gcf
Encounter
Date Preceptor / Site
Details
Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
M25.511 | Pain in right shoulder
Diagnostic Codes:
M25.552 | Pain in left hip
Patient Age: 53 Years
Patient Sex: F
Patient Enthnicity: Black or African American
53 y/o female presents to the clinic for follow-up to LEFT hip pain
shoulder pain. She has a history of chronic pain, fibromyalgia, and
CLINICAL NOTES her back. Pt received an injection two weeks ago in the orthopedic
(Do not enter patient relief. She states that the pain in her shoulder began a few years ag
information that would presently takes Lyrica and naproxen. Pt has full ROM in R arm, A
violate HIPAA noted lateral to spine, near scapular border at the levels of T2-T4.
confidentiality.): is described as sharp. Movement makes the pain worse, and nothin
04- prescribed toradol 60mg IM now, acetaminophen 500mg and ibup
Case Log and advised to f/u in 4 weeks.
24-19
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
30
(min):
Consult with Preceptor
30
(minutes):
Student Participation: 100%
Chief Complaint: Recheck / Shoulder Pain
Type of H&P: Expanded Problem-Focused
Chronic Care
Reason for Visit
Episodic (Acute Care)
(Check at least one):
Follow-up (Routine)
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
, Patient Age: 34 Years
Patient Sex: F
Patient Enthnicity: White
Pt reports to the clinic with non-specific complaints. LMP
CLINICAL NOTES (Do not
nausea, low back pain. All other tests/exams/systems nega
enter patient information that
confirmed with two POC tests. P. 1. Pt advised to east a lo
would violate HIPAA
B6 intake; 3. Ginger chews PRN for nausea. 4. Prenatal Vi
confidentiality.):
with Obstetrics to schedule Progress checks
Setting Type: Outpatient Clinic
Insurance: Insured
Referral: Obstetrics
Time with Patient (min): 30
Consult with Preceptor
15
(minutes):
Student Participation: 100%
Chief Complaint: Nausea
Type of H&P: Problem-Focused
Episodic (Acute Care)
Reason for Visit (Check at
Parenting/Family Education Counseling
least one):
Prenatal Care
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
A60.04 | Herpesviral vulvovaginitis
Diagnostic Codes:
E66.9 | Obesity, unspecified
Patient Age: 37 Years
Patient Sex: F
Patient Enthnicity: Black or African American
CLINICAL NOTES 37-year-old black female patient presenting to the office today wit
(Do not enter patient where her thigh fold is. She had an office visit in June for an initia
information that would prescribed Acyclovir 400mg TID x10 days with positive results. S
violate HIPAA reoccurring symptoms. She denies any fever, chills, night sweats,
, that the symptoms are isolated and warm soaks seems to curtail th
the symptoms return/increase upon exiting the tub and wearing clo
confidentiality.): PO TID x10 days; 2. Refrain from Sexual Intercourse until lesions
500mg PO Q4h PRN Pain; 4. Warm soaks PRN; however, keep ar
the tub to promote healing.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
30
(min):
Consult with Preceptor
30
(minutes):
Student Participation: 100%
Chief Complaint: Recurrent Rash
Type of H&P: Expanded Problem-Focused
Episodic (Acute Care)
Reason for Visit (Check
Gynecologic Care
at least one):
Screening/Health Promotion
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: R51 | Headache
Patient Age: 23 Years
Patient Sex: F
Patient Enthnicity: White
23 y/o male with a history of migraines,She states that sh
CLINICAL NOTES (Do not
and that this headache is not unlike others. CN 2-12 intac
enter patient information that
denies vertigo; states she has Photophobia and that there
would violate HIPAA
dark room. All other systems negative. P: 1. IM ketorolac
confidentiality.):
Refill Rx for topiramate.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient (min): 30
, Consult with Preceptor
15
(minutes):
Student Participation: 100%
Chief Complaint: Headache
Type of H&P: Problem-Focused
Reason for Visit (Check at least
Episodic (Acute Care)
one):
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
F41.1 | Generalized anxiety disorder
Diagnostic Codes: F43.20 | Adjustment disorder, unspecified
F51.02 | Adjustment insomnia
Patient Age: 31 Years
Patient Sex: F
Patient Enthnicity: Black or African American
Pt is a 31 y/o black female with a mother that passed away in August.
improperly and has increased anger, hostility and has distanced hersel
family. Pt denies HI/SI; however, has thoughts of what would it be lik
considered hurting someone in order to elicit a behavioral change in t
CLINICAL NOTES previously taken bupurnoriphen and states she does not like taking me
(Do not enter was increased - she abruptly stopped. Pt is a student and unemployed
patient information frustration. She states that she has had more panic attacks with increas
that would violate Allergies: PCN, Codeine Pr states that she has recently lost 15lbs from
HIPAA children (and one adopted) - she is maintaining the ability to care for
confidentiality.): biological father does not provide child support. Pt is in a relationship
the natural parent and prospective step-parent. Pt denies other sympto
dizziness and anorexia and states that she isnt eating well. . Continue
new medication (Paxil 20mg QD) 3. Trazadone; 4. Follow-up with m
know of medication change.
