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Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have pain and burning with urination."
Reason for Visit (Check at least one): New Consultation
Procedure: Dipstick urinalysis, Urine Culture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Headaches."
Reason for Visit (Check at least one): New Consultation
Procedure: Collection of blood and urine samples for CMP, CBC, Lipid profile Thyroid stimulating hormone. Urinalysis. EKG.
Skills/Procedures (Select All That Apply): EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: D50.9 | Iron deficiency anemia, unspecified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel so tired all the time"
Reason for Visit (Check at least one): New Consultation
Procedure: Collection of blood and urine samples.
Skills/Procedures (Select All That Apply): EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: S93.492A | Sprain of other ligament of left ankle, initial encounter
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Left ankle pain."
Reason for Visit (Check at least one): Episodic (Acute Care)
Follow-up (Consult)
Procedure: IM injection.
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B37.3 | Candidiasis of vulva and vagina
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have vaginal discharge and itching"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 12/29/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fever and loss of smell"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: COVID TEST
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R87.624 | Cytologic evidence of malignancy on smear of vagina
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have a vaginal discharge"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 51 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Treatment and control of my blood pressure"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Collection of blood and urine samples
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J30.1 | Allergic rhinitis due to pollen
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Coughing and sneezing"
Reason for Visit (Check at least one): New Consultation
Procedure: Covid-19 test done.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy
Patient Age: 63 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results and my medication refill."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
M15.9 | Polyosteoarthritis, unspecified
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I came for my lab results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 23 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.8 | Type 2 diabetes mellitus with unspecified complications
I10 | Essential (primary) hypertension
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I need the refill of my medications"
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Collection of blood and urine samples
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 12/28/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results".
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E66.09 | Other obesity due to excess calories
Patient Age: 55 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I'm here for my Diabetes refill "
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Draw blood for CMP, CBC, LP, HbA1c. Urinalysis. Referral for Renal US.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 61 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Follow up."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Nausea."
Reason for Visit (Check at least one): New Admittance
Procedure: HCG blood tests.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N75.1 | Abscess of Bartholin's gland
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: " Vaginal pain "
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Incision and Drainage (I & D)
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for my well woman exam"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Breast exam,
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 12/22/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I need to know if I'm pregnant"
Reason for Visit (Check at least one): New Consultation
Procedure: HCG blood tests.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy
I10 | Essential (primary) hypertension
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for my screening "
Reason for Visit (Check at least one): Chronic Care
Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Fever and cough since yesterday"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: D64.9 | Anemia, unspecified
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Weakness."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J30.9 | Allergic rhinitis, unspecified
Z11.52 | Encounter for screening for COVID-19
Patient Age: 51 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have headache, sore throat and fever"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Sore throat and fever"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N30.00 | Acute cystitis without hematuria
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have pain when urinating"
Reason for Visit (Check at least one): New Consultation
Procedure: Dipstick Urinalysis.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J30.2 | Other seasonal allergic rhinitis
Patient Age: 44 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Runny nose"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Constipation."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 25 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have sore throat and headache"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/21/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L20.9 | Atopic dermatitis, unspecified
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Hand rash".
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough and fever."
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z02.1 | Encounter for pre-employment examination
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for a required employ examination"
Reason for Visit (Check at least one): Employment Physical
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J45.901 | Unspecified asthma with (acute) exacerbation
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fallow up."
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Refilled Prescriptions. Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fever and cough"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K29.00 | Acute gastritis without bleeding
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Endoscopy results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "A sudden feeling of panic."
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Procedure: Referred to a psychiatrist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M54.02 | Panniculitis affecting regions of neck/bk, cervical region
Patient Age: 50 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Neck pain"
Reason for Visit (Check at least one): New Consultation
Procedure: vital signs documented and reviewed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/15/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J44.1 | Chronic obstructive pulmonary disease w (acute) exacerbation
Z87.891 | Personal history of nicotine dependence
Patient Age: 65 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Frequent infections of the lungs."
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Referral to Pulmonologist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: D50.9 | Iron deficiency anemia, unspecified
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Weakness."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N52.9 | Male erectile dysfunction, unspecified
Patient Age: 40 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Reduced sexual desire"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough.'
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M25.512 | Pain in left shoulder
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain in my left shoulder."
Reason for Visit (Check at least one): New Consultation
Procedure: Imaging study ordered. Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I50.9 | Heart failure, unspecified
Patient Age: 68 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B37.3 | Candidiasis of vulva and vagina
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal itching."
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N30.00 | Acute cystitis without hematuria
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Urge to urinate."
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urinalysis done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/14/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K27.3 | Acute peptic ulcer, site unsp, w/o hemorrhage or perforation
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Burning stomach pain."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp
I10 | Essential (primary) hypertension
Patient Age: 50 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: 'Sharp pains or cramps."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z02.1 | Encounter for pre-employment examination
Patient Age: 44 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pre employment lab results."
Reason for Visit (Check at least one): Employment Physical
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J18.9 | Pneumonia, unspecified organism
Patient Age: 71 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough with mucus."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment performed.
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H66.92 | Otitis media, unspecified, left ear
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Left ear pain"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment, Otoscopy.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M79.7 | Fibromyalgia
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Constant dull body pain. "
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K70.31 | Alcoholic cirrhosis of liver with ascites
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Loss of appetite and weight loss."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/08/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Intense urge to go to the bathroom, but only produce a small amount of urine."
Reason for Visit (Check at least one): New Consultation
Procedure: URINALYSIS DONE.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G24.3 | Spasmodic torticollis
Patient Age: 25 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Neck pain that radiates to the shoulders."
Reason for Visit (Check at least one): New Consultation
Procedure: IMAGING STUDY ORDERED, VITAL SIGNS DOCUMENTED AND REVIEWED,
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: A54.09 | Other gonococcal infection of lower genitourinary tract
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal bleeding after intercourse"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a pregnancy test; my period is late"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B35.3 | Tinea pedis
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Scaly rashes."
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment and Vital Signs performed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L70.0 | Acne vulgaris
Patient Age: 17 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Severe acne"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J45.909 | Unspecified asthma, uncomplicated
Patient Age: 47 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Difficulty breathing"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L70.9 | Acne, unspecified
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Persistent pimples on my face"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: C80.1 | Malignant (primary) neoplasm, unspecified
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Skin lesion in my nose"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/07/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L51.1 | Stevens-Johnson syndrome
Patient Age: 69 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Rash and flu-like feeling"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: O02.1 | Missed abortion
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal bleeding and heavy cramping"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Physical Assessment. Referral to a gynecologist for further evaluation.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N83.20 | Unspecified ovarian cysts
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain on my lower abdomen"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: pelvic ultrasound ordered. Physical Assessment performed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: D24.1 | Benign neoplasm of right breast
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I felt a lump on my right breast"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K70.31 | Alcoholic cirrhosis of liver with ascites
Patient Age: 44 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel without energy lately"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N80.0 | Endometriosis of uterus
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pelvic pain and strong menstrual cramps"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N93.0 | Postcoital and contact bleeding
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bleeding after having sex"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z02.1 | Encounter for pre-employment examination
Z11.1 | Encounter for screening for respiratory tuberculosis
Z13.6 | Encounter for screening for cardiovascular disorders
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for required employment exam results"
Reason for Visit (Check at least one): Employment Physical
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 12/01/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
K70.31 | Alcoholic cirrhosis of liver with ascites
Z72.0 | Tobacco use
Patient Age: 43 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fatigue/loss of appetite"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H26.9 | Unspecified cataract
Patient Age: 69 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Clouding on my eyes"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E78.0 | Pure hypercholesterolemia
Patient Age: 50 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Here to see the results from my labs"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 18 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Persistent cough"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I82.401 | Acute embolism and thombos unsp deep veins of r low extrem
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain and redness in my right leg"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Physical Assessment performed.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L03.211 | Cellulitis of face
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Swollen face"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B37.3 | Candidiasis of vulva and vagina
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Vaginal secretion and itchy"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J45.901 | Unspecified asthma with (acute) exacerbation
Patient Age: 25 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough and shortness of breath "
Reason for Visit (Check at least one): New Admittance
Procedure: Physical Assessment performed.
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/30/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L65.9 | Nonscarring hair loss, unspecified
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I am losing hair"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Vital signs documented and reviewed. Referral to dermatologist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp
I10 | Essential (primary) hypertension
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My legs have been tingling"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K80.20 | Calculus of gallbladder w/o cholecystitis w/o obstruction
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain in my upper abdomen due to gallstones"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: C80.1 | Malignant (primary) neoplasm, unspecified
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "A new skin lesion on my nose "
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: S90.861A | Insect bite (nonvenomous), right foot, initial encounter
Patient Age: 20 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Physical Assessment.
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Incision and Drainage (I & D)
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H02.61 | Xanthelasma of right upper eyelid
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Painful eyelid"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J18.9 | Pneumonia, unspecified organism
Patient Age: 67 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Wet cough"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: S52.531S | Colles' fracture of right radius, sequela
Patient Age: 33 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain when bending wrist"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/25/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B36.0 | Pityriasis versicolor
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Skin discoloration on my upper back"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N63 | Unspecified lump in breast
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I came to my annual checkup"
Reason for Visit (Check at least one): Annual/Well Person Exam
Procedure: Physical Assessment. Referral for Mammography. Blood sampling for labs.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H00.011 | Hordeolum externum right upper eyelid
Patient Age: 30 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Inflamed eyelids."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: F50.00 | Anorexia nervosa, unspecified
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Intense fear of gaining weight."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B02.9 | Zoster without complications
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Painful rash on my back"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: COMPLETE PHYSICAL SKIN EXAM PERFORMED, VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M79.7 | Fibromyalgia
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain and tenderness on my back and neck"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G57.61 | Lesion of plantar nerve, right lower limb
Patient Age: 40 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Numbness in the ball of the foot".
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M79.7 | Fibromyalgia
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Constant dull body pain."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M79.7 | Fibromyalgia
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Constant dull body pain."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/23/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H01.009 | Unspecified blepharitis unspecified eye, unspecified eyelid
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Red eyes."
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R50.9 | Fever, unspecified
Patient Age: 37 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fever for 20 days."
Reason for Visit (Check at least one): New Consultation
Procedure: Blood collection for labs.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N94.6 | Dysmenorrhea, unspecified
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Strong cramps during menstruation"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R04.0 | Epistaxis
Patient Age: 43 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Prolonged nose bleeds"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough with phlegm"
Reason for Visit (Check at least one): New Consultation
Procedure: Chest X ray and CBC ordered. Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B35.1 | Tinea unguium
Patient Age: 20 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Flaking white areas on the nail's surface."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 49 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Irregular heartbeats"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: Endoscopy.
Diagnostic Codes: K29.70 | Gastritis, unspecified, without bleeding
Patient Age: 35 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Burning sensation in the stomach."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referral for endoscopy.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/17/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K51.90 | Ulcerative colitis, unspecified, without complications
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bloody and loose stools"
Reason for Visit (Check at least one): New Consultation
Procedure: BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K27.3 | Acute peptic ulcer, site unsp, w/o hemorrhage or perforation
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Burning stomach pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z02.4 | Encounter for examination for driving license
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results."
Reason for Visit (Check at least one): Employment Physical
Skills/Procedures (Select All That Apply): EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: Follow up in one week to review treatment outcomes.
Diagnostic Codes: B86 | Scabies
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Rash on my hands and breasts"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: L30.9 | Dermatitis, unspecified
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Dry skin"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Physical Assessment. Refilled Prescriptions
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: K21.9 | Gastro-esophageal reflux disease without esophagitis
Z68.42 | Body mass index (BMI) 45.0-49.9, adult
Patient Age: 55 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Regurgitation."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referral for upper endoscopy.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp
Patient Age: 60 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G47.00 | Insomnia, unspecified
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Difficulty falling asleep"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/16/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z11.3 | Encntr screen for infections w sexl mode of transmiss
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "STD screening"
Reason for Visit (Check at least one): Annual/Well Person Exam
Procedure: Blood sampling for labs.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: M06.9 | Rheumatoid arthritis, unspecified
Patient Age: 63 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Joint pain'"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G43.909 | Migraine, unsp, not intractable, without status migrainosus
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Tension on my head"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H01.009 | Unspecified blepharitis unspecified eye, unspecified eyelid
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itchy eyelids."
Reason for Visit (Check at least one): New Consultation
Procedure: Visual functional status assessed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J30.1 | Allergic rhinitis due to pollen
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Runny nose."
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H66.42 | Suppurative otitis media, unspecified, left ear
Patient Age: 19 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Ear pain and discharge from my left ear "
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N94.6 | Dysmenorrhea, unspecified
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lower abdominal pain and cramps."
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
R04.0 | Epistaxis
Patient Age: 45 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Nose bleeding."
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 11/09/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N60.12 | Diffuse cystic mastopathy of left breast
Z12.31 | Encntr screen mammogram for malignant neoplasm of breast
Patient Age: 53 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lumps on left breast"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B36.0 | Pityriasis versicolor
Patient Age: 17 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Patches of skin discolorations."
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: N60.01 | Solitary cyst of right breast
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cyst on my right boob"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B35.4 | Tinea corporis
Patient Age: 51 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Circular patches and skin irritation""
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B02.9 | Zoster without complications
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel pain and itching in my back"
Reason for Visit (Check at least one): New Consultation
Procedure: Blood sample for Labs.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: DYSPNEA ASSESSED NOT PRESENT. IMAGING STUDY ORDERED. VITAL SIGNS DOCUMENTED AND REVIEWED.
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 75 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Chest discomfort and phlegm"
Reason for Visit (Check at least one): New Consultation
Procedure: Imaging study ordered. Blood sample for Labs.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G57.61 | Lesion of plantar nerve, right lower limb
Patient Age: 47 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Numbness in the ball of the foot"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/03/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: F50.2 | Bulimia nervosa
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Excessive weight loss"
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: E05.90 | Thyrotoxicosis, unsp without thyrotoxic crisis or storm
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Weight loss and difficulty sleeping"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: Z02.1 | Encounter for pre-employment examination
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for a required employ examination"
Reason for Visit (Check at least one): Employment Physical
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: BODY MASS INDEX, DOCUMENTED. PAIN SEVERITY, ASSESSED. FUNCTIONAL STATUS, ASSESSED. TOBACCO USE, ASSESSED. VITAL SIGNS DOCUMENTED AND REVIEWED.
Diagnostic Codes: M79.7 | Fibromyalgia
Z72.0 | Tobacco use
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain and tenderness on my back and neck"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H00.014 | Hordeolum externum left upper eyelid
Patient Age: 20 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Swollen and painful eyelid"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Physical Assessment. vital signs documented and reviewed.
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: J04.0 | Acute laryngitis
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Raspy voice and sore throat."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: G44.209 | Tension-type headache, unspecified, not intractable
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Headaches and neck pain"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 11/02/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B80 | Enterobiasis
Patient Age: 41 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itching around my anus"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H66.92 | Otitis media, unspecified, left ear
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Left ear pain."
Reason for Visit (Check at least one): New Consultation
Procedure: Otoscopy. culture of the fluid.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B35.1 | Tinea unguium
Patient Age: 22 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Flaking white areas on the nail's surface."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referral to dermatologist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: IMAGING STUDY ORDERED.
