Professional Documents
Culture Documents
Women Emr 2 Revi 3
Women Emr 2 Revi 3
Women Emr 2 Revi 3
School of Nursing
Episodic Document
Patient Information:
Initials: GB__ Age:60________
visit:9/02/15_____
Sex: Female_______
Date of
HPI:
Onset: Approximately 10 years ago
______________________
Location of problem: Gynecological___
_____________________________
Duration of problem: After menopause (approximately
10 years ago)_____
Character of problem: Denies pain at this
time__________ ____________
Intensity rating/10 or other:_0/10
________________________
Aggravating Factors Sexual intercourse
___________________________
Relieving Factors Using lubricants
_______________________________
Treatments Tried KY
Jelly_________________________________________
Smoking: Never smoked____
_____________________________________
Additional information Patient reported that
lubricants help with the vaginal dryness, but wanted
to know of other possible treatments. She does not
want to try any hormonal therapy. Patient is seeking a
natural treatment for vaginal dryness.
Current Medications:
Additional Information:
Allergies: N.K.D.A._______
_______________________________________________________________
Current Immunizations: Up-to-date on all immunizations
_________________
__
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth):
History of HTN, obesity,
hyperlipidemia_____________________________________________________
Past Surgical _Varicose vein surgery 12/2/2013, Total Abdominal
Hysterectomy Bilateral Salpingo Oophorectomy post menopause in 6/22/05;
Cyst removed from right breast in 1976 (negative pathology) _
__
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: Deceased 60s; CVD; DM II__
__________
o Maternal Grandmother: 60s; Hx: Diabetes
Mellitus____________________________________
o Father: Deceased 50s;CVD______
___________________
o Siblings:(2) brothers Both deceased (1-cerebral hemorrhage 50s; 1myocardial infarction-40s) and (1) sister-alive 60s; Hx:
HTN______________________________ _____________________
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
Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Neg.
HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
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Neg.
Respiratory
Pos.
Accessory muscles use
Dyspnea
Stridor
Sputum Production
Wheezing
Neg.
Neg.
Neg.
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
Other: Vaginal Dryness
Menarche age:12
Last Menses: TAH BSO
Regular Irregular
Frequency:
Flow:
Neg.
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
Premature ejaculation
Scrotal mass
Scrotal pain
Other: _______________
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Cough:
Quality_______
Freq:_________
Exposure to TB
Other: _________
Cardiovascular and
Vascular
Neg.
Pos.
Chest Pain
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
Other: _________
Cool extremities
Cyanosis
Edema
Other: _________
Neg.
Skin
Pos.
Acne
Eczema
Pruritus
Psoriasis
Skin lesion
Other:_____________
Neg.
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:
Objective Findings:
Vital Signs:
o Blood Pressure: _128/86________ Pulse: _70______ Respirations:
__14_______
o Temperature:_98.6_______ Pulse Ox: _99________ Weight (lbs):
200__________
o Height (inches): 65___________
BMI: 33.3___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress
No acute distress
Nourishment
Overall Appearance
Age Appropriate
Head/Skull: Show
Appearance
Normocephalic
Facial Features
Other: ______________
Other:
______________
Hair Distribution
Normal Distribution
Other:______________
Eyes: Show
Surrounding Structures OS
Normal Structures
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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
Sclera
OS
Normal
Other:___________
Sclera
OD
Normal
Other:___________
Iris OS
Normal
Other:___________
Iris OD
Normal
Other:___________
Cornea OS
Other:___________
Choose an item.
Cornea OD
Fundoscopy OS
Other:___________
Choose an item.
Other:___________
Fundoscopy
OD
Choose item
Other:___________
Lens OS
Clear
Other:___________
Lens OD
Clear
Other:___________
Ocular Muscles
Red Reflex
Present Bilaterally
Ears: Show
Auricle Right
Normal structure/placement
Page 5
Other:___________
Abnormal:_____________________
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:___________
Normal patency
Naris Left
Normal patency
Other:________________
Other:________________
Turbinates Right
Choose an item.
Other:________________
Turbinates Left
Choose an item.
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Mouth/Teeth:
Lips
Teeth
Normal dentation
Other:__________________
Other:__________________
Buccal
Other:__________________
Page 6
Tongue
Normal
Palate
Choose an item.
Uvula
Normal configuration
Other:__________________
Oropharynx
Tonsils
+1
Other:__________________
Other:__________________
Other:__________________
Other:__________________
Neck:
Palpation of Thyroid: Normal
Describe
Abn:___________________________________
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
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 No
Rate/Rhythm
Murmur
Other:________________
None
Edema: _None____________________________________
Location:____________________________
Capillary Refill: less than 2 seconds in all extremities_______________________________
Pedal Pulses:2 + bilaterally______________________________
Carotid Bruits: Negative _______________________________________
Page 7
Tanner Stage: V
Inspection
Other
Description____________________
No swelling, mass, or tenderness noted
Perineum
Other______________________________
Normal meatus and tone
Anus
Other______________________________
Cervix
TAH BSO
Normal discharge
Discharge
Odor: _None______
Page 8
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
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.
Page 9
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.
Mammogram negative for pathology completed on 8/2015. Pap smear
results collected today pending.
________
Assessment/Plan:
First Diagnosis: Gynecological exam for papanicolaou cervical smear_____ ICD-9:
V72.3 ____________
o
Page 10
Quantity
1 Tube
Dose
OTC
Sig
Apply as needed
for vaginal dryness
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>)
Page 11
References
American College of Obstetricians and Gynecologists. (2014). The Menopause Years
http://www.acog.org/Patients/FAQs/The-Menopause-Years
American College of Obstetricians and Gynecologists. (2011).
http://www.acog.org/Patients/FAQs/Your-Sexual-Health
Centers for Disease Control. (2015). How effective are birth control methods?
Retrieved from
http://www
.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm
Abernethy, K. (2015). Vaginal dryness and the menopause: hormonal and nonhormonal therapies. Journal of Aesthetic Nursing, 4(3), 122-125.
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers
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