Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: SL__________ Age:32______
visit:05/22/15_____

Sex:F_______

Date of

Chief Complaint(s) or Reason for Visit: Frequent and painful

urination_________________
o

HPI:
Onset Approximately a week ago____
_____________________________
Location of problem
_Genitourinary________________________________
Duration of problem Approximately one week___
____________________
Character of problem _Burning with
urination________________________
Intensity rating: 5/10 only with urination.
Denies pain at this time.
___________________________
Aggravating Factors _No aggravating factors
reported_________________
Relieving Factors _OTC
Tylenol____________________________________
Treatments Tried
_None__________________________________________
Smoking:
Nonsmoker____________________________________________

Current Medications and how patient takes the medications:

None
Additional Information:

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 Allergies: _Zithromax Z-Pack causes

palpitations_____________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declines
influenza vaccination during flu season.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
____________________________ ___
Past Surgical Hx: Breast reduction
______
Substance use/amount: Alcohol Y/N amount N/A
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how
long:_N/A_________________
Illicit drugs Y/N amount N/A
__
_____________________
Family Hx:
o Mother: Alive 50s; no known medical
history_________________________________________
o Father: Alive 50s; Hx: HTN__
_____________________________________________________
o Siblings: 1 brother-healthy with no known medical history
__________________________
o Children: 1 daughterhealthy_____________________________________________________

INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits and receiving any recent
procedures.______________________________________________________________
Review of Systems:
Neg.

Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Pos.
Polydipsia
Polyuria
Polyphagia
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute

GCSU Revised Fall 2014

Neg.

HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia
Pharyngitis
Rhinorrhea
Sneezing
Tearing
Vision changes
Vision loss
Other: ____________

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Neg.

Respiratory
Pos.
Accessory muscles use
Dyspnea
Stridor
Sputum Production
Wheezing
Cough:
Quality_______
Freq:_________

Exposure to TB
Other: _________

Cardiovascular and
Vascular
Neg.
Pos.

Chest Pain

Irreg. Heart Beat

Palpitations

Syncope

Neg.

Neg.

Thinning Hair
Other:_________

Gastrointestinal
Pos.
Abdominal Pain
Constipation
Diarrhea
Nausea
Reflux
Vomiting
Other: _____________

Female Reproductive
Pos.
Dysmenorrhea
Dyspareunia
Menorrhagia
Vaginal Discharge
Vaginal itching
Foul vaginal odor
Other:_____________

Menarche age:
Last Menses: 4/30/15
Regular Irregular
Frequency:
Flow:
Neg.

Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________

GCSU Revised Fall 2014

Neg.

Urinary
Pos.
Decreased Urine Output
Dysuria
Enuresis
Flank Pain
Foul urine odor
Hematuria
Other: Frequency

Male Reproductive
Neg.
Pos.

Straining to urinate

Urinary hesitancy

Urinary Retention

Neg.

Erectile dysfunction
Hematospermia
Penile discharge
Premature ejaculation
Scrotal mass
Scrotal pain
Other: _______________

Neurological
Pos.
Aphasia or dysarthria
Agnosia
Balance disturbance
Confusion
Paraesthesia
Seizure
Tremor
Memory loss
Other: _______________

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Neg.

Immunological
Pos.
Allergic Rhinitis
Environmental Allergy
Food allergy
Seasonal allergy
Urticaria
Other: __________

Neg.

Hematologic
Pos.
Easy bleeding
Easy bruising
Lymphadenopathy
Petechiae
Other:_________

Neg.

Musculoskeletal
Pos.
Back pain
Bone pain
Joint pain
Joint swelling
Muscle weakness
Myalgia
Other: _________

Neg.

