Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: CS_______
Age:37________
visit: 5/18/15________

Sex: F_________

Date of

Chief Complaint(s) or Reason for Visit: Left ankle pain and bruise
on left upper leg after falling downstairs. ________________________________________
___
o

HPI:
Onset Today after falling downstairs_
____________________________
Location of problem
Musculoskeletal______________________________
Duration of problem For approximately 40 minutes
(the patient reported immediately coming to doctors
office after fall__
______________
Character of problem: Aching
__________________________________
Intensity rating: 7/10 left ankle_____________
______________
Aggravating Factors: walking, standing on left ankle
_________________
Relieving Factors: Staying off ankle, rest_
______________________
Treatments Tried:
None__________________________________________
Smoking:
Nonsmoker____________________________________________
Additional information: Patient reported she was
walking down the stairs in her socks at her
employees house, which do not allow shoes in their
home and slipped down the stairs landing on her left
side.
______

Current Medications and how patient takes the medications:

Amlodipine 10 mg
GCSU Revised Fall 2014

Take one tablet by mouth daily

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Zoloft 25 mg

Take one tablet by mouth daily

Ferosul 50 mg

Take one tablet by mouth daily

Additional Information:
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 of
HTN, depression, and anemia_____ _________ ___
Past Surgical Hx: Sinus surgery in 2015, umbilical hernia repair
Substance use/amount: Alcohol Y/N amount N/A

__

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 50s; Hx of
HTN______________________________________________________
o Father: Alive 50s: Hx of HTN___
___________________________________________________
o Siblings: 4-brothers and 7-sisters-alive and
healthy_____________________________________
o Offspring: 6-sons and 3-daughter-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: _____________

GCSU Revised Fall 2014

Neg.

HEENT
Pos.
Dysphagia
Ear Discharge
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia

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Neg.

Respiratory
Pos.
Accessory muscles use
Dyspnea
Stridor
Sputum Production
Wheezing
Cough:
Quality_______
Freq:_________
Exposure to TB

Neg.

Neg.

Neg.

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:_____________

Menarche age:
Last Menses: 5/5/15
Regular Irregular
Frequency: monthly Flow: Tapers
Duration: 5-6 days
Neg.

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

GCSU Revised Fall 2014

Neg.

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

Neg.

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

Neurological
Pos.
Aphasia or dysarthria
Agnosia
Balance disturbance
Confusion
Paraesthesia
Seizure

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Other: _________

Cardiovascular and
Vascular
Neg.
Pos.

Chest Pain

Irreg. Heart Beat

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: _________

Neg.

Psychiatric
Pos.
Appropriate interaction
Behavioral changes
Difficulty concentrating
Distorted body image
Obsessive behaviors
Self-conscious

Cool extremities
Cyanosis
Edema
Other: _________

Tremor
Memory loss
Other: _______________

Other: feeling depressed

Objective Findings:
Vital Signs:
o Blood Pressure: 120/72____ Pulse: 82____________ Respirations:
16___________
o Temperature: 97.8 F_______ Pulse Ox: 99%_______
Head Circ
(percentile): N/A______
o Weight (lbs): 150.8__________
Height (inches): 71___________
BMI:
21.3___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

___________
Nourishment

Normal Weight BMI 18.5-24.9

Overall Appearance

Age Appropriate

Other:

Other: ___________

Other: Appropriate attire for weather

Appropriate
interaction______
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:___________________________________________________

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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:___________
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

OS

Normal

Other:___________
Sclera

OD

Normal

Other:___________
Iris OS

Normal

Other:___________
Iris OD

Normal

Other:___________
Cornea OS

Normal

Other:___________
Cornea OD

Normal

Other:___________

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Normal stuctures and sharp disc margin

Fundoscopy OS
Other:___________
Fundoscopy

Normal

OD

Other:___________

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Normal cardinal gaze

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

Light reflex present/TM clear

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:________________

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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

Other:__________________
Teeth

Normal dentation

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Palate

Normal

Uvula

Other:__________________
Other: __________________

Normal configuration

Oropharynx

pink and moist

Tonsils

+1

Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Other:____________________________________________________________________________

Lymphatic: Show
Overview: No noted abnormal swelling/tenderness
Choose an item.

Description of Abn:

Choose an item.

GCSU Revised Fall 2014

Location of Abn:

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Size: ______________________
Other
Findings:__________________________________________________________________________
Respiratory: Show
Normal anatomical configuration

Chest
Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

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:

Choose an item.

