Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-001
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 60 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 787.01 - NAUSEA WITH VOMITING
#2 - 117.9 - OTH/UNS MYCOSES
#3 - 346.00 - MIGRAINE W AURA NOT INTRACT WO STATUS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 6
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - Nausea meds
Neurology - Migraine
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-002
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 60 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 6 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 782.1 - RASH/OTH NONSPEC SKIN ERUPTION
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes
referred to dermatology immediately.

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-003
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 72 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 7 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 250.00 - DIABETES UNCOMPL TYPE II
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-004
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 42 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 19 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 487.1 - INFLUENZA W OTH RESPIRATORY MANIF
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Non-narcotic antitussives
ENT - Miscellaneous ENT
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-005
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 80 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 272.0 - PURE HYPERCHOLESTEROLEMIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Insulin
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140917-006
Date of Service: 9/17/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 66 years
Race: Black or African American
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Annual/Well-Person Exam
Encounter #: 6-10
Type of HP: Detailed
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 272.4 - OTH/UNS HYPERLIPIDEMIA
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-001
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-002
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 428.0 - CONGESTIVE HEART FAILURE UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Diuretics
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-003
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 42 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 729.1 - UNS MYALGIA/MYOSITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-004
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 29 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 19 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 692.6 - CONTACT DERMATITIS PLANTS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Dermatology - Miscellaneous dermatologicals
ENT - Antihistamines
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-005
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 66 years
Race: Black or African American
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 490 - BRONCHITIS NOT SPECIFIED ACUTE/CHRONIC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Non-narcotic antitussives
ENT - Miscellaneous ENT
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140918-006
Date of Service: 9/18/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 18 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 493 - ASTHMA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140922-001
Date of Service: 9/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 68 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 530.81 - ESOPHAGEAL REFLUX
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140922-002
Date of Service: 9/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 42 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 300.09 - OTHER ANXIETY STATES
#2 - 250.00 - DIABETES UNCOMPL TYPE II
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Oral glucose lowering agents
Psychiatric - Benzodiazepines
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140922-003
Date of Service: 9/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 52 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 11 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 111.0 - PITYRIASIS VERSICOLOR
#2 - 550 - INGUINAL HERNIA
#3 - 477.9 - ALLERGIC RHINITIS CAUSE UNS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Nasal decongestants
Other Questions About This Case
Clinical Notes
refer to surgery

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140922-004
Date of Service: 9/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 59 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 599.0 - URINARY TRACT INFECTION UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 5
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Fluoroquinolones
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140922-005
Date of Service: 9/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 340 - MULTIPLE SCLEROSIS
#2 - 272.4 - OTH/UNS HYPERLIPIDEMIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 5
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140924-001
Date of Service: 9/24/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 72 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 185 - MALIGNANT NEOPLASM PROSTATE
#2 - 257.2 - OTH TESTICULAR HYPOFUNCTION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140924-002
Date of Service: 9/24/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 47 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 300.2 - PHOBIC DISORDERS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140924-003
Date of Service: 9/24/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 60 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 21 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 702.1 - SEBORRHEIC KERATOSIS
CPT Billing Codes
#1 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
#2 - 11401 - EXCISE, BENIGN SKIN LESION, INCL MARGINS, EXCEPT SKIN TAG,
TRUNK/ARMS/LEGS; EXCISED DIAM 0.6-1.0 CM
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140924-004
Date of Service: 9/24/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 52 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 465.9 - ACUTE UPPER RESP INFECTIONS UNS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140924-005
Date of Service: 9/24/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 35 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 278.00 - OBESITY UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
adipex

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-001
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 46 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 490 - BRONCHITIS NOT SPECIFIED ACUTE/CHRONIC
CPT Billing Codes
#1 - 9921 is not a valid CPT code.
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-002
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 40 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Insulin
Other Questions About This Case
Clinical Notes
endocrinology referral

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-003
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 65 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
#3 - v12.54 - HISTORY TIA/CEREBRAL INFARCTION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 5
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Insulin
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-004
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 18 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 5 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-005
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: Black or African American
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Cardiology - Diuretics
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-006
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 32 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 490 - BRONCHITIS NOT SPECIFIED ACUTE/CHRONIC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Non-narcotic antitussives
ENT - Nasal decongestants
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140925-007
Date of Service: 9/25/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 13 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 787.01 - NAUSEA WITH VOMITING
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - Nausea meds
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140929-001
Date of Service: 9/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 53 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 461.9 - UNS ACUTE SINUSITIS
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Decongestants/antihistamine combinations
ENT - Intranasal steroids
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140929-002
Date of Service: 9/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 45 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Annual/Well-Person Exam
Encounter #: 2-5
Type of HP: Detailed
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 278.00 - OBESITY UNSPEC
#2 - 375.15 - UNS TEAR FILM INSUFFICIENCY
CPT Billing Codes
#1 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes
referred to opthamology

