of Delivery: 9/9/21) presents for OB Reg visit. Pregnancy cb rh neg, tob, THC Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 30.4 -A1C Dating -TVUS 1/14/21 CRL 3.24 c/w 6w0d, +FCA |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.01 | Less than 8 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | kt |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G2P1001 at 8w0d via L=7wk (Estimated Date of Delivery: 11/9/21) presents for OB Reg visit. Pregnancy cb prior pregnancy with ICP Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 22 Dating by BSUS 3/27 CRL cw L=7wk Constipation -docusate sodium -change PNV, prescription sent in |
| Clinical Notes: | 23 y.o. G2P1001 at 8w0d via L=7wk (Estimated Date of Delivery: 11/9/21) presents for OB Reg visit. Pregnancy cb prior pregnancy with ICP Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 22 Dating by BSUS 3/27 CRL cw L=7wk Constipation -docusate sodium -change PNV, prescription sent in |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified Z3A.08 | 8 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | AG |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Seen in OBT for pain- RLQ abdominal pain LMP 2/2/2021 sure Periods - regular, monthly, took plan B pill 3 months in a row PMH: Migraines since age 16, not taking any meds, has not had one in over a month PSH: Denies ObHx: G2P1001 G1- FTSVD c/b cholestasis G2- Current GynHx:LMP Feb 2nd, regular menses, denies STIs SH:Alcohol use prior to knowing she was pregnancy. Deniestobacco, or other illicit drug use. Lives with husbandAmbrizeand son (2yo). Feels safe at home FH:Mom - HTN, Asthma , Sister- preeclampsia Meds:None Allergies: NKDA |
| Clinical Notes: | 23 y.o. G2P1001 at 8w0d via L=7wk (Estimated Date of Delivery: 11/9/21) presents for OB Reg visit. Pregnancy cb prior pregnancy with ICP Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 22 Dating by BSUS 3/27 CRL cw L=7wk Constipation -docusate sodium -change PNV, prescription sent in |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders M25.572 | Pain in left ankle |
| Patient Age: | 50 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | dn |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here to follow up on anxiety and depression, started taking Effexor XR 75mg 4 weeks ago. Pt states she is feeling 75% better with tx; states she no longer feels he is living under a black cloud; in counseling every other week; DENIES; suicidal ideation. Also reports she rolled her left ankle 3 days ago and having pain and swelling. |
| Clinical Notes: | MUSCULOSKELETAL Swelling noted to L foot; pain with palpation to L anterior ankle; Full ROM to L ankle with pain; sensation intact, pedal pulse +2 . Plan: Treatment: Depression with anxiety Refill Effexor XR capsule, extended release, 75 mg, 1 cap(s), orally, once a day, 90 days, 90, Refills 1 Acute left ankle pain Start naproxen tablet, 500 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60 Tablet, Refills 0 Imaging:RAD ANKLE 3 VIEW LEFT (A17) |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D50.0 | Iron deficiency anemia secondary to blood loss (chronic) F41.8 | Other specified anxiety disorders N92.0 | Excessive and frequent menstruation with regular cycle |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | il |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here today for f/u on low hgb IDA and starting zoloft 4 weeks ago for anxiety/depression. She states she is unable to tolerate the iron pills as they make her have heartburn and nausea/abdominal pain. Has been taking Zoloft 50mg x 4 weeks, feeling 30% better, but has been a lot more stressed lately due to parents splitting up. DENIES: SI or HI. LMP; 3/28/21; is not sexually active, periods lasting 7 days, very heavy, painful periods, interested in starting birth control for heavy periods and for iron levels. |
| Clinical Notes: | Plan: Treatment: Depression with anxiety Increase Sertraline Hydrochloride tablet, 100 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Lab:COMPLETE BLOOD COUNT (Ordered for 04/27/2021) Lab:IRON (FE) (Ordered for 04/27/2021) Menorrhagia with regular cycle Start Portia tablet, 30 mcg-0.15 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Iron deficiency anemia due to chronic blood loss Start Slow Fe tablet, 47.5mg, 1 tab(s), orally, twice a day, 90 days, 180 Tablet, Refills 1 |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.209 | Nicotine dependence, unsp, w unsp nicotine-induced disorders I10 | Essential (primary) hypertension J44.9 | Chronic obstructive pulmonary disease, unspecified |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | dp |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for f/u for med refills as her normal PCP is out. She denies any complaints. Current 1/2 ppd smoker, not interested in quitting right now. |
| Clinical Notes: | Plan: Treatment: Benign essential HTN Refill HydrALAZINE Hydrochloride tablet, 100 mg, 1 tab(s), orally, 2 times a day, 90 days, 180 Tablet, Refills 1 Refill atenolol tablet, 25 mg, 1 tab(s), orally, bid, 90 days, 180, Refills 1 Refill HydrALAZINE Hydrochloride tablet, 50 mg, 1 tab(s), orally, bid along with 100mg tab for total of 150 mg bid, 90 days, 180, Refills 1 Lab:COMPREHENSIVE METABOLIC PANEL (Ordered for 04/27/2021) Lab:COMPLETE BLOOD COUNT (Ordered for 04/27/2021) Lab:LIPID PROFILE (Ordered for 04/27/2021) Lab:THYROID STIMULATING HORMONE (Ordered for 04/27/2021) Chronic obstructive pulmonary disease, unspecified COPD type Refill Atrovent HFA aerosol, CFC free 17 mcg/inh, 2 puff(s), by metered dose inhaler, 4 times a day, 30 day(s), 1 INHALER, Refills 1, Notes: prn Continue DuoNeb solution, 2.5 mg-0.5 mg/3 mL, 3 ml, by nebulizer, 4 times a day, Notes: prn |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.10 | Acute frontal sinusitis, unspecified J02.9 | Acute pharyngitis, unspecified |
| Patient Age: | 50 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | sp |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Onset 1 week ago of headache, sinus pressure, nasal congestion, sore throat. Smoker 1/2ppd. New dry cough, chest tightness, shortness of breath at rest, worse with exertion and coughing x1 week. States she had a CXR for COPD recently and was told she had some spots and needed a CT scan but she has not heard anything. States she would like to stop smoking and is interested in trying medication or nicotine patch. |
| Clinical Notes: | We are currently working on getting your chest CT pre-certed through your insurance and then will call you with an appt. Plan: Treatment: Acute non-recurrent frontal sinusitis Start Amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Tobacco dependence Start Nicoderm C-Q Clear film, extended release, 14 mg/24 hr, 1 patch, transdermally, once a day, 30 day(s), 30, Refills 0 Sore throat Lab:COVID/FLU/RSV PCR (IN HOUSE) |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D62 | Acute posthemorrhagic anemia R04.0 | Epistaxis |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | sh |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt was seen in MGH ER on 03/18/2021 for a nose bleed and was admitted for mutiple blood transfusions due to Hgb of 6.9. Was seen by ENT Dr.Gillum and had a cauterization. Reports nasal congestion, trouble breathing through nose, having blood tinged drainage from Rt nare. Appt with Dr. Gillum to f/u on 4/7.. |
| Clinical Notes: | Keep f/u with ENT on 4/7 Plan: Treatment: Arterial epistaxis Notes: Use a vaporizor by your bedside at night. FU with Dr Gillum next week as scheduled. Acute blood loss anemia Lab:COMPLETE BLOOD COUNT (Ordered for 04/05/2021) Lab:VITAMIN B12 (Ordered for 04/05/2021) |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F90.9 | Attention-deficit hyperactivity disorder, unspecified type R31.9 | Hematuria, unspecified R63.4 | Abnormal weight loss R82.90 | Unspecified abnormal findings in urine Z30.018 | Encounter for initial prescription of other contraceptives |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | bw |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Decreased appetite, states she has lost 10 lbs in 1 month., intermittent hair loss. Reports used to be on zoloft, adderral, vyvanse, intuniv for problems with ADHD, depression, anxiety, and anger. Reports still struggles with anger daily, anxiety daily, and depression only once a week. Mom states she has failed 8 classes in the last 1-2 years and is struggling in school patient states she struggles in school to pay attention and does not understand some of the content. DENIES: SI, HI. GI/GU LMP; 3/2/21, have been irregular in the past and she tried depo shot which made them worse. She denies any dysmenorrhea. She desires birth control for regulation of periods and for pregnancy protection in the future, not currently sexually active. m |
| Clinical Notes: | Plan: Treatment: Attention deficit hyperactivity disorder (ADHD), unspecified ADHD type Clinical Notes: Release form filled out to obtain records/ADHD testing from Family Services. Weight loss Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Cloudy urine Lab:URINE CULTURE AND SENSITIVITY Lab:URINALYSIS NON AUTOMATED WITHOUT MICROSCOPY Encounter for initial prescription of transdermal patch hormonal contraceptive device Start Xulane film, extended release, 35 mcg-150 mcg/24 hr, 1 patch, applied topically, once a week, 90 days, 9, Refills 0 |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension I48.91 | Unspecified atrial fibrillation R10.31 | Right lower quadrant pain |
| Patient Age: | 43 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | jm |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Rt groin pain after having sex 2 days ago, now having intermittent pain as bad as 6/10, worse with movement or walking, pain better with relaxing. He is not taking anything for this. Hx of A-fib w/ RVR in 2/2021, taking Cardizem and Elaquis, just saw Cardiology in 3/2021. States he was at work last week and was told that he "didn't look well" and he was having head pressure went to the Occ health nurse and was sent home with BP of 155/101 and had taken his Lisinopril; states his at home readings are 144/94 DENIES:, chest pain, palpitations, dyspnea on exertion. |
| Clinical Notes: | Plan: Treatment: Rt inguinal pain Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Notes: apply ice or heat to area for comfort. Essential hypertension Increase lisinopril tablet, 10 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 1 Notes: continue to monitor BP at home |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G89.29 | Other chronic pain M25.511 | Pain in right shoulder |
| Patient Age: | 43 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | js |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Rt shoulder pain x 5 months following an injury in Nov 2020, wrestling with his kids and felt something pop. He has been doing PT x 6 weeks and taking ibuprofen daily, but only minimal improvement. He states he works 6 days per week, 60 hours per week lately which makes the pain much worse. He states when he is able to rest for 2 days, his shoulder feels much better, but currently he is only getting 1 day off per week. Would like to discuss FMLA for up to 1 day per week |
| Clinical Notes: | Plan: Treatment: Pain in right shoulder Imaging:MRI SHOULDER WITHOUT RIGHT (UJ06) Notes: FMLA paperwork to be filled out for one day a week prn shoulder pain. Other chronic pain Imaging:MRI SHOULDER WITHOUT RIGHT (UJ06) Take ibuprofen 800mg TID Have your employer fax the FMLA papers to the office |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications E55.9 | Vitamin D deficiency, unspecified F40.01 | Agoraphobia with panic disorder G43.109 | Migraine with aura, not intractable, w/o status migrainosus I10 | Essential (primary) hypertension K21.9 | Gastro-esophageal reflux disease without esophagitis N95.2 | Postmenopausal atrophic vaginitis |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | rr |
| Type of Decision Making: | High Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for routine visit, chronic dis mgmt, to get med refills, because her normal PCP is out of the office for undefined amount of time, |
| Clinical Notes: | Plan: Treatment: Essential hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, QID Refill losartan tablet, 100 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 1 Refill Metoprolol Tartrate tablet, 25 mg, 1, orally, BID, 90 days, 180, Refills 1 Vitamin D deficiency Refill cyanocobalamin solution, 1000 mcg/mL, as directed, intramuscularly, once a month, 90 days, 3, Refills 1 Refill Vitamin D2 (obsolete) capsule, 50,000 intl units, 1 cap(s), orally, once a week, 90 days, 12, Refills 1 Panic disorder with agoraphobia Refill Sertraline Hydrochloride tablet, 25 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 1 Gastroesophageal reflux disease, esophagitis presence not specified Refill pantoprazole delayed release tablet, 40 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 1 |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.90 | Acute sinusitis, unspecified R05 | Cough |
| Patient Age: | 53 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | en |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o bil earache worse on R, sore throat , congestion, headache x 2 weeks. Has been using nasacort and albuterol inhaler (from previous bronchitis), also taking nyquil/dayquil without much improvement. |
| Clinical Notes: | Plan: Treatment: Acute sinusitis, recurrence not specified, unspecified location Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Cough Lab:COVID/FLU/RSV PCR (IN HOUSE) |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R04.2 | Hemoptysis R06.02 | Shortness of breath R31.9 | Hematuria, unspecified S72.352D | Displ commnt fx shaft of l femr, 7thD S91.312D | Laceration without foreign body, left foot, subs encntr |
| Patient Age: | 27 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | cr |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for hospital f/u where he was seen and had surgery. He was on moped and was struck by a vehicle and had Rt femur fx and went to surgery with 2 rods placed. Also had laceration to Rt foot from the accident and has sutures in place x 6 days now. He is taking tramadol once a day at bedtime and pain is uncontrolled 5/10 all the time and worse with movement or walking (using crutches.) He also reports since surgery he wakes up with a cough in the AM and coughs up bright red blood. He also reports shortness of breath since getting home with exertion, has to stop what he is doing and sit down an catch his breath, lasting x 15 min. UA while in hospital also showed rbcs, wbcs, 2+bacteria Patient denies dysuria or increased freq. |
| Clinical Notes: | Plan: Treatment: Closed displaced comminuted fracture of shaft of left femur with routine healing, subsequent encounter Stop Tramadol oral, 50mg, 1, po, TID Start Lorcet tablet, 325 mg-5 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 Clinical Notes: INSPECT report ran and viewed. Laceration of left foot, subsequent encounter Notes: Stop by office Friday for suture removal . Hematuria, unspecified type Lab:UA REFLEX Shortness of breath Imaging:CAT CHEST WITH (CWC) |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.9 | Anxiety disorder, unspecified G43.011 | Migraine without aura, intractable, with status migrainosus |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | al |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for f/u onn buspar PRN for anxiety and taking imitrex prn for migraines. She used to have migraines once a month, but now having once a week and does not like taking the imitrex due to it making her nauseated. She has only been taking the buspar once a week bc it makes her have hot flahses and feel lightheaded, but she continues to have daily anxiety. |
| Clinical Notes: | Plan: Treatment: Anxiety Start sertraline tablet, 25 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 1 Intractable migraine without aura and with status migrainosus Start Nurtec ODT tablet, disintegrating, 75 mg, 1 tab(s), orally, once, 30 day(s), 9, Refills 0 Sample of Nurtec given with 2 tablets. F/u in 6 weeks to recheck |
Case Log/Encounter
| Date: | 03/30/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E55.9 | Vitamin D deficiency, unspecified F41.9 | Anxiety disorder, unspecified R42 | Dizziness and giddiness |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | at |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for f/u appt and refill on omeprazole and zoloft 25 mg She states her anxiety is 100% better on zoloft and would like to continue. She has been feeling lightheadeness intermittently, 3 times per week, hx of anemia due to fibroids, but had hyst. Hx of low Vit. D, not taking anything, has not been rechecked in 2 years. |
| Clinical Notes: | Refill Zoloft tablet, 25 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 3 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Lab:VITAMIN D, 25 HYDROXY Vitamin D deficiency Continue multivitamin capsule, Multiple Vitamins, 1 cap(s), orally, once a day |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K21.9 | Gastro-esophageal reflux disease without esophagitis |
| Patient Age: | 29 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | cc |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports intermittent upper middle abdominal pain x 1 month, worse during times of stress and with exercise; states hot sauce and spicy foods worsened symptoms and eating late at night. Pain rated 1/10 and sometimes radiates to Rt upper back. Reports he has to clear his throat a lot in the morning and throughout the day. States he drinks hard liquor 6 servings every other day, states he has drank 1/2 fifth of hard liquor daily in the past and got a DUI, so he has cut way down in the past year. |
| Clinical Notes: | Plan: Treatment: Gastroesophageal reflux disease, unspecified whether esophagitis present Start omeprazole delayed release capsule, 20 mg, 1 cap(s), orally, once a day in am, 90 days, 90, Refills 1 Start cimetidine tablet, 200 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60, Refills 0 Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L70.0 | Acne vulgaris N92.1 | Excessive and frequent menstruation with irregular cycle |
| Patient Age: | 13 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | sk |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | LMP: 3/14/2021, irregular, painful cramps, having to miss school due to pain. Vaginal discharge daily, concerned about the amount, needing to use panty liners. Reports the color is sometimes creamy white, and light brown to yellow after periods. Reports acne, around hairline, eyebrows, chin line, forehead, shoulders, and back more prominent during the week before her menses. She is interested in using birth control for acne and for painful periods. |
| Clinical Notes: | Discussed all options of bc with patient, including that OCPs are best for acne. She is not sexually active. Treatment: Menorrhagia with irregular cycle Start ethinyl estradiol-levonorgestrel tablet, 30 mcg-0.15 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 0 Lab:HCG,QUALITATIVE URINE HCG,QUALITATIVE URINE NEG Notes: Pt advised if she develops severe headache, chest pain, shortness of breath, abd pain, or calf pain to stop med and FU ASAP. PVU. Acne vulgaris Start Minocin capsule, 50 mg, 1 cap(s), orally, every 12 hours, 30 day(s), 60 Capsule, Refills 1 Notes: Wash face with soap and water and use OTC Acne wash daily. |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications F41.9 | Anxiety disorder, unspecified G62.9 | Polyneuropathy, unspecified I10 | Essential (primary) hypertension I63.9 | Cerebral infarction, unspecified R09.89 | Oth symptoms and signs involving the circ and resp systems Z72.0 | Tobacco use |
| Patient Age: | 62 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | jm |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient comes in for eval of chronic pain, needing refil on pain meds and high blood pressure (196/99 today). Ex-husband who lives with her is here with her today and helps provide hx, as pt has aphasia from TBI. He states all patient does in lay in bed all day long watching TV and smoking cigarettes. They both agree that she smokes about 4-5 packs per day. Pt c/o occ chest pain, palpitations, dyspnea on exertion, chronic productive cough, wheezing, and shortness of breath; FBGL in am have been running 134-170. Ex-husband states pt ran out of her Norco 10mg 3 weeks ago for her chronic back pain; was going to Summit pain and was discharged b/c she was taking more than she was Rx'd . Chronic numbness in R arm; states Lyrica is not helpful; hx of traumatic brain injury; . |
| Clinical Notes: | Refill clonidine tablet, 0.2 mg, 1 tab(s), orally, 2 times a day prn BP >160, 90 days, 180, Refills 0 Stop lisinopril tablet, 10 mg, 1 tab(s), orally, once a day Start hydrochlorothiazide-lisinopril tablet, 12.5 mg-10 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 0 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Lab:MICROALBUMIN RANDOM MIAB Notes: Decrease salt intake in diet. Monitor BP and bring log to FU. Type II diabetes mellitus Refill Admelog SoloStar pen injection, 100 u/ml, units, DX: E11.9, TID with meals per sliding scale, 90 days, 3, Refills 0, Notes: Per patient- max # units of day is 16 units Refill Accu-Check Aviva Plus Lancets As directed, 1, DX: E11.9, QID, 90 days, 360, Refills 1 Refill Accu-Check Aviva Strips Test Strips, 1, DX: E11.9, QID, 90 days, 360, Refills 1 Refill Pen Needles (Flex Pen), 29G x 0.5, as directed, use as directed with flex pens (E11.9), 100 days, 400, Refills 1 Anxiety disorder, unspecified Refill Cymbalta delayed release capsule, 60 mg, 1 cap(s), orally, Q day, 90 days, 90, Refills 0 Cerebrovascular accident (CVA), unspecified mechanism Refill Atorvastatin Calcium tablet, 20 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 0 Neuropathy Start pregabalin capsule, 150 mg, 1 cap(s), orally, 2 times a day, 90 days, 180 Capsule, Refills 0 Bruit of left carotid artery Imaging:ULT DOPPLER CAROTIDS BILATERAL SMD (CB) |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified F41.8 | Other specified anxiety disorders I10 | Essential (primary) hypertension K21.9 | Gastro-esophageal reflux disease without esophagitis M25.50 | Pain in unspecified joint |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | am |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports fatigue, weight gain of 30 lbs in last year, trouble staying asleep due to pain in the joints. She has been dx with RA but has seen a rheumatologists who reportedly told her she doesn't actually have RA, she is taking methotrexate but it is not helping. Covid in 11/2020, feels like ever since she has not gotten her smell back, having shortness of breath with exertion. Pt states she rolled her L ankle 5 weeks ago; went to the ER and was told there was not fracture; c/o continued pain to the top of her L foot and medial ankle; rates pain 6/10 . Reports she is still having left ankle pain and swelling, as well as a tender swollen spot on top of foot, saw Podiatrist and was told it was a bone spur, but she does not believe this, Hx of tubal. LMP: 3/28/2021, irregular, dysmenorrhea, sometimes very heavy. She states she will make an appt with Ob/Gyn Dr. Swan. |
| Clinical Notes: | Plan: Treatment: Essential hypertension Start hydrochlorothiazide tablet, 12.5 mg, 1 tab(s), orally, once a day in am, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Notes: drink plenty of water, avoid salt in diet, monitor BP. Stop by office in 2 weeks for OP BP check PVU. Depression with anxiety Refill Paxil tablet, 40 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE GERD (gastroesophageal reflux disease) Refill famotidine tablet, 20 mg, 1 tab(s), orally, 2 times a day 30 mins before meals, 90 days, 180, Refills 1 Continue Omeprazole OTC, 20 mg, One tablet daily, Orally, BID 30 mins before meals, 90 days Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Hypothyroidism, unspecified type Refill Levothyroxine Sodium tablet, 25 mcg (0.025 mg), 1 tab(s), orally, once a day, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Arthralgia, unspecified joint Continue folic acid, 400 mcg, 1 tab, by mouth, daily Continue methotrexate tablet, 2.5 mg, 10 tabs, orally, 10 pills once a week every friday Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Referral To:TAREK KTELEH Rheumatology Reason:consult and treat |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D64.9 | Anemia, unspecified I10 | Essential (primary) hypertension R42 | Dizziness and giddiness R74.8 | Abnormal levels of other serum enzymes |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ds |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports hx of anxiety, saw NP at Serenity clinic today. She reports she had a panic attack a few days ago and has not felt well since. She is taking Xanax PRN, taking it anywhere from twice a day to not needing it for several days, started Rexulti daily 2 days ago. She is also doing counseling monthly and today increased visits to once every 2 weeks. Reports chest pressure and tightness and palpitations sometimes daily and sometimes every 3 days. She feels this is related to anxiety. Denies any shortness of breath with exertion. Reports she recently saw Cardiology on 3/23/2021 and was discontinued from her Elaquis and Diltiazem and was cleared to follow up only as needed. Reports has been feeling intermittently lightheaded and "wobbly" when she walks for over a year, but more constant in the last 3 weeks, and much worse in the last 3 days. She states symptoms are worse upon standing and walking sometimes. She reports 3 days ago she felt like she was going to pass out. She has brought all of her labwork from last month and yesterday and has highlighted everything that is out of normal range and would like these explained and addressed. Liver enzymes are elevated and hgb and hct and rbc are low. |
| Clinical Notes: | Plan: Treatment: Lightheadedness Lab:UA REFLEX Elevated liver enzymes Lab:HEPATITIS PANEL A,B,C Imaging:ULT LIVER (LIVE) Anemia, unspecified type Lab:IRON (FE) Lab:FERRITIN Lab:VITAMIN B12 Lab:Hemoccult x3, annually Lab:TOTAL IRON BINDING CAPACITY HTN (hypertension) Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E55.9 | Vitamin D deficiency, unspecified F17.200 | Nicotine dependence, unspecified, uncomplicated I10 | Essential (primary) hypertension I48.91 | Unspecified atrial fibrillation N18.6 | End stage renal disease Z99.2 | Dependence on renal dialysis |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | DW |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for hospital f/u was seen in MGH ED for palpitations and heart racing, was found to have new onset a-fib and was transferred to lutheran for admission with dialysis and heart cath. NSTEMI troponin elevated. Decreased appetite, fatigue since hospitalization, states his weight was down today at dialysis. Dialysis mon, weds, friday, full run complete today, saw Nephrologist today.. Pain to left eye from ongoing Bell's Palsy, saw opthalmologist and was told this must resolve with time. Seeing Cardiology on 3/31/2021, f/u on new onset A-fib, started on Elaquis during hospitalization, heart cath 3/18/2021 with 1 new stent placement. DENIES:, chest pain, palpitations, dyspnea on exertion. |
| Clinical Notes: | Plan: Treatment: Atrial fibrillation, unspecified type Continue aspirin delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue Coreg tablet, 12.5 mg, 1 tab(s), orally, 2 times a day Continue Metoprolol Succinate ER tablet, extended release, 50 mg, 1 tab(s), orally, qpm Continue Eliquis tablet, 2.5 mg, 1 tab(s), orally, 2 times a day Notes: FU with your Cardiologist in 2 days as scheduled. HTN (hypertension) Continue Amlodipine besylate tablet, 5 mg, 2 tab(s), orally, once a day Continue hydralazine tablet, 25 mg, 3 tab(s), orally, 3 times a day Nicotine dependence Start Nicoderm C-Q Clear film, extended release, 21 mg/24 hr, 1 patch, transdermally, once a day, 30 days, 30, Refills 0 Start Nicoderm C-Q Clear film, extended release, 14 mg/24 hr, 1 patch, transdermally, once a day, 30 day(s), 30, Refills 0 Start Nicoderm C-Q Clear film, extended release, 7 mg/24 hr, 1 patch, transdermally, once a day, 30 day(s), 30, Refills 0 Vitamin D deficiency Continue ergocalciferol capsule, 50,000 intl units, 1 cap(s), orally Continue calcium acetate cap, 667 mg, 2 cap, po, tid with meals Lab:VITAMIN D, 25 HYDROXY (Ordered for 05/10/2021) |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D50.9 | Iron deficiency anemia, unspecified R05 | Cough R06.02 | Shortness of breath |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | jw |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Intermittent shortness of breath since Dec 2020. Reports shortness of breath is worse with doing water aerobics, but she is used to doing water aerobics 3x per week for 30 years and has never had these symptoms. Family states she has been fine and no shortness of breath with walking around the mall for exercise and wonders if the pool chlorine is irritating her. She was diagnosed with pneumonia in Jan 2021 and finished antibiotics, continued to have the symptoms, and then had a course of steroids and was given a rescue inhaler. She is currently using the rescue inhaler every time before water aerobics 3x per week and this prevents her from having any symptoms. She denies any productive cough but has a chronic dry cough x several years. She denies any chest tightness or pain with symptoms. |
| Clinical Notes: | Plan: Treatment: Shortness of breath Continue albuterol aerosol, 90 mcg/inh, 2 puff(s), inhaled, every 6 hours Lab:COMPLETE BLOOD COUNT Lab:BASIC METABOLIC PROFILE Lab:IRON (FE) Lab:NT-PRO-B-TYPE NATRIERETIC PEPTIDE (BNP) Imaging:PULMONARY FUNCTION WITH REST AND EXERCISE - OUTSIDE OF MGH ONLY Imaging:RAD CHEST PA & LATERAL (CXR) |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M25.561 | Pain in right knee N18.3 | Chronic kidney disease, stage 3 (moderate) |
| Patient Age: | 82 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rb |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o intermittent dull aching pain in Rt anterior medial knee x 3 weeks, rated 4/10, made worse with pressure under knee such as sitting in the chair with legs hanging off. He states it gets somewhat better if he moves pressure off of posterior knee and moves legs off of the chair. Denies any worsening of pain with walking. Denies any known injury |
| Clinical Notes: | Plan: Treatment: Acute pain of right knee Start acetaminophen tablet, 500 mg, 2 tab(s), orally, every 6 hours Imaging:RAD KNEE 3 VIEW RIGHT (K15) |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M25.512 | Pain in left shoulder Z72.0 | Tobacco use |
| Patient Age: | 47 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TK |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Left shoulder pain, gradual worsening x 2 monhts. No known specific injury. Pain rated 5/10, constant, but worse in the morning, gets better throughout the day after moving around. She states it hurts to sleep or lie on her left side. She tried tylenol a few weeks ago which helped some. |
| Clinical Notes: | Plan: Treatment: Acute pain of left shoulder Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets x 4 days, then 2 tablets x 4 days, then 1 tablet x 4 days then stop, orally, once a day, 12 days, 24 tablets, Refills 0 Imaging:RAD SHOULDER 2 VIEW MIN LEFT (S22) |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia N48.1 | Balanitis |
| Patient Age: | 57 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Middle Eastern |
| Patient ID: | ks |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o white penile discharge, itching to tip of penis, dysuria, all intermittently x 3 months; is sexually active with his wife |
| Clinical Notes: | Treatment: Balanitis Start Betamethasone-Clotrimazole cream, 0.05%-1%, 1 app, applied topically, 2 times a day, 30 day(s), 30 Gram, Refills 0 Lab:WOUND CULTURE |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders G89.29 | Other chronic pain M25.551 | Pain in right hip R25.2 | Cramp and spasm |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | jh |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports never been diagnosed with depression, but has felt down and sad, easily tearful, anxious, a few times per week x 10 years. She has never seen anyone for this. Rt hip pain x 3 months, gradually worsening over time. She states this started after she started working out at the gym 3 months ago, bicycle, treadmill, a few machines. Pain is worse with movement, walking, and sometimes with sleeping on that side. Also reports cramps in bilateral lower legs with shooting pains up into her posterior upper legs. Also reports frequent muscle spasms in legs intermittent x 2 years. |
| Clinical Notes: | Plan: Treatment: Pain in right hip Continue acetaminophen tablet, 500 mg, 2 tab(s), orally, every 6 hours Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:ERYTHROCYTE SEDIMENTATION RATE Lab:THYROID STIMULATING HORMONE Lab:RHEUMATOID FACTOR Lab:ANTI-NUCLEAR ANTIBODY Lab:C-REACTIVE PROTEIN Imaging:RAD HIP 2 VIEWS RIGHT W PELVIS (HP2R) Other chronic pain |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.21 | Type 2 diabetes mellitus with diabetic nephropathy E87.1 | Hypo-osmolality and hyponatremia G45.9 | Transient cerebral ischemic attack, unspecified I10 | Essential (primary) hypertension I50.22 | Chronic systolic (congestive) heart failure N18.4 | Chronic kidney disease, stage 4 (severe) |
| Patient Age: | 71 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ct |
| Type of Decision Making: | High Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Here for transitional care management f/u from hospital admission. He was admitted for Rt sided arm and facial weakness which resolved shortly after getting to the ER. However, he was found to have hyponatremia (123) and was given IV fluids and admitted to acute rehab. Hx of polycystic kidney disease and renal mypoathy, recent GFR of 23. Echo on 3/15/2021 45-50% with mildly reduces LV systolic function. Has appt with Cardiology tomorrow 3/30.2021. DENIES:, chest pain, palpitations, dyspnea on exertion. Reports only checking fasting BG in the AM's, running approx 140. He has not been checking before meals or adjusting Novolog as directed. |
| Clinical Notes: | Plan: Treatment: Transient cerebral ischemia, unspecified type Continue aspirin tablet, chewable, 81 mg, 1 tab(s), chewed, once a day Essential hypertension Continue lisinopril tablet, 20 mg, 1 tab(s), orally, once a day Lab:BASIC METABOLIC PROFILE Chronic kidney disease, stage 4 (severe) Continue hydralazine tablet, 50 mg, 1 tab(s), orally, tid, Notes: MGH 3/21/21 Lab:BASIC METABOLIC PROFILE Notes: FU with Nephrology April 12 @ 130 in the Marion Office. Chronic systolic congestive heart failure Continue Cardizem CD capsule, extended release, 240 mg/24 hours, 1 cap(s), orally, once a day for blood pressure Lab:BASIC METABOLIC PROFILE Notes: FU with your Cardiologist tomorrow as scheduled. Type 2 diabetes mellitus with diabetic nephropathy Continue NovoLog FlexPen solution, 100 units/mL, 4 units, subcutaneously, 3 times a day Continue Levemir FlexPen solution, 100 units/mL, 15 units, subcutaneously, ONCE DAILY AT BEDTIME Lab:BASIC METABOLIC PROFILE Notes: Monitor BGL's before meals for insulin dosage; BGL <160 DO NOT TAKE INSULIN BGL > 250 TAKE 8 UNITS. Hyponatremia Lab:BASIC METABOLIC PROFILE |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified R30.0 | Dysuria |
| Patient Age: | 58 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ee |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | urgency, frequency, dysuria x 1 week; states she took bactrim x 2 days and was told to stop . |
| Clinical Notes: | nitrite pos POC urine dip in clinic Plan: Treatment: Urinary tract infection without hematuria, site unspecified Start Phenazopyridine Hydrochloride tablet, 200 mg, 1 tab(s), orally, 3 times a day (after meals), 3 day(s), 9, Refills 0 Start SMZ-TMP DS tablet, 800 mg-160 mg, as directed, orally, every 12 hours, 8 day(s) Lab:URINE CULTURE AND SENSITIVITY Notes: Cystitis - interstitial material was printed for review. Pt advised if culture normal will refer to Dr Jacobs; PVU Drink 6-8 glasses of water daily. Take antibiotic until gone. Wear panty-liner while taking Pyridium as it will numb you and you may dribble some; urine is bright orange and staining. Take Pyridium with food to avoid GI upset. . Dysuria Lab:URINE CULTURE AND SENSITIVITY Lab:URINALYSIS NON AUTOMATED WITHOUT MICROSCOPY |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | H69.82 | Other specified disorders of Eustachian tube, left ear I10 | Essential (primary) hypertension J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ps |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o L earache x 1 week; occ dizziness; pt states this happens every spring and fall DENIES; , sore throat, congestion, rhinorrhea |
