UT Health San Antonio (Acct #3131)

Case ID #: 1444-20180202-002 (Status: Approved) Date of Service: 2/2/2018

Student Information - Krug, Janice
Semester: Spring
Course: NURS 6623: PMHNP Dx & Mgmt I: Clin App
Preceptor: Cordes, Jeffrey
Clinical Site: South Texas Veterans HCS - VA Hospital
Setting Type:
Patient Demographics
Age: 70 years
Race: Hispanic
Gender: Male
Insurance: Medicare
Referral: No referral
Clinical Information
Time with Patient: 40 minutes
Consult with Preceptor: 10 minutes
Type of Decision-Making: Low complexity
Student Participation: Shared (50-50)
Reason for Visit: Follow-up (Routine)
Chief Complaint: "To check on my anxiety."
Encounter #: 2-5
Type of HP: Expanded Problem Focused
Social Problems Addressed:
ICD-10 Diagnosis Codes
#1 - F41.9 - ANXIETY DISORDER, UNSPECIFIED
CPT Billing Codes
#1 - 99213 - OFFICE/OP VISIT, EST PT, 2 KEY COMPONENTS: EXPAND PROB HX; EXPAND PROB
EXAM;MED DECISION LOW COMPLEX
#2 - 90832 - PSYCHOTHERAPY, 30 MINUTES WITH PATIENT
Birth & Delivery
Medications
# OTC Drugs taken regularly: 1
# Prescriptions currently prescribed: 1
# New/Refilled Prescriptions This Visit: 1
Types of New/Refilled Prescriptions This Visit: Adherence Issues with Medications:

Other Questions About This Case

Clinical Notes
70 yo male with hx of gad

started on sertraline 25mg prior visit 2 weeks ago with no improvement, increased to 50mg and f/u in 1 month