Name:

*Select Student Name Adams, Mark Ali, Nadia Andruska, Adam Baker, Teresa Bloom, Andrew Buecker, Tony Bunch, Jennifer Carter, Melinda Cheema, Asmaa Chia, Benjamin Chihade, Deena Christiansen, Peter Cohen, Blake Crowner, Jason Deem, Daniel Dial, Samantha Doerr, Danielle Doolittle, Othniel DuBois, Kimberly DuMontier, Erin Durkin, Rebecca Echeazu, Chinelo Farley, Norah Fisher, Marita Frederick, Luke Freund, Meghan Fultz, Julie Gordon, Tandra Hayes, Sean Henry, Drew Hinzman, Justin Hutto, Justin Jones, Brent Kearns, Bethany Khatibi, Esther King, Adam Kirkwood, Dawn Kotal, Eric Kyte, Natasha Le, Minh-Bao Lindorfer, Christi Lockhart, Kerri Luong, Benjamin McEnerney, Laura Meder, Irene Mendoza, Julie Meyerholz, Andy Milburn, Suzanne Moja, Ashley Mompremier, Emerson Park, Hannah Parkin, Annie Pham, Quoc Pope, David Radford, Lee Reed, Matt Regnier, Holly Richards, Kate Rigdon, Jillian Rodos, Adam Rose, Jennifer Roth, Valerie Rubenacker, Sara Ruthman, Carl Sanford, Tifani Schafer, Erin Shah, Lisa Shah, Neil Shakir, Shariff Sheffer, Doug Simpson, Clint Sinha, Michael Slater, Chris Spence, Tisha Stelle, Lacey Sterrett, Mary Stock, Ryan Suprenant, Suzanne Thompson, Katie VanderWaal, Adam Vasquez, Kelly Weitzel, Bob Wold, Brittany Woods, Teschlyn Young, Justin zztest

Rotation:

Date Patient Seen:

Location:

Patient's Age:

Patient's Gender:

Patient's Race:

African-American Asian Caucasian Hispanic Mixed Native American Other

Patient Problem 1 (select one):

(Bold entries match to Clerkship Quotas)

Patient Problem 2:

Abdominal Pain Abnormal ECG Abnormal Liver Function Tests Abnormalities of White Blood Cells Acid Base and Electrolyte Problems Acute Renal Failure Allergic Reactions Anemia Angina/MI/Acute Coronary Syndromes Arthritis Asthma Back Pain Bleeding Tendency/Bruising Breast Disorders Cancer Cardiac Arrest/Respiratory Arrest Cellulitis Chest Pain/Not CAD Cholelithiasis/cholecystitis Chronic or Acute Kidney Disease Chronic Obstructive Lung Disease [COPD] (including Asthma) Congestive Heart Failure Constipation Coronary Artery Disease

CVA Cyanosis/Hypoxia Dementia/Memory Disturbances Depression Diabetes Mellitus Diarrhea Difficulty Swallowing Dizziness/Vertigo DVT/PE Dyslipidemia Ear Pain Eating Disorders Edema/Anasarca/Ascites Electrolyte and Acid Base Disorders Falls Fatigue Fever Gastrointestinal Bleeding Genetics in Clinical Practice GERD Geriatric Care Headache Hearing Loss/Deafness Hematuria

Hemoptysis Hepatobiliary Disease HIV Infection Hyperlipidemia Hypertension Hypotension Impaired Consciousness Issues of bad news/dying patients Joint Pain Liver Disease (acute or chronic) Low Back Pain Lymphadenopathy Medical Error (explain below) Menopause Neck Mass/Goiter Numbness/Tingling/Paresthesias Otitis media/externa Panic/Anxiety Pap Abnormality Paralysis Peptic Ulcer Disease Pneumonia Poisoning Preventive Health Proteinuria

Pruritus Rash/Skin Lesions Seizures (epilepsy) Sepsis Sexual Dysfunction Shock Sleep Disturbances Splenomegaly Substance Abuse/Drug Addiction/Withdrawal Thromboembolic Disease Thyroid Disease Tinnitus Tuberculosis Upper Respiratory Infection/Common Cold Urinary Tract Infection Visual Disturbance/Loss Vomiting/Nausea Weakness Weight Gain/Obesity Weight Loss Women's Health NONE Other:

Patient Problem 3:

Abdominal Pain Abnormal ECG Abnormal Liver Function Tests Abnormalities of White Blood Cells Acid Base and Electrolyte Problems Acute Renal Failure Allergic Reactions Anemia Angina/MI/Acute Coronary Syndromes Arthritis Asthma Back Pain Bleeding Tendency/Bruising Breast Disorders Cancer Cardiac Arrest/Respiratory Arrest Cellulitis Chest Pain/Not CAD Cholelithiasis/cholecystitis Chronic or Acute Kidney Disease Chronic Obstructive Lung Disease [COPD] (including Asthma) Congestive Heart Failure Constipation Coronary Artery Disease

CVA Cyanosis/Hypoxia Dementia/Memory Disturbances Depression Diabetes Mellitus Diarrhea Difficulty Swallowing Dizziness/Vertigo DVT/PE Dyslipidemia Ear Pain Eating Disorders Edema/Anasarca/Ascites Electrolyte and Acid Base Disorders Falls Fatigue Fever Gastrointestinal Bleeding Genetics in Clinical Practice GERD Geriatric Care Headache Hearing Loss/Deafness Hematuria

Hemoptysis Hepatobiliary Disease HIV Infection Hyperlipidemia Hypertension Hypotension Impaired Consciousness Issues of bad news/dying patients Joint Pain Liver Disease (acute or chronic) Low Back Pain Lymphadenopathy Medical Error (explain below) Menopause Neck Mass/Goiter Numbness/Tingling/Paresthesias Otitis media/externa Panic/Anxiety Pap Abnormality Paralysis Peptic Ulcer Disease Pneumonia Poisoning Preventive Health Proteinuria

Pruritus Rash/Skin Lesions Seizures (epilepsy) Sepsis Sexual Dysfunction Shock Sleep Disturbances Splenomegaly Substance Abuse/Drug Addiction/Withdrawal Thromboembolic Disease Thyroid Disease Tinnitus Tuberculosis Upper Respiratory Infection/Common Cold Urinary Tract Infection Visual Disturbance/Loss Vomiting/Nausea Weakness Weight Gain/Obesity Weight Loss Women's Health NONE Other:

Patient Category
(limit 2)
(to select more than one item, click on each item while holding down the <control> key)

New acute condition or complaint (emphasis on diagnosis) Chronic condition (emphasis on management) Exacerbation of chronic condition (emphasis on management) Asymptomatic patient (preventive case and screening) Patient with limited access to care*
*Patient with limited access to care:  low-income, transportation problems, homebound, poor social circumstance, etc.

Procedure:
(to select more than one item, click on each item while holding down the <control> key)

*None *Other Arterial Puncture Bladder Catheterization Bone Marrow CPR History and Physical ID Injection IM Injection IV Start Lumbar Puncture NG Intubation Paracentesis Proctoscopy Stool Guaiac Thoracentesis Tonometry Exam Urinalysis Venipuncture

       Procedure Role:

Observed Assisted Performed

Problem List:

Notes/Comments: