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Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: AM___ Age:45________
visit:8/28/15_____

Sex: Female_______

Date of

Chief Complaint(s) or Reason for Visit: whitish vaginal discharge,


fishy odor after sex and Pap smear_________
___________________________________
o

HPI:
Onset: Approximately five days ago
_____________________
Location of problem: Gynecological___
_____________________________
Duration of problem: Approximately five days
____ ___________
Character of problem: Denies pain at this
time__________ ____________
Intensity rating/10 or other:_0/10
________________________
Aggravating Factors After sex there is a strong fishy
odor
____
Relieving Factors None
____________________________________
Treatments Tried None
__________________________________________
Smoking: Never smoked____
_____________________________________
Additional information Patient reported the symptoms
began five days ago and she does not have any
burning or itching, however, she reports a strong fishy
odor after sexual intercourse. She stated she
experienced these same symptoms about two years
ago and was diagnosed with a bacterial infection, but
it was not a sexual transmitted disease. She reported
that she had Chlamydia once in her 20s and denies
any other sexual transmitted disease at this time. The
patient is married, has been in a monogamous
relationship with a male for 5 years, and received a
tubal ligation after her third child. The last Pap smear
was done three years ago in Texas and her OB/GYN
office closed after the physician passed. She does not

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recall if she received co-testing or not and did not get


her records from the office before it closed. She
reported having her lab work and medication refilled
by her primary care physician in June. She stated that
her lab work and blood pressure were good. The
patient reported that she has been taking Amlodipine
for almost two years now.

Current Medications:

Amlodipine 5 mg

1 tablet once daily

Additional Information:
Allergies: N.K.D.A._______
_______________________________________________________________
Current Immunizations: Up-to-date on all immunizations
_________________
__
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth):
None
______________________________________________________________________________
Past Surgical Hx: Bilateral tubal ligation
____
Substance use/amount: Alcohol Y/N amount None
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how long:
Never smoked_______ _
Illicit drugs Y/N amount: No illicit drug use
Family Hx:
o Mother: Alive 60s; Hypertension
_______
o Father: Alive 60s; Hypertension, DM II_____
o Paternal Grandmother: Deceased 70s MI
o Maternal Grandmother: Deceased 80s Lung cancer
o Siblings:(2) sister and (2) brothers-alive and well
o Offspring: (2) daughters and (1) son alive and well

INTERVAL HISTORY: Have they been to the ER, seen other providers, any
procedures (mammograms, etc.) since their last visit to the practice? What was
done and why? Have those records been sent to the practice? Patient reported that

she is seen by a primary provider (Dr. Confidential), which prescribes her


medication for hypertension and does her annual lab work. She denies any
recent ER visits and receiving any recent procedures.
_________________________________________
Review of Systems:
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Neg.

Neg.

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
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:13
Last Menses: 8/1/15

GCSU Revised Fall 2014

Neg.

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: ____________

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

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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.
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: _________

Regular Irregular
Frequency :monthly
Flow: normal lasts 5
days

Neg.

Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________

Neg.

Other: _______________

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: Anxious/nervous

Objective Findings:
Vital Signs:
o Blood Pressure: _130/72________ Pulse: _89______ Respirations:
__16_______
o Temperature:_98.6 F (orally)____
Pulse Ox: _98________ Weight (lbs):
195__________
o Height (inches): 67___________
BMI: 30.5___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

Nourishment

Obesity Class I - BMI 30-34.9

Overall Appearance

Age Appropriate

Head/Skull: Show
Appearance

Normocephalic

Facial Features

Normal stucture alignment

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Other: ______________
Other:

______________
Hair Distribution

Normal Distribution

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:___________

Eye Lids OS

Normal

Other:___________

Eye Lids OD

Normal

Other:___________

Pupil OS

PERRLA

Other:___________

Pupil OD

PERRLA

Conjunctiva OS

Clear

Other:___________

Conjunctiva

Clear

Other:___________

OD

Other:___________

Sclera

OS

Normal

Other:___________

Sclera

OD

Normal

Other:___________

Iris OS

Normal

Other:___________

Iris OD

Normal

Other:___________

Cornea OS

Other:___________
Choose an item.

Cornea OD
Fundoscopy OS

Other:___________

Choose an item.

Other:___________
Fundoscopy

OD

Choose item

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles

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Normal cardinal gaze

Page 5

Other:___________

Red Reflex

Present Bilaterally

Abnormal:_____________________

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

Non-tender

Other:________________

Maxillary Sinus Left

Non-tender

Other:________________

Mouth/Teeth:
Lips

GCSU Revised Fall 2014

Normal fullness and symmetry

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Other:__________________
Normal dentation

Teeth

Other:__________________
pink and moist

Buccal

Other:__________________
Tongue

Normal

Palate

Choose an item.

Uvula

Normal configuration

Other:__________________

Oropharynx

pink and moist

Tonsils

+1

Other:__________________
Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness

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 No
Rate/Rhythm
Murmur

Regular Rate and Rhythm

None

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Other:________________

Edema: _None____________________________________
Location:____________________________
Capillary Refill: less than 3 seconds in all extremities_______________________________
Pedal Pulses:2 + bilaterally______________________________
Carotid Bruits: Negative _______________________________________
EKG Results:N/A__________________________________

Female Exam Show


Genitalia

Morbid Obesity Limits Exam Accuracy: Yes or No

Tanner Stage: V

Inspection

Normal structures & pubic hair distribution

Other

Description____________________
Perineum

No swelling, mass, or tenderness noted

Other______________________________
Anus

Normal meatus and tone

Other______________________________
Cervix

Pink, nontender, smooth

White

Discharge

Odor: Yes_____

Os: Horizontal slit__________


position:_Anteflexed_______________
Adnexa: Normal without masses___
N/A_______________________

