Patient Reference: K.B. Course: NURS-7440 (2013 Summer/Fall/Spring)
Race/Ethnicity: European Caucasian Site:Baldwin County Primary Care LLC
Gender: Female Interaction Level:Level 4
Age: 20 years Adult/Child: Adult Marital status at first contact: Single/Never Married
Date patient first seen: 6/11/2013 Primary Payment Method: Self Pay
New Visit
Visits
1 Visit(s): 6/11/2013
Case Type: OBGYN Time: 09:00 - 09:30
Position: Supine BMI: 24.3 Height: 65 Weight: 146
Preceptor: Sandra Alexander
Diagnosis241.0 Thyroid nodule
477.9 Rhinitis, allergic, cause unspec.
623.5 Leukorrhea, NOS
780.79 Fatigue
(Add Visit Data) Diagnosis CPT 2010 Medications Counseling Wellness Diseases Social Immunizations
Student Comments
This patient was a follow-up appointment of sore throat. Sore throat is gone but does have white vaginal discharge she has stated. When started Metrogel had a white ball discharge no puritis she states.
Plan-
1. Advised patient doscharge most likely will residual get from Metrogel treatment.
2. Continue Zyrtec and Flonase
3. Follow-up as scheduled.
Race/Ethnicity: European Caucasian Site:Baldwin County Primary Care LLC
Gender: Female Interaction Level:Level 4
Age: 20 years Adult/Child: Adult Marital status at first contact: Single/Never Married
Date patient first seen: 6/11/2013 Primary Payment Method: Self Pay
New Visit
Visits
1 Visit(s): 6/11/2013
Case Type: OBGYN Time: 09:00 - 09:30
Position: Supine BMI: 24.3 Height: 65 Weight: 146
Preceptor: Sandra Alexander
Diagnosis241.0 Thyroid nodule
477.9 Rhinitis, allergic, cause unspec.
623.5 Leukorrhea, NOS
780.79 Fatigue
(Add Visit Data) Diagnosis CPT 2010 Medications Counseling Wellness Diseases Social Immunizations
Student Comments
This patient was a follow-up appointment of sore throat. Sore throat is gone but does have white vaginal discharge she has stated. When started Metrogel had a white ball discharge no puritis she states.
Plan-
1. Advised patient doscharge most likely will residual get from Metrogel treatment.
2. Continue Zyrtec and Flonase
3. Follow-up as scheduled.