Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:_RM_______ Age:_43_______
visit:_2/06/14______

Sex:_M_____ Date of

Chief Complaint(s) or Reason for Visit: _C/O nausea, headache,

runny nose____________
o

HPI:
Onset _Patient reported nausea, headache, runny
nose, malaise started approximately 2 days ago
progressively worsening
_________________
Location of problem __ Respiratory
________________________
Duration of problem _Approximately 3
days_________________________
Character of problem _Generalized Aching Headache
_________________
Intensity rating: 2 /10
Aggravating Factors _Noise
_________________________________
Relieving Factors _Resting
_______________________________________
Treatments Tried
_Resting________________________________________
Smoking:
_Nonsmoker___________________________________________
Additional information:
How many times in the past year have you had 5 or
more drinks in a day? Response: 1 or more
How many times in the past year have you used a
recreational drug or used a prescription medication
for nonmedical reasons?
Response: None
During the past two weeks, have you been bothered
by little interest or pleasure in doing things? No

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During the past two weeks, have you been bothered

by feeling down, depressed, or hopeless? No
1. How often do you have a drink containing alcohol?
Monthly or less
2. How many drinks containing alcohol do you have on
a typical day when you are drinking? 4-6
3. How often do you have four or more drinks on one
occasion? Monthly
4. How often during the last year have you found that
you were not able to stop drinking once you had
started? Never
5. How often during the last year have you failed to do
what was normally expected of you because of
drinking? Never
6. How often during the last year have you needed a
first drink in the morning to get yourself going after a
heavy drinking session? Never
7. How often during the last year have you had a
feeling of guilt or remorse after drinking? Never
8. How often during the last year have you been
unable to remember what happened the night before
because of your drinking? Never
9. Have you or someone else been injured because of
your drinking? No
10. Has a relative, friend, doctor, or other health care
worker been concerned about your drinking or
suggested you cut down? No
Have you ever been in treatment for an alcohol
problem? Never

Current Medications and how patient takes the medications:

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NONE
Additional Information:
Allergies:
__N.K.D.A._____________________________________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declines
influenza vaccination at this time.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
_____________________________________________
Past Surgical Hx:___None
_
Substance use/amount: Alcohol Y/N amount The patient reported he is a
social drinker and has a drink containing alcohol monthly. He reported that
one or more times in the past year he has drank 5 or more beers at one
time.
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how
long:_N/A_________________
Illicit drugs Y/N amount
N/A
__
Family Hx: Heart disease, DM, cancer, HTN, COPD, strokes, other
___________________________
o Mother:_Alive 60s; HTN, Hyperlipidemia_________
_____________
o Father:_Alive 60s; family history
unknown___________________________________________
o Siblings:_2 sisters-healthy; 2 daughters-healthy_
___________________________________
INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits and receiving any recent

procedures.______________________________________________________________
Review of Systems:
Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _Malaise___

Metabolic
Neg.
Pos.

Polydipsia

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Neg.

HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia
Pharyngitis
Rhinorrhea
Sneezing

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Neg.

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

Exposure to TB
Other: _________

Cardiovascular and

Neg.

Neg.

Polyuria
Polyphagia
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
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:
Regular Irregular
Frequency:
Flow:
Neg.

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

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Neg.

Tearing
Vision changes
Vision loss
Other: ____________

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

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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Vascular
Pos.
Chest Pain
Irreg. Heart Beat
Palpitations
Syncope

Neg.

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: __136/80_______ Pulse: _69___________ Respirations:
__16_______
o Temperature:_98.6 F_______ Pulse Ox: _98 %________
Head Circ
(percentile): ______
o Weight : _175 lbs._________
Height : _72 inches_______
BMI :
_23.6__________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

Other:

No acute distress

___________
Nourishment

Overweight BMI 25-29.9

Overall Appearance

Age Appropriate

Other: ___________

Other: ___________
Other:_________________________________________________
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:___________________________________________________

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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:___________

Eye Lids OS

Normal

Other:___________

Eye Lids OD

Normal

Other:___________

Pupil OS

PERRLA

Other:___________

Pupils OD

PERRLA

Other:___________

Conjunctiva OS

Clear

Other:___________

Conjunctiva

Clear

Other:___________

OD

Sclera

OS

Normal

Other:___________

Sclera

OD

Normal

Other:___________

Iris OS

Normal

Other:___________

Iris OD

Normal

Other:___________

Cornea OS

Normal

Other:___________

Cornea OD

Normal

Other:___________

Fundoscopy OS

Normal stuctures and sharp disc margin

Other:___________
Fundoscopy

OD

Normal

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles
Red Reflex
Vision Screen:

Normal cardinal gaze

Present Bilaterally
Abnormal:_____________________
OS:________ OD:_________ OU:__________________

Ears: Show

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Other:___________

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Auricle Right

Normal structure/placement

Other:____________
Auricle Left

Normal placement/structure

Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

TM Right

Light reflex present/TM clear

Other:___________
TM Left

Light reflex present/TM clear

Other:___________
Hearing

Other:___________

Normal Bilaterally

Nose and Sinus: Show

Naris Right

Discharge - Clear

Naris Left

Discharge - Clear

Other:________________
Other:________________

Turbinates Right

Hypertrophy Mild

Other:________________

Turbinates Left

Hypertrophy Mild

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:________________

Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________

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Tongue

Normal

Other:__________________
Palate

Choose an item.