| Clinical Notes: | Plan: Treatment: Seasonal allergic rhinitis, unspecified trigger Start Flonase spray, 50 mcg/inh, 2 spray(s), in each nostril, once a day, 30 day(s), 1 bottle, Refills 5 Start Zyrtec tablet, 10 mg, 1 tab(s), orally, once a day Notes: Allergic rhinitis material was printed. Essential (primary) hypertension Continue lisinopril tablet, 5 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated F32.9 | Major depressive disorder, single episode, unspecified G89.29 | Other chronic pain M79.641 | Pain in right hand |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rb |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o Rt hand pain x 6-8 months, worse with use of the hand, gripping steering wheel, or working with hands. He states 10 years ago he was struck with a metal piece on the end of a fully outstretched bungy cord that came loose and he thinks this could have something to do with it. He takes Norco, lyrica, and aleve for chronic back pain, but it does not help with the hand pain. He reports the pain sometimes shoots up to his Rt arm/shoulder. He went to ortho and had an xray and was told this is arthritis but he is not accepting this dx and states it "has to be somethign with the nerves." Also reports anxiety and depression is somewhat controlled on meds but "could be better." |
| Clinical Notes: | MUSCULOSKELETAL No swelling or deformity noted to R hand; pain with palpation to palm of R hand only; sensation intact . Treatment: Depression, unspecified depression type Continue desvenlafaxine tablet, extended release, 100 mg, 1 tab(s), orally, once a day Start BuPROPion (Eqv-Wellbutrin SR) tablet, extended release, 150 mg/12 hours, 1 tab(s), orally, 2 times a day, 30 day(s), 60, Refills 0 Pain of right hand Imaging:EMG/NCV, RUE JEFFRIES, MA,ERICKA L 03/29/2021 09:35:35 AM EDT > Please pre cert Other chronic pain Continue Norco tablet, 325 mg-10 mg, 1 tab(s), orally, every 6 hours Continue Lyrica capsule, 100 mg, 2 cap(s), orally, 2 times a day Imaging:EMG/NCV, RUE JEFFRIES, MA,ERICKA L 03/29/2021 09:35:35 AM EDT > Please pre cert Tobacco dependence Start Nicoderm C-Q Clear film, extended release, 21 mg/24 hr, 1 patch, transdermally, once a day, 30 day(s), 30, Refills 0 |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O21.9 | Vomiting of pregnancy, unspecified R11.2 | Nausea with vomiting, unspecified Z3A.16 | 16 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions Admitted 1/31-2/1 for hyperemesis Planned pregnancy Employed: MCHD Nicole husband supportive |
| Clinical Notes: | 23 y.o. G1P0 at 16w3d via 7w1d US (Estimated Date of Delivery: 9/7/21) presents for ROB visit. Pregnancy c/b cHTN, hyperemesis FWB: -FHR reassuring via doppler -FH=GA -Flu vac:10/2/20 -harmony LR male -Tdap @ 28wks -Discussed hydration, n/v, upcoming US, OBT for N/V Ultrasound -dating 1/20 via CRL cw 7w1d -anatomy US 4/26 PNlabs WNL -Pap: 1/10/20 NILM @ CH -3T labs @ 28 weeks -GBS @ 36 weeks Chronic HTN: - started procardia 30 XL 2/15 - BP normotensive today - aware abnl BP 140/90>to call with sustained abnl>all normal - No s/sx of preE - baseline HELLP labs 1/31: Hgb 13.0, Plt 300, Cr 0.52, AST/ALT 16/22, UA 3.9, LD 180, P:C 112.4 - 24HUP uncal - daily ASA 81mg persistent Nausea/vomitting -has been seen in OBT many times -using phenergan, zofran, protonix, unison, B6 -scop patch makes her vision blurry-using on weekend but doesn't notice a big difference -today will try reglan instead of phenergan, stool softeners for regular BM -reluctant to go to OBT-was seen once and was told she wasn't dehydrated enough and was not given IV -each time she has received IV hydration and IV zofran she feels 100% better for about 3 days Postpartum Plans Breast PpBC: Liletta |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.36 | 36 weeks gestation of pregnancy |
| Patient Age: | 35 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 35 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid, contractions and endorses GFM Planned pregnancy Employed: EZ pharmacy Husband Alan supportive FHT: 36 FH: 150 |
| Clinical Notes: | 35 y.o. G1P0 at 36w0d via L=10w5d (Estimated Date of Delivery: 4/23/21) presents for ROB visit. Pregnancy c/b AMA, hypothyroid FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/27/20 -harmony LR -Tdap 2/8/21 -Desires to defer COVID vax until postpartum -Discussed GBS, labor Ultrasound -dating CRL cw LMP 10w5d -extensive anatomy 12/8 placenta anterior, 3VC, EFW 62%, NL anatomy-recommend fu growth -Growth US 2/24/21: ant plac, 3vc, MVP 4.2, 36%ile, nl anat and nl growth. No further US rec'd PN labs WNL -Pap:4/2019 -3T labs 2/8 hgb 10.2, plt 269, 1 hr GTT 114 -GBS 3/25 hypothyroid -followed by PCP -TSH 10/12 4.501 T3 12.3> 2/24 0.745 -Synthroid 125 daily w 2 tabs on Sunday - Discussed the typical need to increase dose throughout pregnancy - Goal is <2.5 throughout pregnancy, recheck q 4-6 weeks -growth US NL AMA -GCdiscussed -extensive US -Genetic testing-harmony LR-does not want to know gender -ASA 81mg daily GERD - Rx'd omperazole previously, not taking - Saw GI, no intervention recommended - Will monitor weight gain and symptoms - 116# at 9w pregnant -> up 18# as of today Postpartum Plans Breast PpBC:None |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri Z3A.15 | 15 weeks gestation of pregnancy |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JA |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32 y.o. G7P4024 presents for NOB visit. Seen in OBT 1/8 for spotting Doing well, but complains of fatigue and nausea. No complaints of: vaginal bleeding, loss of fluid. Planned pregnancy Employed: EZ ER Metao supportive |
| Clinical Notes: | 32 y.o. G7P4024 at 15w5d via 6w5d US (Estimated Date of Delivery: 9/12/21) presents for NOB visit. Pregnancy c/b prior pre-e, rh neg, LEEP FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/28/20 -MQS in future -Tdap @ 28wks -Discussed PTL, preeclamptic s/s, diet, wt gain, meds Ultrasound -1/22 dating cw 6w5d CRL PNlabs WNL -3T labs @ 28 weeks -GBS @ 36 weeks Prior pre-e -baseline HELLP labs 3/25 -ASA 81 mg Pap Hx abnormal pap -6/2018 HSIL w +HPV -9/5/18 LEEP cx CIN2, endocx neg -pap at 12 mths 7/2/19 NILM w -HPV -prefers to update pap at PPV RH neg -rhogam in OBT for bleeding 1/8/21 Postpartum Plans Breast PpBC: BTL |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings Z30.432 | Encounter for removal of intrauterine contraceptive device |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | en |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 39 y.o. female presenting today for removal of IUD. She states she would like to do another method of birth control in the future but does not want to discuss today. She understands and is okay with not having any birth control right now. Last Pap: NILM/HPV neg 1/15/2016, due today all paps normal |
| Clinical Notes: | 39 y.o. female Contraception management -IUD removed today -patient does not wish to discuss further birth control options at this time -encouraged safe sex and PNV Pap -pap with cotesting today |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O21.9 | Vomiting of pregnancy, unspecified Z3A.08 | 8 weeks gestation of pregnancy |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 37 y.o. G2P1001 presents for NOB visit. Reports some brown spotting regularly. Denies any pelvic pain. Doing well. No complaints of: {SMOBComplaints:31373} Planned pregnancy Employed: I.U. school of medicine Matt supportive PMhx factor II mutation, is to start baby asa 81mg daily at 12 weeks |
| Clinical Notes: | 37 y.o. G2P1001 at 7w6d via LMP (Estimated Date of Delivery: 11/5/21) presents for NOB visit. Pregnancy c/b AMA, prior CD, factor II deficiency FWB: -FHR reassuring via doppler -FH=GA -Flu vac: *** -MQS in future, interested in Harmony -Tdap @ 28wks -Discussed PTL, preeclamptic s/s, diet, wt gain, meds PN labs all WNL Pap 2019 NILM /hpv- -3T labs @ 28 weeks -GBS @ 36 weeks Prior CD -arrest of descent Factor II deficiency --ASA 81 mg to start at 12 wks Postpartum Plans Breast PpBC: desires BTL |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified N95.1 | Menopausal and female climacteric states Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings |
| Patient Age: | 54 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 54 y.o. female presenting today for well woman exam. Doing well and no complaints Doing well on HRT-would like to continue Sleep issues with waking up about 2am and not able to go back to sleep>taking benadryl that late causes more fatigue in the am than staying up, she tries to read and take ambien only when needed and then only taking 1/2 of 5mg. |
| Clinical Notes: | Annual -encouraged wt bearing exercise, MVI, CA -lipids and CMP today -swimming with masters swimming 4 days a week HRT -would like to continue vivelle dot -working well for skin dryness, insomnia IUD -perimenopausal bleeding -working well Pap -5/10/19 NILM/HPV -cotesting 5/2024 Mammogram -scheduled insomnia -ambien 5mg -using 1/2 tab PRN |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A38.0 | Scarlet fever with otitis media Z34.90 | Encntr for suprvsn of normal pregnancy, unsp, unsp trimester |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ab |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 19 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions, endorses GFM Unplanned pregnancy-but happy Employed: Methodist screening for covid Koyaun supportive |
| Clinical Notes: | 19 y.o. G1P0 at 38w2d via L=10w6d OSH (Estimated Date of Delivery: 4/7/21) presents for ROB visit. Pregnancy c/b transfer of care, +GBSuria, +anti M, +CT 9/4 w -TOC 11/20/20, asthma FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 11/19/20 -Tdap 1/29/21 -Discussed labor, desires IOL, scheduled today 3/31 10pm Ultrasound 9/15/20 US 10w6d-EDC 4/7/21 11/12/20 US 19w1d, anterior placenta, NL anatomy, EFW 62% Pos antibody screen -anti M -unable to titer 10/14 -titer 12/4 8> 1/29 unable to titer 2/2 low antibody -rarely causes fetal anemia will low titer Pos GBSuria -treated neg culture 10/14/20 Pos CT -pos 9/4>toc neg 10/14>neg 11/20 Asthma -never hosp -mostly with exercise -rarely uses inhaler RLP -back brace Postpartum Plans -nexplanon -breast |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.28 | 28 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | CL |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o.G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractionsendorses GFM Doing well, no HA, visual disturbances or LOF |
| Clinical Notes: | 33 y.o. G2P1001 at 28w1d via L=14w1d (Estimated Date of Delivery: 6/17/21) presents for ROB visit. Pregnancy c/b prior pre-e w SF, BMI 38 FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/28/20 -harmony LR male -Tdap @ 28wks -Discussed PTL, preeclamptic s/s, Ultrasound -dating 12/18 CRL cw LMP 14w1d -extensive anatomy US 2/18 post placenta, 3 VC, AFI NL, EFW 46%, NL anatomy -3T labs @ 28 weeks -GBS @ 36 weeks Prior pre-e w SF -baseline labs 10/30/20 PC ratio uncal, Cr 0.53, AST/ALT 13/30 -HELLP labs 2/3 in OBT PC ratio uncal, Cr 0.40, AST/ALT 10/12, LDH 177, UA 3.7 -24 HUP never collected -daily ASA 81 mg BMI 38 -HA1c 4.8 Postpartum Plans Breast PpBC: will discuss |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KC |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 28 y.o. female presenting today for well woman exam. Doing well, but c/o infrequent, random dysuria after sex, but it resolves on its own Pap up to date in 2019, NILM, no hpv testing at that time |
| Clinical Notes: | Pap -NILM, cotesting due in 3/2023 Dysuria with IC -rare and random after IC -patient instructed to call if occurring more consistently or for longer duration -can consider prophylaxis Annual Exam -encouraged exercise -encouraged PNV -pre-conception counseling -OC FHx Breast Ca -start mammograms at age 39 -encourages SBE |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z39.2 | Encounter for routine postpartum follow-up |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PO-Postpartum Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 30 y.o. G1P1001 is in for her postpartum visit. She was admitted 1 week after delivery for pre- w SF-MgSO4 Pregnancy was cb pre-e with SF, +ct s/p neg TOC, depression. She delivered on 2/19/21 by SVD Breast feeding, denies mastitis |
| Clinical Notes: | Doing well, no complaints, denies PP blues or depression Contraception post-placental lyletta, doing well Continue to periodically monitor BP at home, was good todey 129/89 F/u with PCP for any further BP concerns for cHTN |
Case Log/Encounter
| Date: | 03/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.513 | Supervision of elderly primigravida, third trimester Z3A.37 | 37 weeks gestation of pregnancy |
| Patient Age: | 38 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 38 y.o. G1P0000 presents for ROB visit. Doing well. No complaints of: vaginal bleeding or pain, +FM Planned pregnancy Employed: EZ pharmacist Chris supportive FHT: 150 FH: 37 leapolds: vertex |
| Clinical Notes: | 38 y.o. G1P0000 at 37w1d via L=21w2d US (Estimated Date of Delivery: 4/14/21) presents for ROB visit. Pregnancy c/b AMA FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 9/23/20 -Tdap 1/7/21 -Discussed desires covid vaccine pp Ultrasound -extensive anatomy 12/3 anterior placenta, 3VC, NL AFI, EFW 54%, NL anatomy -growth 2/5 EFW 59%, AFI 14.3 AMA -has seen GC -harmony testing LR female -extensive US NL -daily ASA 81 mg -growth US 30 wks Postpartum BC POP breast |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified |
| Patient Age: | 31 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | PH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Just moved here from out of town and is establishing care. Reports the only health problem he has is hypothyroid and takes levothyroxine 50mcg daily but has been out for 5 days. Denies any symptoms or complaints. |
| Clinical Notes: | Plan: Treatment: Acquired hypothyroidism Refill levothyroxine tablet, 50 mcg (0.05 mg), 1 tab(s), orally, once a day, 30 days, 30, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension N39.0 | Urinary tract infection, site not specified N89.8 | Other specified noninflammatory disorders of vagina R39.15 | Urgency of urination Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | LMP: 3/14/2021, Reports vaginal itching x 3 days.Requesting STI testing.Last PAP 2018; hx of abnormal Paps' DENIES: abnormal vaginal discharge. |
| Clinical Notes: | UA dip shows moderate leukocytes Plan: Treatment: Urinary tract infection without hematuria, site unspecified Start Bactrim DS tablet, 800 mg-160 mg, 1 tab(s), orally, every 12 hours, 5 day(s), 10 Tablet, Refills 0 Lab:URINE CULTURE AND SENSITIVITY Exposure to STD Lab:HEPATITIS PANEL A,B,C Lab:GC & CHLAMYDIA DNA PROBE,URINE Lab:VAGINAL YEAST AND BV Lab:HIV COMBO SCREEN (HIV COMBO) Lab:TREPONEMA PALLIDUM ANTIBODY Lab:TRICHOMONAS - PCR (URINE/SWAB) |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J01.00 | Acute maxillary sinusitis, unspecified |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | pd |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Sore throat, congestion, rhinorrhea, headache, sinus pain x 5 days |
| Clinical Notes: | Plan: Treatment: Acute non-recurrent maxillary sinusitis Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Continue Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 30 day(s) Continue Coricidin HBP Cold & Flu tablet, 325 mg-2 mg, 1 tab(s), orally, every 6 hours Hypertension Continue hydrochlorothiazide-lisinopril tablet, 25 mg-20 mg, 1 tab(s), orally, once a day Continue Toprol XL tablet, extended release, 50 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.00 | Acute maxillary sinusitis, unspecified |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MP |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Sinus congestion, sinus pressure, Rt ear pain x 2 months. States this started after starting to work at a pre-school in Jan 2021. Started taking Zyrtec daily. |
| Clinical Notes: | Plan: Treatment: Acute non-recurrent maxillary sinusitis Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start Allergy Relief (fluticasone) spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 30 day(s), 1, Refills 1 |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for annual physical and med refill. denies any complaints. Hx of: ESSENTIAL HTN MIXED HYPERLIPIDEMIA HYPERGLYCEMIA 11/04 mild depression TYPE 2 DM Barrett's,chronic esophagitis with ulcer on EGD, Normal c'scopy 6/16 Dr. Barrido Taking ferrous sulfate 325 mg tablet 1 tab(s) orally once daily. test strips freestyle lite 1 sq as directed qd. Calcium + D 600mg tablet 1 tab(s) orally once a day. Aspir 81 81 mg delayed release tablet 1 TAB orally DAILY. FISH OIL 1000mg TAB 2 caps PO bid. citalopram 20 mg tablet 1 tab(s) orally once a day. MetFORMIN Hydrochloride 1000 mg tablet 1 tab orally 2 times a day. AmLODIPine Besylate-Valsartan 5 mg-160 mg tablet 1 tab(s) orally once a day. Januvia 100 mg tablet 1 tab(s) orally once a day. Rosuvastatin Calcium 10 mg tablet 1 tab(s) orally once a day (at bedtime). omeprazole 40 mg delayed release capsule 1 cap(s) orally once a day. fenofibrate 160 mg tablet 1 tab(s) orally once a day. glimepiride 4 mg tablet as instructed orally bid. |
| Clinical Notes: | Plan Schedule Mammo and DEXA scan Routine labs: Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Refill all meds |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension K02.9 | Dental caries, unspecified K08.8 | Other specified disorders of teeth and supporting structures |
| Patient Age: | 64 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rg |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Sleep disturbance due to pain; Pt c/o L upper toothache x 3 days; states his crown fell apart; c/o toothpain rates pain 11/10; taking Aleve with no relief; scheduled to see Dentist in 2 weeks . |
| Clinical Notes: | Plan: Treatment: Pain, dental Start Penicillin VK tablet, 500 mg, 1 tablets, orally, tid, 10 days, 30, Refills 0 Start traMADol tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 Continue Aleve tablet, sodium 220 mg, 1 tab(s), orally, every 8 hours prn Notes: FU with Dentist as scheduled. Clinical Notes: INSPECT report ran and viewed. HTN (hypertension) Continue lisinopril tablet, 20 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M25.50 | Pain in unspecified joint M79.1 | Myalgia R53.83 | Other fatigue Z82.61 | Family history of arthritis |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | mw |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Generalized body aches, low energy, fatigue x 1 month. Sore throat x 2 days 3 weeks ago, now resolved. Hx mono in 4th grade and has had a chronic intermittent sore throat ever since. Reports chronic post-nasal drip, she used to take flonase and allergy pill but they did not help. Reports Rt wrist pain dull aching for the last month, no known injury, then a few weeks later began having generalized body aches. |
| Clinical Notes: | Plan: Treatment: Arthralgia, unspecified joint Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:ERYTHROCYTE SEDIMENTATION RATE Lab:THYROID STIMULATING HORMONE Lab:C-REACTIVE PROTEIN Lab:RHEUMATOID FACTOR Lab:ANTI-NUCLEAR ANTIBODY |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E78.2 | Mixed hyperlipidemia F31.9 | Bipolar disorder, unspecified H61.21 | Impacted cerumen, right ear I10 | Essential (primary) hypertension J44.9 | Chronic obstructive pulmonary disease, unspecified |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | kk |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Normal appetite, sleeping 5-7 hours per night. Feels like anxiety and depression are under control, just saw PsychNP yesterday for check up and refills. Bilateral lower leg edema for several years. Saw Cardiology Ajaj 3/8/2021. Chronic shortness of breath, improved since quitting smoking 4 days ago. Reports lightheadedness since stopping smoking for the last 3-4 days, worse with standing up from sitting. |
| Clinical Notes: | Plan: Treatment: Essential hypertension Continue Aspirin Low Dose delayed release tablet, 81 mg, 1 tab(s), orally, once a day, Notes: not every day Refill Metoprolol Succinate ER tablet, extended release, 25 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 3, Notes: Dr Sekhar MD Continue Torsemide tablet, 10 mg, 1 tab(s), orally, once a day Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE COPD (chronic obstructive pulmonary disease) Continue Trelegy Ellipta powder, 100 mcg-62.5 mcg-25 mcg/inh, 1 puff(s), inhaled, once a day Continue ProAir HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, every 6 hours Mixed hyperlipidemia Refill Atorvastatin Calcium tablet, 40 mg, 1 tab(s), orally, once a day (at bedtime), 90 days, 90, Refills 3 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Bipolar disorder Continue Lamictal tablet, 200 mg, 1 tab(s), orally, bid Continue lamictal tablet, dispersible, 25 mg, 1 tab(s), orally, 2 times a day Continue Diazepam tablet, 5 mg, 1 tab(s), orally, 3-4 times/week prn Continue Hydroxyzine HCl tablet, 25 mg, 1/2 TO 1 tabs, orally, 3 times a day PRN FOR ANXIETY, Notes: prn Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Procedures: Cerumen Removal Procedure under direct visualization, right ear cerumen impaction removed manually with ear spoon by NP . Post-procedure Pt tolerated procedure well. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ks |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt states anxiety is controlled with tx DENIES; depression, suicidal ideation . Pt c/o LLL edema and aching from foot to knee x several months. Smoker 1ppd. Reflux controlled with tx . Loss of bladder control in the last year, urgency, saw a urologist for this 3 years ago, but now having the problems again. Reports has been having left sided headaches nearly every day for a few months, states the pain goes away on its own after a few minutes to a few hours. Hx of 4 CVA's. |
| Clinical Notes: | Plan: Treatment: Annual physical exam Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:FREE T4 Lab:THYROID STIMULATING HORMONE Lab:FREE T3 Lab:UA REFLEX Hypertension Refill Klor-Con 10 tablet, extended release, 10 mEq, 1 tab(s), orally, 2 times a day, 90 days, 180, Refills 3 Refill bisoprolol-hydrochlorothiazide tablet, 5 mg-6.25 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Refill furosemide tablet, 40 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:FREE T4 Lab:THYROID STIMULATING HORMONE Lab:FREE T3 Imaging:ULT DOPPLER CAROTIDS COMPLETE BIL (CB1) JEFFRIES, MA,ERICKA L 03/16/2021 01:38:55 PM EDT > Please check on pre cert Hyperlipidemia Refill pravastatin tablet, 40 mg, 1 tab(s), orally, once a day (at bedtime), 90 days, 90, Refills 3 Continue FISH OIL capsule, 1000 mg, 1 cap(s), orally, 3 times a day Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:FREE T4 Lab:THYROID STIMULATING HORMONE Lab:FREE T3 Imaging:ULT DOPPLER CAROTIDS COMPLETE BIL (CB1) JEFFRIES, MA,ERICKA L 03/16/2021 01:38:55 PM EDT > Please check on pre cert GERD (gastroesophageal reflux disease) Refill dicyclomine capsule, 10 mg, 1 cap(s), orally, QID regularly for irritable bowel, 90 days, 270, Refills 3 Refill promethazine tablet, 25 mg, 1 tab(s), orally, every 6 hours, 15 day(s), 60, Refills 5 Refill pantoprazole delayed release tablet, 40 mg, 1 tab(s), orally, bid, 90 days, 180 Tablet, Refills 3, Notes: PRN Anxiety Refill duloxetine delayed release capsule, 30 mg, 1 cap(s), orally, once daily, 90 days, 90, Refills 3 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:FREE T4 Lab:THYROID STIMULATING HORMONE Lab:FREE T3 Cerebrovascular accident (CVA), unspecified mechanism Refill clopidogrel tablet, 75 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Imaging:MRI BRAIN INCLUDING STEM W & WO (B3) JEFFRIES, MA,ERICKA L 03/16/2021 01:42:57 PM EDT > Please check on pre cer Imaging:ULT DOPPLER CAROTIDS COMPLETE BIL (CB1) JEFFRIES, MA,ERICKA L 03/16/2021 01:38:55 PM EDT > Please check on pre cert Iron deficiency anemia, unspecified iron deficiency anemia type Refill ferrous sulfate tablet, 325 mg, 1 tab(s), orally, once daily with a meal, 90 days, 90, Refills 3 Nicotine dependence Imaging:ULT DOPPLER CAROTIDS COMPLETE BIL (CB1) JEFFRIES, MA,ERICKA L 03/16/2021 01:38:55 PM EDT > Please check on pre cert Abnormal thyroid stimulating hormone (TSH) level Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:FREE T4 Lab:THYROID STIMULATING HORMONE Lab:FREE T3 Screening for colon cancer Referral To:JEREMY WILSON General Surgery Reason:pt due to repeat colonoscopy Age-related osteoporosis without current pathological fracture Continue Calcium + D tablet, 600 mg-200 units, 1 tab(s), orally, 3 times a day Clinical Notes: Last Reclast infusion 4/14/20; due 4/14/22. Frequent headaches Imaging:MRI BRAIN INCLUDING STEM W & WO (B3) JEFFRIES, MA,ERICKA L 03/16/2021 01:42:57 PM EDT > Please check on pre cer Others Continue multivitamin tablet, Multiple Vitamins, 1 tab(s), orally, once a day Continue Vitamin C tablet, 1000 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | cm |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for follow up on zoloft for depression. She started taking 8 weeks ago, f/u at 4 weeks and was feeling 25% better, but now at 8 week f/u is feeling worse. Reports continues sleep disturbance due to nightmares, sleeping 6 horus per night, fatigued throughout the day. Reports feeling down, depressed, hopeless every day, feels depression is much worse since starting Zoloft. Counseling every other week, but not liking her counselor, unable to switch at this time due it being court ordered family counseling. Reports having suicidal thoughts nearly every day, much worse since starting Zoloft, thinking about cutting herself, feeling she does not matter and might be better off dead, states she does not intend to do this, but it is a frequeny thought that she has. |
| Clinical Notes: | Plan: Treatment: Depression with anxiety Stop Zoloft tablet, 50 mg, 1 tab(s), orally, once a day Start FLUoxetine Hydrochloride capsule, 10 mg, 1 cap(s), orally, once a day, 30 day(s), 30, Refills 1 |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications F32.9 | Major depressive disorder, single episode, unspecified G56.92 | Unspecified mononeuropathy of left upper limb I10 | Essential (primary) hypertension |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | lm |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports her blood glucose was 500 and then 398 at her weekly cancer center appointment 2 weeks ago and last week. She states she is having increased urinary frequency and excessive thirst over last few weeks. Reports she has been treated for diabetets in the past with Metformin in 2018 but her kidney function went down, so they discontinued and her kidneys recovered. Reports her home glucometer is old and does not work. Reports dropped a metal flashlight onto Rt great toe 2 weeks ago and wound is not healing, using bacitracin without improvment. Reports area is painful. Reports she is very distraught over urinary incontinence and has been more depressed over last few weeks. She is currently on Zoloft 100mg and Prozac 10mg but feels they may need adjusted. She lost her husband, sister-in-law, uncle, and mother all in 2020. She lives alone with 4 dogs and 1 cat and has a neighbor that helps her often. |
| Clinical Notes: | Plan: Treatment: Type 2 diabetes mellitus without complication, without long-term current use of insulin Lab:GLYCATED HEMOGLOBIN Essential hypertension Continue lisinopril tablet, 10 mg, 1 tab(s), orally, once a day Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue Metoprolol Succinate ER tablet, extended release, 50 mg, 1 tab(s), orally, qpm Depression, unspecified depression type Stop FLUoxetine Hydrochloride capsule, 10 mg, 1 cap(s), orally, once a day Continue Zoloft tablets, 150mg, 1 1/2tab, orally, once a day Start Wellbutrin XL tablet, extended release, 150 mg/24 hours, 1 tab(s), orally, every 24 hours, 30 day(s), 30, Refills 0 Neuropathy of left hand Continue duloxetine delayed release capsule, 20 mg, 1 cap(s), orally, 2 times a day Start Physical Therapy, evaluate and treat, as directed, 3 times weekly, 4 week(s) |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified R30.0 | Dysuria R31.9 | Hematuria, unspecified |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | sw |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports urgency, frequency, and bilateral flank pain x 4 days . |
| Clinical Notes: | Urine dip in clinic showed leukocytes and trace blood ABDOMEN: no masses palpated, soft, suprapubic tenderness, no organomegaly, bowel sounds are normal, no guarding or rigidity, non-distended. No CVA tenderness Plan: Treatment: Urinary tract infection, site not specified Start SMZ-TMP DS tablet, 800 mg-160 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Lab:URINE CULTURE AND SENSITIVITY Notes: Drink 6-8 glasses of water daily. Take antibiotic until gone. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D69.6 | Thrombocytopenia, unspecified E03.9 | Hypothyroidism, unspecified I10 | Essential (primary) hypertension I50.32 | Chronic diastolic (congestive) heart failure R42 | Dizziness and giddiness R53.1 | Weakness |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | tb |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o blurred vision, dizziness and headaches x 3 months; dizziness is worse with movement of head; rates pain 8/10; states Tylenol is not helping Pt c/o having body tremors, generalized body weakness and trouble walking x 3 months; states he ambulates with a cane; is scared to fall . He was seen by hematology for thrombocytopenia and they wanted to do some further testing or treatements for anemia and thrombocytopenia but patient declined stating that he has too many doctors. |
| Clinical Notes: | Plan: Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Lab:UA REFLEX Imaging:RAD CHEST PA & LATERAL (CXR) Imaging:EKG (12 LEAD) |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.00 | Acute maxillary sinusitis, unspecified J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 67 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | cc |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sinus pain, nasal congestion, headaches, bil ear pain x 1 week. |
| Clinical Notes: | NOSE: nasal turbinates erythematous, bil maxillary sinus tenderness Plan: Treatment: Acute non-recurrent maxillary sinusitis Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Seasonal allergic rhinitis, unspecified trigger Stop zyrtec tablet, 10 mg, 1 tab(s), orally, once a day Continue Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 30 day(s) Start Fexofenadine Hydrochloride tablet, 180 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Cough Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | js |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o continued elevated BP; saw Dr Mackrell last month; is waiting on stress test, echo, and tilt table test; c/o occ chest pain; DENIES; , chest pain, palpitations, dyspnea on exertion currently . BP today 180/102 currently taking: amlodipine 5 mg tablet 1 tab(s) orally once a day. Metoprolol Succinate ER 25 mg tablet, extended release 1 tab(s) orally qpm. lisinopril 40 mg tablet 1 tab(s) orally once a day at hs. furosemide 20 mg tablet 1/2 tab orally once a day. |
| Clinical Notes: | Plan: Treatment: Essential hypertension Increase amlodipine tablet, 10 mg, 1 tab(s), orally, once a day in am, 30 day(s), 30, Refills 0 Increase Metoprolol Succinate ER tablet, extended release, 50 mg, 1 tab(s), orally, qpm, 30 day(s), 30, Refills 0 Continue lisinopril tablet, 40 mg, 1 tab(s), orally, once a day at hs Continue furosemide tablet, 20 mg, 1/2 tab, orally, once a day |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R10.9 | Unspecified abdominal pain Z30.42 | Encounter for surveillance of injectable contraceptive |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | bo |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here to establish care and due for Depo shot. First started Depo on Jan 2020, had to miss a few doses during COVID, got back on track in Dec 2020, due for injection today. States she is happy with Depo, but has gained weight. States she has mild menstrual cramps monthly, but tolerable. Denies any sexual activity. According to record, weight was the same in Dec 2020. She c/o today intermittent abdominal pain a few times per week that normally goes away after a few hours. |
| Clinical Notes: | Plan: Treatment: Abdominal pain, unspecified abdominal location Notes: Keep a food diary to see if specific foods are causing GI upset. PVU. Encounter for surveillance of injectable contraceptive Start Depo Provera suspension, 150 mg, 150 mg, intramuscularly, q 3 months, 90 days, 1, Refills 2 |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R10.84 | Generalized abdominal pain R11.2 | Nausea with vomiting, unspecified R19.7 | Diarrhea, unspecified |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | as |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Mom reports starting 2 months ago child wakes up every few weeks in the morning with nausea and she vomits several times for a few hours then it resolves. Mom states it is worse in the mornings and she vomits at school, but mom as never seen her vomit before. Child states she feels abdominal pain and nausea before she vomits, but pain does not go away after vomiting. Child also reports occasional diarrhea. She was seen here a month ago for same symptoms and was advised to do a food diary but they never recorded anything because they thought she had a UTI, but the urine culture did not grow anything. |
| Clinical Notes: | Plan: Treatment: Generalized abdominal pain Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Lab:UA REFLEX Lab:URINALYSIS NON AUTOMATED WITHOUT MICROSCOPY Lab:CELIAC DISEASE REFLEXIVE PANEL Notes: Keep a food diary. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension S46.811A | Strain of musc/fasc/tend at shldr/up arm, right arm, init |
| Patient Age: | 64 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports Rt arm pain x 4-5 days. Rt Bicep tear last summer from lifting a heavy object, has improved gradually over time. States last wednesday he was lifting heavy pallets and now having constant pain 6/10 from the Rt scapula to the Rt elbow, forearm, wrist, and hand. Taking tylenol with very little improvement. Denies any worsening of pain with use or movement, states pain is constant but sometimes gets better with rest. NEUROLOGIC Rt 5th finger numbness and tingling. |
| Clinical Notes: | Bp also uncontrolled today 172/80, looking back at last 4 visits, it has been in this range, currently taking only propranolol 160mg. Treatment: Strain of right trapezius muscle, initial encounter Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 hold meloxicam tablet, 15 mg, 1 tab(s), orally, once a day Notes: Hold Meloxicam and restart when Prednisone taper is finished. Hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue Propranolol Hydrochloride LA capsule, extended release, 160 mg, 1 cap(s), orally, once a day Start lisinopril tablet, 20 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 0 Notes: Continue to monitor BP and bring log to FU in 2 months. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K57.32 | Dvtrcli of lg int w/o perforation or abscess w/o bleeding |
| Patient Age: | 67 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Hospital ER f/u visit needing work note to be off rest of this week. Dx with sigmoid diverticulitis and taking augmenting without any problems. Still having pain 4/10 and 10/10 at times, denies n/v/d. He states he feels he is improving but needs more days to rest and recover. |
| Clinical Notes: | Plan: Treatment: Diverticulitis of large intestine without perforation or abscess without bleeding Continue amoxicillin-clavulanate tablet, 875 mg-125 mg, orally Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 5 days, 20, Refills 0 Notes: Work slip given. FU with Dr Wilson as scheduled for overdue colonoscopy. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M54.42 | Lumbago with sciatica, left side |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports chronic back pain with recent worsening and was seen in clinic and has been taking prednisone, tramamdol, flexeril with much improvement from 10/10 pain to current 4/10. Better with lying down, worse with movement, walking, bending. NEUROLOGIC Numbness, Tingling in the lower extremities intermittently. Denies loss of sensation. |
