Academic ServiceUpdated: 03-30-26
FieldworkUpdated: 04-03-26
Case Log
| Date: | 03/26/2026 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessment |
| Comments: | ? |
| Diagnostic Codes: | E11.65 | Type 2 diabetes mellitus with hyperglycemia E66.812 | Obesity, class 2 E78.2 | Mixed hyperlipidemia F41.1 | Generalized anxiety disorder F41.9 | Anxiety disorder, unspecified I10 | Essential (primary) hypertension K21.00 | Gastro-esophageal reflux dis with esophagitis, without bleed Z68.39 | Body mass index [BMI] 39.0-39.9, adult Z79.899 | Other long term (current) drug therapy |
| Patient Age: | 61 Years |
| Patient Sex: | M |
| Patient Ethnicity: | Black or African American |
| CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.): | VSS, no abnormal findings on ROS or physical exam. Routine followup complete. Continue healthy diet and exercise. (-) social Labs ordered: CBC CMP HgA1c Lipid TSH Microalbumin/Creatinine urine ratio Preventive Screening: Colonoscopy up to date Immunizations reviewed: Flu vaccine annually Tdap up to date Rx refill: zolpidem CR 6.25mg HS PRN sleep Alprazolam 0.5mg BID PRN anxiety Amlodipine 5mg daily Atorvastatin 20mg daily Fenofibrate 160mg daily Fluoxetine 40mg daily HCTZ 12.5mg daily Metformin 750mg HS Metoprolol 100mg BID Olmesartan 40mg daily Pantoprazole 40mg daily Followup in 3 months or PRN |
| Student Participation: | 75% |
| Chief Complaint: | "3 month followup and refills" |
| Reason for Visit (Check at least one): | Follow-up (Routine) |
| Skills/Procedures (Select All That Apply): | Lab Studies Interpretation |
Case Log
| Date: | 03/26/2026 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessment |
| Comments: | ? |
| Diagnostic Codes: | E78.2 | Mixed hyperlipidemia F32.A | Depression, unspecified F41.9 | Anxiety disorder, unspecified G47.09 | Other insomnia I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings Z68.27 | Body mass index [BMI] 27.0-27.9, adult Z87.891 | Personal history of nicotine dependence |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.): | VSS, no abnormal findings on ROS or physical exam. Routine followup complete. Continue healthy diet and exercise. (+) social, tobacco 75 ttl pk yr. Quit 5 years ago Labs ordered: CBC CMP Lipid TSH Microalbumin/Creatinine urine ratio Preventive Screening: Colonoscopy up to date Mammogram up to date Referral for CT Lung Cancer Screening Immunizations reviewed: Flu vaccine annually Pneumonia vaccine up to date Tdap up to date Rx refill: Followup in 6 months or PRN |
| Student Participation: | 75% |
| Chief Complaint: | "here for medicare wellness exam" |
| Reason for Visit (Check at least one): | Annual/Well Person Exam |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation Lab Studies Interpretation |
Case Log
| Date: | 03/26/2026 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessment |
| Comments: | ? |
| Diagnostic Codes: | E78.2 | Mixed hyperlipidemia F32.A | Depression, unspecified F41.9 | Anxiety disorder, unspecified G47.09 | Other insomnia I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings Z68.27 | Body mass index [BMI] 27.0-27.9, adult Z87.891 | Personal history of nicotine dependence |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.): | VSS, no abnormal findings on ROS or physical exam. Routine followup complete. Continue healthy diet and exercise. (+) social, tobacco 75 ttl pk yr. Quit 5 years ago Labs ordered: CBC CMP Lipid TSH Microalbumin/Creatinine urine ratio Preventive Screening: Colonoscopy up to date Mammogram up to date Referral for CT Lung Cancer Screening Immunizations reviewed: Flu vaccine annually Pneumonia vaccine up to date Tdap up to date Rx refill: Followup in 6 months or PRN |
| Student Participation: | 75% |
| Chief Complaint: | "here for medicare wellness exam" |
| Reason for Visit (Check at least one): | Annual/Well Person Exam |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation Lab Studies Interpretation |
Case Log
| Date: | 03/31/2026 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessment |
| Comments: | ? |
| Diagnostic Codes: | E66.811 | Obesity, class 1 E78.2 | Mixed hyperlipidemia F41.1 | Generalized anxiety disorder F98.8 | Oth behav/emotn disord w onset usly occur in chldhd and adol I10 | Essential (primary) hypertension K21.9 | Gastro-esophageal reflux disease without esophagitis M79.7 | Fibromyalgia R07.89 | Other chest pain R61 | Generalized hyperhidrosis R73.03 | Prediabetes R82.998 | Other abnormal findings in urine Z68.31 | Body mass index [BMI] 31.0-31.9, adult Z79.899 | Other long term (current) drug therapy |
| Patient Age: | 42 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.): | VSS, presents to office today for followup and c/o intermittent chest pain that she thinks is related to stress. no abnormal findings on ROS or physical exam. Routine followup complete. Continue healthy diet and exercise. (-) social Labs ordered: CBC CMP Lipid HgA1c TSH UA (+ Leuk) Urine Cx Microalbumin/Creatinine urine ratio EKG (NSR) Preventive Screening: Colonoscopy up to date Mammogram up to date Pap up to date Immunizations reviewed: Flu vaccine annually Pneumonia vaccine up to date Tdap up to date Rx refill: None needed today Followup in 3 months or PRN, will call with Urine Cx results |
| Student Participation: | 100% |
| Chief Complaint: | "3 month followup" |
| Reason for Visit (Check at least one): | Episodic (Acute Care) Follow-up (Routine) |
| Skills/Procedures (Select All That Apply): | Cardiovascular Risk Assessment/Management EKG Interpretation Lab Studies Interpretation |
Case Log
| Date: | 03/26/2026 |
| Rotation Type: | NSG6020 - Advanced Health and Physical Assessment |
| Comments: | ? |
| Diagnostic Codes: | E78.2 | Mixed hyperlipidemia F32.A | Depression, unspecified F41.9 | Anxiety disorder, unspecified G47.09 | Other insomnia I10 | Essential (primary) hypertension Z00.00 | Encntr for general adult medical exam w/o abnormal findings Z68.27 | Body mass index [BMI] 27.0-27.9, adult Z87.891 | Personal history of nicotine dependence |
| Patient Age: | 80 Years |
| Patient Sex: | F |
| Patient Ethnicity: | White |
| CLINICAL NOTES (Do not enter patient information that would violate HIPAA confidentiality.): | VSS, no abnormal findings on ROS or physical exam. Routine followup complete. Continue healthy diet and exercise. (+) social, tobacco 75 ttl pk yr. Quit 5 years ago Labs ordered: CBC CMP Lipid TSH Microalbumin/Creatinine urine ratio Preventive Screening: Colonoscopy up to date Mammogram up to date Referral for CT Lung Cancer Screening Immunizations reviewed: Flu vaccine annually Pneumonia vaccine up to date Tdap up to date Rx refill: Followup in 6 months or PRN |
| Student Participation: | 75% |
| Chief Complaint: | "here for medicare wellness exam" |
| Reason for Visit (Check at least one): | Annual/Well Person Exam |
| Skills/Procedures (Select All That Apply): | Interprofessional Collaboration / Referral / Consultation Lab Studies Interpretation |
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