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Academic Service:
Case Log/Encounter
Date: 04/01/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M25.511 | Pain in right shoulder
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.T.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Right shoulder pain HPI: Patient presents with right shoulder pain. Patient works as a receptionist and has noticed for a few months her neck has been hurting. For the past week her right shoulder has been hurting. States it feels numb and tingly shooting pain into last three fingers. has decreased ROM due to the pain and tingling. Denies any injury to area. ROS: + Right side arm numb and tingling. Denies weakness P/E: + Right anterior supraspinatus palpable tenderness + strength 4/5 right grip. was not able to perform apley scratch due to pain Plan: x-ray Right shoulder and cervical spine. Depo-Medrol 40mg IM now. Tizanidine 2mg PO TID PRN. Prednisone 40 mg PO daily X 5 days. Start Prednisone tomorrow and make sure to take it with food or milk in the morning to prevent an upset stomach. Please stop taking Celebrex, ibuprofen, or NSAID medications for the duration of the steroid. Take the muscle relaxer prior to bed for the first dose to make sure it doesn't make you too sleepy. Able to use OTC biofreeze, lidocaine patches PRN
Academic Service:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: M.T.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: Yes
Chief Concern and Patient Notes: CC: New Patient Well-child check S: 11 year old well child check and establish care. Denies having any problems. Has not started period yet. O: VS WNL. Growth chart WNL. Vision 20/40 left eye. 20/50 right eye. Denies any issues with vision A: Referal to eye MD. P: Visit eye MD. Follow up PRN and 12 year WCC
Academic Service:
Case Log/Encounter
Date: 04/15/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: E66.8 | Other obesity
F41.1 | Generalized anxiety disorder
G47.33 | Obstructive sleep apnea (adult) (pediatric)
Patient Age: 27 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.S.
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): 15min
Dx 1: Student Participation: 0-Student Observed
Dx 2: Student Participation: 0-Student Observed
Dx 3: Student Participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: "Wants to stop smoking and try chantex" This visit was the first telehealth visit-observation only. The patient stated that he stopped taking his medications because they were making him nauseated. Wellness labs ordered. Pt started on Adipex and chantex with s/e reviewed. Medication education provided for this patient and no further questions. Physical exam was limited due to COVID19 pandemic.
Academic Service:
Case Log/Encounter
Date: 02/19/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: j.b.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Time with Patient (minutes): 15 min
Dx 1: Student Participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: UTI-UA postive for nitrates. Keflex already ordered by Dr. Samules but hasnt taken d/t needing diflucan 150mg 1 tab now repeat in 3 days
Differential Diagnosis: UTI
Academic Service:
Case Log/Encounter
Date: 02/17/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: E78.4 | Other hyperlipidemia
F06.4 | Anxiety disorder due to known physiological condition
G47.33 | Obstructive sleep apnea (adult) (pediatric)
I10 | Essential (primary) hypertension
J45.20 | Mild intermittent asthma, uncomplicated
K21.9 | Gastro-esophageal reflux disease without esophagitis
N39.0 | Urinary tract infection, site not specified
R10.30 | Lower abdominal pain, unspecified
Patient Age: 61 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: k.a.
Type of Decision Making: Moderate Complexity
Type of Visit: Chronic Disease Management
Setting: Outpatient
Insurance: Medicare
Dx 1: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: comprehensive health assesesment f/u chronic health conditions
Differential Diagnosis: acute csystisit w/ hematuria GAD angiopathy DM Asthma CHF DM HTn HLD MDD Recurrent UTI
Academic Service:
Case Log/Encounter
Date: 02/19/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
J02.8 | Acute pharyngitis due to other specified organisms
J31.2 | Chronic pharyngitis
Patient Age: 80 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.B
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Time with Patient (minutes): 15
Dx 1: Student Participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: sore throat chest congestion sinus drainage- 80yr old male presents with c/o sore tharoat since Saturday and has tried salt water gurlgles with no relief and coughing a couple of times at night--sent pt for a strep swab to r/o strep
Differential Diagnosis: Viral Pharangitis
Academic Service:
Case Log/Encounter
Date: 02/19/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: R04.0 | Epistaxis
Patient Age: 96 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Patient ID: R.M.
Type of Decision Making: Straight Forward
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Time with Patient (minutes): 15
Dx 1: Student Participation: 2-Some Help from the Preceptor
4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: Nose Bleeds- on and off for a few months. ENT referal given d/t pt stating he had previously seen ENT. On exam pt had dry nasal mucosa with no bleeding noted
Differential Diagnosis: Epistaxis
Academic Service:
Case Log/Encounter
Date: 01/29/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: D51.9 | Vitamin B12 deficiency anemia, unspecified
E78.4 | Other hyperlipidemia
F06.4 | Anxiety disorder due to known physiological condition
I10 | Essential (primary) hypertension
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.R
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Time with Patient (minutes): 30
Dx 1: Student Participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: F/u on labs and wants medication for sea sickness HPI: Pt is a 57 y/o female who presents today for follow up lab work and medication refill. Pt will be going on a cruise at the end of February and wants somthing to help with sea sickness. PMH: HTN, HLP, Pernicious anemia, Vit D deficiency, OSA ROS: negative fever, chills, weakness +intentional weight loss HEENT: Normalcephaly, TM WNL, Oropharynx w/o inflammation, erythema, excudate. negative for sinus tenderness. Neck supple. Respiratory. WNL Cardiovascular: Rate R & R. W/o mummer, rub, gallop. No edema Lymphatic/Skin: w/o lymphadenopathy, rash, lesions Musculoskeletal: ROM WNL, W/O deformities, spasms, atrophy
Differential Diagnosis: Motion sickness
Academic Service:
Case Log/Encounter
Date: 01/29/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: J01.90 | Acute sinusitis, unspecified
J44.1 | Chronic obstructive pulmonary disease w (acute) exacerbation
Patient Age: 63 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.H.
Type of Decision Making: Straight Forward
Type of Visit: Chronic Disease Management
Setting: Outpatient
Time with Patient (minutes): 15
Dx 1: Student Participation: 1- Much Help from the Preceptor
Referral Given: No
Chief Concern and Patient Notes:

CC: coughing, chest congestion HPI: Pt has had chest congestion for a few days and continues to feel like he is wheezing. He is taking cough drops to help with releif. He has continued to take COPD medications. Pt quit smoking in 2005. 100% O2 sat on room air. General Survey: Plesant Alert and Oriented male who appears to be in no distress. ENT: Right tympanostomy tube. Left TM normal. posterior orophyrynx w/o erythema, edema. W/o lymphadeopathy, tender sinuses. Respiratory: Positive bilateral expiratory wheezing, postive for cough.

Plan: 

Medro dose pack 4mg 

Doxycycline 100mg PO X 10 days
Differential Diagnosis: COPD exacerbation Acute sinusitis Viral URI
Academic Service:
Case Log/Encounter
Date: 01/22/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: F32.8 | Other depressive episodes
F41.9 | Anxiety disorder, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: S.M
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Time with Patient (minutes): 30min
Dx 1: Student Participation: 0-Student Observed
Dx 2: Student Participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Follow up on depression Pt following up on depression. Pt states she is having less depressed days and less crying episodes than previously. Continue to have trouble in school with focusing. Recent IEP placed at school. Waiting on Riley to call regarding referral for testing or ADD. Pt wants to wait to see how IEP is working before starting medication d/t it taking longer for the referral. Parents recently divorced and pt is no longer spending time with father and coping better not spending time with father.
Differential Diagnosis: Depression Anxiety
Exam CPT Code: 99212-Established Patient Visit Problem-focused
Exam/CPT code: Student Participation: 0-Student Observed
Academic Service:
Case Log/Encounter
Date: 01/22/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: M25.461 | Effusion, right knee
M25.561 | Pain in right knee
M71.21 | Synovial cyst of popliteal space [Baker], right knee
Patient Age: 76 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: G.H
Type of Decision Making: Straight Forward
Type of Visit: FU-Follow Up
Setting: Outpatient
Time with Patient (minutes): 30min
Dx 1: Student Participation: 0-Student Observed
Dx 2: Student Participation: 0-Student Observed
Dx 3: Student Participation: 0-Student Observed
Referral Given: Yes
Chief Concern and Patient Notes: CC: Follow up Right Knee pain. Pt is returning for right knee pain that she was seen by Dr. Monosmith at Ortho Indy from a referral. He drained her knee and gave steroid injection in November. Pt continues to have right knee effusion and bakers cyst. Positive Lachman test. Pt can have an injection but needs to call Dr. Monosmiths office. Recommended pt use Tylenol arthritis BID and referral made to PT.
Differential Diagnosis: Baker cyst Knee effusion
Exam/CPT code: Student Participation: 0-Student Observed
Academic Service:
Case Log/Encounter
Date: 01/22/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: F32.8 | Other depressive episodes
F41.9 | Anxiety disorder, unspecified
Patient Age: 23 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.R.
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): 45 minutes
Dx 1: Student Participation: 0-Student Observed
Dx 2: Student Participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Out of medications and to establish care Pt recently moved to Indiana from California. Was previously prescribed lorazepam for anxiety and wanted a refill also ran out of Zoloft and has been out of it since November. Pt complains of anxiety QD. Uses deep breathing exercises to get through. Pt is open to counseling. Restarted Zoloft at 50mg and titrate up to 100mg PO QD. Started pt on Buspar 10mg 1 tab three times a day. Sent pt for labs and diagnostic testing to get a baseline for care: BMP, CBC, A1C, CKMP, d-dimmer, TSH, chest X-ray, EKG, Mag, Lipid pannel, troponin. Will follow up in three weeks.
Exam CPT Code: 99202-New Patient Visit Expanded problem-focused
Exam/CPT code: Student Participation: 0-Student Observed
Academic Service:
Case Log/Encounter
Date: 01/22/2020
Rotation Type: NUGR 544: Adult Health
Comments:  
Diagnostic Codes: C61 | Malignant neoplasm of prostate
Patient Age: 64 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.C
Type of Decision Making: Straight Forward
Type of Visit: FU-Follow Up
Setting: Outpatient
Time with Patient (minutes): 30min
Dx 1: Student Participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: OBSERVATION: R.C. came in for a follow-up appointment to refill his Tramadol that he could not get filled due to the provider retiring. Pt also complained of nocturia, difficulty starting and stopping the stream. PSA was ordered and rectal exam complete. Tramadol refilled. Right greater toe was noted to have onychomycosis and treatment with lamictal 250mg QD was started. Follow up with LFTs in one month. Pt has hx of DM. Feet assessed on the encounter. Pt requesting knee injection d/t knee pain. Follow up scheduled for injection with NP trained on injections.
