Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: KF___ Age:21________
visit:8/31/15_____

Sex: Female_______

Date of

Chief Complaint(s) or Reason for Visit:6 week postpartum

checkup and no menstrual cycle______________
_________________________________________________
o

HPI:
Onset: No menses since childbirth
______________________
Location of problem: Gynecological___
_____________________________
Duration of problem: No menstrual cycle in last 6
weeks____ ___________
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 receiving
Depo Provera prior to leaving the hospital and reports
no sexual intercourse since childbirth._

Current Medications:

Prenatal Plus Multivitamin with Folic Acid

1 tablet once daily

Additional Information:

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 Allergies: N.K.D.A._______
_______________________________________________________________
Current Immunizations: Up-to-date on all immunizations including
Gardasil_________________
__
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth):
None________________________________________________________________________________
__Past Surgical Hx: None____
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 40s; No medical history ____________
o Maternal Grandmother: 60s; Hx: Diabetes Mellitus
o Father: Unknown__________________________
o Siblings:(1) brother and (1) sister-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 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
Heat intolerance
Hirsute
Thinning Hair

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: ____________

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

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Cool extremities

Neg.

Neg.

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:12
Last Menses: Prior to pregnancy
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: _______________

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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: Anxious/nervous

Cyanosis
Edema
Other: _________

Objective Findings:
Vital Signs:
o Blood Pressure: _120/80________ Pulse: _66______ Respirations:
__14_______
o Temperature:_98.6_______ Pulse Ox: _99________ Weight (lbs):
145__________
o Height (inches): 65___________
BMI: 24.1___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

Nourishment

Normal Weight BMI 18.5-24.9

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:___________

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

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Sclera

OS

Normal

Other:___________

Sclera

OD

Normal

Other:___________

Iris OS

Normal

Other:___________

Iris OD

Normal

Other:___________

Cornea OS

Other:___________

Cornea OD

Choose an item.

Fundoscopy OS

Other:___________

Choose an item.

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:___________

TM Right

Light reflex present/TM clear

Other:___________
TM Left

Light reflex present/TM clear

Other:___________
Hearing

Normal Bilaterally

Nose and Sinus: Show

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Other:___________

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

Normal fullness and symmetry

Other:__________________
Teeth

Normal dentation

Other:__________________
Buccal

pink and moist

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

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Chest

Normal anatomical configuration

Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Choose an item.

Cough

Choose an item.

Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or No
Rate/Rhythm
Murmur

Other:________________

Regular Rate and Rhythm

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

Other

Normal structures & pubic hair distribution

Description____________________
Perineum

No swelling, mass, or tenderness noted

Other______________________________
Anus

Normal meatus and tone

Other______________________________
Cervix
Normal discharge

Odor:_______

Os_Horizontal slit__________
position_Anteflexed_______________
Adnexa_Normal without masses___
Hemocult_N/A_______________________

GCSU Revised Fall 2014

Discharge

Pink, nontender, smooth

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Uterus
Stool

Pelvic Deferred for _N/A________________

Other:__G1, T1 A0 L1__No s/s of postpartum depression
_____________________________________
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, 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

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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:___________________________________
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: _Results from prior labs within normal limits,
PAP test completed________

Assessment/Plan:
First Diagnosis: Postpartum Care After Delivery_______________ ICD-9: V24.
O____________
o

Additional teaching or comments: _Patient informed it possible to not

have a menstrual cycle in the first 6 weeks after delivery and up to fifty
percent of the women within the first year of the use of the progestin
injection experience amenorrhea. Notified patient injections are
administered in 3 month intervals. If the injection is administered
perfectly the failure rate is 0.2% and 6% if typical use or normal use
which is the effectiveness of the method which includes inconsistent

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and incorrect use. The patient verbalized understanding. The patient

was informed that the injection does not protect against sexual
transmitted infections and HIV. Furthermore, can cause weight gain
(approx. 5 lbs. the first year), menstrual cycle irregularities,
depression, and not immediately reversible (takes up to 3 months or
longer). The injection is associated with decreased bone density, thus
the patient was advised to eat a diet rich in calcium and vitamin D or
take a multivitamin with using this medication. The patient was
instructed to inform office of any new medical diagnosis, abnormal
signs/symptoms reviewed due to possible contraindications with
medication. The patient is scheduled for follow-up visit in 2 months to
receive progestin injection and will continue with previously prescribed
prenatal vitamins until completed. Patient verbalized understanding
and denies any concerns/questions at this
time._________________________________
Medications Added This Visit
Medication Name
None

Quantity
None

Dose
None

Sig
None

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>)

59430

References
American College of Obstetricians and Gynecologists. (2014). Combined hormonal
birth control: Pill, patch, and ring, the frequently asked questions, ACOG Clinical
Opinion Number 185.
Centers for Disease Control. (2015). How effective are birth control methods?
Retrieved from
http://www
.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers
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