Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: MF________ Age:_18______
visit:_5/18/15______

Sex: M_

Date of

Chief Complaint(s) or Reason for Visit: __Warts on hand (New

Patient)
_____________
o

HPI:
Onset _Patient reported noticing warts approximately
2 weeks ago that gradually increased in
size________________________________
Location of problem _Right hand_________________
_________________
Duration of problem Noticed approximately 2 weeks
ago______________
Character of problem _No
pain____________________________________
Intensity rating: 0 /10 or other:_N/A______
__________________
Aggravating Factors _N/A
_______________________________________
Relieving Factors
_N/A___________________________________________
Treatments Tried
_None__________________________________________
Smoking:
_N/A_________________________________________________
Additional information__No additional information
provided.___________________________________________________
______________________________________________________________
___

Current Medications and how patient takes the medications:

None
GCSU Revised Fall 2014

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Additional Information:
Allergies:
_N.K.D.A.___________________________________________________________________________
__
Current Immunizations: _Up-to-date on immunizations. Denies receiving
influenza shot. ___________
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No significant past medical
history. ____________________________________
Past Surgical Hx:_No past surgical history
_
Substance use/amount: Alcohol Y/N amount
None
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how
long:_None_______________
_______________________________________________________________________
__
Illicit drugs Y/N amount

None

__

Family Hx: Heart disease, DM, cancer, HTN, COPD, strokes, other
Patient
unaware of current family history.
___________________
o Mother:_30s alive; family history unknown
______________________________________
o Father:_40s alive; family history unknown__________
_____________________________
o Siblings:_1 brother and 1 sister-healthy; unknown history_
_________________________
INTERVAL HISTORY: Patient denies any recent ER visit, procedures and has

not been seen by any other provider in years.

_________________________________
Review of Systems:
Neg.

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

Metabolic
Neg.
Pos.

Polydipsia

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

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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.

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:_____________

GCSU Revised Fall 2014

Neg.

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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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: _________

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: _118/88_______ Pulse: _64__________ Respirations:
_18____________
o Temperature:_97.7 F_________ Pulse Ox: _99%______
Head Circ
(percentile): ______
o Weight (lbs): _153______________
Height (inches): _68______
BMI (%):
_23.26______
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Normal Weight BMI 18.5-24.9

Overall Appearance

Age Appropriate

Other:

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:______________

Other:___________________________________________________
Eyes: Show
Surrounding Structures OS

Normal Structures

Other:___________

Surrounding Structures OD

Normal Structures

Other:___________

GCSU Revised Fall 2014

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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

Other:___________

Normal cardinal gaze

Ocular Muscles

Other:___________

Red Reflex
Present Bilaterally
Abnormal:_____________________
Vision Screen:
OS:_20/20_______ OD:_20/20________
OU:_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

Turbinates Right
Turbinates Left

Normal
Normal

Other:________________
Other:________________
Other:________________
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:________________

GCSU Revised Fall 2014

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Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
pink and moist

Buccal

Other:__________________
Tongue

Normal

Palate

Normal

Other:__________________
Other:__________________

Normal configuration

Uvula
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:
N/A_______________________________________________________________________
Respiratory: Show
Chest
Other:_______________
Inspection
Other:_______________

GCSU Revised Fall 2014

Normal anatomical configuration

Normal respiratory effort

Page 7

Clear Breath Sounds Bilaterally

Auscultation

Location

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: __None present___________________________________
Location:____________________________
Capillary Refill__Less than 2 seconds______________________________
Pedal Pulses:__2+____________________________
Carotid Bruits:__Negative_____________________________________
Other Findings:_______________________________________
EKG Results:__________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or N/A

Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

All four quadrants

Palpation

Location:
Other:________

Normal

All four quadrants

Associated Findings

Location:
Other:________

Choose an item.

Hernia _____________________
CVA Tenderness _____________
Other:______________________

GCSU Revised Fall 2014

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Female Exam Show

Male Exam

Show

Tanner Stage: Choose an item.

Penis Circumcised: Choose an item.

Glans:

Choose an item.

Penile Discharge: Choose an item.

Urethral Meatus:

Choose an item.

Other comments:_Patient deferred this portion of the exam.

________________________________
Scrotum: Choose an item.
Other:___________________________________________________
Epididymis Right: Choose an item.
Choose an item.

Hernia:

Epididymis Left:

Other:________________

Choose an item.

Other:__________________________________________________
Testis:

Choose an item.

Other:__________________________________________________
Choose an item.

Taught Testicular Self-Exam:

Other:________________________________________________________________________________
Anus

Choose an item.

Other______________________________
Prostate Exam: Choose an item.

Other______________________________

Stool Hemocult:________________________
Other:
________________________________________________________________________________
Male Breast Abnormality: N/A
Mass/Nodule: Location:______ Size:_________ Shape:__________
Consistency____________
Delimitation:________________ Tenderness:_____________ Mobility:____________________
Other: ________________________________________________________________________

GCSU Revised Fall 2014

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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:_______________________________
Appearance: Good Hygiene

Describe

Abn:_______________________________
Thought Process: Follows conversation and engages appropriately

Gait: Smooth, active gait

Describe

Abn:___________________________________
CN II-XII: Grossly intact

Describe

Abn:___________________________________
DTRs: upper 2+ Avg

Lower:

Choose an item.

Muscle Bulk, Tone and Strength: Grossly normal

Describe

Abn:_______________________________
Sensory: Grossly normal

Describe Abn:_______________________________

Body Position: Grossly normal

Describe Abn:_______________________________

Other
findings:_N/A______________________________________________________________________

GCSU Revised Fall 2014

Page 10

Skin Show
Overview: Normal overview but detailed examination done of right hand
Describe Abn: Lesion Description: Three firm nontender verrucoid papules (rough,
elevated, round surface) all approximately 5 mm located on the dosal surface of the
right thumb, plantar surface of the right palm and plantar surface of the right index
finger.
Results of labs done today: __N/A_________________________________________________

Assessment/Plan:
First Diagnosis:_ Verruca Vulgaris_______________ ICD-9:_078.10________________
o
o

Additional teaching or comments: _ Wart viruses are contagious. Warts

can be spread by contact with the wart or something that touched the
wart. Patient encouraged to keep warts covered.
Procedure: Cyrotherapy wart: Consent obtained: The patient
understood all the risk and benefits prior to treatment. The risks
explained included scarring, hyper and/or hypo pigmentation. Although
this treatment is highly effective, recurrences do occur and this was
explained to the patient. Method: The warts were treated with liquid
nitrogen times three freeze-thaw cycles. Post-procedure instructions
were given orally, as well as signs of infection. Patient was informed to
call if any signs of infection developed such as increasing pain,
purulent drainage, or beefy redness. The patient was informed that a
blister may occur at the cryo site and that this is an expected event
which requires no intervention. Patient scheduled for a labs (CBC,
Renal & Lipid) to be drawn prior to two week follow-up appointment. _

Medications Added This Visit

Medication Name
None

Quantity
N/A

Dose
N/A

Sig
N/A

Office Code for Visit: Please Highlight

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
99393
11yr)
99394
17yr)
99395

99381
1yr)
99382
4yr)
99383
11yr)
99384
17yr)

17000 CYRO 1 LESION

17003 CYRO 2-14 LESION

GCSU Revised Fall 2014

(<
(1-4yr)
(5(12-

(<
(1(5(12-

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(18yr>)

GCSU Revised Fall 2014

99385
(18yr>)

Page 12