Differential Diagnosis: BPH
Unlisted Diagnosis and Code: Tinia Unguium
Unlisted Dx: Student Participation: 0-Student Observed
Exam CPT Code: 99402-approximately 30 minutes
Exam/CPT code: Student Participation: 0-Student Observed
Clinical Notes: OBSERVATION: R.C. came in for a follow-up appointment to refill his Tramadol that he could not get filled due to the provider retiring. Pt also complained of nocturia, difficulty starting and stopping the stream. PSA was ordered and rectal exam complete. Tramadol refilled. Right greater toe was noted to have onychomycosis and treatment with lamictal 250mg QD was started. Follow up with LFTs in one month. Pt has hx of DM. Feet assessed on the encounter. Pt requesting knee injection d/t knee pain. Follow up scheduled for injection with NP trained on injections.
Affiliations (Universities & Colleges):
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Association & Society Membership:
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Case logs provide a record to show a list of actions taken with a patient, facility of encounter, and date of service.

The entries below are the case logs I've submitted for during my academic career.
Cases & Case Logs:
Hours Tracking Report
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Cases & Case Logs:
Hours Tracking Report-Detailed
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Cases & Case Logs:
Hours Tracking Report
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Cases & Case Logs:
Field Encounter Report
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Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M17.0 | Bilateral primary osteoarthritis of knee
Patient Age: 64 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: S.J.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: Bilateral Knee pain HPI: Pain for 15 years. Has been ROS: Assessment: Plan: Bilateral Knee Pain-Referral to St. Francis
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: G43.821 | Menstrual migraine, not intractable, with status migrainosus
R09.82 | Postnasal drip
R12 | Heartburn
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: S.D.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Nausea and vomiting HPI: Patient presents with nausea. c/o nausea since Tuesday and vomiting after eating. Has taken pepto PRN and c/o dark stools. ROS: + nausea + vomiting + PND Assessment: + epigastric pain + Plan: Protonix 40mg PO QD MiniPill Zyrtec 10mg PO QD EDU: bland diet start protonix, change birth control when able
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
L40.52 | Psoriatic arthritis mutilans
M19.90 | Unspecified osteoarthritis, unspecified site
Patient Age: 74 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.C.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Medication Refill HPI: Patient presents today with f/u HTN and refill Tramadol ROS: + back pain- not new worse or different. + Assessment: +afib Plan: UDS and CSR refill Tramadol 50mg PO BID Wellness labs: BMP, LFT, TSH, Ft4, TSH, A1c, urine microalbumin Order Mamogram
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: F41.1 | Generalized anxiety disorder
F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.F
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 3 month Follow up HPI: Patient states she has been doing well on medication. Requesting an increase to her Effexor XR. States that she has been ROS: Negative Assessment: BP: 130/100 Recheck BP: 128/92 Plan: Anxiety/Depression: Effexor 75mg PO take two tablets PO daily. ADHD: Decrease Vyvance to 20mg PO daily Education: Decrease caffeine intake
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: L03.011 | Cellulitis of right finger
Patient Age: 61 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: H.M.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Right thumb infection HPI: Patient presents today with right thumb redness and swelling. Patient states there has been no injury to the area. He states that it is from biting a hang nail and it became infected. He has not had any fevers. ROS: +Right thumb pain Assessment: +right erythematous edematous thumb with visible purulent fluid. Plan: Right thumb Paronychia I & D right paronychia. Patient agreed to procedure. NKDA, Iodine or shellfish allergies. patient was prepped with iodine. 18g needle punctured to right paronychia drainage expressed. area cleaned with gauze and wrapped with coban. Dressing CDI. Patient tolerated procedure. IM rocephin in the office and start Doxy 100mg PO daily X 7 days. Follow up on Monday and PRN. Go to ED if redness, streaking, fever. Continue to keep area Clean and dry. change and place band aid PRN
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: W19.XXXS | Unspecified fall, sequela
Patient Age: 83 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: P.F
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: hit leg and cut HPI: P.F. fell off chair and hit leg on chair. Denies hitting head. patient went to urgent care and they placed steri strips to area. denies drainage from area. steri strips in place. has put antibacterial soap to clean with bacitracin. to area. States she has had some swelling to lower extremety ROS: + LLE ankle edema. +LLE abrasion Assessment: +LLE edema + LLE skin tear with erythema surrounding the area Plan: Doxycycline 100mg PO BID X 10 days Follow up in 2 weeks and PRN. go to ED if swelling or redness worsens or spreads to area or fever
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: Z00.01 | Encounter for general adult medical exam w abnormal findings
Patient Age: 51 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.P
Type of Decision Making: Low Complexity
Type of Visit: HM-Health Maintenance
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Physical Exam HPI: Patient presents today for physical exam. Pt checking blood pressure at home. 140's/90's. Pt never started zetia due to thinking it would make her have muscle cramping and she is not wanting to have deterioration. ROS: Negative Assessment: + redness of left fifth MIC with full range of motion with flexion, extension. w/o clicking or crepitus. Plan: HTN- will start low dose lisinopril 5mg PO daily Edu: low carb diet and exercise. Increase physical activity. Education on the importance of maintaining low carb and exercise Follow up in 2 week for BP check HM: ordered colonoscopy and mamogram
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: S16.1XXS | Strain of muscle, fascia and tendon at neck level, sequela
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Middle Eastern
Patient ID: G.S.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Neck pain HPI: Pt presents for neck pain. He had previously been seen a month ago for the same problem and he believes he has reinjured the area. He states that a week ago he felt that he was able to lift weights again and he did a shoulder press with less weight and the pain has returned. He c/o decreased ROM of neck and pain to trap muscle. ROS: +neck pain and + decrease cervical ROM Assessment: + decrease ROM with flexion, extension, abduction and adduction. Cranial nerve 11 intact. + palpable tenderness to right and left trapezius right greater than left. -drop arm Plan: Cervical strain Cyclobenzaprine 10mg PO TID Physical therapy Ice/ heat to area Tylenol PRN OTC: lidocaine patches PRN
Cases & Case Logs:
Case Log/Encounter
Date: 04/08/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: Z12.39 | Encounter for oth screening for malignant neoplasm of breast
Z12.4 | Encounter for screening for malignant neoplasm of cervix
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: b.n
Type of Decision Making: Low Complexity
Type of Visit: HM-Health Maintenance
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Pap smear HPI: Patient presents today for pap smear. Patient states she has had heavy periods and was advised to not be on birth control from cardiologist due to high BP. Patient is G3 P3 and LMP 3/17/21. Denies family history of breast of colon cancer ROS: +menorrhagia Assessment: BP 128/88 on recheck. Breast exam WNL. (did not complete pap due to previous pap not containing enough cells) cervix visualized. S1 & S2 audible RRR w/o M/C/R. Plan: Follow up PRN Education on SBE
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E03.9 | Hypothyroidism, unspecified
E11.8 | Type 2 diabetes mellitus with unspecified complications
L57.0 | Actinic keratosis
Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 62 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.T.
Type of Decision Making: Low Complexity
Type of Visit: HM-Health Maintenance
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Dx 4: Student Participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: Welcome to Medicare HPI: Patient presents today with wife for welcome to Medicare appointment. Patient states he has stopped taking the levothyroxine and metformin due thinking his refill was out and did not follow up with lab work. No deficits on medicare wellness exam. Patient also complains of noticing spots on his legs that are itchy and then turn brown. ROS: Negative Assessment: s1,s2 audible without M/C/R RRR, Lungs CTA. +diffuse flat brown scaly papules on lower extremities Plan: Adult examination with abnormality: Wellness labs: BNP, A1C, FLP, LFT, TSH, FT4, Diabetes type 2: recheck A1C Hypothyroid: TSH, Ft4 Actinic Keratosis: Will refer to dermatology Education: Low carb diet, education on weight watcher Follow up in 4 months and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M54.5 | Low back pain
Patient Age: 26 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: N.K.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Ongoing Leg pain HPI: Patient presents today for ongoing right leg pain. States that he previously saw Hannah Mason and was given a muscle relaxer and steroid pack with minimal relief. No imaging has been completed. He states the pain is worse when he is sitting but does not travel past his right knee. He describes the pain as a numb and tingling pain. ROS: +back pain -incontinence of bowel or bladder +limp +decreased ROM Assessment: - faber +SLR +palpable tenderness Plan: Lumbar Spine X-ray Flexeril 10mg PO TID PRN Low back pain stretches reviewed and given handout
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp
E66.9 | Obesity, unspecified
Patient Age: 19 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: C.B.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Numb and tingling in feet HPI: Patient presents today with numb and tingling feet with generalized cramping for about a month. Denies taking the jardiance since December and did not get labs drawn when ordered. He continues to take the victoza and metformin. He is down 9 lbs since last visit. He appears tearful in the office today due to feeling scared of what will happen from his diabetes. He complains of nausea every morning and vomiting 3-4X week. Patient states Blood sugars are 100-115 fasting. He has previously seen Riley endo and had diabetic education. ROS: + generalized muscle cramping + Nausea +vomiting Assessment: BP: 140/90 recheck 130/88 Monofilamint intact +2 bilateral pedal pulses. S1, S2 audible no M/C/R RRR Plan: DM2 with neuropathy: Restart Jardiance 10mg PO Daily Labs: A1c , BMP, Mag, Urine microalbumin Obesity: Declined need for diabetic education states he had previously saw riley endo. Exercise edu provided for cramping relief lower extremities. Increase water intake.
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: J44.1 | Chronic obstructive pulmonary disease w (acute) exacerbation
R30.0 | Dysuria
Patient Age: 90 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: W.A.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: cough & wheezing HPI: Pt presents today with complaints of wheezing for two weeks. Has been using albuterol PRN about two times per day and using the Anoro daily. Denies worsening symptoms while lying down or nighttime awakenings. SOB with exertion. Patient complaints of intermittent dysuria but feels better when she increases water intake ROS: + cough +wheezing +dysuria periodically + dyspnea on exertion -fever -chills Assessment: +scattered Expiratory wheezing -CVA tenderness -SP tenderness Plan: COPD Exacerbation: Chest x-ray Azithromycin 250mg PO 2 tablets on day 1 and 1 tablet for 5 days Prednisone 40mg PO qd X 5 days Dysuria: UA C&S Changed Anoro to Spiriva due to cost
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M54.5 | Low back pain
Patient Age: 72 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.S.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: low back pain HPI: Fell on Saturday on tailbone ROS: +low back pain Assessment: - Faber -SLR -palpable tenderness to lumbar spine Plan: X-ray lumbar spine Norflex 100mg PO TID PRN EDU: given low back exercises Follow up PRN or if symptoms worsen, loss of bowel and bladder function
Cases & Case Logs:
Case Log/Encounter
Date: 04/07/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: L02.421 | Furuncle of right axilla
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: D.W.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Right lump in armpit HPI: Patient presents today for lump in right axilla. ROS: +red nodule in right axilla Assessment: +Right posterior dime sized erythematous nodule Plan: Doxycycline 100mg BID X 7 days Education: Warm compression to area Follow up in 2 weeks if symptoms worsen or redness and streaking to area.
