Professional Documents
Culture Documents
Hypothyroid Emr Adult II
Hypothyroid Emr Adult II
School of Nursing
Episodic Document
Patient Information:
Initials:LL___________ Age:41________
visit:5/22/2015____________
Sex:F_________
Date of
Chief Complaint(s) or Reason for Visit: Right ear pain and f/u for
hypothyroidism_______
o
HPI:
Onset One week ago
_________________________________
Location of problem Endocrine system & Ear___
_____________________
Duration of problem Approximately one
week_______________________
Character of problem Aching ear__________________
________________
Intensity rating: 4/10 or other: right ear
____________________
Aggravating Factors: Tugging of
ear_________________________________
Relieving Factors:
Tylenol_________________________________________
Treatments Tried
None___________________________________________
Smoking: Nonsmoker__
_________________________________________
Additional information Patient reported that she has
been swimming a lot
lately._______________________________________________________
__
Page 1
Additional Information:
Allergies:
_NKDA________________________________________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declined
influenza vaccination during flu season.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
other than hypothyroidism
__________ ___
Past Surgical Hx: IUD removal and replacement in 7/2013
Substance use/amount: Alcohol Y/N amount 1-3 drinks a month
__
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: Alive 60s; Hx: breast cancer__
____________________________________________
o Father: Alive 60s; History unknown __________
_____________________________________
o Siblings: 2-brothers and 1 sister-alive and healthy
____________________________________
o Offspring: 2-sons alive and healthy__________________________________________________
Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Neg.
Pos.
Polydipsia
Polyuria
Polyphagia
Neg.
HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia
Pharyngitis
Rhinorrhea
Sneezing
Tearing
Vision changes
Page 2
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
Neg.
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
Thinning Hair
Other:_________
Gastrointestinal
Pos.
Abdominal Pain
Constipation
Diarrhea
Nausea
Reflux
Vomiting
Other: _____________
Female Reproductive
Neg.
Pos.
Dysmenorrhea
Dyspareunia
Menorrhagia
Vaginal Discharge
Vaginal itching
Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other: Dry skin____________
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
Paraesthesia
Seizure
Tremor
Memory loss
Other: _______________
Page 3
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: Depression
Objective Findings:
Vital Signs:
o Blood Pressure: 122/80______ Pulse: 90___________ Respirations:
18_____________
o Temperature: 98.2 F_______ Pulse Ox:99% _________
Head Circ
(percentile): N/A____
o Weight (lbs):227.2___________
Height (inches):65.5_______
BMI:
37.23___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress
No acute distress
___________
Nourishment
Overall Appearance
Age Appropriate
Other:
Other: ___________
Normocephalic
Fontanels
Choose an item.
an item.
Other: ______________
Choose
Other:________________
Facial Features
Other:
______________
Hair Distribution
Normal Distribution
Other:______________
Other:___________________________________________________
Eyes: Show
Surrounding Structures OS
Normal Structures
Other:___________
Surrounding Structures OD
Normal Structures
Other:___________
Page 4
External Eye OS
Normal
Other:___________
External Eye OD
Normal
Other:___________
Normal
Eye Lids OS
Other:___________
Normal
Eye Lids OD
Other:___________
PERRLA
Pupil OS
Other:___________
PERRLA
Pupils OD
Other:___________
Conjunctiva OS
Clear
Other:___________
Conjunctiva
OD
Clear
Other:___________
Sclera
Normal
OS
Other:___________
Sclera
Normal
OD
Other:___________
Normal
Iris OS
Other:___________
Normal
Iris OD
Other:___________
Normal
Cornea OS
Other:___________
Normal
Cornea OD
Other:___________
Fundoscopy OS
Other:___________
Fundoscopy
OD
Lens OS
Normal
Clear
Page 5
Other:___________
Other:___________
Clear
Lens OD
Ocular Muscles
Red Reflex
Vision Screen:
OU:_20/20_______________
Other:___________
Other:___________
Present Bilaterally
Abnormal:_____________________
OS:_20/20______ OD:_20/20______
Ears: Show
Normal structure/placement
Auricle Right
Other:____________
Normal placement/structure
Auricle Left
Other:____________
Erythema
Other: Slightly
Canal Left
Normal
Other:___________
TM Right
Canal Right
edematous___
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:________________
Non-tender
Other:________________
Page 6
Non-tender
Non-tender
Non-tender
Teeth
Normal dentation
Other:__________________
Other:__________________
Buccal
Other:__________________
Tongue
Normal
Palate
Normal
Uvula
Other:__________________
Other:__________________
Normal configuration
Oropharynx
Tonsils
+1
Other:__________________
Other:__________________
Other:__________________
Neck:
Palpation of Thyroid: Normal
Describe
Abn:___________________________________
Other:____________________________________________________________________________
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
Location of Abn: Choose an item.