Diagnostic Codes: M81.0 | Age-related osteoporosis w/o current pathological fracture
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bone aches"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: Referral to psychiatrist for further evaluation.
Diagnostic Codes: F32.9 | Major depressive disorder, single episode, unspecified
Patient Age: 51 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sudden episodes of profound sadness"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: F43.20 | Adjustment disorder, unspecified
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Have not been sleeping or eating"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: H00.011 | Hordeolum externum right upper eyelid
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My right eye lid is red and swollen"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments:  
Diagnostic Codes: B27.90 | Infectious mononucleosis, unspecified without complication
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat and fatigue"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/27/2022
Rotation Type: NSG6440 - FNP Primary Care
Comments: Sleep study ordered. Follow up in one week to evaluate treatment outcomes and laboratory testing results.
Diagnostic Codes: G47.33 | Obstructive sleep apnea (adult) (pediatric)
Patient Age: 37 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel tired because I have several interruptions when I sleep"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Blood sample for laboratory tests. Urine sample collection.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Referral to Nephrologist.
Diagnostic Codes: R31.9 | Hematuria, unspecified
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Blood in the urine"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Physical Assessment.
Diagnostic Codes: J45.901 | Unspecified asthma with (acute) exacerbation
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son has been coughing, has shortness of breath and wheezing"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: COVID Rapid test positive. Advised to call the office is symptoms worsen or go to the ER if difficulty to breathing.
Diagnostic Codes: U07.1 | COVID-19
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Cough, Fever and body aches"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Physical Assessment.
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Constipation"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Physical Assessment. Vital sings documented and reviewed.
Diagnostic Codes: Z23 | Encounter for immunization
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Flu shot"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 10/19/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Follow up in 10 days if symptoms persist.
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat."
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: U07.1 | COVID-19
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Loss of taste or smell and runny nose.
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: F50.02 | Anorexia nervosa, binge eating/purging type
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " My daughter has been inducing her vomiting after meals so she can look thin."
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Follow up in 1 week if pain persists.
Diagnostic Codes: G24.3 | Spasmodic torticollis
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Neck pain."
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N39.44 | Nocturnal enuresis
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " My son is still pees on himself at night"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: U07.1 | COVID-19
Patient Age: 12 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Dry cough, muscle aches."
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Cold therapy applying a cold compress to the nose bridge to help constrict blood vessels.
Diagnostic Codes: R04.0 | Epistaxis
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: lab result.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J01.00 | Acute maxillary sinusitis, unspecified
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: X-Ray result.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/13/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: D50.9 | Iron deficiency anemia, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Feeling weak, fatigue and sleepy for days"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat and fever"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K64.9 | Unspecified hemorrhoids
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I feel something coming out of my anus with burning sensation and pain when pass poo"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: G24.3 | Spasmodic torticollis
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Neck pain and my neck feel stiff to the right"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Follow up in one week to evaluate treatment outcomes. Patient was instructed to contact the office if symptoms exacerbate or call 911 if is an emergency. No referrals needed at this time.
Diagnostic Codes: L50.9 | Urticaria, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Severe itching.
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My nose is stuffy, and I have a headache"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Case reported to the CDC.
Diagnostic Codes: B26.9 | Mumps without complication
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain during chewing or swallowing"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/12/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N39.44 | Nocturnal enuresis
Patient Age: 7 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My daughter still wets herself during nighttime"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.3 | Tinea pedis
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Redness and itching between my toes"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My nose is stuffy, and I have a headache"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L50.9 | Urticaria, unspecified
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " My son has itchiness and is not going away. "
Reason for Visit (Check at least one): New Consultation
Procedure: Blood draw for labs.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H00.014 | Hordeolum externum left upper eyelid
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Swollen and painful eyelid"
Reason for Visit (Check at least one): New Consultation
Procedure: Eye examination, Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Persistent cough"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Burning urination and mild fever."
Reason for Visit (Check at least one): New Consultation
Procedure: URINALYSIS, DIP STICK/TABLET REAGENT. CULTURE ORDERED.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP 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: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a physical"
Reason for Visit (Check at least one): Annual/Well Person Exam
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/06/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have a fever and runny nose"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.3 | Tinea pedis
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My toes are very itchy and red"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: F42 | Obsessive-compulsive disorder
Patient Age: 9 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "My daughter is constantly picking at her skin"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K35.80 | Unspecified acute appendicitis
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "My stomach hurts a lot and I have fever"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son has sore throat and voice loss"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H10.013 | Acute follicular conjunctivitis, bilateral
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Tearing and itchiness on both eyes"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment,
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R61 | Generalized hyperhidrosis
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I sweat excessively"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R61 | Generalized hyperhidrosis
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I sweat excessively"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 10/05/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H50.9 | Unspecified strabismus
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son's eyes don't move together".
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N20.0 | Calculus of kidney
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Severe pain in the back."
Reason for Visit (Check at least one): New Consultation
Procedure: Dipstick Urinalysis. Referral for Ultrasound.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: A08.4 | Viral intestinal infection, unspecified
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Diarrhea for 3 days"
Reason for Visit (Check at least one): New Consultation
Procedure: Blood draw for CBC and stool test ordered.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J45.901 | Unspecified asthma with (acute) exacerbation
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "it's hard to breath during physical activity"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Difficulties using the bathroom"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Here for annual checkup"
Reason for Visit (Check at least one): Annual/Well Person Exam
Procedure: Physical Assessment, Urine collection and Blood draw for labs.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: S93.401A | Sprain of unspecified ligament of right ankle, init encntr
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: 'Ankle pain in the past three days after to twist"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment, X-rays ordered.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: D50.9 | Iron deficiency anemia, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I get dizzy when standing up"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment, Blood draw for labs.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 09/29/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have a very strong cough"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough and runny nose."
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: E10.9 | Type 1 diabetes mellitus without complications
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Unexplained drop in weight and increased appetite"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J45.901 | Unspecified asthma with (acute) exacerbation
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son has been coughing, has shortness of breath and wheezing"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
Patient Age: 12 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have a fever and soreness in my throat"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP 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
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son needs a physical to join a sports team"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H66.92 | Otitis media, unspecified, left ear
Patient Age: 17 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " My left ear is bothering me"
Reason for Visit (Check at least one): Scheduled Procedure
Skills/Procedures (Select All That Apply): Cerumen Disimpaction
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: F41.0 | panic disorder without agoraphobia
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Palpitations"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/28/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L60.8 | Other nail disorders
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bruise in nail bed"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K35.80 | Unspecified acute appendicitis
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sharp pain on my stomach"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z23 | Encounter for immunization
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I brought my daughter to get the flu vaccine."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Vital signs documented and reviewed.
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
K64.9 | Unspecified hemorrhoids
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "It is very painful to poop"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
J98.01 | Acute bronchospasm
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Feeling of tightness on the chest and back"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L70.0 | Acne vulgaris
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Nothing helps my acne"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B26.9 | Mumps without complication
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My child has very high fever and flu like symptoms"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat and nose congestion"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/22/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B08.5 | Enteroviral vesicular pharyngitis
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have small red and white bumps on the roof of my throat"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L42 | Pityriasis rosea
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itchy rash on stomach and back"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L50.9 | Urticaria, unspecified
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have itchiness, pink and red swollen areas on my skin"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.1 | Tinea unguium
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Nails distorted in shape, thickened"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H50.9 | Unspecified strabismus
Patient Age: 6 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My sons' eyes don't seem to look in the same direction at the same time"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K58.0 | Irritable bowel syndrome with diarrhea
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I constant bloating and stomach pain"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R05 | Cough
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L20.9 | Atopic dermatitis, unspecified
Patient Age: 9 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My daughters has rashes on her arms."
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/21/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H01.001 | Unspecified blepharitis right upper eyelid
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son eyelids are itchy and crusty"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B27.90 | Infectious mononucleosis, unspecified without complication
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Swollen neck and sore throat"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.3 | Tinea pedis
Patient Age: 12 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Cracked skin between my toes."
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.6 | Tinea cruris
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itchy red rash in my genital area"
Reason for Visit (Check at least one): New Admittance
Parenting/Family Education Counseling
Procedure: Physical exam performed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R55 | Syncope and collapse
Patient Age: 7 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My daughter fainted in school earlier today"
Reason for Visit (Check at least one): New Admittance
Procedure: Urine collection and Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments: Lab ordered. F/U in a week to review lab results.
Diagnostic Codes: N34.1 | Nonspecific urethritis
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I get the urge to pee very frequently"
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection and Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: A06.0 | Acute amebic dysentery
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cramping and diarrhea"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B80 | Enterobiasis
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itching around my anus"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/15/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H01.001 | Unspecified blepharitis right upper eyelid
H01.003 | Unspecified blepharitis right eye, unspecified eyelid
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "The skin around my left eye and the eyelid feels like is burning"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Runny nose."
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I think I have a cold"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: E10.9 | Type 1 diabetes mellitus without complications
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "unexplained drop in weight, nausea, and increased appetite"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K52.9 | Noninfective gastroenteritis and colitis, unspecified
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 100
Student Participation: 100%
Chief Complaint: "I feel nauseated and have stomach pain"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 100
Student Participation: 100%
Chief Complaint: "Fever, cough, and malaise"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 3 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Difficulties using the bathroom"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Procedure: Physical exam performed.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: A06.0 | Acute amebic dysentery
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cramping and diarrhea"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/14/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K21.9 | Gastro-esophageal reflux disease without esophagitis
Patient Age: 16 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have been experiencing heartburn"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K59.09 | Other constipation
Patient Age: 10 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Abdominal pain."
Reason for Visit (Check at least one): New Admittance
Procedure: Urine collection and Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
J20.9 | Acute bronchitis, unspecified
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Cough."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
J02.9 | Acute pharyngitis, unspecified
J03.90 | Acute tonsillitis, unspecified
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat and body ache."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: E50.8 | Other manifestations of vitamin A deficiency
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L23.81 | Allergic contact dermatitis due to animal (cat) (dog) dander
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bumps."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: T14.90 | Injury, unspecified
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Foot pain"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L70.8 | Other acne
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Face and back rash."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/08/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J30.2 | Other seasonal allergic rhinitis
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Runny nose for the las week".
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N30.91 | Cystitis, unspecified with hematuria
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain in the right side and my urine is somewhat reddish"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Referral for renal US, dipstick Urinalysis, Urine Culture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have fever and malaise since yesterday "
Reason for Visit (Check at least one): New Consultation
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J03.00 | Acute streptococcal tonsillitis, unspecified
Patient Age: 8 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Sore throat and fever"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z00.129 | Encntr for routine child health exam w/o abnormal findings
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Lab results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J30.81 | Allergic rhinitis due to animal (cat) (dog) hair and dander
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Runny nose for the last two weeks"
Reason for Visit (Check at least one): Follow-up (Routine)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N30.00 | Acute cystitis without hematuria
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Burning urination"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Dipstick Urinalysis, Urine Culture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have fever and malaise"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/07/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I haven't had my menstrual cycle for the last two months"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Fiver and cough since yesterday"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J30.2 | Other seasonal allergic rhinitis
Patient Age: 7 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Nasal congestion"
Reason for Visit (Check at least one): Follow-up (Routine)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H60.592 | Other noninfective acute otitis externa, left ear
Patient Age: 9 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Left ear discomfort"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: otoscopy.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K35.80 | Unspecified acute appendicitis
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Abdominal pain and nausea."
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H66.92 | Otitis media, unspecified, left ear
Patient Age: 12 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Fever and pain in my left ear"
Reason for Visit (Check at least one): New Consultation
Procedure: Otoscopy.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: D64.9 | Anemia, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I feel tired all the time"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: blood draw for labs.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R19.7 | Diarrhea, unspecified
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " She has four diarrheas in the last since yesterday"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Procedure: blood draw for CBC, Stool Culture
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 09/01/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Body pain and fever."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N30.01 | Acute cystitis with hematuria
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain when urinating"
Reason for Visit (Check at least one): New Consultation
Procedure: Dipstick Urinalysis, Urine Culture, referral for renal US
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J03.91 | Acute recurrent tonsillitis, unspecified
Patient Age: 11 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have sore throat and fever"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H66.91 | Otitis media, unspecified. right ear
Patient Age: 8 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My babe has earache and fever"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have fever and cough"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J01.90 | Acute sinusitis, unspecified
Patient Age: 16 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have fever, nasal discharge and headache "
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J30.9 | Allergic rhinitis, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have runny nose and sneezing"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have sore throat, fever and headache"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/31/2022
Rotation Type: NSG6435 - FNP 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: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I bring my child for the general check-up"
Reason for Visit (Check at least one): Annual/Well Person Exam
Parenting/Family Education Counseling
Procedure: Physical exam.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.1 | Tinea unguium
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have my yellow nails"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have sore throat and fever"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: S93.409D | Sprain of unsp ligament of unspecified ankle, subs encntr
Patient Age: 13 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son has swelling in the ankle after a fall".
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L70.9 | Acne, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have pimples in my face"
Reason for Visit (Check at least one): Follow-up (Routine)
Parenting/Family Education Counseling
Procedure: referral to the dermatologist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have sore throat and caught"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 08/25/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have sore throat and fever"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H10.9 | Unspecified conjunctivitis
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have redness and burning sensation in my eyes"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B35.0 | Tinea barbae and tinea capitis
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My child has irregular hair loss."
Reason for Visit (Check at least one): New Consultation
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N30.00 | Acute cystitis without hematuria
Patient Age: 10 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have burning and pain when urinating"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Dipstick Urinalysis, Urine Culture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B36.0 | Pityriasis versicolor
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have spots on my back"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J30.2 | Other seasonal allergic rhinitis
Patient Age: 12 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have runny nose, sore throat and headache"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " My son still has problems to poop"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J18.9 | Pneumonia, unspecified organism
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My daughter has a fever and cough a few days ago."
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Procedure: Blood sampling for CBC.
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have sore throat and runny nose"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP 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: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I bring my son for check-up"
Reason for Visit (Check at least one): Annual/Well Person Exam
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/24/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: R19.07 | Generalized intra-abd and pelvic swelling, mass and lump
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My baby has soft stools"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: CBC, Stool Culture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H60.392 | Other infective otitis externa, left ear
Patient Age: 12 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have left ear pain"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Physical Assessment, Otoscopy.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L70.0 | Acne vulgaris
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have face and back skin lesions"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My child started with running nose and congestion"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K58.0 | irritable bowel syndrome with diarrhea
Patient Age: 15 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have abdominal pain and loose stools"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Sample collection for Stool Testing.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: B86 | Scabies
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My child has a very itchy rash in the arms and trunk"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
Patient Age: 13 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I have pain and discomfort in my throat."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 4 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My child started with low grade of fever, running nose and congestion"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/18/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: My child has fever, runny nose and coughing for more than 3 days.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J39.0 | Retropharyngeal and parapharyngeal abscess
Patient Age: 10 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son has sore throat and fever,"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: K21.9 | Gastro-esophageal reflux disease without esophagitis
Patient Age: 1 Year
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: My son had vomiting and excessive gastric reflux.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 5 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "My child has fever, runny nose and coughing for more than a week."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Physical Assessment.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: J00 | Acute nasopharyngitis [common cold]
Patient Age: 6 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: My child started with low grade of fever, running nose and congestion
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L70.9 | Acne, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Whitehead, red pus-filled pimples in my child face and back "
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: L22 | Diaper dermatitis
Patient Age: 8 Months
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Redness and itching around the diaper area observed"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: H92.02 | Otalgia, left ear
Patient Age: 10 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My son is complaining of ear pain and low grade of fever."
