Student Information - Ruvinov, Manashir

Semester:

FALL

Course:

N693A - Practicum/FNP

Preceptor:

Moysik, Lyubov

Clinical Site:

All private offices & clinics

Setting Type:

Patient Demographics

Age:

35 years

Biological Sex:

Male

Race:

Black or African American

Insurance:

Medicaid and HMO

Referral:

No referral

Clinical Information

Time with Patient:

30 minutes

Consult with Preceptor:

10 minutes

Type of Decision-Making:

Low complexity

Student Participation:

Shared (50-50)

Reason for Visit:

Episodic

Chief Complaint:

Allergies

Encounter #:

2-5

Type of HP:

Problem Focused

Social Problems Addressed:

Procedures/Skills (Observed/Assisted/Performed)

ICD-10 Diagnosis Codes

#1 - 

z68.37 - BODY MASS INDEX (BMI) 37.0-37.9, ADULT

#2 - 

z00.00 - ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS

CPT Billing Codes

#1 - 

99213 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN

#2 - 

99395 - PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE E&M W/HX/EXAM, EST PT; 18-39 YR

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

Notified advisor of time for visit?:

Yes, visit scheduled

Clinical Notes

Allergies / Adverse Reactions No known allergies or adverse reactions : Current Medications FLUTICASONE NASAL 50 MCG/INH IBUPROFEN 400 MG OMEPRAZOLE 40 MG PREVPAC - VITAMIN B-12 1000 MCG VITAMIN D3 50000 INTL UNITS VOLTAREN TOPICAL 1%-100G ZYRTEC 10 MG 

Family History unremarkable 

No history of behavioral health or substance abuse. Denies family history of cancer of Breast, Uterine, Ovaries, Colon. GYN referral given for PAP test and SCREENED FOR CHLAMYDIA COVID vaccination 2021 flu vaccination - refuse, Spoke with patient about importance of FLU VACCINE. Discussed options for coverage through the NYS Health Exchange and availability of on-site representatives for Medicaid.

Past Medical History Obesity back pain born with one left kidney low vitamin D hyperlipidemia 2 x 2 x 2 mm size nodule in the left lobe of the thyroid gland. HELICOBACTER PYLORI POSITIVE (will start treatment if husband is positive) low vitamin D chest pain ( possible anxiety) thyroid nodule 

Social History - Alcohol: none - Cigarettes: none - Recreational Drugs: Never 

Surgical History CS X 1