Uvula

Normal configuration

Oropharynx

pink and moist

Tonsils

+1

Other:__Normal hard palate

Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

Lymphatic: Show
Overview: No noted abnormal swelling/tenderness

Location of Abn:

Choose an item.
Choose an item.

Description of Abn:

Choose an item.

Choose an item.

Size: ______________________
Other
Findings:__________________________________________________________________________
Respiratory: Show
Chest

Normal anatomical configuration

Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Choose an item.

Cough

Choose an item.

None

Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or N/A

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Rate/Rhythm

Regular Rate and Rhythm

Murmur

Timing:

Other:________________
Intensity:

Choose an item.

Choose an item.

Location: Choose an item.

Quality:

Choose an item.

Radiation: ____________
Edema: _None____________________________________
Location:____________________________
Capillary Refill_Less than 2 seconds in all four extremities___________
Pedal Pulses:__2+
____________
Carotid Bruits:_Negative_____________________
Other Findings:_______________________________________
EKG Results:__________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or No

Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

Other:________

Choose an item.

Palpation

Location:

Location:

Normal

Other:________

Choose an item.

Associated Findings

Choose an item.

Hernia _____________________
CVA Tenderness _____________
Other:______________________

Male Exam

Show

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

Describe

Abn:_______________________________

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Muscle Strength: Normal all extremities

Describe

Abn:_______________________________
Joint Stability: Choose an item.

Describe

Abn:_______________________________
Assessment of problem area:___________________________________________________
___________________________________________________________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe

Abn:_______________________________
Appearance: Good Hygiene

Describe

Abn:_______________________________
Thought Process: Follows conversation and engages appropriately
Describe Abn:_______________________________
MMSE Score:_______
Gait: Smooth, active gait

Describe

Abn:___________________________________
CN II-XII: Grossly intact

Describe

Abn:___________________________________
DTRs: upper Choose an item.

Lower:

Choose an item.

Muscle Bulk, Tone and Strength: Grossly normal

Describe

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

Describe Abn:_______________________________
Describe Abn:_______________________________

Other findings:_Negative Depression

Screening________________________________________________
Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:___________________________________
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________

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Results of labs done today: _N/A__________________________________________________

Other labs: __N/A_______________________________________________________________
______________________________________________________________________________________
__
SBIRT
Date of Alcohol Screening: _2/06/2015__________________
Alcohol Screening Instrument(s) Used: _AUDIT____________
Alcohol Screening done by: _Salena Barnes NPS___________
Alcohol Screening Results: Positive
Brief Interventions conducted: Yes (with patients consent to discuss results
to questionnaire)
Brief Intervention delivered by: _Salena Barnes NPS_______
Length of Brief Intervention: _15 minutes
_____________
Audit score: 5 Zone II: At Risk
Referrals to Treatment provided: Yes/No
Type of Referral to Treatment: _N/A_
___
Additional information: In discussing the issue, my medical advice was that
he cut back to no more than 4 drinks in one day and no more than 14 per
week. His readiness for change was 7 on a scale of 0-10. We explored why it
was not a lower number and discussed the patients own motivation for
change. He was unaware of effects excessive alcohol consumption had on
the body. He agreed to cut back to the advised daily and weekly limits. A
prescription for change was provided and the patient will contact the office
for any further questions or concerns.

Assessment/Plan:

First Diagnosis:_Viral Syndrome______________ ICD-9:_079.99________________

o Additional teaching or comments:
The patient was instructed to use Tylenol or ibuprofen for fever, muscle
aching, and headache. Avoid dehydration by drinking 8-12 eightounces glasses of fluids per day. Over-the-counter medications will not
shorten the length of the illness but maybe helpful with the symptoms.
If signs/symptoms worsen contact the office immediately.__
Second Diagnosis:_Nausea_______________ ICD-9:_787.02________________
o Additional teaching or comments: A light diet that is not greasy or
heavy is recommended until resolution of nausea. Patient informed
Colace is a stool softener and makes bowel movements softer and
easier to pass. Encouraged to increase intake of whole grains, fiber and
green leafy vegetables to help with constipation. Zofran is used to
block the chemicals in the body that can trigger nausea and vomiting.
Patient verbalized understanding.
Third Diagnosis:_Counseling on substance use and abuse ICD9:_V65.42________________

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Additional teaching or comments: Patient educated on low-risk

consumption levels and the risks of excessive alcohol use. Verbalized
understanding and will contact office for additional information or if
there are any additional questions. ____________________

Medications Added This Visit

Medication Name
Zofran Tablet

Quantity
12 tablets (no
refills)

Dose
4 mg

Sig
Take one tablet
every 6 hours as
needed by mouth

Office Code for Visit:

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

Additional Procedure Codes,

Immunization, Lab, etc.

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>)

99408

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