Affiliations (Universities & Colleges)Updated: 04-13-21
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AssignmentsUpdated: 04-07-21
Association & Society MembershipUpdated: 04-07-21
Cases & Case LogsUpdated: 04-25-21
Clinicals / Clerkships / ExternshipsUpdated: 01-19-21
Competency AssessmentsUpdated: 04-10-21
Courses TakenUpdated: 04-07-21
Immunization HistoryUpdated: 03-15-22
Licenses & CertificationsUpdated: 03-02-22
MiscellaneousUpdated: 04-07-21PresentationsUpdated: 04-11-21Recommendations & ReferencesUpdated: 03-01-22
Resume & CVUpdated: 03-01-22
Reviews & EvaluationsUpdated: 04-15-21
SkillsUpdated: 04-07-21
salary and benefit
These are two websites that are informational when looking at a NP contract. It helps you remain competitive while negotiating terms.
ViewCase 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: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F43.12 | Post-traumatic stress disorder, chronic I10 | Essential (primary) hypertension |
| Patient Age: | 54 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 3 month follow up with PTSD |
| Clinical Notes: | patient has a failed UDS with Klonpin use A referral was sent to physch to. One month script given. Education provided on how to wean |
Case Log/Encounter
| Date: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C90.00 | Multiple myeloma not having achieved remission J20.9 | Acute bronchitis, unspecified R05 | Cough Z92.25 | Personal history of immunosupression therapy |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| 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: | cough and sinus pressure, Worried that she has bronchitis |
| Clinical Notes: | amxicilling 500 BID x 5 days |
Case Log/Encounter
| Date: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.49 | Type 2 diabetes w oth diabetic neurological complication I10 | Essential (primary) hypertension M25.511 | Pain in right shoulder |
| Patient Age: | 65 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| 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: | Yes |
| Chief Concern and Patient Notes: | 3 month follow up for HTN/DM2 |
| Clinical Notes: | Hgb A1c is 6.3, down from 7.1 reinjury in the right shoulder. Sent to ortho |
Case Log/Encounter
| Date: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | 41 |
| 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 |
| Chief Concern and Patient Notes: | 1 month follow up: HTN |
| Clinical Notes: | The patient's blood pressure is at goal. However, the patient is on lisinopril and was developed a dry, lingering, annoying cough. Switched losartan Education provided on side affects ASL interrupter present |
Case Log/Encounter
| Date: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified E11.21 | Type 2 diabetes mellitus with diabetic nephropathy E78.2 | Mixed hyperlipidemia I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 67 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Home Visit |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 45 |
| 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 |
| Chief Concern and Patient Notes: | yearly medicare wellness visit. |
| Clinical Notes: | The patient is doing well at this time. No new issues. The patient just recently welcomed a son six months ago. Medications refilled, yearly labs ordered. The patient has completed cologaurd for colon screening |
Case Log/Encounter
| Date: | 04/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F41.1 | Generalized anxiety disorder G47.411 | Narcolepsy with cataplexy |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JJ |
| Type of Decision Making: | Straight Forward |
| 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 |
| Chief Concern and Patient Notes: | 3 month follow up for depression, anxiety, and narcolepsy with medication refill |
| Clinical Notes: | The patient is doing well. Medications were refilled at this time. Will follow up in another three months. Labs will have to be drawn next time before medications will be refilled. |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 14 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| 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 |
| Chief Concern and Patient Notes: | cough, fever, loss of taste and smell, muscle aches |
| Clinical Notes: | Rapid COVID and flu A/B are negative. Watch and wait for ten days, call back if symptoms worsen. Take Sudafed and Flonase. |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B02.8 | Zoster with other complications |
| Patient Age: | 65 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TB |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | ED follow |
| Clinical Notes: | Patient presents with shingles surrounding the right eye and scalp. the patient was placed on the appropriate treatment in the ED. Gabapentin re-ordered for another 10 days as well as Ibruphfen 600mg TID for 10 days. Stress the importance of seeing an opth. tomorrow. Also to call her dermatologist because she has presently started an immunosuppressive therapy for her plaque psoriasis. |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F41.1 | Generalized anxiety disorder |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KW |
| Type of Decision Making: | Straight Forward |
| 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 |
| Chief Concern and Patient Notes: | follow up on anxiety and depression |
| Clinical Notes: | medications are working well. Will follow up in 6 months |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.31 | Mood disorder due to known physiol cond w depressv features F41.1 | Generalized anxiety disorder |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KD |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | one month follow up for anxiety and depression |
| Clinical Notes: | 25 mg of Zoloft daily is not working. Increased to 50 mg and encouraged the patient to take her buspar regularly. The patient is wanting to loose weight. She is requesting Adepex. referral given to weight loss clinic and education given on diet and exercise. |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F41.1 | Generalized anxiety disorder |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HM |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 3 month follow up on stress and anxiety |
| Clinical Notes: | The patient refused to go to counseling or to accept that she is depressed. She however did agree to start buspar. Will follow up in one month virtually. FMLA paperwork dropped off |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.610 | Type 2 diabetes mellitus w diabetic neuropathic arthropathy I10 | Essential (primary) hypertension |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MM |
| Type of Decision Making: | Straight Forward |
| 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 |
| Chief Concern and Patient Notes: | HTN and DM follow up |
| Clinical Notes: | Patient's blood pressure is at goal at this time. Medications refilled. HgbA1c ordered with labs. Metformin refilled. Will follow up with labs. see again in 6 months |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | unsteadiness |
| Clinical Notes: | Rachel is a 34 year old female with Downs and is non verbal. Her parents report that she has been slightly unsteady on her feet and requires holding her onto them with walking. upon exam, the patient is noted to have bilateral TM congestion. The patient has been on the same antihistamine for the past 10 years. educated to add Flonase and to change her antihistamine ever three months. |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia I10 | Essential (primary) hypertension J30.2 | Other seasonal allergic rhinitis R05 | Cough Z72.0 | Tobacco use |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MD |
| 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): | 20 |
| 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: | 6 month follow up for DM and HTN |
| Clinical Notes: | Blood pressure is at goal 138/84, refilled medications the patient reports that she has been checking her BP three times weekly in the AM when fasting. Range of results are 110-150s. Ordered HbgA1c with labs Patient also reports a cough for greater than three months. She is awakened by the cough frequently at night. The patient does present with new onset of allergic rhinitis. CXR ap and lat ordered CBC, CMP, TSH, Lipid profile, and Vit D level ordered. Will follow up in 6 months |
Case Log/Encounter
| Date: | 04/20/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M25.511 | Pain in right shoulder |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NB |
| 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: | unresolved right shoulder pain |
| Clinical Notes: | very limited ROM in the right shoulder/arm. Unable to preform a drop arm test. The patient had in injury in the same arm to years ago related to strain from a work injury. Referred the patient to PT, completed an Xray, and referred the patient to ortho. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C50.919 | Malignant neoplasm of unsp site of unspecified female breast Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KH |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV labs infusion |
| Clinical Notes: | recurrent triple negative breast cancer. Patient has bone mets and is currently receiving monthly zometa infusions. Xeloda 2 weeks on 2 weeks off. Disease is shrinking at this time. Will continue with treatment and scan every three months |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | A04.7 | Enterocolitis due to Clostridium difficile C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 67 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KP |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV labs Chemo |
| Clinical Notes: | Treatment was placed on hold at this time. The patient has been to GI for unresolved CDIFF. The patient will be re-evaluated in 4 weeks after treatment is completed for CDIFF and switch treatment to Gemzar at this time |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JP |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV labs chemo |
| Clinical Notes: | second reoccurrence of non-small cell lung cancer. Responding well to weekly carbo/taxol. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C18.0 | Malignant neoplasm of cecum E09.65 | Drug or chemical induced diabetes mellitus w hyperglycemia R06.6 | Hiccough Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 48 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GR |
| 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): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV labs chemo |
| Clinical Notes: | two more cycles of chemo, wait one month, have surgical resection. Update provided to general surgeon. The patient has steroid induced hyperglycemia. Metformin 500 mg BID started. NV is well controlled with antiemtics at this time. Will hold steroids this round to evaluate reduction in blood sugars and hiccoughs. Thorazine was ordered to reduce hiccoughs as needed. Follow up for OV, labs, and chemo in two weeks. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C71.9 | Malignant neoplasm of brain, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GH |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 4 wk follow up post treatment with scans |
| Clinical Notes: | No progression is seen at this time. Cancer is stable at this time. Will continue to observe. Repeat scans and labs in 3 months. Anticipate this aggressive cancer to reoccur within this time frame. educated on s/s to note recurrence. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C95.10 | Chronic leukemia of unsp cell type not achieve remission Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 74 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV. Labs. Treatment |
| Clinical Notes: | Patient is on BR treatment. Patient is doing well at this time. The patient has an ANC of 1100. Threshold for this treatment is 1000. Platelet count and PS are normal at this time. OK to treat. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C18.9 | Malignant neoplasm of colon, unspecified Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 77 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and review post treatment PET scan. |
| Clinical Notes: | Cancer is stable at this point. Will follow up again with CT CAP in 3 months. |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C91.10 | Chronic lymphocytic leuk of B-cell type not achieve remis D69.6 | Thrombocytopenia, unspecified Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 69 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and Chemo |
| Clinical Notes: | Patient is doing well at this time. However, the patient has an ANC of 1244 and low platelets of 31. Treatment on hold for one week. Will redraw labs and treat at this time |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C64.2 | Malignant neoplasm of left kidney, except renal pelvis L03.114 | Cellulitis of left upper limb L03.116 | Cellulitis of left lower limb Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 82 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, Chemo, Labs |
| Clinical Notes: | Patient has med. renal cell CA. The patient devolved bilateral lower ext. cellulitis. Treatment with one round of keflex was affective. The patient has an appointment with wound care later this week. The bilateral legs are very dry and scabbed over. Peri skin is pink. No pain with palpation |
Case Log/Encounter
| Date: | 04/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung E87.6 | Hypokalemia R22.43 | Localized swelling, mass and lump, lower limb, bilateral |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MW |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | OV, labs, chemo |
| Clinical Notes: | Patient is Opdivo. This immunotherapy causes edema in lower extremities. 5 days of Lasix 20mg. Helpful. Will complete another 5 days of Lasix 20 mg and add 10 meq of potassium for one week. K is 3.3 at this time. Proceed with treatment at this time. |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.2 | Malignant neoplasm of middle lobe, bronchus or lung |
| Patient Age: | 91 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RM |
| 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: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | new patient |
| Clinical Notes: | Stage on squamous cell CA. referral made to RXT for SBRT |
Case Log/Encounter
| Date: | 04/14/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z79.01 | Long term (current) use of anticoagulants |
| Patient Age: | 49 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MJ |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 1 year follow up anticoag therapy post cellerbral infarct |
| Clinical Notes: | Ok to continue therapy. See in one year |
Case Log/Encounter
| Date: | 04/14/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, treatment |
| Clinical Notes: | Ok to treat, Labs reviewed. ANC WNL. Opdivo |
Case Log/Encounter
| Date: | 04/14/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C18.4 | Malignant neoplasm of transverse colon |
| Patient Age: | 65 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | NT |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and Treat |
| Clinical Notes: | Labs, ANC, and performance status are all WNL. ok to treat (herceptin) |
Case Log/Encounter
| Date: | 04/14/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C50.919 | Malignant neoplasm of unsp site of unspecified female breast J84.114 | Acute interstitial pneumonitis |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Hospital follow up |
| Clinical Notes: | pneumonitis related to Piqkray (oral mant, therapy for breast CA). Hold treatment for 1 month. Longer steroid taper. The patient has not recovered well . OV, labs, TX 1 month |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VR |
| 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 |
| Chief Concern and Patient Notes: | constipation |
| Clinical Notes: | increase water intake and miralax BID for 4 days then daily |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.39 | Type 2 diabetes w oth diabetic ophthalmic complication E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp F06.30 | Mood disorder due to known physiological condition, unsp I10 | Essential (primary) hypertension R06.02 | Shortness of breath Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 74 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | PG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Medicaid 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 |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | new patient |
| Clinical Notes: | referral to endo POCT Hgb A1c 9.3 improved from 10.6 Referral to PULM clinical for pulmonary rehab Labs Zoloft follow up in one month |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G40.89 | Other seizures Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 54 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EK |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| 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: | yearly wellness exam |
| Clinical Notes: | Wellness exam without abnormal findings. Yearly labs ordered. Tergatrol level ordered. |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 84 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| 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: | Medicare annual wellness |
| Clinical Notes: | Medicare annual wellness visit. Health normal with age and history However, the patient had an elevated BP x 3. Will have patient monitor BP daily at home for 2 weeks and call with daily recordings. Fear of "white coat syndrome" |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R22.31 | Localized swelling, mass and lump, right upper limb S46.312A | Strain of musc/fasc/tend triceps, left arm, init |
| Patient Age: | 59 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: | 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: | shoulder hurts, nails hurt, and thumb hurts |
| Clinical Notes: | left upper arm muscle strain Limited ROM with left thumb, painful Xray ordered |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.31 | Mood disorder due to known physiol cond w depressv features F41.1 | Generalized anxiety disorder |
| Patient Age: | 67 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| 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 |
| Chief Concern and Patient Notes: | one month follow up on anxiety and depression |
| Clinical Notes: | medication are helping. Continue current regimen and see in three months |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R06.02 | Shortness of breath R21 | Rash and other nonspecific skin eruption |
| Patient Age: | 29 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BM |
| 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 |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | new patient establish care |
| Clinical Notes: | Patient reports that he was born with a clasped lung, has asthma (he gets his medications from his dad, or he will go to the ED and get meds), but has never had PFT done. PVTs ordered along with an albuterol inhaler. Lungs were tight and the patient was SOB. 80mg of IM dex ordered and administered. Patient has lesions, open areas, excoriation, and dry skin to bilateral hands. Referal sent to derm/ |
Case Log/Encounter
| Date: | 04/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | L98.9 | Disorder of the skin and subcutaneous tissue, unspecified |
| Patient Age: | 78 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Recurrent boils |
| Clinical Notes: | The patient has had recurrent "boils" to the head for the past 4 months. The patient has not been seen, but other providers have been calling in keflex. The patient has had 6 rounds of keflex . Patient is in today for a different antibiotics. Areas are suspicious for squamous cell CA. Urgent referral sent to Derm. No antibiotic was sent at this time. |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.9 | Candidiasis, unspecified |
| Patient Age: | 37 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: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yeast in folds |
| Clinical Notes: | The patient is morbidly obese. the patient was educated on proper care of folds. nystatin and zinc oxide were ordered. Will follow up in 2 weeks |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F41.1 | Generalized anxiety disorder Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| 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 |
| Chief Concern and Patient Notes: | new patient visit |
| Clinical Notes: | Here to establish care/ Referred to OBGYN, no pap ever, attempting to get pregnant for one year. Not ovulating per home testing |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M76.02 | Gluteal tendinitis, left hip |
| Patient Age: | 81 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 |
| Chief Concern and Patient Notes: | Left hip pain |
| Clinical Notes: | negative leg raise. Muscle tightness/spasm in the left glut. Education on stretching, ice/heat |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N94.5 | Secondary dysmenorrhea |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PS |
| 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 |
| Chief Concern and Patient Notes: | BC refill |
| Clinical Notes: | Patient has been out of BC since January. UPT negative. Medication refilled |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J44.9 | Chronic obstructive pulmonary disease, unspecified R05 | Cough |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SL |
| 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 |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | PTs COPD is not well controlled. Placed the patient on a triple inhaler. 30 day supply. Set up an appointment for one month to ensure that the patient is doing well and the switch of medication is okay with her provider. |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.21 | Type 2 diabetes mellitus with diabetic nephropathy F51.01 | Primary insomnia I10 | Essential (primary) hypertension K21.9 | Gastro-esophageal reflux disease without esophagitis |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| 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: | F/U on HTN and DM |
| Clinical Notes: | HbgA1c at 5.6. down form 6.1 6 months ago. Continue metformin 500 mg BID. Blood pressure is not at goal. 168/88, 158/88. Patient was not taking medication correctly. Re-educated on how to take medications. Will follow up for a blood check. Labs ordered and medications are refilled |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M54.16 | Radiculopathy, lumbar region |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DC |
| Type of Decision Making: | Straight Forward |
| 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: | Yes |
| Chief Concern and Patient Notes: | 6 month follow up on hip pain |
| Clinical Notes: | Pain to right hip has improved some. however, the numbness is worse from below the knee to the foot. Decreased distance of walking. Referred to Spine triage Center |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis Z34.02 | Encntr for suprvsn of normal first preg, second trimester |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| 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 |
| Chief Concern and Patient Notes: | dry cough and chest tightness |
| Clinical Notes: | allergic rhinitis. Flonase daily to both nostrils. Education given on body changes with pregnancy. |
Case Log/Encounter
| Date: | 04/13/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M25.551 | Pain in right hip R53.1 | Weakness Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ON |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 40 |
| 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: | Establish care |
| Clinical Notes: | Patient was released on Sunday from the IU West hospital. The patient was told that the has cancer because he lesions on the hip bone and hypercalcemia. The patient is having hip pain at this time. He will follow up with oncology tomorrow. Pain and care are deferred to oncology at this time. Will request IU West records and follow up in three months. |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F17.200 | Nicotine dependence, unspecified, uncomplicated F17.220 | Nicotine dependence, chewing tobacco, uncomplicated G47.52 | REM sleep behavior disorder Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 27 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| 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): | 45 |
| 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: | Yes |
| Chief Concern and Patient Notes: | establish care |
| Clinical Notes: | Patient in to establish care. C/O sleep apnea like behaviors. Referred to sleep study. Night time awakening, snoring, doesn't wake up feeling rested, and can fall asleep at any time. The patient notes that he is depressed and it makes him angry. He wants to stop smoking, but is not wanting to stop "chewing" Started Welbutrin mg daily for depression and smoking cessation. Blood pressure is slightly elevated at 138/88. will have the patient record BP daily for one month. Educated verbal and written on diet and exercise. Follow up in one month |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R73.09 | Other abnormal glucose Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 47 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CV |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 6 month follow up for high blood sugar |
| Clinical Notes: | patient in for a check of HgbA1c. 6.1 today. Pre-DM. Started on metformin 500mg daily for one week and then BID there after. Will see again in three months. 25 minutes if education provided verbal and written education. Will see again in 3 months |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SW |
| 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 |
| Chief Concern and Patient Notes: | Sore throat |
| Clinical Notes: | history of chronic strep throat. Rapid stress test was negative. PND, bilateral TM congestion, and frontal sinus pressure |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B02.8 | Zoster with other complications |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CB |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | rash, blisters, and pain to the back that come around to the belly botten |
| Clinical Notes: | positive for shingles rash/infection. The patient is immunocompromised. Status post kidney transplant 1 year ago. Vincyclovir TID x 10 days. tylenol for pain per patient request |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TC |
| 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 |
| Chief Concern and Patient Notes: | pain in the left abdomen above the groin |
| Clinical Notes: | CT from February was full of stool. Advised the patient to use miralax two times daily for the next 4 days until still is soft and formed like a snake. |
Case Log/Encounter
| Date: | 04/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings Z23 | Encounter for immunization |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Patient in today for second men B vaccine and wants to have labs drawn. |
| Clinical Notes: | Men B vaccine administered. Labs (CBC, CMP, TSH, Free T4, Vit d, and lipid panel) were drawn because her mother has an enlarged thyroid and she wants to make sure she does not have the same problem. |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N30.01 | Acute cystitis with hematuria R30.0 | Dysuria |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CL |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | hematuria and dysuria |
| Clinical Notes: | vaginal discharge Dysuria Hematuria UA + for WBC and moderate leukocytosis vaginal swab for BV sent out Augmentin BID x 7 days |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.30 | Mood disorder due to known physiological condition, unsp F41.1 | Generalized anxiety disorder Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ED |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 6 month follow up for depression and hypertention |
| Clinical Notes: | patient is not taking his Effexor correctly. Extensive time spent on education. How to take the medication, setting reminders, and the side effects of Effexor. Will follow up in one month. |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp E78.2 | Mixed hyperlipidemia I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| 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: | Medicare physical |
| Clinical Notes: | Exam completed. Labs ordered medications refilled will see again in 6 months |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D32.9 | Benign neoplasm of meninges, unspecified |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SL |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | C-Counseling |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Mass to brain on CT |
| Clinical Notes: | The patient was referred to neuro surgery. The area does not appear to be cancer at this time. Will follow up. If mass is not operable, RXT therapy can be used |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Patient is in to review PET scan results. |
| Clinical Notes: | Due to the patient's age, her and her family wish to not receive treatment and bring hospice onboard. Referral made. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D61.818 | Other pancytopenia |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CJ |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | consult for pancytopenia |
| Clinical Notes: | This patient is known to the service for chronic iron and blood transfusions related to DAVE syndrome. Added perimeters for transfusions and three days or iron IV infusions. Will chart review over the next three days and sign off. Ordered iron studies, TIBC, ferritin |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C44.92 | Squamous cell carcinoma of skin, unspecified K85.1 | Biliary acute pancreatitis R06.02 | Shortness of breath R10.84 | Generalized abdominal pain R53.83 | Other fatigue |
| Patient Age: | 72 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Abd pain, SOB, extreme fatigue |
| Clinical Notes: | no further items to add. Will allow internal medications will add |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C32.3 | Malignant neoplasm of laryngeal cartilage C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JA |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, Labs, TX |
| Clinical Notes: | patient cleared to receive Keytruda |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C64.9 | Malignant neoplasm of unsp kidney, except renal pelvis Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 81 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | FM |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, TX |
| Clinical Notes: | patient has no complaints and was cleared for treatment. Will rescan next visit not note changes on the CT CAP that are mixed. No DX progression suspected. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C90.00 | Multiple myeloma not having achieved remission D61.01 | Constitutional (pure) red blood cell aplasia R06.02 | Shortness of breath R53.83 | Other fatigue |
| Patient Age: | 89 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MD |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | SOB, decreased activity tolerance, and extreme fatigue |
| Clinical Notes: | Patient has MM. The patient did not want to complete treatment. Hemoglobin is 5.6. 1U PRBC ordered for today and tomorrow morning. Talked with the patient about treatment options, blood requirements, and hospice. Follow up next week to note family choice. However, will recheck CBC on Friday 4/9 |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C16.9 | Malignant neoplasm of stomach, unspecified D70.8 | Other neutropenia Z00.01 | Encounter for general adult medical exam w abnormal findings Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 81 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | LH |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and TX |
| Clinical Notes: | Patient is cleared to receive herceptin. The patient has been running low grade fevers (Tmax 100.1 oral this morning). Patient has and ANC of 855. Doxycycline 100mg PO BID x 7 days ordered. will follow up in three weeks and complete scans before visit to monitor treatment response. |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia E66.01 | Morbid (severe) obesity due to excess calories I10 | Essential (primary) hypertension M47.897 | Other spondylosis, lumbosacral region M79.7 | Fibromyalgia |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| 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 |
| Chief Concern and Patient Notes: | Pain medication refill |
| Clinical Notes: | patient in for bimonthly UDS and medication refills. Medication changed to OXY ER 10 mg BID and norco 5/325 1-2 tabs Q 8 hours PRN. Gabapentin refilled. Blood pressure is not at goal. Added a combination blood pressure pill. Yearly labs ordered. CBC, CMP, TSH, Lipid profile, Vit D, hemoglobin A1C, and CRP. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C50.929 | Malignant neoplasm of unsp site of unspecified male breast Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 75 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DJ |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and TX |
| Clinical Notes: | Patient has been on mat. therapy for 4 years. Doing well. No disease progression. Ok to proceed with treatment. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 79 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KW |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, TX |
| Clinical Notes: | Patient is doing well. Maintaining weight. ok to proceed with Alimta and X-geva. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.0 | Candidal stomatitis C09.1 | Malig neoplasm of tonsillar pillar (anterior) (posterior) Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BD |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, TX, FU on oral thrush/infected PEG tube, and RXT |
| Clinical Notes: | Clearance for treatment with weekly cisplatin. Daily RXT therapy. The patient was strain HPV 16 positive. Thrush and PEG tube infection are healing and progressing nicely without complications. Treatment may be administered. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C76.0 | Malignant neoplasm of head, face and neck Z51.11 | Encounter for antineoplastic chemotherapy |
| Patient Age: | 68 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: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, and TX |
| Clinical Notes: | Patient was seen for clearance to receive cycle 3 of Carbo/taxol. Patient is well enough for treatment. Follow up in two week. Order CT head, neck, CAP at this time for treatment response. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J90 | Pleural effusion, not elsewhere classified J96.01 | Acute respiratory failure with hypoxia R11.0 | Nausea R11.10 | Vomiting, unspecified |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Admitting through the ED. SOB, increased O2 use |
| Clinical Notes: | Intractable N/V. ARF. Patient was started on IV steroids. Doing well. Increased O2 demand. Home O2 evaluation ordered. Patient's BL O2 is 3L and she is now on 5L. Plan to discharge within 2 days. |
Case Log/Encounter
| Date: | 04/07/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung Z51.12 | Encounter for antineoplastic immunotherapy |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Black or African American |
| Patient ID: | RO |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | OV, labs, Avastin infusion |
| Clinical Notes: | Patient was seen for OV, Labs, and clearance to receive Avastin. The patient refused the infusion and wanted to get a second opinion. |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.4 | Major depressv disorder, single episode, in partial remis F90.2 | Attention-deficit hyperactivity disorder, combined type Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SB |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | physical exam |