| Clinical Notes: | Plan: Treatment: Lumbago with sciatica, left side Continue Flexeril tablet, 10 mg, 1 tab(s), orally, 3 times a day prn back pain Continue celecoxib capsule, 200 mg, 1 cap(s), orally, 2 times a day Refill TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 20 day(s), 80, Refills 0 Clinical Notes: Pt offerred repeat MRI and referral back to Dr Canavati, pt declined at this time stating he will do his stretches and walk. FMLA paperwork to be filled out from March 5th thru April 4thnd to return April 5th |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M25.551 | Pain in right hip N18.3 | Chronic kidney disease, stage 3 (moderate) W19.XXXA | Unspecified fall, initial encounter |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Reports she lost her footing on uneven ground 3 days ago and fell onto her Rt hip. Hx of Rt hip replacement 2014. She reports unable to bear weight on Rt leg without severe pain to Rt pelvic/groin area, and pain increases with any movement or trying to walk. Most recent surgery was revision of Rt hip replacement 3 years ago. Taking tylenol with little improvement |
| Differential Diagnosis: | Pelvic fracture Muscle Strain |
| Clinical Notes: | Rt hip and pelvic Xrays ordered, please go get these done now. Patient has allergy listed (itching) to hydrocodone and tramadol and GFR is 44 so should not take ibuprofen. May increase prednisone (takes 2.5mg daily for skin condition) for some pain control depending on the xray results. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M54.42 | Lumbago with sciatica, left side |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports chronic back pain with recent worsening and was seen in clinic and has been taking prednisone, tramamdol, flexeril with much improvement from 10/10 pain to current 4/10. Better with lying down, worse with movement, walking, bending. Reports numbness, Tingling in the lower extremities intermittently. Denies loss of sensation. |
| Clinical Notes: | Referral back to neurosurg and MRI were offered, but patient wants to continue conservative therapy. Plan: Treatment: Lumbago with sciatica, left side Continue Flexeril tablet, 10 mg, 1 tab(s), orally, 3 times a day prn back pain Continue celecoxib capsule, 200 mg, 1 cap(s), orally, 2 times a day Refill TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 20 day(s), 80, Refills 0 |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated K03.81 | Cracked tooth K08.8 | Other specified disorders of teeth and supporting structures |
| Patient Age: | 36 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | jt |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o dental pain x 1 week; states he has multiple broken teeth; states his face feels swollen . |
| Clinical Notes: | Plan: Treatment: Pain, dental Start Penicillin VK tablet, 500 mg, 1 tablets, orally, tid, 10 days, 30, Refills 0 Start traMADol tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 5 days, 20, Refills 0 Notes: FU with Dentist ASAP. Clinical Notes: INSPECT report ran and viewed. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis J40 | Bronchitis, not specified as acute or chronic |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | kb |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Nasal congestion x 4-5 days. DENIES:, rhinorrhea, sore throat. PULMONARY productive (green) cough, wheezing, and Chest congestion x 4-5 days. Also Reports caught skin on his left wrsit over a month ago in equipment at work and had a blister ever since that is not going away and is painful if touched deeply. Pt refused COVID swab. |
| Clinical Notes: | Treatment: Bronchitis Start ProAir HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, every 6 hours prn coughing/wheezing/shortness of breath, 30 day(s), 1, Refills 0 Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Seasonal allergies Continue Allergy Relief (fluticasone) spray, 50 mcg/inh, 2 spray(s), intranasally, once a day Start zyrtec tablet, 10 mg, 1 tab(s), orally, once a day Essential hypertension Continue lisinopril tablet, 10 mg, 1 tab(s), orally, once a day Continue aspirin delayed release tablet, 81 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] J02.9 | Acute pharyngitis, unspecified |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ct |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o Rt side ear pain, nasal congestion, and sore throat x 1 week ; not taking otc meds; states symptoms staying the same; not worse or better DENIES; headache, sinus pain . PULMONARY SMOKER 1/2 ppd, coughing more than normal x 1 week, productive yellow mucous intermittently. DENIES: shortness of breath. |
| Clinical Notes: | Plan: Treatment: Acute nasopharyngitis Start DayQuil Cold & Flu capsule, 325 mg-10 mg-5 mg, 2 cap(s), orally, every 4 hours Start Nyquil Cold & Flu Nighttime liquid, 650 mg-30 mg-12.5 mg/30 mL, 30 mL, orally, every 6 hours Notes: Rest and push fluids; FU Wednesday if symptoms persist or worsen. PVU. Sore throat Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R05 | Cough R44.3 | Hallucinations, unspecified Z72.0 | Tobacco use Z86.79 | Personal history of other diseases of the circulatory system Z87.828 | Personal history of oth (healed) physical injury and trauma |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | de |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Pt c/o hallucinations and delusions; stayed inpatient from 3/5-3/10 and was started on new medications; states new medication has resolved hallucinations. Left ear pain and fullness since last night. Pt c/o intermittent chest pain and palpitations for years; saw a Cardiolgist at age 17, states she was told she has a murmur and problem with a valve.. Vaped daily, having cough, States she was told she has beginning stages of emphysema via Chest Xray at Wabash hospital. Reports left deltoid pain ever since getting 2 injections at the site in Cornerstone in Jan 2021. She states the muscle always feels worn out, tired, even when at rest and not using it, trouble lifing objects such as gallon of milk. Reports headaches every other day since having MVC in nov 2020. States she was restrained passenger and was T-boned on her side of the car; She states they go away with sleep or ibuprofen. Also reports dizziness like the room is spinning and lightheaded like she might pass out, approx 3 times per week since having the MVC. She states she used to get these feeling approx once per month, but more frequently now. Also reports every day hallucinations since January, worse since car accident, but now improved since starting the Seroquel March 5, 2021. |
| Clinical Notes: | Plan: Treatment: Hallucinations Continue Seroquel tablet, 100 mg, 1 tab(s), orally, 2 times a day, Notes: 1 in am another at 3pm Continue Seroquel tablet, 300 mg, 1 tab(s), orally, once a day, at bedtime Continue mirtazapine tablet, 15 mg, 1 tab(s), orally, once a day (at bedtime) Imaging:MRI BRAIN INCLUDING STEM W & WO (B3) BUSCH,SUMMER A 03/15/2021 11:06:52 AM EDT > precert Notes: FU with Cornerstone as scheduled. PVU. Referral To:ROBERT FLINT Neurology Reason:consult and treat History of head injury Imaging:MRI BRAIN INCLUDING STEM W & WO (B3) BUSCH,SUMMER A 03/15/2021 11:06:52 AM EDT > precert Referral To:ROBERT FLINT Neurology Reason:consult and treat History of cardiac murmur Imaging:ECHO COMPLETE 2D W/COLOR DOPPLER BUSCH,SUMMER A 03/15/2021 11:07:15 AM EDT > precert Coughing Start ProAir HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, every 6 hours prn coughing/wheezing/shortness of breath, 30 day(s), 1, Refills 0 |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | H10.32 | Unspecified acute conjunctivitis, left eye R14.1 | Gas pain |
| Patient Age: | 1 Month |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | phm |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Mom states child has greenish yellow discharge in eyes and wakes with eyes crusted, but not completely shut, going on x 1 month. Mom reports child is gassy, having normal BMs, but grunting and acting like she is going to spit up, worse when lying down, better when they sit her up, using predominantly breast milk and milk-based formula to supplement |
| Clinical Notes: | Plan: Treatment: Acute bacterial conjunctivitis of left eye Start erythromycin topical gel, 2%, 1 app, applied topically, 2 times a day, 5 day(s), 1 Tube, Refills 0 Gas pain Start Mylicon liquid, 40 mg/0.6 mL, 0.6 mL, orally, 4 times a day (after meals and at bedtime), 5 day(s) Notes: Nursing diet discussed with mother. |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B86 | Scabies |
| Patient Age: | 37 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CB |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports itching and rash to bilateral arms and lower back since November. States he has been itching the areas a lot ad has caused many open sores. States he could have been exposed to something works with his hands cleaning equipment, and he also got new sheets in November and did not wash before using. Using OTC poison ivy cream which helped somewhat with the itching but the rash itself has not improved. |
| Differential Diagnosis: | scabies poison ivy contact dermatitis |
| Clinical Notes: | Treatment: Scabies Start Permethrin cream, 5%, 1 app, applied topically, once, 1 days, 60 Gram, Refills 0 Start HydrOXYzine Pamoate capsule, pamoate 25 mg, 1 cap(s), orally, 4 times a day |
Case Log/Encounter
| Date: | 03/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 57 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | EH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Sleep disturbance, reports trouble falling asleep due to racing thoughts, getting less than 4 hours per night, fatigue. He was seen 4 weeks ago for depression/anxiety surrounding deaths in his family, trouble falling asleep due to racing thoughts. Reports he took the Celexa daily x 1 week, then a few times as needed and feels like it has not worked at all. Denies any anxiety throughout the day. Denies: suicidal ideation. |
| Clinical Notes: | Educated patient on SSRI's and needing to take them daily for 4-6 weeks for full effect. He states problems are not really during the day and he only has problems with sleep. Stop Celexa Treatment: Sleep disturbance Start TraZODone Hydrochloride tablet, 50 mg, 1 tab(s), orally, at hs, 30 day(s), 30, Refills 2 |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.40 | Acute pansinusitis, unspecified R11.0 | Nausea |
| Patient Age: | 37 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rw |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Nasal congestion, sinus pain x sore throat 4 weeks, was seen in clinic a few weeks ago for ear pain and started on flonase and Sudafed, but never got any better. Nausea and generalized abdominal pain intermittently x 2 weeks, diarrhea intermittently, chronic s/p colectomy from colon CA in 2000. |
| Clinical Notes: | NOSE: nasal turbinates erythematous and swollen, bil frontal and maxillary sinus tenderness Plan: Treatment: Acute non-recurrent pansinusitis Continue Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day Continue Sudafed 12-Hour tablet, extended release, 120 mg, 1 tab(s), orally, every 12 hours Start Amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Nausea Start ondansetron tablet, disintegrating, 4 mg, 1 tab(s), orally, 3 times a day prn nausea, 5 days, 15, Refills 0 |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension S93.402D | Sprain of unspecified ligament of left ankle, subs encntr |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | am |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt states she rolled her L ankle 2 weeks ago; went to the ER and was told there was not fracture; c/o continued pain to the top of her L foot and medial ankle; rates pain 6/10 |
| Clinical Notes: | MUSCULOSKELETAL No swelling or deformity noted to L foot; Full ROM to L foot with pain; pain with palpation to L dorsal foot and medial ankle; . ER visits reviewed MGH; 2/27/21; L foot/ankle xray; wnl; no fracures or bone spurs noted; reviewed in Meditech and in scanned docs . Plan: Treatment: Sprain of left ankle, unspecified ligament, subsequent encounter Continue Tylenol tablet, 500 mg, 1 - 2 tablets, orally, q 4 - 6 hours prn, Notes: PRN Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets x 4 days, then 2 tablets x 4 days, then 1 tablet x 4 days then stop, orally, once a day, 12 days, 24 tablets, Refills 0 Notes: Rest, ice, elevate and compress L ankle. |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L73.9 | Follicular disorder, unspecified |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | rz |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Red raised itchy rash noticed last night to trunk and inner upper thighs. Denies any exposure to new detergents, lotions, or soaps. |
| Clinical Notes: | SKIN: warm and dry; diffuse, pustules on erythematous base noted to abdomen and bil sides; no rash noted to back or chest . Plan: Treatment: Folliculitis Start Keflex capsule, 500 mg, 1 cap(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Notes: Folliculitis material was printed. |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F12.10 | Cannabis abuse, uncomplicated R35.0 | Frequency of micturition R55 | Syncope and collapse |
| Patient Age: | 20 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | it |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports last night he was sitting on couch, playing on his phone and smoking marijuana suddenly became lightheaded and dizzy and rolled out of the couch onto the floor. He states he was unconscious for a few seconds and then woke up on his own feeling very hot and sweaty. He then got up and walked to the restroom a few minutes later and again became lightheaded and fell forward striking his head on the sink and fell to the floor and was out for a few seconds. today he states he feels better but somewhat "disoriented". He reports smoking marijuana daily and is unsure why he passed out. Also reports increased urinary frequency x 2 months. no known exposure to infection or unprotected sex. |
| Clinical Notes: | Plan: Treatment: Syncope, unspecified syncope type Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Imaging:RAD CHEST PA & LATERAL (CXR) Imaging:EKG (12 LEAD) Urinary frequency Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Lab:UA REFLEX |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.2 | Candidiasis of skin and nail I10 | Essential (primary) hypertension |
| Patient Age: | 58 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | tc |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o painful red areas under bil breasts x 1 week., pain 8/10. She has been using OTC neosporin without improvement. |
| Clinical Notes: | Plan: Treatment: Candidal intertrigo Start nystatin topical powder, 100000 units/g, 1 app, applied topically, 3 times a day, 14 day(s), 1 bottle, Refills 0 Notes: Keep skin as clean and dry as possible. HTN (hypertension) Continue AmLODIPine Besylate tablet, 10 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | H81.03 | Meniere's disease, bilateral I10 | Essential (primary) hypertension N39.0 | Urinary tract infection, site not specified |
| Patient Age: | 69 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | rf |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | pt c/o dizziness with standing or movement of her head, ringing in her bil ears, headachaes, and her teeth chatter when she puts them together x 6 weeks; has audiology appointment next week; states Tylenol is helpful for headaches; states she saw Dr Reddy in the past |
| Clinical Notes: | Plan: Treatment: Urinary tract infection without hematuria, site unspecified Start Macrobid capsule, macrocrystals-monohydrate 100 mg, 1 cap(s), orally, 2 times a day, 10 day(s), 20, Refills 0 Notes: Drink plenty of water and change position slowly. Meniere's disease of both ears Notes: Mnire disease material was printed. Referral To:DEEPKARAN REDDY Otolaryngology Reason: Hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue lisinopril tablet, 5 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension R60.0 | Localized edema |
| Patient Age: | 51 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | jb |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Rt ankle fracture and surgery with hardware 1/2019, intermittent swelling in the Rt ankle since then, but worse and more consistent over last 6 months. She noticed most notable increase in swelling last night, with no new injury. Denies any weakness or pain to the area |
| Differential Diagnosis: | dependent edema Rt ankle sprain |
| Clinical Notes: | Plan: Treatment: Essential hypertension Start hydrochlorothiazide tablet, 25 mg, 1 tab(s), orally, once a day in am, 30 day(s), 30, Refills 0 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Bilateral lower extremity edema Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M54.5 | Low back pain |
| Patient Age: | 76 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | en |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Left lower back pain x 1-2 months, worse with movement and getting up from sitting, denies any known injury. Taking muscle relaxants and naproxen from previous back pain(3 months ago) which has been helpful |
| Differential Diagnosis: | sciatica lumbar strain |
| Clinical Notes: | Plan: Treatment: Acute midline low back pain without sciatica Refill Skelaxin tablet, 800 mg, 1 tab(s), orally, 3 times a day, 10 day(s), 30 Tablet, Refills 0 Refill naproxen tablet, 500 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60 Tablet, Refills 1 Start Physical Therapy, evaluate and treat, as directed, 3 times weekly, 4 week(s) Imaging:RAD LUMBAR SPINE 4 VIEW MIN (LS) Essential (primary) hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications I10 | Essential (primary) hypertension N39.0 | Urinary tract infection, site not specified R29.6 | Repeated falls Z79.899 | Other long term (current) drug therapy |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt states she just left Rehab 3 days ago for opioid abuse. C/o of Generalized weakness, Occ Blurry vision, states memory loss, slurred speech, falling 5 times per day, difficulty holding on to things, tremors, confusion x 3 months; Pt states she just had an MRI of brain/stem and labs done 3 days ago at Rehab and was told it was all fine; Pt's Mother states pt did not act this way until she started Trazadone, denies any loss of consciousness or head injury from falls. She is currently on several sedating medications: suboxone melatonin seroquel trazodone buspar cymbalta vistaril clonidine |
| Clinical Notes: | BP today 99/55, patient appears very drowsy. A1C 3 months ago was 11.7, she is not checking her sugars at home, states while in rehab they were 100-200 daily. Plan: Treatment: Polypharmacy Continue Suboxone film, 8 mg-2 mg, 2 film(s), sublingually, once a day Continue Trazodone, 50 mg, 1 tab, bedtime Stop buspirone tablet, 10 mg, 1 tab(s), orally, 3 times a day Continue duloxetine delayed release capsule, 60 mg, 1 cap(s), orally, bedtime Continue quetiapine tablet, 50 mg, 1 tab(s), orally, in am Continue quetiapine tablet, 100 mg, 1 1/2 TAB, orally, at bedtime Notes: Pt advised that taking Suboxone with Cymbalta, Vistaril, and Buspar can all cause CNS side effects. Pt advised to FU at Cornerstone and discuss treatment changes if applicable. Frequent falls Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Notes: Change positions slowly; drink plenty of water. Lethargy Stop Melatonin capsule, 10 mg, 1 cap(s), orally, once a day (at bedtime) Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Notes: GO TO THE ER IF SYMPTOMS WORSEN. PVU. Essential hypertension Continue aspirin tablet, chewable, 81 mg, 1 tab(s), orally, once a day, Notes: not on d/s summary 3/13/20 Stop clonidine tablet, 0.2 mg, 1 tab(s), orally, 2 times a day Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Hypomagnesemia Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN Type 2 diabetes mellitus without complications Continue Basaglar Insulin pen, 100 u/ml, 20 units, sq, bid Continue Admelog solution, 100 units/mL, as directed, subcutaneously Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:MAGNESIUM LEVEL Lab:THYROID STIMULATING HORMONE Lab:GLYCATED HEMOGLOBIN |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R06.00 | Dyspnea, unspecified R35.0 | Frequency of micturition R63.6 | Underweight |
| Patient Age: | 11 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | jj |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Mom reports he reports trouble breathing and gets tired more easily with his normal activities since Jan 2020. DENIES: cough, wheezing, shortness of breath. Mom reports he has to urinate often, needing to pee quickly again after going, teacher informed mom that he is frequently asking to use the restroom at school. |
| Differential Diagnosis: | Diabetes UTI |
| Clinical Notes: | Urine dip in office WNL Plan: Treatment: Frequent urination Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Lab:UA REFLEX |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J01.10 | Acute frontal sinusitis, unspecified R05 | Cough |
| Patient Age: | 65 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports trouble sleeping, low grade fever 99 at night time, getting hot and sweaty, then having cold chills and sweats. States she had a sinus infection in January and was tx with antibiotics, but she feels like she never recovered from it. She continues to have sinus congestion, nasal drainage, and frontal headaches. She is using flonase every morning and zyrtec and mucinex every night, but still feels like she has a lot of post-nasal drip causing a cough. |
| Clinical Notes: | NOSE: nasal turbinates erythematous and swollen, bil frontal sinus tenderness Plan: Treatment: Subacute frontal sinusitis Start Omnicef capsule, 300 mg, 1 capsule, orally, every 12 hours, 10 days, 20, Refills 0 Notes: Use a vaporizor by bedside to help loosen secretions. ,Sinusitis in adults - aftercare material was printed. Essential (primary) hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue carvedilol tablet, 3.125 mg, 1 tab(s), orally, 2 times a day Cough Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J45.40 | Moderate persistent asthma, uncomplicated |
| Patient Age: | 23 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | tg |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for follow up on URI, needs a return to work slip. He states he is no longer having any URI symptoms, denies headaches, fever, or chills. Still having some nasal congestion and runny nose at times, as well as some shortness of breath intermittently. He has been only using his rescue inhaler for asthma 2 times per week or less, but using his Breo every 2-3 days instead of daily because it costs $100 montly. |
| Clinical Notes: | Plan: Treatment: Moderate persistent asthma, unspecified whether complicated Continue Breo Ellipta powder, 100 mcg-25 mcg/inh, 1 puff(s), inhaled, once a day Continue Albuterol HFA aerosol, CFC free 90 mcg/inh, 2 puff(s), inhaled, 2 times a day/prn Continue Montelukast Sodium tablet, 10 mg, 1 tab(s), orally, once a day Notes: Call insurance to find out what LABA is covered and we will call that one in for you. |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | dl |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 4 week follow up on adding Wellbutrin to effexor and buspar for refractory depression. Reports she is sleeping 6-8 hours per night, feeling much better since discontinuing the Wellbutrin 4 days ago, states it was giving her vivid nightmares. she also recently quit her job at IWU which she feels was the cause of most of her stress, now working only at TJ Maxx. DENIES: suicidal ideation. She is now happy with just the effexor and buspar and would like to continue these at current dose. |
| Clinical Notes: | Plan: Treatment: Depression with anxiety Refill BusPIRone Hydrochloride tablet, 10 mg, 1 tab(s), orally, 2 times a day prn, 90 days, 90, Refills 1 Refill Venlafaxine Hydrochloride ER capsule, extended release, 75 mg, 1 cap(s), orally, once a day, 90 days, 90 Capsule, Refills 3 |
Case Log/Encounter
| Date: | 03/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R10.13 | Epigastric pain R13.10 | Dysphagia, unspecified Z12.11 | Encounter for screening for malignant neoplasm of colon |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rh |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Epigastric pain, burning in throat and chest, nausea, and vomiting, approx once a week since Nov 2020. He states this happens more after he eats. states last episode was last night after eating chicken noodle soup; c/o dysphagia even with fluids; states he will occ not be able to swallow water. He has been taking Ozempic x 4 months; states symptoms began prior to starting Ozempic . |
| Differential Diagnosis: | GERD Peptic ulcer Esophageal stricture |
| Clinical Notes: | Plan: Treatment: Epigastric pain Start cimetidine tablet, 200 mg, 1 tab(s), orally, 2 times a day prn abd pain, 30 day(s), 60, Refills 0 Start omeprazole delayed release capsule, 20 mg, 1 cap(s), orally, once a day in am, 30 day(s), 30, Refills 5 Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. Referral To:DANIEL BARRIDO Gastroenterology Reason:consult and treat Dysphagia, unspecified type Referral To:DANIEL BARRIDO Gastroenterology Reason:consult and treat Screening for malignant neoplasm of colon Referral To:DANIEL BARRIDO Gastroenterology Reason:consult and treat |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications I10 | Essential (primary) hypertension J30.2 | Other seasonal allergic rhinitis J45.41 | Moderate persistent asthma with (acute) exacerbation R05 | Cough |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | te |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Patient states she recently lost her insurance and needs refills on many meds plus to get her asthma and diabetes under control. She is currently using her albuterol multiple times per day, breathing tx every 6 hours, still waking feeling short of breath. She states she went to another doctor's office and was told her a1c was 11.6 and they sent in metformin but she was not able to get it filled, and they were giving her samples of Rybelsus but they dont have them anymore. they were also giving her samples of Symbicort but no longer have them. She c/o nausea and diarrhea sometimes, dyspnea with exertion, exhaustion. She is morbidly obese, BMI 89. She is trying to work on her diet but states she cannot afford many healthy foods and gets too short of breath to exercise. |
| Clinical Notes: | Plan: Treatment: Essential hypertension Refill amlodipine tablet, 10 mg, 1 tab(s), orally, once a day, 30 day(s), 30 Tablet, Refills 1 Refill lisinopril tablet, 40 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 1 Type 2 diabetes mellitus without complication, without long-term current use of insulin Start glyburide-metformin tablet, 5 mg-500 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60, Refills 2 Stop Rybelsus tablet, 3 mg, 1 tab(s), orally, once a day Notes: Purchase a glucometer OTC and monitor FBGL's daily. Moderate persistent asthma with exacerbation Continue Proventil HFA aerosol, CFC free 90 mcg/inh, 2 puff(s), inhaled, 4 times a day Continue DuoNeb solution, 2.5 mg-0.5 mg/3 mL, 3 mL, inhaled, 4 times a day Refill Singulair tablet, 10 mg, 1 tab(s), orally, once a day (in the evening), 30 day(s), 30, Refills 1 Start Breo Ellipta powder, 100 mcg-25 mcg/inh, 1 puff(s), inhaled, once a day, 30 day(s), 2, Refills 0 Seasonal allergies Continue Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day Start Allegra 24 Hour Allergy tablet, 180 mg, 1 tab(s), orally, once a day Cough Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R06.02 | Shortness of breath R53.83 | Other fatigue |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | gh |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Presents for eval of dizziness and shortness of breath x 1.5 weeks. She states she was doing dancing for theatre and had her mask on a few weeks ago and then started getting dizzy and felt short of breath. She states this has happened a few more times since then, starts with shortness of breath, then she becomes dizzy and lightheaded, sometimes at rest, but worse with exertion. Reports heavy menses lasting 6-7 days monthly. |
| Differential Diagnosis: | anemia PE |
| Clinical Notes: | Plan: Treatment: Fatigue, unspecified type Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Shortness of breath Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E78.2 | Mixed hyperlipidemia F41.9 | Anxiety disorder, unspecified G20 | Parkinson's disease I10 | Essential (primary) hypertension M17.12 | Unilateral primary osteoarthritis, left knee |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | mh |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Here for 3 month follow up and med refills. Currently being managed for HTN, HLD, Parkinsons, Osteoarthritis. He has new complaint today of anxiety and trouble falling asleep, waking up many times in the middle of the night. |
| Clinical Notes: | Plan: Treatment: Essential (primary) hypertension Refill Cozaar tablet, 50mg, 1 tab(s), orally, QD, 90 days, 90, Refills 3 Mixed hyperlipidemia Refill Pravachol tablet, 20 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 3 Parkinson's disease Refill Carbidopa-Levodopa tablet, 10 mg-100 mg, 1 tab(s), orally, 2 times a day, 90 days, 180, Refills 3 Primary osteoarthritis of left knee Refill meloxicam tablet, 7.5 mg, 1 tab(s), orally, twice a day, 90 days, 180 Tablet, Refills 1 Anxiety Start Celexa tablet, 20 mg, 1 tab(s), orally, once a day at hs, 30 days |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R05 | Cough R06.02 | Shortness of breath |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ar |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sneezing, coughing, congestion and runny nose, headache, body aches x 3 days. States she has been having bilateral leg aching ever since having COVID in 11/2020, but last night was having full body aches. Denies sore throat. Reports chest pain and shortness of breath worse with exertion over last 2 days. mild dry cough, shortness of breath |
| Differential Diagnosis: | influenza allergic rhinitis pneumonia |
| Clinical Notes: | Rapid Influenza and COVID tests negative Ordered CXR Viral syndrome instructions given for rest, fluids, anti-pyretics and pain control. |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension R09.81 | Nasal congestion R21 | Rash and other nonspecific skin eruption |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | dw |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | HEENT Reports left ear ringing since yesterday. DENIES: pain or pressure in the ear, blurred vision, rhinorrhea, otorrhea, sore throat, congestion. SKIN Reports open sores to forehead and chin x 1 week. She states the areas start as a swollen red spot, then become ulcerated and open, but she denies squeezing or scratching the areas. She is using OTC antibiotic ointment but this does not help. She reports 2/10 pain to the forehead wound. Denies any hx of drainage from these areas. |
| Clinical Notes: | SKIN: warm and dry; small circular lesion involving the epidermis with erythematous surrounding skin noted to R side of forehead and L side of chin . EARS: tympanic membranes normal Plan: Treatment: Nasal congestion Start Flonase spray, 50 mcg/inh, 2 spray(s), in each nostril, once a day, 30 day(s), 1, Refills 1 Rash of face Start mupirocin topical ointment, 2%, 1 app, applied topically, 3 times a day, 5 day(s), 15 Gram, Refills 0 Notes: FU if symptoms persist or worsen. HTN (hypertension) Continue Zestoretic tablet, 25 mg-20 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M06.9 | Rheumatoid arthritis, unspecified M25.561 | Pain in right knee R53.1 | Weakness |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | cf |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o chronic bil hip pain from RA; has gotten injections in bil hips; c/o R knee pain x 2 weeks; Pain is worse with standing and bearing weight and bending, better with rest and straightening leg; states Norco is helpful . |
| Differential Diagnosis: | rheumatoid arthritis |
| Clinical Notes: | MUSCULOSKELETAL No swelling or deformity noted to R knee; Limited ROM of R knee due to pain; Negative Anterior/posterior drawer sign . Plan: Treatment: Acute pain of right knee Imaging:RAD KNEE 3 VIEW RIGHT (K15) Essential hypertension Continue hydrochlorothiazide-lisinopril tablet, 12.5 mg-20 mg, 1 tab(s), orally, once a day Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Generalized weakness Start Walker, Standard regular size, as directed, as directed, as directed, lifetime, 1, Refills 0 Rheumatoid arthritis involving multiple sites, unspecified whether rheumatoid factor present Continue Norco tablet, 325 mg-5 mg, 1 tab(s), orally, every 6 hours Continue Voltaren gel, 1%, 1 application, topically, once a day Continue amitriptyline tablet, 10 mg, 1 tab(s), orally, once a day (at bedtime) Continue hydroxychloroquine tablet, 200 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L03.115 | Cellulitis of right lower limb R60.0 | Localized edema |
| Patient Age: | 90 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | jd |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Redness and swelling to BLE with open wound to lateral aspect of left ankle. He just finished a 10 day course of Keflex last week with little improvement. Denies pain. |
| Differential Diagnosis: | cellulitis dependent rubor |
| Clinical Notes: | EXTREMITIES: no clubbing, +4 pitting edema noted to BLL, no cyanosis. SKIN: warm and dry; erythema and warmth noted to L medial lower leg . Plan: Treatment: Cellulitis of right lower extremity Start Clindamycin Hydrochloride capsule, 300 mg, 1 cap(s), orally, every 6 hours, 10 day(s), 40, Refills 0 Essential hypertension Continue aspirin delayed release tablet, 81 mg, 2 tab(s), orally, once a day hold hydrochlorothiazide tablet, 25 mg, 1 tab(s), orally, once a day in the am in addition to the lisinopril/hctz already taking Continue AmLODIPine Besylate tablet, 2.5 mg, 1 tab(s), orally, once a day in the evening Continue hydrochlorothiazide-lisinopril tablet, 25 mg-20 mg, 1 tab(s), orally, once a day in the AM Bilateral lower extremity edema Start furosemide tablet, 20 mg, 1 tab(s), orally, once a day, 10 day(s), 10 Tablet, Refills 0 |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension Z98.89 | Other specified postprocedural states |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | rs |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for f/u Incision to left lower abdomen from abscess I&D 2 days ago, no drainage present today DENIES; pain, redness around area . |
| Clinical Notes: | SKIN: incision site to L suprapubic area healing well; surrounding skin wnl; no drainage noted . Plan: Treatment: Status post incision and drainage Continue Bactrim DS tablet, 800 mg-160 mg, 1 tab(s), orally, every 12 hours Continue Keflex capsule, 500 mg, 1 cap(s), orally, every 12 hours |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Report she has been taking Zoloft 100mg daily and was doing better, but since early february, she is gradually getting worse again. She states she has no motivation to work, wanting to sleep more, not wanting to do her work. She states she recently lost her biggest client at work which has caused more stress. She is the primary breadwinner for her household and has not had as much work lately, which has added stress. She is finding she needs to take the klonopin at least twice per day or she feels very anxious and shaky. She is still seeing a counselor via Zoom but had to skip last month due to finances. She is scheduled to see them again on 3/22. GI/GU Hx of ablation last month, but fears it did not work because she had another period since then, f/u with Dr. Swan yesterday 3/9/2021. |
