Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:LL___________ Age:41________
visit:5/22/2015____________

Sex:F_________

Date of

Chief Complaint(s) or Reason for Visit: Right ear pain and f/u for
hypothyroidism_______
o

HPI:
Onset One week ago
_________________________________
Location of problem Endocrine system & Ear___
_____________________
Duration of problem Approximately one
week_______________________
Character of problem Aching ear__________________
________________
Intensity rating: 4/10 or other: right ear
____________________
Aggravating Factors: Tugging of
ear_________________________________
Relieving Factors:
Tylenol_________________________________________
Treatments Tried
None___________________________________________
Smoking: Nonsmoker__
_________________________________________
Additional information Patient reported that she has
been swimming a lot
lately._______________________________________________________
__

Current Medications and how patient takes the medications:

Synthroid 150 mcg

GCSU Revised Fall 2014

Take one tablet on an empty stomach in

the morning

Page 1

Additional Information:
Allergies:
_NKDA________________________________________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declined
influenza vaccination during flu season.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
other than hypothyroidism
__________ ___
Past Surgical Hx: IUD removal and replacement in 7/2013
Substance use/amount: Alcohol Y/N amount 1-3 drinks a month

__

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 60s; Hx: breast cancer__
____________________________________________
o Father: Alive 60s; History unknown __________
_____________________________________
o Siblings: 2-brothers and 1 sister-alive and healthy
____________________________________
o Offspring: 2-sons alive and 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: _____________

Metabolic
Neg.
Pos.

Polydipsia

Polyuria

Polyphagia

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

Page 2

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

Neg.

Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
Thinning Hair
Other:_________

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

Female Reproductive
Neg.
Pos.

Dysmenorrhea

Dyspareunia

Menorrhagia

Vaginal Discharge

Vaginal itching

Foul vaginal odor

Other: No menses due to IUD

implant
Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:
Neg.

Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other: Dry skin____________

GCSU Revised Fall 2014

Neg.

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: _______________

Page 3

Irreg. Heart Beat

Palpitations
Syncope

Cool extremities
Cyanosis
Edema
Other: _________

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: Depression

Objective Findings:
Vital Signs:
o Blood Pressure: 122/80______ Pulse: 90___________ Respirations:
18_____________
o Temperature: 98.2 F_______ Pulse Ox:99% _________
Head Circ
(percentile): N/A____
o Weight (lbs):227.2___________
Height (inches):65.5_______
BMI:
37.23___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Obesity Class II (BMI 35-39.9)

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:___________

GCSU Revised Fall 2014

Page 4

External Eye OS

Normal

Other:___________
External Eye OD

Normal

Other:___________
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

Lens OS

GCSU Revised Fall 2014

Normal
Clear

Page 5

Other:___________
Other:___________

Clear

Lens OD

Normal cardinal gaze

Ocular Muscles
Red Reflex
Vision Screen:
OU:_20/20_______________

Other:___________

Other:___________

Present Bilaterally
Abnormal:_____________________
OS:_20/20______ OD:_20/20______

Ears: Show
Normal structure/placement

Auricle Right
Other:____________

Normal placement/structure

Auricle Left
Other:____________

Erythema

Other: Slightly

Canal Left

Normal

Other:___________

TM Right

Light reflex present/TM clear

Canal Right
edematous___

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:________________

GCSU Revised Fall 2014

Page 6

Non-tender

Frontal Sinus Left

Other:________________

Non-tender

Maxillary Sinus Right

Other:________________

Non-tender

Maxillary Sinus Left

Other:________________
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
Location of Abn: Choose an item.
Choose an item.

Description of Abn:

Choose an item.

Choose an item.

Size: ______________________
Other
Findings:__________________________________________________________________________

GCSU Revised Fall 2014

Page 7

Respiratory: Show
Normal anatomical configuration

Chest
Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Choose an item.
Choose an item.

Cough

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

Inspection

Obese

Auscultation

Normal Bowel Sounds

All four quadrants

Palpation

GCSU Revised Fall 2014

Location:
Other:________

Normal

Location:

Page 8

All four quadrants

Associated Findings

Other:________
Choose an item.

Hernia Negative_______________
CVA Tenderness Negative_______
Female Exam Show
Male Exam

Show

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

GCSU Revised Fall 2014

Lower:

Page 9

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Describe

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

Describe Abn:_______________________________
Describe Abn:_______________________________

Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:_N/A_______________
Other: __________________________________________________________________________

Results of labs done today: TSH Normal _(drawn 3 days prior to

appointment)_____________________

Assessment/Plan:
First Diagnosis: Hypothyroidism________________ ICD-9: 244.8________________
Additional teaching or comments: Patient was educated on the
disorder, diagnosis, treatment and keeping accurate records of daily
weights. Reinforced the need for lifelong hormone replacement
restores proper metabolic function and the need to wear a medical
identification bracelet. Emphasized the importance of adherence to the
prescribed Synthroid regimen and continued medical surveillance to
check TH levels and adjust dose if necessary. Reviewed adverse
reactions of the medication that she be reported such as headache,
sleep problems (insomnia), feeling nervous or irritable, fever, hot
flashes, sweating, pounding heartbeats or fluttering in chest, changes
menstrual periods, appetite changes, and weight changes. Instructed
the patient to contact emergency services if signs/symptoms of
myxedema coma/crisis develop (e.g., mental deterioration, apathy,
confusion, psychosis, severe breathing difficulty, bradycardia [< 60
beats per minute], hypothermia [< 95F/35C], extreme weakness and
fatigue. Patient will follow-up in 3 months and will have labs (CBC, BMP,
Lipid) drawn 3 days prior to visit.
Second Diagnosis: Right otitis externa________________ ICD-9:
380.10_________________
o

GCSU Revised Fall 2014

Page 10

Additional teaching or comments: Patient instructed to apply otic

solution to clean, dry ear once a day for seven days. To prevent
reoccurrence the patient was instructed to avoid irritants such as haircare products, water in ears while swimming, and cleaning ears with
cotton tipped applicators or other objects. May continue Tylenol PRN
for pain. Instructed to avoid swimming for 4 to 6 weeks. Instructed to
use ear plugs for bathing or showering for 4 to 6 weeks. F/U for
reevaluation in 3 to 5 days for otitis externa if no
improvement._________________________________________________________
___
Third Diagnosis: Obesity___________ ICD-9: 278.00_________________
o Additional teaching or comments: Reinforced lifestyle modifications:
low fat, high-fiber and sodium diet which contain lean meats and
fresh/frozen vegetables, routine aerobic physical activity and obtained
a diet history to identify patient eating patterns and the importance of
food to her lifestyle. 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 patient does not want to be referred to a
weight-reduction program. The patient verbalized understanding and
will contact the office if she has further questions.
o

Medications Added This Visit

Medication Name
Synthroid

Quantity
30 tablets
2 refills

Dose
150 mcg

Ofloxacin Solution

1 bottle

0.3% otic solution

Acetaminophen

30 tablets
No refills

650 mg

Sig
Take one tablet on
an empty stomach
in the morning one
hour prior to
breakfast
Place 10 drops into
the affected canal
once a day
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

GCSU Revised Fall 2014

New Pt.
Health Check

Additional Procedure Codes,

Immunization, Lab, etc.

Page 11

99211
99212
99213
99214
99215

------99201
99202
99203
99204
99205

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

GCSU Revised Fall 2014

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

Page 12