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School of Nursing
Episodic Document
Patient Information:
Initials:__KA_______ Age:__32____
visit:__02/18/2015_
Sex:__F_____
Date of
HPI:
Onset _Patient was diagnosed two years ago. She
reported she recently moved to this area.
Location of problem _Cardiovascular_______________
_______________
Duration of problem _2 year (possibly going on prior
to diagnosis). Ongoing problem with HTN.
Character of problem _Currently controlled
______________________
Intensity rating: 0 /10 or
other:__N/A________________________
Aggravating Factors _diet high salt, lack of physical
exercise, weight
gain____________________________________________
Relieving Factors _low salt diet, regular physical
activity, weight loss, taking medications
Treatments Tried _Amlopidine 10 mg daily and HCTZ
12.5 mg daily______
Smoking: _Nonsmoker __________________
______________________
Additional information: Patients blood pressure is
currently under control since addition of HCTZ. The
patient reported taking her medication this morning._
__
Amlopidine 10 mg
HCTZ 10 mg
GCSU Revised Fall 2014
Daily
Daily
Page 1
Additional Information:
Allergies:
_N.K.D.A._____________________________________________________________________
Current Immunizations: _Up-to-date on immunizations. Received influenza
shot in 2014 ____________
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): __PMH of HTN
_____________________________________________________
Past Surgical Hx:_None
_
Substance use/amount: Alcohol Y/N amount :She reported being a social
drinker. She reported that on one or more times in the past year she 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
(HTN,MI)
_________
o Mother: Deceased 60s, MI
___________________________________
o Father:__Alive 60s, Unknown history
_______________________________________________
o Siblings:_2 Sister and 2 Brother
(healthy)__________________________________
o Children: 1-son ; Alive and healthy
Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Neg.
Pos.
Polydipsia
Polyuria
Polyphagia
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.
Neg.
Neg.
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: 2/8/15
Regular Irregular
Frequency:
Flow:
Neg.
Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________
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
Paresthesia
Seizure
Tremor
Memory loss
Other: _______________
Page 3
Chest Pain
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: ____________
Objective Findings:
Vital Signs:
o Blood Pressure: __130/80__
_14__________
o Temperature:__98.4 F______
(percentile): _N/A___
o Weight: __150 lbs._________
_23.5_______
Pulse: _76_________
Respirations:
Head Circ
BMI :
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress
Other:
No acute distress
___________
Nourishment
Overall Appearance
Age Appropriate
Other: ___________
Other: ___________
Other:_________________________________________________
Head/Skull: Show
Appearance
Normocephalic
Fontanels
Choose an item.
an item.
Other: ______________
Choose
Other:________________
Facial Features
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:___________
Page 4
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
Other:___________
Fundoscopy
OD
Normal
Other:___________
Lens OS
Clear
Other:___________
Lens OD
Clear
Other:___________
Ocular Muscles
Red Reflex
Vision Screen:
Other:___________
Present Bilaterally
Abnormal:_____________________
OS:________ OD:_________ OU:__________________
Ears: Show
Auricle Right
Normal structure/placement
Other:____________
Auricle Left
Normal placement/structure
Other:____________
Canal Right
Normal
Other:___________
Canal Left
Normal
Other:___________
Page 5
TM Right
Other:___________
TM Left
Other:___________
Hearing
Other:___________
Normal Bilaterally
Normal patency
Naris Left
Normal patency
Other:________________
Other:________________
Turbinates Right
Choose an item.
Other:________________
Turbinates Left
Choose an item.
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Mouth/Teeth:
Lips
Teeth
Normal dentation
Other:__________________
Other:__________________
Buccal
Other:__________________
Tongue
Normal
Other:__________________
Palate
Uvula
Oropharynx
Tonsils
+1
Other:__________________
Other:__________________
Other:__________________
Page 6
Neck:
Palpation of Thyroid: Normal
Describe
Abn:___________________________________
Other:____________________________________________________________________________
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
Respiratory: Show
Chest
Other:_______________
Inspection
Other:_______________
Auscultation
Location
Bilateral
Cough
Choose an item.
Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or No
Rate/Rhythm
Murmur
Timing:
Other:________________
Choose an item.
Intensity:
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:__________________________________
Abdomen: Show
Page 7
Inspection
Auscultation
Other:________
Palpation
Location:
Location:
Normal
Other:________
Associated Findings
Choose an item.
Hernia _____________________
CVA Tenderness _____________
Other:______________________
Female Exam Show
DEFERRED
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: 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:___________________________________
Page 8
SBIRT
Date of Alcohol Screening: _2/18/2015__________________
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
CN II-XII: Grossly intact
Describe
to questionnaire)
Brief Intervention delivered by: _Salena Barnes NPS_______
Abn:___________________________________
Length
of Brief Intervention: _15 minutes
_____________
Audit
score:
5
Zone
II:
At
Risk
DTRs: upper 2+ Avg
Lower:
Referrals to Treatment provided: Yes/No
Type of Referral to Treatment: _N/A_
___
2+ Avg information: In discussing the issue, my medical advice was that
Additional
she cut back to no more than 3 drinks in one day and no more than 7 per
week. Her readiness for change was 9 on a scale of 0-10. We explored why it
Grossly normal
Tone
and Strength:
Describe
wasMuscle
not a Bulk,
lower
number
and discussed
the patients own
motivation for
change. She was unaware of effects excessive alcohol consumption on the
Abn:_______________________________
body.
She agreed to cut back to the advised daily and weekly limits. A
normal was provided
Sensory: Grossly
Describe
Abn:_______________________________
prescription
for change
and the
patient will contact the office
for any further questions or concerns.
Body Position: Grossly normal
Describe Abn:_______________________________
Other
findings:_________________________________________________________________________
Skin Show
Overview: Normal overview but detail exam not done
Describe
Abn:___________________________________
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: __Prior CBC, Lipid Panel, BMP ordered result
values within normal range
Assessment/Plan:
Page 9
Quantity
60 tablets
Dose
10 mg
HCTZ
60 tablets
12.5 mg
Sig
Take one tablet
daily
Taken one tablet
daily
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>)
99408
Page 10