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Final Emr Sbirt Adult II Rev
Final Emr Sbirt Adult II Rev
School of Nursing
Episodic Document
Patient Information:
Initials: SP_________ Age: 42______
visit:_5/19/2015______
Sex: M__
Date of
HPI:
Onset _Reported being diagnosed with HTN in
30s___________________
Location of problem
_Cardiovascular_______________________________
Duration of problem _For approximately 10 years
( possibly going on prior to diagnosis)
___________________________________________
Character of problem _Blood pressure currently
controlled
__________
Intensity rating: 0 /10 or other: Denies any pain
or discomfort___
Aggravating Factors high salt intake, lack of physical
exercise, weight gain
Relieving Factors _ low salt diet, regular physical
activity, weight loss, taking medications
Treatments Tried _Currently taking Lisinopril-HCTZ
20/12.5 mg_ ________
Smoking:
_Nonsmoker___________________________________________
Additional Information: The patients hypertension
has been controlled since he started taking LisinoprilHCTZ 20/12.5 mg.
Lisinopril-Hydrochlorothiazide 20/12.5
mg
Additional Information:
Page 1
Allergies:
_NKDA________________________________________________________________________
Current Immunizations: __Up-to-date on all immunizations. Declined
influenza vaccine during flu season.
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
other than HTN____________________________ ___
Past Surgical Hx:___None
_
Substance use/amount: Alcohol Y/N amount Patient reported he is a social
drinker and has a drink containing alcohol monthly. He reported that one
or more times in the past year he has drank five 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:
o Mother: Deceased 50s; Hx: Brain Cancer__________
__________________________________
o Father: Deceased 60s; Hx: Diabetes Mellitus Type II___________________
_______________
o Siblings:_1 brother, 4 sisters-healthy with no known medical
history______________________
o Offspring: 2 sonshealthy__________________________________________________________
INTERVAL HISTORY: Patient denies being seen by any other providers, ER
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
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: Tinnitus_
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
Palpitations
Neg.
Neg.
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:
Regular Irregular
Frequency:
Flow:
Neg.
Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________
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: _______________
Page 3
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: _120/78_____ Pulse: _90___________ Respirations:
_16_____________
o Temperature:_98.4__________ Pulse Ox: _98%_____
Head Circ
(percentile): __N/A____
o Weight: _213.8 lbs._____
Height: _67 inches__________
BMI:
_33.48__________
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:___________
External Eye OS
Normal
Other:___________
Page 4
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
Normal
Other:___________
Lens OS
Clear
Other:___________
Lens OD
Clear
Other:___________
Page 5
Ocular Muscles
Red Reflex
Vision Screen:
OU:_20/20_______________
Other:___________
Present Bilaterally
Abnormal:_____________________
OS:_20/20______ OD:_20/20______
Ears: Show
Normal structure/placement
Auricle Right
Other:____________
Normal placement/structure
Auricle Left
Other:____________
Canal Right
Normal
Other:___________
Canal Left
Normal
Other:___________
TM Right
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:________________
Frontal Sinus Left
Non-tender
Other:________________
Maxillary Sinus Right
Non-tender
Page 6
Other:________________
Non-tender
Teeth
Normal dentation
Other:__________________
Other:__________________
pink and moist
Buccal
Other:__________________
Tongue
Normal
Palate
Normal
Other:__________________
Other:__________________
Normal configuration
Uvula
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:__________________________________________________________________________
Respiratory: Show
Chest
Other:_______________
Page 7
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
Auscultation
Palpation
Location:
Other:________
Normal
Associated Findings
Location:
Other:________
Choose an item.
Hernia Negative_______________
CVA Tenderness Negative_______
Page 8
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:
2+ Avg
Page 9
Describe
Describe Abn:_______________________________
Describe Abn:_______________________________
Skin Show
Overview: Normal overview but detail exam not done
Describe
Abn:_N/A_______________
Other: __________________________________________________________________________
Results of labs done today: N/A__________________________________________________
Assessment/Plan:
First Diagnosis: Hypertension________________ ICD-9: 401.9_________________
o
Page 10
Quantity
30 tablets
5 refills
Dose
20/12.5mg
Sig
Take one tablet by
mouth daily
New Pt.
Office
Est. Pt.
Health Check
New Pt.
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>)
99408
Page 11