<table border="0" width="100%" cellpadding="0" cellspacing="0"> <tr> <td bgcolor="#000000" style="padding-left:2px; padding-right:10px; padding-top:2px; padding-bottom:2px"> <p><font color="#FFFFFF" size="2">&nbsp; <b>Miami Regional University&nbsp;&nbsp; </b>(Acct #3111)</font></td> </tr></table><font size="2"></font><table border="0" width="100%" cellpadding="0" cellspacing="0" bgcolor="#C0C0C0"> <tr> <td width="50%"><b><font size="2">&nbsp; Case ID #: 2844-20220302-002</b></font><font size="2">&nbsp;&nbsp;(Status:&nbsp;Approved)</font></td> <td width="50%"> <p align="right"><b><font size="2">Date of Service: 3/2/2022&nbsp;</font></b><font size="2"></b></font></font></font></td> </tr></table><table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td WIDTH="100%" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Student Information – Santiesteban Molina, Osmel</b></font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b>Semester:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2">Spring</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <font size="2"><b>Course:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2">MSN6050C Advanced Practice Women Health</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2">Preceptor: </font></b></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2">TREJO, RODOLFO </font> </td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> <b><font size="2">Clinical Site</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"><font size="2">Neighborhood Family Doctor.Atlantis</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18" valign="top"> <b><font size="2"> Setting Type</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"><font size="2">Underserved area/population</font></td> </tr> <tr> <td WIDTH="100%" bgcolor="#000000" align="right" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Patient Demographics</b></font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><font size="2"><b> Age:</b></font></td> <td bgcolor="#FFFFFF"><font size="2">30 years</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Race</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2">Hispanic</font></td> </tr><tr> <td WIDTH="50%" bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Gender</font></b><font size="2"><b>:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF"><font size="2">Female</font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Insurance</font></b><font size="2"><b>:</b></font></td> <td bgcolor="#FFFFFF"><font size="2">Private insurance</font></td> </tr> <tr> <td bgcolor="#FFFFFF"> <p align="right"><b><font size="2">Referral</font></b><font size="2"><b>:</b></font></td> <td bgcolor="#FFFFFF"><font size="2">No referral</font></td> </tr> <tr> <td valign="top" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>Clinical Information</b></font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b> Time with Patient:</b></font></td> <td bgcolor="#FFFFFF"><font size="2">15 minutes</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <p align="right"><font size="2"><b> Consult with Preceptor:</b></font></td> <td bgcolor="#FFFFFF"><font size="2">5 minutes</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Type of Decision-Making:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2">Straightforward</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Reason for Visit:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2">Episodic</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2"> Chief Complaint:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2">"Cramping in the lower abdomen"</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right"> <b><font size="2">Type of HP:</font></b></td> <td bgcolor="#FFFFFF"> <font size="2">Problem Focused</font></td> </tr> <tr> <td bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">Social Problems Addressed:</font></b></td> <td bgcolor="#FFFFFF"><font size="2">Sanitation/Hygiene<br>Safety<br>Emotional<br>Sexuality<br>Prevention<br>Nutrition/Exercise<br> &nbsp;</font></font></td> </tr></table><TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"><font color="#FFFFFF" size="2"><b>Procedures/Skills (Observed/Assisted/Performed)</b></font></td></tr><tr><td width="100%" bgcolor="#FFFFFF" align="left" colspan="2"><font size="2">Physical Assessment – Physical Assessment (Perf)<BR></font></td></tr></table> <table border="0" cellspacing="0" WIDTH="100%" bordercolor="#99CCFF"> <tr> <td width="100%" bgcolor="#000000" align="center" colspan="2" style="border-style: solid; border-width: 2px"><font color="#FFFFFF" size="2"><b>ICD-10 Diagnosis Codes</b></font></td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">#1 -</font></b><font size="2">&nbsp; </font> </td> <td width="90%" bgcolor="#FFFFFF" align="left"><font size="2">N94.4&nbsp;- PRIMARY DYSMENORRHEA </font> </td> </tr> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px"> <p align="center"><font color="#FFFFFF" size="2"><b>CPT Billing Codes</b></font></td> </tr> <tr> <td width="10%" bgcolor="#FFFFFF" align="right" valign="top"> <b><font size="2">#1 -</font></b><font size="2">&nbsp; </font> </td> <td width="90%" bgcolor="#FFFFFF" align="left"><font size="2">99212&nbsp;- OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; STRTFWD MED DECISION; 10-19 MIN </font> </td> </tr></table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> <p align="center"><b><font size="2" color="#FFFFFF">Birth & Delivery</font></b></td> </tr> </table> <table border="0" cellspacing="0" WIDTH="100%" cellpadding="1"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" style="border-style: solid; border-width: 2px" bordercolor="#99CCFF"> <p align="center"><b><font size="2" color="#FFFFFF">Medications</font></b></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <p><b><font size="2"># OTC Drugs taken regularly:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"><font size="2">2</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2"># Prescriptions currently prescribed:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"><font size="2">1</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="right"> <b><font size="2"># New/Refilled Prescriptions This Visit:</font></b></td> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"><font size="2">2</font></td> </tr> <tr> <td width="50%" bgcolor="#FFFFFF" align="left" valign="top"><u><b><font size="2">Types of New/Refilled Prescriptions This Visit:</font></b></u><font size="2"><BR>Analgesic/Antipyretic – NSAIDS<BR>Endocrinology – Sex steroids/hormones<BR>&nbsp;</font></td><td width="50%" bgcolor="#FFFFFF" align="left" valign="top"><u><b><font size="2">Adherence Issues with Medications:</font></b></u><font size="2"><BR> &nbsp;</font></td></tr></table><TABLE BORDER="0" CELLPADDING="1" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td WIDTH="100%" align="right" bgcolor="#000000" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"> <p align="center"><b><font size="2" color="#FFFFFF">Other Questions About This Case</font></b></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Patient's Primary Language:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"><font size="2">Spanish</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Smoking Assessment:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"><font size="2">History</font></td> </tr> <tr> <td WIDTH="50%" bgcolor="#FFFFFF" align="right" height="18"> <b><font size="2">Advanced Directive:</b></font></td> <td WIDTH="50%" bgcolor="#FFFFFF" height="18"><font size="2">No</font></td> </tr><tr><td bgcolor='#FFFFFF' valign = 'top' width='50%'><p align='right'><font size='2'><b>Packs per day:</b></font></td><td bgcolor='#FFFFFF'><font size='2'>0</font></td></tr></table><TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="100%" bgcolor="#FFFFFF"> <tr> <td width="100%" bgcolor="#000000" align="left" valign="top" colspan="2" bordercolor="#99CCFF" style="border-style: solid; border-width: 2px"><p align="center"><font color="#FFFFFF" size="2"><b>Clinical Notes</b></font></td></tr> <tr> <td width="100%" bgcolor="#FFFFFF" align="left" valign="top" colspan="2"><font size="2"></font></td></tr></table>