| Clinical Notes: | Treatment: Depression with anxiety Stop Zoloft tablet, 100 mg, 1 tab(s), orally, once a day Start Venlafaxine Hydrochloride ER capsule, extended release, 75 mg, 1 cap(s), orally, once a day, 30 day(s), 30, Refills 0 Continue Klonopin tablet, 0.5 mg, 1 tab(s), orally, 3 times a day prn |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K05.30 | Chronic periodontitis, unspecified R51 | Headache |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TW |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports Rt lower dental pain and was seen at dentist on 3/2 and was advised to have #29, 31, and 32 removed, scheduled for surgery on 3/19. She is concerned that her teeth hurt more in last 3-4 days and she is getting daily headaches. She has used tylenol 1000mg every 6 hours, daily, which brings pain from 8/10 to a 2/10, but over last few days pain is not being relieved as well. |
| Differential Diagnosis: | Dental infection |
| Clinical Notes: | Teeth do not look abscessed or infection, nothing broken noted, during the exam. Patient is anxious that she could get a dental infection in the days leading up to the extraction. While here in the clinic, patient was able to call her oral surgeon's office and they can get her in a few days sooner. Treatment: Acute nonintractable headache, unspecified headache type Start acetaminophen tablet, 500 mg, 2 tab(s), orally, every 6 hours Periodontitis Notes: Have teeth extracted next week as scheduled. |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J01.40 | Acute pansinusitis, unspecified |
| Patient Age: | 72 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ML |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o sore throat, ear fullness, congestion, headache, and sinus pain x 2 weeks . |
| Differential Diagnosis: | COVID Sinusitis Allergies |
| Clinical Notes: | HEENT: HEAD: normocephalic EYES: PERRL, EOMI eyes normal clear conjuctiva, nonicteric sclera NOSE: nose clear, bil frontal and maxillary sinus tenderness EARS: tympanic membranes normal THROAT: pharynx and tonsils normal. ORAL CAVITY: clear, no lesions, moist mucous membranes. Plan: Treatment: Acute non-recurrent pansinusitis Start doxycycline tablet, monohydrate 100 mg, 1 tab(s), orally, 2 times a day, 10 day(s), 20, Refills 0 Continue loratadine tablet, 10 mg, 1 tab(s), orally, once a day Continue Flonase spray, 50 mcg/inh, 1 spray(s), intranasally, BID Continue Mucinex tablet, extended release, 600 mg, 1 tab(s), orally, every 12 hours prn ptc Hypertension Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue losartan tablet, 50 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K21.0 | Gastro-esophageal reflux disease with esophagitis |
| Patient Age: | 33 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports he had a lot of junk food, chilli, salsa, and alcohol on 3/4 and then was up all night with abdominal pain and nausea, then vomited a few times and thought there may have been blood in the emesis. He felt better after this, but has been still having intermittent abdominal dicscomfort and is worried about a possible ulcer. He notes that he has had to clear his throat daily and often over the past year. He began taking Nexium OTC 20 mg daily for the last 6 days. He noticed some heartburn and burning in his throat earlier this week after eating spicy sausage. Also requesting routine labs, was not able to get them done at health fair in 2020 due to covid |
| Differential Diagnosis: | GERD PUD |
| Clinical Notes: | Plan: Treatment: Gastroesophageal reflux disease with esophagitis, unspecified whether hemorrhage Start omeprazole delayed release capsule, 20 mg, 1 cap(s), orally, once a day in am, 90 days, 90, Refills 3 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:THYROID STIMULATING HORMONE Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. ,Gastroesophageal reflux disease material was printed. |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J30.89 | Other allergic rhinitis J34.2 | Deviated nasal septum |
| Patient Age: | 75 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | kc |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o nasal congestion and clear drainage, frontal headache, post nasal drip causing a cough for the last 5- 6 months, but worse over the last 3 weeks. He is using saline nasal spray and alka-seltzer severe cold and sinus. |
| Differential Diagnosis: | Acute bacterial rhino sinusitis allergic sinusitis deviated nasal septum |
| Clinical Notes: | NOSE: deviated septum; bil nares pale and very swollen; L nare is not patent; no sinus tenderness Plan: Treatment: Seasonal allergic rhinitis due to other allergic trigger Start Cetirizine Hydrochloride tablet, 10 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 Start Fluticasone Propionate spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 90 days, 3, Refills 3 Essential (primary) hypertension Continue aspirin delayed release tablet, 81 mg, 1 tab(s), orally, once a day Continue losartan tablet, 100 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I82.411 | Acute embolism and thrombosis of right femoral vein |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Here for f/u appt, normally lives in FL 5-6 months out of the year, is back in town now. She states she twisted her Rt ankle in Dec 2020 and had a fall, and saw he dr. in FL for this. After her leg continued to swell into her Rt thigh, she had an US done which revealed a DVT in Rt upper thigh. She was placed on Elaquis 5mg BID and has been taking it without any problems. |
| Clinical Notes: | Continue Elaquis 5mg bid, get f/u US doppler of legs done in mid may, ordered today. Follow up sooner with any concerns. We will reeval length of continuation of elaquis after US. |
Case Log/Encounter
| Date: | 03/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated I10 | Essential (primary) hypertension R60.0 | Localized edema |
| Patient Age: | 37 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ZB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Patient states for his long term disability, he is not getting enough records for his disability payments, patient states they are wanting more records of patient coming in to see us, this is for his wounds on legs. Weight gain of 3.6 lbs since last visit in 1/15/2021. States he is working on his diet to try to cut out soda and high fat foods. Ongoing lower leg edema; states takes water pill daily; was referred to vascular surgeon but has not seen them yet. Denies any open areas to lower legs currently. He has seen wound care in the past for ulcers to BLE |
| Clinical Notes: | Bilateral lower extremity edema Increase Lasix tablet, 40 mg, 1 tab(s), orally, once a day in am, 30 day(s), 30, Refills 0 Lab:BASIC METABOLIC PROFILE (Ordered for 04/05/2021) Lab:GLYCATED HEMOGLOBIN (Ordered for 04/05/2021) Essential hypertension Continue aspirin tablet, 325 mg, 1 tab(s), orally, once a day Continue propranolol capsule, extended release, 80 mg, 1 cap(s), orally, once a day at hs |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O24.410 | Gestational diabetes mellitus in pregnancy, diet controlled Z3A.36 | 36 weeks gestation of pregnancy |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | HF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 25 y.o. G2P0010 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions Endorse GFM Planned pregnancy Employed: EZ radiology Logan supportive Pt was thrown off ATV and hit a tree-broke arm and had some facial injuries, was life-lined to Univ Louisville where she had surgery on her arm US was done in Louisville FHT: 35 FH: 145 |
| Clinical Notes: | 25 y.o. G2P0010 at 36w1d via L=10w5d (Estimated Date of Delivery: 3/25/21) presents for ROB visit. Pregnancy c/b cHTN, sp ATV accident @ 10w5d w L arm open reduction surgery, diet controlled GDM FWB: -FHR reassuring via doppler -FH=GA -Flu vac:10/30/20 -harmony LR-female -Tdap 1/8/20 -Discussed covid vaccine, GDM Ultrasound -8/31/19 UofL TVUS: IUP noted, + cardiac activity. + fetal movement, no gross abnormalities noted. FHR 177. CRL c/w EDD by LMP: 10+5 (EDD 3/25/21). -anatomy 11/10/20 US cw LMP and early US, ant placenta, 3VC, AFI NL, EFW 71%, NL anatomy -growth 2/17 vtx, EFW 57%, AFI 11, MVP 5.3 PNL -Blood type:Apos, rubella immune, antibody neg -PNL: ○ Hgb 12.4 ○ Hct 37 ○ Plt 171 ○ hep B neg ○ Hep C ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: PPV -3T labs (12/22) hgb 10.1, plt 190 -GBS 2/26 SP ATV accident 8/30/20 in Louisville -surgery 8/30 L both-bone forearm fracture open reduction, internal fixation>done at University of Louisville -facial fracture: left ZMC fx involving the posterior orbital floor, max sinus, and left mandibular notch. GDM -1hr GTT 145, 3hr GTT 81/188/161/116 -BS with 1 high fasting abnl in 2 weeks Hx cHTN -no meds since wt loss 2019 -baseline HELLP labs PC ratio 0.03, C 0.62, AST/ALT 12/37, UA 4.9 -normotensive today RLP -back brace ordered Postpartum Breast PpBC: OCP |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L29.9 | Pruritus, unspecified O99.719 | Diseases of the skin, subcu comp pregnancy, unsp trimester Z3A.37 | 37 weeks gestation of pregnancy |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | JN |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32 y.o. G6P3023 at 37w2d (Estimated Date of Delivery: 3/22/21) Presents for itching for the last 2 days to abdomen and bilateral arms. Denies itching to palms or feet. States the itching has been keeping her up at night. She has not tried any medications for this. Denies any known rash. Denies vaginal bleeding, LOF. Endorses GFM. |
| Clinical Notes: | 32 y.o. G6P3023 at 37w2d via L=6 wk us(Estimated Date of Delivery: 3/22/21) Pregnancy cb GBSuria,advanced cervical dilation,elevated BP x1 &hx of preeclampsia, and obesity (BMI49). Itching -rash noted to abdomen -liver function normal -bile acids pending -strict precautions to return with any jaundice or chest pain -PTL and kick counts discussed -appt for NST tomorrow FWB -FHR reactive -Toco Quiet |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O28.8 | Other abnormal findings on antenatal screening of mother Z3A.35 | 35 weeks gestation of pregnancy |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ab |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G5P3013 at 35w4d (Estimated Date of Delivery: 4/3/21) Presents for eval of fetal bradycardia in clinic today, rate of 100's, and was sent to OBT for further monitoring. She states she had not eaten anything prior to appt, but ate some food on the way to OBT. Has been feeling contractions on and off for the past 1 week. She rates these 4/10 and they last approx 30 seconds and occur more than 10 times per day. Endorses GFM. Denies any LOF or vaginal bleeding. |
| Clinical Notes: | 29 y.o. G5P3013 at 35w4d via 20w6d (Estimated Date of Delivery: 4/3/21) Pregnancy cb CDx3 Low FHR baseline on conic NST -FHR baseline in OBT 120>reactive -irreg ctx -labor and kick count instructions given |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R00.0 | Tachycardia, unspecified Z3A.31 | 31 weeks gestation of pregnancy |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | CSA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 22 y.o. G1P0 at 32w4d (Estimated Date of Delivery: 4/24/21) Presents for dizziness/lightheadedness that has been chronic but worsening gradually throughout this pregnancy. She states she has had fast heart rate and feels palpitations intermittently for the last 5 years. She states this all started after she was bitten by a scorpion in Mexico and was admitted in the ICU. She has never followed up with anyone on this or seen cardiology. She states she passed out a few weeks ago at work, states that she was sitting at her desk and suddenly felt very lightheaded and passed out. She states she did not fall, laid her head back, and the next thing she remembers was a lady at her work waking her up. She states she has been feeling nauseated, but has not been vomiting, and denies diarrhea. She is eating and drinking normally. Hx of anemia, is taking PNV, but no additional iron. |
| Clinical Notes: | 22 y.o. G1P0 at 32w4d via L=25 (Estimated Date of Delivery: 4/24/21) Pregnancy cb UTIx1 and anemia. Maternal Tachycardia -IV hydrate -TSH 1.936, glucose 89, K 4.5, hgb 9.2, plt 328 -cardiology referral |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.16 | 16 weeks gestation of pregnancy Z68.30 | Body mass index (BMI) 30.0-30.9, adult |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | AL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G2P0010 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP 11/5/2020 sure Periods - regular, monthly Mhx none - denies Shx none - denies Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - denies gHTN, gDM G1 2018 - SAB @ 12 weeks G2 2019 - TSVD, female G3 - current STI none Pap all NL |
| Clinical Notes: | 26 y.o. G2P0010 at 16w6d via LMP (Estimated Date of Delivery: 8/12/21.) presents for OB Reg visit. Pregnancy uncomplicated. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 30 -Ha1c added today |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z13.89 | Encounter for screening for other disorder Z3A.12 | 12 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | bag |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods monthly Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx FOB cousin, no bleeding or clotting d/o OBhx 4/30/19 SVD 37 wks for ICP STI none Pap all NL |
| Clinical Notes: | 23 y.o. G2P1001 at 12w6d via LMP (Estimated Date of Delivery:9/9/21.) presents for OB Reg visit. Pregnancy cb prior ICP Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Fhx downs -FOB cousin -offered GC and harmony>will discussed with family and call insurance for coverage Nausea and vomiting -rx unison, B6 and zofran rx |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.529 | Supervision of elderly multigravida, unspecified trimester O10.919 | Unsp pre-existing htn comp pregnancy, unsp trimester O24.919 | Unsp diabetes mellitus in pregnancy, unspecified trimester Z3A.10 | 10 weeks gestation of pregnancy |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | tr |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 39 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP 12/17/2020 sure Periods - regular Mhx HLD, cHTN, T2DM-insulin controlled Shx CD x1, breech Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx CD x 1 @ 31 weeks STI - CT 20+ years ago Pap all NL Meds - Atorvastatin, Lisinopril, Basaglar insulin @ bedtime, Lispro Insulin TID with meals, Metformin, Colace |
| Clinical Notes: | 39 y.o. No obstetric history on file. at 10w6dvia LMP (Estimated Date of Delivery: None noted.) presents for OB Reg visit. Pregnancy cb AMA, T2DM-insulin, cHTN, prior CD Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 40 -Ha1c added today T2DM -last Ha1c (12/29) 12.7 -noted from 12/29>will restart lispro 25 units tid with meals and continue glargine 45 units qhs; will also restart Metformin 500 mg bid (unable to tolerate higher doses 2/2 SEs) and start Victoza 0.6 mg qd with titration up to 1.8 mg/day> -patient states never started Victoza or Lispro insulin, is only currently taking Metformin 500mg BID and Basaglar insulin 45 units at bedtime. Instructed to start lispro TID with meals and continue Metformin and Basaglar at bedtime. Instructed to begin checking BG at home fasting in the AM and TID 2 hours after meals. She voiced understanding. She states she has plenty of testing supplies. -just had eye exam -extensive US ordered -Referral to IICare -Referral to Dietician cHTN -baseline HELLP labs today -24 HUP -lisinopril 5mg>change to Labetalol 100 mg BID -aspirin 81mg start in 2 weeks Prior CD AMA -extensive US ordered At end of visit, patient stated that she was contemplating abortion, but that she has looked into it and cannot afford it. She would like some resources or information on this. Consulted with Dr. Bernard and info given to patient. HLD -Stop Atorvastatin |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.12 | 12 weeks gestation of pregnancy Z68.27 | Body mass index (BMI) 27.0-27.9, adult |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 27 y.o. G4P3003 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP 12/4/2020 sure Periods - monthly, regular Mhx - denies Shx - denies Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - FTSVD x3, denies gHTN or gDM STI - CT treated at bellflower 2/2021, trich Pap all NL Meds - denies |
| Clinical Notes: | 27 y.o. G4P3003 at 12w5d via LMP (Estimated Date of Delivery: 9/10/21) presents for OB Reg visit. Pregnancy cb +CT Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed +CT -treated 2/21 -TOC today |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O21.9 | Vomiting of pregnancy, unspecified Z13.89 | Encounter for screening for other disorder Z3A.18 | 18 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | FJA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G7P3033 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Seen in OBT 2/9/2021 LMP / sure Periods - regular Mhx none - denies Shx none - denies Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx Denies gDM or gHTN G6 2017 FTSVD G5 2016 SAB G4 2014 SAB G3 2013 SAB G2 2006 FTSVD G1 2002 FTSVD STI CT Pap all NL Meds - none |
| Clinical Notes: | 33 y.o. G7P3033 at 17w6d via 15w1d US (Estimated Date of Delivery: 8/2/21) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 33 -ha1c today Dating -2/9/21 BSUS measuring 15w1d, ant/fund placenta -anatomy US ordered |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F19.10 | Other psychoactive substance abuse, uncomplicated O10.919 | Unsp pre-existing htn comp pregnancy, unsp trimester O21.9 | Vomiting of pregnancy, unspecified Z13.89 | Encounter for screening for other disorder Z3A.18 | 18 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | jv |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G3P1021 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP 10/25/2020 sure Periods - regular, monthly Mhx cHTN, PSA (cocaine 3 yrs ago, THC current), asthma, depression, bipolar Shx S&C pp Social - uses tobacco, denies alcohol, uses marijuana, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx: G1 2015 ectopic G2 2017 SAB G3 2018 SVD with PPH transfusion 2URBC, cHTN w SI pre-e w SF, no PNC STI trich CT Pap all NL Meds - Gabapentin, Amlodipine, Buspar, rescue inhaler-only using 1-2 times per month |
| Clinical Notes: | 33 y.o. G3P1021 at 18w3d via LMP (Estimated Date of Delivery: None noted.) presents for OB Reg visit. Pregnancy cb cHTN, prior SI pre-e w SF, asthma, prior pph, hx PSA, tob, bipolar, Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 29 -Ha1C added today Asthma -using inhaler 1-2 times per month -never been on vent or hospitalized Polysubstance Abuse -last used cocaine 3 years ago -last used marijuana 2 days ago -using gabapentin for "nerve pain"-does not feel like she can d/c cHTN -baseline HELLP labs today -asa 81mg at 12 weeks -change Amlodipine to Procardia 30XL Depression -buspar, states not working well, taking 3 times per day -appt with mental health provider next week |
Case Log/Encounter
| Date: | 03/03/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri O21.9 | Vomiting of pregnancy, unspecified O99.211 | Obesity complicating pregnancy, first trimester Z3A.10 | 10 weeks gestation of pregnancy |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | mk |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PO-Postpartum Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods - irregular after removal of Mirena in 2017, resumed monthly and regular after birth of son 9/2020 Mhx obesity, cHTN, not taking any meds Shx CD Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx -G1 9/2020 CD for arrest of labor and fetal intolerance to labor, pre-e w/o SF STI trich during G1 Pap all NL - 3/2020 NILM |
| Clinical Notes: | 26 y.o. G2P1001 at 10w3d via LMP (Estimated Date of Delivery: None noted.) presents for OB Reg visit. Pregnancy cb prior CD, prior pre-e wo SF, cHTN, obesity, short interval pregnancy, Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Prior CD -arrest of dilation and fetal intolerance - desires VBAC Prior pre-e -baseline HELLP labs -ASA at 12 weeks BMI 45 -hA1c |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings Z76.89 | Persons encountering health services in oth circumstances |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | LT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 43 y.o. female presenting today for pap smear/well woman exam. Denies any complaints. |
| Clinical Notes: | Ext genitalia: normal in appearance, no lesions Urethral meatus: normal position w/o prolapse Vagina: pink, rugae, normal discharge Cervix: misposition, firm, normal in appearance, no CMT BME: Uterus: normal size, mobile, none tender Adnexa: nontender to palpation, no palpable masses Anus: visually WNL Annual -encouraged to exercise -take vitamins Pap -cotesting today -discussed if neg will cotest in five years STD -screening done today GC/CT/TRIC sent on thin prep -pt desires HIV, HEPC, RPR Mammogram -done today |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri Z3A.24 | 24 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CL |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions endorses GFM Doing well, no HA, visual disturbances or LOF Planned pregnancy Employed: EZ NP Ryan supportive FHT: 140 FH 24 |
| Clinical Notes: | 33 y.o. G2P1001 at 20w1d via L=14w1d (Estimated Date of Delivery: 6/17/21) presents for ROB visit. Pregnancy c/b prior pre-e w SF, BMI 38 FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/28/20 -harmony LR male -Tdap @ 28wks -Discussed PTL, preeclamptic s/s, Ultrasound -dating 12/18 CRL cw LMP 14w1d -extensive anatomy US 2/18 post placenta, 3 VC, AFI NL, EFW 46%, NL anatomy PNL Lab Results Component Value Date ABO O 10/30/2020 RH POS 10/30/2020 LABANTI NEG 10/30/2020 RUBELLAIGGQT Reactive 10/30/2020 -PNL: ○ Hgb 13.3 ○ Plt 238 ○ hep B neg ○ Hep C neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: Lab Results Component Value Date GYNPAPDX Negative for intraepithelial lesion or malignancy 07/25/2018 -3T labs @ 28 weeks -GBS @ 36 weeks Prior pre-e w SF -baseline labs 10/30/20 PC ratio uncal, Cr 0.53, AST/ALT 13/30 -24 HUP never collected -daily ASA 81 mg -mild range BP 141/83 today>repeat 121/79>no other consistent elevated BP documented so not considered gHTN yet BMI 38 -HA1c 4.8 Postpartum Plans Breast PpBC: will discuss |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N92.0 | Excessive and frequent menstruation with regular cycle N94.1 | Dyspareunia Z01.411 | Encntr for gyn exam (general) (routine) w abnormal findings Z12.31 | Encntr screen mammogram for malignant neoplasm of breast |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ct |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 44 y.o. female presenting today for well woman exam. She co today of heavy periods, est in the past 3 mths, she has had some weight loss No bleeding between periods Some dyspareunia not associated with dryness, painful every episode but sometimes worse than others No hot flashes, mother and sisters went through menopause in early 40's |
| Clinical Notes: | 44 y.o. female presents today for WWE. Annual -exercise/wt loss continuation -MVI -tob cessation Menorrhagia -EMB done today -IUD placed today lot# 20022-01 exp-5/2024 -will follow up in two months mammogran -screen ordered Pap -cotest done today -if cotest neg>next pap 2/2026 |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z30.011 | Encounter for initial prescription of contraceptive pills |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | HB |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 27 y.o. female presenting today for well woman exam. No co today Doing well on nuva ring Planning pregnancy in ~6mths Working travel nursing-now @ Union Hosp Has started on Zoloft and is doing well |
| Clinical Notes: | 27 y.o. female presents today for WWE. Annual -encouraged exercise, MVI Birth control -nuva ring -will continue until desires pregnancy Preconceptual -discussed may want to discontinue emgality, elavil, and verapamil -neuro was thinking HA may be better with menopause so maybe also with pregnancy -will start PNV -would like to continue with zoloft |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A35 | Other tetanus |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | db |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G3P1011 at 35w4d via L=20w4d (Estimated Date of Delivery: 4/2/21) presents for ROB visit. Pregnancy c/b BMI 33.6, PTL 12/28>pos GBS |
| Clinical Notes: | FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 11/10/20 -harmony LR-male -Tdap 1/19/21 -Discussed PTL, asthma, US Ultrasound -anatomy 11/17 L=20w4d, ant placenta, NL AFI, EFW 19%, anatomy suboptimal -fu anatomy 2/12 AFI 8.9, MVP 2.9, EFW 23%, vtx PNL -Blood type:Opos, rubella immune, antibody neg -PNL: ○ Hgb 12.7 ○ Hct 38 ○ Plt 296 ○ hep B neg ○ Hep C neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: 5/21/18 NILM -3T labs 1/5 1hr GTT 98, hgb 12, plt 258 -GBS 12/28 pos Asthma -using albuterol inhaler as needed, states rarely -never been hospitalized or on ventilator for asthma -referral pulmonary -add zytrec, flonase>much better BMI 33 -HA1c 5.1 PTL 12/28 -admitted to Methodist -cx 2-3/25/h -s/p Betamethasone 12/28-29 -infection w/u labs NL -GBS pos -strict PTL precautions to return to OBT -works in warehouse for home depot-off work Postpartum Plans Both PpBC: None |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.1 | Major depressive disorder, recurrent, moderate O10.919 | Unsp pre-existing htn comp pregnancy, unsp trimester O26.899 | Oth pregnancy related conditions, unspecified trimester Z3A.31 | 31 weeks gestation of pregnancy Z67.91 | Unspecified blood type, Rh negative Z87.51 | Personal history of pre-term labor |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ar |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G6P2032 non-binary, presents for ROB visit. Previously seen in the trans clinic, was undergoing testesterone for FTM transition, but has stopped since pregnancy, non-binary id, they/them/theirs pronouns Doing well. Having some pressure today with BM, felt like they wanted to push, no vaginal bleeding or LOF, +discharge and lose of mucous plug 2 weeks ago, no LOF, some irreg ctx, endorses GFM Had some heart racing 2 days ago with walking, sat down on took inhaler, and felt better after a couple of minutes, usually just takes some deep breaths and goes away, doesn't last more that a few minutes. Visit Vitals BP (!) 124/85 (BP Location: L Arm, Patient Position: Sitting) Pulse (!) 114 Temp 98.6 F (37 C) (Oral) Ht 60.5" (153.7 cm) LMP 07/27/2020 (Exact Date) SpO2 96% BMI 43.91 kg/m General: Alert,oriented x 3. Pleasant and cooperative. Answers questions appropriately. No acute distress. GI: Abdomen soft and non-tender, no rebound or guarding Extremities: NT, no edema FHT: 150 FH: 30 cx dimple> unable to get finger in os, long firm, high-today cx not at introitus as in past |
| Clinical Notes: | 29 y.o. G6P2032 at 31w4d via 9wk US (Estimated Date of Delivery: 4/30/21) presents for ROB visit. Pregnancy c/b cHTN, depression, obesity, gender dysphoria, RPL, pelvic organ prolapse, rh neg FWB: -FHR reassuring via doppler -FH=GA -harmony LR -Tdap declined -Discussed PTL, Ultrasound -9/25 CRL cw LMP 9wk -11/20 cx length 35.6 -anatomy 12/21 ant placenta, 3VC, AFI NL, MVP 4.7, EFW 14%, cx 31.7, NL anatomy -growth 1/25 AFI 10.3, EFW 13% -growth- needs to be scheduled. PNL Lab Results Component Value Date ABO A 09/25/2020 RH NEG 09/25/2020 LABANTI NEG 09/25/2020 RUBELLAIGGQT Reactive 09/25/2020 -PNL: ○ Hgb 14.2 ○ Plt 216 ○ Hep C neg ○ hep B neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ UDS neg ○ Sickle cell neg -Pap: Lab Results Component Value Date GYNPAPDX Negative for intraepithelial lesion or malignancy 07/13/2020 -3T labs 1hr GTT 104, hgb 13.3, plt 200 -GBS @ 36 weeks Chronic HTN: -BP normotensive today -Not on meds. -Had preeclampsia with previous pregnancies. -Baseline labs 11/9 PC ratio 0.06, Cr 0.75, AST/ALT 31/24 -Taking low dose aspirin -Q4 week growth us: ordered, most recent EFW 13th percentile -Reviewed this result and need for continued growth ultrasounds Rh neg -rhogam 3/2/21 Mental illness: -PTSD, depression. -Continue wellbutrin Pelvic organ prolapse: -patient requested pessary -size 8 dish with support worked well. -Discussed that pessary will not reduce his risk of preterm birth based on current data and that should just utilize for his prolapse (has used in past for prolapse). -Patient declined but wanted to be fitted in case they decide to use in the future. Obesity: -BMI <40, -Normal early A1c -No indication for NSTs. -On aspirin per above. -25+ pound weight gain thus far, discussed, patient trying to make healthy choices Gender dysphoria: -has been on T in the past, no recent exposure (stopped prior to attempting pregnancy). -He/They pronouns. -Need to discuss chestfeeding. Not currently binding. History of pregnancy loss: -15 week SAB (PPROM at home, delivered infant at home immediately after), retained placenta requiring S&C. -2 full term deliveries since then, but did have threatened preterm labor in prior pregnancies. 2 early SABs as well -Had apa work up prior to pregnancy, negative -Given two subsequent term deliveries, will not place prophylactic cerclage. - cervical length at 16 weeks NL Vaginal pressure -cx checked 3/2 c/l/high and firm -reassured PP plans - considering post placental IUD |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E04.9 | Nontoxic goiter, unspecified N95.1 | Menopausal and female climacteric states R10.2 | Pelvic and perineal pain R87.610 | Atyp squam cell of undet signfc cyto smr crvx (ASC-US) Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | gr |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 61 y.o. female presenting today for well woman exam. Doing well, no complaints, no significant dysmenorrhea or dyspareunia, no abnormal vaginal discharge and no dysuria. Reports some decreased sensation and vaginal dryness with intercourse that has happened gradually over the years. Using lubrication during intercourse which has helped. She was prescribed some vaginal estrogen in the past but never got it filled, requesting another prescription. Discussed different options for vaginal estrogen and she prefers cream. |
| Clinical Notes: | 61 y.o. female presents today for WWE. Annual -encourage to continue with MVI, exerecis Mammogram -nl 11/24/20>due 11/2021 Pap -hx above -cotesting today>with neg pap and HPV will need pap in 1 year Enlarged thyroid -Nodule R isthmus>US ordered Vulvar w L left numbness -will try PT-referral Vaginal dryness -premarin vag cream |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E83.110 | Hereditary hemochromatosis Z3A.26 | 26 weeks gestation of pregnancy Z87.59 | Personal history of comp of preg, chldbrth and the puerp |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions , endorses GFM Doing well today Planned pregnancy Employed: EZ physical therapist Husband Collin supportive Visit Vitals BP 116/80 (BP Location: L Arm, Patient Position: Sitting) Pulse 81 Temp 98.4 F (36.9 C) (Oral) Ht 67" (170.2 cm) Wt 154 lb 8.3 oz (70.1 kg) LMP 08/28/2020 SpO2 99% BMI 24.20 kg/m General: Alert,oriented x 3. Pleasant and cooperative. Answers questions appropriately. No acute distress. GI: Abdomen soft and non-tender, no rebound or guarding Extremities: NT, no edema |
| Clinical Notes: | 29 y.o. G2P1001 at 22w4d via L=21w4d (Estimated Date of Delivery: 6/4/21) presents for ROB visit. Pregnancy c/b hereditary hemochromatosis,prior gHTN, SGA, anxiety FWB: -FHR reassuring via doppler -FH |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A34 | Obstetrical tetanus |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ab |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 19 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions, endorses GFM Would only like to work 8 hour shift-note given for work>feeling much better with 8hr shifts Unplanned pregnancy-but happy Employed: Methodist screening for covid Koyaun supportive General: Alert,oriented x 3. Pleasant and cooperative. Answers questions appropriately. No acute distress. GI: Abdomen soft and non-tender, no rebound or guarding Extremities: NT, no edema FHT: 140 FH: 34 |
| Clinical Notes: | 19 y.o. G1P0 at 34w6d via L=10w6d OSH (Estimated Date of Delivery: 4/7/21) presents for ROB visit. Pregnancy c/b transfer of care, +GBSuria, +anti M, +CT 9/4 w -TOC 11/20/20, asthma FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 11/19/20 -Tdap 1/29/21 -Discussed PTL, preeclamptic s/s, covid vaccine, Tdap, 3T labs Ultrasound 9/15/20 US 10w6d-EDC 4/7/21 11/12/20 US 19w1d, anterior placenta, NL anatomy, EFW 62% PNL O pos Lab Results Component Value Date LABANTI POS (Abnormal) 01/29/2021 -PNL: ○ Hgb 11.9 ○ Hct 34.8 ○ Plt 229 ○ hep B neg ○ Hep C neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ Trich neg ○ UDS neg ○ Sickle cell neg -Pap: NA -3T labs 1/29/21 hgb 10.5, plt 163, ! Hr GTT 149, 3hr 75/173/134/129 -GBS @ 36 weeks Pos antibody screen -anti M -unable to titer 10/14 -titer 12/4 8> 1/29 unable to titer 2/2 low antibody -rarely causes fetal anemia will low titer Pos GBSuria -treated neg culture 10/14/20 Pos CT -pos 9/4>toc neg 10/14>neg 11/20 Asthma -never hosp -mostly with exercise -rarely uses inhaler RLP -back brace Postpartum Plans -nexplanon -breast Heart Pain -EKG was in normal sinus -encourage to return to triage if worsen -trail Pepcid if worsens |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D50.8 | Other iron deficiency anemias O30.043 | Twin pregnancy, dichorionic/diamniotic, third trimester Z3A.37 | 37 weeks gestation of pregnancy |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | DO |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Return OB visit, no co bleeding, LOF or contractions, endorses GFM, IOL next week FHT A 140/B 150 FH 41 leapolds vtx/vtx per US Visit Vitals BP 129/78 (BP Location: L Arm, Patient Position: Sitting) Pulse 80 Temp 98.8 F (37.1 C) (Oral) Ht 68" (172.7 cm) Wt 200 lb 9.9 oz (91 kg) LMP 06/16/2020 (Exact Date) SpO2 100% BMI 30.50 kg/m |
| Clinical Notes: | 29 y.o. G3P2002 at 37w0d via L=14wk US (Estimated Date of Delivery: 3/23/21) presents for return OB visit. Pregnancy c/b di-di TIUP, macrocytic anemia, gestational thrombocytopenia. FWB: -FHR reassuring via BSUS -Flu vac: 10/13/20 -Tdap1/12/21 -Discussed labor Ultrasound -9/23 Twin gestation at 14 weeks 1 day. This appears to be a dichorionic, diamniotic twin gestation Fetal sizes are consistent with dating by the LMP . -11/19 anatomy A: ceph R, placenta anterior, 3VC, NL AFI, EFW 73%-male unable to see eye orbits B: ceph L, placenta posterior, 3VC, NL AFI, EFW 50%-female unable to see eye orbits -growth 12/23A: ceph ,AFI NL, EFW 75%, NL anatomy B: breech AFI NL, EFW 50%, NL anatomy -growth 1/27 A: vtx Right, MVP 2.9, EFW 2087 (65%) B: vtx Left, MVP 4.5, EFW 1878 (34%) ITD 10% -growth 2/23 A vtx NL AFI EFW 2947 (64%) B vtx NL AFI EFW 2646 (33%), Appropriate for gesta onal age and concordant fetal growth x2 PNL -Blood type:Bpos, rubella immune, antibody neg -PNL: ○ Hgb 12.6 ○ Hct 37 ○ Plt 177 ○ hep B neg ○ Hep c neg ○ RPR neg ○ HIV neg ○ urine culture neg ○ GC/CT neg ○ UDS + THC ○ Sickle cell neg ○ Hep C neg -Pap: 2019 pap NL per pt OSH -3T labs12/29 1hr GTT 107 -GBS 2/23 neg Macrocytic anemia - taking FE BID - 8/21/20: Hgb 12/6, MCV 94, plt 177 - 12/29/20: Hgb 9.9, MCV 102, plt 115 - No bleeding, no symptoms, no new medications - 12/29 B12, Folate, TSH all normal, retic count 3%, CMP Alk phos 122, Cr 0.52 -1/12 CBC 10.3/31.4/110 -1/19 LDH 194, haptoglobin 69,CBC 9.9/30.1/100,MCV 102, Alk phos 142 Gestational thrombocytopenia - Plt 177 >115, last checked in Dec 2020 - This is diagnosis of exclusion, but most likely gestational given presentation in 3T, and plt >100 - 1/12>110; 1/19>100 Twins di-di -ASA daily -delivery 38 wks-induction scheduled 3/9@ 10pm -No need for NSTs if pregnancy remains low risk -We discussed delivery planning today. She has hx of two term vaginal deliveries. Strongly desires vaginal delivery if possible. We discussed that if presenting twin is breech, will be recommending cesarean, and she was aware of this. As long as presenting twin cephalic, can pursue vaginal delivery, even if Baby B is breech. Discussed internal and external versions and breech vaginal extraction in this case, and she will continue to think about these options. -growth US q 4 wks UDS -quit THC with +UPT -repeat UDS12/29 neg Postpartum Both PpBC: unknown at this time, but knows she doesn't desire BTL (asked about that specifically so papers could be signed if needed).-maybe nuva ring |
Case Log/Encounter
| Date: | 03/02/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A08.19 | Acute gastroenteropathy due to other small round viruses |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ma |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 30 y.o. G2P1001 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions Planned pregnancy Employed: southside WIC Husband Danny supportive |