Cases & Case Logs:
Case Log/Encounter
Date: 04/01/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 70 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: M.F.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Inpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: F/u HTN HPI: Patient here for follow up blood pressure. Patient had been taking BP at home previously and running 150-160/90-100. Patient current BP 120-130 at home and today 120/90. ROS: Negative P/E: S1 S2 audible without M/C/R. RRR. Lungs CTA. Plan: Follow up 6 months and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 04/01/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: H00.023 | Hordeolum internum right eye, unspecified eyelid
I10 | Essential (primary) hypertension
K21.9 | Gastro-esophageal reflux disease without esophagitis
M54.5 | Low back pain
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.M.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
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: CC: 6 month follow up HPI: Patient present for 6-month follow-up. The patient did not obtain wellness labs as ordered. Blood pressure at home running 130/80's when checking. Patient also stated he has had stye on his right eye for months. He has tried warm compresses and baby shampoo with no relief. ROS: + right lesion on the upper eyelid. P/E: + right erythematous lesion on upper eyelid. S1, S2 audible without M/C/R. RRR. Lungs CTA Plan: Follow up in 6 months for HTN F/U. Obtain labs prior to appointment. Ordered colonoscopy. Patient declined COVID vaccination. TDap given today. Erythromycin 0.5% ointment apply 1 cm ribbon to right eyelid twice a day for 10 days. Follow up PRN or if stye is not getting better after treatment.
Cases & Case Logs:
Case Log/Encounter
Date: 04/01/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.M.
Type of Decision Making: Low Complexity
Type of Visit: HM-Health Maintenance
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Insurance Physical HPI: Patient present for insurance physical. The patient states he has seen the eye Dr within the last year. Sees the dentist every 6 months and bruising teeth. Diet consists of fruits and vegtables and lean proteints. Pateint has recently been exercising and doing weight bearing exercise at gym. Recently saw dr samules yesterday and he stated that he has separated cartilage in his chest that has been causing discomfort but none today. Cardiac etiology has been ruled out by dr. samules. ROS: Negative P/E: Well-developed, well-nourished no acute distress. bilateral TM WNL.teeth with good dentition. skin appropriate to cultural background. no JVD lymphadenopathy or thyromegaly. PERRl. Respirations unlabored normal excursion CTA. No murmur or gallop, no edema, carotids full. ROM intact no clubbing cyanosis or inflammatory changes. Bowel sounds active no masses hepatosplenomegaly or tenderness Alert and oriented X3 Cranial nerves II-XII intact motor-sensory and gait grossly intact Plan: Follow up in May with Dr. Samules. Obtain wellness labs previously ordered by Dr. samules prior to the May appointment.
Cases & Case Logs:
Case Log/Encounter
Date: 04/01/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 78 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.D.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 2 week BP f/u HPI: Pt here for BP follow up . BP at last appointment 150-160/80-90. Pt has been taking BP and brought log today and BP has been running 130-140/70-80. Patient started taking BP medication Losartan 20mg PO in the morning instead of NOC. ROS: Negative P/E: s1, s2 audible. no M/C/R. RRR. Lungs CTA. Plan: Continue to take losartan 20 mg PO Daily in morning. Follow up in 6 months for HTN management.
Cases & Case Logs:
Case Log/Encounter
Date: 03/31/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: F10.10 | Alcohol abuse, uncomplicated
I10 | Essential (primary) hypertension
M54.5 | Low back pain
R61 | Generalized hyperhidrosis
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.C.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Dx 4: Student Participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: 6 month f/u HPI: patient presents today for 6 month follow up HTN. Chronic low back pain, history of ETOH abuse with rehab. Patient recently complains of nocturnal lower extremity seating with leg fatigue feeling like he has to stretch them more than normal. ROS: + snoring + muscle fatigue in lower extremeties Assessment: Strenghth 5/5 lower extremeties 2+DTR lower extremeites. s1, s2. lung sounds CTA. Plan: Sleep study referral. Labs BMP, Tsh, FT4, CBC, Ferritin. Refill lisinopril 20mg PO daily and Lexapro 20mg PO daily.
Cases & Case Logs:
Case Log/Encounter
Date: 03/31/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
F90.0 | Attn-defct hyperactivity disorder, predom inattentive type
M85.80 | Oth disrd of bone density and structure, unspecified site
R73.01 | Impaired fasting glucose
Patient Age: 65 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: N.T.
Type of Decision Making: Moderate Complexity
Type of Visit: Chronic Disease Management
Setting: Outpatient
Insurance: Medicare
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: CC: Establish Care HPI: N.T. 65 year old female presents today to establish care. Patient had recently changed insurance and needed to move providers. Pateint has a history of pre DM ADHD, anxiety, anemia that is resolved, and osteopenia. Recent DEXA scan and mamogram completed in 2020. Recent dilated eye exam in 2020 ROS: Negative Assessment: Right PET tube in canal. monofilament test negative. Plan: UDS & CSA every three months for Adderall 15mg PO daily. F/U welcome to medicare within 6 months.
Cases & Case Logs:
Case Log/Encounter
Date: 03/31/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 40 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Patient ID: A.W.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 6 month HTN f/u HPI: Pt here for 6 month HTN f/u. PT taking BP at home and running 120-130/70-80. ROS: Negative Assessment: Negative Plan: BMP, CBC, FLP, TSH, FT4. The patient has controlled BP for the last 6 months and taking medications appropriately. The patient can follow up in 1 year.
Cases & Case Logs:
Case Log/Encounter
Date: 03/31/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M79.661 | Pain in right lower leg
S83.411A | Sprain of medial collateral ligament of right knee, init
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.W.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Right leg pain HPI: L.W. 41 year old female has been having leg pain fro 2 weeks. Felt a pop but no pain with the pop and able to bear weight to leg. No injury to area. Describes the feeling as tight pressure but not pain. Previous dancer for 25 years. ROS: +right lower limb tightness Assessment: Negative homans negative anterior and posterior drawer test. negative faber. Plan: Diagnostic : BMP, D-dimer, CPK. Epson salt soaks when able. Increase water intake.
Cases & Case Logs:
Case Log/Encounter
Date: 03/31/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E11.21 | Type 2 diabetes mellitus with diabetic nephropathy
G52.1 | Disorders of glossopharyngeal nerve
I10 | Essential (primary) hypertension
I69.354 | Hemiplga following cerebral infrc affecting left nondom side
Patient Age: 78 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: W.W.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Medicare
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: CC: 6 month follow up HPI: W.W. here for 6 month f/u appointment of DM2 with neuropathy, HTN, CVA with left sided weakness, Glosopharengeal cancer ROS: Negative Assessment: + left upper extremity weakness grip 3/5., Plan: F/u 6 months. Wellness labs ordered FLP, BMP, CBC. Will obtain records from VA hospital where oncology treatment is being completed.
Cases & Case Logs:
Case Log/Encounter
Date: 03/17/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E55.9 | Vitamin D deficiency, unspecified
E78.5 | Hyperlipidemia, unspecified
I10 | Essential (primary) hypertension
M85.80 | Oth disrd of bone density and structure, unspecified site
Patient Age: 70 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: M.F.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Medicare
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: CC: 6 month Follow up HPI: patient presents today for a 6-month follow-up. Pt monitoring BP at home 140-150/80-90. continuing to take medication lisinopril 20 mg. history of left carotid bruit. left knee pain from previous fall in October. had injection but never an x-ray. ROS: + left knee pain P/E: Cardiac: + left carotid bruit S1,s2 audible without M/R/C Lung: CTA Musculoskeletal: Negative lockman valgus. varus anterior drawer Plan: HTN: lisinopril-HCTZ 20/25mg PO daily- follow up in 2 weeks for BP check. Discussed DNR and post form health care POA Right knee pain: X-ray and injection with Hannah. Vitamin D deficiency: continue supplement OP: continue to take calcium with vitamin D, Fosamax and repeat DEXA scan HM: Colorguard order placed Tdap due May 2021 Pneumovax and Prevnar UTD. Shingrix UTD. COVID vaccination both Pfizer vaccinations.
Cases & Case Logs:
Case Log/Encounter
Date: 03/17/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E28.2 | Polycystic ovarian syndrome
F41.1 | Generalized anxiety disorder
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.L.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: F/U HPI: Recently had admission to community south for suicidal ideation. stopped medications abruptly BP: 140/90 140/86 ROS: + 7.2 weight loss +anxiety Negative thoughts of hurting self of others Negative chest pain heart palpitation P/E: Cardiac: s1 s2 audible without M/C/R RRR Lungs: CTA Psych: apprehensive during exam PHq9: 6 Gad7: 11 Plan: Anxiety: will follow with gallahou april 15th start taking lexapro 10mg PO daily and increase to 20mg PO Friday. Edu on medication to not stop medications abruptly. Follow up in two weeks to recheck BP. PCOS: Continue to take metformin
Cases & Case Logs:
Case Log/Encounter
Date: 03/17/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: G47.00 | Insomnia, unspecified
G47.30 | Sleep apnea, unspecified
Z72.0 | Tobacco use
Patient Age: 59 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.G.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 6 month follow up HPI: Patient today presents stating he continues to smoke but has a goal to quit by april 1st. Patient has improved diet and exercise. doing OTF and home workouts. BP: 142/86 139/90 ROS: Negative for sleep disturbances not wearing CPAP P/E: Cardiac: s1 s2 audible w/o M/C/R RRR Lungs: CTA Skin: Right knee scar from previous surgery Plan: Follow up in 2 weeks for BP check Follow up with JUlie White sleep medicine for CPAP. Pt declined heart and vasculr screening
Cases & Case Logs:
Case Log/Encounter
Date: 03/15/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: L27.0 | Gen skin eruption due to drugs and meds taken internally
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.R.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Rash HPI: patient presents today with rash. Had previously been prescribed doxy for a stye. The stye resolved but pt broke out in a rash and called the optometrist. They prescribed a steroid pack. no resolution ROS: +rash +itching P/E: + diffuse macular papular erythematous rash on the anterior chest and neck Plan: Depo-medrol 40mg IM in office OTC Pepcid 20mg PO daily OTC zyrtec 10mg PO daily Prednisone 20mg PO BID start tomorrow and take with food in the am
Cases & Case Logs:
Case Log/Encounter
Date: 03/15/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: H81.49 | Vertigo of central origin, unspecified ear
Patient Age: 76 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: D.J.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Dizzy for 7 days HPI: Patient c/o being dizzy for 7 days. "Room spinning" consistently when sitting lying down or standing. Has previously had vestibular rehab with kindrend health ROS: +dizziness +fontal headache +felling like passing out P/E:HEENT: TM clear Cardiac: S1 S2 audible without M/C/R RRR Lungs: CTA Neuro: cranial nerves 2-12 intact. Negative romberg Plan: Vertigo: Meclizine 25mg PO Daily follow up in 2-3 weeks if symptoms persit and will place new vestibular rehab
Cases & Case Logs:
Case Log/Encounter
Date: 03/15/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
M77.01 | Medial epicondylitis, right elbow
N18.3 | Chronic kidney disease, stage 3 (moderate)
Z85.46 | Personal history of malignant neoplasm of prostate
Patient Age: 66 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Patient ID: P.G
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Dx 4: Student Participation: 4-Primarily Student Activity
Dx 5: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 6 month F/u HPI: Patient presents today for 6 month f/u. Pt states he believes he passed a kidney stone and had burning on saturday but denies any symptoms currently ROS: Right elbow discomfort Negative Urinary symptoms P/E: Cardiac: S1 S2 aduble without M/G/R RRR Lungs: CTA GU Negative CVA tenderness Negative S/P tenderness Negative tinell and phalen Grips strenght 5/5 Plan: Hematuria: UA + trace Blood CT kidney stone/renal protocol. HTN: continue lisinopril. History of prostate cancer: following with dr vaught Right Epicondylitis: Continue pysical therapy with trainier CKD: continue to follow with renal
Cases & Case Logs:
Case Log/Encounter
Date: 03/15/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: E28.2 | Polycystic ovarian syndrome
F41.9 | Anxiety disorder, unspecified
M77.11 | Lateral epicondylitis, right elbow
R00.2 | Palpitations
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.B.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