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140929-003
Date of Service: 9/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 42 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 728.71 - PLANTAR FASCIAL FIBROMATOSIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140929-004
Date of Service: 9/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 56 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 278.00 - OBESITY UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20140929-005
Date of Service: 9/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 5 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 461.9 - UNS ACUTE SINUSITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Macrolides
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
Depo shot
z pack

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141001-001
Date of Service: 10/1/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 70 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 733.0 - OSTEOPOROSIS
#2 - 401.9 - UNS HYPERTENSION
#3 - 272.4 - OTH/UNS HYPERLIPIDEMIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141001-002
Date of Service: 10/1/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 42 years
Race: Black or African American
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 5 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 054.10 - GENITAL HERPES UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
acyclovir

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141001-003
Date of Service: 10/1/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 054.10 - GENITAL HERPES UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
acyclovir

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141001-004
Date of Service: 10/1/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 66 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 3
# Prescriptions currently prescribed: 8
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141001-005
Date of Service: 10/1/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-001
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 34 years
Race: Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 473.9 - UNS SINUSITIS (CHRONIC)
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Intranasal steroids
ENT - Nasal decongestants
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-002
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 16 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-003
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 38 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 13 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 599.0 - URINARY TRACT INFECTION UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Macrolides
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-004
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 346.9 - MIGRAINE UNSPECIFIED
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
botox injections for migraine

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-005
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 26 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 346.9 - MIGRAINE UNSPECIFIED
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
botox injections for migraine

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141002-006
Date of Service: 10/2/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 23 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 346.9 - MIGRAINE UNSPECIFIED
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
botox injections for migraine

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141006-001
Date of Service: 10/6/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 27 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.00 - ATTENTION DEFICIT DIS WO HYPERACTV
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141006-002
Date of Service: 10/6/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 46 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 13 minutes
Consult with Preceptor: 5 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Diuretics
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141006-003
Date of Service: 10/6/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 54 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 491.21 - OBSTRUCT CHRON BRONCHITIS W EXAC
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Pulmonary - Steroid inhalers
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
steroids

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141006-004
Date of Service: 10/6/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 54 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Annual/Well-Person Exam
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 530.81 - ESOPHAGEAL REFLUX
CPT Billing Codes
#1 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Adrenergic blockers
GI Agents - H+/K+ ATPase enzyme inhibitors (ie
omeprazole)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141006-005
Date of Service: 10/6/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 36 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Annual/Well-Person Exam
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 530.81 - ESOPHAGEAL REFLUX
CPT Billing Codes
#1 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - H2 receptor antagonists
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141008-001
Date of Service: 10/8/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: Black or African American
Gender: Male
Insurance: Medicare
Referral: Physician
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
#3 - v12.54 - HISTORY TIA/CEREBRAL INFARCTION
#4 - 054.9 - HERPES SIMPLEX WO COMPLI
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 8
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Endocrinology - Insulin
Other Questions About This Case
Clinical Notes
refer to endocrinology

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141008-002
Date of Service: 10/8/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 26 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 13 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 787.1 - HEARTBURN
#2 - v25.01 - PRESCRIPTION ORAL CONTRACEPTIVES
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - H+/K+ ATPase enzyme inhibitors (ie
omeprazole)
Gynecology - Oral contraception
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141008-003
Date of Service: 10/8/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 6 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 465.9 - ACUTE UPPER RESP INFECTIONS UNS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141008-004
Date of Service: 10/8/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 55 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 719.46 - PAIN IN JOINT LOWER LEG
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Analgesic/Antipyretic - Miscellaneous
Other Questions About This Case
Clinical Notes
flector patch

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141008-005
Date of Service: 10/8/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 64 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: Physical Therapist
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 386.11 - BENIGN PAROXYSMAL POSITION VERTIGO
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 6
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes
referred to physical therapy

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-001
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 68 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 428.0 - CONGESTIVE HEART FAILURE UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 3
# Prescriptions currently prescribed: 6
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Diuretics
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-002
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 36 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 078.0 - MOLLUSCUM CONTAGIOSUM
#2 - 530.81 - ESOPHAGEAL REFLUX
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - H2 receptor antagonists
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-003
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 34 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicaid
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Pulmonary - Steroid inhalers
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
steroids

