Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: AR_______
Age: 4 years 1 month _
Date of visit: 9/28/15_

Sex: M______

Chief Complaint(s) or Reason for Visit: bottom itching and mother

stated she saw worms
o

HPI:
Onset _Three days
ago___________________________________________
Location of problem
_Gastrointestinal______________________________
Duration of problem _Three
days__________________________________
Character of problem Denies pain at this
time________________________
Intensity rating: /10 or other:
N/A_________________________
Aggravating Factors Worse at
night_________________________________
Relieving Factors
_Nothing________________________________________
Treatments Tried
_None__________________________________________
Smoking: _Never
smoked_________________________________________
Additional information: Mother stated the patient
started complaining of an itchy bottom approximately
three day ago and she said he woke her up saying his
bottom was itching, so she checked his bottom last
night and noticed worms. The mother brought the two
worms in a plastic zip lock bag. She reported he had
his annual check-up about a month ago and
everything was fine. In addition the mother reported
that the patient had no medical condition, only took a
multivitamin, attends daycare, and was a full term
infant delivered vaginally. The mother reported no
complications during pregnancy and she has no
significant medical history._

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Current Medications:

Flintstone Chewable Multivitamin

One tablet daily by mouth

Additional Information:
Allergies:
_N.K.D.A_______________________________________________________________________
Current Immunizations: Up-to-date on all immunizations required for his
age, including influenza vaccine; no special immunizations required due to
lack of co-morbidities_____________ _
PMH, Chronic Problems, Significant birth history: Vaginal birth at 39 weeks
gestational age. APGAR score of 9; No significant medical
history___________________________________________________
Past Surgical Hx:_None
_
Substance use/amount: Alcohol Y/N amount N/A
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how long:
N/A_No one smokes in the home
____________________
Illicit drugs Y/N amount N/A No one uses illicit drugs in the home
Family Hx:
o Mother:34 alive and
well__________________________________________________________
o Father:36 alive and
well___________________________________________________________
o Maternal Grandmother: 50 alive, Hx: DM II
o

Maternal Grandfather: Unknown

Paternal Grandmother: Unknown

Paternal Grandfather: Unknown

Siblings: No siblings (only

child)_____________________________________________________

INTERVAL HISTORY: Have they been to the ER, seen other providers, any
procedures (mammograms, etc.) since their last visit to the practice? Mother
denies the patient has been seen by any other providers, any recent ER visits
and any recent procedures.____________________________
Review of Systems:
Neg.

Constitutional
Pos.

GCSU Revised Fall 2014

Neg.

HEENT
Pos.

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Neg.

Respiratory
Pos.

Neg.

Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability at night
Lethargy
Fever: duration___
Tmax:____
Other: Inability to sleep at night

Metabolic
Pos.
Polydipsia
Polyuria
Polyphagia
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
Thinning Hair
Other:_________

Gastrointestinal
Neg.
Pos.

Abdominal Pain

Constipation

Diarrhea

Nausea

Reflux

Vomiting

Other: Itching, irritation around

anus, and worms

Neg.

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

Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:

GCSU Revised Fall 2014

Neg.

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

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

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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.

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: _________

Cool extremities
Cyanosis
Edema
Other: _________

Neg.

Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:Irritation around anus

Neg.

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

Neg.

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

Objective Findings:
Vital Signs:
o Blood Pressure: _96/58________ Pulse: _95_________ Respirations:
_20_____________
o Temperature: 97.6F (Axillary) __ Pulse Ox: _99%_____ Weight (%): 40lbs
(66%) _____
o Height (%): 43 inches (81%) ____
BMI (%): 15.2 (37%) _____
Physical Exam:
Physical Exam
Constitutional: Show
Head/Skull: Show
Appearance
Fontanels

age
Hair Distribution

Normocephalic

Closed anterior and posterior which is appropriate for

Facial features
Normal Distribution

Eyes: Show

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Normal stucture alignment

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

Cornea OD

Normal

Fundoscopy OS

Other:___________

Choose an item.