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: CC: 6 month F/u HPI: 6 month f/u for heart palpitations, GAD, Right hand epicondilysis, PCOS. Pt c/o still having some palpitations. Previous holter WNL. Pt states HR 130-150 at times when resting. ROS: + palpitations + right hand numbness P/E: + palpable c5 cervical neck pain +3 brachial reflexes Plan: 1. Palpitations: propranolol 10mg PO BID-follow up in 2 weeks for re-evaluation of BP and heart rate 2. GAD: patient refuses treatment however starting propranolol for heart palpitations may help 3. PCOS: continue metformin 4. R hand epicondylitis with right hand numbness: Will send for MRI 5. HM: Wellness labs prior to 6 month follow up appointment. Vit D, FLP, A1c, BMP, Urine, TSH, F4
Cases & Case Logs:
Case Log/Encounter
Date: 03/15/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M54.5 | Low back pain
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.J
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: None
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Back Pain HPI: patient injured back moving a mattress hear back pop. Has tried Ice, ibuprofen, Tylenol with no releif. Patient unable to dit due to pain. Working as a Miner doing physical activity. ROS: + left lower back pain that radiates down past knee into the foot denies loss of bowel and bladder PE: Lung: CTA. Heart: S1 S2 audible without M/R/C RRR. Musculoskeletal: active ROM. Unable to complete faber or straight leg raise due to 10/10 pain. + palpable tenderness from T7-L5 with muscle tension noted. Plan: 1. acute low back pain: OTC lidocaine patches Diclofinac 75mg PO BID X 2 weeks Flexeril 10mg PO TID PRN Tramadol 1-2 tablets PO TID X 2 weeks. back stretches handout given due to no insurance F/U 2 weeks to assess pain
Cases & Case Logs:
Case Log/Encounter
Date: 03/10/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: L03.119 | Cellulitis of unspecified part of limb
Patient Age: 78 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: K.H.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: cat scratch HPI: The patient presents today with left lower extremity cat scratch that progressed to cellulitis. The patient states daughter is NP and prescribed her bactrim for 7 days and she completed the dose. She states that she wants to make sure it looks okay and there are no issues with the area. ROS: + fever Tmax 99.0 + baseline lower extremety edema Assessement: + left lower erythema around round scabbed cat scratch the size of a silver dollar. No abscess to area -homens sign Plan: UTD Tdap 2014 augmentin 800mg PO BOD X 7 days. Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/10/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
R05 | Cough
R50.9 | Fever, unspecified
Patient Age: 54 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.H.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: cough, fever HPI: Patient presents today for cough and fever. Tmax 102.0. Was recently around daughter who was sick but never tested positive for flu strep or mono. Was covid PCR tested and awaiting results. ROS: +cough-yellow sputum +fatigue +fever Assesment: + shotty cervical lymph nodes + PND + dry cough Plan: Fever: Tylenol PRN COugh: Tesslon pearls 200mg PO TID Pharangitis: Strep, flu, mono spot testing
Cases & Case Logs:
Case Log/Encounter
Date: 03/10/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
Patient Age: 17 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: P.V.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: F/U anxiety HPI: P.V. presents today for anxiety follow-up. Pt states doing well on medication. Currently taking zoloft 20mg PO Daily and taking medication every day. Recently found out he is going to be father and excited. Ros: Negative Plan: anxiety: continue to take zoloft 20 mg MO.-continue meal planning and exercising as tolerated Tobacco use: Continue to decrease HM: Meningococcal B and HPV vaccination today Follow up 5 months for med check
Cases & Case Logs:
Case Log/Encounter
Date: 03/10/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: M79.641 | Pain in right hand
Patient Age: 80 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: F.D.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: Right-hand swelling and pain HPI: Sx started 3 weeks ago. Recently fell at menards on elbow and hip. Denies falling on outstretched hand. ROS: + right-hand pain Assessment:+ right-hand palmar nodule fourth digit Plan: referral to hand specialist X-ray right hand Tylenol PRN for pain
Cases & Case Logs:
Case Log/Encounter
Date: 03/11/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: K31.84 | Gastroparesis
R05 | Cough
Patient Age: 78 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: P.G.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: HPI: P.G. had previous covid testing 3/9 and negative. Continues to be SOB and has had vomiting and trouble eating. ROS: + dry cough Assessment: + PND Plan: 1.Gastroparesis-Follow up with GI dr marellie 2. Cough- Chronic regurgitation possible aspiration will get a chest x-ray Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/10/2021
Rotation Type: NUGR 602: Residency
Comments:  
Diagnostic Codes: Z11.3 | Encntr screen for infections w sexl mode of transmiss
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.R.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 2-Some Help from the Preceptor
Referral Given: No
Chief Concern and Patient Notes: HPI: L.H. presents today stating her boyfriend tested positive for Mono. The patient was told that it could be G/C and wants testing. Currently working at a warehouse and not getting enough exercise and up 5 lbs. ROS: Negative Assessment: + 2/6 systolic LSB heart murmer Plan: STD and wellness testing: A1c, TSH, G/C, HSV1 & 2, HIV, Shyphylus, FLP, Ft4, Vit D, CBC, BMP, Urine for trich. Echo for heart murmur HM: Gradisil vaccination today
Cases & Case Logs:
Case Log/Encounter
Date: 03/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.R.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 7 year well child check HPI: Mother presents today with the child. growth chart WNL. Denies any current problems ROS: Negative Assessment: Negative Plan: follow up PRN and 8 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/05/2021
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: White
Patient ID: l.r.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 5 year well check HPI: Child presents today with mother. mother reliable. growth chart WNL. Mother denies any issues ROS: Negative Assessment: Negative Plan: Follow up 6 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: M79.602 | Pain in left arm
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.A.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integerety CC: left arm pain HPI: Fell at school. ROS: Negative ROM WNl Assessment: WNL Plan: left arm x-ray
Cases & Case Logs:
Case Log/Encounter
Date: 03/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: H.A.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in integrity CC: 4 month well check HPI: Child presents today with mother. mother reliable. mother states no isues other than child being fussy. Growth chart WNL ROS: Negative Assessement: Negative Plan: Split shot schedule Follow up 5 months to finish 4 month shot schedule
Cases & Case Logs:
Case Log/Encounter
Date: 03/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
R50.9 | Fever, unspecified
Patient Age: 5 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.A.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Sore throat HPI: Presents to day with mother. Mother states child woke up with fever 100 and cough. Going to disney Monday and wants to know if its okay to go. ROS: +Fever Assessment: Negative Plan: Treat symptoms if needed.
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: O.B.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in Integrety CC: 9 year well child HPI: Child presents today with mother. mother reliable. mother states no current issues with child. Growth chart WNL ROS: + dry skin Assessemnt: +ecezma on upper posterior extremeties Plan: Follow up 10-year well-child check hydrocortisone cream to affected area mixed with aquaphor
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: H.S.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 4 month well child HPI: H.S. presents today with mother. mother is reliable. mother states no current issues. Growth chart WNL. ROS: Negative Assessement: Negative Plan: follow up 6 month visit Immunizations: Rotarix. pedirix. prevnar, hib
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L50.9 | Urticaria, unspecified
Patient Age: 9 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.S.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: Rash HPI: Child presents today with mother. mother states rash started yesterday. No recent sick contacts. Denies Fever. Has given benadryl and used hydrocortizone topical cream with minimal relief. ROS: +Rash Assessment: + diffuse erythemoutus serpentine anular and hive lesions Plan: Prednisone 50mg PO Q day X 5 days Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
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: M
Patient Ethnicity: White
Patient ID: R.C.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 15 month well check HPI: Patient presents today with mother. mother reliable. mother states no issues with child. Growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 18 month WCC. Immunizations: hep A booster
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.J
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC: 15 year well child check HPI: Child presents today with mother and brother. Mother denies any current problems. Growth chart WNL. ROS: Negative P.E.: Negative Plan: Follow up 16 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.J.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Med Check HPI: Child present with mother and brother. Mother is reliable. Child states medication is working well and dose is currently a good dose ROS: Negative PE: Negative Plan: Follow up 4 month med check
Cases & Case Logs:
Case Log/Encounter
Date: 03/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 5 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.C.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: Sore throat HPI: Child presents today with mother. Mother states child has had a sore throat, cough, nasal drainage since last night. Denies N/V/D and fever. ROS: +cough PE: Negative Plan: Treat symptomatically and follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/02/2021
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: White
Patient ID: H.K.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 5 year well child check HPI: Child presents today with mother mother reliable. mother denies any current issues. Growth chart WNL. ROS: Negative P.E.: Negative Plan: Follow up 6-year WCC Immunizations: Hep A
Cases & Case Logs:
Case Log/Encounter
Date: 03/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Month
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.F-G
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: 1 month well child check HPI: Child presents today with mother. mother reliable. mother states child is peeing and pooing WNL. Growth chart WNL. ROS: Negative P.E: Negative Plan: Follow up 2 month WCC
Cases & Case Logs:
Case Log/Encounter
Date: 03/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.D.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 11 year well child check HPI: Child presentes today with mother. mother reliable. child denies any current problems. Growth chart WNL. ROS: Negative P.E.: Negative Plan: Follow up 12 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 22 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: W.H.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Cough HPI: Mother presents with child today. States she has had a cough since she was last seen. States she has given benadryl and tylenol for congestion and fever ROS: +cough P.E.: Negative Plan: Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 24 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: E.E
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integerety CC: 2 year well child check HPI: Child presents today with mother. mother reliable. mother states there are no current concerns. ROS: Negative PE: Negative Plan: Follow up 1 year for WCC and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 2 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.B.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrety CC: 24 month well child check HPI: child presents today with father. father reliable. father denies any issues since getting tubes in ears two weeks ago. ROS: Negative PE: Negative Plan: Follow up 1 year and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.H.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integerety CC:ADHD medication check HPI: Mother states child is doing well on medication. Needs refil and currently using 3mL of quillivent ROS: negative physical exam: Negative Plan: Follow up 4 months medication check
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 2 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: F.O.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC:2 year well child check HPI: Child present with mother. mother reliable. Growth chart WNL. ROS: Negative Assessment: Negative Plan: 3 year well child check Immunizations: Hep A booster
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: S.O.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in Integrety CC: 4 year well child check HPI: mother present with child. mother states no issues with child. Growth WNL. ROS: Negative Assessment: Negative Plan: Follow up 5 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.0 | Attn-defct hyperactivity disorder, predom inattentive type
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Patient ID: H.T.