| Clinical Notes: | 30 y.o. G2P1001 at 18w6d via L=13w2d (Estimated Date of Delivery: 7/28/21) presents for ROB visit. Pregnancy c/b LEEP 2018. FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/29/20 -harmony LR male -Tdap @ 28wks -Discussed PTL, plans covid vaccine when returning to work in May, us next week Ultrasound - dating 1/22 L=CRL 13w2d - anatomy 3/10 |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders G47.9 | Sleep disorder, unspecified |
| Patient Age: | 16 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports 4 weeks ago his brother was arrested and is in prison accused of murder;. He states he has been feeling down, depressed, hopeless, alone, anxious, and like he cannot think straight. Trouble falling asleep due to racing thoughts. |
| Clinical Notes: | Treatment: Depression with anxiety Start Sertraline Hydrochloride tablet, 25 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 0 Sleep disturbance Start Melatonin tablet, 3 mg, 1-2 tab(s), orally, once a day (at bedtime) |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M54.42 | Lumbago with sciatica, left side R29.898 | Oth symptoms and signs involving the musculoskeletal system |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JV |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Reports lower back pain that starts in the middle and radiates to bilateral sides, had similar episode in the summer and was on baclofen and prednisone. States this improved for a while, and was more intermittent. He was referred to PT but has not been able to go tdue to kids being out of school and no babysitter. Now pain is more constant over the last 2 weeks. Improves somewhat with rest, but job involves a lot of bending over and walking. Taking tylenol 4 times a day, and Aleve sometimes, but NSAIDs have caused GI upset in the past. He states he has noticed lately if he stands for a period of time (like standing doing the dishes) his left leg starts to feel weak. |
| Clinical Notes: | BACK: unremarkable, normal range of motion of spine, no evidence of scoliosis, pain with palpation to lumbar spinous process only; no muscles spasms palpated; Negative STraight Leg Raises . NEUROLOGIC EXAM: alert and oriented x 3, no visually appreciable abnormality noted, CN's II-XII grossly intact, no focal abnormality, DTR's 2+ bilaterally and symmetric. Treatment: Lumbago with sciatica, left side Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets for 2 days, 2 tablets for 2 days, 1 tab for 2 days, 1/2 tab for 4 days, orally, once a day, 10 days, 14, Refills 0 Start baclofen tablet, 10 mg, 1 tab(s), orally, qhs prn, 20 days, 20, Refills 0 Imaging:MRI LUMBAR SPINE WITHOUT (L1) Notes: Apply ice or moist heat to back for comfort. Other chronic pain Imaging:MRI LUMBAR SPINE WITHOUT (L1) Weakness of left leg Imaging:MRI LUMBAR SPINE WITHOUT (L1) Essential hypertension Continue hydrochlorothiazide-lisinopril tablet, 25 mg-20 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R04.0 | Epistaxis |
| Patient Age: | 17 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ks |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports bleeding from left nare once a day x 4 days, bleeding x few minutes and stops with using tissues. 2 nights, bleeding lasted x 10 minutes. Also report clear rhinorrhea from bilateral nares since yesterday. Hx of nosebleed from Rt nare, had it cauterized 3 years ago. |
| Clinical Notes: | Treatment: Epistaxis Start Nasal Saline Spray, as directed, intranasally, 14 day(s), Refills 5 Notes: Apply Neosporin to nares on Q-tip ,Nosebleed material was printed. |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E87.1 | Hypo-osmolality and hyponatremia |
| Patient Age: | 83 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | lk |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for ER follow up where he was seen for weakness and feeling shaky, was found to have hyponatremia 129, was gvien 1L normal saline IV and states he felt much better. however, repeat BMP in the ER showed sodium still 129. He states today he is starting to feel slightly weak all over and more fatigued, but denies any shakiness, muscle cramps. headaches, or dizziness. |
| Clinical Notes: | Treatment: Hyponatremia Start Sodium Chloride tablet, 1 gram, 1 tab(s), orally, three times daily, 30 day(s), 90, Refills 3 Lab:URINE SODIUM TIMED COLL Lab:OSMOLALITY, URINE 24 HOUR Lab:BASIC METABOLIC PROFILE (Ordered for 03/03/2021) Notes: Do not drink anymore than 1 Liter of plain water; drink Gatorade/powerade etc. |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated G47.9 | Sleep disorder, unspecified J00 | Acute nasopharyngitis [common cold] M25.532 | Pain in left wrist |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LSH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports pain and swelling to left posterior ulnar area, increased over last 4-5 days. Hx of anxiety and depression, seeing Serenity clinic next week. Taking lorazepam 0.5mg at bedtime to help with sleep, still not sleeping well and needing refill, trouble falling asleep due to racing thoughts, 5 hours per night, not feeling rested in the AM. |
| Clinical Notes: | MUSCULOSKELETAL no swelling or deformity noted to L wrist; Full ROM to L wrist with pain; pain with palpation to L posterior medial wrist; sensation intact . Treatment: Left wrist pain Imaging:RAD WRIST AP & LAT LEFT (W14) Acute nasopharyngitis Start DayQuil Cough liquid, 15 mg/15 mL, 15 mL, orally, every 4 hours Start NyQuil Cold/Flu Relief liquid, 1000 mg-30 mg-12.5 mg/30 mL, 30 mL, orally, every 6 hours Sleep disturbance Refill lorazepam tablet, 0.5 mg, 1 tab(s), orally, qhs, 30 days, 30, Refills 0 Start Melatonin capsule, 10 mg, 1 cap(s), orally, once a day (at bedtime) Notes: avoid caffeine; FU with Trina Greenwald as scheduled. Clinical Notes: INSPECT report ran and viewed. |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J45.41 | Moderate persistent asthma with (acute) exacerbation K21.9 | Gastro-esophageal reflux disease without esophagitis R09.02 | Hypoxemia |
| Patient Age: | 50 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | cc |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports hx of asthma, started having chest tightness, sore throat, hacking dry cough, since last night. She states she has been doing nebulizers every 4 hours with little improvement for approx an hour. Also reports some shortness of breath with exertion at work. Also reports needs a refill of pantoprazole; states Dexilant is better for reflux but insurance won't pay for it right now |
| Differential Diagnosis: | acute asthma exacerbation |
| Clinical Notes: | LUNGS: decreased breath sounds heard to auscultation bilaterally, no wheezes/rhonchi/rales; pt in no resp distress in office . Treatment: Moderate persistent asthma with acute exacerbation Continue Symbicort aerosol, 160 mcg-4.5 mcg/inh, 2 puff(s), inhaled, 2 times a day Continue ProAir HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, 4 times a day prn Continue albuterol-ipratropium solution, 2.5 mg-0.5 mg/3 mL, 3 ml, by nebulizer, 4 times a day Continue Montelukast Sodium tablet, 10 mg, 1 tab(s), orally, once a day Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets x 4 days, then 2 tablets x 4 days, then 1 tablet x 4 days then stop, orally, once a day, 12 days, 24 tablets, Refills 0 Start Depo-Medrol suspension, 80 mg/mL, as directed, IM, once, 1 days Start dexamethasone solution, 4 mg/mL, as directed, IM, once, 1 days Gastroesophageal reflux disease, esophagitis presence not specified Start pantoprazole delayed release tablet, 40 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 3 |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I48.91 | Unspecified atrial fibrillation L03.113 | Cellulitis of right upper limb |
| Patient Age: | 92 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | lc |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for f/u of ER visit 8 days ago, had a fall getting out of bed and laceration to Rt posterior forearm from the corner of a wooden dresser. States he is scheduled to have his daughter (nurse) take his sutures out in a few days but the area is looking more reddened and swollen. He denies any pain to the area, general body aches, fever, or chills. |
| Differential Diagnosis: | cellulitis |
| Clinical Notes: | SKIN: warm and dry; U shaped lacerations noted to R posterior forearm with sutures intact; surrounding skin erythematous, warm, and mildly swollen . ER visits reviewed MGH; 2/16/21;Tdap updated; L forearm xray; no fracture notd; Treatment: Cellulitis of right upper extremity Start Keflex capsule, 500 mg, 1 cap(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Atrial fibrillation, unspecified type Continue Eliquis tablet, 5 mg, as directed, orally, 2 times a day Continue Digitek tablet, 125 mcg (0.125 mg), 1 tab(s), orally, once a day Continue Metoprolol Succinate ER tablet, extended release, 50 mg, 1.5 tablet, orally, once a day Continue Aspir 81 delayed release tablet, 81 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D64.9 | Anemia, unspecified E03.9 | Hypothyroidism, unspecified E55.9 | Vitamin D deficiency, unspecified E78.2 | Mixed hyperlipidemia I10 | Essential (primary) hypertension I25.10 | Athscl heart disease of native coronary artery w/o ang pctrs |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ns |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for 6 month f/u, med refills. No complaints at this time. Hx of CAD, s/p aortic valve replacement in 2017. Has seen cardiology in last 3 months. |
| Clinical Notes: | Physical exam all wnl. Ordered labs and refilled medications. Treatment: Essential hypertension Refill labetalol tablet, 100 mg, 1 tab(s), orally, 2 times a day, 90 days, 180, Refills 1 Refill hydrochlorothiazide tablet, 25 mg, 1 tab(s), orally, once a day in am, 90 days, 90, Refills 1 Refill Losartan Potassium tablet, 50 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Hypothyroidism, unspecified type Refill Levothyroxine Sodium tablet, 25 mcg (0.025 mg), 1 tab(s), orally, qd at hs, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Hyperlipemia, mixed Refill Atorvastatin Calcium tablet, 80 mg, 1 tab(s), orally, once a day, 90 days, 90 Tablet, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Coronary artery disease involving native coronary artery of native heart without angina pectoris Continue aspirin tablet, 81 mg, 1 tab(s), orally, once a day Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Vitamin D deficiency Continue Vitamin D capsule, 2000 intl units, 1 cap(s), orally, once a day Lab:VITAMIN D, 25 HYDROXY Anemia, unspecified type Refill Slow Fe tablet, extended release, (as elemental iron) 45 mg, 1 tab(s), orally, once a day, 90 days, 90, Refills 1 Lab:COMPLETE BLOOD COUNT Lab:IRON (FE) |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J01.00 | Acute maxillary sinusitis, unspecified R11.2 | Nausea with vomiting, unspecified R51 | Headache |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | pb |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Dx 5: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o severe headache and congestion x 7 days; rates pain 5/10; c/o photophobia/phonophobia; states Tylenol not helping; states headache is getting worse |
| Differential Diagnosis: | tension headache sinusitis |
| Clinical Notes: | Acute non-recurrent maxillary sinusitis Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Intractable headache, unspecified chronicity pattern, unspecified headache type Start acetaminophen tablet, 500 mg, 2 tab(s), orally, every 6 hours Nausea and vomiting, intractability of vomiting not specified, unspecified vomiting type Start Ondansetron Hydrochloride tablet, disintegrating, 4 mg, 1 tab(s), orally, 3 times a day prn nausea/vomiting, 5 days, 15, Refills 0 Lab:SARS ANTIGEN COVID POC Negative Essential (primary) hypertension Continue ASA, 81mg, cap, 1 times a day Continue Hydrochlorothiazide tablet, 25 mg, 1/2 tab, orally, once daily Continue Metoprolol Tartrate tablet, 25 mg, 1/2 a day, orally, once a day |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings Z87.898 | Personal history of other specified conditions |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ph |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Here for physical exam for a new job. Denies any complaints. Diagnosed with depression and anxiety and was on medication for a while but went off in Jan 2020 and states she feels fine. LMP: 2/10/2021. Regular, monthly, normally bleeds anywhere from 1 day to 30 days. Has been on Nexplanon in the past and is planning to see Ob/Gyn this month to get another. Currently sexually with 1 partner, using condoms. Hx of seizures, last episode in Dec 2020. States she was seen in th ED and was supposed to be referred to neurology, not taking any meds. |
| Clinical Notes: | New referral to Neurology EEG ordered Okay to start work |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J06.9 | Acute upper respiratory infection, unspecified R50.9 | Fever, unspecified |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sore throat, nasal congestion, runny nose, headache, low grade fever 99.8,, chills, and body aches x 2 days. States he had covid 2 months ago and that he is still having mild shortness of breath with exertion ever since, unchanged. |
| Differential Diagnosis: | URI Sinusitis |
| Clinical Notes: | Rapid Flu in clinic negative Viral upper respiratory tract infection Start Coricidin HBP Cough & Cold tablet, 4 mg-30 mg, 1 tab(s), orally, every 6 hours Start Flonase spray, 50 mcg/inh, 2 spray(s), in each nostril, once a day, 30 day(s), 1 bottle, Refills 0 Notes: Rest and push fluids; use vaporizor by bedside to help loosen secretions; FU Monday if symptoms persist or worsen. Fever, unspecified fever cause Lab:INFLUENZA A&B Supportive therapy x 5 days, please call the office if you do not improve at all by next monday. |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G35 | Multiple sclerosis I51.9 | Heart disease, unspecified M77.8 | Other enthesopathies, not elsewhere classified |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | dm |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient reports 4 weeks ago he almost fell getting out of his vehicle. He grabbed the door handle and caught himself, did not fall, but felt like he strained his left forearm. He has been having constant pain ever since and tingling in all 5 finger tips. He has tried ice and rest with minimal improvement. |
| Differential Diagnosis: | muscle strain tendonitis |
| Clinical Notes: | MUSCULOSKELETAL No swelling or deformity noted to L upper arm or elbow; Limited ROM to L elbow due to pain; mild pain with palpation to L anterior elbow; sensation intact Tendonitis of elbow, left Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Notes: FU if symptoms persist or worsen for Ortho referrall. |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M79.609 | Pain in unspecified limb R20.2 | Paresthesia of skin |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | dd |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt reports left arm numbness and tingling intermittently x 2 months. He states this sensation happens at random, denies any aggravating or aleviating factors. States if he moves the arm around, the sensation may go away. Denies any pain. |
| Clinical Notes: | NEUROLOGIC EXAM: alert and oriented x 3, no visually appreciable abnormality noted, CN's II-XII grossly intact, no focal abnormality; Negative Phalen's and Tinels test. Imaging:EMG/NCV, LUE Imaging:RAD CERVICAL SPINE 4 VIEW MIN (CS4) |
Case Log/Encounter
| Date: | 02/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.69 | Type 2 diabetes mellitus with other specified complication N89.8 | Other specified noninflammatory disorders of vagina Z12.4 | Encounter for screening for malignant neoplasm of cervix |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | df |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o vaginal itching x 4 days. Denies any pelvic pain, vaginal discharge, or odor. States this feels like the many yeast infections she has had in the past. States she is a diabetic and her blood sugars have been running in the 200-300's. |
| Differential Diagnosis: | candida of the vulva and vagina bacterial vaginosis chlamydia |
| Clinical Notes: | FEMALE GU EXAM normal external genitalia, vagina - pink moist mucosa, no lesions, gross amount of thin white discharge noted to vagina, cervix - no discharge or lesions or CMT, adnexa - no masses or tenderness, uterus - nontender and normal size on palpation. Vaginal itching Start fluconazole tablet, 150 mg, 1 tab(s), orally, once, 1 days, 1, Refills 1 Lab:VAGINITIS PANEL Screening for malignant neoplasm of cervix Lab:SUREPATH PAP W/HPV Type 2 diabetes mellitus with other specified complication Continue metformin tablet, 1000 mg, 1 tab(s), orally, 2 times a day Increase Glucotrol XL tablet, extended release, 10 mg, 1 tab(s), orally, once a day, 30 day(s), 30 Tablet, Refills 1 Continue Victoza injection solution, 18mg/3ml, 1.2 mg, SQ, daily for E11.9 Continue lisinopril tablet, 2.5 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders J45.40 | Moderate persistent asthma, uncomplicated |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Patient reports she has been experiencing anxiety and depression over last 3 weeks. She had this in the past and was started on celexa which she states made her feel like a zombie and she does not want this again. she is currently going through a separation and custody proceedings which have added to her stress. Reports sleep disturbances, waking every 2 hours feeling wide awake. Denies trouble falling asleep, not feeling rested in the morning. Reports she feels anxious all the time, and having a panic attack at least once a day for the last 3 weeks. She states she sometimes feels tightness in her chest and has heart palpitations and chest pain. These episodes last approximately 4 hours and then go away on their own. She also states she has a hx of asthma and it is difficult to know if she is feeling short of breath like an asthma attack or a panic attack, but she is having to use her rescue inhaler every other day. She is no longer on a controller daily asthma medication because she ran out of it in the past and felt she was doing well so she never got more. |
| Differential Diagnosis: | Moderate persistent asthma Panic disorder GAD |
| Clinical Notes: | Depression with anxiety Start Zoloft tablet, 25 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 0 Start buspirone tablet, 15 mg, 1/2-1 tab(s), orally, 2 times a day prn anxiety, 30 day(s), 60, Refills 0 Moderate persistent asthma without complication Start Asmanex HFA aerosol, 100 mcg/inh, 1 puf, inhaled, 2 times a day, 30 day(s), 1, Refills 5 Continue Albuterol HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, 3 times a day/prn Offered referral to counseling, but patient declines at this time, stating she does not have time. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss |
| Patient Age: | 20 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JH |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports known exposure to Trichomonas from girlfriend last week. She has been prescribed medication but has not yet started taking it. Denies dysuria, hematuria, discharge. He would like STD testing for "everything". |
| Clinical Notes: | Treatment: STD exposure Start Flagyl tablet, 500 mg, 1 tab(s), orally, bid, 7 day(s), 14, Refills 0 Lab:HEPATITIS PANEL A,B,C Lab:GC & CHLAMYDIA DNA PROBE,URINE Lab:HERPES SIMPLEX VIRUS I & II Ab HSVAB Lab:UA REFLEX Lab:HIV COMBO SCREEN (HIV COMBO) Lab:TREPONEMA PALLIDUM ANTIBODY Lab:TRICHOMONAS - PCR (URINE/SWAB) |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F31.9 | Bipolar disorder, unspecified F41.8 | Other specified anxiety disorders K21.9 | Gastro-esophageal reflux disease without esophagitis Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for annual physical exam for DCS foster system. she has a few complaints and needs. She is having trouble falling asleep and staying asleep, wakes up many times in the night due to nightmares. Takes Trazodone for sleep which helps. She states she is having panic attacks daily, c/o feeling very anxious, crying, feels like she cannot breath, lasting for minutes to hours, resolves with rest and talking to boyfriend. Denies suicidal ideation right now, but has in the past. Goes to counselor @ keystone once a week, but would like to see a different psychiatrist for her diagnosed bipolar disorder. She is taking seasonique birth controll pills. She would like a referral to Ob/Gyn to discuss nexplanon or IUD. Not currently sexually active, but thinking about it soon,. She also reports burning in throat and pain in chest and epigastrium within minutes after eating x a few weeks; states pain getting worse; states after eating cereal today she had the worse pain ever. |
| Differential Diagnosis: | GERD H. Pylori |
| Clinical Notes: | Depression with anxiety Continue Zoloft tablet, 50 mg, 1 tab(s), orally, once a day Referral To:CENTER BOWEN Psychiatry Bipolar 1 disorder Continue lithium tablet, extended release, 450 mg, 1 tab(s), orally, 2 times a day Lab:LITHIUM LEVEL Encounter for initial prescription of implantable subdermal contraceptive Referral To:SHAWN SWAN OBSTETRICS AND GYNECOLOGY for possible IUD or Nexplanon Gastric reflux Start famotidine tablet, 20 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60 Tablet, Refills 1 Lab:H. PYLORI UREASE BREATH, ADULTS |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R07.9 | Chest pain, unspecified Z72.0 | Tobacco use Z82.49 | Family hx of ischem heart dis and oth dis of the circ sys |
| Patient Age: | 38 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SK |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o Chest pain, dizziness, and palpitations x 2 days; states pain on L side of chest and radiates into the R; rates pain 1-6/10; no aggravating or relieving factors; Nitro in ER was not helpful . Fatigue over last 1-2 days, feeling like he wants to sleep all the time |
| Differential Diagnosis: | costochondritis pleurisy angina |
| Clinical Notes: | ER visits reviewed MGH; 2/22/21; WBC 7.5, RBC 4.93, Hgb 16.2, Hct 47.0%, Platelet 240, K 4.2, BUN 14, Creat 0.90, GFR 114, Glucose 140, AST 32, ALT 25, Trop < 0.012, D-Dimer < 235.00, EKG;NSR, CXR;no acute process; CT Head no acute process; reviewed in Meditech and in scanned docs. Chest pain, unspecified type Start naproxen tablet, 500 mg, 1 tab(s), orally, 2 times a day, 15 day(s), 30 Tablet, Refills 0 Imaging:STRESS TREADMILL - WALK |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A54.00 | Gonococcal infection of lower genitourinary tract, unsp A74.9 | Chlamydial infection, unspecified R30.0 | Dysuria |
| Patient Age: | 29 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | mw |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Presents to clinic for urgent care follow up. He went in for penile discharge and was tested for gc/chlamydia and tx with rocephin IM and azithromycin. His tests came back positive a few days later for gc and chlamydia. He states he is no longer having any discharge but does feel some irritation at the tip of the penis. Denies any sores or redness. |
| Differential Diagnosis: | Herpes Urethritis |
| Clinical Notes: | MALE GENITOURINARY: normal external male genitalia, testicles - non-tender and no palpable masses, no scrotal masses, no hernias, no penile lesions or discharge, no lesions. Test of cure today for gc/chlamydia Continue to abstain from any sexual activity until 14 days after tx was administered. Practice safe sex when resuming. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated R05 | Cough R09.89 | Oth symptoms and signs involving the circ and resp systems |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports exposure to daughter who tested positive for covid, has been having symptoms of cough, runny nose, and loss of taste since 2/10. She states most have gotten better but still having a lingering cough that keeps her up at night somtimes. Denies fever or shortness of breath. |
| Differential Diagnosis: | pneumonia URI COPD |
| Clinical Notes: | Cough Start Tessalon Perles capsule, 100 mg, 1 cap(s), orally, 3 times a day, 5 day(s), 15, Refills 0 Start Amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Imaging:RAD CHEST PA & LATERAL (CXR) Tobacco dependence Imaging:RAD CHEST PA & LATERAL (CXR) Runny nose Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified R31.9 | Hematuria, unspecified |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DG |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Burning with urination, increased frequency, lower middle abdominal pain with urination, dribbling, feeling like she has to go but only urinates a small amount, since yesterday |
| Differential Diagnosis: | uti Renal calculus |
| Clinical Notes: | Suprapubic tenderness No CVA tenderness Urine dip positive for Nitrites in office Urinary tract infection, site not specified Start Nitrofurantoin Monohydrate/Macrocrystals capsule, macrocrystals-monohydrate 100 mg, 1 cap(s), orally, 2 times a day, 5 day(s), 10 Capsule, Refills 0 Start Pyridium tablet, 200 mg, 1 tab(s), orally, 3 times a day, 3 day(s), 9, Refills 0 Notes: Drink 6-8 glasses of water daily. Take antibiotic until gone. Wear panty-liner while taking Pyridium as it will numb you and you may dribble some; urine is bright orange and staining. Take Pyridium with food to avoid GI upset. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders J45.40 | Moderate persistent asthma, uncomplicated |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sleep disturbances, waking every 2 hours feeling wide awake. Denies trouble falling asleep, not feeling rested in the morning. Reports she feels anxious all the time, and having a panic attack at least once a day for the last 3 weeks. She states she sometimes feels tightness in her chest and has heart palpitations and chest pain. These episodes last approximately 4 hours and then go away on their own. Reports chest pain and palpitations with panic attacks, shortness of breath daily when carrying kids to the car, feels more short of breath than normal with activity.. |
| Differential Diagnosis: | GAD Panic Disorder Moderate persistent asthma |
| Clinical Notes: | Depression with anxiety Start Zoloft tablet, 25 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 0 Start buspirone tablet, 15 mg, 1/2-1 tab(s), orally, 2 times a day prn anxiety, 30 day(s), 60, Refills 0 Moderate persistent asthma without complication Start Asmanex HFA aerosol, 100 mcg/inh, 1 puf, inhaled, 2 times a day, 30 day(s), 1, Refills 5 Continue Albuterol HFA aerosol, 90 mcg/inh, 2 puff(s), inhaled, 3 times a day/prn |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L50.9 | Urticaria, unspecified T78.40XA | Allergy, unspecified, initial encounter |
| Patient Age: | 51 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KMY |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o itchy rash that started on her scalp x 1 weeks ago; states rash is now on chest, back, abdomen, and legs; c/o intense itching; states benadryl not helping. |
| Differential Diagnosis: | contact dermatitis allergic reaction |
| Clinical Notes: | SKIN: warm and dry; erythematous wheals noted to back, abdomen, breasts, and scalp . Allergic reaction, initial encounter Start Depo-Medrol suspension, 80 mg/mL, as directed, IM, once, 1 days Start dexamethasone solution, 4 mg/mL, as directed, intravenously, IM, 1 days Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Hives of unknown origin Start Zyrtec tablet, 10 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 34 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for ER follow up and to establish care with PCP. He states he has not seen a PCP in over 3 years, but when he did, remembers having some high BP readings. He also states when the occ health nurse comes to his work, he has had a few high readings. He states over the last 3 weeks, he has had a headache 2-3 times per week and feels tingly all over and like he is going to pass out once a day. He went into ER for this and was found to have a mostly normal BP readings, but a few 170's/80's. He had CBC, CMP, Trop, UA, Head CT and CXR. Everything was found to be normal with exception of small amount hematuria. He denies any urinary symptoms or flank pain. He takes ibuprofen for the headaches which takes pain from 6 to 3 out of 10. |
| Clinical Notes: | Essential hypertension Start lisinopril tablet, 10 mg, 1 tab(s), orally, once a day at hs, 30 day(s), 30, Refills 0 Lab:LIPID PROFILE Lab:THYROID STIMULATING HORMONE Other microscopic hematuria Lab:UA REFLEX Diagnose with HTN. Start taking medication, check your BP at home once a week and keep track. Basic labs for annual exam to establish care. We will see if control of BP takes care of headaches, please follow up in 4 weeks. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.9 | Candidiasis, unspecified K92.1 | Melena N91.2 | Amenorrhea, unspecified R31.9 | Hematuria, unspecified Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Dx 5: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Reports she has had blood in her stools, small amount of bright red blood on formed stool. This has been going on for over 5 years and she has seen GI, had colonoscopy (last was over a year ago) and EGD and they have never found any source of bleeding. Denies any abdominal pain, nausea, vomiting, or diarrhea. Hx of IBS, takes dicyclomine PRN. Reports she saw blood in her urine yesterday, but has not seen it again since then. She also reports dysuria twice yesterday, but this has also resolved. Denies flank pain, increased urinary frequency. Also Reports nipple discharge this AM from left nipple piercing, but has resolved now. Also reports redness and itching to the medial left breast. Also reports LMP over 2 months ago, states they have been irregular for several months, not using any BC, using condoms. States she was exposed to genital herpes in August of 2020, but has never had an outbreak or any symptoms, but would like tested. |
| Differential Diagnosis: | Yeast infection under left breast STD exposure |
| Clinical Notes: | Reviewed last colonocopy results from 2018 which were normal but showed a polyp. Advised to follow up with her GI doctor, as there is no active bleeding currently or abdominal pain. Preg test added due to irregular periods STD testing GC/Chlamydia of urine, trichamonas Blood tests for STDs: Hepatitis panel, herpes simplex 1&2, HIV, Syphillis CBC for blood in stools for breast: Start Nyamyc powder, 100,000 units/g, 1 app, applied topically, 3 times a day, 14 day(s), 1 bottle, Refills 0 Notes: Keep skin as clean and dry as possible. Trace blood in urine today, sent for culture and recheck in 1 month |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K52.9 | Noninfective gastroenteritis and colitis, unspecified |
| Patient Age: | 27 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient states 2 weeks ago he believes he had food poisoning with body aches and diarrhea, and his work would not allow him to come in. He states he was off work x 2 weeks and now is feeling much better not having any more symptoms but they are needing a note from provider stating ok to come back to work. |
| Differential Diagnosis: | Gastroenteritis |
| Clinical Notes: | ABDOMEN: no masses palpated, soft, non-tender, no organomegaly, bowel sounds are normal, no guarding or rigidity, non-distended. note given OK to return to work |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | dlm |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt was started on Lisinopril on 01/12/2021 and was good for the first month and then was rechecked on 02/8/2021 and did get refills and states a week ago the Lisinopril started to make him feel dizzy and started to have a tickle in his throat, states that the dizziness would wake him up in the middle of the night . |
| Differential Diagnosis: | Ace inhibitor induced dizziness and cough |
| Clinical Notes: | Patient states he feels he does not need BP medication because he thinks the lisinopril was making him too low. He states the times he has been checked in the office he was really nervous and once was when he was getting ready to get his COVID shot. Advised patient to check BP at home same time every other day for the next week and record in a log. Come into office in 7 days for nurse visit BP check. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders I10 | Essential (primary) hypertension |
| Patient Age: | 5577 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | eh |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sleep disturbance, fatigue, depression, anxiety, racing thoughts x 4 weeks s/p ex-wife dying; states he has lost a number of family members in the last 2 years; states he went and spoke with a counselor yesterday; states he missed Wed-Friday last week due to not being able to sleep. Denies suicidal ideation |
| Differential Diagnosis: | GAD PTSD Adjustment disorder |
| Clinical Notes: | Depression with anxiety Start Citalopram Hydrobromide tablet, 20 mg, 1 tab(s), orally, once a day at hs, 30 day(s), 30, Refills 0 Clinical Notes: Off work from 2/17 to 3/16. Essential (primary) hypertension Continue Aspir-Low enteric coated tablet, 81 mg, 1 tab(s), orally, once a day Continue Diovan HCT tablet, 25 mg-320 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.18 | 18 weeks gestation of pregnancy |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MH |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 27 y.o. G1P0 presents for ROB visit. Doing well. No complaints of: vaginal bleeding, loss of fluid and contractions Had some vomiting and diarrhea after 2nd covid-much better today Planned pregnancy Employed: EZ ER Alex husband supportive |
| Clinical Notes: | 27 y.o. G1P0 at 18w2d via L=8w6d US (Estimated Date of Delivery: 7/17/21) presents for ROB visit. Pregnancy c/b prior heller myotomy 4 years ago FWB: -FHR reassuring via doppler -FH=GA -Flu vac: 10/9/20 -s/p covid x2 -harmony LR-female -Tdap @ 28wks -Discussed upcoming US Ultrasound -US 12/11: CRL c/w 8+6, +FCA -anatomy 3/5 PNL all WNL -3T labs @ 28 weeks -GBS @ 36 weeks prior heller myotomy -4 years ago -no co vomiting, chest pain or heartburn |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O42.919 | Pretrm prem ROM, unsp time betw rupt and onst labr, unsp tri Z3A.34 | 34 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G5P2113 at 34w0d (Estimated Date of Delivery: 3/31/21) Presents for LOF that started at 3 with a big gush of clear fluid and continues to leak, no contractions, no vaginal bleeding, endorses GFM |
| Differential Diagnosis: | BV ROM |
| Clinical Notes: | 23 y.o. G5P2113 at 34w0d via L=7 (Estimated Date of Delivery: 3/31/21) Pregnancy cb hypothyroidism, depression, scant PNC PPROM -34 weeks -clear fluid @ 1500 -cx @ 1730 4/50/-2 -BSUS vtx -FHR reactive/toco quiet -BMTZ @ 1800 -infectious w/u pending Hypothyroid -levothyroixine 100mcg -TSH (9/14/20) 5.637> (2/15/21) 2.642 Admit to Antepartum |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.33 | 33 weeks gestation of pregnancy |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EH |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 21 y.o. G3P2002 at 33w5d (Estimated Date of Delivery: 4/2/21) Presents for pelvic pressure she rates 10/10, constant for the last 2 weeks. She states in addition to this pelvic pressure, she also feels she is having contractions yesterday and today, about 1 hour apart. She states she has tried taking a bath and relaxing at home to relieve pain and tried to put off coming in. She has not yet established prenatal care since moving to indy a few months ago from Lafayette, was seen in OBT last month and states she has been awaiting a call to get set up at Pecar. |
| Clinical Notes: | 21 y.o. G3P2002 at 33w5d via LMP (Estimated Date of Delivery: 4/2/21) Pregnancy cb LTC Abdominal pain -cervix 1/l/h @1530 -TOCO quiet -2 min decel @1500, plan for extended monitoring -IV started -GBS pending -initial prenatal labs collected No prenatal care PP plans: Breast/None |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R10.2 | Pelvic and perineal pain Z3A.24 | 24 weeks gestation of pregnancy |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | SH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G4P2012 at 24w0d (Estimated Date of Delivery: 6/9/21) Presents for back pain, she was seen 2/6 for the same reason but the pain was shooting down her leg, today the pain is more in the "inside of my butt cheeks" pain not worse with fetal movement, worse when sitting still for long periods or in the morning after sleeping, no vaginal bleeding, LOF or contractions-endorses GFM |