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Otoscopy.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 08/17/2022
Rotation Type: NSG6435 - FNP Pediatrics
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 3 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: " My child has foul smelling urine and cloudy pee"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
NSG 6435
View

Academic Service:
Case Log as of 3/17/2021
Date: 08/04/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Menstrual bleeding and a really bad pelvic pressure.
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Referral for Pelvic Ultrasound.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 08/04/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a refill of my contraceptives."
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 08/04/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N93.0 | Postcoital and contact bleeding
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have been bleeding after having."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 08/04/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: R87.618 | Oth abnormal cytolog findings on specimens from cervix uteri
Patient Age: 53 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here to review my labs results."
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/03/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A63.0 | Anogenital (venereal) warts
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I have warts on my genitals"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture for labs.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 08/03/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N87.1 | Moderate cervical dysplasia
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I come to review the results of my Pap smear"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 08/03/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N72 | Inflammatory disease of cervix uteri
Patient Age: 59 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel pain during intercourse"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture for labs.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 08/03/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N94.810 | Vulvar vestibulitis
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have irritation and vulvar pain"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: C50.912 | Malignant neoplasm of unspecified site of left female breast
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here due to my mammogram results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N81.9 | Female genital prolapse, unspecified
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have noticed a lump in my vagina and it itches."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N64.53 | Retraction of nipple
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My nipples are inward"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: referral for mammogram. Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.00 | Herpesviral infection of urogenital system, unspecified
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I feel small lesion on my labia"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N71.9 | Inflammatory disease of uterus, unspecified
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have painful intercourse and vaginal discomfort".
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/28/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Labs ordered: CBC, mammogram, and breast US
Diagnostic Codes: N64.4 | Mastodynia
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have breast tenderness and constant dull pain"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: referral for mammogram. Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I missed menstrual period."
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture. Clinical Notes Pregnancy test done.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D24.1 | Benign neoplasm of right breast
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I felt a lump on my boob".
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: referral for a screening mammogram
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have heavy flow when on my period"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture. referral for imaging study.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E28.2 | Polycystic ovarian syndrome
E66.8 | Other obesity
N91.2 | Amenorrhea, unspecified
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I haven't had my periods for the last three months".
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection, Venipuncture. hcg test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Z01.411 | Encntr for gyn exam (general) (routine) w abnormal findings
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I had heavy menstrual bleeding for more than a week, with a really bad pelvic pressure"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.9 | Encounter for contraceptive management, unspecified
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I need my oral contraceptives refills, and lab results".
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A59.01 | Trichomonal vulvovaginitis
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I am really worried about a bad smelling vaginal discharge that has been observed in my underwear."
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 07/27/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: F17.210 | Nicotine dependence, cigarettes, uncomplicated
I10 | Essential (primary) hypertension
N60.91 | Unspecified benign mammary dysplasia of right breast
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I am here to see my mammogram result".
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: B37.3 | Candidiasis of vulva and vagina
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "irritation and watery white vaginal discharge accompanied of itching"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Conjugated estrogen's vaginal cream 0.625mg/g daily for 21 days followed by 7 days off intravaginally.
Diagnostic Codes: N95.2 | Postmenopausal atrophic vaginitis
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "vaginal dryness and itching".
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have abdominal and pelvic pain for more than 2 weeks.
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z01.411 | Encntr for gyn exam (general) (routine) w abnormal findings
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I am here for my Pap Smear"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have lower abdominal and pelvic pain accompanied by heavy vaginal discharge."
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Lab result and refill for my contraceptive pills.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings
Patient Age: 49 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: I want my gynecological exam.
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 07/21/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I want to know if I am pregnant.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture. HCG Test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N30.01 | Acute cystitis with hematuria
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pain and burning when I pee.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection. (urinalysis (UA) and urine culture.)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: My period is 1 week late.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: HCG Test done. Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z11.51 | Encounter for screening for human papillomavirus (HPV)
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: I want to know if I have the papillomavirus.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Pap Smear
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N30.80 | Other cystitis without hematuria
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I need to pee more often and urgently than normal.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection. (urinalysis (UA) and urine culture.)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Missing the last 2 periods.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E28.310 | Symptomatic premature menopause
I10 | Essential (primary) hypertension
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Hot flushes.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: PEINFUL SEXUAL INTERCOURSE.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 07/20/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: O02.1 | Missed abortion
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Vaginal bleeding.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: HCG test.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E66.01 | Morbid (severe) obesity due to excess calories
I10 | Essential (primary) hypertension
N81.10 | Cystocele, unspecified
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Leakage of urine.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N97.9 | Female infertility, unspecified
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Lab results
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N76.0 | Acute vaginitis
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pain during sex.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: R87.618 | Oth abnormal cytolog findings on specimens from cervix uteri
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pap smear results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N94.3 | Premenstrual tension syndrome
Patient Age: 21 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Breast tenderness.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: HCG Test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.00 | Herpesviral infection of urogenital system, unspecified
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Tiny white painful blisters on my vagina.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: C54.1 | Malignant neoplasm of endometrium
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Pink Vaginal discharge.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/14/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A74.9 | Chlamydial infection, unspecified
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Pain during sex
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z23 | Encounter for immunization
Patient Age: 18 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: HPV vaccine.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N60.01 | Solitary cyst of right breast
Z12.31 | Encntr screen mammogram for malignant neoplasm of breast
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: mammogram results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.40 | Encounter for surveillance of contraceptives, unspecified
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I need a contraceptive.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture., urine pregnancy test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 22 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I think I'm pregnant.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: HCG Test done, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: refill my pills
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
N95.1 | Menopausal and female climacteric states
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: follow up
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Fallow-up and lab results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/13/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Exam Results information.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N71.9 | Inflammatory disease of uterus, unspecified
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Pelvic Pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: HCG Test done. Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.00 | Herpesviral infection of urogenital system, unspecified
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain and itching in my genital area."
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pap Smear results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Kegel exercises ordered to strengthen pelvic floor muscles.
Diagnostic Codes: N81.4 | Uterovaginal prolapse, unspecified
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Sitting on a ball sensation.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pap Smear and Lab result.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Missing my period.
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture. HCG Test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I need my contraceptive pills.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/07/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
N95.0 | Postmenopausal bleeding
Patient Age: 60 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I have a lot of bleeding.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D24.2 | Benign neoplasm of left breast
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: mammogram and labs results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N97.9 | Female infertility, unspecified
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: lab results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: I am tired of these painful periods and so much bleeding.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: I need my contraceptive pills and my labs results.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N83.20 | Unspecified ovarian cysts
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: image study and lab results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D24.2 | Benign neoplasm of left breast
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I want to know what I have in my breast."
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N75.8 | Other diseases of Bartholin's gland
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Pain in the pelvis during sexual intercourse
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 07/06/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: lab and results
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bleeding on my period"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z11.4 | Encounter for screening for human immunodeficiency virus
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Here to get tested for HIV"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My period is late this month"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture. HCG Pregnancy test done. (negative).
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "pelvic pain and vaginal discharge"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N64.3 | Galactorrhea not associated with childbirth
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Milky nipple discharge"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture., urine pregnancy test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.9 | Encounter for contraceptive management, unspecified
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a contraceptive refill"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z23 | Encounter for immunization
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need to get the Human papilloma vaccine"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 06/30/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: B37.3 | Candidiasis of vulva and vagina
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Itchiness in my vagina"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
N95.1 | Menopausal and female climacteric states
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal dryness and painful intercourse"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: R87.618 | Oth abnormal cytolog findings on specimens from cervix uteri
Patient Age: 50 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Im here to review my lab results"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referral to the gynecologist for further evaluation and treatment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N76.0 | Acute vaginitis
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Irritation of my vagina"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "To get a refill"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.00 | Herpes viral infection of urogenital system, unspecified
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Small red bumps on my labia"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment. Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N71.9 | Inflammatory disease of uterus, unspecified
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Painful intercourse."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: F/U in one weeks for labs results.
Diagnostic Codes: N95.0 | Postmenopausal bleeding
Z87.891 | Personal history of nicotine dependence
Patient Age: 54 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "spotting on my underwear"
Reason for Visit (Check at least one): New Consultation
Procedure: Physical Assessment, Vital Signs, referral for imaging study ordered, venipuncture, Urine collection
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/29/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: C50.911 | Malignant neoplasm of unsp site of right female breast
Patient Age: 52 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Mammogram results"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referred to the gynecologist and oncologist for further treatment.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "to get a refill on my birth control"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N81.10 | Cystocele, unspecified
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: A feeling of fullness in my pelvis.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Referred to gynecologist.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A54.09 | Other gonococcal infection of lower genitourinary tract
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal bleeding after intercourse"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: IM injection.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.42 | Encounter for surveillance of injectable contraceptive
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Contraceptive injection and labs result.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Injection.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Missed menstrual period "
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/23/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A54.09 | Other gonococcal infection of lower genitourinary tract
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Painful urination and discharge".
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Patient advice on Kegel exercises to strengthen pelvic muscles and support weakened fascia.
Diagnostic Codes: N81.4 | Uterovaginal prolapse, unspecified
Patient Age: 61 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Heaviness on my pelvis"
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "To get a refill on my birth control"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Refill medication and labs results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N94.6 | Dysmenorrhea, unspecified
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Menstrual pain"
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection, Venipuncture. Urine pregnancy test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Urine pregnancy test done.
Diagnostic Codes: E04.9 | Nontoxic goiter, unspecified
I10 | Essential (primary) hypertension
N91.2 | Amenorrhea, unspecified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have been missing my period lately"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a pregnancy test."
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A63.0 | Anogenital (venereal) warts
Patient Age: 50 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Skin lesions on my intimate area"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Urine pregnancy test done. Breast exam. Vital signs documented and reviewed.
Diagnostic Codes: N64.4 | Mastodynia
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Breast tenderness"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/22/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Body mass (BMI) documented, referral for breast ultrasound, Vital signs documented and reviewed.
Diagnostic Codes: N60.01 | Solitary cyst of right breast
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "My breast hurt "
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: breast exam, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Ultrasound, Pap Smear and labs results.
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
I10 | Essential (primary) hypertension
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N93.0 | Postcoital and contact bleeding
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Bleeding after having sex"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: PATIENT EDUCATION MATERIALS PROVIDED, VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: CBC, urinalysis, US, CT scan, and endometrial biopsy ordered Ibuprofen 400 mg as needed, Combined of estrogen-progestin birth control pills.
Diagnostic Codes: N80.0 | Endometriosis of uterus
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Strong menstrual cramps"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N75.8 | Other diseases of Bartholin's gland
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Vaginal pain"
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Incision and Drainage (I & D)
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D24.1 | Benign neoplasm of right breast
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: mammogram results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Immunizations
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A74.9 | Chlamydial infection, unspecified
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pelvic heaviness"
Reason for Visit (Check at least one): Episodic (Acute Care)
Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N83.20 | Unspecified ovarian cysts
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pain on my lower abdomen"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: REFERRAL FOR IMAGING STUDY, URINE COLLECTION, VENIPUNCTURE
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 06/16/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: O02.1 | Missed abortion
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Vaginal bleeding and heavy cramping"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N76.0 | Acute vaginitis
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Discomfort on my genitals"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need a refill of my contraceptives"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A51.31 | Condyloma latum
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Warts on my groin region"
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N64.53 | Retraction of nipple
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Nipples have turned inwards rather than outwards"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: EDUCATION MATERIALS PROVIDED, COMPLETE PHYSICAL SKIN EXAM PERFORMED, REFERRAL FOR IMAGING STUDY, VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D25.9 | Leiomyoma of uterus, unspecified
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "heavy period with strong cramps"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: VITAL SIGNS DOCUMENTED AND REVIEWED.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
N87.0 | Mild cervical dysplasia
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Review my labs"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N97.9 | Female infertility, unspecified
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Difficulty getting pregnant"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Cultures/Swabs/Wet Mount
Pap Smear
Academic Service:
Case Log as of 3/17/2021
Date: 06/15/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N80.0 | Endometriosis of uterus
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: bleeding during period and pain during sex.
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Urine collection, Venipuncture and breast exam
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N87.1 | Moderate cervical dysplasia
Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Review my last labs"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: D24.2 | Benign neoplasm of left breast
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: mammogram results
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: C54.1 | Malignant neoplasm of endometrium
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Light but persistent bleeding from the vagina"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.00 | Herpes viral infection of urogenital system, unspecified
Patient Age:  Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Pain lesion, and itching on my labia"
Reason for Visit (Check at least one): Episodic (Acute Care)
New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: C50.911 | Malignant neoplasm of unsp site of right female breast
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I'm here for my mammogram results."
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N82.3 | Fistula of vagina to large intestine
Patient Age: 57 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Stool and foul smell from my vagina"
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N94.810 | Vulvar vestibulitis
Patient Age: 44 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "itching and burning sensation on the vulvar"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/09/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: F32.8 | Other depressive episodes
N94.3 | Premenstrual tension syndrome
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm still feeling bad about the time of my periods"
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Reproductive Health Screening/Management
Screen/Manage Sleep Disorders
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Referral for a mammogram.
Diagnostic Codes: D24.1 | Benign neoplasm of right breast
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I feel a mass in my right breast"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Treatment: Clomiphene.
Diagnostic Codes: I10 | Essential (primary) hypertension
N97.9 | Female infertility, unspecified
Patient Age: 34 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I can't get pregnant"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N80.0 | Endometriosis of uterus
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "pelvic pain and strong menstrual cramps"
Reason for Visit (Check at least one): New Consultation
Procedure: Ultrasound Referrals, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: R87.618 | Oth abnormal cytolog findings on specimens from cervix uteri
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Review my lab results"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
N76.0 | Acute vaginitis
Z72.51 | High risk heterosexual behavior
Patient Age: 53 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Painful urination and vaginal bleeding"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N81.10 | Cystocele, unspecified
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I can feel a bulge in my vagina"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A60.04 | Herpesviral vulvovaginitis
Patient Age: 50 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " Irritation of my genital area"
Reason for Visit (Check at least one): Gynecologic Care
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Cultures/Swabs/Wet Mount
Pap Smear
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/08/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z30.41 | Encounter for surveillance of contraceptive pills
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Birth control refill.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: PATIENT EDUCATION MATERIALS PROVIDED.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A51.31 | Condyloma latum
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "grey and white lesions on my vagina"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture blood draw.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: A74.9 | Chlamydial infection, unspecified
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I feel fullness on my pelvic area and lower back pain"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: BLOOD COUNT; COMPLETE CBC, AUTOMATED HGB, HCT, RBC, WBC, & PLATELET
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N64.53 | Retraction of nipple
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "My nipples are inward"
Reason for Visit (Check at least one): New Consultation
Procedure: referral for Imagin studies. Breast exam. venipuncture for lab
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Missing a period.
Reason for Visit (Check at least one): New Consultation
Procedure: hCG blood tests, Venipuncture, Urine collection, referral for Pelvic ultrasound.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N75.1 | Abscess of Bartholin's gland
Patient Age: 41 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Pain during intercourse.
