miss professor

  Miami Regional University   (Acct #3111)

  Case ID #: 1332-20170609-006 

Date of Service: 6/9/2017 

Student Information - Norona, Maria

Semester:

Summer

Course:

MSN6050 Advanced Practice in Primary Care II

Preceptor:

BATISTA, JULIO

Clinical Site:

Julio Batista Ortiz Medical Center

Setting Type:

Underserved area/population

Patient Demographics

Age:

29 years

Race:

Hispanic

Gender:

Female

Insurance:

Private insurance

Referral:

No referral

Clinical Information

Time with Patient:

30 minutes

Consult with Preceptor:

15 minutes

Type of Decision-Making:

Moderate complexity

Reason for Visit:

Episodic

Chief Complaint:

" Follow up an abnormal pap smear."

Encounter #:

2-5

Type of HP:

Problem Focused

Social Problems Addressed:

Sanitation/Hygiene
Safety
Sexuality
Prevention
Nutrition/Exercise
Other: Smoking cessation
 

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment - Physical Assessment (Perf)

ICD-10 Diagnosis Codes

#1 - 

N87.9 - DYSPLASIA OF CERVIX UTERI, UNSPECIFIED

CPT Billing Codes

#1 - 

99214 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: DETAILED HX; DETAILED EXAM; MED DECISION MOD COMPLEXITY

#2 - 

57455 - COLPOSCOPY, CERVIX W/UPPER ADJACENT VAGINA; W/BIOPSY(S), CERVIX

#3 - 

2010F - VITAL SIGNS DOCUMENTED AND REVIEWED

#4 - 

99407 - TOBACCO USE CESSATION INTENSIVE >10 MINUTES

Birth & Delivery

Medications

# OTC Drugs taken regularly:

# Prescriptions currently prescribed:

# New/Refilled Prescriptions This Visit:

Types of New/Refilled Prescriptions This Visit:
 

Adherence Issues with Medications:
 

Other Questions About This Case

Patient's Primary Language:

Spanish

Smoking Assessment:

Current Smoker

Advanced Directive:

No

Packs per day:

15-20 cigarettes

Clinical Notes

CC: " Follow up an abnormal pap smear."
HPI : 29 years old patient attends to the clinic today after an abnormal smear test. She is very anxious and she thinks she might have cancer. The smear is report as a "severe dyskaryosis". She had a previous normal result at age 26, she has not had any postcoital or intermenstrual bleeding. Her first sexual relation started at age 14 and she has had several sexual partner since then. She lives with her current partner who she has been with for 3 years. She was diagnosed with genital herpes several years ago but has not had any attacks for more than 3 years. She has an intrauterine contraceptive device in situs.
PMH: Negative. NKA.
Toxic habits: 15-20 cigarettes daily , alcohol in weekends.
GH: G0,P0.A0.
LMP: 1 week ago.
Objective: Weight 146 lb. Temp 98.5 BP 106/74
Height 165cm Pulse 72 Resp 17
Physical examination:
Cardiovascular: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory: Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal: Abdomen flat and soft, non-tender. BS active in all 4 quadrants. No hepatosplenomegaly. Liver - normal, spleen - normal
Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genital examination: Cervix is macroscopically normal. Rest of the exam within normal limits.
Special test done in office: Colposcopy: acetic acid is apply and an irregular white area is apparent to the left of the Os. Lugol's iodine is applied an the same area stains pale while the rest of the cervix stains dark brown. a biopsy example was obtained and sending to the lab.
Assessment: Possible cervical intraepithelial neoplasia.
Plan: Is based in the biopsy result, if the presumptive diagnosis is confirmed the treatment will be a large loop excision of the transformation zone.
Lab. work orders for possible surgery procedure.
Follow up: Patient will be contacted with the biopsy results.