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Academic ServiceUpdated: 02-15-22
Case Log as of 3/17/2021
| Date: | 02/10/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | L03.211 | Cellulitis of face |
| Patient Age: | 94 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 60 |
| Student Participation: | 75% |
| Chief Complaint: | periorbital redness and swelling |
| Reason for Visit (Check at least one): | Follow-up (Hospital Visit) Nursing Home Visit |
| Procedure: | clarification Discharge order from Hospital |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation |
Case Log as of 3/17/2021
| Date: | 02/11/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | F33.9 | Major depressive disorder, recurrent, unspecified F41.9 | Anxiety disorder, unspecified G47.00 | Insomnia, unspecified |
| Patient Age: | 75 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 40 |
| Student Participation: | 25% |
| Chief Complaint: | Anxiety during HS |
| Reason for Visit (Check at least one): | Care for Psychological/Mental Health Conditions Follow-up (Routine) Nursing Home Visit |
| Procedure: | Maintain previous treatment |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation |
Case Log as of 3/17/2021
| Date: | 02/11/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | G12.21 | Amyotrophic lateral sclerosis M24.511 | Contracture, right shoulder M24.541 | Contracture, right hand M62.412 | Contracture of muscle, left shoulder M62.81 | Muscle weakness (generalized) R27.9 | Unspecified lack of coordination R54 | Age-related physical debility |
| Patient Age: | 72 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 60 |
| Student Participation: | 75% |
| Chief Complaint: | progressive weakness, Amyothrophic lateral sclerosis |
| Reason for Visit (Check at least one): | Chronic Care Follow-up (Consult) Nursing Home Visit |
| Procedure: | Referral to a neurology and gastroenterology |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation |
Case Log as of 3/17/2021
| Date: | 02/11/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | K59.09 | Other constipation |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 55 |
| Student Participation: | 50% |
| Chief Complaint: | No BM in 3 days, emesis episodes |
| Reason for Visit (Check at least one): | Nursing Home Visit |
| Procedure: | Order KUB,Prescribe treatment for constipation |
| Skills/Procedures (Select All That Apply): | X-ray Interpretation |
Case Log as of 3/17/2021
| Date: | 02/11/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | E11.9 | Type 2 diabetes mellitus without complications H40.9 | Unspecified glaucoma R53.81 | Other malaise |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Hispanic or Latino |
| Insurance: | Insured |
| Time with Patient (min): | 50 |
| Student Participation: | 25% |
| Chief Complaint: | polyuria, polydipsia, polyphagia |
| Reason for Visit (Check at least one): | Chronic Care Nursing Home Visit |
| Procedure: | BS screening |
| Skills/Procedures (Select All That Apply): | Lab Studies Interpretation |
Case Log as of 3/17/2021
| Date: | 02/11/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | E87.1 | Hypo-osmolality and hyponatremia F10.20 | Alcohol dependence, uncomplicated |
| Patient Age: | 71 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 45 |
| Student Participation: | 25% |
| Chief Complaint: | Thirsty, status post fall |
| Reason for Visit (Check at least one): | Follow-up (Hospital Visit) New Admittance |
| Skills/Procedures (Select All That Apply): | Lab Studies Interpretation |
Case Log as of 3/17/2021
| Date: | 02/10/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | E87.70 | Fluid overload, unspecified I10 | Essential (primary) hypertension I50.32 | Chronic diastolic (congestive) heart failure |
| Patient Age: | 98 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 60 |
| Student Participation: | 50% |
| Chief Complaint: | SOB |
| Reason for Visit (Check at least one): | Nursing Home Visit |
| Procedure: | BMP, CBC ordered and interpreted, treatment with diuretic, referred to cardiologist , daily weight |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation Lab Studies Interpretation |
Case Log as of 3/17/2021
| Date: | 02/10/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | K21.9 | Gastro-esophageal reflux disease without esophagitis K27.9 | Peptic ulc, site unsp, unsp as ac or chr, w/o hemor or perf K29.70 | Gastritis, unspecified, without bleeding |
| Patient Age: | 69 Years |
| Patient Sex: | M |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 65 |
| Student Participation: | 75% |
| Chief Complaint: | epigastric pain and a burning sensation in the stomach, nausea, vomiting, abdomen distended |
| Reason for Visit (Check at least one): | Episodic (Acute Care) Nursing Home Visit Scheduled Procedure |
| Procedure: | KUB,Stomach CT, CBC |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation Lab Studies Interpretation |
Case Log as of 3/17/2021
| Date: | 02/10/2022 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessement |
| Comments: | |
| Diagnostic Codes: | E46 | Unspecified protein-calorie malnutrition R13.11 | Dysphagia, oral phase R53.81 | Other malaise |
| Patient Age: | 86 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| Insurance: | Insured |
| Time with Patient (min): | 65 |
| Student Participation: | 25% |
| Chief Complaint: | weakness and malaise |
| Reason for Visit (Check at least one): | Chronic Care |
| Procedure: | Hospice referral. Pt denied J-tube |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation |
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