Type of Decision Making: Low Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrety CC: ADHD medication check HPI: Mother present with child. mother states medication has been doing well for child. Growth WNL. ROS: Negative Assessment: Negative Plan: Follow up 4 month med check
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
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: c.m.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 5 year well child check HPI: Child presents with mother. mother denies any current issues. Growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 6 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.M.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrety CC: 4 year well child check HPI: Child presents today with mother. Mother reliable. mother denies any issues. Growth chart WNL. Child meeting milestones. ROS: Negative Assessment: Negative Plan: Follow up 1 year and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 03/01/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B07.9 | Viral wart, unspecified
Patient Age: 8 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.C.
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrety CC: warts HPI: Child states she is wanting wart removed. ROS: +Lesion on right great toe Assessment: + lesion Plan: Continue to monioter area Procedure: wart removal
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: P.M.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 4 month well child check HPI: Child presents today with mother. mother states she would like ears checked. Growth chart WNL ROS: +cough Assessement: Negative Plan: Follow up 6 month well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 18 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: P.H.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in integrety CC: 18 month well child check HPI: Child presents today with mother. mother reliable. mother denies any current issues. Growth chart WNL. Ros: Negative Assessment: Negative Plan: Follow up 2 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 3 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.H.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in integrety CC: 3 year well child check HPI: child presents today with mother. mother is reliable. mother denies any current issues. developmental milestones are met. Growth chart WNL. ROS: Negative Assessment: negative Plan: Follow up 4 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 2 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: W.B
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrety CC: 2 year WCC HPI: W.B. presents today with father. Father reliable. Father denies any current issues. Growth chart WNL. Meeting milestones. ROS: + skin lesion Assessment: +hemangioma Plan: Follow up 3 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.W.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in integrety CC: 4 month well child check HPI: Mother presents today with child. mother reliable. Growth chart WNL. Mother denies any other issues. ROS: Negative Assessment: Negative Plan: Follow up 6 month well child check Immunizations: Rota, Pedirix, hib, prevnar
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.H.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: charted in integrety CC:4 month well child check HPI: Child presents with mother. Mother stated child has diaper rash. Growth chart WNL. ROS: +Rash Assessment:+ papular rash in diaper area Plan: Follow up 6 month WCC. Place aquaphor on diaper rash Follow up PRN if doesnt go away
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.B
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 7 year well child check HPI: Child presents with mother and brother. Mother reliable. Mother denies any current issues. Growth chart WNL. Immunizations due at this visit. ROS: Negative Assessment: G-tube WNL Plan: Follow up 1 year WCC Immunizations: Hep A
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.B.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 11 year well child check HPI: Child presents today with mother. Mother is reliable. Child denies any issues. Growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 12 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/26/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 3 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: M.J.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 3 year WCC HPI: M.J. presents today with mother. mother reliable. mother states no issues with child currently. Growth chart WNL. Denies skin issues ROS: Negative Assessment: Negative Plan: Follow up 1 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.T.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC: 8 year Well child check HPI: T.D. presents today with mother and brother. mother reliable. mother denies any current issues. Growth WNL ROS: Negative Assessment: Negative Plan: Follow up 1 year for WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.R.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 7 year well child check HPI: R.D. presents today for 7 year well child check. Mother present. Mother reliable. MOther denies any current issues ROS: Negative Assessment: Negative Plan: Follow up 1 year for WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC:4 year well child check HPI: R.B. presents today with mother. mother reliable. mother denies any current issues. immunizations current. Growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 1 year for 5 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.T.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC:6 year Well child check HPI: A.T. presents today with mother. Mother reliable. Mother denies any issues. Growth chart WNL. ROS: Negative Assesment: Negative Plan: Follow up 1 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: J01.90 | Acute sinusitis, unspecified
R05 | Cough
Patient Age: 10 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: Cough HPI: R.H. presents today with mother. mother is reliable. mother states child has been coughing more at night and has a runny nose ROS:+cough +rhinorhea Assessment: + clear nasal discharge Plan: Use a humidifier at night. Can use Benadryl 5mL PO Daily for drainage.
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: I.M.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 15 year WCC HPI: I.M. presents today with mother. I.M. is reliable. Denies any current issues. Growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 1 year and PRN Urine WNL Vision 20/20
Cases & Case Logs:
Case Log/Encounter
Date: 02/25/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: K42.9 | Umbilical hernia without obstruction or gangrene
Patient Age: 6 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: W.H
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: Hernia HPI: W.H. presents with mother. mother reliable. mother states child has protrusion to belly button. ROS: Negative Assessment: Umbilical protrusion Plan: Continue to monitor
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 6 Days
Patient Sex: M
Patient Ethnicity: White
Patient ID: G.Z
Type of Decision Making: Moderate Complexity
Type of Visit: N-Newborn Visit (0-28 days)
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 1 week newborn check HPI: Mother states child is growing well eating and poop has transitioned into the yellow seedy. Umbilical cord still present ROS: Negative Assessment: Negative Plan: Follow up 1 month wcc
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H66.003 | Acute suppr otitis media w/o spon rupt ear drum, bilateral
Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 9 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 9 month well child check HPI: Mother worried child has ear infection due to congestion ROS: +rhinorhea Assessment: + bilateral purulent fluid behind TM +buldging TM + erythematous canal Plan: Amoxicillin 5mL PO BID X 10 days
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: M.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 9 year well child check HPI: M.S. here with mother for well child check. Mother states child has had some increase worry about performance at school. ROS: +anxiety Assessment: Negative Plan: Speak to school counciler Follow up PRN and 10-year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: E30.1 | Precocious puberty
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: M.W.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: "sick visit" HPI: Mother and father worried that child has a few sparce pubic hairs on mons pubis and axilla ROS: Negative Assessment: +sparce black hair on mons. pubis and axilla Plan: Bone age X-ray. Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: J01.90 | Acute sinusitis, unspecified
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: B.D
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Congestion HPI: Child c/o runny nose, cough, headache ROS:+ rhinorrhea Assessment: Negative Plan: COVID swab and symptomatic treatment
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 7 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: N.C.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Sore throat HPI: Mother states child woke up complaining of sore throat and runny nose ROS: +rhinorhea +sore throat Assessment: Negative Plan: continue to monitor symptoms and treat symptomatically if needed. needed covid test to return to school
Cases & Case Logs:
Case Log/Encounter
Date: 02/23/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R30.0 | Dysuria
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.K.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC:Pain with urination HPI: Child presents today with mother. mother states child has been going to the bathroom more often and c/o pain with urintation. ROS: Negative Assessment: Negative. Urine Negative Plan: Increase fluids. Schedule time for bathroom breaks.
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H66.91 | Otitis media, unspecified. right ear
R50.9 | Fever, unspecified
Patient Age: 11 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: E.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Fever HPI: Mother states child has had fever tmax 100.3. Child recently had ear infection and goes to daycare. Child has been having trouble sleeping at NOC and drainage from nose. ROS: +fever Assessment: + Right bulging TM with purulent fluid present Plan: Cefdinire 2.5mL PO BID x 10 days. Follow up after for ear check
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R11.10 | Vomiting, unspecified
R50.9 | Fever, unspecified
Patient Age: 15 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC: Fever HPI: E.H. presents today with mother. mother is reliable. Mother states child has had tmax 100.7 pulling at ears and vomited yesterday. Child recently had ear infection and completed amoxicillin treatment. ROS: Fever, Rhinorrhea, decreased appetite Assessment: Negative Plan: Continue to watch and wait. Symptomatic treatment with Tylenol or ibuprofen. Decrease milk products. Start to use Pedialyte PRN. Follow up PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 3 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: D.L.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: 3 year well child check HPI: D.L. presents today with mother. mother reliable. mother states child is meeting developmental milestones. Child plots out on growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 4 year well child check. Immunizations: Hep A
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: F.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 4 month Well child check HPI: B.F. presents today with mother and grandmother. Mother is reliable. mother states child is developing and meeting milestones WNL. Growth chart WNL. Child appears healthy well-nourished. ROS: Negative Assessment: Negative Plan: Follow up 6-month well-child check Immunizations: Pedirix, IPV, Rota
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: O.P.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC:4 year well-child check HPI: O.P. here for well child check. Father and mother present. both reliable. Mother states child has not seen eye dr due to COVID-19. Parents stated child may need surgery for strabismus. Child growth chart WNL. Child developmentally has graduated from speech and no longer using first steps. ROS: Negative Assessment: Negative Plan: Follow up 5 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/22/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.P.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC: 4-year well-child check HPI: E.P. here for 4 year well child check. Mother and father present. Both parents reliable. Child plots out on growth chart WNL. Immunizations current. Child developmentally doing well ROS: Negative Assessment: Negative Plan: Follow up 5 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrety CC: 7 year Well child check HPI: R.B. presents today with mother. mother is reliable. mother states child has been peeing, pooping, no change in appeteite and no current issues. Child plots out on growth chart WNL. ROS: Negative Assessment: Negative Plan: Follow up 8 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H66.91 | Otitis media, unspecified. right ear
J01.90 | Acute sinusitis, unspecified
R05 | Cough
Patient Age: 6 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: W.H
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Dx 3: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Cough HPI: W.H. Presents today with grandfather. Grandfather reliable. Grandfather states child has had a cough and fussy since yesterday. Mother wanted child to be looked at. Denies fever, change of appetite, tugging at ears ROS: +fussy Assessment: + Right erythematous bulging TM Plan: Amoxicillin 4mL PO BID X 10 days. Follow up after finished treatment to assess ear.
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L30.9 | Dermatitis, unspecified
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: P.G.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: Rash HPI: G.P. presents with mother. mother is reliable. mother states child has had rash for a day. denies fever. mother denies change in soaps or lotions. mother has put on a cream that she got from a friend and can't remember the name of it. ROS: +Rash Assessment: + diffuse erythematous maculopapular rash Plan: Apply an OTC topical steroid cream mixed with Aquaphor on the affected area. pat dry after bathing. Follow up PRN if area does not clear.
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Year
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.M.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in integrity CC: 1 year well child check HPI: R.M. presents today with mother. Mother states child has been eating, drinking, and feeling well. Child plots out on growth chart WNL. Mother denies any peeing, pooping, or diet problems. ROS: Negative Assessment: Negative Plan: Follow up 18 month well child check and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 3 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.M.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: 3 years well check HPI: D.M. presents today with mother. mother states child has been eating, peeing, pooping normally. Growth chart WNL. Denies any pertinent issues ROS: Negative Assessment: Negtaive Plan: Follow up 1 year for 4 year wcc
Cases & Case Logs:
Case Log/Encounter
Date: 02/19/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.8 | Attention-deficit hyperactivity disorder, other type
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: C.B.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: Charted in Integrity CC: ADHD medication check HPI: C.B. is a 16 year old male who presents today for ADHD medication refill. C.B. denies any issues with medication and states it has been working well for him. ROS: Negative Assessment: Negative Plan: Follow up in 3 months for medication refill and well check.
