Please complete the attached clinical log for adult patients. You can choose which ever problem you like.
THIS IS AN EXAMPLE
|
Date |
Client Age |
Presenting Problem |
Clinical Experience |
|
9/30/2020 |
Middle adult: 40s to 60s |
“I am homeless and am hearing things and they scare me” |
Z00.01 Encounter for general adult medical examination with abnormal findings; R94.31 Abnormal electrocardiogram [ECG] [EKG]; I15.0 Renovascular hypertension; E08.5 Diabetes mellitus due to underlying condition with circulatory complications; R44.0 Auditory hallucinations |
|
9/30/2020 |
Young-old: 60s to 74 years |
“I am seeing double everyday” |
Z00.0 Encounter for general adult medical examination; H54.51 Low vision, right eye, normal vision left eye; H53.2 Diplopia |
|
9/30/2020 |
Young-old: 60s to 74 years |
“I have been feeling strange and feel like my heart races at times” |
Z00.01 Encounter for general adult medical examination with abnormal findings; R94.31 Abnormal electrocardiogram [ECG] [EKG]; I48.4 Atypical atrial flutter |
|
9/30/2020 |
Young adult: 20s and 40s |
“I have been having lots of abdominal pain that comes monthly” |
Z00.01 Encounter for general adult medical examination with abnormal findings; R10.2 Pelvic and perineal pain; N80.0 Endometriosis of uterus |
|
9/30/2020 |
Middle adult: 40s to 60s |
“I have been having lots of migraines that won’t go away” |
Z00.01 Encounter for general adult medical examination with abnormal findings; G43.0 Migraine without aura; G43.01 Migraine without aura, intractable |
|
9/30/2020 |
Middle adult: 40s to 60s |
“I have not peed in several days and feel very weak” |
Z00.0 Encounter for general adult medical examination; N18.3 Chronic kidney disease, stage 3 (moderate); Z49.0 Preparatory care for renal dialysis |
|
9/30/2020 |
Middle adult: 40s to 60s |
“I have some swelling on my legs” |
Z00.0 Encounter for general adult medical examination; R22.4 Localized swelling, mass and lump, lower limb |
|
9/30/2020 |
Middle adult: 40s to 60s |
“I need a new provider and want my annual examination” |
Z00.0 Encounter for general adult medical examination; I15.2 Hypertension secondary to endocrine disorders; E05.8 Other thyrotoxicosis |
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