DGSOM UCLA Ambulatory Internal Medicine Patient Log



Required Clinical Experiences TOC \o "1-3" \h \z \u DGSOM UCLA Ambulatory Internal Medicine Patient Log PAGEREF _Toc31791695 \h 2DGSOM UCLA Family Medicine Patient Log PAGEREF _Toc31791696 \h 4DGSOM UCLA Inpatient Internal Medicine Patient Log PAGEREF _Toc31791697 \h 8DGSOM UCLA Neurology Patient Log PAGEREF _Toc31791698 \h 10DGSOM UCLA Obstetrics and Gynecology Patient Log PAGEREF _Toc31791699 \h 12DGSOM UCLA Pediatrics Patient Log PAGEREF _Toc31791702 \h 14DGSOM Psychiatry Patient Log PAGEREF _Toc31791705 \h 16DGSOM UCLA Surgery Patient Log PAGEREF _Toc31791707 \h 18DGSOM UCLA Ambulatory Internal Medicine Patient LogStudents must log a minimum of 40 entries and see all 18 plaints (multiple selections allowed):Abdominal painAltered mental statusAnxietyChest painChronic painCoughDiarrheaHeadacheHeartburnLower back painObesityPharyngitisShortness of breathSubstance abuseTraumaOther ComplaintDiagnoses (multiple selections allowed):ArthritisAsthma/COPDCoronary artery diseaseDepressionDiabetesEnd-of-life issues * (optional)FatigueGERD/HeartburnHealth maintenanceHeart FailureHyperlipidemiaHypertensionLow back pain/back painObesityStrain/sprain/traumaThyroid diseaseTobacco/alcohol use or addictionURIUTI/STIOther DxProcedures (multiple selections allowed):Basic BLSDrawing venous bloodStarting an IVSuturingOther ProcedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsAtherosclerotic Cardiovascular Disease (ASCVD) riskHgbA1cLipid panelUrinalysisYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoDGSOM UCLA Family Medicine Patient LogStudents must log a minimum of 40 entries and see all 46 plaints (multiple selections allowed):Abdominal painAltered mental statusAnxietyChest painChronic painDizzinessCoughHeadacheHeartburnLow back painShortness of breathOther complaintDiagnoses (multiple selections allowed):Abnormal uterine bleedingAbscess/cellulitisAllergic rhinitisAnemiaAngina prectorisAnxiety disorderAsthma/COPDAtherosclerotic Cardiovascular DiseaseBenign prostatic hyperplasiaBreast mass/MastalgiaBronchitis/PneumoniaChronic kidney diseaseCongestive heart failureContraception managementDementiaDepression/AnxietyDiabetes MellitusDomestic violence* (optional)Eating disorderEnd-of-life/POLST/DPoAFatigueFatty liver disease/NASHGastroenteritis/Constipation/DiarrheaGastro-Esophageal Reflux DiseaseGender-affirming/Transgender careHeadacheHemorrhoid/Anal fissureHigh school athlete sports PPEHIV/PrEPHyperlipidemiaHypertensionHyperthyroidismIrritable bowel syndromeLiver cirrhosisMalignancyMusculoskeletal injuryObesityOsteoarthritisOsteoporosisOtitis Media/externaParonychia/OnychomycosisRashSTI/VaginitisSubstance abuseSyncope/Pre-syncope/VertigoUpper respiratory infectionUTI/STIOther diagnosisProcedures (multiple selections allowed):Basic BLSDrawing venous bloodIncision and drainageIUD insertion/removalJoint aspirationMinor surgical procedureMMSEPap smearPunch biopsyShave biopsyStarting an IVSuturingToenail removalWound repairOther procedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsAtherosclerotic Cardiovascular Disease (ASCVD) riskGlomerular Filtration RateHIV antibodyRPRUrine chlamydiaUrine culture and sensitivityUrine dipstickUrine gonorrheaYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoDGSOM UCLA Inpatient Internal Medicine Patient LogStudents must log a minimum of 24 entries and see all 17 plaints (multiple selections allowed):Abdominal painAltered mental status/confusionChest painFeverShortness of breathOther complaintDiagnoses (multiple selections allowed):AnemiaAsthma/COPDCancerCardiac arrhythmiaCellulitis/AbscessCoronary artery diseaseDiabetes MellitusDVT/Pulmonary embolismElectrolyte/Acid-base disorderEnd-of-life issuesGI bleedingHeart failureHypertensionLiver disease/failurePneumoniaRenal insufficiency failureUTI/STIOther diagnosisProcedures (multiple selections allowed):Basic