| Clinical Notes: | 26 y.o. G4P2012 at 24w0d via 22wk us (Estimated Date of Delivery: 6/9/21) Pregnancy cb LTC, tob Pelvic pain -cw MSK -rx flexeril -discussed PT-will call if would like referral -culture for urine, GC/CT/Trich -FHR reassuring per doppler -appt for US and OB reg discussed |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O16.3 | Unspecified maternal hypertension, third trimester Z3A.34 | 34 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | SA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 23 y.o. G2P1001 at 34w3d (Estimated Date of Delivery: 3/28/21) Presents for evaluation of mild range blood pressure readings in clinic today. She denies any complaints today. She denies epigastric pain, headache, visual changes, or chest pain. She states she did have gHTN during previous pregnancy, but was never placed on any medications. She is currently taking ASA daily but nothing for blood pressure. She denies hx of preeclampsia. |
| Clinical Notes: | 23 y.o. G2P1001 at 34w3d via 20w5d US (Estimated Date of Delivery: 3/28/21) Pregnancy cb mild range BP noted in clinic. Mild range BP -mild range in clinic x 3 -normotensive in OBT -HELLP labs PC ratio 0.237, hgb 12.6, plt 242, Cr 0.6, AST/ALT 12/13, -taking ASA 81 mg daily FWB -FHR reactive/toco quiet -strict precautions discussed for return pre-e , PTL |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O24.012 | Pre-exist diabetes, type 1, in pregnancy, second trimester O99.89 | Oth diseases and conditions compl preg/chldbrth Z3A.21 | 21 weeks gestation of pregnancy Z87.59 | Personal history of comp of preg, chldbrth and the puerp |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | YA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 30 y.o. G3P0101 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods irreg Mhx Type 1 DM insulin controlled Shx CD Social t/a/d denies, feels safe at home Genetic hx daughter and brother duodenal atresia , no bleeding or clotting d/o OBhx G1 PPROM 36wk, polyhydramnios w duodenal atresia G2 CD for fetal distress and macrosomia STI none Pap all NL |
| Clinical Notes: | 30 y.o. G3P0101 at 21w4d via LMP (Estimated Date of Delivery: 6/26/21.) presents for OB Reg visit. Pregnancy cb DM-I on insulin and history of duodenal atresia in G1 with PPROM at 36 weeks gestation, prior CD Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Prior CD -fetal distress and macrosomia Hx PPROM - in G1 pregnancy at 36 weeks likely secondary to polyhydramnios with duodenal atresia - States her water broke the day before her IOL, which was scheduled for 36wks due to macrosomia (EDD was 10/18 and IOL scheduled for 9/19. Newborn weight 8lbs 10oz) Type 1 diabetes: -diagnosed age 19, states her blood sugar was 700 at time of diagnosis. Been on insulin since -currently on glargine 10U, Lispro10U with meals>followed with Endo last seem 2/9 -FBS highest 101, before meals highest 147 - iiCare referral placed - start ASA 81mg at 12 wks, script sent - Will obtain baseline HELLP labs, -Protein, urine, 24 hour -Hemoglobin A1c -referral to Dietician -referral to ophthalmology Family Hx duodenal atresia -daugher G1 and brother -extensive US BMI 30 Time in 1135/out 1215 and greater than 50% of this time was spent in face-to-face counseling and/or coordinating care. Dispo: RTC for NOB visit |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z13.89 | Encounter for screening for other disorder Z3A.23 | 23 weeks gestation of pregnancy |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | SD |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. G4P3003 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof. Seen at CH for cramping -us done on that date cw LMP>post placenta LMP / sure Periods - irregular, was on Depo shot Mhx - denies Shx - denies Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - G4, SVD x3, denies gHTN or gDM STI none Pap - states all NL, last in 2019 |
| Clinical Notes: | 31 y.o. G4P3003 at 23w0d via L=19w6d (Estimated Date of Delivery: 6/16/21) presents for OB Reg visit. Pregnancy cb LTC. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 22 US for anatomy rx PNV Due to language barrier, an interpreter was present during the entire visit with this patient. Time in 1144/out 12 and greater than 50% of this time was spent in face-to-face counseling and/or coordinating care. Dispo: RTC for NOB visit |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R85.612 | Low grade intrepith lesion cyto smr anus (LGSIL) Z3A.01 | Less than 8 weeks gestation of pregnancy |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | CH |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 25 y.o. G3P2002 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, c/o diarrhea once a day every morning, nausea every day, declines medication for this now. LMP / unsure Periods - irregular, once every 3 months, bleeding x 4 days, light Mhx - denies Shx - denies Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - G3, denies any gHTN, gDM, had low iron during G1, had to have iron infusion, FTSVD x 2 STI none Pap - Low grade in 2019, never repeated in 2020, will be due at New OB |
| Clinical Notes: | 25 y.o. G3P2002 at 7w3d via LMP (Estimated Date of Delivery: 10/3/21) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed abnl pap -LGSIL 2019 -needs repeat at NOB visit BMI - 22.8 Time in 11/out 11 and greater than 50% of this time was spent in face-to-face counseling and/or coordinating care. Dispo: RTC for NOB visit |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O26.849 | Uterine size-date discrepancy, unspecified trimester Z3A.14 | 14 weeks gestation of pregnancy Z68.34 | Body mass index (BMI) 34.0-34.9, adult |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | LQ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 26 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Feeling great-no nausea LMP / sure Periods monthly Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx 2013 FTSVD no GDM or HTN STI none Pap all NL Med PNV |
| Clinical Notes: | 26 y.o. G2P1001 at 12w0d via LMP (Estimated Date of Delivery: 9/1/21) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 34 -ha1c Dating US for S |
Case Log/Encounter
| Date: | 02/17/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension I82.402 | Acute embolism and thombos unsp deep veins of l low extrem O21.9 | Vomiting of pregnancy, unspecified Z13.89 | Encounter for screening for other disorder Z3A.14 | 14 weeks gestation of pregnancy Z68.41 | Body mass index (BMI) 40.0-44.9, adult |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | AA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 34 y.o. G1P0 presents for OB Reg visit. Subjective: Reports doing well now, but had frequent nausea and vomiting in December and January. Would like something for intermittent nausea. Denies ctx/cramping, vaginal bleeding, lof LMP / sure Periods - regular, montly Mhx chronic non - occlusive DVT in distal femoral and popliteal veins Shx - Tonsils & Adenoids, Rt 3rd finger surgery Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx G0 STI - chlamydia, trich, several years ago Pap - NILM in 2016, due at New OB |
| Clinical Notes: | BSUS + CA and FM Assessment/Plan: 34 y.o. G1P0 at 14w1d via LMP (Estimated Date of Delivery: 8/17/21.) presents for OB Reg visit. Pregnancy cb hx DVT, obesity Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 40 -HA1c chronic non-occlusive DVT in distal femoral and popliteal veins -probable estrogen -followed by heme-currently on lovenox 100mg daily Elevated BP -mild range BP noted 12/28> 140/92 -baseline HELLP labs done Nausea -rx zofran, B6 and unison Time in 10/out 11 and greater than 50% of this time was spent in face-to-face counseling and/or coordinating care. Dispo: RTC for NOB visit |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O02.1 | Missed abortion |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | SRC |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 41 y.o. G3P2002 at 9w4d via LMP (Estimated Date of Delivery: 9/11/21) presents for vaginal spotting. Ms. Carrera was seen on both 1/7 and 1/12 in OBT for vaginal spotting. TVUS on 1/7 showed a +IUP with a gestational sac and yolk sac, but no fetal pole. The TVUS on 1/12 also showed an intrauterine gestational sac and yolk sac without a fetal pole. She did not have an initial viability scan 11 days after initial TVUS, but says that she did get an ultrasound yesterday. States that they "did not see anything" but they did not tell her at all what was going on or "if she was still pregnant". Ms. Carrera reports abdominal pain began this past Saturday. The pain is intermittent. Sometimes the pain feels like a cramp and sometimes it feels like her "abdomen is swollen". The pain is a 5/10 currently. She also complains of pressure when she pees. Endorses increased urinary frequency. She has not tried anything for her pain. She also complains of vaginal bleeding. She first started having an increase in discharge on Saturday that turned into bleeding on Sunday. The bleeding has increased today which prompted her to come in to OBT. She has gone through 2 panty liners today. Denies saturation of these liners. Denies fevers, chills, shortness of breath, chest pain, constipation, diarrhea, or other associated sx. No additional concerns at this time. |
| Differential Diagnosis: | Missed AB Inconsistent gestational age |
| Clinical Notes: | SVE: cl/lg/hi SSE: Pelvic Exam: Normal external female genitalia Clitoris: normal Vagina: normal mucosa without prolapse or lesions, normal without tenderness, ~5 ml of old dried blood in vault. Several small clots Cervix: small amount of blood from external os. Os visually closed Missed AB: - TVUS 1/7: +IUP w/ GS and YS, no fetal pole - TVUS 1/12: +IUP w/ GS and YS, no fetal pole - TVUS today Intrauterine gestational sac, no YS, no FP. Gestational sac measuring 1.23 x 1.44 x 1.21cm (MSD 1.28, 6w0d). No adnexal masses - Diagnosed with missed AB given >11 days from initial TVUS showing +IUP w/ GS and YS and still no fetal pole with cardiac activity on ultrasound - Discussed diagnosis with patient - Discussed management options including expectant, medical, and procedural management. After discussing risks/benefits of all options using an interpreter, she desires to proceed with medical management. - Patient does not desire to take medication in OBT because she has not had any food to eat. Due to this, will not be able to give Mife/Miso combo. - Rx given for Misoprostol. Discussed taking 800mcg buccal misoprostol with plan to take an additional dose if she does not start cramping/bleeding 24hrs after initial dosage - Rx given for Ibuprofen and Zofran - Discussed plan to take at home pregnancy test in 4 weeks - Rh+, no indication for Rhogam - Discussed future fertility. She declines contraception at this time. Instructed to have at least one menstrual cycle before trying to conceive again. - Discussed return precautions including fevers >100.4, uncontrolled pain, and bleeding >2 pads per hour for 2 consecutive hours UTI: - Udip + nitrites - UCx sent in OBT - Rx given for Macrobid BID x 7 days Dispo: Will discharge to home with strict return precautions |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R76.8 | Other specified abnormal immunological findings in serum Z13.89 | Encounter for screening for other disorder Z3A.14 | 14 weeks gestation of pregnancy Z82.79 | Fam hx of congen malform, deformations and chromsoml abnlt |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | MAS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 19 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / unsure Periods monthly Mhx lupus-no meds at this time Shx none Social t/a/d denies, feels safe at home Genetic hx FOB brother cleft palate, no bleeding or clotting d/o OBhx G1 2016 FTSVD no GDM or HTN STI none Pap NA meds PNV, vit D |
| Clinical Notes: | 19 y.o. G2P1001 at 14w2d via LMP (Estimated Date of Delivery: 8/9/21) presents for OB Reg visit. Pregnancy SLE Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed SLE -followed w rheumatology -baseline HELLP labs sent today -ASA 81mg daily -no meds/no flare -us ordered |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O26.849 | Uterine size-date discrepancy, unspecified trimester Z3A.09 | 9 weeks gestation of pregnancy |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | KA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 25 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / unsure Periods - irregular Mhx - denies Shx - CDx1 Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o, FOB's brother has sickle cell anemia OBhx - G1 FT, CD due to failure to progress, denies gHTN or gDM STI none Pap all NL Meds - PNV, refilled today |
| Clinical Notes: | 25 y.o. G2P1001 at 9w6d via LMP (Estimated Date of Delivery: 9/9/21) presents for OB Reg visit. Pregnancy cb prior CD x1. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 29.36 -HA1C added today Dating US ordered, unsure LMP Prior CD x1 |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.16 | 16 weeks gestation of pregnancy |
| Patient Age: | 33 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | sm |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 33 y.o. G5P1013 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods monthly Mhx none Shx CD Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx G1 2007 FTCD arrest of dilation-2cm G2 2009 FTCD repeat G3 2016 FTCD repeat G4 2015 sab -no HTN or GDM STI none Pap all NL |
| Clinical Notes: | 33 y.o. G5P1013 at 16w6d via LMP (Estimated Date of Delivery: 7/22/21) presents for OB Reg visit. Pregnancy cb prior CDx3 Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI -Ha1c Anatomy US scheduled Prior CDx3 |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E05.90 | Thyrotoxicosis, unsp without thyrotoxic crisis or storm Z3A.13 | 13 weeks gestation of pregnancy |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ow |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 31 y.o. G3P2002 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods - regular, monthly Mhx - Hyperthyroidism, was scheduled for thyroidectomy in 1/2021, but she was pregnant Shx - CDx2 Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx, G1 FT failure to progress, G2 failure to progress, denies complications during pregnancy STI none Pap - 2019 had abnormal result, will bring the document to next appt, was told to f/u in 1 year |
| Clinical Notes: | 31 y.o. G3P2002 at 18w5d via LMP (Estimated Date of Delivery: 7/9/21) presents for OB Reg visit. Pregnancy cb Graves Disease. Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Ordered US anatomy scan today, scheduled Graves Disease -following with Endocrinology, on PTU -Referral to II Care -thyroid labs repeated today BMI 30.24 -Add A1C |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.522 | Supervision of elderly multigravida, second trimester Z3A.16 | 16 weeks gestation of pregnancy |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | JJ |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 34 y.o. G7P3124 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods - monthly, regular Mhx - denies Shx - D&C following SAB Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o, Maternal aunt cervical CA OBhx - G7 STI none Pap - 1 abnormal pap, f/u in 1 year and was resolved |
| Clinical Notes: | 34 y.o. G7P3124 at 16w2d via LMP (Estimated Date of Delivery: 7/26/21) presents for OB Reg visit. Pregnancy cb prior PTD, AMA Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 23 |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z13.89 | Encounter for screening for other disorder Z3A.33 | 33 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | MB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G2P1001 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / unsure No PNC or US Mhx none Shx none Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx G1 FTSVD, no GDM or HTN STI none Pap all NL Med none |
| Clinical Notes: | 33w3d via LMP (Estimated Date of Delivery: 3/28/21) presents for OB Reg visit. Pregnancy cb Late to Care Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Pt aware will need 1hr GTT next visit Anatomy US ordered |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.17 | 17 weeks gestation of pregnancy |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | CM |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 29 y.o. G3P1011 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods monthly PMH: anemia Surgeries: none Meds PNV Allergies: Chloroquine, ibuprofen OB hx: G1 sab, G2 FTSVD no complications, G3 current -no GDM or HTN Gyn hx:LMP 10/8, regular periods, denies STI, never had a pap Social hx: no e/t/d |
| Clinical Notes: | 29 y.o. G3P1011 at 17w6d via L=16w US (Estimated Date of Delivery: 7/15/21) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 31 -ha1c |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.15 | 15 weeks gestation of pregnancy |
| Patient Age: | 31 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ES |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 31 y.o. G1P0 Transgender male, Female assigned at birth, presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods - regular monthly Mhx - denies Shx - double mastectomy Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - G1 Meds - PNV STI none Pap all NL |
| Clinical Notes: | 31 y.o. G1P0 at 5w3d via LMP (Estimated Date of Delivery: 10/10/21.) presents for OB Reg visit. Pregnancy cb transgender status Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O09.299 | Suprvsn of preg w poor reprodctv or obstet history, unsp tri O10.019 | Pre-existing essential htn comp pregnancy, unsp trimester Z3A.12 | 12 weeks gestation of pregnancy Z87.59 | Personal history of comp of preg, chldbrth and the puerp |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | DMB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | 32 y.o. G3P1102 presents for OB Reg visit. Seen in OBT for back pain, doing better now. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, LMP / sure Periods - monthly, regular PMH:cHTN-takes meds PRN PSH:CD x1 for fetal intolerance, cholecystectomy OBHx:G1 term FTSVD, G2 PLTCD for fetal intolerance at 34wks due to preE w/ S, also c/b IUGR per report, G3 current GYNHx:denies STDs, denies abnormal paps Meds:PNV All:NKDA STI: Denies Pap: All NL SHx: denies t/e/d. Lives with FOB and 2 children. |
| Clinical Notes: | 32 y.o. G3P1102 at 12w6d via L=8w1d (Estimated Date of Delivery: 8/19/21) presents for OB Reg visit. Pregnancy cb CD, PTD @ 34wk, prior pre-e Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed Prior pre-e/cHTN -stated takes meds when she feels bad-unsure what med -baseline HELLP labs -ordered 24HUP -ASA daily -fu 1 wk for BP Prior PTD at 34wks -inducted for pre-e Prior CD -fetal intolerance BMI -HA1c |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z3A.09 | 9 weeks gestation of pregnancy |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AL |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32 y.o. G3P1011 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof LMP / sure Periods monthly Mhx - none Shx - none Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o, Maternal grandmother with breast CA OBhx - 1 ab,1 SVD FT no gdm or HTN STI none Pap all NL - HPV+ 10 years ago, due for pap 2021 at new OB |
| Clinical Notes: | 32 y.o. G3P1011 at 9w2d via LMP (Estimated Date of Delivery: 9/13/21) presents for OB Reg visit. Pregnancy uncomplicated Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O10.019 | Pre-existing essential htn comp pregnancy, unsp trimester R11.10 | Vomiting, unspecified Z3A.10 | 10 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KG |
| Type of Decision Making: | High Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G1P0 presents for OB Reg visit. Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, Admitted for hyperemesis 1/31-2/1 Had some elevated BP at that time LMP / sure Periods - regular monthly Mhx - depression/anxiety, not taking any meds, doing well Shx - 2008 left arm fracture Social t/a/d denies, feels safe at home Genetic hx denies, no bleeding or clotting d/o OBhx - G1 STI none Pap all NL |
| Clinical Notes: | 23 y.o. G1P0 at 10w1d via 7w1d US (Estimated Date of Delivery: 9/7/21) presents for OB Reg visit. Pregnancy cb cHTN Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed cHTN -baseline HELLP labs 2/1 PC ratio .112, Cr 0.52, AST/ALT 16/22, LDH 180, UA 3.9 -24HUP 2/1 uncal -will monitor at home>will call in 3 days to FU |
Case Log/Encounter
| Date: | 02/10/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | O21.9 | Vomiting of pregnancy, unspecified Z3A.15 | 15 weeks gestation of pregnancy |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | tsl |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | PR-Prenatal Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 23 y.o. G4P0030 presents for OB Reg visit. Seen in OBT 1/2 for N/V, states now improved Subjective: Doing well. Denies ctx/cramping, vaginal bleeding, lof, PMHx:cHTN PSurgHx:Dx Laparoscopy, D&C x2 Meds:PNV Allergies:NKDA OBHx: 1/2019G1 Ectopic - Wedge resection 1/2020G2 MAB - D&C 6/2020G3 MAB - D&C GynHx:Patient's last menstrual period was 04/25/2020..Regularcycles, DeniesSTIs and has not had a pap smear FaHx: Denies fam hx of endometrial/ovarian/colon CA. Denies any hx of bleeding/clotting disorders. SoHx: Denies t/a/d. Lives at home withher husband -- feels safe at home. |
| Clinical Notes: | Pregnancy cb cHTN, RPL Welcomed to OB care at Eskenazi Health. NOB labs drawn today OBT uses discussed BMI 28 cHTN -never on meds -baseline HELLP labs today -taking Aspirin 81mg -24HUP ordered -RTO for BP check |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | S86.911A | Strain of unsp musc/tend at lower leg level, right leg, init |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports 2-3 weeks ago she did a new workout that included running and lunges and woke the next morning with increased Rt knee pain and stiffness. She previously had Rt knee aching intermittently when running (normally runs 5-8 miles per day). Has been taking ibuprofen 600mg every 6 hours and icing with little relief. She also states she fell on the ice 2 weeks ago and landed on Rt knee which caused a bruise but she states she was having pain before that and pain did not increase after the fall. |
| Differential Diagnosis: | knee sprain Meniscus tear |
| Clinical Notes: | No swelling or deformity noted to knee; Full ROM to knee intact, but with pain. No pain with palpation to knee. Negative Anterior/Posterior drawer sign; Positive McMurrays sign, and Positive Valgus/Varus stress. No swelling or deformity noted to knee; Full ROM to knee intact, but with pain. No pain with palpation to knee. Negative Anterior/Posterior drawer sign; Positive McMurrays sign, and Positive Valgus/Varus stress. Start naproxen delayed release tablet, 500 mg, 1 tab(s), orally, 2 times a day, 30 days, 60 Tablet, Refills 1 Notes: Rest, ice, elevate, and compress R knee for comfort. Refrain from exercise x 1 week then slowly return as tolerated. If not improving, may need to refer to PT and get MRI. |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 7 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient presents to physical exam to be medically cleared for a dental procedure with sedation, to have caps placed on some teeth. In past exams he was found to have a murmur on auscultation and f/u echo revealed no murmur. |
| Differential Diagnosis: | Physiologic murmur |
| Clinical Notes: | HEART: regular rate and rhythm, no murmurs sitting or supine, no click or rubs. Full head to toe physical exam performed without abnormality found. Patient is cleared for dental procedure with sedation with no restrictions. Follow up as needed. |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N89.8 | Other specified noninflammatory disorders of vagina R00.0 | Tachycardia, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | GS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Reports for annual medicaid physical as part of the Indiana foster system. She also requests a referral to Ob/Gyn for vaginal discharge, states she does not want pelvic exam today, would like to see ob/gyn because she has never been before and wants to "make sure my discharge and my smell is right." She has ongoing tachycardia, but previous visits were in the low 100's - 106, today is 120. She states "it's because of my Vyvanse." She has also had a 52 lb weight gain over last 1 year. She states she has not had a period since age 12, is on Depo shot for more than 4 years. She states she is no sexually active but was using the depo to "regulate periods." |
| Differential Diagnosis: | hyperthyroidism Weight gain related to depo shot |
| Clinical Notes: | Ordered TSH for wt gain and tachycardia, also routine labs for CBC and CMP Refer to OB/Gyn as requested and to address long term use of Depo, discuss alternatives |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G89.29 | Other chronic pain M54.6 | Pain in thoracic spine V89.2XXA | Person injured in unsp motor-vehicle accident, traffic, init |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Reports upper middle back and lower bilateral back pain x 4-5 years, worse and more constant over the last few months. States upper middle back pain got a little worse since getting rear ended in her vehicle a month ago. She states her airbags did deploy. Reports numbness and tingling intermittently that goes "down the spine, legs, and all the way to my toes." She states this sensation happens randomly, 3-4 times in the last few months. Had Xray of back years ago and was told it was normal. Denies in weakness in extremities. DENIES: loss of control of bowels or bladder |
| Differential Diagnosis: | thoracic spine strain chronic pain Disc herniation |
| Clinical Notes: | Pain with palpation to thoracic spine around T3-T4. No pain with palpation to paraspinal muscles; no muscle spasms palpated; Negative Straight Leg Raises Start Naproxen Sodium tablet, extended release, 500 mg (as sodium), 1 tab(s), orally, once a day, 30 day(s), 30 Tablet, Refills 1 Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 5 days, 28, Refills 0 Imaging:RAD THORACIC SPINE 3 VIEWS (TS) If no improvement and normal Xrays, will refer to PT |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | M25.532 | Pain in left wrist W19.XXXD | Unspecified fall, subsequent encounter |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KP |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports ongoing Rt lateral wrist pain x 8 weeks with no known injury, had xrays done in 12/2020 that were resulted as normal. Two days ago, she had a slip and fall on the ice, landing with Rt arm outstretched and caught herself with Rt hand. She reports increased pain from the fall and now also having medial wrist pain. |
| Differential Diagnosis: | Wrist sprain Colle's fracture |
| Clinical Notes: | Start ibuprofen tablet, 600 mg, 1 tab(s), orally, every 6 hours RICE therapy Xray 3 views of Rt wrist |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | I27.2 | Other secondary pulmonary hypertension I48.91 | Unspecified atrial fibrillation |
| Patient Age: | 81 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LB |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Patient presents for follow up from hospital admission for TCM (Transitional care management). She went in on 2/2/2021 for generalized weakness, palpitations, shortness of breath with minimal exertion. She was found to have new onset A-fib with RVR and new onset pulmonary hypertension. She was on Cardizem inpatient and then transitioned to Metoprolol 150mg daily, digoxin, and Lasix. She is currently wearing a holter monitor until 2/18/2021 and has a f/u with Cards on 3/2 and PCP on 3/8. |
| Differential Diagnosis: | Pulmonary hypertension |
| Clinical Notes: | Ordered labs for digoxin level and BMP for potassium since starting lasix. Please keep f/u appt with Cardiology. Reviewed all new diagnoses and medications and patient voiced understanding. She is getting around well at home, denying any shortness of breath upon exertion, just feels fatigued. |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M25.561 | Pain in right knee |
| Patient Age: | 58 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Rt knee pain s/p twisted it walking about 1.5 weeks ago. Hx of arthritis in the knee and it has felt "unstable" for the last month. Also states now her left hip from limping on the Rt knee, also has a hx of arthritis in the left hip. She has been icing it over the weekend and feels the pain is a little better today. She is not taking any OTC medications. |
| Differential Diagnosis: | Knee sprain Arthritis |
| Clinical Notes: | Patient states she cannot take NSAIDs due to stomach upset Cannot take steroids or steroid injections due to increased Blood glucose levels in the past when taking knee injection. She would like to try PT. Start Ultram tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 Notes: Rest, ice, elevate, and compress R knee for comfort. Referral to PT Ace wrap applied |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia I48.0 | Paroxysmal atrial fibrillation I50.32 | Chronic diastolic (congestive) heart failure I50.9 | Heart failure, unspecified |
| Patient Age: | 87 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | IM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports fatigue, weakness; weight gain of 15 lbs x 2 weeks . Also reports chest pain, palpitations, dyspnea on exertion, and PND, x 2 weeks; states she has been sleeping upright in her chair due to SOB; c/o leg edema . C/o dry cough, , shortness of breath x 2 weeks, and pain to legs; rates pain 10/10. |
| Differential Diagnosis: | CHF DVT |
| Clinical Notes: | LUNGS: Bil lower lobes diminished to auscultation bilaterally, no wheezes/rhonchi/rales; pt in no resp distress in office . +3 pitting edema noted to BLL up to groin Patient sent to ER for acute exacerbation of CHF for possible IV lasix (currently taking 20 mg lasix at home BID) |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders G47.9 | Sleep disorder, unspecified |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | cm |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Present with grandmother for 4 week follow up after staing zoloft 25mg and buspar 3 mg PRN; still having sleep disturbance, trouble falling asleep and staying asleep d/t racing thoughts, falls asleep after a few hours but cannot stay asleep; sleeping on avg 4 hours per night; takes 10 mg melatonin 30 min before bed, then reads for a few hours then falls asleep. Reports does not feel rested in the morning. Doing counseling every other week, going well. Reports has been taking the Zoloft 25 mg daily and is 25 % better on this, but feeling "empty" and unmotivated. She feels like her mood is much more stable, but mostly down. States her anxiety, excessive worry, overthinking is much better. Using Buspar 4-5 times per week and feels like her anxiety is under control. She feels anxious before theatre so she takes more often around that. DENIES suicidal ideation, suicidal plan, physical abuse, sexual abuse. |
| Differential Diagnosis: | MDD GAD |
| Clinical Notes: | Increase Zoloft to 50mg daily and follow up in 5 weeks time. Continue using buspar as needed. Continue with counseling. |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F11.10 | Opioid abuse, uncomplicated K21.9 | Gastro-esophageal reflux disease without esophagitis R11.2 | Nausea with vomiting, unspecified |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CR |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports nausea and vomiting, especially after eating, ongoing x 3-4 months. Hx of heroin abuse, last used 2 days ago, also going to the methadone clinic daily. States she had a neg preg test at methadone clinic yesterday. Denies birth control use, states she desires pregnancy, has plans to stop heroin and methadone if she becomes pregnant. |
| Differential Diagnosis: | Cyclic vomiting syndrome GERD Gastroenteritis |
| Clinical Notes: | Start omeprazole delayed release capsule, 20 mg, 1 cap(s), orally, once a day in am, 30 day(s), 30, Refills 5 Start Tums tablet, chewable, 500 mg, 1 tab(s), chewed, once a day Lab:H. PYLORI UREASE BREATH, ADULTS Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. Start Phenergan tablet, 25 mg, 1/2 tablet - 1 tablet, orally, every 6 hrs prn, 5 days, 12, Refills 0 Pt advised on Negative SE of becoming pregnancy while using Heroin and Methadone. |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | M47.812 | Spondylosis w/o myelopathy or radiculopathy, cervical region |
| Patient Age: | 86 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | HR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Reports neck pain ongoing for a year, worse with movement of neck and activity. He was seen in the ER for this recently and had a CT scan showing spondylosis of the C-spine. He takes tylenol which helps some. He rates pain 1/10 when at rest, and up to 5-6/10 with activity |
| Differential Diagnosis: | cervical spondylosis |
| Clinical Notes: | Full ROM to cervical spine with pain to R trapezius muscle only; pain with palpation to R trapezius muscle only; no muscle spasms palpated; Negative Spurling test. Cervical arthritis Start Physical Therapy, evaluate and treat, as directed, 3 times weekly, 4 week(s) Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J01.80 | Other acute sinusitis |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | jg |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | sore throat, congestion, rhinorrhea, and sinus pain x 1 week. Reports intermittent chest pain with deep breath. Diarrhea a few times over last 1-2 weeks |
| Differential Diagnosis: | COVID 19 Influenza Sinusitis |
| Clinical Notes: | Rapid Covid and Flu negative in the office. Maxillary sinus pain upon palpation, ongoing x 9 days. Acute non-recurrent sinusitis of other sinus Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start Mucinex extended release, 600 mg, 1 tab(s), orally, every 12 hours |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | L23.5 | Allergic contact dermatitis due to other chemical products Z30.011 | Encounter for initial prescription of contraceptive pills |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | LC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Reports was using a new eye make up remover wipe product x 4-5 days and then started having redness, dryness, pain, swelling to bilateral upper eyelids. She states she stopped use of the product and the rash persisted for a few days and has now started to improve with use of hydrocortisone OTC. |
| Differential Diagnosis: | Contact dermatitis Allergic reaction |
| Clinical Notes: | Bilateral upper eyelids no longer reddened, but patient provided photo of when they were. Now they appear slightly dry with some flaking skin. D/c use of the hydrocortisone. Start Elocon cream to upper eyelids x 2 ays then discontinue use and begin a gentle moisturizer such as CereVe. Patient also requesting birth control pills, has been on some in the past but felt like she gained weight and had acne. Start Portia tablet, 30 mcg-0.15 mg, 1 tab(s), orally, once a day, 90 day(s), 90 Tablet, Refills 0 |
Case Log/Encounter
| Date: | 02/09/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R06.00 | Dyspnea, unspecified R07.9 | Chest pain, unspecified R53.83 | Other fatigue |
| Patient Age: | 32 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Patient states he noticed a somewhat tender marble sized lump on Rt testicle 2 days ago. States he has also noticed feeling overly fatigued for the last 2 weeks, and has been having intermittent left sided chest pain about once a day that lasts a few minutes and then goes away on its own. |
| Differential Diagnosis: | Testicular mass R06.00 - not found in this directory Angina Anxiety |
| Clinical Notes: | Pea sized mass palpated on the inferior Rt testicle, slightly tender to touch. Testicular US ordered EKG CBC CMP TSH |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders Z23 | Encounter for immunization |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Here for 4 week follow up from starting Zoloft 25mg daily for anxiety. Pt states she is feeling 85% better with tx; states she is happy with tx DENIES; suicidal ideation |