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-004
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 21 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 461.9 - UNS ACUTE SINUSITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Nasal decongestants
Infectious Diseases - lactams
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-005
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 34 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 471.9 - UNS NASAL POLYP
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes
refer to ENT due to nasal polyps obstructing nasal passageway

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141009-006
Date of Service: 10/9/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 63 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 250.00 - DIABETES UNCOMPL TYPE II
#3 - v12.54 - HISTORY TIA/CEREBRAL INFARCTION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Adrenergic blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141013-001
Date of Service: 10/13/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 67 years
Race: Black or African American
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 724.4 - UNS THORACIC/LUMB NEURITIS/RADICUL
#2 - 401.9 - UNS HYPERTENSION
#3 - 477.9 - ALLERGIC RHINITIS CAUSE UNS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 8
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141013-002
Date of Service: 10/13/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 48 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 10 minutes
Consult with Preceptor: 1 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Pulmonary - Steroid inhalers
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
depo shot

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141013-003
Date of Service: 10/13/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 22 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - v25.40 - UNS CONTRACEPTIVE SURVEILANCE
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Gynecology - Depo-Provera (IM)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141013-004
Date of Service: 10/13/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 55 years
Race: White, Non Hispanic
Gender: Male
Insurance: No insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 250.00 - DIABETES UNCOMPL TYPE II
#2 - 401.9 - UNS HYPERTENSION
#3 - 753.12 - POLYCYSTIC KIDNEY UNS TYPE
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 8
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Endocrinology - Insulin
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141013-005
Date of Service: 10/13/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 68 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 682.9 - UNSPEC CELLULITIS/ABSCESS
#2 - 244.9 - UNS HYPOTHYROIDISM
#3 - 340 - MULTIPLE SCLEROSIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 3
# Prescriptions currently prescribed: 6
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Miscellaneous antibiotics
Other Questions About This Case
Clinical Notes
Septra DS and silvadine

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141015-001
Date of Service: 10/15/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 54 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 274.9 - UNS GOUT
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
depo shot and colchichine

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141015-002
Date of Service: 10/15/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 72 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 6 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
#2 - 272.4 - OTH/UNS HYPERLIPIDEMIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Non-narcotic antitussives
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141015-003
Date of Service: 10/15/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 22 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 15 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 724.2 - LUMBAGO
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - Muscle relaxants
Analgesic/Antipyretic - NSAIDS
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141015-004
Date of Service: 10/15/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 32 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 787.91 - DIARRHEA
#2 - 558.9 - OTH NONINFECTIOUS GASTROENTERITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - Diarrhea meds
GI Agents - Nausea meds
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-001
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: Black or African American
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-002
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 22 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-003
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 19 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: Mental Health/Counseling
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 296.3 - MAJOR DEPRESSIVE DISORDER RECURR
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Antidepressants
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-004
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 23 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 12 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - v25.09 - OTH COUNSEL/ADVICE FOR CONTRACEPT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Gynecology - Oral contraception
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-005
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 33 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 881.0 - OPEN WOUND OF ELBOW/FOREARM WO CMP
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141016-006
Date of Service: 10/16/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - ACE inhibitors
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141020-001
Date of Service: 10/20/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Observation only
Reason for Visit: Annual/Well-Person Exam
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 250.00 - DIABETES UNCOMPL TYPE II
#3 - 530.81 - ESOPHAGEAL REFLUX
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Endocrinology - Oral glucose lowering agents
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141020-002
Date of Service: 10/20/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 724.2 - LUMBAGO
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - Muscle relaxants
Analgesic/Antipyretic - NSAIDS
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141020-003
Date of Service: 10/20/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Non-narcotic antitussives
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141020-004
Date of Service: 10/20/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 52 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: Physician
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 791.0 - PROTEINURIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141020-005
Date of Service: 10/20/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 22 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Moderate complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 702.11 - INFLAMED SEBORRHEIC KERATOSIS
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 11400 - EXCISE, BENIGN SKIN LESION, INCL MARGINS, EXCEPT SKIN TAG,
TRUNK/ARMS/LEGS; EXCISED DIAM 0.5 CM/<
#2 - 99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM;
MED DECISION MOD COMPLEXITY
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-001
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 3
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Non-narcotic antitussives
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-002
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 32 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-003
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 44 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 13 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 244.9 - UNS HYPOTHYROIDISM
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Angiotensin II receptor blockers
Endocrinology - Thyroid
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-004
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 27 years
Race: Black or African American
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 401.9 - UNS HYPERTENSION
#2 - 278.01 - MORBID OBESITY
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Cardiology - Calcium channel blockers
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-005
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 89 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: Physician
Clinical Information
Time with Patient: 22 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: >10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 578.9 - UNS HEMORR GASTROINTESTINAL TRACT
#2 - v12.54 - HISTORY TIA/CEREBRAL INFARCTION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
refer to GI