| Clinical Notes: | normal female exam. Medication refilled and cleared to scuba dive in Mexico granted |
Case Log/Encounter
| Date: | 04/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D72.819 | Decreased white blood cell count, unspecified I10 | Essential (primary) hypertension M54.5 | Low back pain Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 44 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TJB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| 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: | Physical Exam |
| Clinical Notes: | Yearly physical exam. No abnormal finding. Patient had labs outstanding from February to note resolution of leukopenia post COVID infection on Jan. Patient uses smokeless tobacco. Education provided on the risks, s/s of oral cancer. Blood pressure is below goal. Refill of lisinopril and Ibuprofen. will see again in 6 months for BP check, medication refill, and labs |
Case Log/Encounter
| Date: | 04/06/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.0 | Major depressive disorder, recurrent, mild F41.1 | Generalized anxiety disorder |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NM |
| 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 |
| Chief Concern and Patient Notes: | Physical exam |
| Clinical Notes: | new anxiety/depression attempting to conceive, zoloft and buspar ordered. Base line labs, CBC, CMP, TSH, Lipid profile, and Vit d level |
Case Log/Encounter
| Date: | 04/06/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.8 | Type 2 diabetes mellitus with unspecified complications |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | DM2 follow up 6 months |
| Clinical Notes: | HbgA1C 5.6, taking glipizide Blood pressure at goal 120/72 |
Case Log/Encounter
| Date: | 04/06/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F10.129 | Alcohol abuse with intoxication, unspecified T14.91 | Suicide attempt |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | NJ |
| 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): | 75 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | anxiety, depression, suicidal thoughts with a plan, alcoholism, |
| Clinical Notes: | The patient is a danger to himself and others, He was sent to the new physiatry intake at Hendricks |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.90 | Malignant neoplasm of unsp part of unsp bronchus or lung |
| Patient Age: | 53 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | pleural effusion |
| Clinical Notes: | the patient has been awaiting cytology for pleural fluid. Fluid is positive for recurrent disease. Family meeting. Will have pleurex placed tomorrow and will start optdivo outpatient at MV |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C22.9 | Malig neoplasm of liver, not specified as primary or sec C50.111 | Malignant neoplasm of central portion of right female breast C50.112 | Malignant neoplasm of central portion of left female breast |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BF |
| Type of Decision Making: | High Complexity |
| Type of Visit: | C-Counseling |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 40 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | second opinion for breast cancer |
| Clinical Notes: | Disease process has been present for 2 years. Disease has progressed and is now stage 4. Bone, liver, and bilateral breast lesions/mass are present. Port placement and chemo on Tuesday |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C61 | Malignant neoplasm of prostate |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | elevated PSA, enlarged long nodules |
| Clinical Notes: | IFD FF. Patient is reluctant to treatment. Disease has returned and progressed a this time. Will start treatment today. |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D50.9 | Iron deficiency anemia, unspecified |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | ED follow up for hemoglobin 6.8 |
| Clinical Notes: | The patient was unable to stay at the ED yesterday for a blood transfusion. the patient is in today to have a transfusion and to learn about her IDA. Iron 500 mg IV x 2 doses before she moves to KC,KS. History of bariatric surgery 15 years ago. Patient knows that she has been low on iron in the past but she didn't do anything about it |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C53.9 | Malignant neoplasm of cervix uteri, unspecified D46.4 | Refractory anemia, unspecified D50.8 | Other iron deficiency anemias K57.30 | Dvrtclos of lg int w/o perforation or abscess w/o bleeding R10.84 | Generalized abdominal pain |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SG |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Inpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 40 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | abdominal pain, nausea, vomiting, diarrhea |
| Clinical Notes: | Patient presented with abdominal pain for three months. Positive for occult blood, gross blood in stool Anemia IDA Per CT scan the patient has a large cervical mass with lymphadenopathy and carcinomatosis. Will replace iron 300mg IV x 3 infussions. Will BX the cervical mass. await results to begin treatment. |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C61 | Malignant neoplasm of prostate N30.01 | Acute cystitis with hematuria |
| Patient Age: | 73 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RT |
| Type of Decision Making: | High Complexity |
| Type of Visit: | C-Counseling |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Consult for prostate mass and liver lesion (seen on CT) |
| Clinical Notes: | Pt is deaf, ASL interpreter present on MARTI. Lengthy discussion, review of scans, plan of treatment, and talking with the daughter on the phone about the likelihood of metastatic prostate cancer. BX of liver lesion ordered. PSA is 8.6. Assume this disease is fast growing and poorly diff. Ordered a chest CT for further stating. After the biopsy, plan of treatment will be decided and implemented. |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.00 | Acute myeloblastic leukemia, not having achieved remission D64.81 | Anemia due to antineoplastic chemotherapy |
| Patient Age: | 73 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | AML |
| Clinical Notes: | Doing well. Day 7 post chemo. CBC and CMP and trending as expected. 1 U PRBC today. Epistaxis has resolved |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.00 | Acute myeloblastic leukemia, not having achieved remission |
| Patient Age: | 78 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | AML (new, MDS conversion) |
| Clinical Notes: | Patient is doing well, Day two of chemo. Q12 hours sub Q AHA-C and venetalcax (will increase to 200mg today) PO daily. Monitor labs and performance status |
Case Log/Encounter
| Date: | 03/31/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D46.9 | Myelodysplastic syndrome, unspecified E80.6 | Other disorders of bilirubin metabolism E87.6 | Hypokalemia K90.89 | Other intestinal malabsorption |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | MDS, chemo induction |
| Clinical Notes: | Follow up on patient. Albumin is working. Will give another 50G with 40 IV Lasix today. Replace K with 60 meq (2.6). Patient is on tele with a strip reading of SR total bili is 6.4. Related to antifungal medication. |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.00 | Acute myeloblastic leukemia, not having achieved remission |
| Patient Age: | 78 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| Type of Decision Making: | High Complexity |
| Type of Visit: | C-Counseling |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | MDS that has converted to AML |
| Clinical Notes: | Hydrating the patient and starting allopurinol to ward off TLS. Family meeting deciding to use Vyexos or Myelotarg |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D61.810 | Antineoplastic chemotherapy induced pancytopenia |
| Patient Age: | 73 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | new AML |
| Clinical Notes: | blood and plt transfussion today. Waiting on count recovery |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.00 | Acute myeloblastic leukemia, not having achieved remission J44.1 | Chronic obstructive pulmonary disease w (acute) exacerbation |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | new AML,, secondary cancer, NCSLCA with acheived remission. |
| Clinical Notes: | Discharged |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D61.810 | Antineoplastic chemotherapy induced pancytopenia D70.8 | Other neutropenia E83.42 | Hypomagnesemia E83.51 | Hypocalcemia E87.79 | Other fluid overload G89.3 | Neoplasm related pain (acute) (chronic) |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Dx 5: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | High grade MDS |
| Clinical Notes: | thrid spacing, gave albumin, lasix. Blood, platelets, mag, potassium transfusions the pateint's albumin is 2.1. Albmin replaced becasue of his malabsorption syndrome. He is unable to have a central line do to his fungal infection. Famly meeting/discusion of code status |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G93.89 | Other specified disorders of brain H53.2 | Diplopia R11.0 | Nausea R26.0 | Ataxic gait |
| Patient Age: | 54 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TD |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Cerebral mass |
| Clinical Notes: | the pateint presented with a change in gait, nausea without vomitting, and left eye diplopia. The patient was found to have a cerebral mass after a head CT with contrast was preformed. a mass in the Cecum was found during the abd/pelvis/chest CT Neruosurgery was consulted for resection and biopsy. However, the pateint's BMI is 62. The surgery is not optimal, so they have opted to place a VP shunt. The patient was supposed to undergo a colonoscopy today but the prep was not adequate. will complete tomorrow. Spent 20 minutes in ITD meeting with the patient to discuss the plan of care. |
Case Log/Encounter
| Date: | 03/29/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D72.0 | Genetic anomalies of leukocytes U07.1 | COVID-19 |
| Patient Age: | 53 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AH |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Chronic leukocytopenia |
| Clinical Notes: | Extensive chart review. The paient is seen by an oncologist in Bloomington. A call was made to her oncologist to cordinate plan of care and follow up. Signed off because there was nothing else to add |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified R63.6 | Underweight |
| Patient Age: | 87 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JE |
| 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: | 6 month hyperthyroidism visit |
| Clinical Notes: | patient in today to have THS drawn and medication refills. The patient has dropped 5 pounds since the last visit 6 months ago. Extensive dietary education with patient and her daughter. |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M54.16 | Radiculopathy, lumbar region M62.838 | Other muscle spasm |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SB |
| 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): | 25 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | MVA ED follow up |
| Clinical Notes: | the patient was in a motor vechical accident three weeks ago while drinking her mail truck At the IU ED a CT was completed. No acute process found. The patient states that she has not gotten any better and now her muscle spams in her neck are constant and she had numbness and tingling in the left leg that radiates to the lower back and back up again. MRI of the lumbar spine and pelvis ordered without contrast. Bacolfen 5 mg ordered TID |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D63.1 | Anemia in chronic kidney disease E78.4 | Other hyperlipidemia F06.30 | Mood disorder due to known physiological condition, unsp F06.4 | Anxiety disorder due to known physiological condition J45.20 | Mild intermittent asthma, uncomplicated |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| 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 |
| Chief Concern and Patient Notes: | 6 month follow up on Asthma |
| Clinical Notes: | Patient is doing well. Since moving from California, the patient has notice a significant decrease in his asthma symptoms. Medications were refiled CBC, CMP, TSH, Vit B12 level, CK, lipid profile Will see again in 6 months. |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder M72.2 | Plantar fascial fibromatosis |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KC |
| Type of Decision Making: | Straight Forward |
| 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: | six month anxiety follow up |
| Clinical Notes: | Patient is in today for six month follow up on anxiety. Cymbalta is working well. The patent's anxiety was do more to complications of mesopause. Patient has a complaint of worsening plantar fasciitis. The patent has had this in bilateral feet from greater than 15 years, Gave teechback and written instructions for treatment and therapies. CBC, CMP, Lipid profile, CK, TSH with reflux, and vitamin D level. See see again in six months. |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J45.20 | Mild intermittent asthma, uncomplicated |
| Patient Age: | 27 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 25 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Hypertension and Moderate persistent Asthma |
| Clinical Notes: | Blood pressure is at goal. Refilled medications and made a referral to urology for a vesectomy |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism E66.8 | Other obesity K21.9 | Gastro-esophageal reflux disease without esophagitis K59.00 | Constipation, unspecified K92.1 | Melena R11.2 | Nausea with vomiting, unspecified |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicaid |
| Time with Patient (minutes): | 25 |
| 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: | 3 month follow up for melena and back pain |
| Clinical Notes: | Patient states that her melena is resolved as well as her back pain. The patient did not completed PT per recommendations. the patient was also referred to GI with the last visit and has not scheduled an appointment due to not being able to get the office to return her calls. Reports in creased GERD. Omeprazole was increased to 40 mg daily and the patient was educated to take the medication on an empty stomach 30 minutes before meal. The patient is complaining of recurrent and constant nausea. Zofran is being taken regularly at an interval of every 8 hours and a seven pill refill was sent to the pharmacy. The patient had requested Phenergan, this is not a medication that my preceptor will prescribe. Patient stated that she has been dieting and exercising but is gaining weight. the patient no longer drinks soda and juice. Partakes in a high salt diet. Educated the patient to use a salt substitute while cooking, to taste food first, pour salt into the palm of her hand to add to foods and not to openly shake the salt shaker over foods. The patient also reveled she had a mother and sister with hypothyroidism and a maternal grandmother with T2DM. no labs on file in the last 5 years. CBC. CMP, TSH, TPO, free T4, Lipid profile, vit D level, and a HA1C ordered. Will see again in 6 months or if labs are abnormal. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C43.9 | Malignant melanoma of skin, unspecified |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TA |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | 6 month follow up on Melanoma to the left temporal post resection and chemo. Scans area clear supporting CR. No new symptoms of N/V, headaches, changes in vision or weight loss. Will see again in 6 months to repeat scans, labs, and OV. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R59.1 | Generalized enlarged lymph nodes |
| Patient Age: | 25 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | referral for chronic lymphadenopathy |
| Clinical Notes: | Extensive chart review of medical history and scans. Abdominal Lymphadenopathy seems to be resolving per scan. The patient is negative for presenting sings and symptoms for HL and testicular cancer. the patient was in jail for an undisclosed period of time within the last year. Reports an unhealthy diet, an occasional smoker, and drinker. Educated on life style changes. Physical exam was negative. Will follow up with a CT abdomen pelvis in three months. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C56.9 | Malignant neoplasm of unspecified ovary |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BB |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Ovarian cancer in remission for 5 years. |
| Clinical Notes: | Reviewed Scans and labs. New nodules found on the right lung. The three nodules are all less then 1 cm. No need for interventions at this time. Watch and wait. Rescan in three months and follow up. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.00 | Acute myeloblastic leukemia, not having achieved remission S71.002A | Unspecified open wound, left hip, initial encounter S71.102D | Unspecified open wound, left thigh, subsequent encounter |
| Patient Age: | 73 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 25 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Pancytopenia |
| Clinical Notes: | Rounded on this patient last week. Bone marrow results were pending. The patient has since been diagnosed with MDS that has transitioned into AML. The patient is day 2/5 on Vexyous. The patient is going well. Time spent educating the patient about the nadir and the importance of oral care and neutropenic fever. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C93.12 | Chronic myelomonocytic leukemia, in relapse D70.8 | Other neutropenia R04.0 | Epistaxis R52 | Pain, unspecified |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | MDS, first round of Vexyos Neutropenic fever Pancytopenia |
| Clinical Notes: | Saw this patient last week in the hospital. During this time, the patient has finished his chemo, extreme bone pain has occurrred, and the patient has been have tempatures. TMAX 103.4 degrees oral. The patient is positive for 4/6 blood cultures. Both the cultures from the hickman line, and peripheral stick are grow a rare form of mold; Fusenium. ID is consulted. All line, the PICC/Hickman and PIV were pulled. New PIV were placed. Platelet count of 9 today. I U platelets are currently transfusing. Rhino Rocket is in place in the left nostril placed by ENT |
Case Log/Encounter
| Date: | 03/25/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C71.9 | Malignant neoplasm of brain, unspecified G81.01 | Flaccid hemiplegia affecting right dominant side R06.6 | Hiccough R13.19 | Other dysphagia |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | HH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Left sided weakness |
| Clinical Notes: | Patient was admitted to oncology for left sided weakness. The patient is having difficulty walking, using the left arm/leg. and difficultly swallowing. A MRI of head was completed. Resulted in recurrent gleoblastoma. Loading dose of dexamethasone 10 mg IV BP and 4 mg IV every 6 hours. Day two of admission: Left sided weakness has vastly improved. OT PT are recommending home with outpatient OT PT. ST is coming to day to complete a bedside swallow study. Patient will start sport RXT therapy for 5 to 15 rounds for recurrent DX. Related to RXT and resection greater than 6 months ago. Anticipate discharge within 2 days |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K66.1 | Hemoperitoneum |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PG |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Retroperitoneal hematoma |
| Clinical Notes: | oncology was consulted for anemia related to chronic disease and retroperitioneal hematoma. Extensive chart review. Awaining iron studies and light kappa chains and LAMBA chains to rule out MDS. Patient has a history of gastric bipass. Ordered iron BID. Follow up as an outpatient with labs and an office visit in 2 weeks. Oncology signed off at this time. |
Case Log/Encounter
| Date: | 03/24/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D50.8 | Other iron deficiency anemias |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GF |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 10 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Blood loss, anemia |
| Clinical Notes: | Hospital course is currently consists of Acute blood loss related to a sever GI bleed. The oncology team was consulted for anemia due to blood loss. Chart was reviewed and 1U PRBC ordered. Iron studies are still pending. Chart review complete. Will see the patient tomorrow. Note entered. |
Case Log/Encounter
| Date: | 03/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.1 | Major depressive disorder, recurrent, moderate F41.1 | Generalized anxiety disorder R10.9 | Unspecified abdominal pain |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KH |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | follow up for UTI at med check |
| Clinical Notes: | Recurrent UTI, >12 in one year. Consult to urology. Patient also reports that she believes that she is having side effects of her Prozac. Prozac changed to Lexapro and Buspar 5 mg ordered. One month virtual scheduled for follow up |
Case Log/Encounter
| Date: | 03/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.1 | Major depressive disorder, recurrent, moderate F41.1 | Generalized anxiety disorder |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Moderate 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 |
| Chief Concern and Patient Notes: | 6 month follow up for A/D |
| Clinical Notes: | GAD and depression is not in control at this time. The patient is sleeping more and has no interest in activities. increased lexapro to 20 mg and buspar to 10 mg TID Will follow up as needed. Advised the patient to call if side effects occur or she does not feel better in one month |
Case Log/Encounter
| Date: | 03/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E08.311 | Diab due to undrl cond w unsp diabetic rtnop w macular edema E11.21 | Type 2 diabetes mellitus with diabetic nephropathy E78.2 | Mixed hyperlipidemia |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JM |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 3 month follow up on DM2 and hyperlipidemia |
| Clinical Notes: | Diabetic foot exam completed. A1C was 7.0. It was 6.3 three months ago. The patient was educated that she is now in full DM2, extensive dietary education, and on oral PLD1. One mouth sample of PLD1. Patient encouraged to have an eye exam complete. Will follow up in 3 months. All other medications refilled |
Case Log/Encounter
| Date: | 03/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.1 | Major depressive disorder, recurrent, moderate F41.1 | Generalized anxiety disorder |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | one month follow up for anxiety and depression |
| Clinical Notes: | This patient has an extensive anxiety and depression. The patient has been off medications for years and started medication one month ago. Medication is not working. Increased her Buspar to 10 mg TID and her Lexapro to 20 mg OD. Will follow up again in one month |
Case Log/Encounter
| Date: | 03/19/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | S29.011A | Strain of muscle and tendon of front wall of thorax, init |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Asian |
| Patient ID: | CH |
| 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 |
| Chief Concern and Patient Notes: | complaint of pain in left breast |
| Clinical Notes: | Examined, diagnosed, treated, provided plan, and wrap up. Exam noted tighten muscles in the left upper chest wall. over used injury from an occupational hazard. Tordol injection 60 mg IM given x 1. Advised the patient to not take ibuprofen for 8 hours after the injection. To use ice and heat to the affected area, light stretching, and rest over the weekend. Patient was also advised to take 600mg of Ibuprofen BID for 7-10 days to aid in recover. Patient advised to call if symptoms do not improve in the next 72 hours. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C91.00 | Acute lymphoblastic leukemia not having achieved remission |
| Patient Age: | 42 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BD |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Admit for chemotherapy |
| Clinical Notes: | Patient was admitted for second consolidation therapy while awaiting transplant. Day 1 of Hyper CVAD. Awaiting labs and PICC line placement. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D61.818 | Other pancytopenia |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Pancytopenia |
| Clinical Notes: | The patient is known the to service because last month the patient was admitted for an infection of the right femur with an I & D. Pancytopenia resolved with treatment of infection. However, the patient returned with a hemoglobin of 3.3 and pancytopenia. BMBX revealed new AML with 12 % blast. Family meeting scheduled for tomorrow to talk about treatment options. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R17 | Unspecified jaundice |
| Patient Age: | 96 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | obstructive jaundice |
| Clinical Notes: | Patient is 96 years old with a new liver mass. The patient was admitted for obstructive jaundice. Bili drain placed, open/patent and draining well. Outpatient appoint scheduled with DR, Slaughter to discuss treatment options. Treatment is not likly due to the patient's age and performance status. However, the patient will agree to treatment if the daughter wants to her to. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D01.1 | Carcinoma in situ of rectosigmoid junction E86.0 | Dehydration R13.19 | Other dysphagia R63.4 | Abnormal weight loss |
| Patient Age: | 69 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Dehydration and dysphagia |
| Clinical Notes: | Patient presented with dehydration, dysphagia, and a 20-30 pound unexplained weight loss in the last 4 months. The patient has an out patient work up and it was found the patient has stage 4 GE junction CA with mets to the liver and carcinomatosis. The patient is here to correct dehydration, have a PED tube, and port placed. The PEG was not able to be placed subcutaneously. General surgery consulted. RD has already placed feeding recommendations. Will continue to observe and follow for PED tube feeding/education. All cancer treatment will be completed outpatient after nutritional and performance status is improved. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C83.31 | Diffuse large B-cell lymphoma, nodes of head, face, and neck |
| Patient Age: | 50 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Admitted for cycle 2 of R-EPOH |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Extensive chart review. The patient arrived in the ED two months ago in ARD and airway obstruction. The patient had a large mass completely obstructing the trach on the right side. Emergency trach placed and biopsy obtained. Diagnosed with diffuse b cell lymphoma. Cycle one of treatment shrank the mass and is not able to be seen on xray. the patient handled treatment well with no side effects. Day one of treatment without complications. Will monitor labs daily and treat complications as they arise. Monitor mouth sores |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D46.9 | Myelodysplastic syndrome, unspecified |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Relapsed and progression of MDS to 2 Admitted for chemo |
| Clinical Notes: | Patient has an extensive history. The patient has had treatment for chrons disease that caused prolonged immuno suppression. This medications allowed the body to convert into MDS. The goal of treatment has been to complete CR and keep the MDS from converting into AML. Currently, the patient has had MDS for 4 years and has completed 3 different cycles of chemotherapy. Currently, the patient is on the verge of converting into ALL. Last treatment option is to use a new treatment of VYXEOS. Will monitor labs closely and treat accordingly |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.01 | Acute myeloblastic leukemia, in remission |
| Patient Age: | 52 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | AML in CR, round two of consolidation chemo while awaiting an bone marrow transplant |
| Unlisted Dx: Student Participation: | 2-Some Help from the Preceptor 3-Joint Care 50/50 |
| Clinical Notes: | extensive chart review and discussion was completed on this patient. New AML in Nov 20. 4 % blast, hemoglobin of 3.3, and plt of 15. BMBX reported 90 % blast and CD33 marker. Induction chemo of 7 + 3. BMBX on day 14 reported 30% blasts. Indicated failure of induction. Second induction completed and 12/8/20 CR was achieved. Patient is currently completing second consolidation therapy while awaiting transplant. |
Case Log/Encounter
| Date: | 03/16/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C34.91 | Malignant neoplasm of unsp part of right bronchus or lung U07.1 | COVID-19 |
| Patient Age: | 55 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JK |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | COVID infection, r/o COVID pneumonia |
| Clinical Notes: | Patient has new small cell lung cancer stage III. Status post cycle one of platin and etoposide. The patient was exposed to COVID 19 from he grandchild that attends school and lives in the home. Patient has asymptomatic and had a Rapid positive test and PCR. The patient is now febrile, TMAX 103.2 oral, have 3-5 loose stools a day, and increased O2 needs form 2L NC to 6 L NC. Stool sent for CDiff. The patient is positive for a nonproductive cough (tessalon is effective) and headache. Treatment is on hold. Will re evaluate the patient as a outpatient for treatment once he is fully recovered from COVID. |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F90.2 | Attention-deficit hyperactivity disorder, combined type R06.02 | Shortness of breath |
| Patient Age: | 17 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | ADHD follow up |
| Clinical Notes: | ADHD follow up. Referred to pulmonary rehab to evaluate for asthma |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 75 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | six month follow up for hypertension |
| Clinical Notes: | blood pressure is at goal. No change in medication. Patient has not had routine labs in one year. Labs ordered. PSA added due to HX of prostate CA |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism I10 | Essential (primary) hypertension |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JF |
| Type of Decision Making: | Straight Forward |
| 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: | three month follow up on change in thyroid medication |
| Clinical Notes: | blood pressure is at goal. TSH drew today. Will adjust thyroid medication based of lab level. Follow up in 6 months |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified I10 | Essential (primary) hypertension Z77.22 | Cntct w and expsr to environ tobacco smoke (acute) (chronic) |
| Patient Age: | 68 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RK |
| Type of Decision Making: | Straight Forward |
| 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 |
| Chief Concern and Patient Notes: | 6 month follow up for HTN, HLD |
| Clinical Notes: | Blood pressure is not at goal. 149/96. Increased losartan to 50 mg BID. Did not change HCTZ. at this time. Scheduled a virtual visit for one month to note blood pressure readings. routine labs ordered. |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.0 | Candidal stomatitis B37.3 | Candidiasis of vulva and vagina N30.90 | Cystitis, unspecified without hematuria N89.9 | Noninflammatory disorder of vagina, unspecified Z00.01 | Encounter for general adult medical exam w abnormal findings Z11.2 | Encounter for screening for other bacterial diseases Z11.3 | Encntr screen for infections w sexl mode of transmiss Z11.4 | Encounter for screening for human immunodeficiency virus |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HP-Health Promotion |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| 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: | Yes |
| Chief Concern and Patient Notes: | Physical |
| Differential Diagnosis: | BV G and C candidal vulvovaginitis/oral |
| Clinical Notes: | the patient was in today for a physical. However, the patient had a concern for recurrent cystitis. The patient has been to the urgent care 10 times over the last three years for cystitis without hematuria. Pain, burning urination. C/O of white furry tongue. Thick, white and greyish, almost mucous like vaginal discharge that the patient scrapes off the vaginal wall daily. the patient has to change her under ware 2-3 times daily because the discharge is copious. The discharge has been present for a "while now" The patient is not using STI prevention with condoms and preforms oral sex on her partner for lubrication. "pull out" method used to prevent pregnancy. however, the patient allows her partner to ejaculate in the vaginal vault when she is menstruating. The patient is reporting she has been with one partner for the last 5 years, but he has been unfaithful. STI and cystitis work up ordered. In office urine and vaginal swab for GC, BV, and tirch. Labs ordered for Hep C, HIV, Syphilis, and routine labs (CBC, CMP, TSH, Lipid profile, and Vit D level). Patient was educated to abstain from all sexual activity (vaginal, anal, and oral penetration). Was able to charge for the physical and use a modifier to bill optimally for this visit. |
Case Log/Encounter
| Date: | 03/09/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G44.209 | Tension-type headache, unspecified, not intractable J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RI |
| Type of Decision Making: | Straight Forward |
| 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: | one month follow up on tension headache |
| Clinical Notes: | Patient headache days have been cut in half over the last month. Medication was switched from flexeril to baclofen so the patient can take the medication at work. The patient also has uncontrolled season allergic rhinitis. Added a decongestant OTC. If this does not work will complete a sleep study. |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder Q90.9 | Down syndrome, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid 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 |
| Chief Concern and Patient Notes: | New patient, establish care, and physical |
| Clinical Notes: | Normal physical exam without abnormal findings. Behaviors, depression, anxiety are will controlled. Will see in one year for follow up |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.32 | Mood disord d/t physiol cond w major depressive-like epsd F31.70 | Bipolar disord, currently in remis, most recent episode unsp F84.5 | Asperger's syndrome Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MT |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid 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 |
| Chief Concern and Patient Notes: | new patient, establish care, physical |
| Clinical Notes: | Yearly exam without abnormal findings. Behaviors are under better control. will see again in 6 months for medication refil. |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Q90.9 | Down syndrome, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 42 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| 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: | yearly physical |
| Clinical Notes: | Wellness visit without abnormal findings. Behaviors, depression, and anxiety well controlled. Will follow up one year. Nurse visit made for an ear cleaning |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.3 | Candidiasis of vulva and vagina E10.29 | Type 1 diabetes mellitus w oth diabetic kidney complication F31.76 | Bipolar disorder, in full remis, most recent episode depress F41.1 | Generalized anxiety disorder Q90.9 | Down syndrome, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid 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 |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yearly physical |
