Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: MM________ Age:16______
visit:9/28/15_____

Sex: F________

Date of

Chief Complaint(s) or Reason for Visit: yearly check-up, shots if

needed, and cramping with menstrual cycles
o HPI:
Onset Approximately around 14 years old
__________________________
Location of problem Gynecological__________________
Duration of problem Only with monthly menstrual
cycles______________
Character of problem
_Cramping___________________________________
Intensity rating: /10 or other:
N/A_________________________
Aggravating Factors
_N/A_________________________________________
Relieving Factors _Heating pad,
Ibuprofen___________________________
Treatments Tried Heating pad,
Ibuprofen____________________________
Smoking: Never
smoked__________________________________________
Additional information obtained without parent
present: Patient denies any complaints at this time
and reported she visits the dentist and eye doctor
once a year. She reported she is not sexually active
(oral, anal, and vaginal), but has a boyfriend who is a
member of her church. She stated that she is going to
wait until she gets married and that she and her
mother have had that talk concerning sex, birth
control, and condoms and she knows about the sexual
diseases. Her cycle is monthly and last four days. The
patient reported she asks her mom when she needs
Ibuprofen for cramping and it stops the pain. She
states she has been experiencing mild cramps only
with her menstrual cycle since she was almost 14
years old. The cramping was rated a 5/10 and is worse
the first two days of her cycle. She likes to read, going
bike riding, and enjoys helping with the children in
GCSU Revised Fall 2014

Page 1

Sunday school. She denies the use, as well as trying

drugs or alcohol.

Current Medications and how patient takes the medications:

None
Additional Information:
Allergies:
_N.K.D.A_______________________________________________________________________
Current Immunizations: Up-to- date on all immunizations except influenza
vaccine____________ _____
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 N/A
__
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:40 alive and
well__________________________________________________________
o Father:41 alive and well____________
_____________________________________________
o Maternal Grandmother: 61 alive with history of hypertension
o

Maternal Grandfather:65 alive with history of prostate cancer

Paternal Grandmother: 60 alive with history of hypertension

Paternal Grandfather: 68 alive with history of hypertension

Siblings:(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.__________________________________________________________________
___
GCSU Revised Fall 2014

Page 2

Review of Systems:
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

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

Page 3

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

Cool extremities
Cyanosis
Edema
Other: _________

Other:_____________

Menarche age:13
Last Menses: 9/20/15
Regular Irregular
Frequency: monthly Flow:4 days normal

Neg.

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

Neg.

Premature ejaculation
Scrotal mass
Scrotal pain
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: ____________

Other: _________

Objective Findings:
Vital Signs:
o Blood Pressure: _104/60_____ Pulse: _62___________ Respirations:
_14_____________
o Temperature: 98.6F (oral)______ Pulse Ox: _99%________
Weight: 130
lbs (67%)._____
o Height: 67 inches (87%)
______
BMI: 20.4 (48%)_____
Physical Exam:
Physical Exam Constitutional: Show
Head/Skull: Show
Eyes: Show

Ears: Show
Nose and Sinus: Show

GCSU Revised Fall 2014

Page 4

Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

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

Respiratory: Show
Cardiac: Show
Murmur
None
Edema: _None_______________________________
Capillary Refill: less than 3 seconds in all extremities
Pedal Pulses:2 + bilaterally
Radial Pulse: 2 + bilaterally
Carotid Bruits: Negative
EKG Results: N/A
Abdomen: Show
Female Exam Show

Musculoskeletal Show
Neurological Show

GCSU Revised Fall 2014

Page 5

Skin Show
Results of labs done today: _CBC results within normal
limits____________________________________

Assessment/Plan:

First Diagnosis: Well Child

ICD9:V20.2_____________
o Additional teaching or comments: Mother was informed that each teen
is unique and during adolescence she may face social and emotional
challenges. Major challenges may consist of: learning to manage
feeling and moods, sexual development and body image changes,
eating behaviors, risky behaviors, preventing injuries, sexual
experimentation, sexuality, heterosexual peer groups, and more selfdirected or self-centered behaviors. She was given anticipatory
guidance concerning what to expect during this developmental time,
encouraged to identify her daughters strengths and her parental
abilities, keeping open lines of communication, and tips for when,
where and how to seek help if required. The mother verbalized
understanding and denies any questions/concerns at this time.

Second Diagnosis: Primary Dysmenorrhea______________ ICD-9:

625.3_____________
o Additional teaching or comments: Mother informed patient is up-todate on all immunizations except the influenza vaccine in which they
will be receiving more of the vaccine on Monday. Mother was instructed
that she does not need to make an appointment for vaccination just
come by and the nurse will administer the vaccine. The mother and
patient were informed she was diagnosed with primary dysmenorrhea
which is lower abdominal cramping pain just before or during menses
and lasts 2-3 days, and additional signs/symptoms may occur such as
pain that radiates to lower back, thighs, as well as nausea, fatigue,
bloating, and general malaise. Her physical exam was completely
normal, as well as her labs. Treatment of primary dysmenorrhea
consists of the use of a nonsteroidal anti-inflammatory drug (NSAID)
for pain relief, relaxation techniques, utilizing heating pads, and
continue to exercise during this time. A prescription for Ibuprofen has
been sent to your pharmacy, however it is available OTC as the mother
is aware. She can take 400 mg every 4 to 6 hours, but no more than 4
tablets in 24 hours. The mother was informed that an OTC multivitamin
was recommended for the patient to ensure the patient is getting
enough essential nutrients for her body, to stay healthy and strong,
due to most teens skipping meals, as well as eating fewer healthier

GCSU Revised Fall 2014

Page 6

snacks. Mother and patient verbalized understanding. The mother

reported she will scheduled her first OB/GYN appointment so the
patient will have an opportunity to talk and get acquainted with this
type of doctor. The mother and patient were instructed to inform the
office of any abnormal bleeding, discharge, new medical diagnosis, and
any other abnormal signs/symptoms. The patient and mother
verbalized understanding and deny any concerns/questions at this
time._______
Medications Added This Visit
Medication Name
Multivitamin OTC

Quantity
Per OTC

Dose
1 tablet

Ibuprofen

120 tablet
No refills

400 mg

Sig
Take one tablet
daily
Take one tablet
every 4-6 hours as
needed for pain.
Maximum 6
tablets in a day
(24 hours)

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>)

99394
36415
85025

Reference
Burns, C., Dunn, A., Brady, M. Starr, N., & Blosser, C. (2012). Pediatric Primary Care.
(5th ed.) Saunders.
Chien, L., Chang, H., & Liu, C. (2013). Effect of yoga on serum homocysteine and
nitric oxide levels in
adolescent women with and without dysmenorrhea.
Journal of Alternative & Complementary
Medicine, 19(1), 20-23 4p.
doi:10.1089/acm.2011.0113

GCSU Revised Fall 2014

Page 7

Ga Eul, J., Nam Hyun, C., & Sok, S. R. (2014). Factors influencing the dysmenorrhea
among Korean
adolescents in middle school. Journal of Physical Therapy
Science, 26(9), 1337-1343 7p. doi:10.1589/jpts.26.1337
Gagua, T., Tkeshelashvili, B., & Gagua, D. (2012). Primary dysmenorrhea:
prevalence in adolescent population of Tbilisi, Georgia and risk factors. Journal of
the Turkish-German Gynecological
Association, 13(3), 162-168 7p.
doi:10.5152/jtgga.2012.21
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers

GCSU Revised Fall 2014

Page 8