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141022-006
Date of Service: 10/22/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 48 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 10 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 461.9 - UNS ACUTE SINUSITIS
#2 - 296.3 - MAJOR DEPRESSIVE DISORDER RECURR
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Antihistamines
ENT - Nasal decongestants
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-001
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 17 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 314.01 - ATTENTION DEFICIT DIS W HYPERACT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Psychiatric - Miscellaneous psychiatric
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-002
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 724.2 - LUMBAGO
#2 - 401.9 - UNS HYPERTENSION
#3 - 250.00 - DIABETES UNCOMPL TYPE II
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 5
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Cardiology - ACE inhibitors
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-003
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 22 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 346.9 - MIGRAINE UNSPECIFIED
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
botox injections for migraines

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-004
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 34 years
Race: White, Non Hispanic
Gender: Male
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 726.64 - PATELLAR TENDINITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-005
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 68 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 599.0 - URINARY TRACT INFECTION UNSPEC
#2 - 401.9 - UNS HYPERTENSION
#3 - 272.4 - OTH/UNS HYPERLIPIDEMIA
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 2
# Prescriptions currently prescribed: 4
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Macrolides
Urology - Antispasmodic, urinary
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141023-006
Date of Service: 10/23/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 28 years
Race: Black or African American
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 558.9 - OTH NONINFECTIOUS GASTROENTERITIS
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
GI Agents - Nausea meds
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141027-001
Date of Service: 10/27/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 73 years
Race: White, Non Hispanic
Gender: Female
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 413.9 - OTH/UNS ANGINA PECTORIS
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Clinical Notes
possible h pylori.

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141027-002
Date of Service: 10/27/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 73 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 14 minutes
Consult with Preceptor: 3 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Other
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 715.00 - OSTEOARTHROSIS GENERALIZED UNS SITE
#2 - 401.9 - UNS HYPERTENSION
#3 - 274.9 - UNS GOUT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Analgesic/Antipyretic - NSAIDS
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141027-003
Date of Service: 10/27/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 18 years
Race: Black or African American
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - v25.09 - OTH COUNSEL/ADVICE FOR CONTRACEPT
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Gynecology - Depo-Provera (IM)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141027-004
Date of Service: 10/27/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 62 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 4 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 599.0 - URINARY TRACT INFECTION UNSPEC
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 2
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Infectious Diseases - Penicillins
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141029-001
Date of Service: 10/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 36 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 18 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 346.9 - MIGRAINE UNSPECIFIED
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 0
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Miscellaneous - Not covered elsewhere
Other Questions About This Case
Clinical Notes
botox injections for migraines

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141029-002
Date of Service: 10/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 66 years
Race: White, Non Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 16 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Observation only
Reason for Visit: Follow-up (Routine)
Encounter #: 6-10
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - 466.0 - ACUTE BRONCHITIS
#2 - 401.9 - UNS HYPERTENSION
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 3
# New/Refilled Prescriptions This Visit: 2
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
ENT - Non-narcotic antitussives
Pulmonary - Nonsteroidal anti-inflammatory (ie Tilade)
Other Questions About This Case
Clinical Notes

Albany State University CHP (Acct #7157)

Case ID #: 1532-20141029-003
Date of Service: 10/29/2014
Student Information - Warren,Alexander
Semester: Fall
Course: Nurs 6211 Primary Care of Adults
Preceptor: Sule, Judit
Clinical Site: Medical Diagnostics
Setting Type:
Patient Demographics
Age: 18 years
Race: White, Non Hispanic
Gender: Female
Insurance: Private insurance
Referral: No referral
Clinical Information
Time with Patient: 20 minutes
Consult with Preceptor: 2 minutes
Type of Decision-Making: Low complexity
Student Participation: Less than shared
Reason for Visit: Follow-up (Routine)
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-9 Diagnosis Codes
#1 - v25.40 - UNS CONTRACEPTIVE SURVEILANCE
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
Medications
# OTC Drugs taken regularly: 0
# Prescriptions currently prescribed: 0
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Gynecology - Oral contraception
Other Questions About This Case
Clinical Notes