| Clinical Notes: | Patient for yearly physical. Behaviors, depression, and anxiety are well controlled at this time. C/O of vaginal itching, burning after urination, and thick white discharge. Diflucan 150 mg x 1. Will follow up in 6 months |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate F41.1 | Generalized anxiety disorder N40.1 | Enlarged prostate with lower urinary tract symptoms |
| Patient Age: | 67 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Moderate 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 |
| Chief Concern and Patient Notes: | follow up for A/D six months |
| Clinical Notes: | Currently the patient has a c/o uncontrolled anxiety and depression. The patient is currently on 20mg of celexa. This medication is maxed out for the patient's age. However, the patient is taking 10 mg of Buspar TID. Increased to 15mg TID. Will follow up with the patient in one month |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JT |
| Type of Decision Making: | Straight Forward |
| 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: | 6 Month follow up for HTN |
| Clinical Notes: | Blood pressure is at goal. No change in medications needed. screenings are up to date. Labs ordered. will see again in 6 months |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SC |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Insurance: | Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yearly Medicare physical |
| Clinical Notes: | Patient seen today for yearly Medicare Physical. Exam normal and patient has no complaints. Works out regularly and is very social. The patient is up to date on mammogram, colonoscopy. Patient send for cardiovascular screen do to family history of MI and for annual labs. |
Case Log/Encounter
| Date: | 03/08/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| 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 |
| Chief Concern and Patient Notes: | swollen left lymph node for the past year |
| Clinical Notes: | Patient was in today with concerns of a swollen left poritid lymph node. Upon examination shotty node node. Non tender to palpation. cobble stoning is noted at the back of throat with noted. Bilateral TM are dull and congested. Nasal mucosa is dull and clear rhinorrhea noted. Patient has c/o nasal drainage and congestion for the past year. Advised to take 25 mg PO of Benadryl nightly until she feels better. Follow up PRN and PCP for all other needs |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F90.2 | Attention-deficit hyperactivity disorder, combined type Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 21 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | WR |
| Type of Decision Making: | Straight Forward |
| 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: | six month follow up and medication refill |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M79.601 | Pain in right arm |
| Patient Age: | 76 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: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Clinical Notes: | Patient in today for evaluation of right arm pain. The patient has no joint pain with abduction or adduction in the elbow. However the patient does have numbness and tingling at the hands with movements. Small, firm, mobile cyst to the right lateral arm. No pain/discomfort with palpation. Patient has DVT and chronic joint pain in the right leg. DX of OA. The patient is taking 6000 mg of Tylenol. advised to stop taking Tylenol. A person over 65 years is recommended 3000mg per day, Switched the patient to Tylenol arthritis 650mg 1 pill every 8 hours. |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.8 | Type 2 diabetes mellitus with unspecified complications F31.74 | Bipolar disorder, in full remis, most recent episode manic Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SP |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | new patient visit |
| Clinical Notes: | spent 45 minutes with the patient obtaining medical history and obtaining a report with the patient. he is in today to establish care and to see if he is comfortable with the provider. Preceptor came in after the information was obtained and spoke with the patient for another 15 minutes. Will see again in 3 months for a physical |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HMH |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| 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 |
| Chief Concern and Patient Notes: | 6 month follow up on HTN and HLD |
| Clinical Notes: | Patient's blood pressure is at goal (133/73). Taking HCTZ and lisinopril daily. However, the patient is not compliant with her statin. She forgets to take it daily. Educated to use a pill box or to place the medication by her toothbrush. The patient is under extreme stress at this time. the patient's 16 year old daughter attempted suicide three weeks ago. Will follow up on mood Labs ordered. Medications refilled will see again in 6 months |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G47.429 | Narcolepsy in conditions classified elsewhere w/o cataplexy I10 | Essential (primary) hypertension |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JM |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 3 month follow up for narcolepsy and Adderall refill |
| Clinical Notes: | Three month follow up and Adderall refill for narcolepsy. Adderall is both long and short acting. Patient is doing well. UDS, CBC, CMP, TSH, Lipid profile, and Vit D. C2 contract up to date Follow up in three months |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DB |
| 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 |
| Chief Concern and Patient Notes: | new patient. Establish care |
| Clinical Notes: | Patient in today to established patient care. The patient has a complaint of mild depression. The patient is currently going through marriage counseling and is going to start proceeding with a divorce. At this time she is not wanting to start medication at this time. Education and support provided. The patient is complaining of right lateral foot pain after physical exercise. She is a PT and is using RICE and gotten arch support. Refused xray at this time. Encouraged to add an NSAID to help ease the pain. Complaint of constipation. The patient reports thin, bright red, spots of blood on toilet paper with whipping after strainning with a BM. Stools are larger, hard, and small in amount. Encouraged the patient to not strain, increase fiber in the diet (Metamucil) , and to add a stool softener twice daily. History of HSV2. Not currently in an outbreak. On suppression therapy of Acyclovir. GYN is following and managing. no other needs at this time. Exam is negative except for stool is noted in the LLQ. Labs ordered. CBC, CMP, Lipid profile, TSH with reflex, Vit D. Will follow up with a year and PRN |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Clinical Notes: | Pt is in today for yearly physical. Negative exam. CBC, CMP, Lipid panel, TSH with reflex, and Vitd ordered. All mediations were refilled. Will see again in one year and as needed |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified I10 | Essential (primary) hypertension J47.0 | Bronchiectasis with acute lower respiratory infection J47.9 | Bronchiectasis, uncomplicated M54.5 | Low back pain Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 65 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 25 |
| 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 |
| Chief Concern and Patient Notes: | Follow up on hypertension, lower back pain, COPD, and Hyperlipidemia |
| Clinical Notes: | The patient has well controlled hypertension. Is taking medications daily and monitoring BP 3-4 times weekly. Lower back pain is the same, is taking Tylenol #3 1-2 weekly. The patient is using fitness tracker to help her loose weight and to eat healthy. COPD is not under control because the patient is not able to afford her Aurno. Samples given and paperwork for assistance program. Will follow up again in 6 months. Labs ordered. CBC, CMP, TSH, Lipid provide, and Vit D |
Case Log/Encounter
| Date: | 03/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B00.2 | Herpesviral gingivostomatitis and pharyngotonsillitis |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Mouth sores |
| Clinical Notes: | C/O mouth sores with peeling/cracked lips. The patient had been seen in May of 2020 for the same problem. She was prescribed nystatin ointment. The patient uses the ointment 3-4 times daily and has not seen any improvement. Mouth and lips are painful (6/10), painful to swallow, no difficulty swallowing or getting stuck food with swallowing. The patient has lost a right upper molar. Mouth is bright red in color and scattered white patches on the upper and lower gum line and bilateral cheeks. The lower front gum line is the most affected. The patient has poor dentation and has not seem a dentist in a long while. Mucosal tissue is peeling off. No halitosis. The patient is a daycare worker. No current outbreak of hand foot and mouth disease. I believed the patient to have mucositis and was wanted to prescribe Marys Magic Mouthwash with tetracycline. However, my preceptor and I looked her symptoms up on update and noted her s/s are more inline with gingivostomatitis. MMM ordered TID swish and spit three times daily for 5 days. Store mouth wash in the frig. Encouraged the patient to seek dental care. |
Case Log/Encounter
| Date: | 03/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D51.9 | Vitamin B12 deficiency anemia, unspecified F06.31 | Mood disorder due to known physiol cond w depressv features F41.1 | Generalized anxiety disorder |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BQ |
| Type of Decision Making: | Straight Forward |
| 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: | 6 month follow up on anxiety, depression, vit B12 def |
| Clinical Notes: | Patient is doing well. PHQ9 and GAD7 and lower than 6 months ago. Patient is loosing weight, exercising, and has no new complaints. Celexa, Buspar, and B12 injection refilled. CBC, CMP, TSH, Vit D/B12, Lipid profile ordered. Will see again in 6 months and PRN |
Case Log/Encounter
| Date: | 03/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HP-Health Promotion |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 40 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | establish care, new patient. H&P |
| Clinical Notes: | Patient is here to establish care and to gain a second opinion. The patient has been DX with fibromyalgia for the past six years and been on chronic Lyrica. The patient has stopped the medciation on her own without weaning. The patient has recently reconnected with her sister. Her sister has SLE and other autoimmune disorders. Patient's s/s are consistent with SLE and lyrica side effects. CBC, CMP, ANA, RA, CRP, Lipid profile, TSH with reflex, and Vit D |
Case Log/Encounter
| Date: | 03/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F06.31 | Mood disorder due to known physiol cond w depressv features F41.1 | Generalized anxiety disorder |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AW |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | follow up on anxiety/depression and medication refill |
| Clinical Notes: | Patient was seen today for a follow up on anxiety and depression. The patient has been out of her medication since Friday 2/26/21. The patient is very upset because she is in withdraw. The patient was educated about the half life of the medication and concerns were addressed. It was very helpful to watch my preceptor address these concerns. She was able to bring the patient around and calm her into staying with the practice. The office manager was brought in to help correct the breakdown in communication. The patients medication was refilled for 30 days and informed her labs would have to be completed in the next 30 days before new refills would be given. |
Case Log/Encounter
| Date: | 03/01/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | N20.9 | Urinary calculus, unspecified N76.4 | Abscess of vulva |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AG |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) Medicaid |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | ED follow up |
| Clinical Notes: | Patient has chronic abscess to the vaginal area and bilateral arm pits. In obtaining a history and physical exam, the patient shaves all hair from these areas. The patient was seen in the ED to have an I & D. The patient was also placed on keflex by the ED for foliculitis. Today the abscess is still slightly draining. Drainage is serosanginous, small in amount, and non odorous. However, the periwound if firm in nature and tender to palpation. The patient was educated to clean the external area of the vagina and armpits with hipaclense after shaving. This will decrease bacteria on the surface area in hopes to reduce reoccurance. The pateint was also educated to not shave the vaginal area, but to wax. Patient also has complaint of right flank pain to the severity and sequalla of past kidney stones. Patient was advised to call urology, the provider she has seen in the past, for management. |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C24.0 | Malignant neoplasm of extrahepatic bile duct |
| Patient Age: | 57 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | abdominal pain |
| Clinical Notes: | Oncology was consulted for visualization on a Klaskin Tumor. Biopsy was taken during ERCP. Awaiting results. at this time the patient has not had staging workup completed. CA 125 and CA 19-9 ordered. The rest of staging will be completed out patient. Due to Cr. of 4.7 a CT with contrast per staging perimeters is not able to be completed. Learned about NCCN guidelines and created an account. This lays out the means of all staging for all cancers. |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | R20.9 | Unspecified disturbances of skin sensation |
| Patient Age: | 64 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | KS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | patient was admitted for asymmetrical numbness. Consult. |
| Clinical Notes: | Over an hour spent reviewing chart, inturp. labs, confirming with IDT, and researching disease process. It was determined the patient has Churg-Strauss. High dose steroids ordered. Will follow daily to monitor response and send home one a long term taper. steroids could even be life long. 45 minutes spent with the patient and his wife going over findings, treatment, and reassurance. |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | D75.82 | Heparin induced thrombocytopenia (HIT) |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | AS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Inpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Consult for possible HIT |
| Clinical Notes: | Extensive chart review and IDT discussion. The patient is not in true HIT because his SRA is negative. It was determined the source of the patient's thrombcytopenia is due to the use of IV Vancomycin. Will sign off for now. Gave recommendations on transfusion perimeters. Will chart review daily. |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C92.02 | Acute myeloblastic leukemia, in relapse D70.9 | Neutropenia, unspecified |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Neutropenic fever |
| Clinical Notes: | Patient has been admitted for neutropenic fever. Source is noted to mucositis fungal infection. The patient is doing well and has been A febrile for 12 hours. If the patient continues to remain fever free for 24 hours that patient will DC home and follow up with primary oncologist for labs and chemo on Friday 2/26/21 |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B96.89 | Oth bacterial agents as the cause of diseases classd elswhr C18.9 | Malignant neoplasm of colon, unspecified |
| Patient Age: | 50 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Asian |
| Patient ID: | VH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Fever of unknown origin |
| Clinical Notes: | Patient has metastatic colon cancer, stage 3. The patient has failed 6 cycles of FOLFOX. After one cycle of FOLFIRI, the patient developed a fever. BC 4/4 were positive for aggrefatibacter, but repeat BC four days later were negative, UA and TEE were negative. No mucositis. Patient will complete daily Rocephin at home through the port. ID will follow. Hold treatment for 10 days post completion of therapy on 3/3/21. Patient was discharged home. |
Case Log/Encounter
| Date: | 02/22/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C91.11 | Chronic lymphocytic leukemia of B-cell type in remission |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | B cell ALL. Admitted for induction chemotherapy. |
| Clinical Notes: | Patient completed induction therapy 9 days chemotherapy. The patient is now waiting on count recovery. 1 U PRBC and 1 unit of Plt. Transfused today for a hemoglobin of 6.5 and Plt of 10. Mag and Potassium were also replaced. These were all replaced per protocol by the nursing staff. The patient is complaining of hard stools. Senna S daily ordered. Last recorded bowel movement was 2-21-20. WBC is 0.45. Plan to start neupogen 300 mg daily sub Q. Patient remains a febrile. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E16.2 | Hypoglycemia, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JC |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | establish care hypoglycemia |
| Clinical Notes: | Patient is in today to establish care. assessment is negative. However, the patient reports a history of gestational DM and hypertension. All resolved post birth two years ago. The patient consumes a moderately healthy diet, but skips breakfast 3-4 times weekly. consumes a Bang energy drink daily. The patient reports that she has not been using a form or back up birth control while on an antibiotic in December and in January. LMP was 1/28. Cycle was shorter and lighter than normal. At home pregnancy test negative. Research on Bang energy drinks note to have 300 mg of caffeine and ace-K. Ace-K is an artificial sweetener that is 200 times sweeter than regular sugar. Ace-K can also cause problems with blood sugar regulation. The patient is reporting she is having increased hypoglycemia in the afternoons. CBC, CMP, HCG, HA1c, TSH, Lipid panal, and Vit D labs were ordered. The patient as educated to stop drinking bangs daily. Will follow up in one year unless labs are abnormal. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified R10.84 | Generalized abdominal pain |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 25 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | chronic diarrhea and abdominal pain. |
| Clinical Notes: | the patient has been seen several times over the last 2 years for constipation by NP, GI, Proctology, and ED services. The patient was supposed to have a colonoscopy but she would not complete the bowel prep. Normal exam and CT scan for 2/8/2021. Patient encouraged to follow up with GI and complete a colonoscopy. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B00.1 | Herpesviral vesicular dermatitis L23.1 | Allergic contact dermatitis due to adhesives |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Recurrent HSV1 outbreak on upper and lower lip. |
| Clinical Notes: | Recurrent HSV1 outbreak on upper and lower lip. The patient was taking acyclovir 500 mg BID for prophylactic before pregnancy. The patient just gave birth at 34 weeks per c-section, Twin girls. the patient had preeclampsia and is currently taking labetalol. The patient is currently breast feeding. Treatment switched from oral to 5% topical five times daily for 5 days. Contact dermatitis noted to the right AC, FA, right flank, and mid upper abdomen. OTC hydrocortisone cream ordered. the patient was educated to call if the s/s worsen or do not resolve. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension R80.0 | Isolated proteinuria |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JT |
| 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: | follow up for UTI, proteinuria, and elevated blood pressure |
| Clinical Notes: | The patient is in for a follow up for a positive UTI, proteinuria, and elevated BP. UA notes a resolved UTI and no proteinuria. BP is 140/98 and retaken to be 120/92. Lisinopril 5mg i tab PO daily. Educated to take blood pressure three times weekly, record the values, and will follow up per virtual visit in one month. Education given on the s/s of ACEi verbal and written. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M72.2 | Plantar fascial fibromatosis Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BGB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | establish care and c/o bilateral foot pain |
| Clinical Notes: | Normal general exam of a healthy male with nonverbal s/s of anxiety. However, the patient reports s/s of plantar fasciitis in bilateral feet. The patient is currently doing stretches, ice, rest, and has specialty insoles. Information given on feet splints for night and more exercises. Referral placed for podiatry if pain is worse. CBC, CMP, TSH, Lipids, and Vit D level ordered. Will see in one year and PRN |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K86.2 | Cyst of pancreas |
| Patient Age: | 69 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CM |
| Type of Decision Making: | Straight Forward |
| 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: | follow up on CT |
| Clinical Notes: | Patient was in the office on a follow up on an abdominal CT. There was a pancreatic cyst found by accident on when the patient was positive for kidney stones. The patient was seen by oncology. No significant information to add to the case. Recommended the patient see GI, have and MRI, and possible biopsy with GI. Referral sent for MDT and GI. |
Case Log/Encounter
| Date: | 02/23/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate F41.1 | Generalized anxiety disorder R53.82 | Chronic fatigue, unspecified |
| Patient Age: | 55 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 6 month follow up on, Anxiety, depression, and chronic fatigue |
| Clinical Notes: | patient in for follow up on anxiety. depression, and chronic fatigue. The patient is stable and feels that her mood has improved greatly and notices she is able to deal with situations differently. chronic shoulder pain. Increased loss of range in motion of the right shoulder. The patient was referred to ortho a year ago, but the patient did not schedule PT per recommendations. PT referral was made. The patient was sledding with her grandchildren and injured her tailbone. The patient is currently completing adequate symptomatic care. educated the patient to continue with care and to call if pain has not improved or resolved in the next two weeks. |
Case Log/Encounter
| Date: | 02/18/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | M12.89 | Oth specific arthropathies, NEC, multiple sites |
| Patient Age: | 57 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): | 25 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | painful hands |
| Clinical Notes: | patient reports that she has had a problem in her bilateral hands for the past seven years. Initial employment was banking for over 20 years. Now the patient works in the seely/temperpedic mattress factory. Upon starting with the company, the patient was sewing corners. By the end of the day, the patient's hands hurt to the point on non use and stiffness the patient was unable to open a water bottle. Her jobs have changed over the last six years. Her hands have continued to get worse, the PIP of bilateral fingers and thumbs are hypertrophied, but not inflamed. The patient had a positive Phalen's test. Most likely the patient has OA (her mother has a history of OA and Raynods) and Carpal tunnel. RA factor and CRP ordered along with CBC, CMP, TSH, and a lipid profile. Work note given for sewing restriction for the next 30 days while work up for arthritis is being done. The patient was educated and given a hand out on the hand exercises and to continuing using the creams, ice, and heat. Will follow up with labs by Monday and see the patient in one month for a follow up appointment. If RA factor is not present and CRP is not elevated, a xray of the bilateral hands and wrist will be ordered along with an EMG of the bilateral wrist. Referral to the hand specialist is needed after determining the type of arthritis the patient has. No referral was made do to type being unknown and the direction or treatment vastly differs. |
Case Log/Encounter
| Date: | 02/18/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G43.009 | Migraine w/o aura, not intractable, w/o status migrainosus |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KK |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | one month follow up: new migraine medication |
| Clinical Notes: | Patient has had chronic non-intractable migraines without an aura since she was a teenager. Migraines resolved with pregnancy but have since returned and are worse than before. Seen one month ago. Placed on Imatrex and Erenumab-aooe Q 28 day injectable. Imatrex is not effective and the injectable has been denied per prior autherization twice. New prior auth sent and the patient was switched to Topamax. The patient has been on BB in the past and noted they were not effective as a preventive medication. Will follow up again in one month |
Case Log/Encounter
| Date: | 02/18/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E06.3 | Autoimmune thyroiditis E55.9 | Vitamin D deficiency, unspecified E78.5 | Hyperlipidemia, unspecified I10 | Essential (primary) hypertension |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LP |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 6 month follow up for Hypertension, hyperlipidemia, and hypothyroidism. |
| Clinical Notes: | hypertension is well controlled with medications and low salt diet. Patient was encouraged to do at home exercise through free apps on her phone. Increased fatigue. Patient is unsure if fatigue is from the weather, the winter, her thyroid, or vit D. patient is taking medications as prescribed. Labs ordered CBC, CMP, TSH, Vit D, and a lipid profile. Will see patient again in three months. all medications were refilled for 3 months. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SA |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | New patient, referral to have Xanax refilled |
| Clinical Notes: | Patient wanting to establish care and to be referred to any dr to have her xanax refilled that she has been taking on and off the last year. The patient has just moved here from California 6 months ago. Last refill of Xanax, acorrding to INSPECT was May of 2020. Dose is .25mg PO BID PRN. The patient went to another provider and no medication or referral were given. Anxiety has began to increase over the last 6 months with COVID numbers increasing. She has been in the ED twice and taken a friends Xanax once to control her anxiety attacks. The patient is not wanting to take anything daily at this time because the side effects are not worth it. Plus she does not believe she has a daily problem with anxiety. However, the patient is figiting, picking at her nails, and labile in affect. Referral to physiatry made. Talked the patient into trying Buspar 5 mg PO daily with a second dose as needed until seen by physiatry. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SQ |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 50 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | new patient physical |
| Clinical Notes: | Patient in to establish care. Extensive history completed. Patient is having extreme anxiety due to a family issue. Referral to behavioral health. Buspar 5mg TID PRN. The patient also had an abnormal exam. LTM is congested with mucoid. Non-bulging. RTM is congested, injected, and non-bulging. Suggested an over the counter antihistamine daily, flonase, and to continue suddefed for three days. then stop the suddefed. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E08.21 | Diabetes due to underlying condition w diabetic nephropathy I10 | Essential (primary) hypertension L03.116 | Cellulitis of left lower limb |
| Patient Age: | 72 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Follow up on HTN, DM2 |
| Clinical Notes: | Blood pressure is at goal. However, the patient's A1c is not at goal. The patient had a left knee replacement 6 weeks ago. The patient is being treated by ortho for cellulitis of the inscion site. She is on two types of antibiotics. Sugars have been elevated since her surgery; |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp I10 | Essential (primary) hypertension |
| Patient Age: | 74 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 6 month follow up on Hypertension and DM2 |
| Clinical Notes: | Blood pressure and A1c at goal. Medications refilled and will follow up again in 6 months. The pt is two years post kidney transplant. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Medicare wellness physical |
| Clinical Notes: | Medicare wellness visit. Has received both doses of Maderna COVID vaccine. The patient has notice that her RA has been worse and her knees are more painful and sore since receiving the second dose two weeks ago. Eye exam scheduled for 2 months All screenings completed Slight decrease in hearing 2/3 recall the right ear with Whisper test |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | J30.89 | Other allergic rhinitis R55 | Syncope and collapse |
| Patient Age: | 48 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | dizziness with position changes |
| Clinical Notes: | Dizziness x 2 days with position changes. Worsening over the last 24 hours. Worse when leaning forward. Maxillary sinus pressure when bending forward, but negative to palpation. Bilateral TM are dull with extensive congestion. Nares are gray with bogie turbinates. Extensive cobblestoning to the O/P. Advised to have the patient take an OTC antihistamine daily for the next two weeks and prescribe meclizine PRN. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism F41.1 | Generalized anxiety disorder I10 | Essential (primary) hypertension M54.14 | Radiculopathy, thoracic region |
| Patient Age: | 48 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CW |
| 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): | 50 |
| 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: | New patient visit/establish care |
| Clinical Notes: | New patient/establish care Extensive medical history review, medication review, and mental health review. Medications were reordered for a three month supply. Patient scheduled for three month follow up to have a physical. Referral to OB made. Mammogram ordered. CBC, CMP, TSH, lipid profile, and Vit D ordered. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.8 | Type 2 diabetes mellitus with unspecified complications F41.1 | Generalized anxiety disorder F52.21 | Male erectile disorder I10 | Essential (primary) hypertension |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SH |
| 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): | 20 |
| 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: | medication refill and follow up on HTN/DM |
| Clinical Notes: | Patient is not willing to follow a low salt, low sugar, low carb diet. His A1c is 7.0 which is up from 6.1 6 month ago. Attempted to place on glipizide but patient took it twice and didn't like the way he felt. Hypertension is uncontrolled. Does not take BP daily as ordered. New C/O of ED. Due to the patient's cardiac history and uncontrolled HTN he is unable to be prescribed oral treatment for ED. Will follow up in 3 months. CBC, CMP, TSH, Lipid profile, and Vit D ordered. |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BM |
| 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 |
| Chief Concern and Patient Notes: | 6 month follow up: hypertension. |
| Clinical Notes: | Hypertension: uncontrolled. The patient is not taking medication as prescribed. Educated to set an alarm on his phone and set the pills by where he places his keys. Labs ordered (CBC, CMP, TSH, Lipid profile, and Vit D). Will follow up in three months. If BP is not controlled will switch the patient to a combo medication. Pt is currently on Norvac 10 mg Q day and HCTZ BID |
Case Log/Encounter
| Date: | 02/12/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate F41.1 | Generalized anxiety disorder |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JH |
| Type of Decision Making: | Straight Forward |
| 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: | medication refill for anxiety/depression: 6 month follow up |
| Clinical Notes: | patient ran out of meds two weeks ago. Increased anxiety related to death of a family friend and her son eloping to be married. chronic problem. Medications refilled and labs (CBC, CMP, TSH, lipid panel , and Vit D level) follow up in 6 months |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E08.21 | Diabetes due to underlying condition w diabetic nephropathy I10 | Essential (primary) hypertension J44.9 | Chronic obstructive pulmonary disease, unspecified M06.9 | Rheumatoid arthritis, unspecified |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MC |
| 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): | 20 |
| 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: | follow for HTN and COPD Episodic with bilateral knee pain |
| Clinical Notes: | HTN well controlled COPD is controlled, but with mandatory mask use SOB occurs more frequently with decreased activity tolerance. Referred to ortho for bilateral knee pain and "giving out" |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F10.10 | Alcohol abuse, uncomplicated F17.290 | Nicotine dependence, other tobacco product, uncomplicated F52.21 | Male erectile disorder S46.012A | Strain of musc/tend the rotator cuff of left shoulder, init Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 56 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RA |
| 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): | 45 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| 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: | annual physical episodic for shoulder pain and ED |
| Clinical Notes: | Patient in for an annual physical. Abnormal findings of left muscle strain related to in injury three months ago. Toradol 60 mg IM injection given. Referred to PT. ED= patient has used PD5 on the past and is requesting to reorder. Patient states that he has cut his drinking down by 1/3. Wants to stop smoking Nicotine patches with education were given. |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G43.009 | Migraine w/o aura, not intractable, w/o status migrainosus J45.20 | Mild intermittent asthma, uncomplicated |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | OD |
| 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 |
| Chief Concern and Patient Notes: | 6 month Asthma follow up |
| Clinical Notes: | Patient was to have a pulmonary functioning test and a sleep study before todays visit. The patient has an at home sleep study, but Pulm wanted the patient to have an inpatient sleep study and PVT. The patient had an anxiety attack and these test were cancelled. The tests were rescheduled for two weeks ago, but the patient had kidney stones. A lithotripsy with stent placement occured. Stent was removed by the patient this past sunday. Now the patient has uncomplicated cystitis. C/O of recurrent migraines with an aura of photophobia and a "foggy head". Imetrex has been effective in the past. Reordered. Will follow up again in months |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism M06.9 | Rheumatoid arthritis, unspecified M10.08 | Idiopathic gout, vertebrae |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RF |
| Type of Decision Making: | Straight Forward |
