Clinical Log Detailed Report –
Chamberlain College Of Nursing.
NR511: Differential Diagnosis and Clinical Site: Affordable Quality Care Patient
... [Show More] 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.
Scott, Dorothy
Page: 3
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.
Scott, Dorothy
Page: 4
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.
Scott, Dorothy
Page: 5
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 [Show Less]