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
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: N.L.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: cc: 5 year well child check HPI: N.L.presents today with mother for WCC. Mother states child is meeting all developmental milestones. Growth chart WNL. peeing, pooping, and eating normally. Denies any delays ROS: Negative Assessment: Negative Plan: Follow up 1 year for WCC. Immunizations: MMRV
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.G.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 4 month WCC HPI: G.L. presents today with mother. mother is reliable. mother states child is still having issues at night with reflex. Child is meeting developmental milestones appropriate to gestational age. Growth chart is WNL. ROS: Negative Assessment: +torticollis Plan: Follow up 6 month appointment and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Month
Patient Sex: M
Patient Ethnicity: White
Patient ID: B.C.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 1-month WCC HPI: B.C. presents today with mother and father. Both mother and father reliable. The mother states feeding, peeing and pooping are WNL. Plotted on the growth chart 50% weight 25% length 90% head ROS: Negative Assessment: Negative Plan: Follow up in 1 month and PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Month
Patient Sex: M
Patient Ethnicity: White
Patient ID: C.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 months well child check HPI: C.S. presents today with mother. Mother is reliable. Mother states child is meeting developmental milestones. Growth chart WNL. Denies any peeing, pooping, or feeding issues. ROS: Negative Assessement: Negative Plan: Follow up 1 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month WCC HPI: C.S. presents today with mother. Mother is reliable. Mother denies any problems with peeing, pooping, child is meeting developmental milestones. ROS: Negative Assessment: + orange tinge color to nose and bilateral cheecks Plan: Follow up 1-year visit Hgb, lead assessment
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L25.9 | Unspecified contact dermatitis, unspecified cause
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: H.B.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Rash HPI: Child brought in by mother stating rash had appeared this a.m. and is very itchy. Mother gave child zyrtec and rash on legs has gotten better but still there. ROS: Negative Assessment: + macular papular rash on arms, legs, and dorsum foot Plan: Continue to use Zyrtec PRN and OTC hydrocortisone cream
Cases & Case Logs:
Case Log/Encounter
Date: 02/18/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L01.00 | Impetigo, unspecified
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.W.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Rash HPI:Child presents today with mother. mother is reliable. Mother states child is a wrestler and frequently gets ring worm and impetigo. Rash has been present for a few days. ROS: +Rash Assessment: + honey crusted rash along hairline Plan: Apply bactroban ointment to affected area BID
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L01.00 | Impetigo, unspecified
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: H.D.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Fever and Rash HPI: H.D. presents today with fever and honey crusted rash on hands and face. Mother states the rash has occured for a few days and is not getting better and worried that it is infected. ROS:+fever +rash Assessment: +honey crusted maculalpapular rash on right forarm and right cheek. Plan: Bactroban 2% 1 gram place on affected areas twice a day and PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: M79.671 | Pain in right foot
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: N.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 13 year Well child check HPI: N.B. presents today with mother. Child able to answer questions appropriately. Growth Chart plots out 72% weight 55% height. Child hurt foot playing football with homeschool team. States he has not been putting weight on foot at this time. ROS: + right foot edema and eccemosis Assessment: + right foot Plan: Right foot 3 view x-ray. Immunizations: Tdap Follow up in 1 year and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: A.R.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 4 year well child check HPI: A.R. presents today with mother. Mother is reliable. Mother states child is meeting developmental milestones. Growth chart 8% weight 5% height. eating and drinking pooping and peeing normal. Will try foods. ROS: Negative Assessment: Negative Plan: Follow up PRN and 5 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 9 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: V.E.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check HPI: V.E. presents today with mother. mother is reliable. mother states child has been hitting all developmental milestones. Growth chart 56% weight 36% height. ROS: Negative Assessment: Negative Plan: Hgb and Lead. Follow up at 1 year well child check and PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 8 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: S.I.
Type of Decision Making: High Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Sore Throat HPI: S.I. presents today with mother. Mother is reliable. Mother states child has been taking amoxicillin for positive strep a few days ago and does not seem to be getting better. ROS: +cough Assessment: +erythemautous oral pharynx Plan: Mono spot completed and negative. Azithromycin 13mL PO Q day X 5 days. Gargle with salt water for pain.
Cases & Case Logs:
Case Log/Encounter
Date: 02/12/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 13 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: H.D.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Yellow Skin HPI: H.D. presents today with mother. Mother is reliable. Mother states that she has noticed color of childs skin has become more yellow over the past month. Childs diet consists of 12 oz of cows milk a day and pouches of food. Child has had a decreased diet over the past few weeks. ROS: +decreased appetite Assessment + firm abdomen +yellowing around nose Plan: Add mirilax to help with constipation. Educated the mother that foods containing carotine will cause the yellowing in the skin and this is normal.
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 8 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 8 year well child check HPI: E.B. presents today with mother. Mother is realiable. Mother states child is developmentally on track. Vision 20/20. BP WNL. Urine WNL. Child growth chart 50% height 45% weight. ROS: Negative Assessment: Negative Plan: Follow up PRN and 9 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: B.G.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Private Pay
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 6 year well child check HPI:B.G. presents today with mother. mother is reliable. mother states child developmentally has been excelling. growth chart height:70% weight 50%. Mother denies any house hold changes. Ros: Negative Assessment: Negative Plan: follow up in 1 year and PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: T.G.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Private Pay
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 14 year well child check HPI: T.G. presents today with mother. Mother is reliable. T.G. states he has no complaints at this time. Child states he is not playing sports at this time. Plotting out on growth chart in 75%. height and 60% weight ROS: Negative Assessment: Negative Plan: Follow up 15 year appointment and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 2 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: L.R.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 2 year well child check HPI: R.L. presents today with father. Father is reliable. Father states child is meeting developmental milestones. Child plots out on growth chart in 90th percentile. To be seen at pediatric dentistry for tooth decay. ROS: Negative Assessment: + tooth decay on top 4 incisors Plan: Follow up 3 year and PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R30.0 | Dysuria
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Patient ID: S.L.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Possible UTI HPI: Child presents with mother. Mother states she feels that child has UTI. Child c/o burning with urination and frequent urination. ROS: + dysuria Assessment: +CVA tenderness Plan: Obtain Renal Ultrasound. Treat with Bactrim 12.7mL PO BID X 10 days.
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L30.9 | Dermatitis, unspecified
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: American Indian / Alaska Native
Patient ID: A.G.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: Eczema HPI: Child presents today with mother. Mother is reliable. Mother states child has been having trouble with eczema and breaking out frequently. ROS:+ puritis Assessment: + excoriated extensor surfaces Plan: Refer to Dermatology. Triamcinolone acetonide 1% apply to affected areas for one week.
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 18 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.M.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 18 year well child check HPI: Child presents today with mother. Child is able to answer questions appropriately. Child denies any eating problems. Recently moved out and living with a friend on Mass ave. Child states that she has occasionally been smoking THC but not every day. Every other weekend. Denies drinking. States she is sexually active and continues to take birth control and use condoms. States she has been having trouble with anxiety but able to manage by talking with friends. ROS: Negative Assessment: Negative Plan: Follow up with ADHD screening tool from school when able. Urine sent to check for gonorrhea and clamidya
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: G.G.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check HPI: G.G. presents today with mother. Mother is reliable. Mother states child is meeting developmental milestones. Child is sleeping, feeding, and eating well. Growth chart within normal limits ROS: Negative Assessment: + hemangioma on anterior chest Plan: Follow up 1 year and PRN. Immunizations: Flu booster. Hgb. Lead finger stick
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: P92.9 | Feeding problem of newborn, unspecified
Patient Age: 13 Days
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.F-G.
Type of Decision Making: Moderate Complexity
Type of Visit: N-Newborn Visit (0-28 days)
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Weight Check HPI:Infant presents today for weight check. Birth weight 7lbs 6 oz. Current weight 8lbs 2oz. Mother states child is feeding with formula Greber soothe. Child is having soft BMs. ROS: Negative Assessment: + hemangioma on anterior chest Plan: Follow up 1 year and PRN. Hgb Lead tested. Immunizations: flu booster
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
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: B.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 5 year well child check HPI: Child presents today with mother. Mother reliable. Mother states child has been eating, drinking, playing, having normal BM's. Child can write name, knows letters and can count. ROS: Negative Assessment: Negative Plan: Follow up 6 year well child check. Immunizations today: Hep A, MMRV, Kenrix
Cases & Case Logs:
Case Log/Encounter
Date: 02/11/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B37.9 | Candidiasis, unspecified
H66.91 | Otitis media, unspecified. right ear
Patient Age: 3 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: M.P.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Cough HPI:Mother states child has been more fussy and tugging at right ear. Child has not been sleeping well and having fever. Child also has had yeast that parent feels she cant get rid of with desitin. ROS: +Fever Assessment: + right bulging TM with purulent fluid + erythematous white maculopapular rash Plan: Amoxicillin 4mL BID PO X 10 days and Nystatin 100,000 units per gram. Apply to affected area BID
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.111 | Health examination for newborn 8 to 28 days old
Patient Age: 11 Days
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.S.
Type of Decision Making: Moderate Complexity
Type of Visit: N-Newborn Visit (0-28 days)
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Weight Check HPI: C.S. presents today for weight check. Born at 7lbs 3oz. Weight today 8lbs 2 oz. Mother states no issues with latching or feeding. continuing to have seedy stools. sleeping around 3 hours and feeding every 2 -4 hours. ROS: Negative Assessment: Negative Plan: Follow up 1 month WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.L.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Medication f/u HPI: K.L. presents today with mother. Mother reliable. Mother states child has been doing okay on dosage but wanting to increase the dose due to decrease concentration during days at home. ROS: +inattention Assessment: Negative Plan: Increase Quillivant to 30mg PO daily. Follow up 4 weeks for Med check
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: B.J.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Med check HPI: B.H. presents today with mother. mother is reliable. Mother states child has been doing better on medication at increased doseage. Child states that he feels better and more able to focus while doing e-learning. ROS: Negative Assessment: Negative Plan: Follow up 16 year WCC and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R51 | Headache
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Patient ID: E.P.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Headaches HPI: Child accompanied by parents who complain of child having headaches every day. Parents deny child waking in middle of night with headaches. Parents state the headaches mostly occur at school and do not spend alot on screens for screen time. Parents have tried to use tylenol and ibuprophen to help with headaches but they seem to still be happening. ROS: Negative Assessment: Negative Plan: Phenergan: 7.8ML PO HS for headaches. Use a headache journal to determine the number of headaches and frequency. Continue to use tylenol and ibuprophen as needed. Follow up if headaches continue and phenergan does not seem to be helping.
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B08.1 | Molluscum contagiosum
Patient Age: 2 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: S.K.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: Yes
Chief Concern and Patient Notes: CC: Rash HPI: child presents today with mother. mother reliable source. Mother states two spots on her back have been irritating her lately and they seem to bother her. ROS: Negative Assessment: + two papules posterior back Plan: Refer to dermatology to have areas removed.