BLSDrawing venous bloodStarting an IVSuturingOther procedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsABGCXREKGYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoUCLA Neurology Patient LogStudents must log a minimum of 24 entries and see all 13 diagnosesComplaints (multiple selections allowed):Altered mental status CNS infection Cognitive impairment or dementia Disturbance of speech or language Dizziness or vertigo Headache Loss of consciousness, coma, or brain death Numbness or altered sensation Seizure/epilepsy StrokeTremor or other involuntary movements Vision loss or diplopia WeaknessOther complaintProcedures (multiple selections allowed):Basic BLSDrawing venous bloodStarting an IVSuturingOther procedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsLumbar punctureYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoDGSOM UCLA Obstetrics and Gynecology Patient LogStudents must log a minimum of 20 entries and see all 34 diagnosesDiagnoses (multiple selections allowed):Gynecology:Abnormal uterine bleedingAcute Vaginitis and STIsAdolescent gynecologyBenign pelvic and adnexal massesContraception provision and counselingDomestic violenceEndometriosisGynecological cancerHuman sexualityInfertilityManagement of abnormal pap smearMenopause/OsteoporosisMolar PregnancyPain - pelvic/abdomenPelvic painPregnancy TerminationPubertyRoutine preventative gynecologic examUrinary incontinenceOther diagnosisObstetrics:Abnormal laborDomestic violenceFetal Heart rate abnormalIntrapartum fetal assessmentNormal laborObstetrical complications including:Diabetes in pregnancyHypertensive disordersInfectionMulti-fetal pregnancyObstetrical hemorrhagePost term pregnancyPreterm laborPostpartum carePreconception carePrenatal careRoutine antepartum careOther diagnosisProcedures (multiple selections allowed):Gynecology:Basic BLSDrawing venous bloodStarting an IVSuturingFoley catheter placementBimanual pelvic palpationObtaining pap smearSTI and vaginitis evaluationSpeculum examinationVaginal and cervical culture acquisitionWell women exam – breast exam and pelvic examOther Gyn procedureObstetrics:Assessment of fetal lie presentationBasic BLSCervical exam in laborDelivery of placentiaDrawing venous bloodStarting an IVSuturingStation (if cervical exam done)Vaginal deliveryOther OB procedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening tests1st trimester pregnancy ultrasound2nd/3rd trimester pregnancy ultrasoundFerning test (rule-out rupture of membranes)Gynecologic pelvic ultrasoundPre-eclampsia labsYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoDGSOM UCLA Pediatrics Patient LogStudents must log a minimum of 30 entries and see all 20 diagnosesComplaints (multiple selections allowed):Abdominal painBehavioral problemCoughCyanosisDiarrheaFeverHeadacheJaundicePainRashRespiratory distressRunny noseSore throatSubstance abuseTraumaVomitingWeight lossOther complaintDiagnoses (multiple selections allowed):Acute abdominal painAnemiaAsthmaBehavioral concernsCongenital heart diseaseDevelopmental delayDiarrhea/DehydrationFailure to thriveFever without sourceGastroenteritisGenetic syndromeLower respiratory tract infectionMalignancy of childhoodNeonatal jaundiceNewborn problemsOtitis mediaRash UTI/STIVaccine information/hesitancyWell child careOther diagnosisProcedures (multiple selections allowed):Basic BLSDrawing venous bloodIncision and drainageStarting an IVSuturingSplinting/CastingOther procedureClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationPresented oral presentation on patient family centered careYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsApgar scoreDevelopment assessmentImmunization schedule (is the patient up to date when provided with the immunization record?)Lumbar punctureYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes NoDGSOM Psychiatry Patient LogStudents must log a minimum of 13 entries and see all 13 plaints (multiple selections allowed):AggressionAlcohol abuseAnxietyBehavioral problemsChronic painDepressedInsomniaMedication side effectsPsychosisSelf-injurySubstance abuse Suicidal ideationTraumaWeight loss or weight gainOther complaintDiagnosis (multiple selections allowed):Adjustment disorderAnxiety disorder (general anxiety/panic/social)Bipolar DisorderEating disorderMajor depressive disorderNeurocognitive disorder (delirium, dementia, traumatic brain injury)Neurodevelopmental disorders (ADHD, Autism Spectrum Disorder, Intellectual disability)OCDPersonality disorderPost traumatic stress disorderPsychotic disorderSomatization disorderSubstance abuse (including alcohol use disorder)Other diagnosisClinical Skills (multiple selections allowed):SkillFeedback GivenPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsMOCA/MMSEPsychiatric symptom rating scalesYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one member of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoScreened for substance use disorderYes NoCounseled patient on smoking cessationYes NoAttended group therapyYes NoNoneYes NoDGSOM UCLA Surgery Patient LogStudents must log a minimum of 55 entries and see all 14 General Surgery plaints (multiple selections allowed):Abdominal painAcid-base disturbanceBreast lumpFluid and electrolyte disturbanceMultisystem traumaRectal bleedingRectal pain/discomfortVaricose veinsOther complaintDiagnoses (multiple selections allowed) (dependent on Specialty selection):AnesthesiologyApproach to failed intubCode basicsLAs toxicity/dosesOpioids/pain managementPre-oxygenationOther diagnosisEmergency MedicineAbdominal painChest painIV placementLacerationOrthopedic injuryShortness of breathTrauma resuscitationOther diagnosisGeneral Surgery - Clinical problemsAppendicitisBiliary/Pancreatic diseaseBowel obstructionColorectal/Anorectal diseaseEsophageal/Gastric diseaseHerniasSurgical infectionsThyroid and PARTHY diseaseTrauma (blunt/penetrating)Other diagnosisGeneral Surgery - Perioperative careFluids and electrolytesInformed consentPostoperative carePreop evaluationWound/Intestinal stoma managementOther diagnosisHead and NeckNeck massOtitisThyroid and PARTHY diseaseOther diagnosisNeurosurgeryBrain tumorC-spine traumaHead traumaIntracranial hemorrhageOther diagnosisOncologyBreast diseaseColon cancerMelanomaOther diagnosisOphthalmologyCataractConjunctivitisCorneal abrasionDiabetic retinopathy - proliferativePapilledemaOther diagnosisOrthopedicsArthritisDislocationsFracturesLigament and tendon injuriesOrtho emergency - compartment syndromeOrtho emergency - joint infectionOrtho emergency - open fracturesOsteoporosisOther diagnosisPediatricsAbdominal wall defectsIntussusceptionPediatric intestinal obstructionOther diagnosisPlastic SurgeryPostmastectomy reconstructionSkin graftsOther diagnosisUrologyBenign prostatic hypertrophyKidney stonesProstate diseaseVaricoceleOther diagnosisVascularAneurysmal diseaseCarotid artery diseaseVenous diseaseOther diagnosisProcedures (multiple selections allowed):Basic BLSDrawing venous bloodStarting an IVSuturingOther ProcedureClinical Skills (multiple selections allowed):SkillFeedback GivenObserved surgeryYes NoAssisted surgeryYes NoPerformed historyYes NoPerformed Clinical ExamYes NoDeveloped differential diagnosisYes NoWrote patient noteYes NoPerformed oral patient presentationYes NoIncorporated literature into clinical decision-makingYes NoInterpreted common diagnostic and screening testsAGBCXRFast scanKUBPelvic XRYes NoWrote ordersYes NoProvided education to patient and/or familyYes NoInteracted on patient care with at least one members of the inter-professional team (RN, case manager, physical therapist, pharmacist, social worker, nutritionist)Yes NoParticipated in a family meetingYes NoPerformed a patient hand-offYes NoObtained informed consentYes NoNoneYes No ................
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