| 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 |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 6 month follow up for gout, RA, hypothyroidism |
| Clinical Notes: | Pt is doing well. No pain, muscle weakness, or increased fatigue. Ordered CBC, CMP, TSH, Uric Acid, Lipid profile. Medication refills given |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | B37.49 | Other urogenital candidiasis |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BC |
| 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 |
| Chief Concern and Patient Notes: | rash to right upper thigh |
| Clinical Notes: | upon assessment, the patient was noted to have fungal rash to his right groin. Nystatin ordered. Follow up PRN is s/s do not improve or worsen |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.21 | Type 2 diabetes mellitus with diabetic nephropathy I10 | Essential (primary) hypertension |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) 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: | 6 month follow up on Hypertension and DM2 with neuropathy |
| Clinical Notes: | Patient into for a follow up on HTN and DM2 with neuropathy. The pt is non compliant with DM and heart healthy diet and exercise. The patient's blood pressure is not at goal. However, the patient did have COVID without a hospitalization in the first two weeks of January. Full recovery. Patient has all of smell and most of taste returned. scheduled to receive the COVID vaccine later this month. Due to illness, education was provided verbally and written on a heart healthy and DM diet. What items to sub for breads and carbs. Will follow in three months to see if life style changes have been made. If BP is still not to goal with increase her Lisinopril. |
Case Log/Encounter
| Date: | 02/11/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | C50.111 | Malignant neoplasm of central portion of right female breast G61.0 | Guillain-Barre syndrome G61.1 | Serum neuropathy R19.7 | Diarrhea, unspecified R53.82 | Chronic fatigue, unspecified Z00.8 | Encounter for other general examination Z42.1 | Encounter for breast reconstruction following mastectomy |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HP-Health Promotion |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 40 |
| 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: | Yes |
| Chief Concern and Patient Notes: | new patient: establish care |
| Clinical Notes: | The patient has just moved to Indiana from California in November. Patient in today to establish a PCP and to obtain referrals to Neurology (GBS), oncology (breast CA in 2017, post right mastectomy, reconstruction 2018, two new lumps in 2019 post lumpectomy), GI for chronic diarrhea (on a bulking agent), cardiology (chronic SVT, SR noted on exam, however, S1 is louder than S2), and Pain management (chronic use of tramadol). Weakness is noted with exam on breathing. The patient walks with a cane, but still drives. Labs ordered. CBC, CMP, TSH, VitD, and Lipid profile to establish baseline. Mammogram ordered since the patient missed her last scan with the move. Records requested from pervious PCP and specialist |
Case Log/Encounter
| Date: | 02/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 92 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EL |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 18 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 6 month hypertension follow up |
| Clinical Notes: | no new complaints, blood pressures well controlled. Medications refilled. return in 6 months. |
Case Log/Encounter
| Date: | 02/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder |
| Patient Age: | 92 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 17 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | anxiety follow up |
| Clinical Notes: | 3 month follow up on anxiety. Medication refill given for one month. The patient has to come in to have a medication refill, complete a new C2 contract, and complete a UDS. If the patient does not show for the appointment it will be a failed screening and the medications will not longer be prescribed by preceptor. |
Case Log/Encounter
| Date: | 02/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia I10 | Essential (primary) hypertension Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 43 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yearly physical uncontrolled DM and hypertension |
| Clinical Notes: | The patient is in today for medication refill of lisinopril. He has not been seen in over a year. Uncontrolled hypertension and diabetes. He is noncompliant with all medications, diet, exercise, and monitoring. The patient is in chronic pain and will have back surgery on 10 days. Encouraged the patient to be compliant and to do more, but he says he's been fine for years and he will be better after his surgery. Yearly labs ordered. Will follow up in three months |
Case Log/Encounter
| Date: | 02/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension R73.09 | Other abnormal glucose |
| Patient Age: | 66 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RN |
| Type of Decision Making: | Straight Forward |
| 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: | 3 month follow up for HTN and pre diabetes |
| Clinical Notes: | Controlled hypertension on 40 mg lisinopril daily. The patient is being followed by Cardiology for chronic Afib. He is going to see a new cardiologist to add combination medication for better control after three episodes for chest pain with AFib with RVR. Pre-diabetic, HA1c is 5.8 today. The patient is noncompliant with the diet, exercise, and monitoring blood pressure daily. Encouraged a heart healthy diet and exercise. Will see again in the office in three months. yearly labs, CBC/CMP/TSH/PSA/Lipid profile ordered. |
Case Log/Encounter
| Date: | 02/05/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate F41.1 | Generalized anxiety disorder |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MF |
| 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): | 21 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | uncontrolled depression and anxiety |
| Clinical Notes: | Patient has been having depression and anxiety over the last three and a half years. Approx. four years ago, the patient had an injury to the shoulder and neck. This injury caused the patient to be unable to work. Her husband left her and she had personal items happen within the family. The patient has failed talk therapy and 5 medications. The patient was referred to psych for medication management but the patient has not called them back because she doesn't think it will help. The patient was educated that this is for medication management and they will do a genetic test to prove which medications will work for her. She seemed ok with it in the end. The patient's medication was switched back to Lexapro. Will follow up monthly until she gets in with psych. |
Case Log/Encounter
| Date: | 02/04/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 15 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LL |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 15 months old WCC |
| Clinical Notes: | WCC. Exam WNL. Small hemangioma to the back on the right leg at the knee. Umbilical hernia, soft, and reducible. Vertical hernia is soft and reducible. Monitor for increase in size or strangulation. Education provided. Pneumonia and HEP A vaccine given today. |
Case Log/Encounter
| Date: | 02/04/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G43.C0 | Periodic headache syndromes in chld/adlt, not intractable R05 | Cough R09.81 | Nasal congestion |
| Patient Age: | 6 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | cough and stuffy nose x 4 days |
| Clinical Notes: | Patient is in full time Kindergarten. Arrives today to the office with cough, headache, and sore throat for the last 4 days. DNP noted with congested ears and nares. Cobblestoning present. RAPID COVID is negative. Treat with Zyrtec , push fluids, and rest. |
Case Log/Encounter
| Date: | 02/04/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J05.0 | Acute obstructive laryngitis [croup] |
| Patient Age: | 3 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HF |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | cough |
| Clinical Notes: | Ill appearing toddler. Has had croup in the past and the mother believes that he has the same bark like cough that he had that last time. Last night he had a coughing fit that was resolved by opening the window and breathing in cold air. Cough heard in the office and mimics croup. Ears are congested and pink, advised mom to ask about ear pain, Croup can lead to OM. Deltasone 9.5 mg IM given in the office. Ask for mom to call the office tomorrow with an update and to keep him home from "school" until Monday. |
Case Log/Encounter
| Date: | 02/04/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | B35.4 | Tinea corporis Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 18 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | KR |
| Type of Decision Making: | Straight Forward |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 18 yr old WCC |
| Clinical Notes: | WCC and sports physical. 18 year old senior. Will graduate on time and play baseball at a small college in MI. He is sexually active with one partner. uses condoms and his partner is on birth control. Corpus Tinea is noted on the left top of forearm. Treat with OTC antifungal. Second Meng vaccine administered. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R09.81 | Nasal congestion |
| Patient Age: | 2 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Other |
| Patient ID: | NS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | nasal congestion with blood noted |
| Clinical Notes: | Mom brought in son because she noted blood tinged spit up after nasal suctioning. Frequently suctioned with out normal saline. Effective teachback provided on nasal suctioning with NS and bulb suctioner. |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R05 | Cough |
| Patient Age: | 7 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DF |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Unresolved cough x 12 days |
| Clinical Notes: | patient in on 1/25/21 with complaints of cough, barky, and worse at night. Bilateral OM and bronchiolitis diagnosed. Amoxicillin and a steroid burst ordered. Currently two days left on Antibiotic. Today, bilateral TM are dull, lungs are clear, but hoarse voice. Moist strong cough noted once. Hydrated, drooling, happy, and interactive. AP/LAT CXR ordered since cough has not resolved within 12 days. If CXR is negative, will order a COVID PCR |
Case Log/Encounter
| Date: | 02/02/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G44.211 | Episodic tension-type headache, intractable J02.9 | Acute pharyngitis, unspecified R05 | Cough |
| Patient Age: | 6 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TC |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Cloudy, fluid filled TM bilaterally, slightly erythematous O/P. Post T & A three years ago. Ill appearing, irritable, and lethargic. Negative rapid strep and COIVD, Provide symptomatic care. Can return to school once fever and symptom free for 24 hours. |
Case Log/Encounter
| Date: | 01/28/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R11.2 | Nausea with vomiting, unspecified R19.7 | Diarrhea, unspecified |
| Patient Age: | 7 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VH |
| 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): | 10 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | N/V/D |
| Clinical Notes: | Sent for COVID rapid. Negative exam. Known sick exposure |
Case Log/Encounter
| Date: | 01/28/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified R68.12 | Fussy infant (baby) |
| Patient Age: | 10 Days |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | Ev |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Fussiness and constipation |
| Clinical Notes: | Pain, crying, grunting, and staining with BM. No excessive spot up. Poor weight gain. Only a 2.5 ounce weight gain in 8 days. Will change formula from Gerber gentle to sooth. Feed 2oz every 2 hours for 48 hours and then return to 3 every three. Weight check on Monday. |
Case Log/Encounter
| Date: | 01/27/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J30.89 | Other allergic rhinitis |
| Patient Age: | 2 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: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | tugging on bilateral ears |
| Clinical Notes: | ET tubes in place. Afebrile. Tonsilectomy noted for 2/2/2021. Coblestoning noted. Added Zyrtec 2.5 ml Q HS |
Case Log/Encounter
| Date: | 01/27/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R10.9 | Unspecified abdominal pain |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | GH |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | lower abdominal pain that radiates to bilateral flanks. |
| Clinical Notes: | UA negative, negative for CVA tenderness. Negative exam. No CVA tenderness. Symptomatic care and to folllow upas needed. |
Case Log/Encounter
| Date: | 01/27/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | B80 | Enterobiasis |
| Patient Age: | 3 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | KH |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 45 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | follow up from renal and bladder ultra sound. |
| Clinical Notes: | Patient has had an increased in excessive urination over the last to months. UA & C have been negative. UA is negative today. Renal and bladder ultra sound are normal. Into day to review ultra sound results. The patient has had increased urgency and frequency. Noted to have erythomodious vaginal vault and anal opening. C/O of itching in these areas. The provider turned down all the lights, and after 5 minutes looks into anal opening. Small with worms noted in the anal opening. DX of pinworms. OTC treatment and educated to trim nails and wash linens in hot wat |
Case Log/Encounter
| Date: | 01/27/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R10.13 | Epigastric pain R63.4 | Abnormal weight loss R68.81 | Early satiety |
| Patient Age: | 16 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | HW |
| 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): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 12 # weight loss since June, pain in the RLQ with eating, not able to eat as much, and diarrhea. |
| Clinical Notes: | Normal physical exam. Notes that he had gained weight over the stay at home order. Started football and lost 7 pounds, but after football the patient continues to loose weight, The patient has cut out all caffeine, coffee, all acid based foods, and notices that Mexican food is worse than others. No travel or injection of unclean H2O. Notices that he is not eating as much and will get full very fast. Pain with eating occurs intermittently. No trouble with grains or dairy to report. Blood sugar was 96 and hemoglobin is 18. CBC, CMP, TSH, Free T3/T4, Lipids, IgA, and TTG ordered. |
Case Log/Encounter
| Date: | 01/27/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H92.02 | Otalgia, left ear |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | VR |
| 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: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Left ear otalgia |
| Clinical Notes: | Negative exam. Bilateral TM WNL. O/P is injected. Negative rapid strep test. Symptomatic care. Call If pain increases or new symptoms arise. |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 43 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CB |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yearly wellness exam |
| Clinical Notes: | no change in medical history over the last year. Well appearing man, with no health complaints or medication. Lab panel ordered: CBC, CMP, Vit D, TSH, Lipid profile, and PSA. only complaint is urination stream pressure has decreased. No urgency or difficulty starting stream. Will see yearly and PRN |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.8 | Type 2 diabetes mellitus with unspecified complications E78.5 | Hyperlipidemia, unspecified |
| Patient Age: | 29 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx: Student overall participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | New diagnosis of DM2 and hypertriglyceridemia HgA1c:11.6 glucose (fasting): 439 triglycerides: 2759 HDL: 26 could not calculate the LDL because all other levels were too elevated. |
| Clinical Notes: | Spent 30 minutes with patient on extensive education of diet, exercise, metformin, glipizide, and pravastatin. Education materials given as hands outs as well. Will follow up in three months with an office visit and a redraw of HgA1C. |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E06.3 | Autoimmune thyroiditis H81.10 | Benign paroxysmal vertigo, unspecified ear Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 64 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Asian |
| Patient ID: | CH |
| 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): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Re-establish care new unset of vertigo |
| Clinical Notes: | Patient seen in office over 5 years before move to California. The patient moved to Cali in 2015 and then to Texas in 2017, and returned to Indiana in Aug of 2020. The patient has Hashimoto's thyroiditis. Her MD in Texas last drew a TSH in July and refilled 75 mcg of levothyxine for three months. here to re-establish care. ED visit on 1/18/2021 for vertigo. Meclizine daily has resolved the vertigo. The patient does have a small hole in the left hear that has been there since childhood. Otherwise BTM are WNL. Labs ordered. Medications are not refilled until lab results are returned. |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G43.709 | Chronic migraine w/o aura, not intractable, w/o stat migr |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx: Student overall participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Refill on controlled Fioricet. New pain contract and UDS |
| Clinical Notes: | Daily migraines. Taking PRN medication 2 times per day per patient report, but she has gone through 90 pills in one month. Switched injectable to Erenumab. Awaiting prior authorization. educated to keep on the same schedule and ensure 28 days are in-between injections. Follow up in 1 month. |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified F32.5 | Major depressive disorder, single episode, in full remission G43.109 | Migraine with aura, not intractable, w/o status migrainosus K58.0 | Irritable bowel syndrome with diarrhea Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Chronic Disease Management |
| 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 |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Dx 5: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | establish care, Medicare Replacement Recurrent LCIS being followed by Dr. Mayer. |
| Clinical Notes: | Here to establish care. MD retired and needing a new provider. CBC, CMP, TSH, Free T4, Lipid profile, and Vit D level drawn. Will await levels before refilling Synthroid and simvastatin. |
Case Log/Encounter
| Date: | 01/26/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | T88.1XXS | Oth complications following immunization, NEC, sequela |
| Patient Age: | 29 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JM |
| 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 |
| Chief Concern and Patient Notes: | CC: reaction at injection site |
| Clinical Notes: | Patient received Moderna COVID vaccine 14 days ago. Patient reports that she has a history of site injection reactions with all vaccines she has ever received. Two days post injection, the patient experienced swelling, erythema, and pain at the injection site. The patient is using ice and oral Advil/benadryl to help sleep. Over the last two weeks the area has a macular , scattered rash, and numbness and tingling. Educated the patient to use ice and heat, to use topical benadryl, and to report side effects to the Moderna website. Encouraged to complete the second dose of the COVID vaccine. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CE |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Hypertension follow up |
| Clinical Notes: | Patient is deaf. Interpreter in present. Blood pressure taken BID. Ranges from 120-150/80-85. Compliant with ACEi. No changes at this time. Will follow up again in three months |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 54 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SL |
| 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): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | yearly well visit C/O frequent stooling after meals |
| Clinical Notes: | Wellness visit. patient has a history for right lower lobectomy. Post malignancy. Cholecystectomy. 6-8 watery stools daily. KUB ordered to rule out obstruction. a referral to GI has been made. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder |
| Patient Age: | 15 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | KS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Anxiety, severe, out of medication for one month |
| Clinical Notes: | 15 year old transgender male. Female assigned female at birth. Patient's provider left the practice over three months ago. The patient was looking for a new PCP within the IU network. Was unable to find a provider. Patient is here to establish care and refill medications. The patient is not a harm to self or others. Paxil reordered at 25 mg 1 tab PO daily for one month and then increase back to 50 mg 1 tab PO daily. VV scheduled for one month. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 77 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | yearly wellness exam |
| Clinical Notes: | 77 year old well female. Currently being seen my oncology for bilateral Stage 2A breast cancer. Bilateral mastectomy two years prior. Currently on Alimitia. Stable disease process. Hypertension is stable. Labs completed by oncology. Order to add on a TSH with next lab draw in three days. Will follow up in one year or PRN |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension M79.602 | Pain in left arm Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | Yearly adult well visit. Hypertension- unstable, New complaint of twisting bone pain in left upper arm |
| Clinical Notes: | Wellness visit is normal except, change to family and personal history. Patient reports that he had a paternal grandfather with colon cancer and in his early 20s he had a colonoscopy positive for polyps. This will rule him out for cologaurd. Referred to GI for standard of care colonoscopy for age and risk factors. Hypertension is not controlled, the patient has been out of his ACEi for one month, but has been compliant with his Beta Blocker. medications reordered. Educated to take BP daily in the AM, record results, and send them through the mychart portal in one month. Pain to left arm. Xray of left shoulder and arm ordered. history of muscle stain and over use. however, the patient is an exsmoker and has a significant family history of cancer. CBC, CMP, mag, phos, lipid profile, TSH, PSA, and vit d level ordered. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.0 | Major depressive disorder, recurrent, mild F41.1 | Generalized anxiety disorder |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | 6 month follow up with Paxil for anxiety and depression. |
| Clinical Notes: | virtual visit. Patient stated that she continues to do well taken her medication daily and mood/anxiety is stable. No complaints at this time in regards to GAD/Depression. Referral given for adult and child. The patient feels that she is feeling more isolated because of COVID and would like to get a handle on her feelings before she has a chance to spiral. Good insight noted. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F33.0 | Major depressive disorder, recurrent, mild F90.9 | Attention-deficit hyperactivity disorder, unspecified type |
| Patient Age: | 26 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Chief Concern and Patient Notes: | 3 month follow up for ADHD medication, UDS, and refill |
| Clinical Notes: | UDS was clean of all other substances except for Adderall. The patient is verbalizing situations of depression. Spent time talking with JR about the issues troubling him in his life and made an appointment for him to come back in a month once he restarted his exercise program and moved into his new home. If at that time, or anytime until then, if his depression progresses, will start an SSRI. New three month supply given for ADHD, Adderall 25 mg 1 tab PO Q day. New pain contract completed with ease. |
Case Log/Encounter
| Date: | 01/21/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F32.9 | Major depressive disorder, single episode, unspecified F90.9 | Attention-deficit hyperactivity disorder, unspecified type G43.001 | Migraine w/o aura, not intractable, with status migrainosus |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SBB |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | CC of a migraine. Migraines are chronic but have become unstable. Pt has had two intense migraines in the last week . Normally, SBB has them 3-4 every three months. Pt is related in increase to the COVID vaccine. |
| Clinical Notes: | Refill of Adderall for ADHD. UDS and pain contract nurse visit scheduled for 1340 today. Patient is an NP. She requested to have Wellbutrin. She is more fatigued and has not desire to complete activities or interact with her family. The patient appeared to be depressed. She would not make direct eye contact and had a slight disheveled appearance. will follow up at well visit in April. |
Case Log/Encounter
| Date: | 01/19/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | B35.0 | Tinea barbae and tinea capitis L21.1 | Seborrheic infantile dermatitis L30.9 | Dermatitis, unspecified |
| Patient Age: | 10 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Obtained history and physical exam. Diffuse, pink, papular rash to bilateral posterior legs. Eczema, acute. Hydrocortisone 1% cream OTC 2 times daily until area clears. Educated to not use on the face, peri area, or genitals. Fungal infection of the right thumb. Right thumb is erythema, slightly swollen, and fissures with scant amount of old dried blood noted at the middle and lower joints of the thumb. OTC clomotrin 1% cream ordered to be applied to the area three times daily. Apply a glove to unsure the thumb is unable to be sucked. Remove the glove for sleep and eating. Ensure the area is washed once the glove is removed. Scant amount of craddle cap noted. Educated to not use oils, lotions, or body washes on the scalp. Educated to alternate between J&J baby shampoo and dandrift shampoo until cleared. |
Case Log/Encounter
| Date: | 01/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | S13.4XXA | Sprain of ligaments of cervical spine, initial encounter |
| Patient Age: | 66 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: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | MVA 5 weeks ago. Patient went to the ED one week after being rear-ended and experiencing whip lash. patient is guarding and the head is tilting to the left side. CN II-XII intact and equal. bilateral grip is moderate and equal. no numbness or tingling noted. 2/5 muscle strength to resistance to left turn and 3/5 muscle strength to resistance to right turn. pain is 6/10 and radiates down the back. Pain with circumduction. Bacolfen 10 mg TID PRN ordered, referred to PT, and written instructions given for neck exercises. |
Case Log/Encounter
| Date: | 01/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | E11.29 | Type 2 diabetes mellitus w oth diabetic kidney complication |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SF |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | 6 month follow up for DMMI2. Patient's sugars range for 140-150. Checking sugars once daily. Patient is currently being monitored post transplant for MM. On an oral maint. Patient is on metformin and injectable. Refill for insulin needles. will see again in 6 months. Labs ordered, TSH, vit d to be drawn next month with cancer labs |
Case Log/Encounter
| Date: | 01/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | GAD depression hypertention |
| Clinical Notes: | New patient visit to establish care. CC of HTN and worried she may have DM. Current history: obesity, 9 months antepartum, breast feeding, history of gestational DM/hypertension (non-preeclampsia), on labetalol until 2 weeks antepartum. Family history of DM. Pt states that she has always had anxiety and is a picker. When she is anxious her pulse elevates and her pulse is high and her heart feels like it is jumping out of her chest. physical exam normal. ordered labs (CBC, CMP, Vit D, TSH, HA1C, and Lipid panel), zoloft (used in pregnancy, safest for breast feeding), and monitor BP for one month daily. F/U in one month. BP today was 120/ 85 |
Case Log/Encounter
| Date: | 01/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | K76.0 | Fatty (change of) liver, not elsewhere classified N20.0 | Calculus of kidney R10.11 | Right upper quadrant pain |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HM |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient in the office with severe RUQ pain. Patient has been to the ED three times in the last 2.5 weeks. Twice to IU Morgan and once to SF MV. At SF MV, ran a CT wo contrast. It was noted the patient had a 2 mm calculi in the left kidney and liver steatosis. Physical exam noted severe pain with movement and position changes. 10/10 pain with light and deep palpation. Hepatomegaly noted. Urgent referral sent to GI. Non-urgent referral sent to urology. 7 day supply of Norco 5/325 mg 1 tab PO Q 6 hours PRN for pain. Educated to avoid fatty foods and to eat a bland diet. hand out given with AVS. if pain increases or becomes intolerable, the patient was encouraged to go back to the ED in Indianapolis. |
Case Log/Encounter
| Date: | 01/15/2021 |
| Rotation Type: | NUGR 602: Residency |
| Comments: | |
| Diagnostic Codes: | G47.411 | Narcolepsy with cataplexy |
| Patient Age: | 36 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LL |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient into for a 6 month follow up and refill of medication. Medication is working well. the patient is now able to hold down a steady job and notes zero to one falling asleep episode per month. Ordered yearly labs of CBC, BMP, TSH, and Vit D |
Case Log/Encounter
| Date: | 01/13/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | B35.4 | Tinea corporis R21 | Rash and other nonspecific skin eruption V95.01XD | Helicopter crash injuring occupant, subsequent encounter |
| Patient Age: | 7 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Unknown |
| Patient ID: | ZM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: rash. Rash started three days ago with a few pimples on the left chest. The patient woke up yesterday and the rash had spread all over the body. No change in products or foods. tinea corpus noted to left mid calf. Viral exanthem noted because the macules will reduce when blanched. hydrocortizone cream, zyrtec. lomotrin given to treat ringworm, educated it will take 4-8 weeks for treatment. |
Case Log/Encounter
| Date: | 01/13/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J01.00 | Acute maxillary sinusitis, unspecified M79.1 | Myalgia R09.81 | Nasal congestion R68.83 | Chills (without fever) |
| Patient Age: | 16 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | LH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | FLU COVID sinusitis |
| Clinical Notes: | CC: pressure in head, low grade fever, body aches, chills, and hot flashes. Physical exam (chart by reception). Bilateral TM have partical mucoid fluid and buldging TM. L>R. O/P erythemodous. Head feel like a balloon with pressure and increases when bending over. Positive Rombergs test. Cefdinir 300mg PO BID X 7day |
Case Log/Encounter
| Date: | 01/13/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G43.A0 | Cyclical vomiting, not intractable R50.9 | Fever, unspecified |
| Patient Age: | 1 Year |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: vomiting and fever. yesterday, the child was at her grandmothers (gm watches the child daily along with her cousin) and the GM noted that she was fussy and was waking up frequently from her nap. SS is also cuddly. These are not normal characteristics. Vomiting x 5 episodes. SS was able to keep down crackers, yogurt, and milk this AM. TMAX 100.4. Tylenol last administered at 0430. Temp at 1115 was 98.3. Physical exam was negative. However, the child appears to not feel well. Do to the fact the patient's s/s have not been >4 days, the patient was sent to have a COVID PCR collected. |
Case Log/Encounter
| Date: | 01/13/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R09.81 | Nasal congestion |
| Patient Age: | 30 Days |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AK |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 30 day old infant in today with CC of nasal congestion. Started about two days ago and has progressively gotten worse over night. Using the blue bulb suctioning with no NS. Nasal passages are block with green, thick exudate noted. Mom (whom is a pallative/pain specialist MD) reports coastal retractions but resolved with nasal suctioning. Concern for RSV. RSV swab was negative in the office. Educated mother on the use of NS with nasal suctioning, symptomatic care, and when to call the office or take the infant to the ED. Requested an update on infant's s/s later today and tomorrow morning by the use of mychart. |
Case Log/Encounter
| Date: | 01/13/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] J01.90 | Acute sinusitis, unspecified R05 | Cough R09.81 | Nasal congestion |
| Patient Age: | 2 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PK |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient arrived with a CC of cough. Cough was observed to be wet and non productive. Negative exam. ET intact and in place. No other alternative SS were determined. RAPID COVID completed. Negative results. Acute nasopharyngitis. Supportive care. Education on nasal suction provided. |
Case Log/Encounter
| Date: | 01/12/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H66.019 | Acute suppr otitis media w spon rupt ear drum, unsp ear J02.0 | Streptococcal pharyngitis |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MC |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 8 y/o presenting with a CC of left ear otalgia and non productive cough. Voice was "strep like" and it sounded if the patient was trying not to swallow. Decreased app. and not drinking as much, however, the patient denies throat pain. During the physical exam the left TM had ruptured and presence of white to yellow exudate present. O/P was erythemadous, tonsils +2 without exudate. Rapid strep test is positive. Auscultation noted wheezing in the RLL with "tightness" Sent for a CXR. No noted infection, but inflammation, mild is present. Albuterol DMI Q 4 hours PRN ordered and education provided on use. Amoxil 400mg/5ml. 12.5 ml, BID x 10 days. |
Case Log/Encounter
| Date: | 01/12/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified |
| Patient Age: | 9 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | EV |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | virtual visit. EV was sent home today from school today for abdominal pain. Transient abdominal pain over the last three weeks. Abdominal pain is noted to be in the umbilical area and is worse after eating. Patient reports BM almost daily. Stools have been hard balls. She is also holding her stool while at school because she doesn't want other people to know that she is going poop. Miralax ordered. Educated to increased water intake daily, to limit dairy to servings per days, add more fiber to the diet, eat more fruits/veggies, and to sit on the toilet 20 minutes after eating dinner for ten minutes in hopes of training the bowels to evacuate daily at this time. Note sent to school to ensure that the patient does not have COVID related symptoms and could return to school the following day. |
