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Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
 Initials: KS___ Age:36________
visit:8/31/15_____

Sex: Female_______

Date of

 Chief Complaint(s) or Reason for Visit: thick white vaginal
discharge, itching for three days, and time for a pap
smear._____________
___________________________________
o

HPI:
 Onset: Approximately three days ago
_____________________
 Location of problem: Gynecological___
_____________________________
 Duration of problem: Aproximately three days
____ ___________
 Character of problem: Denies pain at this
time__________ ____________
 Intensity rating/10 or other:_0/10
________________________
 Aggravating Factors None
______________________________
 Relieving Factors None
____________________________________
 Treatments Tried None
__________________________________________
 Smoking: Never smoked____
_____________________________________
 Additional information Patient reported that she was
treated with antibiotics for a upper respiratory
infection about nine days ago and believes she has a
yeast infection. The patient has been in a
monogamous relationship with a male for ten years
and has had a tubal ligation. She denies any odor to
her vaginal discharge and reported getting a yeast
infection after taking antibiotics last year in which she
took Diflucan and it worked. The last Pap smear was
done a little over three years ago.

Current Medications:

Centrum Multivitamin
GCSU Revised Fall 2014

1 tablet once daily
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etc. other complications of birth): None ______________________________________________________________________________ Past Surgical Hx: Bilateral tubal ligation ____  Substance use/amount: Alcohol Y/N amount None __  Tobacco (smoke any form. bilirubin.K. any procedures (mammograms. Chills Decreased activity Weight Gain Weight Loss Fussiness Irritability Lethargy Fever: duration___ Tmax:____ Other: _____________ Metabolic Pos. Hx: Diabetes Mellitus o Father: Alive 60’s. ☒ ☒ ☒ ☒ ☐ ☐ ☐ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Neg. ☒ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Respiratory Pos. ER visits and receiving any recent procedures.__________________________________________________________________ ___ Review of Systems: Neg.) since their last visit to the practice? What was done and why? Have those records been sent to the practice? Patient denies being seen by any other providers.A. seen other providers. Hypertension._______ _______________________________________________________________  Current Immunizations: Up-to-date on all immunizations _________________ __  PMH. Accessory muscles use Dyspnea Stridor Sputum Production Wheezing Cough: Quality_______ Freq:_________ ☐ ☐ ☐ ☐ Exposure to TB Other: _________ Cardiovascular and . DM II _______ o Maternal Grandmother: 60’s. 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 60’s. apgar scores. GCSU Revised Fall 2014 Neg.Additional Information:  Allergies: N. Constitutional Pos. Chronic Problems. Unknown___________________ o Paternal Grandmother:Deceased 70’s MI o Siblings:(2) sister-alive and well o Offspring: (2) daughters alive and well  INTERVAL HISTORY: Have they been to the ER.D. Significant birth history (NNICU admission. ☒ ☐ ☐ ☐ ☐ ☐ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ HEENT Pos. Dysphagia Ear Discharge Esotropia Exotropia Eye Discharge Eye Redness Headache Hearing loss Nasal Congestion Otalgia Pharyngitis Rhinorrhea Page 2 Neg.