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Incision and Drainage (I & D)
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z01.419 | Encntr for gyn exam (general) (routine) w/o abn findings
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for my gynecology care"
Reason for Visit (Check at least one): Gynecologic Care
Procedure: Breast exam. Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N30.00 | Acute cystitis without hematuria
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Burning sensation when I urinate"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Dipstick Urinalysis, Urine Culture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/02/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z32.02 | Encounter for pregnancy test, result negative
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I want to know if I'm pregnant"
Reason for Visit (Check at least one): New Consultation
Procedure: hCG blood tests.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: Z11.51 | Encounter for screening for human papillomavirus (HPV)
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Papillomavirus test"
Reason for Visit (Check at least one): New Consultation
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Pap Smear
Pelvic Exam
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N30.90 | Cystitis, unspecified without hematuria
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Burning sensation while urinating.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Dipstick Urinalysis, Urine Culture, Venipuncture.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E66.09 | Other obesity due to excess calories
I10 | Essential (primary) hypertension
N39.490 | Overflow incontinence
Patient Age: 60 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: weak urine stream.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I haven't had my menstrual cycle in 3 months"
Reason for Visit (Check at least one): Gynecologic Care
New Admittance
Procedure: hcg test, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Pelvic Exam
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: N94.6 | Dysmenorrhea, unspecified
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Menstrual cramps.
Reason for Visit (Check at least one): Episodic (Acute Care)
Gynecologic Care
Procedure: Urine collection, Venipuncture. 
Skills/Procedures (Select All That Apply): Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E28.310 | Symptomatic premature menopause
I10 | Essential (primary) hypertension
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Hot flashes.
Reason for Visit (Check at least one): Chronic Care
Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
M81.8 | Other osteoporosis without current pathological fracture
Patient Age: 58 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Lab results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 06/01/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments: Referral for Pelvic Ultrasound.
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "Pelvic Pain."
Reason for Visit (Check at least one): Episodic (Acute Care)
Gynecologic Care
Procedure: Urine collection, Venipuncture
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 05/25/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 66 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Refill.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 05/25/2022
Rotation Type: NSG6430 - FNP Women's Health
Comments:  
Diagnostic Codes: E78.1 | Pure hyperglyceridemia
I10 | Essential (primary) hypertension
M54.9 | Dorsalgia, unspecified
Patient Age: 70 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up (Consult)
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
NSG6430
View

Academic Service:
Case Log as of 3/17/2021
Date: 05/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Psa, CBC, CMP, LP, EKG, Urinalysis, Referral for Renal US, HbA1C, Fundoscopy, Thyroid- Stimulating Hormone, T3, T4.
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 69 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Fatigue.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urinalysis, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J30.9 | Allergic rhinitis, unspecified
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I'm here for my allergies"
Reason for Visit (Check at least one): Episodic (Acute Care)
New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 35 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Fever and malaise.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: S93.492A | Sprain of another ligament of left ankle, initial encounter
Patient Age: 26 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Left ankle pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Neck pain started yesterday, moving head side to side makes it worse.
Diagnostic Codes: M54.2 | Cervicalgia
Patient Age: 51 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: neck pain
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Diabetes medication refill.
Reason for Visit (Check at least one): Chronic Care
Procedure: Nutritional status. Wellness/health maintenance coaching. Urine collection, Venipuncture
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F32.2 | Major depressv disord, single epsd, sev w/o psych features
Patient Age: 31 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Headache.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M16.10 | Unilateral primary osteoarthritis, unspecified hip
Patient Age: 63 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Medication refills.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: T81.4XXD | Infection following a procedure, subsequent encounter
Patient Age: 47 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Wound drainage.
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: K59.09 | Other constipation
K64.8 | Other hemorrhoids
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Bloody stools.
Reason for Visit (Check at least one): Episodic (Acute Care)
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Burning urination.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 05/19/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
L03.90 | Cellulitis, unspecified
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Thigh pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.59 | Type 2 diabetes mellitus with oth circulatory complications
L97.401 | Non-prs chr ulcer of unsp heel and midft lmt to brkdwn skin
Patient Age: 62 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Heel pain.
Reason for Visit (Check at least one): Chronic Care
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 70 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Nutritional status. Wellness/health maintenance coaching. Urine collection and Venipuncture
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 18 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: sore throat
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 21 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Coughing.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: G43.101 | Migraine with aura, not intractable, with status migrainosus
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Headache.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Wellness/health maintenance coaching
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
Z71.3 | Dietary counseling and surveillance
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Lab results.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
M54.5 | Low back pain
Patient Age: 52 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Back pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: lab results
Reason for Visit (Check at least one): Annual/Well Person Exam
Sports Physical
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/18/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.65 | Type 2 diabetes mellitus with hyperglycemia
I10 | Essential (primary) hypertension
Patient Age: 57 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: COLLECTION, VENOUS BLOOD, VENIPUNCTURE
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.29 | Type 2 diabetes mellitus w oth diabetic kidney complication
E66.01 | Morbid (severe) obesity due to excess calories
I10 | Essential (primary) hypertension
K59.00 | Constipation, unspecified
Patient Age: 55 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cerumen Disimpaction
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Counseling about diet and drinking cessation.
Diagnostic Codes: K29.00 | Acute gastritis without bleeding
Patient Age: 39 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Burning sensation in the stomach.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Endocrinology referral stat for uncontrolled diabetes.
Diagnostic Codes: E11.65 | Type 2 diabetes mellitus with hyperglycemia
J01.10 | Acute frontal sinusitis, unspecified
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Facial pain/pressure.
Reason for Visit (Check at least one): Chronic Care
Episodic (Acute Care)
Procedure: Wellness/health maintenance coaching,
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F31.30 | Bipolar disord, crnt epsd depress, mild or mod severt, unsp
I10 | Essential (primary) hypertension
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: B96.81 | Helicobacter pylori as the cause of diseases classd elswhr
Patient Age: 37 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 14 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: cough and fever.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M54.9 | Dorsalgia, unspecified
Patient Age: 54 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Back pain,
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: H81.393 | Other peripheral vertigo, bilateral
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Dizziness.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/12/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: K52.89 | Other specified noninfective gastroenteritis and colitis
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Diarrhea.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Stool culture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E66.01 | Morbid (severe) obesity due to excess calories
I10 | Essential (primary) hypertension
Patient Age: 68 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: R51 | Headache
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Headache.
Reason for Visit (Check at least one): New Admittance
New Consultation
Procedure: Ophthalmoscopy, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: L60.0 | Ingrowing nail
Patient Age: 35 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Scheduled Procedure
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Ingrown Toenail Removal
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: THYROID HORMONE (T3/T4). THYROID STIMULATING HORMONE (TSH). BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC. ULTRASOUND, HEAD/NECK TISSUES, REAL TIME W/IMAGE DOCUMENTATION.
Diagnostic Codes: E07.9 | Disorder of thyroid, unspecified
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Asian
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Fatigue.
Reason for Visit (Check at least one): New Admittance
New Consultation
Procedure: Venipuncture, referral for USG.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: K21.0 | Gastro-esophageal reflux disease with esophagitis
Patient Age: 47 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Acid reflux.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E03.9 | Hypothyroidism, unspecified
E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 58 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: H10.33 | Unspecified acute conjunctivitis, bilateral
Patient Age: 27 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: red, itching eyes.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: N20.9 | Urinary calculus, unspecified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/11/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 52 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Blood pressure
Reason for Visit (Check at least one): Chronic Care
New Admittance
Procedure: Nutritional status. Wellness/health maintenance coaching. Urine collection Venipuncture
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: H61.23 | Impacted cerumen, bilateral
Patient Age: 55 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Trouble hearing.
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Cerumen Disimpaction
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: Z71.2 | Person consulting for explanation of exam or test findings
Patient Age: 33 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: lab results.
Reason for Visit (Check at least one): Annual/Well Person Exam
Follow-up (Consult)
Sports Physical
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.8 | Type 2 diabetes mellitus with unspecified complications
E66.01 | Morbid (severe) obesity due to excess calories
I10 | Essential (primary) hypertension
J45.20 | Mild intermittent asthma, uncomplicated
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Medications refill.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Venipuncture, urine collection.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Peak Flow Meter
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: K35.80 | Unspecified acute appendicitis
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 56 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Hypertension.
Reason for Visit (Check at least one): Chronic Care
New Admittance
Procedure: Venipuncture for CMP, CBC, LP. Urine Collection.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: R19.7 | Diarrhea, unspecified
Patient Age: 9 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: " My child have soft stools"
Reason for Visit (Check at least one): New Admittance
Procedure: CBC, Stool Culture,
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.621 | Type 2 diabetes mellitus with foot ulcer
E78.0 | Pure hypercholesterolemia
I10 | Essential (primary) hypertension
Patient Age: 64 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Follow-up diabetes.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Venipuncture, Urine collection.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
I10 | Essential (primary) hypertension
K59.00 | Constipation, unspecified
K64.9 | Unspecified hemorrhoids
Patient Age: 53 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: blood in stool.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/05/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
J45.30 | Mild persistent asthma, uncomplicated
Patient Age: 23 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Cough.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Peak Flow Meter
Spirometry in office
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: B36.0 | Pityriasis versicolor
I10 | Essential (primary) hypertension
Patient Age: 30 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: skin rash.
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: A59.09 | Other urogenital trichomoniasis
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Vaginal itching.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
M06.09 | Rheumatoid arthritis w/o rheumatoid factor, multiple sites
Patient Age: 57 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: Hispanic, daughter that accompanied her to the clinic said that patient just lost her husband a couple weeks back, patient suddenly stopped eating, cries all the time, hardly sleeps and always wants to be left alone. PMHx. includes elevated blood sugar as a result of non compliance in checking blood sugar or taking her medication (metformin 1000 mg Po BID), A1C 8.9 acute depression and grief from the loss of her husband. Denies any desire of killing herself or wanted to die.
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
F32.9 | Major depressive disorder, single episode, unspecified
Patient Age: 60 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: No appetite.
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
S33.8XXA | Sprain of oth parts of lumbar spine and pelvis, init encntr
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Back pain
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M10.09 | Idiopathic gout, multiple sites
M15.0 | Primary generalized (osteo)arthritis
Patient Age: 66 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: BLE pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture (Done).
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Nebulizer was prescribed for patient; was educated on how to use it.
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
J43.9 | Emphysema, unspecified
Patient Age: 50 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: shortness of breath.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Screen for tobacco use.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Spirometry in office
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F31.9 | Bipolar disorder, unspecified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Needs refill.
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 05/04/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC.
Diagnostic Codes: G40.309 | Gen idiopathic epilepsy, not intractable, w/o stat epi
I48.91 | Unspecified atrial fibrillation
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Asian
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture (Done
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presenting with difficulty walking do to increase swollen and pain to BLE x 3 days.
Diagnostic Codes: I50.9 | Heart failure, unspecified
Patient Age: 77 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Leg pain.
Reason for Visit (Check at least one): Chronic Care
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
J44.0 | Chronic obstructive pulmon disease w acute lower resp infct
S86.811A | Strain of musc/tend at lower leg level, right leg, init
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Body pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F33.3 | Major depress disorder, recurrent, severe w psych symptoms
G47.00 | Insomnia, unspecified
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: sleeping problems
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: D63.8 | Anemia in other chronic diseases classified elsewhere
E78.0 | Pure hypercholesterolemia
I10 | Essential (primary) hypertension
M25.511 | Pain in right shoulder
Patient Age: 50 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Shoulder pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M79.669 | Pain in unspecified lower leg
R05 | Cough
Z87.898 | Personal history of other specified conditions
Patient Age: 64 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Leg pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Screen for tobacco use.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Spirometry in office
Academic Service:
Case Log as of 3/17/2021
Date: 04/28/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Pt need screen for work. Tb screening redone because he did not make it back for reading, denies fever, chills, cough or headaches
Diagnostic Codes: Z11.1 | Encounter for screening for respiratory tuberculosis
Patient Age: 33 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: TB test.
Reason for Visit (Check at least one): New Consultation
Procedure: TB Skin test.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/26/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: F/U insulin presenting with shakiness, blurred vision, fatigue, nervousness, diaphoretic after he started taking lispro insulin around a month ago. Pt stated sometimes I experienced these symptoms after I eat and take the 12 units of lispro insulin. He was in insulin 70/30 but due to insurance purpose he needed to change insulins PMHx. Diabetes taking metformin 500 mg PO BID. Lantus 40 units SQ. BS this morning 128. Refer to podiatrist Doctor and draw blood for A1C. advise to take BS if symptoms continue. Last eye exam 02/2022, colon screen 2021 and it was neg.
Diagnostic Codes: E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unsp
E16.1 | Other hypoglycemia
Patient Age: 66 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Shakey.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 04/26/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 49 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Elevated blood pressure.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/26/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J06.9 | Acute upper respiratory infection, unspecified
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Sore throat
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Cough.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Spirometry in office
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Adherence Issues with Medications: Complexity/demands of treatment. Denial of need. Forgetfulness. Knowledge deficit.
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
K58.9 | Irritable bowel syndrome without diarrhea
R10.9 | Unspecified abdominal pain
Patient Age: 66 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: abdominal pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: S93.692A | Other sprain of left foot, initial encounter
Patient Age: 35 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: foot pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M54.9 | Dorsalgia, unspecified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Back pain.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: A54.00 | Gonococcal infection of lower genitourinary tract, unsp
Patient Age: 25 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: penile discharge
Reason for Visit (Check at least one): Episodic (Acute Care)
New Consultation
Procedure: Urine collection. Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Refer to podiatrist Doctor and draw blood.
Diagnostic Codes: E11.621 | Type 2 diabetes mellitus with foot ulcer
L97.401 | Non-prs chr ulcer of unsp heel and midft lmt to brkdwn skin
Patient Age: 72 Years
Patient Sex: M
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Heel ulcer.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Diabetic Foot Care
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: G40.909 | Epilepsy, unsp, not intractable, without status epilepticus
Patient Age: 38 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Blood work and annual physical.
Reason for Visit (Check at least one): Annual/Well Person Exam
New Consultation
Screening/Health Promotion
Procedure: Venipuncture (Done).
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: sharp pain with pressure to left heel started a week ago, its worse in the morning. I'm a waiter work 6 days a week. Hx. diabetes taking metformin 1000 mg PO BID. BS this morning 125.