Case Log/Encounter
| Date: | 01/12/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R11.10 | Vomiting, unspecified R19.7 | Diarrhea, unspecified |
| Patient Age: | 13 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CW |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | gastroenteritis COVID stomach flu |
| Clinical Notes: | Virtual visit. 13 y/o white female with diarrhea x 3 days. Notes 4 watery stools per day. abdominal cramping 8/10, transient. 3 episodes of vomiting between yesterday and today. Travel history. Has been to Canada for a funeral and to NYC over the last month. before each trip and upon arrival home, a rapid COVID test has been completed. All four tests have been negative. To return to school the patient must have a negative COVID test. Since the patient has not had symptoms for >4 days, the patient was sent to have a COVID PCR completed. Education provided on the proper method of quarantine. |
Case Log/Encounter
| Date: | 01/12/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J02.9 | Acute pharyngitis, unspecified R05 | Cough R09.81 | Nasal congestion |
| Patient Age: | 6 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RD |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | strep throat acute viral phyaringitis COVID-19 |
| Clinical Notes: | CC: deep cough reported beginning last evening. This AM woke up with sore throat with swallowing and at rest, and nasal congestion. negative exam except for bilateral anterior cervical LAD, slightly, tonsils +2, and O/P with erythema. Returned to in person schooling on 1/4/21. Rapid strep test negative/ Sent for COVID PCR. Did not complete in the office because patient's symptoms have not occurred for >4 days. advised to quarantine the patient and family until results are back. |
Case Log/Encounter
| Date: | 01/12/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F90.2 | Attention-deficit hyperactivity disorder, combined type R06.2 | Wheezing R09.81 | Nasal congestion |
| Patient Age: | 7 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | ZT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | COVID 19 pneumonia common cold |
| Clinical Notes: | Pt arrived in the office for follow up for ADHD medication. Adderal XR 10 mg 1 PO OD. medication started at 5 mg two months prior and increased to 10 mg one month ago. Mother and patient report increased ability to focus while completing e-learning (the patient has not gone back to in person schooling at this time). Grades have improved, but with virtual learning the mother is checking work and having ZT correct it before turning the assignment in. No nausea or headache with the onset of medication. ZT has had a 5 lbs weight loss since beginning the medication. Mom reports they have all started eating healthier over the last two months. They have cut out red med, processed foods, drive thrus, and sugars. Added more fruits and vegetables to daily meals. Increased water intake. Constipation is chronic and reports of BM QOD. Encouraged to eat 1/2 of a sandwich and fruit at lunch with an afternoon snack. Will recheck weight in one month. Visit became episodic. CC of nasal congestion x 1.5 weeks and a productive cough x 4 days. Pt has a history of pneumonia. Wheezing to RLL and rightness. Stat CXR. Bilateral TM WNL. O/P slightly red, no cobblestoning noted. Mucous membranes present with erythemodous, swollen turbines with yellow/green sticky exudate. Albuterol inhaler with DMI ordered Q4 hours PRN (educated on DMI and to give every 4 hours with the next 48 hours.) Rapid COVID (in office) was negative. Will review CXR and treat accordingly. |
Case Log/Encounter
| Date: | 01/06/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R09.81 | Nasal congestion |
| Patient Age: | 16 Days |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MF |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 16 day old white male. Brought in by both parents for nasal congestion, cough, and fussiness x 4 days. A febrile. Negative physical exam. COVID rapid completed in office. Negative result. Supportive care. |
Case Log/Encounter
| Date: | 01/06/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G44.209 | Tension-type headache, unspecified, not intractable J01.00 | Acute maxillary sinusitis, unspecified |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) Medicaid |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Recurrent patient. CC sever headache, left ear pain, painful in eyes and nose while bending over. OP erythemedous with cobblestoning. LTM effusion and RTM dull, mucoid. High dose AMOXICILLIN 1000mg BID X 10 days |
Case Log/Encounter
| Date: | 01/06/2021 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H60.20 | Malignant otitis externa, unspecified ear H60.21 | Malignant otitis externa, right ear L23.89 | Allergic contact dermatitis due to other agents |
| Patient Age: | 3 Years |
| Patient Sex: | F |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Recurrent rash to buttocks |
| Clinical Notes: | 11/7- folliculitis to bilateral gluteus Maximus. Ten day course of antibiotics. Dad reports that not all of the medication was taken. The rash is still Present. JT is currently in a pull up at NOC and it appears that her father does not remove the pull up at the time of awakening. Small area of psoriasis noted to the left buttocks. Apply hydrocortisone 1% thin layer to area BID. cover the area with Aquaphore cream to buttocks BID. Wear loose clothing and underwear. Right blocked ET with particle injection and clear exudate. Cipro gtts 5 gtts BID |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] |
| Patient Age: | 2 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC "barky cough," nasal drainage, clear, and fussiness for the last three days. Negative exam. However, allergic shinners present. Sent for COVID testing. |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] |
| Patient Age: | 3 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VT |
| 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): | 50 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Sudden onset of fatigue, fussiness (crying, melting down which is out of character), and sore throat (refused to eat lunch). Emesis x 1. Did not eat lunch. Able to keep down water. Tactile fever. Negative Flu and RST. Sent for COVID testing. |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | M41.114 | Juvenile idiopathic scoliosis, thoracic region |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | HE |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 6 month follow up on curvature. Less than 10 percent noted on physical exam. right scapula is higher than the right when the child in bent at the waist with arms dangling and eyes looking at the belly button. Not noted on xray. will continue to visualize on physical exam every 6 months |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | B27.10 | Cytomegaloviral mononucleosis without complications |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | follow up after three weeks after initial mono infection. No spleenomegally. Patient reports that she is about 75%. Released to return to work for 4 hour shifts at a time. Will follow up again in one week. |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K37 | Unspecified appendicitis |
| Patient Age: | 10 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BO |
| 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): | 50 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: sever abdominal pain for 12 hours. Pain is in the RLQ. Pain started with dinner and awakened the patient frequently throughout the night. Rating 7/10 with walking and 3/10 when sitting. Toxic appearing, observed to walk bent over at the waist. Positive for pain 10/10 with palpation. Negative Tap test, jump test, and for rebound tenderness. Sent for an ultrasound of the appendix/abdomen, STAT. test and results returned with 50 minutes. US positive for appendicitis without an abscess. Call general surgery at Riley hospital. Coordinated admission through the ED for a surgery scheduled in the next three hours. At 1610, mother called with an update. Surgery was laparoscopic, successful, and the child is doing well. |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J30.0 | Vasomotor rhinitis |
| Patient Age: | 14 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC tactile fever, cough, runny nose x 7 days. See with her twin brother for the same s/s. DX with purulent rhinitis. Amoxicillin 80 mg/kg= 4.5ml BIDx 10 days PO. sent for COVID testing. Her and her brother stay at home and have no known exposures. However, and aunt and cousin in the house hold work at and attend daycare. |
Case Log/Encounter
| Date: | 12/16/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J30.89 | Other allergic rhinitis |
| Patient Age: | 14 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | OR |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of fussiness, cough, clogged nasal passage, and tacitile fever. alternating Tylenol and NSAID every eight hours. Used over the counter Zarbees cough and cold with noticeable difference x 1 dose. Mucus membranes are red and clogged with dried mucous. Wet, productive cough noted. Bilateral anterior cervical lympadnopathy. bilateral TM are infected and retracted. Amoxicillin 78 mg/kg= 5ml PO BID x 10 days. Sent for COVID testing |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.121 | Encounter for routine child health exam w abnormal findings |
| Patient Age: | 12 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | ST |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 12 year old well child exam. Patient is requesting a sports physical to play tennis in the spring. The exam was normal expect a grade 1, systolic murmur was noted at the LSB while lying and while lying left lateral position. No murmur was noted in the history and the mother or patient do not ever remember hearing that she had a murmur. ECHO ordered. Did not sign the sports physical for play clearance. Will follow up |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N76.0 | Acute vaginitis R53.81 | Other malaise R53.83 | Other fatigue R59.0 | Localized enlarged lymph nodes T38.4X5A | Adverse effect of oral contraceptives, initial encounter |
| Patient Age: | 14 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| 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): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Dx 5: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 14 year old how presented to the office with a complaint of enlarged cervical lymphnodes, fever, and hot flashes. Upon ROS, it was noted the patient had enlarged bilateral cervical nodes with time last year with a scalp infection. In the last months the patient has gotten a new "Bar" piercing in the right ear. The piercing starts in the lower pinna and ends in the upper pinna. Three days ago the patient was hit in the ear and the top of the piercing is swollen and painful to the touch. No infection noted. Educated to ice the area, removed the piercing daily for cleaning and placing antibiotic ointment to the holes within the ear once the bar is replaced. The patient also reported that she has been extremely tried over the last month and it just doesn't go away. A mono spot was ordered and negative. The patient is also negative for depression. Ordered a vit D supplement daily. Last, the patient complained of a thick, grey vaginal discharge that swells "really bad." With the ROS is was determined that the smell is "fishy". Dx with BV: flagyl 500 mg BID for 7 days ordered |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.03 | Acute serous otitis media, bilateral |
| Patient Age: | 7 Months |
| Patient Sex: | F |
| Patient Ethnicity: | Middle Eastern |
| Patient ID: | KA |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient was in for a nursing visit for the second series of the flu vaccine. The mother expressed that the infant has been fussy, irregular sleep pattern, not eating solid foods offered to her, and not acting herself. The nurse requested a provider to examine the infant. Upon exam the infant was fussy. No teeth were noted to be erupting. Bilateral TM were injected, bulging, with noted mucoid fluid. Amoxicillin 4.5 ml BID x 10 days |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | L20.82 | Flexural eczema N49.2 | Inflammatory disorders of scrotum R26.9 | Unspecified abnormalities of gait and mobility |
| Patient Age: | 23 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EW |
| 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): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: 1-eczema. flexor hydrocortisone 2.5% ordered. 2. Scrotal edema and anular rash to right testicle sac. No edema noted. Rash has no central clearing, no itching, no pain noted with palpation. Place nystatin cream to area three times daily for one week. place send photos through my chart when edema occurs. 3. Uneven gait to left leg. Leg will externally rotate with ambulation. History of foot drag with crawling. Attended programs for first steps last year. Hip joints are hyper reflexive. No clicking or pain noted with maneuver. Sent for a fog leg xray to ensure proper hip joint alignment. |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified R50.9 | Fever, unspecified |
| Patient Age: | 15 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EC |
| 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): | 65 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of fever for the last 4-5 days. Exposure to COIVD 19 at daycare on the 16th. COVID test collected and resulted today of negative. Exam is WNL. Decreased app. Drinking well and normal amount of wet diapers. Loose stools but not diarrhea. Negative for the flu. Bag placed for a urine sample. Urine dip is positive for moderate WBC, many leukocytes, and moderate protein. In and out cath preformed for a culture. Bacterium (8mg/kg) 4.5ml BID for 10 days |
Case Log/Encounter
| Date: | 12/02/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 5 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | QG |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | normal well child visit for a 5 year old. He was able to count to 14 (mother reported preschool reported he is able to count to 20). Knows A-T. Is able to name six colors. Only abnormal finding is he had a slight pronation of right foot. |
Case Log/Encounter
| Date: | 11/25/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.01 | Acute serous otitis media, right ear J30.89 | Other allergic rhinitis |
| Patient Age: | 3 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Two or More Races |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of clear to purulent drainage from the right ear. Has occurred in the last month, called MD and Cipro drops were called into the pharmacy. Increase nasal drainage for the last week. Right ear is painful to the touch and when unstimulated. history of recurrent ear infections. Pt is currently on his second set of tubes. They have been in place for approx 18 months. ET are noted to be migrating out of the cannal. TM are inflamed and injected. Purulent drainage and blockage is noted in the nasal cavity. Continue ear drops and start amox BID for 10 days. |
Case Log/Encounter
| Date: | 11/25/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H92.01 | Otalgia, right ear J02.9 | Acute pharyngitis, unspecified J30.89 | Other allergic rhinitis |
| Patient Age: | 13 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of sore throat. Decreased eating due to painful swallowing. History of strep. Last case approx 9 months ago. 2 cases in four years. Bilateral tonsils +1, erythema. BTM are injected with bubbling. hypertrophy of bilateral turbinates. RST was negative. Start zyrtec 10 mg daily. |
Case Log/Encounter
| Date: | 11/25/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J30.89 | Other allergic rhinitis |
| Patient Age: | 7 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | KS brought in by her mother for worry about COVID. KS is positive for a solider salute, dry itchy eyes, injected conjunctiva (L < R). Boggy bilateral turbinates (L>R). Cobble stoning noted at the OP. Positive for snoring. A febrile. Injected TM with bubbling noted. (L>R). Symptoms are been present on and off for the last months. And allergy increase occurs when the family's heat is turned on. Patient is overweight, home school. Daily Zyrtec daily, patalol eye gtts. 1gtts in each eye daily for 14 days and PRN there after. Nasonex 1 spray each nostril daily. Patient is taking elderberry currently. |
Case Log/Encounter
| Date: | 11/25/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R63.6 | Underweight |
| Patient Age: | 5 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LH |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | saw infant days ago for an episodic visit. Infant was underweight. Saw today for one week check. Infant gained 10 ounces. Feedings were increased to 6 oz per bottle at daycare, and feeding 5-10 minutes past let down. Infant is tolerating well. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F43.0 | Acute stress reaction R10.10 | Upper abdominal pain, unspecified R21 | Rash and other nonspecific skin eruption R50.9 | Fever, unspecified |
| Patient Age: | 2 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DT |
| 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): | 90 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | sudden symptoms of extreme fatigue, abdominal pain, macular rash to bilateral armpits (migrates to the nipple and down the side of chest, and arm), around the neck (migrates up the scalp), in the "diaper" area, in the elbow bends, behind the knees, and on the tops of bilateral feet. Afebrile. 02 stat was less than 94 %. Monitor the infant for over in hour. gave snack and apple juice. He perked up for about 10 minutes and just as he was leaving all of his symptoms occurred again. Sent the child to the ED at Riley. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] K00.7 | Teething syndrome R50.9 | Fever, unspecified |
| Patient Age: | 11 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Infant presenting with a fever TMAX 102.4 oral running nose, nasal congestion. Physical exam is unremarkable Sent for COVID testing |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] R63.5 | Abnormal weight gain |
| Patient Age: | 5 Months |
| 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): | 40 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | healthy appearing 5 month infant. Meeting milestones. However, the patient is not gaining sufficient weight. the infant is breast feed two to three times daily and is currently new to daycare where she is having three 5oz bottles of breast milk. She was introduced to cereal two weeks ago. being fed before the nightly feeding. Dad brought infant in for cough/congestion x 3 weeks. COVID testing ordered. Education given to dad and in writing to increase bottles to 6oz and to wake the infant around 3AM for a night time feeding for the next week. The mother was also advise to not start loosing weight at this time because it decreases milk production and to feed 3-5 minutes past let down. Also to consume 500 extra calories daily to aid in milk supply. follow up weight check in 6 days. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified |
| Patient Age: | 5 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | JAO |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | C-Counseling |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 2-Some Help from the Preceptor |
| Clinical Notes: | Patient in again for the third time in three weeks with constipation. The infant has had no weight gain in one week. the mother is leaving for African on Monday. EXTENSIVE education was given on why the infant cannot have vaccines early, what vaccines he has already had, and when he needs to receive while they are in Africa. Sent for sickle cell testing since trait is noted. Again spent 15 educating on how to mix cereal and to only give it for one meal a day and continue to use the glycerin supp. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K00.6 | Disturbances in tooth eruption Q82.9 | Congenital malformation of skin, unspecified Z76.2 | Encntr for hlth suprvsn and care of healthy infant and child |
| Patient Age: | 12 Days |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| 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): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Two week WCC of a healthy infant born at 37 weeks and 1 day gestation. Extensive education given on breast feeding and over feeding. infant has two natal teeth in the bottom front. Sees specialist every two weeks. Small, noncommunicating sacral dimple. Ultrasound ordered. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H02.402 | Unspecified ptosis of left eyelid R05 | Cough |
| Patient Age: | 8 Months |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EC |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Clinical Notes: | cough in a pediatric patient. Physical exam was not impressive. No acute disease process noted. A COVID test was not ordered because he is Asymptomatic. Instructed to quarantine for 14 days. however, infant presented with a structural helmet and severe left eye ptosis. Referred to neurosurgery at PMCH. |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H61.21 | Impacted cerumen, right ear H66.92 | Otitis media, unspecified, left ear |
| Patient Age: | 11 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| 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): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | LTM is injected, puss filled RTM no visualized because of cerumen impaction. attempted to clear, unsuccessful because of infant discomfort |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H60.592 | Other noninfective acute otitis externa, left ear |
| Patient Age: | 11 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | cerumen inpaction |
Case Log/Encounter
| Date: | 11/19/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | F90.0 | Attn-defct hyperactivity disorder, predom inattentive type |
| Patient Age: | 7 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | ZT |
| Type of Decision Making: | High Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 90 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient is into with the initial visit with ADHD. Extensive review of the NICHO surveys by parents and two separate teachers. Extensive education on disease process and medication management. Will start on Adderall 5mg Q day and follow up in two weeks |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J31.0 | Chronic rhinitis |
| Patient Age: | 13 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): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | assessment not remarkable. Noted chronic allergies/Rhinitis (per history). Sent for COVID testing. |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.01 | Acute serous otitis media, right ear |
| Patient Age: | 2 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | EE |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC cough, congestion, otalgia, afebrile, retractions noted throughout the night. Resolved post albuterol treatment. Noted right acute serous OM on exam and patient was sent for a COVID test |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | P92.4 | Overfeeding of newborn |
| Patient Age: | 24 Days |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | PW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of cough. After evaluation and history it was determined the infant is being over fed. He is breast feed and is switching to bottle feeding of breast milk. Intensive co-education of sings an infant is full, to cut of dairy, and how to keep the infant upright for 30 minutes post feeding. |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J31.0 | Chronic rhinitis |
| Patient Age: | 2 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CW |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | double sickness. recurrent purulent rhinitis Ill appearing child omncef |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H66.93 | Otitis media, unspecified, bilateral |
| Patient Age: | 10 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | DA |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC of cough, congestion, and runny nose x 10 days. Attends daycare. COVID negative on 10/6/2020 injected LTM and RTM is bulging. Amox 5ml BID x 10 days |
Case Log/Encounter
| Date: | 11/12/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G43.A1 | Cyclical vomiting, intractable |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KD |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient is well known to the practice. She is experience extreme fatigue, nausea, vomiting, and abdominal pain. Negative for pregnancy or UTI. Patient sent for a complete abdominal series US. US was negative. Collaborated with Riley GI. Appointment set for Tuesday for eval and treat. |
Case Log/Encounter
| Date: | 11/11/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.03 | Acute serous otitis media, bilateral |
| Patient Age: | 2 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | Riley |
| 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: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | c/o ear pain for one week. Afebrile. Amoxicillin 400mg/5ml. 78mg/kg = 6ML BID x 10days |
Case Log/Encounter
| Date: | 11/11/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N60.19 | Diffuse cystic mastopathy of unspecified breast |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | Kylie |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC lump in the breast, right. Ten days ago she had a sharp pain in the right breast and then noticed a lump in the under side of the right breast. Pain and lump are not related to menstral cycle. Upon exam fibrocystic tissue noted on bilateral breast. Small lump noted at 6 oclock and a large lump noted between 7-8 oclock. Lumps are mobile, non tender. No lymphadnopathy noted. there is a history of breast cancer on her mothers side. her mother is positive for the BARD gene. The patient was educated to cut out caffeine and start taking vit E. Will follow up in one month |
Case Log/Encounter
| Date: | 11/11/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K59.00 | Constipation, unspecified |
| Patient Age: | 5 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | JAO |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Exam/CPT code: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient's mother has been sending mychart messages over the last month to discuss transitioning solid foods into the diet of this strictly breast fed month old. The mother has also complained that the infant has had hard stools and is not going as frequently as he has in the past. the patient has had success with 1/2 of a Glycerin supp. with success two weeks ago. Upon exam a hard stool was noted outside of the anal opening. Anal stimulation was provided. The infant was well hydrated. He produced tears and is drooling. education was completed for 20 minutes on how to mix cereal with breast milk, how much baby food at each setting. The mother was educated to only feed the infant cereal at night, one fruit and one veggie during the day. Breast feed as normal and to give the infant 1 ounce of pedilyte three times daily for three days. The mother called and stated the infant had a large stool. |
Case Log/Encounter
| Date: | 11/11/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z11.59 | Encounter for screening for other viral diseases |
| Patient Age: | 15 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | Lukas |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: sore throat and bilateral otalgia. Afebrile. The patient is not sleeping well. He is not eating well related to pain with swallowing. Injected bilateral turbinates, O/P are injected. tonsils +2. RST and flu A/S swabs are negative. Sent for COVID testing |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Asian |
| Patient ID: | TT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Normal well child visit. Flu vaccine administered |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R59.0 | Localized enlarged lymph nodes |
| Patient Age: | 7 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | FT |
| 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): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient come in contact with seed tick nest two weeks ago. The patient has over 300 seed ticks removed within 48 hours. The patient was seen during a virtual visit with the MD 8 days ago. No actions were taken at this time. Lymphadenopthy noted behind the left ear. Preventive amoxicillin started for Lyme disease. will follow closely and refer as warranted. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N89.9 | Noninflammatory disorder of vagina, unspecified |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ET |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 5 yr old female brought in because of not wanting to wear under ware, tights, or to have any clothing touch her vagina. Upon exam the labia is excoriated and the open is bright red with scratch marks noted. Child denies toughing herself or others touching her. the patient is also incont. while wearing a pull up at night. Cannot rule out contact dermatitis. Education provided on air out the vagina and tricks to help reduce nocturnal bed wetting. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | D64.9 | Anemia, unspecified F43.23 | Adjustment disorder with mixed anxiety and depressed mood R53.83 | Other fatigue |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient is falling asleep in class. Brought in by mother for extreme fatigue. POCT hemoglobin was 11. Sent for lab work and to keep appointment with adult and child the next day. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 17 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | WCC and sports physical without abnormal findings . |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H92.02 | Otalgia, left ear R60.9 | Edema, unspecified |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | VR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient presented with un-resolving left otalgia and left facial swelling. The patient has been to a dentist, had xrays with negative results. The patient has followed a soft diet for the past 10 days and the otalgia has gotten worse. LTM has an effusion and blood present in upper portion of the TM. Painful to touch the inner canal, but on externa pain. Antibiotic given and education on supportive care. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | R05 | Cough R50.9 | Fever, unspecified |
| Patient Age: | 8 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | Kitley |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | Fever and cough |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient was active and not ill appearing upon examination. the patent's mother reports that she has had a fever and an episode of wheezing and shortness of breath that resolved with the use of an abuterol rescue inhaler. Upon examination the bilateral tonsils with extremely red and c/o painful swallowing. RST was negative. The patient was sent for COVID testing. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | G43.C0 | Periodic headache syndromes in chld/adlt, not intractable R07.0 | Pain in throat R53.1 | Weakness R53.81 | Other malaise |
| Patient Age: | 5 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | FS |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Dx 5: Student Participation: | 3-Joint Care 50/50 |
| Chief Concern and Patient Notes: | fever, TMAX 101.8f for the past two days, fatigue, weakness, and sore throat. |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Exam noted bilateral erythematous tonsils with white exudate. RST negative, Flu negative, and monospot negative. Patient sent for COVID testing. Education provided on supportive care. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | K21.9 | Gastro-esophageal reflux disease without esophagitis |
| Patient Age: | 44 Days |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AE |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Previously seen this patient two weeks ago for over feeding and changing formula 5 times since birth. The patient was seen last week by the MD and was educated to thicken formula with cereal and to use premixed formula. The mother reports that she is feedings the infant 2-3 ounces every 2-4 hours, burping half way through, and sitting the baby upright for 30-40 minutes after each feeding. At this time, the infant is still have episodes of vomiting, weak cry, and report of lethargy. The infant was interactive, meeting appropriate milestones, reflexes in tact, full cry, but when the gag reflex was replicated with a tongue depressor, reflux was noted at the back to the throat and the infant received his last bottle 1.5 hours ago. NP collaborated with MD. Referral made to GI and started on Prilosec BID. |
Case Log/Encounter
| Date: | 10/28/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | T16.2XXA | Foreign body in left ear, initial encounter |
| Patient Age: | 4 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CW |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient stuck an airfreshener soft, gel bead in the left ear. The bead was flushed out and are reexam with no internal injury noted. education provided to the parents and the patient on harms of placing objects in the ears or in nostrils. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J18.1 | Lobar pneumonia, unspecified organism |
| Patient Age: | 3 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: Cough, fever, and congestion x 4 days. Right LLL pneumonia noted. Sent for COVID testing. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | N30.90 | Cystitis, unspecified without hematuria |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Ill appearing child with a presenting fever of 104.5 in the office. The patient has had high fevers the last 3 days. She also has a history of UTI and was being seen my urology. No UTI in the last 9 months. UA dipstick is positive. Bactrim x 10 days ordered. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | Q52.5 | Fusion of labia |
| Patient Age: | 2 Years |
| Patient Sex: | F |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: parental concern of UTI (increased frequency and bright red labia) The patient is well known to the office and has just been reunified with her mother and father over the last six months for physical abuse. UA dipstick was negative for UTI External exam. Labia is bright red and there is yellow exudate in surrounding the clitoris. Labial adhesion noted. estorgen cream prescribed. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J05.0 | Acute obstructive laryngitis [croup] |
| Patient Age: | 2 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: cough that worsens at night and sounds like a bark *(seal) and a stomach ache Steroid injection given *+ |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H66.91 | Otitis media, unspecified. right ear J02.9 | Acute pharyngitis, unspecified |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KJ |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: congestion and decreased appetite greater than 10 days. the patient is positive left post auricular and sub-mandibular lymphadnopathy. Right bulging TM. Positive exudation and sever erythema of the pharynx. DX: right AOM and pharyngitis |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | H65.119 | Acute and subacute allergic otitis media (serous), unsp ear |
| Patient Age: | 2 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: congestion greater than 10 days. Negative strep test left ear is positive for a mucoid. Treated because of age and sister in office with a full ear infection with her symptoms started three days sooner. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | P92.4 | Overfeeding of newborn |