| Clinical Notes: | Continue with 25 mg zoloft daily x 90 days and f/u as needed. Patient declines counseling referral. |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] R05 | Cough |
| Patient Age: | 35 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TM |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Onset 3 days fatigue, chills, dry cough, sore throat, nasal congestion. Starting yesterday, onset chest tightness, anterior chest wall pain with deep inhale and cough. Denies fever. |
| Differential Diagnosis: | COVID 19 Influenza Bronchitis |
| Clinical Notes: | Pain to maxillary sinuses with palpation. LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales. 98% on room air. No acute respiratory distress noted. Rapid flu and covid both negative in office. Likely viral URI: Start Coricidin HBP Cough & Cold tablet, 4 mg-30 mg, 1 tab(s), orally, every 6 hours Start Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 30 day(s) Call back to the office if not getting any better by Friday 2/12/2021 |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F17.210 | Nicotine dependence, cigarettes, uncomplicated R53.83 | Other fatigue R74.8 | Abnormal levels of other serum enzymes |
| Patient Age: | 32 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Decreased appetite x 1.5 weeks, Low energy. States he gets more tired than usual with little exertion at work. States last night he was feeling dizzy, lightheaded and became diaphoretic so he went in to the ER. Exam was normal and he had labs, CXR, CT of head all of which came back normal with exception of elevated liver enzymes. They then added Hepatitis panel which also came back negative/normal. |
| Differential Diagnosis: | Fatty liver disease Cholecystitis |
| Clinical Notes: | Abdominal exam reveals guarding when palpating RUQ, but no murphy's sign present. Will do further workup on fatigue, low energy, as well as Liver US. Low energy Lab:THYROID STIMULATING HORMONE Lab:TESTOSTERONE,TOTAL Lab:VITAMIN D, 25 HYDROXY |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M25.511 | Pain in right shoulder |
| Patient Age: | 75 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o R shoulder pain x 6 weeks; rates pain 9/10 DENIES; radiation of pain, fall, injury; states Tylenol has been slightly helpful . |
| Differential Diagnosis: | Rotator cuff injury Arthritis |
| Clinical Notes: | No swelling or deformity noted to R shoulder; Pain with palpation to R shoulder AC joint only; Negative Drop Arm Test, Negative Empty Can Supraspinatus Test, Positive Lift off Subscapularis, Negative External Rotation, and Negative Cross-body Adduction. Equal bilateral upper extremity strength, good sensation, and capillary refill < 3 seconds. Acute pain of right shoulder Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Start Ultram tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 Notes: Rest and apply ice or moist heat for comfort. HTN (hypertension) Continue Coreg tablet, 3.125 mg, 1 tab(s), orally, 2 times a day Continue Cozaar tablet, 25 mg, 1/2 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z12.4 | Encounter for screening for malignant neoplasm of cervix Z30.41 | Encounter for surveillance of contraceptive pills |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HP-Health Promotion |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient presents for refill of birth control, taking Reclipsen 0.15 mg-0.03 mg tablet, prescribed for acne and dysmenorrhea. Denies sexual activity, would like to continue this BC method, happy with results. Due for first ever pap smear today. |
| Clinical Notes: | Pelvic exam and pap performed. Declines STI testing, not sexually active. Refilled birth control. Pregnancy test negative. |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.92 | Unspecified nonsuppurative otitis media, left ear |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JF |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt states L ear feels like water is in it; occ popping in her ear. Onset 4 days |
| Differential Diagnosis: | Otitis media Serous effusion of left TM |
| Clinical Notes: | Serous effusion noted to left TM Start Flonase spray, 50 mcg/inh, 1 spray(s), in each nostril, once a day, 30 day(s), 1 bottle, Refills 1 |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N64.4 | Mastodynia R00.2 | Palpitations R63.4 | Abnormal weight loss |
| Patient Age: | 57 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | BS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Reports weight loss of 14 pounds over last 1-2 months, noticing that he clothes are bigger, not trying to lose weight. Pt c/o sharp L breast pain for over a year that feels like "shooting pains" that come and go randomly; rates pain 6/10; Reports palpitations in her chest aproximately once a day that goes away after a few seconds. Reports dyspnea with exertion x several years, worse in the past. States she is due for her annual mammogram. |
| Differential Diagnosis: | Pleuritic chest pain Hyperthyroidism Anemia |
| Clinical Notes: | Ordered Diagnostic Mammogram Fatigue: CBC, CMP, TSH, Palpitations: EKG, CXR We will call you with the results |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J10.1 | Flu due to oth ident influenza virus w oth resp manifest R50.9 | Fever, unspecified |
| Patient Age: | 25 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | PB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | C/o fever, cough, fatigue x 7 days, taking OTC mucinex with some relief. |
| Differential Diagnosis: | Influenza COVID 19 URI viral |
| Clinical Notes: | Rapid Flu test in clinic positive for Flu A&B. Gave instructions on supportive therapy. Respirations 20/min, 98% on room air, in no apparent distress, okay to treat at home with fluids, tylenol, ibuprofen, rest. |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J45.21 | Mild intermittent asthma with (acute) exacerbation R05 | Cough |
| Patient Age: | 7 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JP |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Dry then productive (clear) cough x 9 days. Hx of asthma, taking Xyzal, Budesonide, albuterol PRN, has not used albuterol rescue inhaler in over a month. Mom states he is sleeping well through the night and relieving cough during the day with Delsym. |
| Differential Diagnosis: | Asthma exacerbation Bronchitis Pneumonia |
| Clinical Notes: | LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales. Instructed to use albuterol inhaler during the day every 4 hours as needed for coughing. Continue Delsym. Rapid Flu and COVID negative. Start prednisolone liquid, (as sodium phosphate) 20 mg/5 mL, 5 ml, orally, bid, 5 day(s), 50 Milliliter, Refills 0 |
Case Log/Encounter
| Date: | 02/08/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | L02.01 | Cutaneous abscess of face |
| Patient Age: | 13 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Follow up from urgent care 6 days ago where he was diagnosed with parotiditis following c/o left sided facial and cheek/jaw area swelling and pain. Has completed course of prednisone and half days of augmentin. Facial swelling has gotten better generally, but now having redness and smaller area of circular swelling and pain to left cheek area. |
| Differential Diagnosis: | Skin abscess Parotiditis Lymphadenopathy |
| Clinical Notes: | erythematous, tender skin abcess noted to L cheek; surrounding skin wnl . Appears to be an obvious skin abscess. Urgent referral to ENT, go directly there today for possible I&D. |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 32 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | FC |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here to follow up after 1 month of taking Zoloft 25mg and Buspar as needed. States he started taking 50 mg zoloft instead after 2 weeks because he did not feel the 25mg was working. He took 1 dose of the buspar and states it made him sick to his stomach, tried cutting it in half and 1/4 and still made him sick so he prefers not to take. |
| Clinical Notes: | He states he feels approx 50% better, still having daily anxiety. Stop buspar. Continue 50mg Zoloft x 2 weeks, then start 75mg zoloft daily and follow up in 6 weeks or sooner if needed. |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss Z30.09 | Encounter for oth general cnsl and advice on contraception |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Father brings patient in stating that she has been having a sexual relationship with someone who he states "sleeps around" and he wants her checked for "everything" and put on birth control. Patient agrees to this plan and states okay for dad to be present. She states she did have unprotected sex about 1 month ago. She also states she was sexually assaulted around age 10 and has been seeing a counselor every other week for this. |
| Clinical Notes: | counseled on all forms of birth control and patient would like a nexplanon. Referral to OBGyn for this. Testing today for pregnancy, negative. Sent for all STI testing: Lab:HEPATITIS PANEL A,B,C Lab:HERPES SIMPLEX VIRUS I & II Ab HSVAB Lab:GC CHLAMYDIA DNA PROBE,URINE Lab:TRICH UR Lab:HIV AG/AB COMBO (SCREEN) Lab:TREPONEMA PALLIDUM ANTIBODY |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.91 | Unspecified nonsuppurative otitis media, right ear Z3A.40 | 40 weeks gestation of pregnancy |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports feeling off balance and dizzy like the room was spinning 4 days ago and episode resolved with taking a hot shower and resting for about an hour. States she started to feel like ears were "filling up" again over last few days, having bilateral ear pain, and having nasal congestion with some clear and bright green drainage. Within the last few years has been having episodes of ear fullness and dizziness, Diagnosed with meniere's disease 10 years ago but not doing anything for this |
| Differential Diagnosis: | Otitis media Serous effusion Vertigo |
| Clinical Notes: | Patient declines to take flonase of other nasal spray stating that they have made her symptos recur and worsen in the past. Right TM effusion noted with no bulging or erythema; L TM WNL Start Pseudoephedrine Hydrochloride tablet, extended release, 120 mg, 1 tab(s), orally, every 12 hours follow up as needed or with your OB |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J01.00 | Acute maxillary sinusitis, unspecified M54.2 | Cervicalgia W19.XXXA | Unspecified fall, initial encounter |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | States was stepping down wooden stairs that were covered in snow and slipped and fell this past Saturday 1/30/2021. States she landed onto left back side and c/o left hip pain, bilateral shoulder pain, Rt elbow pain, and posterior midline neck pain. . She reports later that day she was turning in her car and slid on the ice into the curb. Denies airbag deployment, states she was going approx 5 mph. She states this seemed to worsen her pain from the fall. Now also having tingling and numbness in the left fingertips after fall. Also she was seen in the ED 2 weeks ago and diagnosed with URI. States she has been sinus pressure, clear to green drainage, post nasal drainage that causes occasional cough x 2 weeks now. |
| Differential Diagnosis: | Cervical radiculopathy Cervical strain Sinusitis |
| Clinical Notes: | Acute non-recurrent maxillary sinusitis Start amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Neck pain Start prednisone 10 mg tapering dose tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days then 1 tab qd x 2 days, orally, once a day, 8 day(s), 20, Refills 0 Start Acetaminophen Extra Strength tablet, 500 mg, 2 tab(s), orally, every 6 hours Imaging:RAD CERVICAL SPINE 4 VIEW MIN (CS4) Fall, initial encounter Imaging:RAD CERVICAL SPINE 4 VIEW MIN (CS4) |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | L02.416 | Cutaneous abscess of left lower limb L72.3 | Sebaceous cyst |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient was seen and diagnosed with abscess 2 days ago but preferred at that time to only try antibiotics, not to have I&D. She returns today for follow up, has been taking the bactrim and keflex and redness has decreased, but swelling the same and more painful. Patient now would like to have the I&D. |
| Clinical Notes: | I&D performed per K. Higginbotham with this student observing. Minimal amount of bloody drainage and moderate amount white waxy substance drained. Packed with iodoform gauze. Continue antibiotics and f/u in 2 days to recheck and repack if needed. |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F41.8 | Other specified anxiety disorders |
| Patient Age: | 17 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Following up today after being started Zoloft 50 mg 1 month ago for anxiety. He started taking only 25 mg instead because a few doses of the 50 mg made him to tired. He had not felt the need to take the buspar at all. |
| Differential Diagnosis: | generalized anxiety disorder major depressive disorder |
| Clinical Notes: | Sleeping well, 8-10 hrs per night, waking feeling rested. States he is no longer having any symptoms of anxiety or depression on the 25 mg dose and is happy with this, feels 100% better. Continue 25 mg daily, refilled x 6 months, please follow up sooner or call with any questions. |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K21.9 | Gastro-esophageal reflux disease without esophagitis R11.2 | Nausea with vomiting, unspecified |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Here for ER follow up - diarrhea x 4 days, nausea, vomiting x 3 days. Went to the ER and was given IV fluids and CT scan was normal. Was prescribed Protonix and Reglan and has been unable to keep pills, food, or liquids down. Also reports constant generalized abdominal pain. Had CT in ER and was found to be normal. Given scripts for reglan and protonix. ,states she is not keeping them down. |
| Differential Diagnosis: | viral gastroenteritis cyclic vomiting syndrome |
| Clinical Notes: | Start ondansetron tablet, disintegrating, 4 mg, 1 tab(s), orally, 3 times a day, 5 days, 15 Tablet, Refills 1 Start Phenergan solution, 25 mg/mL, as directed, intramuscularly, once Clear liquid diet x 24 hours and advance slowly as tolerated Continue pantoprazole delayed release tablet, 40 mg, 1 tab(s), orally, once a day Referral to GI |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | M79.644 | Pain in right finger(s) |
| Patient Age: | 66 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | kd |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o pain to bil thumbs and R middle finger x 6 weeks, worse with movement, difficulty bending and straightening the thumb. |
| Differential Diagnosis: | arthritis |
| Clinical Notes: | No swelling, deformity, Herberdens or Bouchards nodules noted to bil hands; Pain with palpation and ROM to bil thumbs and R 3rd phalange; sensation intact Start Diclofenac Sodium Topical gel, 1%, as directed, applied topically, 4 times a day, 30 day(s), 60 Gram, Refills 1 Notes: FU if symptoms persist or worsen for Ortho referrall. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | M54.5 | Low back pain |
| Patient Age: | 87 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | dk |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o low back pain x 7 days s/p working under sink; rates pain 9/10 with movement; states relieved with rest and heat; Denies any numbness of tingling anywhere |
| Differential Diagnosis: | Sciatica Lumbar strain |
| Clinical Notes: | BACK: limited range of motion of spine due to pain, no evidence of scoliosis, pain with palpation to R lumbar paraspinal muscles only; no muscle spasms palpated . NEUROLOGIC EXAM: alert and oriented x 3, no visually appreciable abnormality noted, CN's II-XII grossly intact, no focal abnormality, DTR's 2+ bilaterally and symmetric. Start Prednisone 10 mg tapering dose DP tablet, 10 mg, 4 tab(s) qd x 2 days, 3 tab(s) qd x 2 days, 2 tab(s) qd x 2 days, 1 tab(s) qd x 2 days once a day 8 day(s), orally, once a day, 8 day(s), 20, Refills 0 Start metaxalone tablet, 800 mg, 1 tab(s), orally, 3 times a day, 7 day(s), 21, Refills 0 Notes: Rest and apply moist heat or ice to back for comfort. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K21.9 | Gastro-esophageal reflux disease without esophagitis R09.1 | Pleurisy |
| Patient Age: | 46 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | es |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports midsternal chest burning on and off x 2 weeks, has tried pepcid and TUMS which helps some but does not completely relieve the pain. States this became worse after eating mongolian beef. She has changed her diet to bland and this has helped. |
| Differential Diagnosis: | GERD Pleurisy |
| Clinical Notes: | Start omeprazole delayed release capsule, 20 mg, 1 cap(s), orally, once a day in am on empty stomach, 30 day(s), 30, Refills 0 Start Tagamet HB tablet, 200 mg, 1 tab(s), orally, 2 times a day, 14 days, 28 Tablet, Refills 0 Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension L02.31 | Cutaneous abscess of buttock L03.317 | Cellulitis of buttock |
| Patient Age: | 28 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports possible cyst on left buttock x 5 days that started out seeming like a pimple but has grown in size and is more painful. rates pain 9/10; Denies any drainage. . |
| Differential Diagnosis: | cutaneous abscess cellulitis |
| Clinical Notes: | erythema, warmth, and exquisite tenderness to touch L medial buttocks, center of lesion has small scab with no drainage noted; lesion is very thickened and hard . Patient declines I&D today, pleading to start antibiotics and see if improves. Follow up in 3 days to recheck. Cellulitis of buttock Start SMZ-TMP DS tablet, 800 mg-160 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start Cephalexin Monohydrate capsule, 500 mg, 1 cap(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn pain, 7 days, 28, Refills 0 Notes: Go to the ER if symptoms worsen, fever, chills, nausea/vomiting, etc |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J01.80 | Other acute sinusitis |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | KD |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for ER follow up. Pt states she was Positive for COVID 2 weeks ago; , decreased appetite, fatigue, weakness x 2 weeks; states she is starting to feel better today . Went to MGH ER 5 days ago for earache and sinus pain and was given Bactrim; is taking with relief of headache and sinus pain. |
| Differential Diagnosis: | sinusitis - improving |
| Clinical Notes: | Acute non-recurrent sinusitis of other sinus Continue Bactrim DS tablet, 800 mg-160 mg, 1 tab(s), orally, 2 times a day Continue Fluticasone Propionate spray, 50 mcg/inh, as directed, in each nostril, once a day, 30 day(s) Continue Mucinex tablet, extended release, 600 mg, 1 tab(s), orally, every 12 hours |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | D64.9 | Anemia, unspecified E11.9 | Type 2 diabetes mellitus without complications F41.9 | Anxiety disorder, unspecified I10 | Essential (primary) hypertension I48.91 | Unspecified atrial fibrillation L98.9 | Disorder of the skin and subcutaneous tissue, unspecified R42 | Dizziness and giddiness S09.90XA | Unspecified injury of head, initial encounter |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TF |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 2-Some Help from the Preceptor |
| Dx 4: Student Participation: | 2-Some Help from the Preceptor |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Weakness in bilateral legs ; sleep disturbance due to racing thoughts; states he's up every few hours. Pt states he feels scared and worried all the time; History of bleeding ulcers diagnosed after having EGD and colonoscopy, states he was placed on pantoprazole per Dr. Barrisdo but only took for 10 days because then he got a rash and peeling to his face. Stopped taking but still having this rash and facial peeling on and off. Reports Rt knee pain after a fall last week. States he drank some beers and then also had "too much whiskey" and fell onto his Rt knee outside, states "maybe I slipped on the ice." . Reports dizziness at rest, worse upon standing, getting progressively worse over last 1 week. States he has fallen 3 times, did hit his head once, but denies LOC. . Reports red rash to face last week and then facial skin was peeling, so he discontinued his pantoprazole, but rash and peeling still comes and goes. He also states his back sometimes "feels like it's sunburnt." states lesions bleed when he itches them . |
| Differential Diagnosis: | Anemia Alcoholism Orthostatic Hypotension Hypoglycemia |
| Clinical Notes: | Referral to Derm for skin complaints Labs ordered: CBC, CMP, TSH, A1C, UA, MRI of brain Follow up with GI about bleeding ulcers, restart taking Pantoprazole |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications E78.5 | Hyperlipidemia, unspecified F41.8 | Other specified anxiety disorders M79.644 | Pain in right finger(s) M79.645 | Pain in left finger(s) |
| Patient Age: | 50 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DN |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Reports had a panic attack yesterday, had full body sweats, heart racing, and had to do some deep breathing exercises to calm herself down. She states she is feeling anxious every day, not sleeping well, trouble falling alseep and waking a few times each night, sometimes feeling panicked. States she has a lot of extra stress going on in life right now with a recent divorce, has to be out of her apartment in a few months, needs to file for bankruptcy. States she has been on medication for anxiety and depression since age 30 (effexor, xanxax, many others that she cannot remember) but went off of all of her medications 3 years ago because she thought she had a seizure, but never had this checked out. She states symptoms have been getting progressively worse over last few years. Reports some thoughts of harming self such as going out into the cold or drowning herself, has these thoughts approx 2 times per week. States she has no intention or plan to do these things. also states her blood glucose levels at home have never been less than 150 and she is taking her metformin and lantus. Also due for annual labs |
| Differential Diagnosis: | Major Depressive Disorder Generalized Anxiety Disorder Adjustment disorder |
| Clinical Notes: | Depression with anxiety Start sertraline tablet, 50 mg, 1 tab(s), orally, once a day, 30 day(s), 30, Refills 0 Start BusPIRone Hydrochloride tablet, 30 mg, 1 tab(s), orally, 2 times a day prn anxiety, 30 day(s), 60, Refills 0 Type 2 diabetes mellitus without complication, unspecified whether long term insulin use Refill metformin tablet, extended release, 500 mg, 1 tab, orally, bid, 30 day(s), 60 Tablet, Refills 2 Increase Lantus Solostar Pen solution, 100 units/ml, as directed, subcutaneously, 18 units at bed time, 30 day(s), 1 bottle, Refills 2 Lab:BASIC METABOLIC PROFILE Lab:LIPID PROFILE Lab:GLYCATED HEMOGLOBIN Notes: Increase Lantus by 2 units every 3 days until FBGL's range around 100-120 then hold at that dosage. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified E28.2 | Polycystic ovarian syndrome F41.9 | Anxiety disorder, unspecified |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Here for acute visit, her doctor's office did not have any available appointments and she is needing refill on Metformin which she takes for PCOS. |
| Clinical Notes: | PCOS (polycystic ovarian syndrome) Refill metformin tablet, 500 mg, 1 tab(s), orally, 2 times a day, 90 days, 180, Refills 1 Hypothyroidism Continue Synthroid tablet, 100 mcg (0.1 mg), 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 02/03/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated I10 | Essential (primary) hypertension J02.9 | Acute pharyngitis, unspecified R05 | Cough |
| Patient Age: | 36 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | Z.B. |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports fever, generalized aching, fatigue. Sore throat x 3 days, states he started feeling this way after his car got stuck in the snow and he was out in the cold for 2 hours, clear drainage from nose, fever yesterday (100.5), was COVID tested at his work but pending x 5 days Also having headaches 2-3 times per day and feels like BP running high. Today 144/89 |
| Differential Diagnosis: | COVID 19 Influenza strep throat |
| Clinical Notes: | POC tests for Rapid Strep, Rapid Flu, and Rapid COVID all negative in the office. Ordered chest Xray due to inspiratory and expiratory wheezes and rhonchi in uppr lung fields, diminished in bases. Hx of daily smoker. will call with CXR results and f/u accordingly A |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G25.81 | Restless legs syndrome K21.9 | Gastro-esophageal reflux disease without esophagitis R10.11 | Right upper quadrant pain Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Presents for annual physical and med refill - on gabapentin for restless leg syndrome which is working well. She is seeing Ob/Gyn next month for mammo and pap. She c/o heartburn 2-3 times per month, especially after eating chocolate or having caffeine, not currently taking any medication daily for this. Takes TUMS which helps but does not completely relieve the pain. States she will have some nausea and has vomited once with these episodes. Reports last episode was last week and states she still feels some soreness in the Rt chest at times. States when she has these episodes, she will then change to a bland diet which seems to help. she used to be on a daily preventative medication for GERD but no longer taking it. |
| Differential Diagnosis: | Cholecystitis Cholelithiasis GERD |
| Clinical Notes: | Annual labs CBC, CMP, TSH, Lipid profile, Vitamin D Gallbladder US ordered |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | L03.211 | Cellulitis of face |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | sc |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt states he was working with a large open pipe than fell back and hit him on his face; patient states that today he woke up and noticed his face was swollen. Patient feels he can hardly move right jaw, denies any LOC. Reports he feels like there is swelling around Rt eye as well which makes it hard to see at times out of Rt eye. |
| Differential Diagnosis: | Contusion Cellulitis Facial bones fracture |
| Clinical Notes: | Start Bactrim DS tablet, 800 mg-160 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start Keflex capsule, 500 mg, 1 cap(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Notes: Go to the ER if symptoms persist or worsen. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z30.011 | Encounter for initial prescription of contraceptive pills |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | OW |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Presents for counseling on contraception. States she just recently became sexually active last month for first time. States she used protection and is not concerned about any STI's, denies any vaginal itching, discharge, or pain. She is leaning toward birth control pills but would like to hear about all of the options. |
| Clinical Notes: | POC pregnancy test in office - negative. Pap not required at this time, patient declines STI testing. Counseled on all forms of birth control including referral to Ob/Gyn for nexplanon or IUD if desired. Patient still desires to try bc pills at this time. Prescription for Portia 30mcg/0.15mg tablet, take 1 tablet daily |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G89.29 | Other chronic pain I10 | Essential (primary) hypertension M79.671 | Pain in right foot M79.672 | Pain in left foot |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports pain to bilateral feet and ankles, rates pain 9/10; worse with prolonged standing; having pain 2-3 x per week, made better with aleve and rest, occ gout flare ups about once a year; saw a Podiatrist in Muncie and was told he has arthritis in his feet |
| Differential Diagnosis: | rheumatoid arthritis arthritis gout |
| Clinical Notes: | Counseled on possible RA and workup, but patient does not have insurance and would like to do minimal lab testing at this time. Start tramadol tablet, 50 mg, 1 tab(s), orally, every 6 hours Start meloxicam tablet, 7.5 mg, 1 tab(s), orally, once a day, 30 day(s), 30 Orders: Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:ERYTHROCYTE SEDIMENTATION RATE Lab:URIC ACID Lab:C-REACTIVE PROTEIN Imaging:RAD FOOT 3 VIEW BILAT |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K52.9 | Noninfective gastroenteritis and colitis, unspecified |
| Patient Age: | 19 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 19-year-old male patient presenting to the emergency department with complaint of no appetite. He was diagnosed with Covid recently and just finished his period of isolation. He states that during Covid he did not have much of an appetite either but over the last week he has not felt like eating anything. States that he has nausea and typically vomits if he tries to eat something. He has not had any vomiting today. He is not complaining of any abdominal pain. Denies fever or chills. Denies cough or shortness of breath. Denies chest pain. Denies any hematemesis. He has a documented allergy to promethazine. He states "it is just weird" and that is why he came in to be evaluated this evening. He is awake and alert, afebrile and nontoxic, no acute distress. |
| Differential Diagnosis: | gastroenteritis covid 19 |
| Clinical Notes: | Zofran as prescribed for nausea. Push fluids to maintain hydration. No spicy, greasy or fatty foods. No alcohol or caffeine. Consider clear liquids over the next 24 hours then go to a bland diet. Slowly advance your diet as tolerated. Follow up with your primary care provider for reevaluation as necessary. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to the emergency department for reevaluation. Scripts Ondansetron (ONDANSETRON ODT) 4 Mg Tab.rapdis 4 MG PO Q8H PRN for Nausea/Vomiting, #9 TAB 0 Refills |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K04.7 | Periapical abscess without sinus |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | This is a 26-year-old male patient who presents to the emergency department with complaints of left upper dental pain for 3 days. He states that he went to his dentist a month and a half ago and was told that he has a "bad tooth" and is scheduled to see them again for possible surgery. He states that today he was drinking a beer just prior to arrival and the beer touching the left upper gumline caused a "warm and tingly" feeling. He states that when he ran his tongue across his gumline he felt like there was an area of swelling. He denies any difficulty swallowing, fever, body aches. He has been using salt water rinses at home. He denies any known past medical history and is not taking any routine medications. He is afebrile, nontoxic, in no acute distress. |
| Differential Diagnosis: | dental abscess dental infection gingivitis |
| Clinical Notes: | Practice good dental hygiene. Warm salt water gargles may be helpful for dental pain. It is very important that you follow up with a dentist as soon as possible. I have provided a dental list as a resource for you. If you are a smoker, quit smoking. Complete full course of antibiotics as prescribed. Return to the emergency department for any new or worsening symptoms, as discussed. Scripts Penicillin V Potassium 250 Mg/5 Ml (PENICILLIN V POTASSIUM 250 MG/5 ML) 250 Mg/5 Ml Soln.recon 10 ML PO Q6H for 7 Days, #280 ML 0 Refills |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K92.0 | Hematemesis R10.84 | Generalized abdominal pain |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ED |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | This is a 19-year-old female patient who presents to the emergency department today with complaints of ongoing abdominal pain. She states that she has had problems with abdominal pain for the last 6 years and has seen her primary care doctor but has never had any testing done. She states that for the last 6 months she is started to notice blood in her stool. She states that today she noticed bright red blood in her emesis starting today. She states that the abdominal pain is worse after eating. She has a past medical history of diabetes and high blood pressure but states she was recently diagnosed with these and is not taking any medication. She also complains of a heartburn anytime she eats anything, but is not taking any medication for this. She was on ranitidine in the past but she has stopped taking this. She is afebrile, nontoxic, in no acute distress. |
| Differential Diagnosis: | gastroenteritis ulcerative colitis peptic ulcer |
| Clinical Notes: | Take omeprazole daily as prescribed. Push fluids to maintain hydration. No spicy, greasy or fatty foods. No alcohol or caffeine. Avoid NSAIDs (ibuprofen, aleve, naproxen, etc.) and aspirin. Avoid eating large meals. Avoid eating 2-3 hours before bed time. Follow up with your primary care provider for reevaluation. You may benefit from GI referral for further evaluation of these symptoms. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to the emergency department for reevaluation. Scripts Omeprazole 20 Mg (OMEPRAZOLE 20 MG) 20 Mg Capsule.dr 20 MG PO DAILY, #30 CAP |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K03.81 | Cracked tooth K04.7 | Periapical abscess without sinus |
| Patient Age: | 34 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ZS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | This is a 34-year-old male patient who presents to the emergency department today with complaints of right upper dental pain. He states that 2 weeks ago he believes a filling came out of one of his right upper molars. He states he had pain to this area for 1 to 2 days, but then it went away on its own. He reports that this evening he began having pain to that area again along with headache and pain to right jaw and some right-sided facial swelling. He denies any known fevers, body aches, or chills. He denies any past medical history or taking any routine daily medications. He is a smoker. He has taken 800 mg ibuprofen around 9 PM today but states this did not help much. He denies any neck pain, sore throat, or difficulty swallowing. He is afebrile, nontoxic, and in no acute distress. |
| Differential Diagnosis: | dental infection dental abscess |
| Clinical Notes: | Patient has a history of tooth pain. There is no evidence of acute dental fracture, Ludwig's angina (patient has no neck swelling, difficulty swallowing, stridor, trismus, dysphagia or submandibular stiffness), peridental abscess. This patient will need proper dental followup. At this time, I will treat this patient symptomatically on an outpatient basis, as there is no obvious sign of infection that requires drainage or hospital admission. Patient will be discharged home on antibiotics. Discussed at length proper follow up and return precautions. Patient understood diagnosis and is in agreement with the plan. Dental list provided as a resource to arrange proper dental follow up. Practice good dental hygiene. Warm salt water gargles may be helpful for dental pain. It is very important that you follow up with a dentist as soon as possible. I have provided a dental list as a resource for you. If you are a smoker, quit smoking. Complete full course of antibiotics as prescribed. Return to the emergency department for any new or worsening symptoms, as discussed. Scripts Diclofenac Potassium 50 Mg (DICLOFENAC POTASSIUM 50 MG) 50 Mg Tablet 50 MG PO BID PRN for Pain, #20 TAB 0 Refills WITH FOOD Penicillin V Potassium 500 Mg (PENICILLIN V POTASSIUM 500 MG) 500 Mg Tablet 500 MG PO Q6H for 7 Days, #28 TAB 0 Refills |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B34.9 | Viral infection, unspecified |
| Patient Age: | 10 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RT |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 10-month 6-day-old male infant presenting to the emergency department with mom for evaluation of fever. For the last 2 days he has had a fever intermittently that she has been managing with Tylenol and ibuprofen at home. Last dose of Tylenol was at 2 PM, last dose of Motrin at 6 PM. She states that the fever does respond to the medication but "it comes back higher". States that today he had 2 episodes of vomiting. No diarrhea. Normal appetite and fluid intake. Normal wet diapers. He has not been pulling on his ears. He has had some rhinorrhea. No cough. No recent ill contacts. States that he has had a diaper rash recently that she has been managing with butt paste and it is getting better. Mom reports he is otherwise healthy, born full-term, all vaccinations are up-to-date with the exception of the this years influenza vaccination. No known drug allergies. No routine prescription medications. |