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R30.0 | Dysuria
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.Z.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: painful Urination HPI: Child presents today with father. Father is reliable. Father states that child has not had BM since Saturday. Child was not able to give urine sample. Child has not changed any eating or drinking habits. Father denies any discharge in childs underwear. ROS: Negative Assessment: Negative Plan: Obtain urine sample while at home and bring back to office. Continue to push fluids and monitor symptoms
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.M.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Sick HPI: M.R. presents today for a sick visit. Child is present with mother. Patient needing COVID testing to return to school. ROS: cough Assessment: Positive for lymphadenopathy Plan: COVID swab and symptomatic treatment
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H50.22 | Vertical strabismus, left eye
Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 9 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.T
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Government Subsidized (Tri-Care/HIP)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check HPI: R.T. presents today with mother. Mother reliable. Mother states child is meeting all developmental milestones. Child is still rear facing and in infant seat. Child has been eating table foods no meats yet. Mother advised that she can start to encorporate these into diet. ROS: Negative Assessment: Negative Plan: Follow up for 1 year well-child check and PRN. Will continue to monitor left eye and refer if needed.
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F06.4 | Anxiety disorder due to known physiological condition
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: K.H.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Medication follow up HPI: K.H is a 16 year old white female. Presents today without parent. K.H. states that she feels the medication is appropriate and denies any side effects. States that she continues to do well in school acheving A's. She is getting ready to start track tryouts in the summer. ROS: Negative Assessement: Negative Plan: Follow up March for well child check and PRN. Will refill zoloft today.
Cases & Case Logs:
Case Log/Encounter
Date: 02/09/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 15 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.R.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 15 month well child check HPI: Child accompanied by mother. mother reliable. Child meeting developmental milestones. Child is eating, sleeping, pooping, peeing. Denies trouble sleeping. ROS: Negative Assessment: Negative Plan: Follow up 18 month well child check Immunizations Due: IVP, Varicella, hep A
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 6 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 6 month well child check HPI: D.B. presents today with mother. mother is reliable. Mother states child is meeting developmental milestones. He is currently walking. Eating, drinking, peeing, and pooping normally. Child is still rear-facing in the car seat. ROS: Negative Assessment: WNL Plan: Follow up 8 month WCC- Immunizations: IVP, RV, Dtap, pcv13
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Year
Patient Sex: M
Patient Ethnicity: White
Patient ID: O.G.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 1 year well child check HPI: O.G. presents today with mother. Mother states child is meeting developmental milestones. Child is peeing, pooping, and sleeping appropriately. Mother denies skin issues. ROS: Negative Assessment: WNL Plan: Follow up 2-year WCC. Immunizations: Hep B, HIB, PCV13, IPV.
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F51.01 | Primary insomnia
F88 | Other disorders of psychological development
G40.89 | Other seizures
Q99.8 | Other specified chromosome abnormalities
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 5 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: S.H.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Dx 2: Student Participation: 2-Some Help from the Preceptor
Dx 3: Student Participation: 2-Some Help from the Preceptor
Dx 4: Student Participation: 2-Some Help from the Preceptor
Dx 5: Student Participation: 2-Some Help from the Preceptor
Referral Given: No
Chief Concern and Patient Notes: CC: 5 year Well child check HPI: S.H. presents today with mother. mother is reliable. mother states child has been doing better verbally and continues to participate in PT/OT/Speech. Child still following with Cincinnati children's hospital for developmental delays. Child presents today with helmet on. Denies any problems pooping, peeing, eating, and drinking. ROS: Negative Assessment: WNL. Developmentally continues to improve but delayed. Plan: Follow up for 6 year well-child check and follow up with cincinati regarding seziures. Labs: ferritin, iron, CMP
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: E.S-M.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check HPI: E.S-M. presents today with mother. mother is reliable. Mother states child has met all milestones and denies any current issues. ROS: Negative Assessment: Negative Plan: Follow up 1 year WCC and PRN. Immunizations today: Hep B, IPV, Flu
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
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: R.T.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 5 year Well child check HPI: 5-year-old presents today with mother. Mother is reliable source. Mother states child has met all milestones appropriately and denies any current problems. ROS: Negative Assessment: Negative Plan: Follow up 6 year Well child check. Immunizations today: Dtap. IVP. MMR. Varicella. Flu
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 10 Months
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Patient ID: Z.C.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month WCC HPI: Z.C. presents today with mother. mother is reliable. Mother states child is meeting all milestones appropriately. Mother denies any pertinent problems. ROS: Negative Assessment. WNL Plan: Follow up 1-year WCC and PRN. Labs due: Hgb & lead
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L22 | Diaper dermatitis
Patient Age: 16 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.B.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Diaper rash HPI: K.B. is a 1-year male presents with mother. Mother is reliable. The mother states that she has been fighting a diaper rash for about a week that has gotten worse over the weekend. ROS: No fever + Rash in groin Assessment: + satellite lesions around genitals Plan: OTC lotrainmin. Keep area as clean and dry as possible. If rash persists may need to do oral fluconazole but continue to watch and wait.
Cases & Case Logs:
Case Log/Encounter
Date: 02/08/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R30.0 | Dysuria
Patient Age: 3 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: R.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: Dysuria HPI: 3 year old female presents with mother. Mother states she has been potty trained and having very bad accidents this weeked. Mother wanted to make sure she does not have UTI. Last BM prior to arrival. Denies constipation ROS: Dysuria Assessment: WNL Urinialysis: PH: 6.0 Urine specific gravity: 1.030 Negative protein Negative leucocytes Negative Nitrites Plan: Monitor behaviors. Provide a more regular routine for child. Follow up PRN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: L20.82 | Flexural eczema
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.D.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: 7 year well child check HPI: 7 year old female presents today with mother. mother is reliable. Parent states child is eating, drinking, peeing, pooping well. Child states she enjoys school. science is her favorite part. Child enjoys eating a variety of fruits and vegatables. Eating yogurt everyday. Denies any problems at home. ROD: Negative Assessment: Negative Plan: Follow up for 8 year well child check and PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: J.R.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: Follow up medication check HPI: J.R. is a 13 year old male who presents with mother. Mother is reliable source. Mother states child has been on and off of vyvance and she has noticed significant mood changes when off medication. Mother is requesting to change medication from long acting to a shorter-acting medication. ROS: +dysphoric mood Assessment: + dysphoric mood Plan: Referal to behavioral psych. Follow up 14 next well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 9 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: E.V.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check HPI: Child accompanied by mother for well child check. Mother is reliable. Mother states child is eating, drinking, peeing, pooping normally. Starting to pull up on objects but not walking yet. Child plots out on growth chart not gaining any weight than previously. No pertinent medical history ROS: Negative Assessment: Negative Plan: Continue to bottle feed and table feed. Minimize the amount of table food ensuring the child is receiving about 24oz of breast milk per day. Follow up for weight check in one month.
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F06.4 | Anxiety disorder due to known physiological condition
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: K.S.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 3-Joint Care 50/50
4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 14 year well child check HPI: child presents with mother and sister. Mother is reliable. Mother states child has had issues with anxiety and depression. Child has been on/off prozac at thimes. Child states that it has not helped her and she feels better off of the medication. Child states she has tried CBT with no success. She feels that she has not found someone she conects with. Patient states she is sexually active. She has nexplanon and using safe sexual practices. Teen spoke with without mother and teens states that she has been struggling with the family dynamic due to the recent changes in the past year with her mother back in the picture. ROS: Negative Assessment: +acne otherwise exam negative Plan: Follow up in 1 month to see how she is managing off medication currently. Patient will follow up with GYN.
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 8 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: J.B.
Type of Decision Making: Moderate Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicaid
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 8 year well child check HPI: Child presents today with her mother who is a reliable historian. Child here for well child check. Has not been seen since age 6. Child states she is eating, drinking, pooping well. No problems at school or home reported. No significant history reported. ROS: Negative Assessment: WNL Plan: Obtain flu vaccination. Follow up PRN and 9 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: J.R.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: F/U medcheck HPI: Daughter presents with father for f/u medication check. Father states mother would like us to know she has started her period. child denies any issues or questions regarding period. ROS: Negative Assessment: WNL Plan: Follow up June and PRN for well child check/ medication f/u
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: J.R.
Type of Decision Making: Moderate Complexity
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: Med check ADHD HPI: Child presents for medication check. Father present and reliable source of information. Child states medicaton works well for him and continues to take everyday. Denies side effects. Father states medication vyvance is very expensive and would like to try another type of medication if at all possible that would be cheaper. ROS: Negative Assessment: WNL Plan: Follow up for well child check in June. Father will check with insurance for pricing on other medications to be able to switch to another medication within the same class.
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R07.0 | Pain in throat
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: N.C.
Type of Decision Making: Straight Forward
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Sore throat HPI: Child woke up with sore throat. No sick exposures. Father is a reliable source of information. Child denies cough or fever ROS: +sore throat Assessment: +pettichie on soft palate. Otherwise exam negative Plan: Strep swab negative. Patient sent for COVID swab to be able to return to school
Cases & Case Logs:
Case Log/Encounter
Date: 02/05/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H65.02 | Acute serous otitis media, left ear
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: J.J.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Cold HPI: Child presents today with father. Father reliable source of information. Child has had symptoms for 3 days. Has kept child home from school for 2 days due to cough and runny nose ROS: +cough +rhinorhia Assessment: +erythema +edema left ear +left bulging TM Plan: AOM-Amoxicillin 40mg/kg/day=5.78mg/dose
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H65.02 | Acute serous otitis media, left ear
Patient Age: 10 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: E.H.
Type of Decision Making: Straight Forward
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Cough HPI: Child presents with mother who is a reliable source. Mother states child is in daycare and a few children have been sick. Mother is concerned child has infection. Symptoms of cough and runny nose have occurred for two days. ROS: + cough + Fever +rhinorhia Exam: + Left AOM Plan: Amoxicillin 40mg/kg/day. Supportive care
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 4 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: J.B
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: Three year well child check S: Child presents with mother. mother is reliable. mother sates child is eating, drinking, sleeping well. Child is UTD on all immunizations. Denies any problems at this time. O: Growth chart WNL. VS WNl. ROS Negative. Exam WNL. A: WNL well child exam P: Follow up for 5 year WCC and immunizations
Cases & Case Logs:
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: 2 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: A.F
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 4-Primarily Student Activity
Referral Given: No
Chief Concern and Patient Notes: CC: 2 year old well child check S: Child presents with mother. mother reliable. Mother states child is sleeping well, eating well, peeing and pooping well. Mother was concerened about child having a hammer toe and questions about asthma. O: VS WNL. Growth chart WNL. + Right foot hammer toe that is flatt when child is in the standing position. All other systems negative A: Well child assessment WNL. P: Continue to monitor hammer toe and if it becomes a problem follow up with office visit. Continue to montior symptoms of possible asthma due to family history.
