Date Encounter
Details Preceptor / Site
04-
24-19 Case Log
Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type:
... [Show More] NSG6430
Diagnostic Codes: M25.511 | Pain in right shoulder
M25.552 | Pain in left hip
Patient Age: 53 Years
Patient Sex: F
Patient Enthnicity: Black or African American
CLINICAL NOTES
(Do not enter patient
information that would
violate HIPAA
confidentiality.):
53 y/o female presents to the clinic for follow-up to LEFT hip painshoulder pain. She has a history of chronic pain, fibromyalgia, andher back. Pt received an injection two weeks ago in the orthopedicrelief. She states that the pain in her shoulder began a few years agpresently takes Lyrica and naproxen. Pt has full ROM in R arm, Anoted lateral to spine, near scapular border at the levels of T2-T4. is described as sharp. Movement makes the pain worse, and nothinprescribed toradol 60mg IM now, acetaminophen 500mg and ibupand advised to f/u in 4 weeks.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
(min): 30
Consult with Preceptor
(minutes): 30
Student Participation: 100%
Chief Complaint: Recheck / Shoulder Pain
Type of H&P: Expanded Problem-Focused
Reason for Visit
(Check at least one):
Chronic Care
Episodic (Acute Care)
Follow-up (Routine)
04-
24-19
Case Log Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
Patient Age: 34 Years
Patient Sex: F
Patient Enthnicity: White
CLINICAL NOTES (Do not
enter patient information that
would violate HIPAA
confidentiality.):
Pt reports to the clinic with non-specific complaints. LMPnausea, low back pain. All other tests/exams/systems negaconfirmed with two POC tests. P. 1. Pt advised to east a loB6 intake; 3. Ginger chews PRN for nausea. 4. Prenatal Vwith Obstetrics to schedule Progress checks
Setting Type: Outpatient Clinic
Insurance: Insured
Referral: Obstetrics
Time with Patient (min): 30
Consult with Preceptor
(minutes): 15
Student Participation: 100%
Chief Complaint: Nausea
Type of H&P: Problem-Focused
Reason for Visit (Check at
least one):
Episodic (Acute Care)
Parenting/Family Education Counseling
Prenatal Care
04-
24-19
Case Log Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: A60.04 | Herpesviral vulvovaginitis
E66.9 | Obesity, unspecified
Patient Age: 37 Years
Patient Sex: F
Patient Enthnicity: Black or African American
CLINICAL NOTES
(Do not enter patient
information that would
violate HIPAA
37-year-old black female patient presenting to the office today witwhere her thigh fold is. She had an office visit in June for an initiaprescribed Acyclovir 400mg TID x10 days with positive results. Sreoccurring symptoms. She denies any fever, chills, night sweats,
confidentiality.):
that the symptoms are isolated and warm soaks seems to curtail ththe symptoms return/increase upon exiting the tub and wearing cloPO TID x10 days; 2. Refrain from Sexual Intercourse until lesions500mg PO Q4h PRN Pain; 4. Warm soaks PRN; however, keep arthe tub to promote healing.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
(min): 30
Consult with Preceptor
(minutes): 30
Student Participation: 100%
Chief Complaint: Recurrent Rash
Type of H&P: Expanded Problem-Focused
Reason for Visit (Check
at least one):
Episodic (Acute Care)
Gynecologic Care
Screening/Health Promotion
04-
24-19
Case Log Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: R51 | Headache
Patient Age: 23 Years
Patient Sex: F
Patient Enthnicity: White
CLINICAL NOTES (Do not
enter patient information that
would violate HIPAA
confidentiality.):
23 y/o male with a history of migraines,She states that shand that this headache is not unlike others. CN 2-12 intacdenies vertigo; states she has Photophobia and that there dark room. All other systems negative. P: 1. IM ketorolacRefill Rx for topiramate.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient (min): 30
Consult with Preceptor
(minutes): 15
Student Participation: 100%
Chief Complaint: Headache
Type of H&P: Problem-Focused
Reason for Visit (Check at least
one): Episodic (Acute Care) [Show Less]