Uterus
Stool Hemocult:

Pelvic/Other:_G3, T3 A0 L3; whitish-gray vaginal discharge with foul odor noted on


vulva and vaginal mucosa on pelvic examination. Vaginal wet mount saline slide
revealed clue cells with adherent coccoid bacteria, no WBCs. KOH slide results:
positive whiff-test, negative for pseudohyphae and buds; saline slide negative for
trichomoniasis
Breast Exam
Tanner Stage: V
Self-Breast Exam Taught: Yes
Right Breast
Breast Inspection: Normal Contour
Other:________________________________________
Breast Palpation: Normal Exam

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Nipple Discharge: No Discharge


Other:________________________________________
Lymphatic: No noted swelling or tenderness of nodes
Left Breast
Breast Inspection: Normal Contour
Other:________________________________________
Breast Palpation: Normal Exam
Nipple Discharge: No Discharge
Other:________________________________________
Lymphatic: Normal
Description:_________________________________________
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:_______________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe

Abn:_______________________________
Appearance: Age Appropriate

Describe

Abn:_______________________________
Thought Process: Follows conversation and engages appropriately
Describe
MMSE Score:N/A______
Gait: Smooth, active gait

Describe

Abn:___________________________________

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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
Body Position: Grossly normal

Describe Abn:_______________________________
Describe Abn:_______________________________

Skin Show
Overview: Normal overview but detail exam not done

Results of labs done today: _Records requested from PCP, co-testing


PAP/HPV test completed with results pending. Declined HIV test due to
receiving one in June 2015 with annual lab work at PCP.

Assessment/Plan:
First Diagnosis: Gynecological exam for papanicolaou cervical smear_____ ICD-9:
V72.3 ____________
o

Additional teaching or comments: _Patient informed to allow two weeks


for Pap smear results and any abnormalities will be discussed at the
scheduled follow-up appointment. The patient was instructed to inform
office of any abnormal bleeding, discharge, new medical diagnosis, and
any other abnormal signs/symptoms. Furthermore, that her next cotesting (Pap smear/HPV) needs to be scheduled in five years if results
are normal, unless follow-up required concerning Pap results or other
abnormalities. Patient verbalized understanding and denies any
concerns/questions at this time._______

Second Diagnosis: Bacterial Vaginosis_____________________________ ICD9:616.1______________


o

Additional teaching or comments: Patient informed that she has


bacterial vaginosis (BV), which is not a sexually transmitted disease,
but caused by an alteration of normal vaginal flora in which loss of
lactobacilli results in a higher pH and overgrowth of anaerobic bacteria.

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Risk factors for BV include multiple sex partners, new sex partners,
shared sex toys, and douching. The patient was informed that
Metronidazole is used to treat bacterial vaginosis and alcohol should
not be consumed during and 24 hours after completion due to a
disulfiram effect which consists of flushing, nausea and vomiting. Other
side effects may include a metallic taste, nausea, headache, dry mouth
and dark-colored urine. The patient was instructed that if
signs/symptoms persist or worsen to contact the office immediately.
Patient verbalized understanding and denies any concerns/questions at
this time.
Third Diagnosis: Hypertension_______________ ICD-9:_401.9________________
Additional teaching or comments: Reinforced lifestyle modifications:
weight reduction, DASH eating plan, dietary sodium reduction, and
aerobic physical activity (150 min of moderate activity weekly). Patient
instructed on avoiding intake of saturated fats, excessive sugar, and
foods high in cholesterol, encouraged consumption of lean meats, fresh
fruits, and vegetables. Instructed on importance of taking blood
pressure medication every day, as well as taking blood pressure
readings. Patient educated on select target organ damage from
uncontrolled HTN (brain, eye, heart, kidneys). Discussed signs and
symptoms that are important to seek medical attention for unrelenting
HA, dizziness, blurred vision and any other unusual signs or symptoms.
She will continue with previously prescribed hypertension medication
by her PCP and was instructed to notify the office of any new diagnosis,
medications, and surgeries. Patient verbalized understanding and no
questions as this time.

Fourth Diagnosis: Obesity___________ ICD-9: 278.00_________________


o Additional teaching or comments: Reinforced lifestyle modifications:
low fat, high-fiber and low sodium diet, as well as lean meats, and
fresh/frozen vegetables, routine aerobic physical activity. Obtained a
diet history to identify patient eating patterns and explained the
impact of diet to a healthy 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 refused weight-reduction
program. The patient verbalized understanding and will contact the
office if she has further questions.

Medications Added This Visit


Medication Name
Metronidazole

Quantity
1 tablet

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Dose
500 mg
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Sig
Take 1 tablet by

mouth twice a day


for seven days
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>)

87621

References
Bradshaw, C. S., & Brotman, R. M. (2015). Making inroads into improving treatment
of bacterial vaginosis - striving for long-term cure. BMC Infectious Diseases, 15(1),
1-12. doi:10.1186/s12879015-1027-4
Center for Disease Control and Prevention. (2010). Bacterial Vaginosis (BV)
Statistics. Retrieved from
http://www.cdc.gov/std/bv/stats.htm
Li, X., Wang, C., Zhang, X., Gao, G., Tong, F., Li, X., & ... Sun, Y. (2014). Risk factors
for bacterial vaginosis:
results from a cross-sectional study having a sample of
53,652 women. European Journal of
Clinical Microbiology & Infectious Diseases:
Official Publication of the European Society of
Clinical Microbiology, 33(9),
1525-1532. doi:10.1007/s10096-014-2103-1
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers
The American College of Obstetricians and Gynecologists. (2011). Vaginitis.
Retrieved from
http://www.acog.org/Patients/FAQs/Vaginitis#why

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