Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:__KA_______ Age:__32____
visit:__02/18/2015_

Sex:__F_____

Date of

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

hypertension
_________
o

HPI:
Onset _Patient was diagnosed two years ago. She
reported she recently moved to this area.
Location of problem _Cardiovascular_______________
_______________
Duration of problem _2 year (possibly going on prior
to diagnosis). Ongoing problem with HTN.
Character of problem _Currently controlled
______________________
Intensity rating: 0 /10 or
other:__N/A________________________
Aggravating Factors _diet high salt, lack of physical
exercise, weight
gain____________________________________________
Relieving Factors _low salt diet, regular physical
activity, weight loss, taking medications
Treatments Tried _Amlopidine 10 mg daily and HCTZ
12.5 mg daily______
Smoking: _Nonsmoker __________________
______________________
Additional information: Patients blood pressure is
currently under control since addition of HCTZ. The
patient reported taking her medication this morning._
__

Current Medications and how patient takes the medications:

Amlopidine 10 mg
HCTZ 10 mg
GCSU Revised Fall 2014

Daily
Daily
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Additional Information:
Allergies:
_N.K.D.A._____________________________________________________________________
Current Immunizations: _Up-to-date on immunizations. Received influenza
shot in 2014 ____________
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): __PMH of HTN
_____________________________________________________
Past Surgical Hx:_None
_
Substance use/amount: Alcohol Y/N amount :She reported being a social
drinker. She reported that on one or more times in the past year she has
drank 5 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: Heart disease, DM, cancer, HTN, COPD, strokes, other
(HTN,MI)
_________
o Mother: Deceased 60s, MI
___________________________________
o Father:__Alive 60s, Unknown history
_______________________________________________
o Siblings:_2 Sister and 2 Brother
(healthy)__________________________________
o Children: 1-son ; Alive and healthy

INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits, and receiving any recent procedures._
_________________________________________________________
Review of Systems:
Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________

Metabolic
Neg.
Pos.

Polydipsia

Polyuria

Polyphagia

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

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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.

Neg.

Neg.

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:
Last Menses: 2/8/15
Regular Irregular
Frequency:
Flow:
Neg.

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

GCSU Revised Fall 2014

Neg.

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

Neg.

Erectile dysfunction
Hematospermia
Penile discharge
Premature ejaculation
Scrotal mass
Scrotal pain
Other: _______________

Neurological
Pos.
Aphasia or dysarthria
Agnosia
Balance disturbance
Confusion
Paresthesia
Seizure
Tremor
Memory loss
Other: _______________

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Chest Pain
Irreg. Heart Beat
Palpitations
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: __130/80__
_14__________
o Temperature:__98.4 F______
(percentile): _N/A___
o Weight: __150 lbs._________
_23.5_______

Pulse: _76_________

Respirations:

Pulse Ox: _98%_______

Head Circ

Height : _67 inches_______

BMI :

Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

Other:

No acute distress

___________
Nourishment

Normal Weight BMI 18.5-24.9

Overall Appearance

Age Appropriate

Other: ___________

Other: ___________
Other:_________________________________________________
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:___________

External Eye OD

Normal

Other:___________

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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

Normal

Other:___________

Cornea OD

Normal

Other:___________

Fundoscopy OS

Normal stuctures and sharp disc margin

Other:___________
Fundoscopy

OD

Normal

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles
Red Reflex
Vision Screen:

Normal cardinal gaze

Other:___________

Present Bilaterally
Abnormal:_____________________
OS:________ OD:_________ OU:__________________

Ears: Show
Auricle Right

Normal structure/placement

Other:____________
Auricle Left

Normal placement/structure

Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

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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.

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

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Other:__________________
Palate
Uvula

Other: Normal hard palate

Normal configuration

Oropharynx

pink and moist

Tonsils

+1

GCSU Revised Fall 2014

Other:__________________
Other:__________________
Other:__________________

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Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

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

Bilateral

Cough

Choose an item.

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

Regular Rate and Rhythm

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:__________________________________
Abdomen: Show

GCSU Revised Fall 2014

Morbid Obesity Limits Exam Accuracy: Yes or No

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Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

Other:________

All four quadrants

Palpation

Location:

Location:

Normal

Other:________

All four quadrants

Associated Findings

Choose an item.

Hernia _____________________
CVA Tenderness _____________
Other:______________________
Female Exam Show

DEFERRED

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: Choose an item.

Describe

Abn:_______________________________
Assessment of problem area:___________________________________________________
___________________________________________________________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person

Describe

Abn:_______________________________
Appearance: Good Hygiene

Describe

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

Describe

Abn:___________________________________

GCSU Revised Fall 2014

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SBIRT
Date of Alcohol Screening: _2/18/2015__________________
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
CN II-XII: Grossly intact
Describe
to questionnaire)
Brief Intervention delivered by: _Salena Barnes NPS_______
Abn:___________________________________
Length
of Brief Intervention: _15 minutes
_____________
Audit
score:
5
Zone
II:
At
Risk
DTRs: upper 2+ Avg
Lower:
Referrals to Treatment provided: Yes/No
Type of Referral to Treatment: _N/A_
___
2+ Avg information: In discussing the issue, my medical advice was that
Additional
she cut back to no more than 3 drinks in one day and no more than 7 per
week. Her readiness for change was 9 on a scale of 0-10. We explored why it
Grossly normal
Tone
and Strength:
Describe
wasMuscle
not a Bulk,
lower
number
and discussed
the patients own
motivation for
change. She was unaware of effects excessive alcohol consumption on the
Abn:_______________________________
body.
She agreed to cut back to the advised daily and weekly limits. A
normal was provided
Sensory: Grossly
Describe
Abn:_______________________________
prescription
for change
and the
patient will contact the office
for any further questions or concerns.
Body Position: Grossly normal
Describe Abn:_______________________________
Other
findings:_________________________________________________________________________
Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:___________________________________
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: __Prior CBC, Lipid Panel, BMP ordered result
values within normal range

Assessment/Plan:

First Diagnosis:Essential Hypertension

______________ ICD9:_401.9________________
o 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).
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 HA, dizziness, blurred vision and any other unsual
s/sx. Patient verbalized understanding and no questions as this time.
Patient will follow-up in two months and encouraged to call office for
any questions or concerns (patient verbalized understanding).
_____________

GCSU Revised Fall 2014

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Medications Added This Visit: Continue previously prescribed medications

Medication Name
Amlopidine

Quantity
60 tablets

Dose
10 mg

HCTZ

60 tablets

12.5 mg

Sig
Take one tablet
daily
Taken one tablet
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

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