Diagnostic Codes: M72.2 | Plantar fascial fibromatosis
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Left heel pain
Reason for Visit (Check at least one): Chronic Care
Episodic (Acute Care)
Procedure: Wellness/health maintenance coaching, Nutritional status, Diabetic consultation
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/25/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
M10.00 | Idiopathic gout, unspecified site
Patient Age: 60 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 25%
Chief Complaint: Knee soreness.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F32.8 | Other depressive episodes
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: No appetite
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
M06.9 | Rheumatoid arthritis, unspecified
Patient Age: 62 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Shoulder pain.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: A59.9 | Trichomoniasis, unspecified
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: vaginal itching
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: A 46 year old Hispanic man presented to the clinic for a routine checkup and to discuss the result of the lab work done last week. Last week he verbalized experiencing shortness of breath lately especially with exercise, like when using the treadmill or climbing a flight of stairs. Patient had a complete Physical last week including blood work. This was his first Physical Exam in over 8 years. Majority of his blood work showed stats that were all within normal parameters except for his lipid panel which showed a total cholesterol level of 290, a low density lipoprotein (LDL) level of 202, a high density lipoprotein (HDL) level of 32, and a triglyceride level of 400. PMHx none. Social Hx. He likes to eat fast food, , regular outdoor activities, actively involved in his community, volunteers at a church shelter in his area. Patient denies smoking or use of street drugs, but stated that he usually has a bottle of beer with his evening meal, and occasional glass of wine at party's maybe once a month or even less. ROS: reviewed O: VS- BP 115/80 HR 85 RR 22 H 175 cm W 173 lbs. BMI 25.5 General Survey: Well-nourished appears stated age. Neurological A/Ox3. Normal sensation to touch. HEENT: PERRLA. EOMI. No carotid bruits. Fundi: No exudates, hemorrhages or papilledema Respiratory: Bilateral clear to auscultation. Heart: Normal S1 and S2. No rubs, gallops, or murmurs GI: Rotund, non-tender. Normal bowel sounds. A/DX: Hypertriglyceridemia
Diagnostic Codes: E78.1 | Pure hyperglyceridemia
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: LAB RESULT
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F31.9 | bipolar disorder, unspecified
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Medication refill
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: present with skin rash to neck, rt side Abd and back very itched when is hot x 7 months. Denies any food allergic. Also needs refill for diabetes metformin 500 PO BID. BS this morning 115 per patient.
Diagnostic Codes: B36.0 | Pityriasis versicolor
E11.9 | Type 2 diabetes mellitus without complications
Patient Age: 43 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Skin rash.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J20.9 | Acute bronchitis, unspecified
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Cough.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Spirometry in office
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 04/20/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: follow-up on blood pressure and medication refill. She has been in the Philippines the last few months and had run out of her medications. The patient states that she has been noticing occasional red blood in the in the toilet after having a bowel movement and at the toilet paper for the past year. She states that she usually uses Preparation-H for her hemorrhoids but had recently run out. She's not sure if she is having hemorrhoidal bleeding. She denies ever having a colonoscopy. P: Refer to proctologist for evaluation. (Refer to GI for colonoscopy) Continue plan of care for hypertension. Patient education: Eat high-fiber diet with adequate fluids. Avoid constipation or straining on toilet.
Diagnostic Codes: I10 | Essential (primary) hypertension
K64.9 | Unspecified hemorrhoids
Patient Age: 46 Years
Patient Sex: F
Patient Ethnicity: Asian
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: blood in stool
Reason for Visit (Check at least one): Chronic Care
Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: for follow-up for diabetes. The patient come in to have a physical exam. Her last visit was 6 months ago. The patient states that she is feeling fine with no problems with her medications except for running out. Labs: CBC w/ diff., CMP, lipid panel, plasma glucose, hgbA1c, UA. Return back in 2 days to review results and evaluate plan of care. Patient education: Eat nutritious meals, limit carbohydrates intake. Exercise regularly. Assess feet regularly
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E78.0 | Pure hypercholesterolemia
M15.0 | Primary generalized (osteo)arthritis
Patient Age: 66 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Urine collection (Done). Venipuncture (Done)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presents to the clinic complaining of easy fatigability, increased thirst, and increased urinary frequency. He also complains of weight gain, where he has gained 17 lbs. from him last visit 1 month ago. The patient states that he was under the assumption that his diabetes was controlled. He states he felt good and voluntarily stopped his medication several months ago. He is concerned all of his new symptoms are related to his diabetes
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Fatigue and weight gain,
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Wellness/health maintenance coaching (Done), Venipuncture (Done), Urine collection (Done).
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: complaining of 2-day history of fever, chills, and chest pain. She also complains of headache and a cough that makes the chest pain worse.
Diagnostic Codes: J15.9 | Unspecified bacterial pneumonia
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Fever, chills, cough and chest pain
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): EKG Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: He had one episode of severe left-sided abdominal pain 3 days ago. He states that it was the first time he had the pain, and it was severe enough for him to call an ambulance to take him to the emergency room. He states that he had an abdominal ultrasound in the E.R. and was diagnosed with kidney stones. Per the patient he was given medications to dissolve the stones and for pain. Currently he rates the left-sided abdominal pain a 3 on the 0-10 pain scale, aching in character with no nausea and no vomiting. He is requesting a referral to see a urologist. Hx.
Diagnostic Codes: N20.9 | Urinary calculus, unspecified
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
New Consultation
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: H10.33 | Unspecified acute conjunctivitis, bilateral
Patient Age: 32 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Red, itching eyes.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Ophthalmoscopy.
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Follow-up on routine blood work from 04/04/2022. Patient states he is feeling fine and has no problems with his medications. Lab results reveal a FBS= 288, HgBa1c= 7.5, and TSH= 0.22L. Patient states he does not exercise as much as he'd like and denies consuming large amounts of carbohydrates
Diagnostic Codes: E03.9 | Hypothyroidism, unspecified
E11.9 | Type 2 diabetes mellitus without complications
Patient Age: 44 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Elevated blood sugar
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: T07 | Unspecified multiple injuries
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Asian
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Rashes
Reason for Visit (Check at least one): Annual/Well Person Exam
New Consultation
Procedure: Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: complaining of a 1-month history of right-sided abdominal pain. She rates the pain a 4 on the 0-10 pain scale and describes it as a constant burning and sharp at times. She states that it worsens with prolonged sitting, where she'll get up to walk around and the pain will be alleviated. At night she will lay on her right side to ease the pain as well. She states eating does not make the pain better or worse. She denies fever, nausea, or vomiting. She denies diarrhea but admits to constipation requiring a laxative about once a week. She states she had a cholecystectomy last year with no complications
Diagnostic Codes: I10 | Essential (primary) hypertension
R10.11 | Right upper quadrant pain
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: referral for USG.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/14/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E78.0 | Pure hypercholesterolemia
K21.0 | Gastro-esophageal reflux disease with esophagitis
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Acid reflux
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Nutritional status (Done), Wellness/health maintenance coaching (Done).
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presents to the clinic with chief complaint of easy fatigability for the last month. She states that she has no energy and tires out over the simplest tasks such as walking or running small errands. She has been noticing tremors in the morning and has lost 10 pounds in the last 2 months without change in diet or an effort to lose weight. She denies vision changes or palpitations. She denies any changes in bowel symptoms or ankle swelling. She voices concern over having a goiter but denies difficulty swallowing or voice changes. HEENT: Bilateral peri-orbital edema. NECK: Enlarged thyroid gland Respiratory: Bilateral clear to auscultation. Heart: Normal S1 and S2. No rubs, gallops, or murmurs GI: Soft, non-tender. Normal bowel sounds. Musculoskeletal: Full ROM all extremities. + DTRs all extremities A/DX: R/O Hyperthyroidism RX: none P: Labs: TSH, T4, T3, CBC. Imaging: Refer for thyroid ultrasound. Return in 3 days to follow-up on lab results
Diagnostic Codes: E07.9 | Disorder of thyroid, unspecified
Patient Age: 49 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up
Reason for Visit (Check at least one): New Consultation
Procedure: Venipuncture (Done). referral for USG.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.311 | Type 2 diabetes w unsp diabetic retinopathy w macular edema
I10 | Essential (primary) hypertension
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: Asian
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: pre-op
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Urine collection (Done), Venipuncture (Done)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
R51 | Headache
Patient Age: 79 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Headache.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: Patient presenting with a surgery clearance request. He is scheduled to have a right total hip replacement on March 18th with Dr. Peterson at Pacific Alliance Medical Center. He complains of right hip pain with walking, and he uses a cane on a daily basis. He denies chest pain or shortness of breath. Denies snoring. No known drug allergies. Taking aspirin 81 mg PO QD, Lisinopril 20 mg PO QD ROS: reviewed O: VS- BP 132/82, HR 80, RR 18, T 98.9F. Ht 73.5 in, Wt 198 lbs. General Survey: Well-nourished appears stated age. Sitting comfortably in chair and answering questions appropriately HEENT: Normocephalic, atraumatic, no lesions noted. Pink mucosa, no tonsillar-pharyngeal congestion/selling/exudates. No lesions, tenderness, discharges to ears, (-) tragus sign. Septum appears normal without deviation. No lesions, exudates, discharges. SKIN: warm and dry to touch Respiratory: Bilateral clear to auscultation Heart: Normal S1 and S2. No rubs, gallops, or murmurs GI: Soft, non-tender. Normal bowel sounds. Neurologic: AAX3 Musculoskeletal: Decreased ROM to right hip. A/DX: Right hip pain, Hypertension RX: cont. with current meds for now. P: Diagnostic tests: EKG, chest-x-ray, Labs: CBC, CMP, lipid panel, UA. Return to office in 3 days to discuss results
Diagnostic Codes: M25.551 | Pain in right hip
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Hip surgery.
Reason for Visit (Check at least one): Scheduled Procedure
Procedure: Urine collection (Done), Venipuncture (Done). Nutritional status (Done)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Follow up in 2 weeks, sooner if symptoms worsen.
Diagnostic Codes: H81.393 | Other peripheral vertigo, bilateral
K52.89 | Other specified noninfective gastroenteritis and colitis
Patient Age: 26 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: dizziness
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urine collection, venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: M54.9 | Dorsalgia, unspecified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Back pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Nutritional status (Done), Wellness/health maintenance coaching (Done)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presented to the clinic today with a cc of burning, urgency and whitish penile discharge x 1 week. He has been having the frequency to go to the rest room even more than before. He has multiple sexual partners; he has been feeling uncomfortable and feverish x 3 days. He denied nausea, vomiting or loss of appetite, no itching. No headache ROS: reviewed O: VS- - T 99.9; P 87; R 16; BP 118/78; BMI 25 General Survey: Well-groomed, well-developed normal weight young man, appeared stated age and in no apparent distress. Respiratory: Symmetrical chest expansions, clear bilaterally to auscultation, no adventitious sounds Heart: S1, S2 heard, no murmurs, gallops or bruits. GI: Flat, non-tender. BS normoactive. GU: Whitish penile discharge on milking, no odor, no redness. No lesions Circumcised male. No groin lymphadenopathy. A/DX: Gonorrhea RX: Rocephin 250mg with 2cc lidocaine IM Azithromycin 1g PO once P: Condoms, Labs - VDRL/HIV, UA, STD counseling Encourage patient to inform sexual partners to get treated to avoid recurrence.
Diagnostic Codes: A54.00 | Gonococcal infection of lower genitourinary tract, unsp
Patient Age: 30 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Penile discharge.
Reason for Visit (Check at least one): Episodic (Acute Care)
New Admittance
New Consultation
Procedure: Nutritional status (Done), Urine collection (Done), Venipuncture (Done), Wellness/health maintenance coaching (Done).
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presented to the clinic with the complains of coughing everyday x 2 weeks. She has taken Dayquil but no improvement. She has some green thick mucus with every cough, she denies vomiting, nausea, diarrhea or lost of appetite. She has a slight fever few days ago. Does not drink, smoke or use any illicit drug ROS: reviewed O: VS-: Vital signs- T 99.5; P 87; R 19; BP 136/86; BMI 26 General Survey: Well-groomed, well-developed normal woman, appeared to be in mild discomfort HEENT: Normocephalic, no lesion, no mass, no tenderness, PERRLA, EOMI, no cervical lymphadenopathy, throat with erythema and exudate , nontender maxillary sinuses. Whispered words heard bilaterally, pearly gray tympanic membrane, trachea midline, pink palpebral conjunctivae, anicteric sclera, no discharge. Nose is clear, no discharge Respiratory: (+) productive green cough, symmetrical chest expansions, clear bilaterally to auscultation, no adventitious sounds Heart: S1, S2 heard, no murmurs, gallops or bruits, no edema GI: + BS A/DX: Acute Bronchitis Acute Pharyngitis RX: Betamethasone 4mg/1mL, 2 mL IM now Z- pack 250 mg PO 2 tabs first dose than 250 mg 1 Tab PO x 3 days Motrin 600 mg Take one tablet PO TID times a day PRN fever, take it with food P: Strep throat culture. Medication compliance - complete course of antibiotics Increase fluid and rest. Follow up in 2 weeks, return sooner if symptoms worsen
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
J20.9 | Acute bronchitis, unspecified
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: COUGH.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Injection (IM), Nutritional status (Done). Wellness/health maintenance coaching (Done).
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Spirometry in office
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 04/13/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presented to the clinic today accompanied by her daughter, complaining of "my stomach hurts right now, feels gassy and nervous now" pain sometimes id after eating and sometimes before eating. She has been having this anxiety for a week. Patient denies any nausea, vomiting had 2 bowel movements today, and feels like she lost her appetite ROS: reviewed O: VS T 98.9; P 88; R 19; BP 142/69; BMI 28.9 General Survey: Well-groomed, obese woman appeared to be in mild discomfort, guarding her stomach with one hand Respiratory: symmetrical chest expansions, clear bilaterally to auscultation, no adventitious sounds Heart: S1, S2 heard, no murmurs, gallops or bruits, no edema, cap refill < 3 seconds GI: (+) distended, tenderness to epigastric region with deep palpation, hyperactive BS in all 4 quadrants A/DX: Gastritis r/o H Pyloric RX: Omeprazole 40 mg PO for 4 weeks P: Labs: CBC, CMP, H. Pyloric UB Test, avoid sugar drinks, avoid spice, irritant foods Clear liquid diet for now, advance as tolerate, Avoid NSAIDS Return in 2 weeks for lab results or sooner if symptoms worsen
Diagnostic Codes: B96.81 | Helicobacter pylori as the cause of diseases classd elswhr
E66.09 | Other obesity due to excess calories
K52.89 | Other specified noninfective gastroenteritis and colitis
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Abdominal pain
Reason for Visit (Check at least one): New Consultation
Procedure: VENIPUNCTURE FOR COMPREHENSIVE METABOLIC PANEL, BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC, ANTIBODY; HELICOBACTER PYLORI.
Skills/Procedures (Select All That Apply): EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presents to the clinic complaining of right abdominal pain with loss of appetite, diarrhea, for 1 week; too fatigue to go to work today.
Diagnostic Codes: K52.89 | Other specified noninfective gastroenteritis and colitis
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Venipuncture, Urine collection (Done). Wellness/health maintenance coaching (Done).
Skills/Procedures (Select All That Apply): Long-Term Contraceptive Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: presents to the clinic complaining of right eye redness and pain, 2 nights ago while he was working in his car and felt something got into his right eye, he washed eye profusely with water. Today he still complaining of redness and pain, no blurred vision or any vision changes, does not feel a foreign object in his eye. ROS: reviewed O: Vital sign- T 97.8; P 82 ; R ; BP 132/78; O2:98 % RA ; BMI: 36 General Survey: Well-developed, well-nourished young man in mild distress HEENT:EYES: sclera reddened, conjuctivae swelling, yellow discharge,PERRLA, EOMI, no lesion or mass observed in mouth, no cervical lymphadenopathy, throat without erythema or exudate, nontender maxillary sinuses Respiratory:Symmetrical chest expansions, bilaterally to auscultation, no adventitious sounds Heart:S1, S2 heard, no murmurs, gallops or bruits. Neurologic:AAOX3 A/DX: RX:Conjunctivitis P: Tobramycin Ophthalmic instill 2 drops to right eye every 4 hours for 7 days. tylenol 650 mg PO BID PRN pain Implement good hand washing to avoid effection of left eye. Do not use same tissue for both eyes If burning, pain, itching or increase redness stop eye drops and notify FNP. Follow up in 2 weeks or sooner if symptoms worsen
Diagnostic Codes: H10.33 | Unspecified acute conjunctivitis, bilateral
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Right eye pain
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Wellness/health maintenance coaching (Done).