Abdominal Pain Constipation Diarrhea Nausea Reflux Vomiting Other: _____________ Female Reproductive Pos. ☐ Allergic Rhinitis ☐ Environmental Allergy ☐ Food allergy ☐ Seasonal allergy ☐ Urticaria ☐ Other: __________ Neg. Aphasia or dysarthria Agnosia Balance disturbance Confusion Paraesthesia Seizure Tremor Memory loss Other: _______________ Page 3 Vascular Pos. Pos. Chest Pain Irreg. ☐ ☐ ☐ ☐ ☒ ☐ Skin Pos. ☒ ☐ ☒ ☒ ☒ ☒ ☐ Musculoskeletal Pos. ☐ ☐ ☐ ☐ ☐ ☐ Immunological Pos. ☐ Dysmenorrhea ☐ Dyspareunia ☐ Menorrhagia ☐ Vaginal Discharge ☒ Vaginal itching ☐ Foul vaginal odor ☐ Other:_____________ Menarche age:12 Last Menses: 8/15/15 ☒Regular ☐Irregular Frequency :monthly Flow: normal lasts 6 days Neg.☒ ☒ ☒ ☐ ☒ ☒ ☐ ☐ ☐ Neg. ☐ ☒ ☒ ☒ ☒ ☒ ☒ Psychiatric Pos. Heart Beat Palpitations Syncope Neg. ☒ Appropriate interaction ☐ Behavioral changes ☐ Difficulty concentrating ☐ Distorted body image ☐ Obsessive behaviors ☐ Self-conscious ☐ Other: Anxious/nervous Cool extremities Cyanosis Edema Other: _________ . ☐ Back pain ☐ Bone pain ☐ Joint pain ☐ Joint swelling ☐ Muscle weakness ☐ Myalgia ☐ Other: _________ Neg. ☒ ☒ ☒ ☒ ☒ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Sneezing Tearing Vision changes Vision loss Other: ____________ Urinary Pos. ☒ ☒ ☒ ☒ ☐ ☐ ☐ ☐ ☒ ☒ ☒ ☐ ☐ ☐ ☐ ☐ Neg. ☒ ☐ ☒ ☒ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Erectile dysfunction Hematospermia Penile discharge Premature ejaculation Scrotal mass Scrotal pain Other: _______________ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Neurological Pos. Decreased Urine Output Dysuria Enuresis Flank Pain Foul urine odor Hematuria Other: ____________ Male Reproductive Neg. ☒ ☒ ☒ ☒ ☐ Hematologic Pos. ☒ ☒ ☒ ☒ ☒ ☒ ☐ Neg. ☒ ☒ ☒ ☒ ☐ ☒ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Polydipsia Polyuria Polyphagia Brittle Nails Cold intolerance Heat intolerance Hirsute Thinning Hair Other:_________ Gastrointestinal Pos. ☐ ☐ Straining to urinate ☐ ☐ Urinary hesitancy ☐ ☐ Urinary Retention ☐ ☐ ☐ ☐ ☐ ☐ ☐ Neg. ☐ Acne ☐ Eczema ☐ Pruritus ☐ Psoriasis ☐ Skin lesion ☐ Other:_____________ GCSU Revised Fall 2014 ☐ ☐ ☒ ☒ ☐ Neg. ☐ Easy bleeding ☐ Easy bruising ☐ Lymphadenopathy ☐ Petechiae ☐ Other:_________ Neg.

9 Overall Appearance Age Appropriate Head/Skull: Show Appearance Normocephalic Facial Features Normal stucture alignment 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:___________ GCSU Revised Fall 2014 Page 4 .8 F (orally)____ Pulse Ox: _98________ Weight (lbs): 147__________ o Height (inches): 68___________ BMI: 22.5-24.3___________ Physical Exam: Physical Exam Constitutional: Show Level of Distress No acute distress Nourishment Normal Weight BMI 18.Objective Findings:  Vital Signs: o Blood Pressure: _120/70________ Pulse: _81______ Respirations: __14_______ o Temperature:_98.

Other:___________ Fundoscopy OD Choose item Other:___________ Lens OS Clear Other:___________ Lens OD Clear Other:___________ Ocular Muscles Normal cardinal gaze Red Reflex Present Bilaterally Other:___________ Abnormal:_____________________ Ears: Show Auricle Right Normal structure/placement Other:____________ Auricle Left Normal placement/structure Other:____________ Canal Right Normal Other:___________ Canal Left Normal Other:___________ GCSU Revised Fall 2014 Page 5 . Fundoscopy OS Other:___________ Choose an item.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 Other:___________ Cornea OD Choose an item.

Uvula Normal configuration Other:__________________ Oropharynx pink and moist Tonsils +1 Other:__________________ Other:__________________ Other:__________________ Neck: GCSU Revised Fall 2014 Other:__________________ Page 6 . 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 Normal fullness and symmetry Other:__________________ Teeth Normal dentation Other:__________________ Buccal pink and moist Other:__________________ Tongue Normal Palate Choose an item.TM Right Light reflex present/TM clear Other:___________ TM Left Light reflex present/TM clear Other:___________ Hearing Other:___________ Normal Bilaterally Nose and Sinus: Show Naris Right Normal patency Naris Left Normal patency Other:________________ Other:________________ Turbinates Right Choose an item.

mass. Other: ___________________________________________________________________ Cardiac: Show Morbid Obesity Limits Exam Accuracy: Yes or No Rate/Rhythm Murmur Regular Rate and Rhythm Other:________________ None Edema: _None____________________________________ Location:____________________________ Capillary Refill: less than 2 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 Description____________________ Perineum No swelling. or tenderness noted Other______________________________ Anus GCSU Revised Fall 2014 Normal meatus and tone Page 7 Other . Cough Choose an item.Palpation of Thyroid: Normal Describe Abn:___________________________________ Lymphatic: Show Overview: No noted abnormal swelling/tenderness Respiratory: Show Chest Normal anatomical configuration Other:_______________ Inspection Other:_______________ Normal respiratory effort Auscultation Clear Breath Sounds Bilaterally Location Choose an item.