Setting Type: Outpatient Clinic
Insurance: Insured
Referral: Mental Health Services
Time with Patient
45
(min):
Consult with 30
Encounter
Date Preceptor / Site
Details
Kimberly McKissack
Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
M25.511 | Pain in right shoulder
Diagnostic Codes:
M25.552 | Pain in left hip
Patient Age: 53 Years
Patient Sex: F
Patient Enthnicity: Black or African American
53 y/o female presents to the clinic for follow-up to LEFT hip pain
shoulder pain. She has a history of chronic pain, fibromyalgia, and
CLINICAL NOTES her back. Pt received an injection two weeks ago in the orthopedic
(Do not enter patient relief. She states that the pain in her shoulder began a few years ag
information that would presently takes Lyrica and naproxen. Pt has full ROM in R arm, A
violate HIPAA noted lateral to spine, near scapular border at the levels of T2-T4.
confidentiality.): is described as sharp. Movement makes the pain worse, and nothin
04- prescribed toradol 60mg IM now, acetaminophen 500mg and ibup
Case Log and advised to f/u in 4 weeks.
24-19
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
30
(min):
Consult with Preceptor
30
(minutes):
Student Participation: 100%
Chief Complaint: Recheck / Shoulder Pain
Type of H&P: Expanded Problem-Focused
Chronic Care
Reason for Visit
Episodic (Acute Care)
(Check at least one):
Follow-up (Routine)
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: Z32.01 | Encounter for pregnancy test, result positive
, Patient Age: 34 Years
Patient Sex: F
Patient Enthnicity: White
Pt reports to the clinic with non-specific complaints. LMP
CLINICAL NOTES (Do not
nausea, low back pain. All other tests/exams/systems nega
enter patient information that
confirmed with two POC tests. P. 1. Pt advised to east a lo
would violate HIPAA
B6 intake; 3. Ginger chews PRN for nausea. 4. Prenatal Vi
confidentiality.):
with Obstetrics to schedule Progress checks
Setting Type: Outpatient Clinic
Insurance: Insured
Referral: Obstetrics
Time with Patient (min): 30
Consult with Preceptor
15
(minutes):
Student Participation: 100%
Chief Complaint: Nausea
Type of H&P: Problem-Focused
Episodic (Acute Care)
Reason for Visit (Check at
Parenting/Family Education Counseling
least one):
Prenatal Care
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
A60.04 | Herpesviral vulvovaginitis
Diagnostic Codes:
E66.9 | Obesity, unspecified
Patient Age: 37 Years
Patient Sex: F
Patient Enthnicity: Black or African American
CLINICAL NOTES 37-year-old black female patient presenting to the office today wit
(Do not enter patient where her thigh fold is. She had an office visit in June for an initia
information that would prescribed Acyclovir 400mg TID x10 days with positive results. S
violate HIPAA reoccurring symptoms. She denies any fever, chills, night sweats,
, that the symptoms are isolated and warm soaks seems to curtail th
the symptoms return/increase upon exiting the tub and wearing clo
confidentiality.): PO TID x10 days; 2. Refrain from Sexual Intercourse until lesions
500mg PO Q4h PRN Pain; 4. Warm soaks PRN; however, keep ar
the tub to promote healing.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient
30
(min):
Consult with Preceptor
30
(minutes):
Student Participation: 100%
Chief Complaint: Recurrent Rash
Type of H&P: Expanded Problem-Focused
Episodic (Acute Care)
Reason for Visit (Check
Gynecologic Care
at least one):
Screening/Health Promotion
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
Diagnostic Codes: R51 | Headache
Patient Age: 23 Years
Patient Sex: F
Patient Enthnicity: White
23 y/o male with a history of migraines,She states that sh
CLINICAL NOTES (Do not
and that this headache is not unlike others. CN 2-12 intac
enter patient information that
denies vertigo; states she has Photophobia and that there
would violate HIPAA
dark room. All other systems negative. P: 1. IM ketorolac
confidentiality.):
Refill Rx for topiramate.
Setting Type: Outpatient Clinic
Insurance: Insured
Time with Patient (min): 30
, Consult with Preceptor
15
(minutes):
Student Participation: 100%
Chief Complaint: Headache
Type of H&P: Problem-Focused
Reason for Visit (Check at least
Episodic (Acute Care)
one):
04- Case Log Kimberly McKissack
24-19 Hampton Veterans Administration Medical Center
Rotation Type: NSG6430
F41.1 | Generalized anxiety disorder
Diagnostic Codes: F43.20 | Adjustment disorder, unspecified
F51.02 | Adjustment insomnia
Patient Age: 31 Years
Patient Sex: F
Patient Enthnicity: Black or African American
Pt is a 31 y/o black female with a mother that passed away in August.
improperly and has increased anger, hostility and has distanced hersel
family. Pt denies HI/SI; however, has thoughts of what would it be lik
considered hurting someone in order to elicit a behavioral change in t
CLINICAL NOTES previously taken bupurnoriphen and states she does not like taking me
(Do not enter was increased - she abruptly stopped. Pt is a student and unemployed
patient information frustration. She states that she has had more panic attacks with increas
that would violate Allergies: PCN, Codeine Pr states that she has recently lost 15lbs from
HIPAA children (and one adopted) - she is maintaining the ability to care for
confidentiality.): biological father does not provide child support. Pt is in a relationship
the natural parent and prospective step-parent. Pt denies other sympto
dizziness and anorexia and states that she isnt eating well. . Continue
new medication (Paxil 20mg QD) 3. Trazadone; 4. Follow-up with m
know of medication change.
Setting Type: Outpatient Clinic
Insurance: Insured
Referral: Mental Health Services
Time with Patient
45
(min):
Consult with 30