| Patient Age: | 23 Days |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AE |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The mother reports that she was in the office 12 days ago because the infant was projectile vomiting. In the last 12 days the infants formula has been changed three times and a total of 5 times since birth. The infant was feed in the office and it was noted that he is an very aggressive eater and the nipple flow of his bottle is too much. Extensive education was provided about signs and symptoms of over feeding, when a baby is full, not to change his formula for atleast 7 days, and to change the nipple flow to a smaller opened nipple to ensure the milk is not coming out too quickly. Education about pyloric stenosis was again provided. will follow with this patient in one week. |
Case Log/Encounter
| Date: | 10/07/2020 |
| Rotation Type: | NUGR 564: Pediatrics |
| Comments: | |
| Diagnostic Codes: | J18.1 | Lobar pneumonia, unspecified organism |
| Patient Age: | 5 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NB |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: cough greater than 10 days. Non productive, afebrile, and no noted respiratory expressed. Upon exam, it was noted that there was consolidation in the right lower lobe. We are unable to complete a breathing treatment in the office due to new COVID regulations. The patient was prescribed a z-pack and a steroid burst. Follow up lung check scheduled for Friday 10/9 |
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Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 10 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | JC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | follow up with an ear infection from two weeks ago. still tugging at ears, exam was WNL. The infant is currently teething. Received first or two flu vaccines today |
Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | G40.89 | Other seizures |
| Patient Age: | 24 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MT |
| 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: | 1- Much Help from the Preceptor |
| Clinical Notes: | Patient was seen today for increased anxiety. The patient just got out of jail and reported drinking a 1/5 of fireball a day and other drugs. In the middle of talking to the patient she stood looked at the wall, and began to seize. The MA witnessed, lowered the patient to the floor. Toxic-clonic seizure lasting 5 minutes. 911 called and patient transferred to the ED |
Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F33.1 | Major depressive disorder, recurrent, moderate F41.1 | Generalized anxiety disorder F43.11 | Post-traumatic stress disorder, acute Z72.4 | Inappropriate diet and eating habits |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AC |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient was raped one year ago. She has always battled with depression and anxiety but it has been worse since the rape. The patient is completing daily therapy out patient at Valley Vista and is doing ok. She has been diagnosed with anorexia and is having trouble sleeping. She states that her Lexapro is helpful but just not enough. mood stabilizer added. Educated to monitor or fatigue and triedness. The patient has just started working nights at mejier full time. |
Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 45 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient is in for yearly wellness visit. The patient states that she is having right lower back pain, that radiates up the right arm. Numbness and tingling in right arm and hand is on and off. Referral sent to PT. C/O blood in stool. The patient was seen in the last week by GYN for pelvis and pap. Appointment was made with Dr. Reedi. Will check CBC, CMP, TSH, Lipids per routine and to r/o internal bleeding/anemias. Other wise the patient's exam was WNL. |
Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 15 Months |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DF |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | 15 month WCC. Child is meeting all of her developmental milestones. Eating well (table food and on demand breast feeding), using a spoon, and drinking well from a sippy cup. Did well with the exam and shots. Vaccinations are now UTD |
Case Log/Encounter
| Date: | 09/17/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AP |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Patient in for wellness exam. Exam was within normal limits. referrals sent for mammogram (yearly, routine) and to GI for screening/diagnostic colonoscopy. EHCO ordered because the patient is concerned about developing hypertension and Afib because of family history, she is a smoker, and she has recent elevated cholesterol. The patient is on the schedule for a CT heart scan. Referral sent to inspire to help the patient to stop smoking, the patient states that she is ready but afraid to fail. |
Case Log/Encounter
| Date: | 09/04/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M54.5 | Low back pain |
| Patient Age: | 73 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Day two of trigger point injections. 3 points injected with 1% lidocaine without epi. |
Case Log/Encounter
| Date: | 09/04/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BF |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | normal well visit. patient is not taking her thyroid medication. patient was educated on the risk and benefits of not taking her medication. The patient will take medication and labs drawn in two months. |
Case Log/Encounter
| Date: | 09/04/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M25.561 | Pain in right knee |
| Patient Age: | 51 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | old injury from child hood has flared. Referral to sports medicine surgeon |
Case Log/Encounter
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | R42 | Dizziness and giddiness |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 40 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient reported that she has stopped drinking monster (two a day) and cut down her Dr. Pepper consumption from 8/day to 4/day. Dizziness with change of plane, slight headache. No SOB. However, the patient has an irregular heartbeat and reported that she had a heart history and was supposed to have an ablation on 2016 but she never had it completed. EKG completed in the office. Normal SR with low voltage. Meclizine sent in and referral to cardiology sent |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N76.0 | Acute vaginitis |
| Patient Age: | 47 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SW |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | CC: vaginal itching, vaginal discharge, and foul odor. New sexual partner. Pelvic exam with STD screening completed. BV confirmed per wet mount and whiff test. Clindamycin ordered. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J45.30 | Mild persistent asthma, uncomplicated |
| Patient Age: | 3 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AP |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | presented today for a wet cough. Allergic Rhinitis noted. Barking cough noted upon exam. Started on second generation anticholinergic and referred to an allergist. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | H66.92 | Otitis media, unspecified, left ear |
| Patient Age: | 4 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Present to the office for the second time in two weeks. The first visit the patient had her ears cleaned out with no infection noted. However today left ear AOM was noted. Amoxicillin noted. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | H66.92 | Otitis media, unspecified, left ear |
| Patient Age: | 9 Months |
| Patient Sex: | M |
| Patient Ethnicity: | Two or More Races |
| Patient ID: | JC |
| 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 |
| Clinical Notes: | exposure to strep throat, clear nasal drainage, teething, and tugging at left ear. Positive for AOM |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 51 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Annual exam without abnormal findings. Mammogram scheduled for tomorrow. Received pneumonia, flu, and tetanus vaccines given today. Script for shingles vaccine given to have completed at the pharmacy. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M54.5 | Low back pain |
| Patient Age: | 73 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Lower right back pain. No radiation. The patient has increased back pain but she has been moving. Trigger point injections completed by this student under the observation of the instructor. Injection of 40mg steroid and 2 ml of 1% lidocaine. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | E07.89 | Other specified disorders of thyroid M62.81 | Muscle weakness (generalized) N30.00 | Acute cystitis without hematuria R42 | Dizziness and giddiness R53.1 | Weakness R53.81 | Other malaise |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HC |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 40 |
| 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 |
| Clinical Notes: | The patient came to the office today with a CC of sever fatigue, weakness, dizziness, SOB, and palpitations. Over the last week the patient has noted episodes of not being able to get enough sleep. No change in menstral cycle. The patient has had increase in depression and anxiety. Extreme pallor noted. Thyroid is noted to be enlarged with nodule on the right lateral aspect of the thyroid. CBC, CMP, TSH, CXR, EKG, and thyroid US ordered. Treated UTI with Macrobid, encourage rest/fluids/food, and will follow up with patient within the next two weeks to address the patient's increased anxiety and depression. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M54.5 | Low back pain |
| Patient Age: | 14 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SA |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient was seen one week ago for the same issue. At the time a UTI and pregnancy were ruled out. The patient was educated to rest, use ice/heat, and to take an NSAID. The patient reports that she has not been taken NSAID and not icing. The patient helped a friend move over the weekend and has not rested from softball. Referral to sports medication was made and rest from sports was prescribed until released by SM |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | R21 | Rash and other nonspecific skin eruption |
| Patient Age: | 30 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient had a complaint of areas to scalp line and behind ears of "welt-like, areas that have opened up and then crusted" Upon exam it was hard to determine what the rash was. The rash's appearance were different on the hair line and behind the ears. Ruled out inphentagio. Refered to Derm. Having trouble finding a MD that will take her Medicaid. Steroid and antibiotic sent to pharmacy. |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F41.9 | Anxiety disorder, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient was seen per video chat. The patient has a CC of increased anxiety because she is tired of being a full time mom, house cleaner, teacher, and working from home. It not how she ever saw her life. The patient is just yelling and angry all the time. She is not able to get to sleep at night and is waking up in the middle of the night thinking about events of the day that she wishes she could have done differently. Ordered at CBC, CMP, TSH. Wanted to order Effexor but the patient will have to research it first. Will follow up |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F32.2 | Major depressv disord, single epsd, sev w/o psych features R25.2 | Cramp and spasm Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 18 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient arrived today for her yearly health exam. The patient has a CC of increased abdominal cramping and irregular periods. The patient is taking her birth control daily. The patient is taking Tylenol with some relieve, but would like something stronger. A prescription was sent for Naproxen. Patient and mother requested STI screen. C & G screened per urine and blood testing for HIV, syphilis, and Hep. TSH was also ordered to check thyroid before switching birth control. The patient is also in moderate depression from the breakup of her parents. The patient is currently taking her mothers Celexa from time to time with favorable outcome. Celexa ordered. The patient is also requesting that her person at adult health be changed because she did not like the new person she is seeing. They do not "vibe" Will follow this patient closely |
Case Log/Encounter
| Date: | 09/03/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | Hispanic or Latino |
| Patient ID: | FB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient arrived today for her yearly visit. She received her meningococcal vaccine, but her B meningococcal vaccine was not given because the office was out. Follow up appointment made for two weeks and letter sent to school about the gap in care. The patient is very depressed at this time. She scored a 22 on her PHQ-9. She also scored a 17 on her GAD 7. The patient was withdrawn, would not make eye contact, had a labile mood (tearing when talking about event, to stoic), and not interactive. Would only nod or say "meh" to answer questions. Currently, the patient's father, who is controlling, drained they family bank account, left there mother, and is currently in PR. A prescription for Celxa was sent and a referral to behavioral health was placed. Will provide close follow up with this family. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KT |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Presents today for yearly exam. The patient is not over 100 lbs. Patient is thin, but shows no visual signs of anorexia or bulimia. The patient did complain about severe acid reflux after eating. R/O celiac disease. Urine is negative for protein or infection. Blood work (CBC, CMP, TSH), breath test for H-Pylori ordered. Referral made to GI for EGD. Referral made to have pulmonary functioning testing completed since it has been four years. Asthma is well controlled and the patient knows her triggers and avoids them. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N30.00 | Acute cystitis without hematuria |
| Patient Age: | 4 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 4 year old. C/o belly pain and back pain for one week. no c/o burning with urination. However, the patient's mother reports increased frequency. UA is positive. Culture sent. ABX ordered |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | R10.9 | Unspecified abdominal pain |
| Patient Age: | 14 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CH |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient reported she has had left flank pain for one day. The patient is a softball player and reports practice last night. The patient denies that she has injured herself, burning/pain with urination, fever, and/or felling ill. The patient is positive for CVA tenderness. The patient report that she has not had a period since April. The patient reports that she is not sexually active. The patient has her father in room at bedside. UA and UPT are negative. TSH and serum HCG were ordered. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N76.0 | Acute vaginitis Z00.01 | Encounter for general adult medical exam w abnormal findings Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 25 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient went to the ED yesterday for vaginal discharge and itching. The patient was negative for BV, yeast, and Trich per a wet mount. C & G were collected and sent to the lab. Awaiting results. The patient decline ABX treatment for C/G in the ED. Today the patient reports her vaginal discharge was gone but the itching has not gone away. The patient reports that she has had many new sexual partners as of late. Currently she only has one partner who is a "friend with benefit." Pelvic and Pap were completed. The patient had a copious amount of vaginal discharge during the exam. Per wet mount the patient was positive for clue cell and had a positive whiff test. Flaggyl cream ordered for 5 days. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F32.8 | Other depressive episodes |
| Patient Age: | 38 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SF |
| 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): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient is complaining of severe depression and the medication she is on is no longer working. The patient is having a lot of life events with having her two step sons in the home for the summer and events at work. complaints are frequent restless sleep, and raging mood swings. Labs (CBC, CMP, TSH, VitB) are from the last year and are WNL. Wellbutrin was doubled Lexapro was switched to Zoloft. Visit scheduled for 5 weeks. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 39 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AS |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient is here for a wellness visit without pelvic exam. The patient is complaining of insomnia, extreme allergies, and PHQ-9 score of moderate depression. Sleep study and referral to an allergies was ordered. Trazadone ordered for sleep and Lexapro for depression. Follow up virtual visit scheduled for 5 weeks. |
Case Log/Encounter
| Date: | 08/27/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z30.432 | Encounter for removal of intrauterine contraceptive device |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KN |
| 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): | 20 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | the patient had her IUD removed today to have a baby. Extensive education given to the patient to see you physc DR to wean off of Klonopin, Abilify, and Topamax before becoming pregnant. The patient is aware of needing to do this. |
Case Log/Encounter
| Date: | 08/21/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | FL |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Wellness visit. The patient is doing well. Off of her Prozac with a PHQ 9 score of 6, but reports that she is fine and does not want to go back on it as of right now. Has a new job as a PCA at the meadows. The patient is sexually active with one partner for the last year. C & G urine collected. Assessment WNL. Vaccines given according to schedule (MEN) |
Case Log/Encounter
| Date: | 08/21/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M62.830 | Muscle spasm of back |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DH |
| 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 |
| Clinical Notes: | day two of trigger point injection to right mid-lower back r/t muscle spasms. post motorcycle accident |
Case Log/Encounter
| Date: | 08/21/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 88 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | medicare wellness visit without abnormal findings. All preventative tasks are not valid due to age. scheduled in appointment in one month for the patient to receive flu and pneumonia vaccine |
Case Log/Encounter
| Date: | 08/21/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J01.90 | Acute sinusitis, unspecified |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KA |
| 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 |
| Clinical Notes: | The patient tested negative for COVID although she had a direct positive exposure. The patient is not getting any better. She has a history of asthma. The patient called in three days ago and received a steroid x 5 days. The patient returns today for consultation on lung function and sounds. Lungs are course bilaterally in the upper airway. The patient also presents with sinusitis s/s x 12 days. ABX given. Will continue to monitor. |
Case Log/Encounter
| Date: | 08/21/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KV |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient was seen on the ED one week ago for abdominal pain and bleeding. The patient had an elective abortion two months ago and has not had a menstrual cycle since the abortion. In the ED the patient was diagnosed with a UTI and an ovarian cyst less than 5 cm. However, the patient has not picked up the ABX and the patient has increased abdominal pain and bleeding has stopped as of yesterday. Exam was negative and the patient was encouraged to pick up her ABX. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | R11.2 | Nausea with vomiting, unspecified R42 | Dizziness and giddiness R51 | Headache |
| Patient Age: | 49 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HC |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Virtual visit: direct exposure to COVID, order sent to get tested. N/V Severe headache, diarrhea Dizziness |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N93.8 | Other specified abnormal uterine and vaginal bleeding O20.0 | Threatened abortion Z33.1 | Pregnant state, incidental |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AM |
| 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: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient appears to be 5 weeks pregnant. Went to the ED on Saturday for abdominal pain. Pap, TVU, and HCG level. Scant bleeding the past week. No repeat HCG. HCG level ordered. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M62.830 | Muscle spasm of back V89.0XXS | Person injured in unsp motor-vehicle acc, nontraf, sequela |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DH |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient was in a motor cycle accident. She was on her motorcycle and ended up on the ground. All scans were clear. However, the patient sneezed and has had extreme pain in her back for the last three days. Trigger point injections were administered. 40mg/ 1 ml of steroid and 2.5 ml of 2% lidocaine without epi was administered. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M25.552 | Pain in left hip |
| Patient Age: | 51 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RD |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | received a bursitis injection last week and the pain has not resolved. A referral was sent to ortho to evaluated the patient. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F06.4 | Anxiety disorder due to known physiological condition Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 52 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DO |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient is a flight attendant. The patient has extreme increased stress related to her divorce, loss of greater that 45 hours at work, had to buy a new car, and has a special needs child. The patient has lost over 100 lbs and kept it off over the last two years. Wants a medication but does not want it to cause her to have weight gain. Started in Effexor 37.5 mg daily x 2 weeks. Then increase to 75mg daily. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M25.511 | Pain in right shoulder |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BR |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient stopped her ex husband from falling and caught him with her right arm last week. The patient stated that she was getting better and then she tripped over a foot stool and hurt the right more. No relief with NSAIDS and is not sleeping well. Muscle strength and ROM completed and compared bilaterally. Pain medication given, One pill nightly for the next 7 days. Referred to ortho. |
Case Log/Encounter
| Date: | 08/20/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N77.1 | Vaginitis, vulvitis and vulvovaginitis in dis classd elswhr N93.9 | Abnormal uterine and vaginal bleeding, unspecified |
| Patient Age: | 36 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient has a history of HPV with cystoscopy and removal of left breast cyst. CC: abnormal and heavy vaginal bleeding x 1 month. The bleeding has stopped yesterday and the patient states that she noticed it has smelled. Physical exam, breast exam, papsmear, wet mount completed by this student. The patient was positive for clue cells and whiff test. Referral was made to GYN for bleeding for an ultrasound and workup/treatment of the bleeding. |
Case Log/Encounter
| Date: | 08/14/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | S89.91XA | Unspecified injury of right lower leg, initial encounter |
| Patient Age: | 49 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BW |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | education for s/s of infection, when to return to the MD, and how to dress the wound/topical ABX/cleaning of the wound. |
Case Log/Encounter
| Date: | 08/14/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | A59.00 | Urogenital trichomoniasis, unspecified Z01.411 | Encntr for gyn exam (general) (routine) w abnormal findings |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SF |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient is now 21. She is here for back to school (school of nursing) labs. The patient is now of age to have a papsmear with cytology. patient is on birth control. G1P1 |
Case Log/Encounter
| Date: | 08/14/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J30.2 | Other seasonal allergic rhinitis |
| Patient Age: | 25 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KP |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | no COVID s/s. Allergic rhinitis |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F06.31 | Mood disorder due to known physiol cond w depressv features F06.4 | Anxiety disorder due to known physiological condition L70.0 | Acne vulgaris |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AW |
| 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): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient's anxiety and depression and not well controlled. Medication was augmented and a referral to behavioral health was made it aid in medication adjustments. The patient was not interactive and she would not look at the provider and was flat in affect. Acne is better. Medication is working and refilled. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J06.9 | Acute upper respiratory infection, unspecified |
| Patient Age: | 32 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Patient is running a fever and has URI s/s. Sent to have a Rapid rule out for COVID. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J01.90 | Acute sinusitis, unspecified |
| Patient Age: | 34 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TO |
| 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 |
| Clinical Notes: | Patient is allergic to mold and dust. It is high at this time. The patient has also been exposed to mold at her work place. education given on OTC medications to use. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | F06.4 | Anxiety disorder due to known physiological condition I15.9 | Secondary hypertension, unspecified |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BV |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | anxiety improved. Blood pressure is not controlled. The patient had not been taking her blood pressure medication for the last month because she had been out and did not call for a refill. Medication reordered and a nurse visit was scheduled for blood pressure check in one month. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | A59.09 | Other urogenital trichomoniasis R10.31 | Right lower quadrant pain |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CL |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Came in for RLQ abdominal pain. Extensive history for the last 5 months for UTI and BV. Patient reported increased foul discharge. Pelvic completed. Wet mount completed in office. Positive for Trich. Education provided on transmission and partner treatment. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | K60.1 | Chronic anal fissure Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Papsmear, breast exam, and physical completed. Anal fissures, recurrent were found. referral to colorectal made. Scheduled for annual labs and mammogram. |
Case Log/Encounter
| Date: | 08/13/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | J34.1 | Cyst and mucocele of nose and nasal sinus |
| Patient Age: | 20 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AO |
| 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 |
| Clinical Notes: | examined and diagnosed Patient. Treatment joint effort. Charting completed. |
Case Log/Encounter
| Date: | 08/06/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | M79.671 | Pain in right foot |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | FC |
| 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: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient is a track and CC runner. She is having increased pain with ambulation and activity in the right medical foot along the tendon. Possible tendonitis. A referral was made to sports medicine do to the longevity of injury and need to participate in CC. |
Case Log/Encounter
| Date: | 08/06/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | B37.3 | Candidiasis of vulva and vagina |
| Patient Age: | 40 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Recurrent yeast infection. The patient is on extensive antibiotics to treat her Pustular Psoriasis for the hands and feet. A swab was obtained by the patient to send to lab for C&S. Difulcan with refills given in the mean time. The ABX the patient is receiving is causing the patient to loose her toe and finger nails. Several are ingrown. Patient referred to podiatry. |
Case Log/Encounter
| Date: | 08/06/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | L03.113 | Cellulitis of right upper limb Z66 | Do not resuscitate |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Cellulitis of the right elbow. Keflex suggested and ordered by this student Signed POST form |
Case Log/Encounter
| Date: | 08/06/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | Z00.129 | Encntr for routine child health exam w/o abnormal findings Z76.0 | Encounter for issue of repeat prescription |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | This was an initial visit for a new patient. The NP sees the patient's mother and siblings. The patient has returned home from a state mental hospital for a 5 month stay. At the hospital, the patient ingested two batteries and required two emergency EGD. The acid has eroded the patient's throat and has sever GERD. A referral was placed to Indy Gastro for follow up care. Medications were refilled and behavioral health appointments confirmed. The teenager has an extensive physiological history related to hypoxic brain injury during birth. |
Case Log/Encounter
| Date: | 08/06/2020 |
| Rotation Type: | NUGR 546: Womens Health |
| Comments: | |
| Diagnostic Codes: | N77.1 | Vaginitis, vulvitis and vulvovaginitis in dis classd elswhr Z01.411 | Encntr for gyn exam (general) (routine) w abnormal findings Z34.81 | Encounter for suprvsn of normal pregnancy, first trimester |
| Patient Age: | 22 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | This the the patient's 4 pregnancy. She had her first child at the age of 17and this is her third pregnancy since 2018. The patient was on birth control, but did not pick up here refill during COVID lock down and reported inconsistent condom use. A pelvic without pap was preformed by this student. The patient was positive of BV. Confirmed by a wet mount and a Whiff test. IPV information given by the NP and all prenatal labs ordered and dawn. |
Case Log/Encounter
| Date: | 08/03/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 81 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | WB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Talked with patient and wife about code status and advanced care planning. Confirmed that the patient is a DNR but will consent to intubation if needed because of COVID status. |
Case Log/Encounter
| Date: | 08/03/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | spoke with son about the wishes of intubation for the patient. She is now a DNR/DNI. we were unable to speak to the patient because she was not responding and in a transition to the ICU related to needed two pressors at the max infusion |
Case Log/Encounter
| Date: | 08/03/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LM |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | chart review completed. The patient was in procedures all 4 times we attempted to see the patient. A message left with daughter to confirm advanced care planning documents. |
Case Log/Encounter
| Date: | 07/31/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 87 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Talk with patient at bedside and daughter on the phone. We changed the patent's code status to DNR/DNI and completed a POST form and Health care rep. |
Case Log/Encounter
| Date: | 07/31/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | TM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Student went to follow up on the patient's comfort level since going CMO at the end of day 7/30/20. When this student arrived in the room the patient was moaning, respirations of 35, and extremely restless. Upon a chart review, it was noted the patient had not received morphine in the last 15 hours for respirations greater than 22. Requested the medication to be given by the bedside nurse. 10 minutes past administration, the patient was less restless and respirations decreased to 22. Two hours later, upon follow up, the patient was in the same state and a daughter we did not know that he had was at bedside. We again requested medication administration from the bedside nurse and removal of his restraints. These actions were preformed. We provided emotion support for the daughter. We had a long talk with the bedside nurse about comfort care and expectations. The patient was moved to the oncology unit to receive better comfort care. |
Case Log/Encounter
| Date: | 07/31/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care Z99.11 | Dependence on respirator [ventilator] status |
| Patient Age: | 76 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NG |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 180 minutes |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient was COVID positive. It was transmitted to her at church. The patient had been on the vent for a total of 22 days, failed prone, two weans, and was on a rotprone bed for three days. At this time we spent over an hour with the family (son and daughter) and bedside nurse discussing all of the measures taken over the last 22 days for their mother. The MD came in the room at the end and explained there was nothing more they could do for their mother. The children decided they were going to terminally wean from the vent. This process took over an hour and a half related to poor response when tapering/stopping the paralytic. Much of this time was spent listening the the family about stories and helping them pass the time. The patient however was able to be wean and lasted 10 minutes breathing on her own before she passed. The family and staff were at her bed side. 30 more minutes were spent on supportive care with. |
Case Log/Encounter
| Date: | 07/31/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 48 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 65 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | spent over an hour talking about palliative care, hospice, and disease management. A health care rep was also brought up but the patient did not know who she would want as a healthcare rep. information was given verbally and written. Will not control pain management because it is chronic in nature. MD, NP are aware. Consult order changed. Palliative outpatient consult made. |
Case Log/Encounter