Psychiatric
Pos.
Appropriate interaction
Behavioral changes
Difficulty concentrating
Distorted body image
Obsessive behaviors
Self-conscious
Other: ____________

Cool extremities
Cyanosis
Edema
Other: _________

Objective Findings:
Vital Signs:
o Blood Pressure: 144/96_____ Pulse: 75____________ Respirations:
18______________
o Temperature: 99.1______ Pulse Ox: 99%_________
Head Circ
(percentile): N/A______
o Weight (lbs): 298_________
Height (inches): 66___________
BMI :
48.09___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Obesity Class III - BMI >40

Overall Appearance

Age Appropriate

Other:

Other: ___________

Other: Appropriate attire for weather

Appropriate
interaction______
Head/Skull: Show
Appearance

Normocephalic

Fontanels

Choose an item.

an item.

Other: ______________

Choose

Other:________________

Facial Features

Normal stucture alignment

Other:

______________
Hair Distribution

Normal Distribution

Other:______________

Other:___________________________________________________
Eyes: Show
Surrounding Structures OS

Normal Structures

Other:___________

Surrounding Structures OD

Normal Structures

Other:___________

External Eye OS

Normal

Other:___________
External Eye OD

Normal

Other:___________

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Normal

Eye Lids OS
Other:___________

Normal

Eye Lids OD
Other:___________

PERRLA

Pupil OS
Other:___________

PERRLA

Pupils OD
Other:___________
Conjunctiva OS

Clear

Other:___________
Conjunctiva

OD

Clear

Other:___________
Sclera

Normal

OS

Other:___________
Sclera

Normal

OD

Other:___________
Normal

Iris OS
Other:___________

Normal

Iris OD
Other:___________

Normal

Cornea OS
Other:___________

Normal

Cornea OD
Other:___________
Fundoscopy OS

Normal stuctures and sharp disc margin

Other:___________
Fundoscopy

OD

Normal

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles

Normal cardinal gaze

Red Reflex

Present Bilaterally

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Other:___________
Abnormal:_____________________

Vision Screen:
OU:_20/20_______________

OS:_20/20______

OD:_20/20______

Ears: Show
Normal structure/placement

Auricle Right
Other:____________

Normal placement/structure

Auricle Left
Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

TM Right

Light reflex present/TM clear

Other:___________
Light reflex present/TM clear

TM Left
Other:___________

Normal Bilaterally

Hearing

Other:___________

Nose and Sinus: Show

Naris Right

Normal patency

Naris Left

Normal patency

Other:________________
Other:________________

Turbinates Right

Choose an item.

Other:________________

Turbinates Left

Choose an item.

Other:________________

Frontal Sinus Right

Non-tender

Other:________________
Frontal Sinus Left

Non-tender

Other:________________
Maxillary Sinus Right

Non-tender

Other:________________
Maxillary Sinus Left

Non-tender

Other:________________

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Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Palate

Normal

Uvula

Other:__________________
Other: __________________

Normal configuration

Oropharynx

pink and moist

Tonsils

+1

Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
Choose an item.

Location of Abn:
Description of Abn:

Choose an item.

Size: ______________________
Other
Findings:__________________________________________________________________________
Respiratory: Show
Chest

Normal anatomical configuration

Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

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Location

Choose an item.
Choose an item.

Cough

Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or No
Regular Rate and Rhythm

Rate/Rhythm
Murmur

Timing:

Other:________________

Choose an item.

Intensity:

Choose an item.

Location: Choose an item.

Quality:

Choose an item.

Radiation: ____________
Edema: _No edema present______________
Location:_______________________ _____
Capillary Refill Less than 2 seconds in all four extremities_
Pedal Pulses: 2+__________________________
____
Carotid Bruits: Negative____________________________
Other Findings:_______________________________________
EKG Results: N/A_________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or No

Inspection

Obese

Auscultation

Normal Bowel Sounds

All four quadrants

Location:
Other:________

Normal

Palpation
All four quadrants

Associated Findings

Location:
Other:________

Choose an item.