| Differential Diagnosis: | Otitis media Pneumonia COVID 19 |
| Clinical Notes: | Child is awake and alert, nontoxic in appearance. Does not appear acutely ill. Appears well-hydrated. Serology testing is negative for strep, influenza, RSV and COVID-19. Lungs are clear to auscultation throughout, no hypoxia or tachypnea, no respiratory distress. There is no reported history of cough or wheezing at home. I have a low suspicion for lower respiratory tract involvement at this time therefore I did not obtain chest x-ray. Discussed this with mom and she verbalized understanding and was agreeable with foregoing imaging at this time. Child is still maintaining adequate fluid intake and having normal wet diapers. Urinalysis is negative for any evidence of infection at this time, urine culture will be obtained for definitive evaluation. Child was given medication for fever and did have some defervescence here in the emergency department. I am suspicious symptoms may be likely secondary to viral syndrome. I have recommended continuation of symptomatic care and pediatric follow-up. Reviewed all test results. Reviewed all discharge instructions with the parent/guardian and they verbalized understanding. They are agreeable with the treatment plan and deny further questions or concerns prior to discharge. Strict return instructions were discussed and parent/guardian verbalized understanding. Patient stable for discharge. Push fluids. You may use Children's Tylenol and/or ibuprofen over-the-counter per package instructions as necessary for pain or fever, see dosage chart included. Follow up with your pediatrician for reevaluation. If you do not have a primary care provider/pediatrician, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to the emergency department for reevaluation. |
Case Log/Encounter
| Date: | 01/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K52.9 | Noninfective gastroenteritis and colitis, unspecified |
| Patient Age: | 22 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | cd |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | This is a 22-year-old male patient who presents to the emergency department today with complaints of abdominal pain, nausea, vomiting, and diarrhea for the last 3 days. He was seen in this ER last night for the same symptoms and prescribed naproxen and Zofran. He states that he has been taking the Zofran and it "helps for a few hours and then comes right back". He states the pain and nausea becomes worse after eating so he has been trying to eat smaller meals. He also states he has been having 4-5 diarrhea stools per day. He reports lightheadedness when he stands. He denies fever, chest pain, or shortness of breath. He denies any known medical history, does not take any prescriptions daily, and denies abdominal surgical history. He is afebrile, nontoxic, and is in no acute distress. |
| Differential Diagnosis: | GASTROENTERITIS COLITIS DIVERTICULITIS APPENDICITIS |
| Clinical Notes: | Cbc Auto Diff Included Comprehensive Metabol Pnl Cmp Lipase Metoclopramide 10 mg IV Sodium Chloride 1000ml at 125ml/hr Iv Invasive Line Ed Enteric panel stool Famotidine 20 MG IV Phenergan as prescribed for nausea. Phenergan may make you drowsy. Do not take this medication and drive, operate machinery or drink alcohol. Push fluids to maintain hydration. No spicy, greasy or fatty foods. No alcohol or caffeine. Consider clear liquids over the next 24 hours then go to a bland diet. Slowly advance your diet as tolerated. Follow up with your primary care provider for reevaluation as necessary. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to the emergency department for reevaluation. Scripts Promethazine Hcl (PHENERGAN) 25 Mg Tablet |
Case Log/Encounter
| Date: | 01/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | S01.412A | Laceration w/o foreign body of left cheek and TMJ area, init |
| Patient Age: | 32 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 32-year-old male patient presenting to urgent care for evaluation of laceration left side of his head. States that he was head butted by a goat 2 to 3 hours ago. He has a superficial laceration to the left temporal region. He states that he has cleaned it but it has been oozing/bleeding since it started. Denies any headache or dizziness. Denies loss of consciousness. Denies any visual changes. Denies any ear pain or bleeding from the ears. Denies any other complaints or concerns. He is unsure of his last tetanus. He has no known drug allergies. He is awake and alert, afebrile and nontoxic, no acute distress. |
| Differential Diagnosis: | laceration abrasion avulsion wound |
| Clinical Notes: | Tetanus shot given. 3 sutures to the left temporal area of scalp. Skin reapproximated well. Keep sutures dry and intact. Monitor for signs/symptoms of infection such as redness, drainage, warmth, swelling, increased pain, etc. Follow up in 5-7 days for suture removal. You may follow-up with your primary care provider for suture removal or return to urgent care. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to urgent care or go to the emergency department for reevaluation |
Case Log/Encounter
| Date: | 01/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B34.2 | Coronavirus infection, unspecified |
| Patient Age: | 42 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | WS |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 42-year-old male patient presenting to urgent care reporting loss of taste and smell that he noticed today. States yesterday he had some nasal congestion and thought he was just getting a "head cold". Denies any fever or chills. He has had a minimal nonproductive cough. No chest pain or shortness of breath. No abdominal pain, nausea or vomiting. No generalized body aches. He states he has had some fatigue. He does report that a couple of guys at work this week have tested positive for COVID-19. He has no known drug allergies. He takes lisinopril daily. He is awake and alert, no acute distress. He is afebrile and nontoxic. |
| Differential Diagnosis: | covid 19 sinusitis allergic rhinits |
| Clinical Notes: | Push fluids. Rest. You may use Tylenol over-the-counter per package instructions as necessary for pain or fever. You are to isolate at home for 10 days from symptom onset (1/22/2021). You may return to work after 10 days from symptom onset (2/2/2021) as long as you have not had a fever for 24 hours without fever reducing medications and your symptoms have improved. Please refer to CDC guidelines and your employer's policies with regard to returning to work after your period of isolation. Stay home except to get medical care. Restrict activities outside your home. Do not go to work, school, or public areas. Avoid using public transportation. As much as possible, separate yourself from other people in your home. Use a separate bathroom, if available. Call ahead before visiting your doctor if you have a medical appointment. Wear a facemask when you are around other people and before you enter a healthcare provider's office. Cover your mouth and nose with a tissue when you cough or sneeze, then throw used tissues away. Wash your hands often. Wash hands with soap and water for at least 20 seconds, especially after coughing/sneezing/etc, after using the bathroom and before eating. Avoid touching your eyes, nose and mouth with unwashed hands. Do not share personal household items (dishes, drinking glasses, towels, etc.) with other people in your home. Seek prompt medical attention if your illness is worsening (i.e. increasing fever, difficulty breathing, breathing fast, etc.). If you have a medical emergency and need to call 911, notify the dispatch personnel that you have, or are being evaluated for COVID-19. If possible, put on a facemask before emergency medical services arrive. |
Case Log/Encounter
| Date: | 01/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.00 | Acute maxillary sinusitis, unspecified |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AR |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | This is a 28 year old female patient who presents to urgent care today with complaints of nasal congestion with left sided sinus tenderness for 8 days. She denies any known or suspected covid exposures recently and had covid 3 months ago. She has tried to take sudafed at home without much relief. She denies any shortness of breath, chest pain, loss of taste or smell, or diarrhea. She denies any fever or sore throat. She has a history of anxiety and depression and takes Effexor daily. She has no known allergies. She is afebrile, non-toxic, and in no acute distress. |
| Differential Diagnosis: | allergic rhinitis sinusitis URI |
| Clinical Notes: | Push fluids. Rest. Flonase as directed for nasal congestion and postnasal drainage. Complete full course of antibiotics. Follow up with your primary care provider for reevaluation as necessary. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to urgent care or go to the emergency department for reevaluation. Scripts Amoxicillin/Potassium Clav 875-125 (AUGMENTIN 875-125 TABLET) 1 Each Tablet 875 MG PO BID for 10 Days, #20 TAB 0 Refills |
Case Log/Encounter
| Date: | 01/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | H01.001 | Unspecified blepharitis right upper eyelid |
| Patient Age: | 50 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | A-Antepartum Visit |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 50-year-old female patient presenting to urgent care for evaluation of redness to the right eye since yesterday. Symptoms have worsened since onset. She is complaining of some redness and crusting discharge to the outer aspect of the right eye. She is not complaining of any associated pain or burning. No photophobia. No recent injury or trauma to the eye. She denies that she has been rubbing or scratching the eye. She denies any changes in vision. She does report a history of histoplasmosis in the left eye and chronic visual problems. She wears glasses, she does not wear contacts. She denies any fever or chills, denies any recent illness. Denies chest pain or shortness of breath. Denies headache, nausea or vomiting. She has allergies to penicillins, tuberculin PPD. She is not reporting any routine prescription medications at home. She is awake and alert, in no acute distress. She is afebrile and nontoxic. Last Tetanus Shot: UNKNOWN |
| Differential Diagnosis: | blepharitis chalazion Conjunctivitis |
| Clinical Notes: | Patient presenting for evaluation of redness to the right eye. No recent injury or trauma reported. No evidence of serpiginous uptake, no vesicular lesions, no dermatomal rash or other signs or symptoms to increase my suspicion for herpes zoster. No fever or chills, no pain with extraocular movements, no visual changes, no proptosis, no headache/nausea/vomiting, or other associated symptoms to suggest orbital cellulitis or acute glaucoma. Her visual acuity is normal for her. She does have redness just lateral to the outer canthus and along the lateral upper eyelid as well as some yellow crusting appearing discharge. I am suspicious for blepharitis. She was encouraged to use warm compresses daily, perform daily hygiene care of the eyelid and I will prescribed erythromycin ointment. She was encouraged to follow-up with her ophthalmologist early next week, Monday ideally, for reevaluation. Reviewed all discharge instructions with the patient and patient verbalized understanding. Patient is agreeable with the treatment plan and denies further questions or concerns prior to discharge. Strict return instructions were discussed and patient verbalized understanding. Patient stable for discharge. Impression: Primary Impression: Blepharitis of right eye Admitting Patient: No Time of Disposition: 17:51 Disposition: 01 HOME, SELF-CARE Condition: Stable Patient Instructions: Treating Blepharitis: Self-Care, What Is Blepharitis? Additional Instructions: Warm compresses several minutes a couple times a day will help with drainage and inflammation. Cleanse the eyelid margins daily. Apply erythromycin ointment as prescribed. Follow-up with your ophthalmologist early next week for recheck. Return to the emergency department for pain, any purulent discharge, changes in vision, pain with eye movements, fever, or any other new or worsening symptoms, as discussed. Scripts Erythromycin Base (Erythromycin) 1 Gm Oint...g. 1 CM OP QID for 7 Days, #1 TUBE 0 Refills |
Case Log/Encounter
| Date: | 01/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J01.10 | Acute frontal sinusitis, unspecified |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | This is a 63 year old female who presents to urgent care for evaluation of sinus pressure and congestion for the last 7 days. She states that she gets sinus infections a few times per year and is supposed to use Flonase daily but has not been using it. She states she "always" has a dry cough, but over last week, it has been more productive (green, yellow). She reports mild dyspnea with exertion which is unchanged from her normal. She denies any chest pain, shortness of breath, loss of taste or smell, sore throat, or fever. She denies any nausea, vomiting, or diarrhea. She is awake and alert, afebrile and nontoxic. She has allergies to sulfa, Augmentin, clindamycin, doxycycline and levofloxacin. |
| Differential Diagnosis: | COVID 19 Sinusitis Allergic rhinitis |
| Clinical Notes: | Patient Instructions: ED Sinusitis (Antibiotic Treatment) Additional Instructions: Push fluids. Rest. Flonase as directed for nasal congestion and postnasal drainage. Complete full course of antibiotics. Follow up with your primary care provider for reevaluation as necessary. If you do not have a primary care provider, please call Marion General Hospital access line 765-660-6444, they will help you get in contact with a provider. For acute worsening or new symptoms, please return to urgent care or go to the emergency department for reevaluation. Scripts Cefdinir 300 Mg (OMNICEF 300 MG) 300 Mg Capsule 300 MG PO BID for 10 Days, #20 CAP 0 Refills |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L02.412 | Cutaneous abscess of left axilla |
| Patient Age: | 49 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | ctf |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o sore in left axilla x 10 days. States he squeezed it a few nights ago and pus came out. He states he has taken a few antibiotics from home that he had leftover, and area has decreased in swelling, but still having pain |
| Differential Diagnosis: | cutaneous abscess axillary lymphadenopathy folliculitis |
| Clinical Notes: | Incision and drainage to left axilla, cultures collected. Treatment: Cutaneous abscess of left axilla Start Bactrim DS tablet, 800 mg-160 mg, 1 tab(s), orally, 2 times a day, 10 day(s), 20 Tablet, Refills 0 Notes: Keep area clean and dry. Remove packing tomorrow; hold warm compress to area to help promote drainage; FU Monday for recheck. Procedures: I & D Indication Abscess. Prep We cleaned the skin with Betadine and alcohol . Anesthesia We anesthetized with Xylocaine 1% . Guidance We used palpation for guidance. Technique We used an 11-blade to incise the skin contiguous with the abscess cavity. Yield The fluid was blood-tinged with large amount of white waxy substance . Result This substantially decompressed the swelling. Dressing We placed a clean dressing. Tolerance The patient tolerated the procedure well. |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M51.36 | Other intervertebral disc degeneration, lumbar region M54.41 | Lumbago with sciatica, right side M79.609 | Pain in unspecified limb R20.2 | Paresthesia of skin Z91.19 | Patient's noncompliance w oth medical treatment and regimen |
| Patient Age: | 47 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Rt lower back pain x 5 days, constant, radiating to the Rt groin, Rt lateral thigh numbness. Denies any known injury. Denies any loss of bladder or bowels.. NEUROLOGIC Numbness in Rt lateral thigh, lower leg and foot.. |
| Differential Diagnosis: | Lumbar disc herniation Sciatica Lumbar strain |
| Clinical Notes: | Acute right-sided low back pain with right-sided sciatica Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets x 4 days, then 2 tablets x 4 days, then 1 tablet x 4 days then stop, orally, once a day, 12 days, 24 tablets, Refills 0 Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn, 7 days, 28, Refills 0 Start Depo-Medrol suspension, 80 mg/mL, as directed, by intra-articular injection, once, 1 dose(s) Imaging:MRI LUMBAR SPINE WITHOUT (L1) |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E87.1 | Hypo-osmolality and hyponatremia F17.200 | Nicotine dependence, unspecified, uncomplicated R60.0 | Localized edema |
| Patient Age: | 31 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | cz |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | States he has been eating a lot of tuna, salted nuts, and drinking gatorade; weight gain of 5 lbs in 1 month. Pt c/o BLL edema since yesterday |
| Differential Diagnosis: | DVT Dependent edema Congestive heart failure |
| Clinical Notes: | Treatment: Bilateral lower extremity edema Lab:COMPREHENSIVE METABOLIC PANEL Notes: Drink plenty of water and decrease salt intake in diet. PVU. Hyponatremia Lab:COMPREHENSIVE METABOLIC PANEL |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension I50.22 | Chronic systolic (congestive) heart failure J96.11 | Chronic respiratory failure with hypoxia K21.9 | Gastro-esophageal reflux disease without esophagitis R10.12 | Left upper quadrant pain |
| Patient Age: | 62 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DC |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Hx of leukemia CLL and recently stopped oral chemo due to drop in BP, has been talking with her oncologist about possible starting back on infusions. Today episodic visit for c/o upper middle abdominal pain x 4 days and nausea and vomiting after eating yesterday. Also today feeling more short of breath than normal she noticed when walking into the office, was 90% on her normal 3L and had to increase to 4L. |
| Differential Diagnosis: | Pancreatitis Pneumonia Diverticulitis |
| Clinical Notes: | pt c/o epigastric and LUQ abdominal pain x 3 days s/p eating greasy food; c/o nausea, vomiting, and light grey/tan colored stool today, hx of GERD but states is diet controlled Treatment: Gastroesophageal reflux disease without esophagitis Start Pepcid tablet, 20 mg, 1 tab(s), orally, 2 times a day, 30 day(s), 60 Tablet, Refills 1 Notes: Avoid spicy, greasy foods, onions, citrus fruits, eating late at night, caffeinated beverages, alcohol, and smoking as all of these things make GERD worse. Elevate HOB to help reduce symptoms, Do not lie flat for 2-3 hours after eating. May take Gaviscon prn pain relief. Left upper quadrant abdominal pain Lab:COMPLETE BLOOD COUNT Lab:COMPREHENSIVE METABOLIC PANEL Lab:AMYLASE LEVEL Lab:UA REFLEX Lab:LIPASE Imaging:RAD CHEST PA & LATERAL (CXR) |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N89.8 | Other specified noninflammatory disorders of vagina N95.2 | Postmenopausal atrophic vaginitis |
| Patient Age: | 72 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o vaginal itching constant since 12/21/2020, but then she had a colonoscopy and was told she had an intestinal yeast infection and that it was cleared out by the colonoscopy prep. Hx of hysterectomy, not sexually active x 3 years. Incontinence intermitently x "years" and has had bladder lift x 2 in 30's |
| Differential Diagnosis: | Candidiasis of vulva and vagina Lichens sclerosis Atrophic vaginitis |
| Clinical Notes: | Start Premarin Vaginal cream with applicator, 0.625 mg/g, as directed, intravaginally, once daily at bedtime x 21 days; then 3x a week, 30 day(s), 1 TUBE, Refills 3 Notes: Atrophic vaginitis material was printed. |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated I10 | Essential (primary) hypertension J45.21 | Mild intermittent asthma with (acute) exacerbation R05 | Cough |
| Patient Age: | 42 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Reports sore throat, postnasal drip, x 6 days , dry cough , wheezing, shortness of breath; states he always uses his inhaler 1-2x daily his entire life. |
| Differential Diagnosis: | Acute exacerbation of asthma COVID 19 URI |
| Clinical Notes: | Treatment: Mild intermittent asthma with acute exacerbation Start Anoro Ellipta powder, 62.5 mcg-25 mcg/inh, 1 puff(s), inhaled, once a day, 30 day(s) Continue Albuterol HFA aerosol, 90mcg/inh, 1-2 puff(s), inhaled, every 4-6 hours, prn Cough Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated H61.22 | Impacted cerumen, left ear H66.002 | Acute suppr otitis media w/o spon rupt ear drum, left ear R05 | Cough |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | NH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports fever (101.8 at home), decreased appetitie, fatigue, left earache, sore throat, sinus congestion, and headache. Also Productive (green reported) cough x 1 week; shortness of breath at times while sitting. |
| Differential Diagnosis: | Otitis media Pneumonia URI |
| Clinical Notes: | R TM wnl; L TM serous effusion noted s/p cerumen removal, lung sounds clear, dry cough noted Non-recurrent acute suppurative otitis media of left ear without spontaneous rupture of tympanic membrane Start Amoxicillin tablet, 875 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Start Flonase spray, 50 mcg/inh, 2 spray(s), in each nostril, once a day, 30 day(s), 1 bottle, Refills 0 Cough Lab:SARS ANTIGEN COVID POC Negative |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J45.20 | Mild intermittent asthma, uncomplicated R50.9 | Fever, unspecified |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports fever 101 last night and then today started having chest tightness, headache, cough, and sore throat. Exposed to COVID in the healthcare setting for work. |
| Differential Diagnosis: | COVID-19 Influenza URI |
| Clinical Notes: | COVID-19 Notes: Rest at home, push fluids, take Tylenol as needed for pain/fever, and self quarantine x 10 days; Go to the ER for shortness of breath. PVU. Fever, unspecified fever cause Lab:SARS ANTIGEN COVID POC Positive BUSCH,SUMMER A 01/22/2021 01:59:09 PM EST > symptomatic, pos Mild intermittent asthma without complication Refill Xopenex HFA aerosol, 45 mcg/inh, 2 puff(s), inhaled, every 4-6 hours prn wheezing/dyspnea, 30 day(s), 1, Refills 1, Notes: prn |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N89.8 | Other specified noninflammatory disorders of vagina R32 | Unspecified urinary incontinence Z20.2 | Contact w and exposure to infect w a sexl mode of transmiss |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | DG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports she had unprotected sex 2 months ago and is concerned about possible UTI, yeast infection and/or STD. C/o malodorous vaginal discharge, decreased urine output, and generalized abdominal cramping and diarrhea. Denies use of birth control. |
| Differential Diagnosis: | UTI gonorrhea/chlamydia BV |
| Clinical Notes: | Pelvic exam performed with collection of swabs for BV, trich, yeast, urine sent for UA and gonorrhea and chlamydia. Femoral lymphadenopathy present upon exam. Patient declines birth control. She states she just had a pap smear done a few months ago. Counseled on safe sex. Testing for above mentioned STI's as well as bloodwork ordered for hepatitis, Syphillis, HIV, and Herpes sim 1&2. |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N17.9 | Acute kidney failure, unspecified R65.21 | Severe sepsis with septic shock |
| Patient Age: | 57 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LL |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Here for transitional care management, hospital admission follow up. She was admitted to the hospital with kidney stone, had stent placement and became septic and was intubated and on vasopressors. She was admitted x 2 weeks and then set up for outpatient dialysis 3 x week. She has been going to dialysis but feeling overly weak, having palpitations daily. she did have Afib with RVR while in the hospital but has not followed up on this. Emotionally she is also feeling overwhelmed and gets what feels like a panic attack every time before going into dialysis. She has been checking BP at home daily and it is running in the 180-190's over 80-90's each day. She is currently taking Metoprolol Tartrate 25mg BID. |
| Differential Diagnosis: | Chronic kidney failure Hypertension Panic disorder |
| Clinical Notes: | Called and set up for Nephrology follow up next week Cardiology referral for possible Afib/palpitations Increase metoprolol to 50mg BID Labs today CMP, TSH |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F17.200 | Nicotine dependence, unspecified, uncomplicated M25.561 | Pain in right knee |
| Patient Age: | 55 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | MUSCULOSKELETAL pt c/o pain in Rt anterior lateral knee x 4 days, with radiation to posteior knee and down the lateral side of Rt leg and into Rt ankle. C/o pain in the knee joint with movement and walking and pain in the Rt ankle with movement and walking. No known injury to the area. |
| Differential Diagnosis: | DVT Joint Effusion Knee Sprain |
| Clinical Notes: | Treatment: Acute pain of right knee Start TraMADol Hydrochloride tablet, 50 mg, 1 tab(s), orally, every 6 hours prn, 7 days, 28, Refills 0 Imaging:Doppler : Venous, RLE |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M54.5 | Low back pain N18.3 | Chronic kidney disease, stage 3 (moderate) |
| Patient Age: | 64 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o back pain x 4 weeks, worse with cough, movement, reaching behind, getting up from recliner, and lifting. Started taking naproxen yesterday because pain was much worse and it helped somewhat. Took ibuprofen this AM and he is now having minimal discomfort. |
| Differential Diagnosis: | Lumbar sprain Lumbar disc herniation Pyelonephritis |
| Clinical Notes: | BACK: No pain with palpation to lumbar vertebral spine or paraspinal muscle; no muscle spasms palpated; Negative Straight Leg Raises . ABDOMEN: no masses palpated, soft, non-tender, no organomegaly, bowel sounds are normal, no guarding or rigidity, non-distended. NEUROLOGIC EXAM: alert and oriented x 3, no visually appreciable abnormality noted, CN's II-XII grossly intact, no focal abnormality, DTR's 2+ bilaterally and symmetric. Treatment: Acute bilateral low back pain without sciatica Start Prednisone 20 mg Taper tablet, 20 mg, 3 tablets x 4 days, then 2 tablets x 4 days, then 1 tablet x 4 days then stop, orally, once a day, 12 days, 24 tablets, Refills 0 Start metaxalone tablet, 800 mg, 1 tab(s), orally, 3 times a day, 7 day(s), 21, Refills 0 Notes: Apply ice or moist heat to back for comfort. Essential hypertension Continue lisinopril tablet, 40 mg, 1 tab(s), orally, once a day at hs Continue amlodipine tablet, 10 mg, 1 tab(s), orally, once a day Continue spironolactone tablet, 25 mg, 1 tab(s), orally, 2 times a day Stage 3 chronic kidney disease Stop ibuprofen capsule, 200 mg, 1 cap(s), orally, every 6 hours prn back pain Notes: Do not take Aleve, IBU, or Advil due to kidney function. |
Case Log/Encounter
| Date: | 01/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L73.9 | Follicular disorder, unspecified Z80.3 | Family history of malignant neoplasm of breast |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ID |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Pt c/o a lump under her left armpit, noticed it approx 1 month ago while putting on deodorant, states it went away x 2 weeks then came back. states area is painful when she moves the arm a certain way. Denies any drainage from the lump, nipple retraction or nipple discharge.Mother had left sided triple negative breast CA diagnosed at age 32 and had partial mastectomy, chemo, and radiation through age 33 and has not had any recurrence since. |
| Differential Diagnosis: | axillary lymphadenopathy Folliculitis axillary cutaneous abscess |
| Clinical Notes: | BREASTS: nipples unremarkable, no nipple discharge, no axillary lymphadenopathy. SKIN: warm and dry, small superficial palpable lump to left axilla. No erythema, opening in skin or drainage noted. Patient denies pain to palpation of the area. Folliculitis Start mupirocin topical ointment, 2%, 1 app, applied topically, 3 times a day, 5 day(s), 15 Gram, Refills 0 Family history of breast cancer in first degree relative Lab:BRCA 1 AND 2 SEQUENCING |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G47.00 | Insomnia, unspecified |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient reports problems with falling asleep since she was a teenager. During adolescence, she states she took many different medications to combat this, including amitriptyline, ambien, melatonin, and a few others that she cannot remember. She was apprehensive to trying any medication, but has recently changed her mind and would like to try something. She states she goes to bed every night at 8pm with her 5yo daughter who sleeps in the same bed with her, and it takes her about 1-1.5 hours to fall alseep. She then wakes up approx 5-6 times per night, and feels tired all day. She drinks 5-6 cups of caffeine per day (tea) and last drink is normally around 3:30pm. |
| Differential Diagnosis: | insomnia caffeine dependence poor sleep hygiene, screen time use |
| Clinical Notes: | Start trazodone 50mg daily at bedtime Lifestyle modifications and sleep hygiene materials given Advised not to use phone once in bed. Advised possible considering having her daughter sleep train to sleep alone. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension K21.9 | Gastro-esophageal reflux disease without esophagitis R11.2 | Nausea with vomiting, unspecified R50.9 | Fever, unspecified R93.3 | Abnormal findings on dx imaging of prt digestive tract Z72.0 | Tobacco use |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | AK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Patient was seen in ER late last night/early this AM and advised to follow up asap for possible GI referral. He was seen for abdominal pain, nausea, vomiting, had CT scan done and was dx with possible Achalasia of the esophagus. He was also given IV fluids, zofran, and pepcid. He has been dx with GERD in the past but is not currently taking anything, has not been seen by GI. |
| Differential Diagnosis: | GERD Achalasia Gastroenteritis |
| Clinical Notes: | Urgent referral given for Dr. Barrido, GI specialist. Please follow up ASAP. Start ondansetron 4mg ODT every 4 hours as need for n/v. Start Pepcid 20mg BID Start omeprazole 20mg DR capsule, once daily May use Gaviscon PRN pain relief |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified E11.9 | Type 2 diabetes mellitus without complications E78.5 | Hyperlipidemia, unspecified F17.200 | Nicotine dependence, unspecified, uncomplicated F34.1 | Dysthymic disorder I10 | Essential (primary) hypertension |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | dc |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient here for follow up and chronic disease management to have medications all renewed and written for 90 days at a time instead of previous 30. She is also reporting nausea and vomiting episodes at least 2 times per week that result in her needing to leave work. She previously had GI upset when trying the januvia, ozempic, and other injectables for DM but these have been dc'd and Metformin increased to 1000mg BID. |
| Differential Diagnosis: | Medication side effect Gastroenteritis Gastroparesis |
| Clinical Notes: | Refill Losartan 12.5 once daily Refill Hydrochlorithiazide 12.5mg daily Decrease Metformin to 500mg ER twice daily Start Glimeperide 2mg once a day Start Atorvastatin 10mg due to recent high cholesterol in labs and 30.4% score for ASCVD risk factor |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension L08.9 | Local infection of the skin and subcutaneous tissue, unsp S61.552A | Open bite of left wrist, initial encounter W55.01XA | Bitten by cat, initial encounter |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | pt c/o cat bite to L wrist 2 days ago; c/o pain to the wrist with movement, and redness and warmth to the wrist and distal forearm. |
| Differential Diagnosis: | cellulitis animal bite |
| Clinical Notes: | Start Augmentin tablet, 875 mg-125 mg, 1 tab(s), orally, every 12 hours, 10 day(s), 20, Refills 0 Continue Norco tablet, 325 mg-5 mg, 1 tab(s), orally, bid prn Notes: Monitor area for signs of worsening infection and go to the ER if develops. Continue spironolactone tablet, 25 mg, 1 tab(s), orally, twice a day Continue Metoprolol Succinate ER tablet, extended release, 50 mg, 1 tab(s), orally, once a day Continue amlodipine tablet, 5 mg, 1 tab(s), orally, once a day Continue losartan tablet, 25 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia I10 | Essential (primary) hypertension I25.10 | Athscl heart disease of native coronary artery w/o ang pctrs R07.89 | Other chest pain R11.0 | Nausea |
| Patient Age: | 65 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AH |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Here for follow up on recent ER visit for chest pain. She was told all results were normal and dx with atypical chest pain, advised to follow up with cardiology and PCP, and get echo. |
| Clinical Notes: | Pt states she has not had any chest pain since being discharged from the hospital, states that she is feeling ok today and states she has been getting light headaches and states that she needs new glasses and thinks that is the cause of the headaches , states does not have any complaints or concerns today, pt would like a script for nausea medication she states at times she is nauseated. States she never got an order for the echo and never followed up with cards in feb 2020 due to snow. New referral to f/u with cards, and ordered echo. Continue metformin tablet, 1000 mg, 1 tab(s), orally, 2 times a day Continue Levemir Flextouch pen, 100 u/ml, 20 units, subq, bid Start Ondansetron Hydrochloride tablet, disintegrating, 4 mg, 1 tab(s), orally, 3 times a day prn nausea, 5 day(s), 15, Refills 0 Continue Toprol XL tablet, extended release, 50 mg, 1 tab(s), orally, once a day Continue lisinopril tablet, 20 mg, 1 tab(s), orally, once a day Continue Lipitor tablet, 40 mg, 1 tab(s), orally, once a day (at bedtime) Continue Aspirin Enteric Coated delayed release tablet, 81 mg, 1 tab(s), orally, once a day |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B08.5 | Enteroviral vesicular pharyngitis J02.9 | Acute pharyngitis, unspecified |
| Patient Age: | 17 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ct |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Reports sore throat, headache, sinus congestions, rhinorrhea, earache, x 2 days, productive cough, body aches. |
| Differential Diagnosis: | covid 19 influenza strep pharyngitis |
| Clinical Notes: | Erythema notes to palatoglossal arch with ulceration noted to left arch. COVID 19 test negative in office Start lidocaine 2% oral solution, use before meals and at bedtime. Take tylenol every 4 hours and motrin every 6 hours as needed for pain as directed on package instructions for dosing. Rest and drink plenty of fluids. Herpangina materials were printed for patient. |
Indiana Code for Prescriptive Authority
210406091705_IC_25_23_1_19.5Advanced_practice_registered_nurses_authority_to_prescribe_drugs.pdf (.5Advanced_practice_registered_nurses_authority_to_prescribe_drugs) 0.03mb
Indiana Code for NP APN RX Authority Law 848 IAC 4-1-4
210406091621_Indiana_Code_4_1_4_NP_Defined.pdf (.pdf) 0.26mb 
Prescriptive authority application
210406090800_Prescription_Authority_Application_blank_.pdf (.pdf) 0.59mb
Malpractice Insurance for UINDY
210406094340_2020_2021_Student_Professional_Liability_Certificate.pdf (.pdf) 0.04mb
Malpractice Application (blank) for personal coverage as NP
210406092345_Medical_Malpractice_Insurance_Application.pdf (.pdf) 0.34mb
Professional References
Stacey Murrell - MSN, RN, WHNP
Phone: (317)797-7532 | Email: stacey.murrell@eskenazihealth.edu
Kim Lovelady - MSN, RN, FNP-C
Phone: (765)673-4133 | Email: kim.lovelady@mgh.net
Eric Emery - MSN, RN, FNP-C
Phone: (765)667-6160 | Email: ericemeryjr@gmail.com
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