Other:________________
Intensity:

Choose an item.

Location: Choose an item.

Quality:

Choose an item.

Radiation: ____________
Edema: _No edema present except for site of injury (refer to MS)______________
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

Morbid Obesity Limits Exam Accuracy: Yes or N/A

Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

All four quadrants

GCSU Revised Fall 2014

Location:
Other:________

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Normal

Palpation
All four quadrants

Associated Findings

Location:
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:_Grade I left

ankle/hip sprain________
Assessment of problem area: Antalgic gait, favoring the right leg. Full ROM in left hip
with mild pain on internal rotation, small subcutaneous hematoma (2inches in
diameter) noted on left lateral mid-thigh, left ankle tenderness noted at lateral
malleolus, 1+ edema noted. ______________________
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___________________________________

GCSU Revised Fall 2014

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CN II-XII: Grossly intact

Describe Abn:

N/A___________________________________
DTRs: upper 2+ Avg

Lower:

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Describe

Abn:_______________________________
Sensory: Grossly normal
Body Position: Grossly normal

Describe Abn:_______________________________
Describe Abn:_______________________________

Skin Show
Overview: Abnormal
Describe Abn: Small abrasion (1in X 0.5 in) pink tissue noted on left lateral malleolus
(covered with band-aid) and small subcutaneous hematoma (approx. 2 inches in
diameter) ecchymosis noted on left lateral mid-thigh.
______________
Results of x-rays done today: Left ankle 2 views: No prior films for
comparison. No acute fracture or dislocation noted. Alignment of all the
bones and joints normal. Impression: No acute fracture of dislocation
noted.__________________________________________________

Assessment/Plan:

First Diagnosis: Sprain of left ankle________________ ICD-9:

845.00_________________
o Additional teaching or comments: Splint ankle brace applied to the
patients left ankle. RICE explained to patient-rest, ice, compression and
elevation to affected area, as well as limited activity to prevent further
injury, and range-of motion exercises. The patient instructed to elevate
the affected joint above the level of the heart for 48-72 hours and
apply ice intermittently for the first 12 to 48 hours. Encourage patient
to take their ankle out of their brace intermittently and move it through
a pain-free ROM. An example was given of spelling the letters of the

GCSU Revised Fall 2014

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alphabet with their foot and ankle several times per day is one simple
activity to recommend. Drug administration, dosage and possible
adverse reactions to report discussed with patient. Follow-up
scheduled in one week for reevaluation of physical activity, and
contact office if signs/symptoms worsen. Patient verbalized
understanding.

Second Diagnosis: Sprain of left hip________________ ICD-9:

843.9_________________
o Additional teaching or comments: As previously stated the patient was
explained to rest, because it promotes tissue healing and avoid
activities that cause increased pain or swelling. Encouraged to
continue pain-free movements during this time and the use of ice for
the first 12 to 48 hours. Adverse reactions of Ibuprofen explained
(abdominal pain, bleeding, decreased urine output, vomiting,
heartburn, indigestion, flatulence, headache, dizziness), as well as to
stop using Tramadol and call your doctor at once if you have any of
these serious side effects: agitation, hallucinations, fever, fast heart
rate, overactive reflexes, nausea, vomiting, diarrhea, loss of
coordination, fainting;
seizure (convulsions); a red, blistering, peeling skin rash; or shallow
breathing, weak pulse.

Third Diagnosis: Hematoma of left hip________________ ICD-9:

924.00_________________
o Additional teaching or comments: The patient was informed that
hematomas of the skin and soft tissues are often treated
with RICE(rest, ice, compression, elevation) and resolve eventually on
their own. She verbalized understanding.

Medications Added This Visit

Medication Name
Ibuprofen
Tramadol HCL

Quantity
21 tablets
No refills
28 tablets
No refills

Dose
800 mg
50 mg

Sig
Take one tablet
three times a day
Take one tablet as
every 6 hours as
needed for pain

Office Code for Visit: Please Highlight

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

99211
99212
99213
99214
99215

------99201
99202
99203
99204
99205

99391
1yr)
99392
99393
11yr)
99394

99381 (<
1yr)
99382 (14yr)
99383 (5-

GCSU Revised Fall 2014

(<
(1-4yr)
(5-

Additional Procedure Codes,

Immunization, Lab, etc.

(12-

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17yr)
99395
(18yr>)

GCSU Revised Fall 2014

11yr)
99384 (1217yr)
99385
(18yr>)

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