Hernia Negative_______________
CVA Tenderness Negative_______
Female Exam Show
Male Exam

Show

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Musculoskeletal Show
Overview: Normal ROM, muscle strength, and Stability
Posture: No structural abnormalities
ROM: Normal ROM all extremities

Describe

Abn:_______________________________
Muscle Strength: Normal all extremities

Describe

Abn:_______________________________
Joint Stability: Normal all extremities

Describe

Abn:_______________________________
Assessment of problem area: N/A__________________________________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe Abn:

N/A__________________________
Appearance: Age Appropriate

Describe Abn:

N/A_______________________________
Thought Process: Follows conversation and engages appropriately
Describe Abn: N/A_____________
MMSE Score: N/A______
Gait: Smooth, active gait

Describe Abn:

N/A___________________________________
CN II-XII: Grossly intact

Describe Abn:

N/A___________________________________
DTRs: upper 2+ Avg

Lower:

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Describe

Abn:_______________________________
Sensory: Grossly normal
Body Position: Grossly normal

GCSU Revised Fall 2014

Describe Abn:_______________________________
Describe Abn:_______________________________

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Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:________________
Other: __________________________________________________________________________
Results of labs done today: _UA-leukocyte esterase positive, nitrite positive,
urobilinogen normal, blood negative, trace protein, specific gravity 1.020,
ketone negative, bilirubin negative, glucose
negative_________________________________________________

Assessment/Plan:

First Diagnosis: Urinary Tract Infection_______________ ICD-9:

599.0_________________
o Additional teaching or comments: Discussed diagnosis, and treatment
for UTI. Patient instructed to complete prescribed antibiotic therapy,
discussed drug administration, dosage, also possible adverse effects to
report immediately, proper cleaning after toileting, and emptying
bladder after sexual intercourse. She declined the prescription for
Pyridium due to previous experience of urine discoloration while taking
this medication. Patient informed this was a normal effect of Pyridium
and will take Tylenol for the pain/discomfort as needed. Patient
encouraged to drink fluids to flush bladder, especially cranberry juice.
She verbalized understanding and will contact office if further
questions arise._

Second Diagnosis: Morbid Obesity BMI 45.0-49.9____________ ICD-9:

278.01______ _______
o Additional teaching or comments: Discussed lifestyle modifications:
weight reduction, DASH eating plan, dietary sodium reduction, low fat
diet, and routine aerobic physical activity (150 minutes of moderate
activity weekly) which will aid in weight loss and help decrease blood
pressure. Patient informed blood pressure elevated on this visit and an
additional elevated reading would indicate the need for
antihypertensive medications. Discussed self-monitoring of blood
pressure, normal parameters, and recording of the readings in a journal
for review on follow-up visit. Discussed the importance of avoiding
high-sodium antacids, as well as OTC cold and sinus medications
containing harmful vasoconstrictors. Discussed signs and symptoms
that are important to seek medical attention for such as headaches,
dizziness, blurred vision and any other unusual signs/symptoms.
Current BMI discussed, as well as a mutual goal of weight loss was
established by next office visit along with the need for long-term
maintenance after desired weight is achieved. Recommended dietary
guidelines were covered and safe weight loss practices. Currently, the

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patient does not want to be referred to a weight-reduction program

and declines medications that assist with weight loss. Reviewed the
importance of follow-up care in 2 weeks and having labs (CBC, BMP,
Lipid panel, TSH) drawn three days prior to follow-up visit. The patient
verbalized understanding and will contact the office if she has further
questions.
Medications Added This Visit
Medication Name
Levaquin
Acetaminophen

Quantity
7 tablets
No refills
20 tablets
No refills

Dose
500 mg
650 mg

Sig
Take one tablet by
mouth daily
Take one tablet by
mouth as needed
every 6 hours for
pain

Office Code for Visit:

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

99211
99212
99213
99214
99215

------99201
99202
99203
99204
99205

99391 (<
1yr)
99392 (1-4yr)
99393 (511yr)
99394 (1217yr)
99395
(18yr>)

99381 (<
1yr)
99382 (14yr)
99383 (511yr)
99384 (1217yr)
99385
(18yr>)

GCSU Revised Fall 2014

Additional Procedure Codes,

Immunization, Lab, etc.

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