case log

Student Information

Semester:

Summer

Course:

MSN5700C Advanced Practice in Primary Care I

Preceptor:

Clinical Site:

Setting Type:

Patient Demographics

Age:

72 years

Biological Sex:

Female

Race:

Hispanic

Insurance:

Dual Eligible

Referral:

No referral

Clinical Information

Time with Patient:

30 minutes

Consult with Preceptor:

15 minutes

Type of Decision-Making:

Moderate complexity

Reason for Visit:

Episodic

Chief Complaint:

I can't sleep at night

Type of HP:

Problem Focused

Social Problems Addressed:

Sanitation/Hygiene Safety Grief Emotional Nutrition/Exercise  

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment - Physical Assessment (Perf) General Skills - Vital Signs (Perf)

ICD-10 Diagnosis Codes

#1 - 

G47.00 - INSOMNIA, UNSPECIFIED

#2 - 

Z63.4 - DISAPPEARANCE AND DEATH OF FAMILY MEMBER

CPT Billing Codes

#1 - 

99214 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-39 MIN

Birth & Delivery

Medications

# OTC Drugs taken regularly:

2

# Prescriptions currently prescribed:

3

# New/Refilled Prescriptions This Visit:

2

Types of New/Refilled Prescriptions This Visit: Psychiatric - Antidepressants Psychiatric - Benzodiazepines  

Adherence Issues with Medications:  

Other Questions About This Case

Patient's Primary Language:

Spanish

Smoking Assessment:

Never

Advanced Directive:

Yes, on file

Packs per day:

Clinical Notes

Patient presented to the office today with C/O insomnia for a couple of months after the death of her husband, patient tried OTC medications with no improvement. Referral for psychology visit.