| Date: | 08/03/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 48 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LK |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | This patient was a follow up from Friday. The patient was talked to for over an hour by this writer and preceptor. Palliative care, hospice, and pain management were discussed and written materials were given to think on over the weekend. The patient has chronic pain and we told the patient, the MD, and NP that we would not manage pain. However, we were called back for pain management and to switch the patient from IV medication to oral. This student recommended to add Bupropion 100mg BID and to increase the fentanyl patch to 150 mcg and to continue all other medications per home order. Conversion calculations were also made to switch the patient to oral hydromorphone or to increase Oxy-IR to 90 mg Q 4hours PRN. |
Case Log/Encounter
| Date: | 07/30/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JR |
| Type of Decision Making: | High Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 70 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Asked to see the patient for advanced care plan and goals of care. The patient has been admitted to the hospital 5 times in the last two months with a COPD ex. He has extensive lung and heart disease. The patient has all living will, health care rep, and POST forms in place. spent extensive time with the patient talking about home routine, sleep routine, and what activities cause SOB. Extensive education was provided. the patient was agreeable to have out patient palliative services follow him outpatient. I was able to provide this 80% alone and I charted the initial H&P |
Case Log/Encounter
| Date: | 07/15/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 47 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | PG |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 120 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient has liver and renal failure from ETOH abuse. The patient as been in and out of the hospital several times over the last 6 months. The patient is not a candidate for transplant and is refusing dialysis. family meeting at bedside with the patient, wife, MD, and palliative care team. Hospice consult made. Will DC tomorrow home with hospice |
Case Log/Encounter
| Date: | 07/15/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | ZR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Placed patient on a CMO plan of care. DC'd all medications. Place on a fent. drip and supportive Ativan, spoke with the wife multiple times throughout the day |
Case Log/Encounter
| Date: | 07/24/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 94 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | spent time talking with the patient and daughter. Changed code status to DNR |
Case Log/Encounter
| Date: | 07/24/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MF |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Spoke with oncologist and pulmonologist who are agreeable with hospice plan of care. Awaiting for the bother to return call to coordinate a plan of care for DC with hospice |
Case Log/Encounter
| Date: | 07/24/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 78 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JO |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Chart review completed. The patient was placed in the vent over night related to COVID 19 complications. The wife is also on MPCU with a positive COVID status. The NP and this writer spent time attempting to coordinate a zoom for the wife and family to see the husband and make further choices on his care. The patient however is a DNR |
Case Log/Encounter
| Date: | 07/24/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 81 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 70 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Attempted to obtain a health care rep, but the patient was unable to appoint one. Ask legal to get involved in the case. However, the husband consented for the patient to have a R BKA related to ischemic disease. Talked with the patient for 30 minutes but could make no headway. the husband is not yet ready to let go and make the wife a DNR/DNI |
Case Log/Encounter
| Date: | 07/30/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DR |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | chart review Will await MBS results and then determine care or to sign off |
Case Log/Encounter
| Date: | 07/30/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | 15 minutes spent on a chart review 5 minutes spent with the nurse 10 minutes spent talking with the patient awaiting home O2 evaluation to determine plan of care. The patient is currently off of HHF O2 and is on a salter NC |
Case Log/Encounter
| Date: | 07/30/2020 |
| Rotation Type: | NUGR 600: Behavioral Health |
| Comments: | |
| Diagnostic Codes: | Z51.5 | Encounter for palliative care |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MT |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 2.5 hours |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | This patient admitted to the hospital with an acute ischemic stroke with a clot in the MCA. During his hospital stay he as declined significantly, failed OT/PT, swallow eval, and the patient has currently become terminally agitated. 45 minutes was spent on a chart review to determine the Indiana state law of hagiarchy to determine if HCR could be the patient's friend. the two brothers have opted out of their right to act as the patient's health care representative. It was determined that the friend was allowed to make decisions for the patient since he is unable to make them himself. 30 minutes was spent at the bedside talking with the bedside RN and evaluation of the patient. The patient was able to give yes/no answers at this time. The patient was in non-violent wrist restraints, has on a posey belt, and had a sitter at the bed side. Over an hour was spent on the phone with the friend and the SW to determine the next plan of care. The friend is going to tour the hospice house and attempt to obtain financial records for the patient to fill out a charity application for the hospice house. Remainder of time was spend coordinating care between the palliative MD and the Critical care MD to have palliative care take over as the primary condition. |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G20 | Parkinson's disease |
| Patient Age: | 80 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient has a DX of Parkinson disease but is not on any medication. A phone call was placed to the daughter of the patient asking about the patient's diagnosis. The daughter stated that he had that but its gotten better and he doesn't have it anymore. Then patient however seems to be in a flair. The patient was an unsteady gait, shuffles when walking, pill rolling of left hand, a resting tremor present in the right hand, and a positive cogwheel test. The patient was started on sinemet 10-100 mg TID |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I87.303 | Chronic venous hypertension w/o comp of bilateral low extrm |
| Patient Age: | 92 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | edema has significantly improved. From +4 to trace edema with increase in Lasix to 40 mg OD. Kidneys and electrolytes are WNL |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 95 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MF |
| Type of Decision Making: | High Complexity |
| Type of Visit: | LTC-Long Term Care |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 40 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Hypertensive crisis vs vasovagal. It is was discovered the patient did not have her clonidine patch in place. New procedure set up to have all patched checked and signed off on placement at every shift change by two nurses |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | W17.89XA | Other fall from one level to another, initial encounter |
| Patient Age: | 89 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ER |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Post fall with injury. Multiple skin tears with hematoma above left eye. Will hold eliquis x 3 days. HAS BLED score is 3.74 |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | S98.111S | Complete traumatic amputation of right great toe, sequela |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | weekly follow up. Wound to foot is healing well, wound vac in place. The patient is still non weight baring the right foot. Right groin inscion is healing, well approximated, firm to the touch. |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F41.9 | Anxiety disorder, unspecified R06.00 | Dyspnea, unspecified |
| Patient Age: | 91 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | patient is doing well on the increase of her Ativan to TID. Her breathing is better controlled and in turn she feels that she breaths better. |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | L02.413 | Cutaneous abscess of right upper limb |
| Patient Age: | 66 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient had and I & D on Wednesday,. Follow up from procedure. WBC has significantly declined and the wound is improving |
Case Log/Encounter
| Date: | 07/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I48.0 | Paroxysmal atrial fibrillation |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient had a recent admission to the hospital for Afib with RVR. The patient is on Coumadin and is non therapeutic. Will keep dose at 3 mg and will monitor PT/INR on Monday |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified |
| Patient Age: | 83 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The NP was called to see the patient related to a positive urine dipstick and culture pending (the LPN did not follow the McGeers criteria before sending the culture). The patient had just finished a round of keflex on 7/5 for a UTI that was sensitive to the ABX. It was reported the patient has gross hematuria, but none was observed by this student. The patient was asymptomatic upon objective data x2 assessments. The NP suggested to wait for the culture and ask the staff about the patient daily to ensure that we are not incorrectly treating bacteria. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified N39.42 | Incontinence without sensory awareness |
| Patient Age: | 92 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | the NP was called to see the patient because of positive urine dipstick and the patient has also been having nocturnal hallucinations. The Patient has a fever and is positive for suprapubic pain upon palpation. Upon reviewing the chart, a urine culture was noted unsigned within the chart form 11 days prior. The patient was treated with augmentin BID for 10 days. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | K59.09 | Other constipation |
| Patient Age: | 94 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Called to see the patient for increased urinary frequency and urgency. The LPN obtained a urine dipstick and sent a culture. After this student spoke with the CNA, it was noted that this is not a new behavior. It has been going on for the last two months. However, the CNA noted the patient has been digging her stool out manually almost daily and is up more to have a bowel movement than urination. It was also noted the patient has been removing her clothing and dedicating by her chair twice in the last two weeks. This student talk with the NP and discussed how the urinary symptoms were related to constipation. Daily miralax was ordered and the pending urine culture will be noted when it arrives. The LPN did not follow the McGeer criteria before obtaining a urine culture. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R79.1 | Abnormal coagulation profile |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient has a resent hospitalization for A-Fib with RVR. The patient was on a lovenox and coumdain bridge. The lovenox was stopped on 7/10. The INR today is 1.5. the patient is currently on 1 mg on coumadin daily. This student ordered the patient to increase the coumadin does to 2 mg daily and to recheck the INR on Wed/Friday and adjust accordingly. The NP agreed with these orders. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I95.0 | Idiopathic hypotension |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CR |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient has a reported 4 pound unintentional weight loss in 2 weeks and hypotention (89/40s this AM). The patient is on coreg 3.125 BID and torsemide daily. The patient reports no dizziness, light headedness, and orthostatic hypotention was negative. This student suggested to DC the resident's torsemide and follow up with the patient in one week. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E87.0 | Hyperosmolality and hypernatremia |
| Patient Age: | 90 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | DB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient was taken off of her ACE inhibitor two weeks prior. Her hyperkalemia has resolved. However, the patient sodium remains low, but rising. The patient had a urine osmolarity of 424 and sodium osomolarity of 49. The patient is non compliant with the 1500ml daily fluid restriction. Per the algorithm on UpToDate, the patient is suggestive of SIADH. As TSH and cortisol were ordered for the AM and the patient was incouraged to comply with the fluid restriction. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R60.0 | Localized edema |
| Patient Age: | 97 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | upon reviewing the chart, this student noted leg lower extremity edema was noted in the last 5 progress notes over the last 5 months. It was been charted at a +1 by each provider. The diagnosis of chronic edema was added to the resident's current list of diagnosis. The NP also spoke with the family about a hospice referral. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | L03.031 | Cellulitis of right toe |
| Patient Age: | 93 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | WA |
| Type of Decision Making: | High Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The NP was called to see the resident by the wound nurse. It was reported the right great toe had possible cellulitis. Once observing the toe, it was far more extensive than cellulitis. The foot was red-purple from the mid foot to the tips of all toes with +4 pitting edema. The great medical toes was 5x the size of the left toe and had an open area the size of a quarter. There was no drainage. However, the resident has severe pain with palpation. The foot was marked with a body marker, wrapped, and elevated. The patient has no allergies. The resistance reported was obtained and the patient was placed on an antibiotic with daily dressing changes. The NP will follow up with the resident on Wednesday and Friday of this week to observer healing. |
Case Log/Encounter
| Date: | 07/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.50 | Vascular dementia without behavioral disturbance M70.61 | Trochanteric bursitis, right hip |
| Patient Age: | 85 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CI |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The NP was called to see the patient for a pump and bruising on the right hip. When the hip was observed, there was a large fluid filling sac to the right trohanter and almost healed bruising from the knee to the hip joint. Upon investigation, it was noted the resident has fallen 3 weeks ago out of bed onto the right side. The NP ask the MD rounding to look at the area. The MD took this student with him and explained that observation was the best course of action for this resident because the resident was asymptomatic. Orders were written to trace the area with a body marker and observe the area Q shift for enlargement or s/s of infection. |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | A51.46 | Secondary syphilitic osteopathy N45.3 | Epididymo-orchitis |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | CJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicaid Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient has a right great toe ambutation. sctrotal edema is resolving |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.50 | Vascular dementia without behavioral disturbance |
| Patient Age: | 75 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | doing well. NNC |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G47.51 | Confusional arousals K25.1 | Acute gastric ulcer with perforation |
| Patient Age: | 88 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | WN |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare Private Pay |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | patient was pleasantly confused women with the bed of personalities. NNC, will continue plan of care |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E71.311 | Medium chain acyl CoA dehydrogenase deficiency J81.0 | Acute pulmonary edema R06.02 | Shortness of breath Z86.73 | Prsnl hx of TIA (TIA), and cereb infrc w/o resid deficits |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JD |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | the patient was recovering from a mitral valve thrombus repair, when the patient threw a clot, had CVA/MCA, and now has Coumadin and lovenox bridge. the patient is non verbal, but will follow some commands |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E87.70 | Fluid overload, unspecified N18.3 | Chronic kidney disease, stage 3 (moderate) S37.001D | Unspecified injury of right kidney, subsequent encounter |
| Patient Age: | 87 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | The patient is supposed to DC on Monday. The staff has not began to wean down her O2. The patient is on 2L at home and is currently at 5.5L. Lung sounds are course and do not clear with a cough. The patient has +3 bilateral edema of the lower extremities. increase the patient torsemide back to 100 daily x 3 days. |
Case Log/Encounter
| Date: | 06/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M62.81 | Muscle weakness (generalized) |
| Patient Age: | 87 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | JC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | weekly follow up for the patient. also follow up from UTI (last day of ABX is today). C/O diarrhea, the patient is on Augmentin. Educated this medication can cause diarrhea and prescribed a probiotic (florastor) |
Case Log/Encounter
| Date: | 06/19/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M86.18 | Other acute osteomyelitis, other site S98.122S | Partial traumatic amputation of left great toe, sequela |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | left great toe and particle 1/5 of foot amputation related to osteomyelitis. Infection occurred secondary to non healing DM foot ulcer. observed wound vac dressing change positive for a large hematoma to the left groin/LQ surgical incision secondary fem pop |
Case Log/Encounter
| Date: | 06/19/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | N30.00 | Acute cystitis without hematuria |
| Patient Age: | 91 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | GC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | C&S positive. Many allergies. 10 minutes spent on finding the correct AXB. Keflex 500mg Q12 hours |
Case Log/Encounter
| Date: | 06/19/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | B34.2 | Coronavirus infection, unspecified |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HO |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | COVID-19 recovered. Discharge eval and paperwork |
Case Log/Encounter
| Date: | 06/19/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | D63.1 | Anemia in chronic kidney disease |
| Patient Age: | 53 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | discharge evaluation and paper work |
Case Log/Encounter
| Date: | 06/19/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R11.10 | Vomiting, unspecified |
| Patient Age: | 33 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BR |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | isolated event. Felt better post vomiting episode. The patient stated that this will happen every once in a while and he is now ready to take on a buffet!! Increased VS to one Q shift/patient ended AXB 3 days ago for complicated cystitis |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E08.65 | Diabetes due to underlying condition w hyperglycemia M80.851S | Oth osteopor w current path fracture, right femur, sequela |
| Patient Age: | 77 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Weekly follow up. Reviewed weights, labs, rehab progress, and increase basal insulin |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism |
| Patient Age: | 86 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | HL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Review labs. TSH was 11.3. Increase synthroid. Patient has reports of fatigue |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | K22.11 | Ulcer of esophagus with bleeding |
| Patient Age: | 93 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Reported to the NP the patient was not participating in therapy by the nursing staff. NP and student spoke to therapy, patient, and the son to attempt to motivate the patient to participate. The patient will DC home in two weeks. Needs to get stronger to return home per the son |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M84.359S | Stress fracture, hip, unspecified, sequela |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | NNC weekly follow up reviewed labs, pain control, and talked to therapy about participation will DC in 10 days |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R19.7 | Diarrhea, unspecified |
| Patient Age: | 87 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PG |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | diarrhea is isolated. Will continue to observe. CPM. NNC or recommendations at this time |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E64.0 | Sequelae of protein-calorie malnutrition |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | SP |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicaid |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | weekly follow up. Participating in therapy. Eating well. have gained 1.5 # |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G89.11 | Acute pain due to trauma M80.821A | Oth osteopor w current path fracture, r humerus, init W19.XXXS | Unspecified fall, sequela |
| Patient Age: | 83 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| 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 |
| Clinical Notes: | pain is not controlled at night. Student suggested increasing tramadol to 100 mg PO Q HS. Preceptor agreed |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.50 | Vascular dementia without behavioral disturbance J16.8 | Pneumonia due to other specified infectious organisms |
| Patient Age: | 94 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PN |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Switched antibiotic. The patient showed no improvement after 72 hours |
Case Log/Encounter
| Date: | 06/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.51 | Vascular dementia with behavioral disturbance R62.7 | Adult failure to thrive |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | LTC-Long Term Care |
| Setting: | Inpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | Reviewed notes from behavioral health. Zoloft was added 3 days prior. Patient is stating that she is depressed and wants to stop the feedings in the feeding tube and just go to heaven. The son is not willing to bring hospice in and comply with the resident's wishes. Patient remains full code |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.51 | Vascular dementia with behavioral disturbance Y92.10 | Unsp residential institution as place |
| Patient Age: | 93 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ER |
| Type of Decision Making: | High Complexity |
| Type of Visit: | LTC-Long Term Care |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Clinical Notes: | the patient is in the memory care unit of the nursing home. The patient has significant dementia and wonders freely within the locked unit. The patient was observed to be standing in her doorway and a loud thud occurred after the witness walked by. The patient fall and hit her head on the door. The patient was observed to have a broken right hip due to non alignment of the feet. The NP tightly tied a sheet around the patients hips to stabilize the patient to be moved from the floor to her bed. Because the patient is a DNR/DNI/CMO, the NP had to talk to the DON before all orders were made. The first conversation was completed with the daughter of the resident. The daughter did not want her mother to have surgery at this time, she wanted her mother to stay there and receive pain medication and be comfortable. However the daughter wanted the night to think it over and reserve the right to change her mind at any time. The patient was placed on one on one care and oral solution morphine was ordered for patient comfort. It is very hard to take a step back and not complete all standards of care you know you should do because the family does not want to put their demented mother through that. The NP had a valid concern that he resident would continue to get up because she would not remember she has an injury and this would result in further injury. |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | L89.103 | Pressure ulcer of unspecified part of back, stage 3 M46.04 | Spinal enthesopathy, thoracic region |
| Patient Age: | 68 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient is a rehab patient and must be seen weekly. Watched the nursing staff change dressing to the sacral wound. Spinal abcess is resolved. Plan to rehab to home in the next 10 days |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | T84.59XD | Infect/inflm reaction due to oth internal joint prosth, subs |
| Patient Age: | 71 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | This is the third time in 4 years this patient has had an infected hardware in the hip. The NP and I trended her ESR/CRP. The NP explained the tending of these values will indicate if the current antibiotics are working. ID switched IV antibiotics to cef and dapto. This patient is doing well and will follow up ID on 6/11. Plan to rehab to home once spacer is removed and hardware replaced. |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E87.1 | Hypo-osmolality and hyponatremia |
| Patient Age: | 79 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | EL |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | The patient is a rehab patient and must be seen weekly. Time spent trending weekly labs. All improving. The patient will rehab to home. COVID recovered |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.50 | Vascular dementia without behavioral disturbance |
| Patient Age: | 90 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Patient is a rehab patient and must be seen weekly. The patient will rehab to home over the next three weeks. right ORIF and COIVD recovered. |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I12.0 | Hyp chr kidney disease w stage 5 chr kidney disease or ESRD I15.9 | Secondary hypertension, unspecified |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | FJ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | HD MWF, no volume overload noted. hypertension uncontrolled. CCB increase 1 week ago, Blood pressures are slightly changed. No change in medication. Will follow up weekly |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F02.80 | Dementia in oth diseases classd elswhr w/o behavrl disturb |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Student spoke with staff about the patients behaviors since being placed on Zyprexa in the last 48 hours. Staff states that her behaviors are unchanged, but they have noticed that she is getting slightly better during the day. Spent time looking up Zyprexa, it's 1/2 life, and the amount of time to take max effect. Recommended to follow up with the patient on the following Monday since max effect of medication is 7 days. NP agreed. |
Case Log/Encounter
| Date: | 06/10/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R10.10 | Upper abdominal pain, unspecified |
| Patient Age: | 77 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | Cellulitis around gtube site constipation |
| Clinical Notes: | The patient would only answer in yes or no responses. When asked three different ways if the patient had pain, the patient would respond differently. The patient did not show non verbal s/s of pain with light or deep abdominal palpation. Gtube in place with continuous feeds. the patient was changed in have feedings on for 12 hours and off for 12 hours to encourage oral intake. BM within the last 24 hours. Nursing staff educated to take better daily care of Gtube site and to apply split gauze. |
Case Log/Encounter
| Date: | 06/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | K11.3 | Abscess of salivary gland |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | Patient has recurrent parotiditis. Talked with daughter about progress after this course of ATB therapy. Spoke with wound LPN about measuring the area of firmness daily for the next 10 days |
Case Log/Encounter
| Date: | 06/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.51 | Vascular dementia with behavioral disturbance M84.321S | Stress fracture, right humerus, sequela |
| Patient Age: | 82 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | NA |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Time with Patient (minutes): | 10 |
| Dx 1: Student Participation: | 0-Student Observed |
| Clinical Notes: | right broken humerus post fail, noted bruising. No surgical intervention at this time pain well controlled . arm resting comfortably in a sling |
Case Log/Encounter
| Date: | 06/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F01.51 | Vascular dementia with behavioral disturbance F41.1 | Generalized anxiety disorder |
| Patient Age: | 90 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | SM |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | Monthly required visit of the resident. patient is having increased behaviors Ativan added |
Case Log/Encounter
| Date: | 06/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I87.332 | Chronic venous htn w ulcer and inflammation of l low extrem |
| Patient Age: | 77 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | KW |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | 2 layered una boot to bilateral legs patient is non-adherent to the una boot on left leg and with elevation of bilateral lower extremities. Lasix 20mg QD at 1200 added. |
Case Log/Encounter
| Date: | 06/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | B02.9 | Zoster without complications L08.9 | Local infection of the skin and subcutaneous tissue, unsp R52 | Pain, unspecified |
| Patient Age: | 97 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 25 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Dx 2: Student Participation: | 1- Much Help from the Preceptor |
| Dx 3: Student Participation: | 1- Much Help from the Preceptor |
| Referral Given: | No |
| Chief Concern and Patient Notes: | I & D of left hip abcess on 6/4/2020. pain out of control with wound care |
| Clinical Notes: | listened to the NP collaborate with Hospice nurse and daughter to coordinate care and educate on adequate pain medication needed for care |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | S30.826S | Blister of unsp external genital organs, female, sequela |
| Patient Age: | 27 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | LE |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | spider bite herpes bister/boil of unknown origin abscess, infected |
| Clinical Notes: | The patient had a boil in the in side of the right leg educated on Epson salt soaks, heat compresses, and antibiotics. |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J20.6 | Acute bronchitis due to rhinovirus J30.89 | Other allergic rhinitis |
| Patient Age: | 41 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DR |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | allergic rhinitis acute bronchitis pneumonia |
| Clinical Notes: | educated on OTC medications. Self precautions. When to come back to the clinic |
Case Log/Encounter
| Date: | 03/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.2 | Major depressv disord, single epsd, sev w/o psych features F41.1 | Generalized anxiety disorder |
| Patient Age: | 19 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | ML |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Medicaid |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Differential Diagnosis: | asthma generalized anxiety disorder depression |
| Clinical Notes: | started the patient on Lexapro 10 my 1 tab PO daily Buspar 5mg 3 tabs PRN |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.2 | Major depressv disord, single epsd, sev w/o psych features F41.1 | Generalized anxiety disorder |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MJ |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | depression general anxiety disorder |
| Clinical Notes: | well controlled depression-will see again in 6 months |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | S63.501A | Unspecified sprain of right wrist, initial encounter |
| Patient Age: | 35 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | PC |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Differential Diagnosis: | right wrist sprain |
| Clinical Notes: | referral made to OT/PT work note given education provided on lifting/twisting/pulling instructions |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R10.10 | Upper abdominal pain, unspecified R10.12 | Left upper quadrant pain R19.7 | Diarrhea, unspecified |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | WR |
| 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): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | IBS/IBD infectious diarrhea PUD |
| Clinical Notes: | The patient was sent of an abdominal CT. I thought that I felt an enlarged liver or an abdominal mass |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.2 | Major depressv disord, single epsd, sev w/o psych features |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CK |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | increased Lexapro and added buspar as needed |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | D07.5 | Carcinoma in situ of prostate E08.21 | Diabetes due to underlying condition w diabetic nephropathy F06.4 | Anxiety disorder due to known physiological condition F32.1 | Major depressive disorder, single episode, moderate R39.15 | Urgency of urination |
| Patient Age: | 62 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | BM |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Medicare |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | Yes |
| Differential Diagnosis: | depression Anxiety recurrent prostate CA |
| Clinical Notes: | the patient had a vast amount of diagnosis to follow up on. The patient was encouraged to call urologist because it is possible his prostate cancer is back. |
Case Log/Encounter
| Date: | 03/09/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate |
| Patient Age: | 43 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | CL |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | depression Anxiety |
| Clinical Notes: | 14 on the depression scale |
Case Log/Encounter
| Date: | 03/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.3 | Major depressv disord, single epsd, severe w psych features R45.851 | Suicidal ideations |
| Patient Age: | 63 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | TV |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 40 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | sever depression suicidal |
| Clinical Notes: | The patient had a plan and no fear to commit suicide. The NP called the non emergent line and had a police and ambulance to the hospital for a72 hour hold. the patient went willingly stating that she knows that she needs the help. |
Case Log/Encounter