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.01 | Encounter for general adult medical exam w abnormal findings
Patient Age: 11 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: V.A.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 9 month well child check S: Grandparents have brought child into this appointment with mother on telephone. Mother reliable for information. Child had recent burn from grabbing the stove and being followed by the burn center. O: VS WNL. Growth chart WNL. ROS negative. + for bilateral second degree burns. skin sloughing on right hand. Left hand wrapped at this time. A: Lead testing for child. Results came back 4. restuck child and results still 4.5. P: Child will go to lab for lead testing and continue to monitor burns with burn clinic
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 5 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: T.W.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 5 year old WCC S: 5 year old here for well-child check. Mother is reliable. Eating well, sleeping well, having normal BM. Mother denies any issues O: VS WNL. Growth chart WNL. ROS negative. + mild Curvature in spine. A: Well child check w abnormality-mild curvature in spine P: Lumbar X-ray to note degree of curvature- to be monitored every visit.
Cases & Case Logs:
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: 5 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: C.W.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 5 year WCC S: Patient here for well-child check. Mother has given reliable information. The child is eating, drinking, and sleeping well. Mother denies any current problems O: Growth chart WNL. VS stable. ROS negative. Exam negative. A: Varicella,IVP,DTAP, MMR vaccinations due P: Kindergarten immunizations due at this visit follow up PRN and 6 year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F90.9 | Attention-deficit hyperactivity disorder, unspecified type
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Patient ID: T.H.
Type of Decision Making: Straight Forward
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: ADD Initial visit S: Parents at the appointment to discuss Vanderbilt scoring from school to determine a treatment plan for child. O:Child not present at this appointment A: ADHD- Quilllivant XR 25mg/5ML suspension reconstitusted ER PO per day P: Return for office visit in 3 weeks for med check
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: R41.840 | Attention and concentration deficit
Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.C.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Well-child check S: 13-year-old male presents with mother both mother and patient source of information. Past medical history reviewed. The patient states no pertinent problems other than pinpoint pain in both knees at times when walking. Trouble focusing at school and completing assignments. Mother states that his grades have been getting worse and that is out of character for him. O: VS WNL. Growth Chart WNL. Negative exam. A: ADD: Start 25mg Straterra. Obtain records from school for Vanderbilt scoring P: Start straterra 25mg PO daily for ADD. Return for office visit in 4 weeks for med check
Cases & Case Logs:
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: 6 Days
Patient Sex: M
Patient Ethnicity: White
Patient ID: R.F-G
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: New patient WCC S: Parent and baby responding well to each other. Parent attends to infant during exam. Parent is comforting baby when crying. Delivery was WNL. infant had respiratory issue and was in NICU for 3 days. No issues since. baby is formula fed. O: Growth WNL- 39th% weight 45% height 67 % head. 7lbs 9 oz. ROS WNL. Exam WNL. A: 6-day old infant feeding, pooping, peeing WNL. mother denies any issues. P: Follow up in 1 week for weight check/PRN
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
F90.2 | Attention-deficit hyperactivity disorder, combined type
F98.9 | Unsp behav/emotn disord w onst usly occur in chldhd and adol
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: J.S.
Type of Decision Making: Straight Forward
Type of Visit: FU-Follow Up
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Anxiety S: Patient presents with mother. Had recently discontinued Prozac last visit. Mother states that she has had many outbursts since the last visit and it's becoming hard to manage her at home. The patient was to be seen by neuro to determine if she truly has Tourettes vs behavioral problems. O: VS WNL. Growth WNL. + for anxiety. Exam WNL P: Started patient on Zoloft 25 mg PO daily
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B35.6 | Tinea cruris
Patient Age: 9 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: E.C.
Type of Decision Making: Straight Forward
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Diaper Rash S: Mother states daughter has had diaper rash. Has used the Riley diaper cream with no success. O: Scaley rash with discoloration bilaterally on labias. fungal in nature. A: Tinea Cruris P: Continue to keep the area clean and dry as much as possible. Using OTC anti-fungal cream along with aquaphore. Fluconozol 6mg/kg/day X 14 Days.
Cases & Case Logs:
Case Log/Encounter
Date: 02/04/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: P78.83 | Newborn esophageal reflux
Patient Age: 4 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: L.G.
Type of Decision Making: Straight Forward
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 3-Joint Care 50/50
Referral Given: No
Chief Concern and Patient Notes: CC: Loose Stool/ Spitting up S: Infant recently released from NICU born at 26 weeks. Mother states infant is doing well on PPI. However, she feels that she is still spitting up a lot and still thinks she is feeling uncomfortable. The mother also states she feels the infant is colic every night around 5 pm. O: Growth WNL. + epstine pearls on soft palate. Exam otherwise Negative A: GERD P: Continue to use PPI. Try to have infant sleep elevated using a bouncy seat. Make sure infant is in safe place and it is okay to walk away if child is fed and clean and on back.
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 2 Months
Patient Sex: M
Patient Ethnicity: Other
Patient ID: Z.S.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 2 month well child check S: 2 month well-child check. mother continues to breastfeed. Denies any issues O: Growth chart WNL. Denies ROS. + Mongolian spot on sacrum otherwise exam negative A: WNL well child exam P: Follow up PRN/ 3 month well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 3 Years
Patient Sex: M
Patient Ethnicity: Other
Patient ID: Z.S.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 3 year old well child check S: Three year old well child check. Mother denies any issues. Child meeting all milestones per parent. Child has G-tube from previous MD office. Child getting bolus feedings. Parent to follow with child development Feb 25. O: VS WNL. Growth Chart WNL per guidelines. Exam WNL. A: WNL well-child assessment. P: Follow up with developmental health, PRN and 4 year old WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H66.92 | Otitis media, unspecified, left ear
Z00.121 | Encounter for routine child health exam w abnormal findings
Patient Age: 18 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: S.J.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 18 moth WCC S: WCC. Previous appointment child had ear infection and parents did not want to treat with antibiotics. Parents deny fevers or tugging at ears. Parents want to continue to hold on immunizations until child is older. O: Growth chart WNL. left ear positive for purulent fluid otherwise exam negative A: Left Otitis Media. P: Continue to monitor child for fever/ discomfort. Follow up PRN/ 19 month WCC.
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 1 Month
Patient Sex: M
Patient Ethnicity: White
Patient ID: N.J.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 1 month WCC S: 1 month WCC. Mother breastfeeding along with formula feeding. The child has an appointment for a repeat hearing test due to failing the previous test and not cooperating for recent testing. Meeting all other milestones. Parents wanting to hold off on immunizations currently. O: Weight WNL. Growth chart WNL. Physical exam WNL A: WNL 1 month WCC P: Follow up PRN and for 2-month WCC. Follow up with hearing specialist.
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 12 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: M.H.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Medicare
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: WC 1 year well child S: 1 year well-child check. Mother weaning breast feeding O: Weight WNL. Growth chart WNL. ROS WNL. Exam WNL A: WNL 12 month WCC P: Follow up PRN and 13 month WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: S.T.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: New Patient well-child check S: Well-child check O: VS WNL. Growth chart WNL. Denies any issues A: WNL 9-year-old WCC P: F/u PRN and 10-year WCC
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 6 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: G.S.
Type of Decision Making: Straight Forward
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 6 month well child check S: 6 month well child check. Mother denies any patient problems. O: VS WNL. Meeting milestones. Growth Chart WNL. A: 6 month WNL. P: Return PRN and 8 month Well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 24 Months
Patient Sex: F
Patient Ethnicity: White
Patient ID: M.W.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 2 year old well child check S: Three-year well-child check Parent denies any problems. Meeting milestones. Growth chart WNL. O: VS WNL. ROS Neg. A: WNL well-child check. P: Return PRN and 3 year well child check
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: Z00.110 | Health examination for newborn under 8 days old
Patient Age: 4 Days
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.S.
Type of Decision Making: Low Complexity
Type of Visit: WCC-Well Child Check
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: 1 Week NB check S: 1 week weight check. Child is here for one week weight check. Mother denies any issues with breast feeding O: VS WNL. Weight WNL. Growth Chart plotted and WNL A: WNL well child assessment P: Follow up PRN and 1 week for weight check
Cases & Case Logs:
Case Log/Encounter
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B08.1 | Molluscum contagiosum
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 7 Years
Patient Sex: F
Patient Ethnicity: White
Patient ID: C.R.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: Yes
Chief Concern and Patient Notes: CC: 7 Year Well Child S: Well-child check. Child has what appears to be molluscum around left eye that started with one spot. The spot does not itch. However, she has itched the spot off and more have appeared. O: VS WNL. Growth chart 65% weight 80% height. Exam WNL. + three white round firm painless bumps with central umbilication around the left eye. A: Molluscum P: Return PRN and referral to dermatology for molluscum
Cases & Case Logs:
Pediatric
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B97.11 | Coxsackievirus as the cause of diseases classified elsewhere
Patient Age: 5 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: G.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Spots all over the body S: Recently got into the hot tub and has had spots all over the body that continue to pop up O: No fever, sore throat, headache. + blisters. A: + blisters on torso, hands, face, and back P: Symptomaticly treat may return to school when 24 hours fever free with no new spots appearing for 48-72 hours
Cases & Case Logs:
Pediatric
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B97.11 | Coxsackievirus as the cause of diseases classified elsewhere
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: I.H.
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Spots all over the body S: Recently got into the hot tub and has had spots all over the body that continue to pop up O: No fever, sore throat, headache. + blisters. A: + blisters on torso, hands, face, and back P: Symptomaticly treat may return to school when 24 hours fever free with no new spots appearing for 48-72 hours
Cases & Case Logs:
Pediatric
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: B97.11 | Coxsackievirus as the cause of diseases classified elsewhere
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: White
Patient ID: D.H
Type of Decision Making: Moderate Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Spots all over the body S: Recently got into the hot tub and has had spots all over the body that continue to pop up O: No fever, sore throat, headache. + blisters. A: + blisters on torso, hands, face, and back P: Symptomaticly treat may return to school when 24 hours fever free with no new spots appearing for 48-72 hours
Cases & Case Logs:
Pediatric
Date: 02/02/2021
Rotation Type: NUGR 564: Pediatrics
Comments:  
Diagnostic Codes: H92.03 | Otalgia, bilateral
Patient Age: 15 Months
Patient Sex: M
Patient Ethnicity: White
Patient ID: K.B
Type of Decision Making: Low Complexity
Type of Visit: AE-Acute Episodic
Setting: Outpatient
Insurance: Commercial (Anthem (Non Medicaid)/Advantage, Cigna, etc.)
Dx: Student overall participation: 0-Student Observed
Referral Given: No
Chief Concern and Patient Notes: CC: Ear pain S: Tugging at ears no fever O: Tugging at the left ear, flushed face A: TM WNL, S1 S2 audible P: Continue to monitor and treat symptomatically with Tylenol and ibuprofen
Competency Assessments:
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Reviews & Evaluations:
Preceptor Evaluation
210428111435_2021_04_28_Evaluation_17_.doc (.doc) 0.03mb
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Preceptor Evaluation
210428111410_2021_04_28_Evaluation_16_.doc (.doc) 0.03mb
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Preceptor Evaluation
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Preceptor Evaluation
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Preceptor Evaluation
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Preceptor Evaluation
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Preceptor Evaluation
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Preceptor Evaluation
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Preceptor Evaluation
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