Clinical Log Detailed Report

Chamberlain - Family Nurse Practitioner Report Date/Time: 6/11/2019 1:56:56 PM Report Filters: Report Calendar Year: 2019 Selected User(s): Scott, Dorothy Selected Course(s): NR511: Differential Diagnosis and Primary Care Practicum(10871) Selected Session(s): May 2019 Selected Status: Accepted Course Name: NR511: Differential Diagnosis and Clinical Site: Affordable Quality Care Patient Initials: EC Primary Care Practicum (10871) Log Date: 05/07/2019 Age Range: 1-4 years Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Male Course Session: May 2019 Minutes: 00:25 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Site: Family Medicine Type of Visit: Acute / Episodic Care Physical Exam: Cardiac, Constitutional / Vital Signs, Heent, Medical Reconciliation, Respiratory Type of Diagnostics: N/A Ordering Diagnostics: N/A Procedures: Medications: N/A Therapeutics: Medication management, Nutrition therapeutics Education Comments: Medication Management of OTC meds Referrals: N/A Follow-up: 1 month Coding: -Acute bronchiolitis -Other allergic rhinitis Skills & Procedures: N/A Notes: 99213 Establish level 3 visit Tx: continue taking OTC tylenol and ibuprofen Educated: Take OTC tylenol and ibuprofen for fever and can alternate.  Use as directed on the label.  Humidifier to help with the thicken mucus and drink plenty of fluids to prevent dehydration and signs to look for dehydration.   Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Clinical Site: Affordable Quality Care Log Date: 05/07/2019 Patient Initials: JR Age Range: 5-11 years Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Female Course Session: May 2019 Minutes: 00:25 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Antibiotic administration Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: N/A Type of Visit: Acute / Episodic Care Procedures: Follow-up: 3 months Physical Exam: Cardiac, Constitutional / Vital Signs, Dermatology, Heent, Medical Reconciliation, Respiratory Medications: Anti-Infectives, Glucocorticoids Therapeutics: Initiate medication Coding: -Other specified local infections of the skin and subcutaneous tissue Skills & Procedures: N/A Notes: 99213 Established level 3 visit TX: prescribe prednisone and itraconazole Education:  apply to affected area until it is all gone.  Wash hands w/soap and warm water.  Take prednisone w/food and plenty of fluids.   Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Clinical Site: Affordable Quality Care Log Date: 05/07/2019 Patient Initials: EN Age Range: 5-11 years Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Female Course Session: May 2019 Minutes: 00:30 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Antibiotic Administration Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: N/A Type of Visit: Acute / Episodic Care Procedures: Follow-up: 3 months Physical Exam: Cardiac, Constitutional / Vital Signs, Heent, Medical Reconciliation, Pain Assessment, Respiratory Medications: Anti-Infectives Therapeutics: Initiate medication Coding: -Acute suppurative otitis media without spontaneous rupture of ear drum, right ear Skills & Procedures: N/A Notes: 99214 Established level 4 visit Tx: prescribe Ciprodex Education: instructed to distill 1-2 drops in affected ear until drops are all gone.  Do not discontinue even if affected ear starts to feel better.   Course Name: NR511: Differential Diagnosis and Primary Care Practicum (10871) Clinical Site: Affordable Quality Care Log Date: 05/07/2019 Patient Initials: BV Age Range: 12-17 years Course Section: Section- 0 Last Updated: 05/29/2019 Gender: Male Course Session: May 2019 Minutes: 00:30 Ethnicity: Hispanic or Latino Faculty: Washington, Cynthia Date Of Clinical: 05/07/2019 Client Complexity: Episodic (Acute Condition) Preceptor: Williamson, Danny Student Level of Function: 25% Student/75% Preceptor Type of Diagnostics: N/A Education Comments: Asthma Action Plan Type of Site: Family Medicine Ordering Diagnostics: N/A Referrals: Ophthalmology Type of Visit: Acute / Episodic Care Procedures: Follow-up: 3 months Physical Exam: Cardiac, Constitutional / Vital Signs, Heent, Medical Reconciliation, Neurological, Pain Assessment, Respiratory Medications: N/A, Anti-Asthmatic Agents Therapeutics: Disease Specific Teaching Coding: -New daily persistent headache (NDPH) -Asthma Skills & Procedures: N/A Notes: 99214 Established level 4 visit Tx: Referral to opthamology and prescribe Singulair, Proair HFA, Albuteral inhaler Education: Triggers to avoid to prevent asthma flair up.  Signs to look for to seek medical help.  Use inhaler as prescribed.  Take singulair in order to help prevent asthma flair up.  place a cool rag behind your neck and laydown to help with headache and take OTC tylenol to help alleviate the pain.   .....................................................CONTINUED...................................................