| Date: | 03/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R19.7 | Diarrhea, unspecified |
| Patient Age: | 51 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | Infectious diarrhea IBS/IBD Viral diarrhea |
| Clinical Notes: | education provided on BRAT diet, fluid intake, and home stool collection. |
Case Log/Encounter
| Date: | 03/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J06.9 | Acute upper respiratory infection, unspecified J30.89 | Other allergic rhinitis |
| Patient Age: | 45 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MM |
| 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 |
| Differential Diagnosis: | Acute Bronchitis Upper Respiratory Infection-viral Acute Rhino sinusitis |
| Clinical Notes: | Education provided by student on OTC medications and appropriate use and when to come back if the conditions worsens. |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | GM |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | depression-controlled |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J30.9 | Allergic rhinitis, unspecified |
| Patient Age: | 59 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HM |
| 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 |
| Differential Diagnosis: | Allergic Rhinitis Allergic Sinusitis Acute Bronchitis |
| Unlisted Dx: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | Patient s/s have lingered. Has been on a plane in the last month (US state travel only) Gave work note, the patient is not contagious |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.4 | Major depressv disorder, single episode, in partial remis S39.001S | Unsp injury of muscle, fascia and tendon of abdomen, sequela |
| Patient Age: | 34 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: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | Inguinal hernia Groin muscle strain (right side) Inguinal ligament strain |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | referred to US and educated to not lift as much weight patient stated that he weaned himself off of all antidepressants and is not working out. The patient feels that this is controlling his depression. |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F32.1 | Major depressive disorder, single episode, moderate I10 | Essential (primary) hypertension Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 25 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MZ |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Clinical Notes: | the patient is displaying s/s of depression and anxiety, but is not willing to go on medication. New onset of HTN. education provided about diet and how to take a blood pressure. Log given. because the patient is self pay, the NP will call the patient in one month to follow up on his medication use and BP reading. |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 67 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | FP |
| Type of Decision Making: | High Complexity |
| Type of Visit: | HE-Health Education |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 60 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | Hypertension Cardiac Stent Placement |
| Clinical Notes: | This patient is was very aggressive. The patient was going around and around about medications and the use of all the meds since the stent they placed in her (without her consent, NP showed her the consent form). The patient was also presenting with signs of delusions with religious fixations. |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PT |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | Hypothyroidism |
| Clinical Notes: | s/s are well controlled. Will follow up in 6 months for refills and lab work |
Case Log/Encounter
| Date: | 03/06/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 67 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | AB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Time with Patient (minutes): | 40 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | Hypertension Anxiety |
| Clinical Notes: | Welcome to Medicare visit Screenings completed |
Case Log/Encounter
| Date: | |
| Rotation Type: | |
| Comments: |
Case Log/Encounter
| Date: | 03/13/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F33.0 | Major depressive disorder, recurrent, mild |
| Patient Age: | 23 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HL |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Chief Concern and Patient Notes: | The patient is here for a follow up on Lexapro 10 mg started one month ago. The patient states that she is seeing no difference in her mood or "feeling as if she is drowning" |
| Differential Diagnosis: | GAD Recurrent depression |
| Clinical Notes: | Increased medication to 20 mg Q day and will follow up again in 1 month. Asked why we do not complete a depression screen again at all follow up visits when adjusting medications. |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R09.1 | Pleurisy |
| Patient Age: | 36 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | FA |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 20 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | pleurisy |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension J45.20 | Mild intermittent asthma, uncomplicated M50.10 | Cervical disc disorder w radiculopathy, unsp cervical region |
| Patient Age: | 44 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | GM |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Dx 3: Student Participation: | 2-Some Help from the Preceptor |
| Referral Given: | No |
| Differential Diagnosis: | Primary hypertension |
| Unlisted Dx: Student Participation: | 4-Primarily Student Activity |
| Exam CPT Code: | 99211-Exam Brief-Established Office Visit |
| Clinical Notes: | follow up blood pressure well controlled inhaler given |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M10.071 | Idiopathic gout, right ankle and foot |
| Patient Age: | 65 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HC |
| 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 |
| Referral Given: | No |
| Differential Diagnosis: | acute gout flair |
| Unlisted Exam/CPT code: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | learned how to use cholchline |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | H65.02 | Acute serous otitis media, left ear J20.6 | Acute bronchitis due to rhinovirus |
| Patient Age: | 72 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | FC |
| Type of Decision Making: | High 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 |
| Differential Diagnosis: | acute bacterial rhiosinusitis acute otitis media acute viral rhinosinusitis |
| Unlisted Dx: Student Participation: | 4-Primarily Student Activity |
| Exam CPT Code: | 99201-New Patient Visit Problem-focused |
| Clinical Notes: | this was a patient from another provider. Sever lung disease. Increase CODP inhaler (NP preference) |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism I10 | Essential (primary) hypertension |
| Patient Age: | 78 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JS |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | primary hypertension hypothyroidism |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | 6 month follow up and labs |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 53 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MD |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | sprained right ankle lesions of unknown origin |
| Clinical Notes: | new patient history and physical |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G43.001 | Migraine w/o aura, not intractable, with status migrainosus G47.01 | Insomnia due to medical condition |
| Patient Age: | 21 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BJ |
| 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 |
| Differential Diagnosis: | insomnia migraines |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 60 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | RR |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Government Subsidized (Tri-Care/HIP) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | HTN ETOH abuse COPD |
| Clinical Notes: | patient is unable to pay for his medications. samples not available. This patient is non compliant with medications r/t finical burden. All meds looked up on GoodRx and all together refill of meds will be less than $30 |
Case Log/Encounter
| Date: | 02/24/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism |
| Patient Age: | 49 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | PR |
| 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): | 20 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | Hypothyroidism |
| Clinical Notes: | Patient reports her DLBCL has returned and is now terminal. Supportive are provided and reassurance given. |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R19.7 | Diarrhea, unspecified |
| Patient Age: | 26 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BT |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicaid |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | Abdominal Pain Uncontrolled diarrhea |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | at the end of the appointment the patient asked for a work excuse. Stating that if I miss work again I will loose my job. Once the work note was agreed upon the patient's demeanor changed. |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | N39.0 | Urinary tract infection, site not specified |
| Patient Age: | 53 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Differential Diagnosis: | Acute bacterial UTI (per UA) |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 4-Primarily Student Activity |
| Clinical Notes: | charted, assessed, and determined treatment. |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J20.8 | Acute bronchitis due to other specified organisms |
| Patient Age: | 68 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BT |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Differential Diagnosis: | acute bronchitis "double sickness" |
| Unlisted Dx: Student Participation: | 1- Much Help from the Preceptor |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | no charting. Patient given breathing treatment, 80mg steroids, and 1g IM Rocephin |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | H65.01 | Acute serous otitis media, right ear J01.00 | Acute maxillary sinusitis, unspecified |
| Patient Age: | 69 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | BL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | acute bacterial sinusitis AOM |
| Exam CPT Code: | 99201-New Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 3-Joint Care 50/50 |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J00 | Acute nasopharyngitis [common cold] R68.2 | Dry mouth, unspecified |
| Patient Age: | 73 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | Bredle |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | acute allergic sinusitis dry mouth related to decongestant |
| Exam CPT Code: | 99201-New Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 0-Student Observed |
| Clinical Notes: | the NP likes the see the MD patient's that are placed on her service |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | L08.89 | Oth local infections of the skin and subcutaneous tissue |
| Patient Age: | 81 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Unknown |
| Patient ID: | NE |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | infection of an unknown origin to the right index finer and 4th finger of the right hand. |
| Clinical Notes: | The patient was extreme vascular disease. Still smoking |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R19.7 | Diarrhea, unspecified |
| Patient Age: | 70 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | KC |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Insurance: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) Medicare |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Differential Diagnosis: | diarrhea of an unspecified cause |
| Clinical Notes: | bowel sounds were distant and hypoactive. may be related to stress. |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 52 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | DE |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | hypertension |
| Clinical Notes: | the patient's blood pressure is up and down per the recordings. The patient ran out of medications 1 week ago. per the readings the blood pressure was controlled on this current regimen. Found it interesting that the patient is on an ACEi and an ARB |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E11.618 | Type 2 diabetes mellitus with other diabetic arthropathy I10 | Essential (primary) hypertension |
| Patient Age: | 88 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: | Medicaid Medicare |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Differential Diagnosis: | uncontrolled hypertension uncontrolled DM type 2 |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | the patient had an elevated A1C, and blood pressure blood pressure mediations were adjusted |
Case Log/Encounter
| Date: | 02/17/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E08.21 | Diabetes due to underlying condition w diabetic nephropathy |
| Patient Age: | 49 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | IH |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | Private Pay |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | uncontrolled Diabetes Type 2 Uncontrolled diabetic neuropathy |
| Unlisted Dx: Student Participation: | 3-Joint Care 50/50 |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | the patient was again asking for a CII, the provider did not give the patient the requested Lyrica due to price, swelling, |
Case Log/Encounter
| Date: | 02/14/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M41.123 | Adolescent idiopathic scoliosis, cervicothoracic region Y93.02 | Activity, running |
| Patient Age: | 16 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | P.Z. |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Dx 2: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | sports physical for running |
| Differential Diagnosis: | well child |
| Exam CPT Code: | 99214-Established patient visit Detailed |
Case Log/Encounter
| Date: | 02/14/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M62.830 | Muscle spasm of back R10.9 | Unspecified abdominal pain |
| Patient Age: | 28 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | M.A. |
| 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: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Chief Concern and Patient Notes: | flank pain (left greater than the right) elevated Ketones on urine dip (school) |
| Differential Diagnosis: | polyneohritis (recurrent) dehydration muscle strain |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
Case Log/Encounter
| Date: | 02/14/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F02.80 | Dementia in oth diseases classd elswhr w/o behavrl disturb F51.5 | Nightmare disorder G89.29 | Other chronic pain I10 | Essential (primary) hypertension |
| Patient Age: | 91 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | B.V. |
| Type of Decision Making: | Moderate 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 |
| Dx 3: Student Participation: | 4-Primarily Student Activity |
| Dx 4: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | 3 month blood pressure follow up, need to sign a new controlled substance contract |
| Differential Diagnosis: | Hypertension chronic back pain |
| Clinical Notes: | patient functioned very well with her DX and clinical picture was better than expected. Abnormal procedure. NP allowed that patient to receive NORCO from another provider while she prescribes benzo. Rational age, never failed a drug screen, and the patient is not refilling that C2 medications monthly. |
Case Log/Encounter
| Date: | 02/14/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 63 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | W.R. |
| 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 1: Student Participation: | 4-Primarily Student Activity |
| Referral Given: | No |
| Chief Concern and Patient Notes: | increased blood pressure |
| Differential Diagnosis: | essential hypertension |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 4-Primarily Student Activity |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G25.1 | Drug-induced tremor G89.29 | Other chronic pain I82.493 | Acute embolism and thombos of deep vein of low extrm, bi Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | B.R. |
| Type of Decision Making: | Low 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: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Dx 3: Student Participation: | 0-Student Observed |
| Dx 4: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | DVT left lower extremity; post surgical |
| Clinical Notes: | anti coag dose adjusted F/U in 2 months refil of albuterol inhaler |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | M.R. |
| 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 1: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | Chronic back pain |
| Exam CPT Code: | 99211-Exam Brief-Established Office Visit |
| Clinical Notes: | drug screening Narcotic refill given |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M25.512 | Pain in left shoulder Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 71 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | W.D. |
| Type of Decision Making: | Low 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: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | Over active bladder over use injury muscle strain/pull |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | medication refill baclofen prescribed |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension Z00.01 | Encounter for general adult medical exam w abnormal findings |
| Patient Age: | 34 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| Patient ID: | K.N. |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Dx 2: Student Participation: | 1- Much Help from the Preceptor |
| Differential Diagnosis: | type I hypertension |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | patient had an elevated blood pressure upon last office visit and this one lost 4 lbs with lifestyle modifications from last visist patient will be watched again for two months (patient drank a read bull and was not compliant with BP readings. because of the patient's age and lack of risk factors, the patient was educated to take BP three times weekly and track them, and to bring them at the follow appointment |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F41.1 | Generalized anxiety disorder I10 | Essential (primary) hypertension R00.2 | Palpitations R55 | Syncope and collapse |
| Patient Age: | 44 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | S.J. |
| 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): | 40 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Dx 3: Student Participation: | 3-Joint Care 50/50 |
| Dx 4: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | anxiety attack near syncope R/O MI |
| Clinical Notes: | the patient presented with sever anxiety. Patient believes he is having a heart attack. Patient decline to be referred to adult and child or to be placed on an antidepressant Pt placed on Propranolol |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 71 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | M. P |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Differential Diagnosis: | expected normal exam unsteady gait, loss of balance |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | labs, UA (drug screen). Referral to PT for balance training |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.8 | Other specified hypothyroidism J02.9 | Acute pharyngitis, unspecified R51 | Headache R53.1 | Weakness R68.83 | Chills (without fever) |
| Patient Age: | 75 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | B.M. |
| 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: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Dx 3: Student Participation: | 0-Student Observed |
| Dx 4: Student Participation: | 0-Student Observed |
| Dx 5: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Differential Diagnosis: | Viral vs Bacterial sinusitis/pharyngitis Viral URI Flu |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Clinical Notes: | flu swab negative encouraged to drink water and given OTC reccomendations for cough/cold medications |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | E.D. |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | None |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | unremarkable exam controlled hyperlipidemia |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Unlisted Exam/CPT code: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | unremarkable exam, labs drawn, medication reodered for one year. Follow up in one year |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | E.D. |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | None |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | hyperlipidemia |
| Exam CPT Code: | 99214-Established patient visit Detailed |
| Clinical Notes: | patient had yearly physical completed, labs drawn, and Lipitor reodered for one year F/U in 12 months |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E78.5 | Hyperlipidemia, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | E.D. |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Insurance: | None |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 3-Joint Care 50/50 |
| Dx 2: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Differential Diagnosis: | hyperlipidemia |
| Exam CPT Code: | 99214-Established patient visit Detailed |
| Clinical Notes: | patient had yearly physical completed, labs drawn, and Lipitor reodered for one year F/U in 12 months |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G44.83 | Primary cough headache J02.9 | Acute pharyngitis, unspecified Z00.00 | Encntr for general adult medical exam w/o abnormal findings |
| Patient Age: | 46 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | F.E |
| 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 1: Student Participation: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Differential Diagnosis: | seasonal allergies acute pharyngitis allergic rhinitis |
| Exam CPT Code: | 99214-Established patient visit Detailed |
| Clinical Notes: | referral made to GYN r/t pelvic/pap smear r/t abnormal paps in the past. referral to ophthalmology, pt reported decline in far vision requested to see a dentist. Poor dentition, upper left molars are broken, gums are painful/swollen/erythemtic |
Case Log/Encounter
| Date: | 02/05/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | M25.512 | Pain in left shoulder |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | HM, H |
| 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: | 3-Joint Care 50/50 |
| Referral Given: | No |
| Chief Concern and Patient Notes: | Patient was in a MVA in the AM. Hit an embankment, but is now sore/stiff |
| Differential Diagnosis: | Acute Left shoulder pain Muscle spams FX clavicle |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | education provided on heat, ice, NSAIDS. Day three and four will be the worst. Advised if pain got worse, to go to the nearest ED for further evaluation. Gave an IM tordol 30mg injection |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J01.01 | Acute recurrent maxillary sinusitis |
| Patient Age: | 72 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: | Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.) |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Referral Given: | No |
| Differential Diagnosis: | acute viral sinusitis versus bacterial sinusitis allergic rhino sinusitis common cold |
| Clinical Notes: | also went over bone scan results and educated on the use of an organic supplement Amoxicillin 500mg BIS PO x 7 days ordered. watch and wait not observed r/t clinical presentation of maxillary sinus pressure/edema, smell changes, and edematous/erythema of the nasal turbinates |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | R06.00 | Dyspnea, unspecified |
| Patient Age: | 37 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | AP |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Referral Given: | Yes |
| Differential Diagnosis: | Dyspnea new onset asthma new onset COPD |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 1- Much Help from the Preceptor |
| Clinical Notes: | albuterol treatment given in the office. Some help. SABA ordered PRN. sent out for Pulmonary Functioning Testing |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G43.829 | Menstrual migraine, not intractable, w/o status migrainosus N80.8 | Other endometriosis N92.0 | Excessive and frequent menstruation with regular cycle |
| Patient Age: | 31 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JB |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HP-Health Promotion |
| Setting: | Outpatient |
| 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: | 3-Joint Care 50/50 |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | pelvic exam and pap smear |
| Differential Diagnosis: | heavy menstrual cycle painful intercourse cyst to external bowel undiagnosed endometriosis |
| Exam CPT Code: | 99395-18 years or older |
| Exam/CPT code: Student Participation: | 3-Joint Care 50/50 |
| Clinical Notes: | preformed a HPI, pelvic exam, pap smear, and breast exam. |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | A88.1 | Epidemic vertigo F06.4 | Anxiety disorder due to known physiological condition F32.8 | Other depressive episodes |
| Patient Age: | 41 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | RL |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Dx 1: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | Anxiety depression chronic vertigo seeking |
| Clinical Notes: | new patient visit the patient has been out of medications for about four months left other PCP poor historian ordered Lexapro only and sent to neurology and proctology |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified N18.4 | Chronic kidney disease, stage 4 (severe) |
| Patient Age: | 38 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | MS |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | A-Antepartum Visit |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | hypothyroidism gout CKD stg 4 (awaiting transplant, genetic disorder) |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | F45.42 | Pain disorder with related psychological factors G43.001 | Migraine w/o aura, not intractable, with status migrainosus |
| Patient Age: | 57 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | JH |
| Type of Decision Making: | High Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Chief Concern and Patient Notes: | migraine headaches |
| Differential Diagnosis: | pain contract failure migraine HA chronic pain |
| Clinical Notes: | the patient had a pain contract failure. The patient failed to have a drug screen/pill count within 24 hours. the patient was educated that this was her only allowed failure and told what to do in the event that a pill count occurs again when she is at work. |
Case Log/Encounter
| Date: | 01/29/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | I10 | Essential (primary) hypertension |
| Patient Age: | 59 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | B.H. |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Clinical Notes: | 6 month follow up and lab draw completed today for next appointment in 6 months. The patient also updated the provider on outside care at IU with his surgeon and neurologist. IU records reviewed in the cloud |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J11.89 | Influenza due to unidentified influenza virus w oth manifest |
| Patient Age: | 17 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | M.A. |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | Influenza Cough- productive |
| Clinical Notes: | patient tested positive for the flu 96 hours post start of s/s no meds encouraged to drink note given to return to school on 1/23 |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | D50.9 | Iron deficiency anemia, unspecified L70.0 | Acne vulgaris |
| Patient Age: | 15 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | A.C |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | WCC-Well Child Check |
| Setting: | Outpatient |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | anemia normal yearly physical behavior-laughs at inappropriate situations Anxiety acne vulgaris |
| Clinical Notes: | Routine labs ordered. CBC/CMP/UA (including GC screen, the patient nor the guardian were informed for this test by the NP, but the NP stated it is ran in her clinic as routine because the prevalence of GC are high among the teens in her patient demographic) the patient was socially awkward. The patient's mother also had a different demeanor, speech, and interaction with this child than her sister. Will continue to observe interactions. |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | L70.0 | Acne vulgaris Y93.6A | Actvty,physcl games assoc w school recess, sumr camp & child |
| Patient Age: | 13 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | A.C. |
| Type of Decision Making: | Straight Forward |
| Type of Visit: | WCC-Well Child Check |
| Setting: | Outpatient |
| Time with Patient (minutes): | 30 |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Chief Concern and Patient Notes: | New patient visit and physical |
| Differential Diagnosis: | Acne vulgaris |
| Clinical Notes: | Routine labs ordered. CBC/CMP/UA (including GC screen, the patient nor the guardian were informed for this test by the NP, but the NP stated it is ran in her clinic as routine because the prevalence of GC are high among the teens in her patient demographic) |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | J96.00 | Acute respiratory failure, unsp w hypoxia or hypercapnia R06.02 | Shortness of breath R06.2 | Wheezing |
| Patient Age: | 46 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | R.M. |
| Type of Decision Making: | High Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Time with Patient (minutes): | 45 |
| Dx 1: Student Participation: | 1- Much Help from the Preceptor |
| Dx 2: Student Participation: | 1- Much Help from the Preceptor |
| Dx 3: Student Participation: | 1- Much Help from the Preceptor |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Patient c/o of SOB, unable to keep O2 stats above 89% (no home O2), and the feeling that he is unable to catch his breath. The patient comes to office often for similar issues. He is a smoker (found out at visit that the patient has been vaping CBD oil for pain control r/t RA), recurrent pneumonia, post trach removal three years ago. The patient was unable to talk without dsypnea, and air was forced out to speak. Audible wheezing with cough (non productive). Patient received 40mg dexamethazone IM, and a duoneb breathing treatment. |
| Differential Diagnosis: | Pneumonia Acute Respiratory Failure COPD exacerbation |
| Clinical Notes: | Patient was told to go to the ED, but refused to go straight to the MVED because he had to get things completed at work. when the NP followed up on the patient almost three hours last he had just checked into the ED 20 minutes prior. |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E03.9 | Hypothyroidism, unspecified |
| Patient Age: | 20 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | N.C. |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Referral Given: | No |
| Chief Concern and Patient Notes: | New patient follow up from labs drawn and thyroid US from Ohio Requested MA to obtain records |
| Differential Diagnosis: | Obesity Hypothyroidism Extreme lethergy |
| Clinical Notes: | NP requested to have labs drawn before the patient left. He was reluctant, but agreed after a few minutes. The patient however left without having his labs drawn |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | B37.89 | Other sites of candidiasis H00.015 | Hordeolum externum left lower eyelid J00 | Acute nasopharyngitis [common cold] |
| Patient Age: | 27 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Patient ID: | N.A. |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Setting: | Outpatient |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Dx 3: Student Participation: | 0-Student Observed |
| Chief Concern and Patient Notes: | Patient came in with a fever, n/v, malaise, congestion, sty, and c/o of thrush/thick tongue. Patient has history of CP |
| Differential Diagnosis: | oral Candida Hordeolum Common cold, Viral |
| Clinical Notes: | patient was prescribed nystatin, warm compress, and eye cream |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G44.83 | Primary cough headache |
| Patient Age: | 44 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | N.W-C. |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | AE-Acute Episodic |
| Dx 1: Student Participation: | 0-Student Observed |
| Differential Diagnosis: | acute cough Viral rhino sinusitis epitasis |
| Clinical Notes: | OTC medications Tessalon pearls rubatussin plus codeine |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | Z79.890 | Hormone replacement therapy (postmenopausal) |
| Patient Age: | 57 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | J.H. |
| Type of Decision Making: | Low Complexity |
| Type of Visit: | HM-Health Maintenance |
| Time with Patient (minutes): | 15 |
| Dx 1: Student Participation: | 0-Student Observed |
| Chief Concern and Patient Notes: | follow up for labs and refill for hormone replacement |
| Differential Diagnosis: | postmenopausal hormone therapy use |
| Clinical Notes: | referral to GYN to manage hormone therapy replacement |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | G89.4 | Chronic pain syndrome |
| Patient Age: | 56 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | B.C |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | HM-Health Maintenance |
| Setting: | Outpatient |
| Dx 1: Student Participation: | 0-Student Observed |
| Chief Concern and Patient Notes: | refill of pain mediation per contract r/t fiber myalgia |
| Differential Diagnosis: | Chronic Pain Fiber Myalgia |
| Clinical Notes: | chronic pain r/t fiber myalgia, back pain Referral to Spine MD |
Case Log/Encounter
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | E89.0 | Postprocedural hypothyroidism K74.60 | Unspecified cirrhosis of liver R10.819 | Abdominal tenderness, unspecified site R19.5 | Other fecal abnormalities |
| Patient Age: | 61 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | T.H. |
| Type of Decision Making: | High Complexity |
| Type of Visit: | Chronic Disease Management |
| Setting: | Outpatient |
| Time with Patient (minutes): | 20 minutes |
| Dx 1: Student Participation: | 0-Student Observed |
| Dx 2: Student Participation: | 0-Student Observed |
| Dx 3: Student Participation: | 0-Student Observed |
| Dx 4: Student Participation: | 0-Student Observed |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Blood pressure check up |
| Differential Diagnosis: | Acute GI bleed Abdominal tenderness: R/O constipation hypothyroidism hepatomegaly |
| Clinical Notes: | referred to GI Send to imaging center for a abdominal series |
day 1 CW
| Date: | 01/20/2020 |
| Rotation Type: | NUGR 544: Adult Health |
| Comments: | |
| Diagnostic Codes: | H81.319 | Aural vertigo, unspecified ear |
| Patient Age: | 60 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Patient ID: | MC |
| Type of Decision Making: | Moderate Complexity |
| Type of Visit: | FU-Follow Up |
| Setting: | Outpatient |
| Dx 1: Student Participation: | 0-Student Observed |
| Referral Given: | Yes |
| Chief Concern and Patient Notes: | Follow up for an ED visit r/t vertigo |
| Differential Diagnosis: | vertigo recurrent stroke |
| Exam CPT Code: | 99212-Established Patient Visit Problem-focused |
| Exam/CPT code: Student Participation: | 0-Student Observed |
Preceptor evaluations
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