negative for trichomoniasis and bacterial vaginosis _____________ Breast Exam Tanner Stage: V Self-Breast Exam Taught: Yes Right Breast Breast Inspection: Normal Contour Other:________________________________________ Breast Palpation: Normal Exam 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.Other______________________________ Cervix Discharge Pink. T2 A0 L2. cottage cheese consistency vaginal discharge and mild inflammation of the vagina noted on pelvic examination. Vaginal wet mount KOH slide revealed pseudohyphae and buds. nontender. muscle strength. thick white. smooth White Odor: None_____ Os: Horizontal slit__________ position:_Anteflexed_______________ Adnexa: Normal without masses___ N/A_______________________ Uterus Stool Hemocult: Pelvic Deferred for _N/A________________ Other:__G2. and Stability Posture: No structural abnormalities GCSU Revised Fall 2014 Page 8 .

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. 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: _Results from prior labs within normal limits (CBC. CMP. PAP test completed and last pap smear done was normal________ GCSU Revised Fall 2014 Page 9 . Lipid Profile). Person Describe Abn:_______________________________ Appearance: Age Appropriate Describe Abn:_______________________________ Thought Process: Follows conversation and engages appropriately Describe MMSE Score:N/A______ Gait: Smooth. Place. Muscle Bulk. active gait Describe Abn:___________________________________ CN II-XII: Grossly intact Describe Abn:___________________________________ DTRs: upper 2+ Avg Lower: Choose an item.

Medications Added This Visit Medication Name Diflucan Quantity 1 tablet GCSU Revised Fall 2014 Dose 150 mg Page 10 Sig Take 1 tablet by mouth (one time dose) . wearing wet bathing suits or tight clothing (pants. Patient verbalized understanding and denies any concerns/questions at this time. as well as sitting in hot tubs frequently. that her next Pap smear needs to be scheduled in three years if results are normal. The patient was instructed to inform office of any abnormal bleeding. Patient verbalized understanding and denies any concerns/questions at this time. change feminine products frequently.3 ____________ o Additional teaching or comments: _Patient was informed to allow two weeks for Pap smear results and any abnormalities will be discussed in a scheduled follow-up appointment once results are received. and any other abnormal signs/symptoms. new medical diagnosis. leggings) that trap sweat in the vaginal area for long periods of time should be avoided. wash underwear in hot water. pantyhose. Furthermore. feminine sprays or powders. discharge.Assessment/Plan: First Diagnosis: Gynecological exam for papanicolaou cervical smear_____ ICD-9: V72. The patient was informed that Diflucan is a one-time dose used to treat yeast infections and that if symptoms persist or worsen to contact the office immediately. perfumed soaps. She was encouraged to wear breathable cotton underwear. The patient was educated on ways to help prevent yeast infections by avoiding items that may inflame the vaginal membrane or change the normal balance of the vagina such as scented detergents. and eat yogurt or take supplements with lactobacillus._______ Second Diagnosis: Vaginal Candidiasis_____________________________ ICD9:112. unless follow-up required concerning Pap results or other abnormalities.1______________ o Additional teaching or comments: Patient was informed that broad spectrum antibiotics kill lactobacillus bacteria which can allow yeast to overgrow. change out of wet or sweaty clothing. tights. Furthermore. scented toilet paper or tampons/pads. and bubble baths. douching. wipe from front to back after using the toilet.

P. 1.2014. Journal Of Infection And Chemotherapy. Health Check New Pt.. M. Petrić.. & Nagashima.011 Pendharkar. & Larsson.5633/amm. Immunization.. (2015). & Krtinić. A. 46.. S.1186/s12879. (2011) Women’s Gynecologic Health 2nd Edition. D. A..1016/j. Pt. Y. Nakazuru. BMC Infectious Diseases.. Pt. Okayama.Office Code for Visit: Est.2015. VAGINAL CANDIDIASIS GYNECOLOGICAL ASPECT OF THE PROBLEM. R. Lab. etc. Jones & Bartlett Publishers Živadinović. (2014).. Marcotte. References Mikamo. E. H. & LIkis. Office Est.53(4). L. doi:10. M. Office New Pt. F. doi:10. 21520-526.jiac. doi:10.. Original article: Efficacy and safety of a single oral 150 mg dose of fluconazole for the treatment of vulvovaginal candidiasis in Japan. 15(1).03..0409 GCSU Revised Fall 2014 Page 11 . 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.015-0971-3 Schuiling. Brandsborg. H. Matsumizu. Vaginal colonisation by probiotic lactobacilli and clinical outcome in women conventionally treated for bacterial vaginosis and yeast infection. K.. (2015). Acta Medica Medianae. Hammarström.