Skills/Procedures (Select All That Apply): Exam of Eye for Foreign Body
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: complaining of a 4-day history of headache, fever, left-sided abdominal pain and diarrhea She presented to the ER yesterday and was diagnosed with viral syndrome and given medications: Bentyl, Lomotil, Zofran and IV fluids before being sent home. She rates the headache and abdominal pain a 5 on the 0-10 pain scale and states that they are both aching in nature. She denies nausea, vomiting, or diarrhea. Denies shortness or breath or chest pain. Afebrile.
Diagnostic Codes: B97.89 | Oth viral agents as the cause of diseases classd elswhr
I10 | Essential (primary) hypertension
Patient Age: 56 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Headache, fever, Abdominal pain, and diarrhea
Reason for Visit (Check at least one): Chronic Care
Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: Difficulty breathing when walking and swollen legs for 3 weeks. He notices the swelling subsides when he sleeps and get worse when he is standing. He complains frequent coughing when lying at night. Patient has no complaints of chest pain PMH: HTN ROS: reviewed O: VS: BP 148/74 HR 97 RR 25 T 98.7 F W 154 Lbs. H 5'5" MBI 24.1 General Survey: looks well nourish, HEENT: normocephalic, pupils Perla, nose clear no redness noted, tonsil normal. Lymph nodes nonpalpable Skin: warm and dry to touch Respiratory: breath sounds, crackles bilateral, no wheezing, resonance Heart: Right jugular vein distention, Normal rate and rhythm, s1 s2, normal rate and rhythm. Right jugular vein distention. GI: + bowel sound Musculoskeletal: Extremities - Pitting edema 2 + to bilateral lower extremities, pulses 1+ of lower extremity, 2+ pules of upper extremity, no cyanosis, no clubbing, range of motion intact, pulses , normal range of motion Neurologic: AOX3, no facial drop noted, or slurred speech A/DX: Heart Failure and d hypertension Rx: Lasix 20 mg PO QD P:F/U in 2 weeks. CBC, CMP, BNP, EKG. Low salt, restricted liquid diet, exercise as tolerated. The patient is taught to elevate both legs when sitting and sleeping. Support stocking may be worn to reduce edema. Health teachings also includes daily weight to assess for increase water weight,, avoidance of smoking and alcohol intake. Continue with Lisinopril 20 mg
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 68 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Difficulty breathing and swollen leg.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: lads results, upon reviewing her labs noted her A1C 9.9. Pt has a blister inside the nose and is painful, started to have some drainage. She has postnasal drip and severe sinus pressure x 3 days. Denies temp in the past PMH: allergic sinusitis, diabetes, insulin dependent Medications: Lantus 70/30 50 units SQ QD, Januvia 100 mg PO BID, loratadine 10 mg PO QD.Pt smokes every day x8 years 5 cigarettes a day ROS: reviewed O: VS: BP 135/78 HR 86 RR 17 Temp. 98.9 f General Survey: looks well nourish HEENT: normocephalic, pupils Perla, nasal sore, nostrils red, swollen and some yellow discharge noted. tonsil normal. Lymph nodes nonpalpable Skin: dry skin with some scabs to BLE Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds GI: + bowel sound A/DX: DM uncontrolled, acute sinus infection. P: C&S nares to R/O MRSA screen, endocrinology referral stat for uncontrolled diabetes. Discuss with patient about uncontrolled blood sugars and all Labs. Pt is aware. Cont. with same meds. Instructed the importance to take all medication as prescribe. Explained about Smoke cessation
Diagnostic Codes: E11.65 | Type 2 diabetes mellitus with hyperglycemia
J01.10 | Acute frontal sinusitis, unspecified
Patient Age: 52 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Nose pain.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Referral for GI. F/u in a month. Counseling about diet and drinking cessation.
Diagnostic Codes: K29.00 | Acute gastritis without bleeding
M54.09 | Panniculitis aff regions, neck/bk, multiple sites in spine
Patient Age: 67 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Collection, Venus blood, venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
J44.1 | Chronic obstructive pulmonary disease w (acute) exacerbation
K57.32 | Dvtrcli of lg int w/o perforation or abscess w/o bleeding
K59.09 | Other constipation
Patient Age: 49 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Abdominal pain.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: URINE COLLECTION, VENOUS BLOOD, VENIPUNCTURE.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/07/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.65 | Type 2 diabetes mellitus with hyperglycemia
Patient Age: 45 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Lab results.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Referral for CT of spine Dx muscle spasms and pain. Cont. with PT
Diagnostic Codes: M06.9 | Rheumatoid arthritis, unspecified
M54.05 | Panniculitis affecting regions of neck/bk, thoracolumbar region
R05 | Cough
Patient Age: 52 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Back pain/cough.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): EKG Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: severe neck pain with increased numbness and tingling of left arm x 2 days. Pain starts at the neck and goes down to my arm. Needs refills PMH: HTN, neck pain with radiculopathy, hypercholesteremia Medications: metoprolol tartrate 50 mg tablet PO QD. Atorvastatin 40 mg PO QD. Losartan 50 mg PO QD. Norco5-325 mg 1 tab BID PRN pain. Diclofenac sodium 75 mg PO BID ROS: reviewed O: VS: BP 123/68 HR 62 RR 18 W 333 H 65 in BMI 55.4 General Survey: patient looks obese HEENT: normocephalic, pupils Perla, nose clear no redness noted, tonsil normal. Lymph nodes nonpalpable Skin: no rash noted Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds GI: + bowel sound Musculoskeletal: normal ROM according to patient's age. Has difficulty bending over Neurologic: AOX3, no facial drop noted, or slurred speech A/DX: morbid obesity, hypertension, neck pain with radiculopathy, hypercholesteremia Rx: Metoprolol tartrate 50 mg tablet PO QD. Atorvastatin 40 mg PO QD. Losartan 50 mg PO QD. Norco5-325 mg 1 tab BID PRN pain. Diclofenac sodium 75 mg PO BID P: refilled all meds, referral for physical therapy for neck pain. Cont. with all medications as prescribed
Diagnostic Codes: E66.01 | Morbid (severe) obesity due to excess calories
E78.0 | Pure hypercholesterolemia
I10 | Essential (primary) hypertension
M54.02 | Panniculitis affecting regions of neck/bk, cervical region
Z71.3 | Dietary counseling and surveillance
Patient Age: 38 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Neck pain.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: G43.101 | Migraine with aura, not intractable, with status migrainosus
Patient Age: 20 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Headache.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J11.1 | Flu due to unidentified influenza virus w oth resp manifest
Patient Age: 29 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Coughing.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Spirometry in office
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: sore throat x 3 days with cough, green thick sputum, denies any fever or earache. Also needs Advair medication PMH: Asthma ROS: reviewed O: VS: BP 118/80 HR 68 RR 22 T 98.9 F General Survey: looks well nourish HEENT: normocephalic, pupils Perla, nose clear no redness noted, tonsil slightly swollen and red. Lymph nodes no palpable Skin: no rash noted Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds GI: + bowel sound Musculoskeletal: normal ROM A/DX: tonsillitis
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
J45.22 | Mild intermittent asthma with status asthmaticus
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Sore throat.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Spirometry in office
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
E78.0 | Pure hypercholesterolemia
I10 | Essential (primary) hypertension
S14.9XXS | Injury of unspecified nerves of neck, sequela
Patient Age: 79 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Left side neck pain.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
L97.401 | Non-prs chr ulcer of unsp heel and midft lmt to brkdwn skin
Patient Age: 49 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Right heel pain
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Diabetic Foot Care
Immunizations
Lab Studies Interpretation
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 04/06/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Left Wrist pain started 3 weeks ago it comes with numbness, tingling, needles and sometimes my wrist lock. At took Motrin over the counter and it help just little bit. She works with computers entering data x 5 years. Her BS this morning was 109 PMH: Diabetes x 15 years Medications: Metformin 500 mg PO BID. Referral to endocrinology. 
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
G56.90 | Unspecified mononeuropathy of unspecified upper limb
Patient Age: 68 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Left wrist pain
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: dizziness, light headedness, nausea, vomiting lasting for a few minutes, come and go. x 4 days. Pt denies any vision changes, hearing loss, temperature, leg or arm weakness, trouble speaking, difficulty walking, or loss of consciousness.
Diagnostic Codes: H81.392 | Other peripheral vertigo, left ear
I10 | Essential (primary) hypertension
Patient Age: 75 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Dizziness
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: G89.29 | Other chronic pain
N39.0 | Urinary tract infection, site not specified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Underinsured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Burning urination.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Urinalysis.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: Rt wrist pain after it was twisted 5 days ago. Feeling a popping in the wrist. It's more painful when I move my hand. "I took Tylenol but it dint help me." Musculoskeletal: pulses present. Rt wrist slightly swollen able to move fingers, cap refill < than 3 sec. fingers warm to touch, pulses present A/DX: muscle sprain Rx: Ibuprofen 600 mg PO TID PRN pain P: referral for wrist X-ray. Keep Rt hand immobilize
Diagnostic Codes: S66.911A | Strain of unsp musc/fasc/tend at wrs/hnd lv, r hand, init
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: wrist pain
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Wrist pain.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: LT ear pain x 2 days, difficult hearing, some drainage at ear T max 100.0 F yesterday, denies any running nose. BS 126 PMH: diabetes and takes Januvia 100 mg PO QD ROS: reviewed O: VS: BP 138/80 HR 82 RR 18 T 98.9 F General Survey: looks well nourish HEENT: normocephalic, ears drum red and some yellow drainage noted. pupils Perla, nose clear no redness noted, throat tonsil normal. Lymph nodes nonpalpable Skin: no rash noted Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds GI: + bowel sound Musculoskeletal: pulses present deep tendon reflexes intact. A/DX: otitis media Rx: Ibuprofen 600 mg PO TID PRN pain, Amoxicillin 500 mg Po TID x 10 days P: call within a week if you don't get better. Continue with diabetes medication.
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
H66.90 | Otitis media, unspecified, unspecified ear
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 8
Student Participation: 100%
Chief Complaint: Earache
Reason for Visit (Check at least one): Episodic (Acute Care)
Follow-up (Consult)
Procedure: Visual acuity (Done).
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Peak Flow Meter
Spirometry in office
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 11 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 75%
Chief Complaint: Sore throat.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
K64.8 | Other hemorrhoids
Patient Age: 75 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: bloody stools.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Wellness/health maintenance coaching and Nutritional status done.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CBC, CMP, LP, Left Breast Ultrasound (Ordered)
Diagnostic Codes: D24.2 | Benign neoplasm of left breast
Patient Age: 36 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Uninsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 75%
Chief Complaint: "I feel a small lump in my left breast"
Reason for Visit (Check at least one): New Consultation
Procedure: venipuncture for blood draw.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 03/31/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: N91.2 | Amenorrhea, unspecified
Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Underinsured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need to know if I'm pregnant"
Reason for Visit (Check at least one): New Consultation
Procedure: venipuncture for blood draw.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: Z00.00 | Encntr for general adult medical exam w/o abnormal findings
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I came for my well woman exam"
Reason for Visit (Check at least one): Annual/Well Person Exam
Gynecologic Care
New Admittance
Procedure: Breast exam. Venipuncture for blood draw
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: Z11.51 | Encounter for screening for human papillomavirus (HPV)
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: "I need a Papillomavirus test"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Immunizations
Pelvic Exam
Reproductive Health Screening/Management
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: headache s and very tired x 1 week, tenderness to scalp, neck and shoulder, aching, dull. She also worries about her job because she feels sick. Denies having desire of killing herself PMH: headaches, and depression. ROS: reviewed, HEENT: denies dizziness, double vision, running nose or earache O: General Survey: looks well nourish and stated age. Cries too easy, anxious VS: BP 110/70 HR 77 RR 20 Skin: no rash noted, skin warm and dry to touch Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds Musculoskeletal: pulses present deep tendon reflexes intact. A/DX: tension head, depression Rx: Venlafaxine 10 mg PO QD P: continue with Naproxen 500 mg 1 tab BID PRN pain, and Omeprazole 20 mg Po QD. Discontinue, Cyclobenzaprine HC 1 tab PO QHS PRN Gabapentin 300 mg PO QHS. Increase Venlafaxine to 10 mg PO QD Referral to counseling and Psychiatric. F/U in one week
Diagnostic Codes: F32.9 | Major depressive disorder, single episode, unspecified
R51 | Headache
Patient Age: 37 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: Headache.
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Follow-up (Routine)
Procedure: Wellness/health maintenance coaching
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: corn to LT fifth toe with pain, burning and itching since January 2022. Nothing makes it better some shoes make it worse. Podiatrist referral.
Diagnostic Codes: L85.1 | Acquired keratosis [keratoderma] palmaris et plantaris
Patient Age: 65 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: Pain to left fifth toe.
Reason for Visit (Check at least one): New Consultation
Screening/Health Promotion
Procedure: Venipuncture for blood draw.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
L44.8 | Other specified papulosquamous disorders
Patient Age: 52 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: Rash to knees and elbow.
Reason for Visit (Check at least one): Chronic Care
Episodic (Acute Care)
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 53 Years
Patient Sex: M
Patient Ethnicity: White
Insurance: Uninsured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Fallow up.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Lab Studies Interpretation
Prostate Examination
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Knee pain started 2 years ago it get worse when is cool or walk long distance, not related to work. Meloxicam 7.5 mg is not alleviating pain.
Diagnostic Codes: I10 | Essential (primary) hypertension
M15.9 | Polyosteoarthritis, unspecified
Patient Age: 65 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: knee pain.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Current medications: glyburide 5 mg 1tab. PO BID ROS: reviewed A/DX: diabetes Rx: metformin 500 mg1 tab. PO BID, glyburide 5mg 1 tab. PO BID P: discussed need for exercise, diet: high in fiber, low fat, low carbohydrates. CMP, lipid panel, A1C, UA. Referral to eye doctor. F/U in 1 month
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
Patient Age: 76 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Underinsured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Refills.
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Venipuncture, Urine collection.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/30/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: F32.8 | Other depressive episodes
I10 | Essential (primary) hypertension
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Asian
Insurance: Underinsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 100%
Chief Complaint: Medication refills for Blood pressure.
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Follow-up (Consult)
Procedure: BMI or Waist: Hip Ratio done, Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: PMH: patient is on Birth control pills
Diagnostic Codes: Z00.00 | Encounter for general adult medical exam w/o abnormal findings
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: ROUTINE.
Reason for Visit (Check at least one): Annual/Well Person Exam
Gynecologic Care
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Immunizations
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Podiatrist referral
Diagnostic Codes: T14.90 | Injury, unspecified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 75%
Chief Complaint: Right foot pain
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Immunizations
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: face and back rash X 4 months ago. Nothing makes them worse or better. LMP 3/14/22 normal, denies any weight gain ROS: reviewed Skin: denies any itching, pain or burning O: General Survey: looks well nourish VS: BP 110/70 HR 69 Skin: some pimples/papules on face and a few on back Respiratory: breath sound clear bilaterally Heart: no murmur, normal heart sounds A/DX: Acne Rx: benzoyl peroxide 1% lotion apply at night, clindamycin cream applies at nighttime P: exercise, try to avoid fatty foods, f/u in 2 weeks.