Other:___________
Fundoscopy

OD

Choose item

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles

Normal cardinal gaze

Red Reflex

Present Bilaterally

Ears: Show

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Nose and Sinus: Show

Mouth/Teeth:
Normal fullness and symmetry

Lips

Other:__________________
Normal dentation

Teeth

Other:__________________
pink and moist

Buccal

Other:__________________
Normal

Tongue

Other:__________________
Palate

Choose an item.

Uvula

Normal configuration

Oropharynx

pink and moist

Tonsils

+2

Other: Normal____________
Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Lymphatic: Show

Respiratory: Show
Cardiac: Show

Abdomen: Show
Male Exam

Show

Musculoskeletal Show
Neurological Show
Skin Show

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Results of labs done today: _No labs collected today, prior labs drawn a
month ago within normal limits

Assessment/Plan:

Diagnosis: Enterobiasis
ICD-9:127.4_________________
Additional teaching or comments: The patients mother was notified that he has pinworms and
these small, thin white worms can live in the colon and rectum of humans. She was informed that
at night these worms leave the intestine through the anus and lay their eggs on the surrounding
skin, which leads to the itching around the anus, and difficulty sleeping at night. These worms
can be found in persons of various ages, and demographics. However, the pinworm infection
usually occurs in more than one person in the household and child care centers. This infection is
spread by fecal-oral route. There are some specific hygiene and household cleaning which will
need to be performed as follows: make sure your son and other members of the household wash
their hands with soap, and warm water especially before eating, encourage all members of the
household to take a shower not bath in the morning, and make sure to change underwear, clean
all fingernails, and cut them short, instruct all family members who bite their nails not to do so,
discourage your son from scratching his bottom, and if he does have him wash his hand
immediately, use hot water and high heat when doing the laundry, avoid shaking clothing or linen
to keep the pinworm eggs from spreading in the air and being ingested while breathing, clean all
surfaces that may be infected including toys, floors, countertops, toilet seats, etc., and vacuum all
carpeted areas. These worms can survive 2-3 weeks on clothing, bedding, etc. It is important for
everyone to get treated simultaneously in the household to eliminate this infection from the
home. The mother was informed to use over the counter Calmoseptine cream as needed around
the anus which will relieve pain/itching and will act as a skin protectant for relieving skin
irritation. She was instructed to give 2 (200 mg) chewable Albendazole tablets now with food
and wait 2 weeks to give the last two chewable tablets with food for the pinworm infection. The
mother was instructed to contact the office if any adverse reactions (nausea, vomiting, dizziness,
abdominal pain, etc.) discussed are noted, as well as if signs/symptoms persist or worsen. She
verbalized understanding and has no questions or concerns at this time.
Medications Added This Visit
Medication Name
Calmoseptine
Cream OTC
Albendazole

Quantity
OTC (1 tube)

Dose
OTC strength

4 tablets

200 mg (chewable
tabs)

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Sig
Apply to affected
area as needed
Take two chewable
tablets now by
mouth with food
and wait 2 weeks
to take the last two

chewable tablets
with food
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>)

Additional Procedure Codes,

Immunization, Lab, etc.

Reference
Burns, C., Dunn, A., Brady, M. Starr, N., & Blosser, C. (2012). Pediatric Primary Care.
(5th ed.) Saunders.
Kim, D., Son, H., Kim, J. Y., Cho, M. K., Park, M. K., Kang, S. Y., & ... Yu, H. S. (2010).
Parents' knowledge
about enterobiasis might be one of the most important
risk factors for enterobiasis in children.
The Korean Journal of Parasitology,
48(2), 121-126. doi:10.3347/kjp.2010.48.2.121
Patrizi, A., Virdi, A., & Neri, I. (2012). Cutaneous mastocytosis exacerbated by
pinworms in a young
boy. Pediatric Dermatology, 29(2), 229-230.
doi:10.1111/j.1525-1470.2011.01530.x
Van Weyenberg, S., & De Boer, N. (2013). Enterobiasis vermicularis. Video Journal
and Encyclopedia Of
GI Endoscopy, 1(Special Issue: Expert Encyclopedia Lower GI Tract, Bile Duct and Ampullary
Region), 359-360. doi:10.1016/S22120971(13)70157-2
Watkins, J. (2015). Common causes of itching in children. Practice Nursing, 26(7),
345-359 15p.

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