Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: SP_________ Age: 42______
visit:_5/19/2015______

Sex: M__

Date of

Chief Complaint(s) or Reason for Visit: _Follow-up for

hypertension and medication refill_
o

HPI:
Onset _Reported being diagnosed with HTN in
30s___________________
Location of problem
_Cardiovascular_______________________________
Duration of problem _For approximately 10 years
( possibly going on prior to diagnosis)
___________________________________________
Character of problem _Blood pressure currently
controlled
__________
Intensity rating: 0 /10 or other: Denies any pain
or discomfort___
Aggravating Factors high salt intake, lack of physical
exercise, weight gain
Relieving Factors _ low salt diet, regular physical
activity, weight loss, taking medications
Treatments Tried _Currently taking Lisinopril-HCTZ
20/12.5 mg_ ________
Smoking:
_Nonsmoker___________________________________________
Additional Information: The patients hypertension
has been controlled since he started taking LisinoprilHCTZ 20/12.5 mg.

Current Medications and how patient takes the medications:

Lisinopril-Hydrochlorothiazide 20/12.5
mg

Take one table by mouth daily

Additional Information:

GCSU Revised Fall 2014

Page 1

 Allergies:
_NKDA________________________________________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declined
influenza vaccine during flu season.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
other than HTN____________________________ ___
Past Surgical Hx:___None
_
Substance use/amount: Alcohol Y/N amount 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 five 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:
o Mother: Deceased 50s; Hx: Brain Cancer__________
__________________________________
o Father: Deceased 60s; Hx: Diabetes Mellitus Type II___________________
_______________
o Siblings:_1 brother, 4 sisters-healthy with no known medical
history______________________
o Offspring: 2 sonshealthy__________________________________________________________
INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits and receiving any recent

procedures.______________________________________________________________

Review of Systems:
Neg.

Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Pos.
Polydipsia
Polyuria
Polyphagia
Brittle Nails
Cold intolerance

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
Vision loss
Other: Tinnitus_

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

Irreg. Heart Beat

Palpitations

Neg.

Neg.

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.

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

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: _120/78_____ Pulse: _90___________ Respirations:
_16_____________
o Temperature:_98.4__________ Pulse Ox: _98%_____
Head Circ
(percentile): __N/A____
o Weight: _213.8 lbs._____
Height: _67 inches__________
BMI:
_33.48__________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Obesity Class I - BMI 30-34.9

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:___________

External Eye OS

Normal

Other:___________

GCSU Revised Fall 2014

Page 4

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

Normal

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

GCSU Revised Fall 2014

Page 5

Normal cardinal gaze

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

Other:___________

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

Other:________________
Other:________________

Turbinates Right

Choose an item.

Other:________________

Turbinates Left

Choose an item.

Other:________________

Frontal Sinus Right

Non-tender

Other:________________
Frontal Sinus Left

Non-tender

Other:________________
Maxillary Sinus Right

GCSU Revised Fall 2014

Non-tender

Page 6

Other:________________
Non-tender

Maxillary Sinus Left

Other:________________
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:__________________________________________________________________________
Respiratory: Show
Chest

Normal anatomical configuration

Other:_______________

GCSU Revised Fall 2014

Page 7

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

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 Negative_______________
CVA Tenderness Negative_______

GCSU Revised Fall 2014

Page 8

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

Lower:

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Abn:_______________________________

GCSU Revised Fall 2014

Page 9

Describe

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: N/A__________________________________________________

Assessment/Plan:
First Diagnosis: Hypertension________________ ICD-9: 401.9_________________
o

Additional teaching or comments: Reinforced lifestyle modifications:

weight reduction, DASH eating plan, dietary sodium reduction, and
routine aerobic physical activity (150 minutes of moderate activity
weekly). Instructed on importance of compliance with
antihypertensive therapy, as well as establishing a daily routine for
taking prescribed medications. Reinforced self-monitoring of blood
pressure and recording of the readings in a journal for review. Patient
instructed to report any adverse effects of the drug such as (coughing,
swelling of the face/lips/tongue/throat (angioedema), and the
importance of avoiding high-sodium antacids, as well as OTC cold and
sinus medications containing harmful vasoconstrictors. Discussed signs
and symptoms that are important to seek medical attention for such as
headaches, dizziness, blurred vision and any other unusual
signs/symptoms. Patient verbalized understanding and no questions as
this time. Reviewed the importance of follow-up care in 6
months._______

Second Diagnosis: Obesity___________ ICD-9: 278.00_________________

o Additional teaching or comments: Reinforced lifestyle modifications:
low fat 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 his
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 referral to a weight-reduction program. The

GCSU Revised Fall 2014

Page 10

patient verbalizes understanding and will contact the office if he has

further questions.
Third Diagnosis: Counseling on substance use and abuse ICD9:_V65.42________________
Date of Alcohol Screening: _05/19/2015__________________
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 teaching or comments: In discussing the issue, medical

advice given that he cut back to no more than four drinks in one day
and no more than fourteen per week. His readiness for change was
nine on a scale of 0-10. We explored why it was not a lower/higher
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. I
provided a prescription for change and the patient will contact the
office for any further questions or concerns. The patient was educated
on low-risk consumption levels and the risks of excessive alcohol use
including negative consequences and increase for health complications
(DM, liver function decline).

Medications Added This Visit

Medication Name
Lisinopril-HCTZ

Quantity
30 tablets
5 refills

Dose
20/12.5mg

Sig
Take one tablet by
mouth daily

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

GCSU Revised Fall 2014

Page 11