Diagnostic Codes: L70.8 | Other acne
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: face and back rash.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Blood work, pt. needs CMP, lipid panel, TSH, A1C and UA. VS: BP 140/90 HR 73 RR 22 Temp 98.2 F HEENT: no problems noted Lungs: breath sounds clear bilaterally Heart: normal heart sounds no murmurs GI: bowel sounds present Extremities: no edema noted A: HTN, diabetes, anxiety P: blood drawn. Continue with current medication for BP, diabetes and anxiety Buspirone 10 mg PO TID, glimepiride 2mg PO BID
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
F41.9 | Anxiety disorder, unspecified
R03.0 | Elevated blood-pressure reading, w/o diagnosis of htn
Patient Age: 47 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: blood work
Reason for Visit (Check at least one): Employment Physical
Procedure: Venipuncture. Urine collection.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC/HPI: present with Lt foot pain x 4 days, also needs med refill HX. hypertension, taking lisinopril, Lasix O: VS: BP- 136/88, HR- 98, RR- 18, T- 98.6 General: looks tired appears stated age HEENT: PERRLA, conjunctiva is pink with no cyanosis or redness, TM is pearly grey with no swelling or redness. moist mucus membrane. no problems with nose, throat and mouth. Respiratory: Bil breath sounds clear CV: S1, S2 normal no murmurs GI: NBS Musculoskeletal: There is presence of edema on patients' bilateral lower extremities, left foot is red and warm to touch., +1 peripheral pulses present. neg Homen's sign PLAN: Dx: cellulitis, hypertension, pain RX: levofloxacin 500 mg PO QD, Ibuprofen 600 mg PO BID PRN pain and her Lasix was increased to 40m PO q day. cont. with BP meds. f/u in 2 weeks.
Diagnostic Codes: I10 | Essential (primary) hypertension
L03.116 | Cellulitis of left lower limb
R52 | Pain, unspecified
Patient Age: 86 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Underinsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: leg pain.
Reason for Visit (Check at least one): Follow-up (Routine)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
Wound Management
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Bilateral feet swelling x 5 days, especially when standing for a long time. also, weakness and fatigue O: VS: BP- 158/102, HR- 98, T- 98.3, RR- 16 W: 221, H: 5"6 Skin/ extremities: BUE edema +1, pulses present, skin warm and dry to touch
Diagnostic Codes: F41.9 | Anxiety disorder, unspecified
I10 | Essential (primary) hypertension
M06.9 | Rheumatoid arthritis, unspecified
Patient Age: 91 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 100%
Chief Complaint: SWELLING FEET, AND FATIGUE.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Nutritional status, Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: F/U after surgery. Pt was discharged from the hospital 5 days after hernia repair. Pt verbalized having flatus but no bowel movement for almost a week now O: BP= 120/67, P= 69, R=20, T= 96.8 Pt was awake, alert and oriented to person, place and time. eyes PERRLA. CV: normal S1 S2 with no murmurs. Lungs: clear bilateral. Abdomen: round, soft and slightly tender due to recent surgery, presence of scar tissue formation at incision site, surgical wound was closed, stitches have been removed and no discharge was noted. BLE: Negative edema or cyanosis noted on all extremities. PLAN: DX. constipation laxative, stool softener, adequate fiber intake, promote and educate on more of fruits and vegetables. avoid strenuous exercises.
Diagnostic Codes: K59.09 | Other constipation
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: F/U after hernia surgery.
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Peak Flow Meter
Spirometry in office
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 03/24/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: medication refill. History of present illness includes HTN, DM II, O: VS: BP = 142/ 78, P= 88, T= 98.2, RR= 20 general: Patient was in no immediate distress. Pt was alert and oriented to person, place and time skin/ extremities: EDEMA + 1 bilateral lower extremities, +2 pedal pulses bilateral. skin warm and dry to touch, negative cyanosis Lungs were clear on auscultation bilateral. CV: S1, S2 heard without murmur. PLAN: DX: Hypertension, edema, and Diabetes CBC, METABOLIC PANEL, URINALYSIS. A1C RX: ASA 81 mg PO QD, Metformin 1000 PO BID, Benazepril 10 mg PO QD, Tramadol HCL 50 mg QID PRN pain
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
R60.9 | Edema, unspecified
Patient Age: 85 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Underinsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: Routine
Reason for Visit (Check at least one): Follow-up (Routine)
Procedure: Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cardiovascular Risk Assessment/Management
EKG Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: CC of an object in his left ear, and pain, sore throat and dry cough for the past 2 days. pain to be 8/10; he has never experienced this before. he denied any fever, nausea or vomiting. he does not smoke, use any illicit drug or drink no alcohol. No known allergy to food or drug. O: Vital sign- T 98.3; P 88; R 16; BP125/82; BMI 29.62 Well-developed, well-nourished, overweight young in mild distress HEENT: Blue-yellow object visible in ext auditory canal, no redness or swollen noted. normocephalic, pupils Perla, nose clear no redness noted, tonsil slightly red. Lymph nodes nonpalpable. thyroid non palpable CVS: S1, S2 heard, no murmurs, gallops or bruits. LUNGS: Symmetrical chest expansions, bilaterally to auscultation, no adventitious sounds ABDOMEN: Flat, non-tender. BS normoactive. NEURO: AOx3r SKIN: dry, warm to touch, good skin turgor A: foreign object middle of ear URI P: Cephalexin (Keflex) 500mg 2 cap Q6Hr x 7d days Sudafed 30mg Q 8 HR Motrin 600mg Q 8HR PRN pain Referral for surgical removal of object Lifestyle modification - diet and exercise
Diagnostic Codes: H74.8X1 | Other specified disorders of right middle ear and mastoid
J06.9 | Acute upper respiratory infection, unspecified
Patient Age: 27 Years
Patient Sex: M
Patient Ethnicity: White
Insurance: Uninsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 100%
Chief Complaint: object in right ear, pain, sore throat and dry cough X2 days.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: BMI or Waist: Hip Ratio, Nutritional status, FT (Pulmonary Function Test) interpretation
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cultures/Swabs/Wet Mount
Peak Flow Meter
Spirometry in office
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Female 45 y/o, c/o headaches, knee pain, and rash at knee and elbows. A headache is mainly on the back of his head. Pain is 5/10 on the scale 0/10 x 1 week. Knee pain is 2/10 when walking is 8/10 x2 years. He has had the rash on his knees and elbows x 2 years also. Pt is currently on benazepril 10 mg PO daily, Pravastatin 40 mg Po daily, and Meloxicam 40mg Po daily. She run out of medicine and not taking anything medication at this moment. Past Medical/Surgical History: constipation, hypertension, hyperlipidemia, and chronic knee pain. Family HX mother hypertension and diabetes and father died of stroke. ROS: reviewed O: VS 170/90, HR 93, RR 22, wight 190 Height 5'5" Skin- white patches at elbows and knees Respiratory: clear and equal breath sounds cardiac: NSR, no mummers Muscle skeletal- limit ROM to knees, but no edema noted pulses present A:1. HTN 2. Osteoarthritis 3. Psoriasis P: CMP and Lipid panel Tylenol #3 1 tab PO q8 PRN pain calcipotriol cream apply small amount BID for rash continue with benazepril and pravastatin teaching- the importance to take medication as prescribed, diet, and smoking cessation as well as moderate drinking.
Diagnostic Codes: I10 | Essential (primary) hypertension
L40.8 | Other psoriasis
M15.9 | Polyosteoarthritis, unspecified
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Underinsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 100%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Chronic Care
Sports Physical
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Lab Studies Interpretation
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: 50 y/o male, Asian. Medication refill Pt stated she stayed away from alcohol and tobacco since she started taking her medication and using her patch. Denies any adverse effect to the medication she is taking. Hx Depression, nicotine and Etoh abuse. taking Nicotine Patch 21 mg daily Pamelor (Nortriptyline) 25mg 1-tab QHS O: Vital sign- T 98.6; P 78; R 16; BP 132/82. Well dressed, well-developed, well-nourished young man, appeared stated age and in no apparent distress. Lungs: clear bilaterally CV: NSR, S1 S2 no murmur GI: NBS A: Nicotine Addiction ETOH Abuse Depression P: CBC UA CMP Nicotine Patch 21 mg daily Pamelor (Nortriptyline) 25mg 1-tab QHS - refill for 30 days Take medication as prescribed Return to clinic if condition gets worst. Follow -up in 6months
Diagnostic Codes: F32.5 | Major depressive disorder, single episode, in full remission
Z65.8 | Oth problems related to psychosocial circumstances
Z87.898 | Personal history of other specified conditions
Patient Age: 50 Years
Patient Sex: M
Patient Ethnicity: Asian
Insurance: Underinsured
Time with Patient (min): 60
Consult with Preceptor (minutes): 10
Student Participation: 75%
Chief Complaint: Follow-up.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Nutritional status, Screen for alcohol, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 60
Consult with Preceptor (minutes): 5
Student Participation: 100%
Chief Complaint: frequent, burning, painful urination.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Breast exam, Pap smear, Pelvic exam, Urine collection, Venipuncture
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: Patient is 19 y/o Hispanic female, Spanish speaking only presented to the clinic with c/o bumps that are very itchy all over her body x 2 days. She stated that she visited a friend over the weekend and the friend has a dog. she noted the bumps on the uncover parts of her body after she when home she stated to itch and a few hours later the bumps appeared. She has never been allergic to dog or cat. She has not changed her cream or soap, has not travelled and gardening has never been her hobby. She doesn't have any allergy to medication and food and has not taken any new medication in the recent days. O: Vital signs- T 98.9; P 96; R 18; BP 115/84; BMI 22 Well-developed, appeared stated age in mild distress, scratching her body intermittently HEENT: PERRLA, EOMI, no lesion or mass observed in mouth, no cervical lymphadenopathy, throat without erythema or exudate, nontender maxillary sinuses CVS: S1, S2 heard, no murmurs, gallops or bruits. LUNGS: Symmetrical chest expansions, bilaterally to auscultation, no adventitious sounds ABDOMEN: Flat, non-tender. BS normoactive. NEURO: Alert, awake, orientated to time, person, place and situation SKIN: raised, red, papules over the arms, back, chest, skin warm to touch, dry, no vesicles, good skin turgor MS: Able to move all extremities with no difficulties, steady gait A: Allergic dermatitis Fleabites P: Kenalog 0.20% apply topically BID Benadryl 25mg Q12Hr Cut nails to prevent skin excoriation and infection. Avoid contact with dogs. Take medication as prescribed.
Diagnostic Codes: L23.81 | Allergic contact dermatitis due to animal (cat) (dog) dander
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: bumps.
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: COLLECTION, VENOUS BLOOD, VENIPUNCTURE.
Skills/Procedures (Select All That Apply): Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: S: Patient is a 38 y/o Hispanic male presented to the clinic for checkup and medication refill. Patient stated his condition has improved since his last visit, but c/o of weakness and poor appetite. He denied smoking, drinking and use of illicit drug. Sexually active but has no partner presently. He ran out of his Iron, Vitamin d and the medication for his colitis. He denied any adverse effect of medication he is taken. Stated that his diarrhea has reduced 1-2 bowel movements a day. PMH ulcerative colitis. Denies any weight loss O: Vital sign- T 98.7; P 78; R 15; BP115/72; BMI 25.4 Well dressed, well-developed, well-nourished young man, appeared stated age and in no apparent distress HEENT: PERRLA, EOMI, no cervical lymphadenopathy, nontender maxillary sinuses. Speech clear. Tympanic membrane normal with no perforation or sclerosis whisper and rub heard equally in both ears, No lateralization on weber test. Thyroid gland normal in size and consistency. No carotid bruits heard. CVS: S1, S2 heard, no murmurs, gallops or bruits. Cap refill <3sec, no edema LUNGS: Symmetrical chest expansions, clear bilaterally to auscultation, no adventitious sounds ABDOMEN: Flat, non-tender. BS normoactive present in all 4 quadrants NEURO: Alert, orientated to time, person, place and situation SKIN: dry, warm to touch, good skin turgor, no rash MS: Able to move all extremities with no difficulties, steady gait. Muscle strength 5/5 A: Ulcerative colitis Iron Deficiency Anemia Vitamin D deficiency P: CBC UA CMP STD test Iron 3235mg 1 tab PO BID Sulfasalazine 500mg 1 tab PO TID Vitamin D 50,000UI 1 tab twice/week Diet to increase iron, vitamins and folic acid Activity as tolerated Take medication as prescribed, especially sulfasalazine takes it after meals and full glass of water to prevent stomach upset. Return to clinic if condition gets worst in 3 months, and we will be calling you for lab result.
Diagnostic Codes: D50.8 | Other iron deficiency anemias
E63.8 | Other specified nutritional deficiencies
K51.80 | Other ulcerative colitis without complications
Patient Age: 38 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: weakness and poor appetite/ checkup and refill.
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: COLLECTION, VENOUS BLOOD, VENIPUNCTURE. BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET). WBC. METABOLIC PANEL.
Skills/Procedures (Select All That Apply): STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: S: Patient is a 28 y/o African American male who presented today to the clinic with a c/o sore throat 5/10, body ache x2 day. He has taken Tylenol and it does not help. He denied nausea and vomiting, having slight difficulty swallowing food, changes in his voice and weakness. He denies smoking, does not drink alcohol or use any illicit drugs. He has had sore throat before but non like this. No history of any recent skin infection and cannot remember if he had been in contact with any one with throat or skin infection. No known allergy to medication or food. O: Vital sign- T 101.9; P 78; R 17; BP130/76; BMI 28.3 Well-developed, well-nourished, overweight man no distress noted HEENT: PERRLA, EOMI, swollen and erythematous tonsils, no palpable cervical lymph nodes, non-tender maxillary sinuses. CVS: S1, S2 heard, no murmurs, gallops or bruits. LUNGS: Symmetrical chest expansions, clear bilaterally to auscultation, no adventitious sounds ABDOMEN: Flat, non-tender. BS normoactive. NEURO: Alert, awake, orientated to time, person, place and situation SKIN: dry, warm to touch, good skin turgor MS: Able to move all extremities with no difficulties, steady gait, no joint swelling A: Acute pharyngitis Acute tonsillitis Strep throat P: Penicillin V 250mg PO BID x 10days Motrin 600mg PO Q8hr PRN pain/fever Warm salt gargle morning and evening Frequent hand washing Return to clinic if condition gets worse - severe difficulty swallowing, fever that does not go away with Motrin.
Diagnostic Codes: J02.0 | Streptococcal pharyngitis
J02.9 | Acute pharyngitis, unspecified
Patient Age: 32 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: Sore throat and body ache x2 .