Choose an item.
Description of Abn:
Choose an item.
Choose an item.
Size: ______________________
Other
Findings:__________________________________________________________________________
Page 7
Respiratory: Show
Normal anatomical configuration
Chest
Other:_______________
Inspection
Other:_______________
Auscultation
Location
Choose an item.
Choose an item.
Cough
Other: ___________________________________________________________________
Cardiac: Show
Morbid Obesity Limits Exam Accuracy: Yes or N/A
Regular Rate and Rhythm
Rate/Rhythm
Murmur
Timing:
Other:________________
Choose an item.
Intensity:
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: N/A_________________________________
Abdomen: Show
Inspection
Obese
Auscultation
Palpation
Location:
Other:________
Normal
Location:
Page 8
Associated Findings
Other:________
Choose an item.
Hernia Negative_______________
CVA Tenderness Negative_______
Female Exam Show
Male Exam
Show
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:_______________________________
Assessment of problem area: N/A__________________________________________________
Neurological Show
Mental Status: Alert, Oriented to Time, Place, Person
Describe Abn:
N/A__________________________
Appearance: Age Appropriate
Describe Abn:
N/A_______________________________
Thought Process: Follows conversation and engages appropriately
Describe Abn: N/A_____________
MMSE Score: N/A______
Gait: Smooth, active gait
Describe Abn:
N/A___________________________________
CN II-XII: Grossly intact
Describe Abn:
N/A___________________________________
DTRs: upper 2+ Avg
Lower:
Page 9
2+ Avg
Describe
Abn:_______________________________
Sensory: Grossly normal
Body Position: Grossly normal
Describe Abn:_______________________________
Describe Abn:_______________________________
Skin Show
Overview: Normal overview but detail exam not done
Describe
Abn:_N/A_______________
Other: __________________________________________________________________________
Assessment/Plan:
First Diagnosis: Hypothyroidism________________ ICD-9: 244.8________________
Additional teaching or comments: Patient was educated on the
disorder, diagnosis, treatment and keeping accurate records of daily
weights. Reinforced the need for lifelong hormone replacement
restores proper metabolic function and the need to wear a medical
identification bracelet. Emphasized the importance of adherence to the
prescribed Synthroid regimen and continued medical surveillance to
check TH levels and adjust dose if necessary. Reviewed adverse
reactions of the medication that she be reported such as headache,
sleep problems (insomnia), feeling nervous or irritable, fever, hot
flashes, sweating, pounding heartbeats or fluttering in chest, changes
menstrual periods, appetite changes, and weight changes. Instructed
the patient to contact emergency services if signs/symptoms of
myxedema coma/crisis develop (e.g., mental deterioration, apathy,
confusion, psychosis, severe breathing difficulty, bradycardia [< 60
beats per minute], hypothermia [< 95F/35C], extreme weakness and
fatigue. Patient will follow-up in 3 months and will have labs (CBC, BMP,
Lipid) drawn 3 days prior to visit.
Second Diagnosis: Right otitis externa________________ ICD-9:
380.10_________________
o
Page 10
Quantity
30 tablets
2 refills
Dose
150 mcg
Ofloxacin Solution
1 bottle
Acetaminophen
30 tablets
No refills
650 mg
Sig
Take one tablet on
an empty stomach
in the morning one
hour prior to
breakfast
Place 10 drops into
the affected canal
once a day
Take one tablet by
mouth as needed
every 6 hours for
pain
New Pt.
Office
Est. Pt.
Health Check
New Pt.
Health Check
Page 11
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>)
Page 12