Professional Documents
Culture Documents
Womens Final 1 Emr
Womens Final 1 Emr
School of Nursing
Episodic Document
Patient Information:
Initials: KF___ Age:21________
visit:8/31/15_____
Sex: Female_______
Date of
HPI:
Onset: No menses since childbirth
______________________
Location of problem: Gynecological___
_____________________________
Duration of problem: No menstrual cycle in last 6
weeks____ ___________
Character of problem: Denies pain at this
time__________ ____________
Intensity rating/10 or other:_0/10
________________________
Aggravating Factors None
______________________________
Relieving Factors None
____________________________________
Treatments Tried None
__________________________________________
Smoking: Never smoked____
_____________________________________
Additional information Patient reported receiving
Depo Provera prior to leaving the hospital and reports
no sexual intercourse since childbirth._
Current Medications:
Additional Information:
Page 1
Allergies: N.K.D.A._______
_______________________________________________________________
Current Immunizations: Up-to-date on all immunizations including
Gardasil_________________
__
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 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: Alive 40s; No medical history ____________
o Maternal Grandmother: 60s; Hx: Diabetes Mellitus
o Father: Unknown__________________________
o Siblings:(1) brother and (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
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
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: ____________
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
Syncope
Page 2
Cool extremities
Neg.
Neg.
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:12
Last Menses: Prior to pregnancy
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
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: Anxious/nervous
Cyanosis
Edema
Other: _________
Objective Findings:
Vital Signs:
o Blood Pressure: _120/80________ Pulse: _66______ Respirations:
__14_______
o Temperature:_98.6_______ Pulse Ox: _99________ Weight (lbs):
145__________
o Height (inches): 65___________
BMI: 24.1___________
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
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
Page 4
Sclera
OS
Normal
Other:___________
Sclera
OD
Normal
Other:___________
Iris OS
Normal
Other:___________
Iris OD
Normal
Other:___________
Cornea OS
Other:___________
Cornea OD
Choose an item.
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
Other:___________
Abnormal:_____________________
Ears: Show
Auricle Right
Normal structure/placement
Other:____________
Auricle Left
Normal placement/structure
Other:____________
Canal Right
Normal
Other:___________
Canal Left
Normal
Other:___________
TM Right
Other:___________
TM Left
Other:___________
Hearing
Normal Bilaterally
Page 5
Other:___________
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:________________
Non-tender
Other:________________
Non-tender
Other:________________
Non-tender
Other:________________
Mouth/Teeth:
Lips
Other:__________________
Teeth
Normal dentation
Other:__________________
Buccal
Other:__________________
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
Page 6
Chest
Other:_______________
Inspection
Other:_______________
Auscultation
Location
Choose an item.
Cough
Choose an item.
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 _______________________________________
EKG Results:N/A__________________________________
Tanner Stage: V
Inspection
Other
Description____________________
Perineum
Other______________________________
Anus
Other______________________________
Cervix
Normal discharge
Odor:_______
Os_Horizontal slit__________
position_Anteflexed_______________
Adnexa_Normal without masses___
Hemocult_N/A_______________________
Discharge
Page 7
Uterus
Stool
Describe
Abn:_______________________________
Muscle Strength: Normal all extremities
Describe
Abn:_______________________________
Joint Stability: Normal all extremities
Describe
Abn:_______________________________
Neurological Show
Page 8
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.
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,
PAP test completed________
Assessment/Plan:
First Diagnosis: Postpartum Care After Delivery_______________ ICD-9: V24.
O____________
o
Page 9
Quantity
None
Dose
None
Sig
None
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>)
59430
References
American College of Obstetricians and Gynecologists. (2014). Combined hormonal
birth control: Pill, patch, and ring, the frequently asked questions, ACOG Clinical
Opinion Number 185.
Centers for Disease Control. (2015). How effective are birth control methods?
Retrieved from
http://www
.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers
GCSU Revised Fall 2014
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