Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: GB__ Age:60________
visit:9/02/15_____

Sex: Female_______

Date of

Chief Complaint(s) or Reason for Visit: Presents for pap smear

and has complaints of vaginal dryness.
_____________________________________________________________
o

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:

Centrum Multivitamin for Women OTC

GCSU Revised Fall 2014

1 tablet once daily

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Chewable Aspirin 81 mg OTC

Simvastatin 10 mg
Triamterene/HCTZ 25mg-37.5 mg

1 tablet once daily

1 tablet at bedtime
1 tablet once a day

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

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

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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:

GCSU Revised Fall 2014

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

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: _________

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

Obesity Class I - BMI 30-34.9

Overall Appearance

Age Appropriate

Head/Skull: Show
Appearance

Normocephalic

Facial Features

Normal stucture alignment

Other: ______________
Other:

______________
Hair Distribution

Normal Distribution

Other:______________

Eyes: Show
Surrounding Structures OS

GCSU Revised Fall 2014

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

Normal cardinal gaze

Red Reflex

Present Bilaterally

Ears: Show
Auricle Right

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Normal structure/placement

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Other:___________
Abnormal:_____________________

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:________________

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

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________

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Tongue

Normal

Palate

Choose an item.

Uvula

Normal configuration

Other:__________________

Oropharynx

pink and moist

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:_______________

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 No
Rate/Rhythm
Murmur

Regular Rate and Rhythm

Other:________________

None

Edema: _None____________________________________
Location:____________________________
Capillary Refill: less than 2 seconds in all extremities_______________________________
Pedal Pulses:2 + bilaterally______________________________
Carotid Bruits: Negative _______________________________________

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EKG Results: Completed 5/2015 Normal Sinus Rhythm

__________________________________

Female Exam Show

Genitalia

Morbid Obesity Limits Exam Accuracy: Yes or No

Tanner Stage: V

Normal structures & pubic hair distribution

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______

Os: TAH BSO__________

Adnexa: TAH BSO
___
(8/1015)____

Uterus position: TAH BSO_______________

Stool Hemoccult: Negative x3

Pelvic Deferred for _N/A________________

Other:__Nulligravida. Vaginal walls dry and thinning. No inflammation or petechiae
noted.__________
Breast Exam
Tanner Stage: V
Self-Breast Exam Taught: Yes
Right Breast
Breast Inspection: Normal Contour
Other:________________________________________
Breast Palpation: Normal Exam
Nipple Discharge: No Discharge
Other:________________________________________
Lymphatic: No noted swelling or tenderness of nodes
Left Breast
Breast Inspection: Normal Contour

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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.

Muscle Bulk, Tone and Strength: Grossly normal

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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

Additional teaching or comments: _Patient informed of changes that

occur during menopause, as well as, hormonal and non-hormonal
therapy treatments used to alleviate symptoms and treat the
underlying cause of vaginal dryness. Discussed the risk and benefits
and concerns associated with vaginal creams. Patient requests to use
non-hormonal therapy treatments at this time. Informed water-soluble
lubricants, vaginal creams and vitamin E may be utilized at the time of
intercourse, but also on a daily basis to aid comfort, if desired. To help
with dyspareunia patient informed to use a lubricant, empty bladder
before sex, take a warm bath, allow plenty of time for arousal before
penetration, and try different sexual positions or activities that do no
involve intercourse. The patient was instructed to inform office of any
new medical diagnosis, abnormal signs/symptoms reviewed due to
possible contraindications with medication. The patient is scheduled
for follow-up visit in 3 months to receive medication refill and will
continue with previously prescribed medication, unless follow-up
required concerning Pap results. Patient verbalized understanding and
denies any concerns/questions at this time.________________

Second Diagnosis: Hypertension_______________ ICD-9:_401.9________________

o Additional teaching or comments: Reinforced lifestyle modifications:
weight reduction, DASH eating plan, dietary sodium reduction, and
aerobic physical activity (150 min of moderate activity weekly).
Instructed on importance of taking blood pressure medication every
day, as well as taking blood pressure readings. Patient educated on
select target organ damage from uncontrolled HTN (brain, eye, heart,
kidneys). Discussed signs and symptoms that are important to seek
medical attention for HA, dizziness, blurred vision and any other

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unusual signs or symptoms. Patient verbalized understanding and no

questions as this time. ___________________________________________

Third Diagnosis: Hyperlipidemia_______________ ICD-9:_272.4________________

o Additional teaching or comments: Reinforced lifestyle modifications:
avoiding intake of saturated fats, excessive sugar, and foods high in
cholesterol, encouraged consumption of lean meats, fresh fruits, and
vegetables. Patient informed of signs and symptoms (chest
pain/discomfort, dizziness, LOC, altered mental status, weakness, facial
drooping, as well as any other unusual sign and symptoms) that
require medical evaluation. Patient verbalized understanding and
denies any concerns/questions at this time.

Fourth Diagnosis: Obesity___________ ICD-9: 278.00_________________

o Additional teaching or comments: Reinforced lifestyle modifications:
low fat, high-fiber and sodium diet which contain lean meats and
fresh/frozen vegetables, routine aerobic physical activity and obtained
a diet history to identify patient eating patterns and the importance of
food to her lifestyle. Current BMI discussed, as well as a mutual goal of
weight loss was established by next office visit along with the need for
long-term maintenance after desired weight is achieved.
Recommended dietary guidelines were covered and safe weight loss
practices. Currently, the patient does not want to be referred to a
weight-reduction program. The patient verbalized understanding and
will contact the office if she has further questions.

Medications Added This Visit

Medication Name
OTC Water Soluble
Lubricant

Quantity
1 Tube

Dose
OTC

Sig
Apply as needed
for vaginal dryness

Office Code for Visit:

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 (1-4yr)
99393 (511yr)
99394 (1217yr)
99395
(18yr>)

99381 (<
1yr)
99382 (14yr)
99383 (511yr)
99384 (1217yr)
99385
(18yr>)

GCSU Revised Fall 2014

Additional Procedure Codes,

Immunization, Lab, etc.

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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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