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
X-ray Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 03/23/2022
Rotation Type: NSG6420 - FNP Adults & Gerontology
Comments: S: This 20 y/o Caucasian male patient presented to the clinic today with CC of fever and dry cough for the past 3 days. Fever started 2 days ago and the cough 3 days. He also c/o of slight sore throat and left lower quadrant pain. Denied nausea and vomiting. She denied smoking, use of drug or alcohol consumption O: Vital sign- T100.6; P 98; R 22; BP102/74; BMI 20 Well-developed, well-nourished young man in mild distress HEENT: PERRLA, EOMI, no lesion or mass observed in mouth, no cervical lymphadenopathy, throat without erythema or exudate, nontender maxillary sinuses CVS: S1, S2 heard, no murmurs, gallops or bruits. LUNGS: Symmetrical chest expansions, bilaterally to auscultation, no adventitious sounds ABDOMEN: Flat, non-tender. BS normoactive. NEURO: AOX3 SKIN: dry, warm to touch, good skin tugor MS: Able to move all extremities with no difficulties, steady gait A: URI Viral P: Sudafed 30mg PO Q 8 HRs Tylenol 650mg PO Q 6HR PRN pain/fever Robitussin DM 10ml PO Q8 HR PRN Congestion Teaching - increase fluid Take medication as prescribed Hand washing all the time
Diagnostic Codes: J06.9 | Acute upper respiratory infection, unspecified
Patient Age: 20 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: fever and dry cough x3 days.
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
NSG6420
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Academic Service:
NSG6420
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Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: G89.29 | Other chronic pain
N39.0 | Urinary tract infection, site not specified
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Burning urination"
Reason for Visit (Check at least one): Episodic (Acute Care)
Screening/Health Promotion
Procedure: URINALYSIS, VENIPUNCTURE.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: H66.90 | Otitis media, unspecified, unspecified ear
Patient Age: 49 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: 'Earache'
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
K64.8 | Other hemorrhoids
Patient Age: 70 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Bloody stools"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: FOBT, Stools culture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E66.9 | Obesity, unspecified
T81.4XXA | Infection following a procedure, initial encounter
Patient Age: 48 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 50%
Chief Complaint: "Wound drainage."
Reason for Visit (Check at least one): New Admittance
Procedure: Venipuncture.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Cultures/Swabs/Wet Mount
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
L44.8 | Other specified papulosquamous disorders.
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Rash to knees and elbow"
Reason for Visit (Check at least one): New Admittance
Procedure: EKG, Venipuncture, fundoscopy.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
I10 | Essential (primary) hypertension
Patient Age: 83 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "FU/ Medication refill."
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: Venipuncture. EKG. Fundoscopy.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
M15.8 | Other Poly osteoarthritis
Patient Age: 50 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Knee pain."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture, EKG.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Immunizations
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: E66.9 | Obesity, unspecified
I10 | Essential (primary) hypertension
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Medication refills for Blood pressure."
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Venipuncture, Urine collection, EKG.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: M54.2 | Cervicalgia
Patient Age: 28 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: "Neck pain."
Reason for Visit (Check at least one): New Admittance
Procedure: Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Immunizations
Academic Service:
Case Log as of 3/17/2021
Date: 02/09/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 58 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have headaches" that started 1 weeks ago.
Reason for Visit (Check at least one): New Admittance
Procedure: CMP, CBC, LP, EKG, Urinalysis.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/03/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: J03.00 | Acute streptococcal tonsillitis, unspecified
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have sore throat, fever and cough"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: COVID TEST.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 02/03/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: R10.9 | Unspecified abdominal pain
Patient Age: 47 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: "I started with pain in my abdomen last night "
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: CBC, CMP, LP, Urinalysis, Abdominal US, Stool Culture.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 02/03/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 15 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: " My girl can't poop"
Reason for Visit (Check at least one): New Admittance
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: R19.7 | Diarrhea, unspecified
Patient Age: 14 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 50%
Chief Complaint: " My child have soft stools"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: CBC, Stool Culture
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: " I have Sore Throat and fever"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Nasal Swap.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J30.9 | Allergic rhinitis, unspecified
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: "I have allergy attacks".
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Nasal Swap.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E66.09 | Other obesity due to excess calories
I10 | Essential (primary) hypertension
Patient Age: 38 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Routine"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: EKG, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Long-Term Contraceptive Management
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
L03.119 | Cellulitis of unspecified part of limb
R52 | Pain, unspecified
Patient Age: 63 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: "Leg pain."
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Nutritional status, EKG, Urine collection, Venipuncture.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E11.9 | Type 2 diabetes mellitus without complications
G89.29 | Other chronic pain
I10 | Essential (primary) hypertension
Patient Age: 60 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: Follow-up (Consult)
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: EKG,
Skills/Procedures (Select All That Apply): Diabetic Foot Care
EKG Interpretation
Immunizations
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: K59.09 | Other constipation
Patient Age: 53 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 40
Student Participation: 75%
Chief Complaint: " F/U after hernia surgery".
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Nutritional status ,
Skills/Procedures (Select All That Apply): Wound Management
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
L40.8 | Other psoriasis
M15.9 | Poly osteoarthritis, unspecified
Patient Age: 55 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Pain and rash."
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Procedure: EKG, Nutritional status, Screen for alcohol, Screen for tobacco use ,Venipuncture Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: F32.5 | Major depressive disorder, single episode, in full remission
Z65.8 | Oth problems related to psychosocial circumstances
Z87.898 | Personal history of other specified conditions
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Follow up. I feel sad"
Reason for Visit (Check at least one): Care for Psychological/Mental Health Conditions
Procedure: Nutritional status, Screen for alcohol, Urine collection, Venipuncture, Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Screen/Manage Sleep Disorders
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: frequent, burning, painful urination
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Pelvic exam, Urine collection, Venipuncture, Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: L23.81 | Allergic contact dermatitis due to animal (cat) (dog) dander
Patient Age: 22 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 35
Student Participation: 75%
Chief Complaint: "SKIN LESIONS"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Wellness/health maintenance coaching.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: D50.8 | Other iron deficiency anemias
E63.8 | Other specified nutritional deficiencies
K51.80 | Other ulcerative colitis without complications
Patient Age: 39 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 35
Student Participation: 75%
Chief Complaint: " weakness and poor appetite/ checkup and refill"
Reason for Visit (Check at least one): Follow-up (Consult)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment.
Comments:  
Diagnostic Codes: N60.01 | Solitary cyst of right breast
Patient Age: 54 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: " I come to follow my breast"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: Breast ultrasound.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E11.8 | Type 2 diabetes mellitus with unspecified complications
I10 | Essential (primary) hypertension
Patient Age: 66 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I need the refill of my medications"
Reason for Visit (Check at least one): Chronic Care
Procedure: CMP, CBC, LP, Urinalysis.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 02/02/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: K35.80 | Unspecified acute appendicitis
Patient Age: 28 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have pain located on the lower right abdomen"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: Abdominal U/S, CBC.
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: " I have malaise and fever for the last two days "
Reason for Visit (Check at least one): New Consultation
Procedure: Nasal Swab.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: K29.00 | Acute gastritis without bleeding
Patient Age: 48 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 50
Student Participation: 100%
Chief Complaint: "I come for consultation because I have heartburn and pain in my stomach for more than 1 week"
Reason for Visit (Check at least one): New Admittance
Procedure: EKG, CMP, CBC, Lipid panel, H. Pylori (Negative), Referred to the Gastroenterologist for endoscopy.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J01.90 | Acute sinusitis, unspecified
Patient Age: 37 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I have fever, nasal discharge and headache for more that 1 week"
Reason for Visit (Check at least one): New Admittance
New Consultation
Procedure: CMP, LIPID PANEL, CBC, SEDIMENTATION, CULTURE, SINUSES X RAY.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: H60.591 | Other noninfective acute otitis externa, right ear
Patient Age: 45 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 100%
Chief Complaint: "I have pain in my right ear for the las 4 days"
Reason for Visit (Check at least one): New Consultation
Procedure: Right ear culture.
Skills/Procedures (Select All That Apply): Cerumen Disimpaction
Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy
I10 | Essential (primary) hypertension
Patient Age: 60 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: "I'm here for my screening and refill my medication"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: CMP, CBC, LP, HbA1c, Renal US, EKG, Urinalysis, Fundoscopy.
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 30 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "Missed menses"
Reason for Visit (Check at least one): New Consultation
Procedure: Human chorionic gonadotropic assay, CBC, PT, Thyroidstimulating hormone (TSH) and free T4 aPTT, ALT, AST, Prolactin, Thyroid-stimulating hormone (TSH) and free T4
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Reproductive Health Screening/Management
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: D46.4 | Refractory anemia, unspecified
Patient Age: 35 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: "I feel very tired all the time "
Reason for Visit (Check at least one): New Admittance
Procedure: CMP, CBC, TOTAL IRON, VIT B12, FOLATES, LIPID PANEL, EKG.
Skills/Procedures (Select All That Apply): EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 25 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 30
Student Participation: 100%
Chief Complaint: " I have fever and malaise for the last two days "
Reason for Visit (Check at least one): New Consultation
Procedure: Nasal Swab.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy
Patient Age: 67 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 60
Student Participation: 100%
Chief Complaint: " I'm here for my Diabetes screening"
Reason for Visit (Check at least one): Follow-up (Consult)
Parenting/Family Education Counseling
Screening/Health Promotion
Procedure: CMP, CBC, LP, HbA1c, Renal US, EKG, Urinalysis, Fundoscopy.
Skills/Procedures (Select All That Apply): Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J30.2 | Other seasonal allergic rhinitis
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Uninsured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: " I have runny nose for the last two weeks"
Reason for Visit (Check at least one): New Consultation
Procedure: Nasal Swap.
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/27/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessment
Comments:  
Diagnostic Codes: N73.9 | Female pelvic inflammatory disease, unspecified
Patient Age: 42 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 60
Student Participation: 75%
Chief Complaint: "I have pain in my genitals"
Reason for Visit (Check at least one): New Admittance
New Consultation
Procedure: Vaginal Culture, Pelvic Ultrasound, Abdominal Ultrasound, CBC
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pap Smear
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E03.9 | Hypothyroidism, unspecified
Patient Age: 32 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: "I'm here for screening and refill my medication"
Reason for Visit (Check at least one): New Consultation
Procedure: TSH, T3, T4, FREE T3, REVERSE T3, EKG
Skills/Procedures (Select All That Apply): EKG Interpretation
Pelvic Exam
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: B37.41 | Candidal cystitis and urethritis
Patient Age: 53 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: "I have inflammation, intense itchiness, and a thick, white discharge from my vagina"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: IgG levels, Dipstick Urinalysis, Urine Culture, Renal US
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Pelvic Exam
STD & HIV Screening/Counseling
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: I10 | Essential (primary) hypertension
Patient Age: 57 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: " I'm here for my screening and refill of my medication"
Reason for Visit (Check at least one): Follow-up (Consult)
Procedure: CBC, CMP, LP, EKG, Urinalysis, Renal US, HbA1C, Fundoscopy
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 50
Student Participation: 75%
Chief Complaint: " I'm here for my Diabetes screening "
Reason for Visit (Check at least one): New Consultation
Procedure: CMP, CBC, LP, HbA1c, Renal US, EKG Urinalysis
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Diabetic Foot Care
EKG Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: N30.91 | Cystitis, unspecified with hematuria
Patient Age: 40 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 40
Student Participation: 75%
Chief Complaint: "I have burning urination for the last three days"
Reason for Visit (Check at least one): New Consultation
Procedure: CBC, Dipstick Urinalysis, Urine Culture, Renal US
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 24 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 35
Student Participation: 75%
Chief Complaint: " I need to know if I'm pregnant"
Reason for Visit (Check at least one): New Consultation
Parenting/Family Education Counseling
Procedure: HCG Test done.
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: Z11.52 | Encounter for screening for COVID-19
Patient Age: 46 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 40
Student Participation: 75%
Chief Complaint: " I have fever and malaise for the last two days"
Reason for Visit (Check at least one): New Consultation
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Lab Studies Interpretation
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: B36.0 | Pityriasis versicolor
Patient Age: 20 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 30
Student Participation: 75%
Chief Complaint: "I have spots on my back"
Reason for Visit (Check at least one): Episodic (Acute Care)
Parenting/Family Education Counseling
Skills/Procedures (Select All That Apply): Interprofessional Collaboration / Referral / Consultation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J03.90 | Acute tonsillitis, unspecified
Patient Age: 22 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 75%
Chief Complaint: " I have sore throat and headache"
Reason for Visit (Check at least one): Episodic (Acute Care)
New Admittance
Skills/Procedures (Select All That Apply): Cultures/Swabs/Wet Mount
Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E03.9 | Hypothyroidism, unspecified
Patient Age: 67 Years
Patient Sex: F
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 45
Student Participation: 100%
Chief Complaint: "feeling tired and hair falling out"
Reason for Visit (Check at least one): Episodic (Acute Care)
Procedure: LABORATORY TESTS INDICATED. BLOOD SAMPLE COLLECTED
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: H61.21 | Impacted cerumen, right ear
Patient Age: 53 Years
Patient Sex: M
Patient Ethnicity: Black or African American
Insurance: Insured
Time with Patient (min): 45
Student Participation: 100%
Chief Complaint: ""I finish the drops of the ear but I still do not listen
Reason for Visit (Check at least one): Follow-up (Consult)
Scheduled Procedure
Skills/Procedures (Select All That Apply): Cerumen Disimpaction
Ear Lavage
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: N39.0 | Urinary tract infection, site not specified
Patient Age: 33 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 35
Student Participation: 100%
Chief Complaint: " Burning when urinating"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Lab Studies Interpretation
Academic Service:
Case Log as of 3/17/2021
Date: 01/26/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: L60.0 | Ingrowing nail
Patient Age: 19 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 30
Student Participation: 100%
Chief Complaint: " I have a lot of pain in my left great toenail"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: K59.00 | Constipation, unspecified
Patient Age: 29 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 25
Student Participation: 100%
Chief Complaint: "I haven't poop for 5 days"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: E08.9 | Diabetes due to underlying condition w/o complications
I10 | Essential (primary) hypertension
Patient Age: 65 Years
Patient Sex: M
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 100%
Chief Complaint: " I need my medications refill".
Reason for Visit (Check at least one): Chronic Care
Follow-up (Consult)
Skills/Procedures (Select All That Apply): Cardiovascular Risk Assessment/Management
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: H11.002 | Unspecified pterygium of left eye
H53.9 | Unspecified visual disturbance
Patient Age: 56 Years
Patient Sex: F
Patient Ethnicity: Black or African American
Insurance: Uninsured
Time with Patient (min): 25
Student Participation: 100%
Chief Complaint: " I have redness and itching on my left eye".
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: J02.9 | Acute pharyngitis, unspecified
Patient Age: 27 Years
Patient Sex: F
Patient Ethnicity: Hispanic or Latino
Insurance: Insured
Time with Patient (min): 45
Student Participation: 100%
Chief Complaint: " I have sore throat since yesterday"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): Strep / Influenza Testing
Academic Service:
Case Log as of 3/17/2021
Date: 01/19/2022
Rotation Type: NSG6020 - Advanced Health and Physical Assessement
Comments:  
Diagnostic Codes: R10.10 | Upper abdominal pain, unspecified
Patient Age: 37 Years
Patient Sex: M
Patient Ethnicity: White
Insurance: Insured
Time with Patient (min): 35
Student Participation: 50%
Chief Complaint: "I have stomach pain for 3 days"
Reason for Visit (Check at least one): Episodic (Acute Care)
Skills/Procedures (Select All That Apply): NOT APPLICABLE