Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials:_SM__________
visit:_2/4/15___________

Age:_62_______

Sex:_F____ Date of

Chief Complaint(s) or Reason for Visit: _F/U from evaluation at ER

for hyponatremia and hypokalemia,
confusion__________________________________________
o

HPI:
Onset _Patient uncooperative and unable to answer
questions. However, her stepson reported patients
confusion has progressively gotten worse over the
last two days. The patient has been experiencing
intermittent episodes of confusion for the last week
per stepson.
Location of problem
_Neurological_________________________________
Duration of problem _Approximately four weeks per
stepson but possibly longer._____ _
Character of problem __Patient uncooperative.
______________________
Intensity rating: Unable to assess /10 or other:
No grimacing, guarding noted.
Aggravating Factors _None reported by stepson.
Patient uncooperative.
Relieving Factors _None reported by stepson. Patient
uncooperative. __
Treatments Tried _None reported by stepson. Patient
uncooperative. __
Smoking: _Her stepson reported she is a smoker,
however has not been smoking that he is aware of
since she became confused approximately a week
ago._____________ _
Additional information The stepson is also her
nephew. His father married his moms sister so she
would be able to be place on his medical insurance to
get treatment for her illness. The stepson is currently
staying with his father, who has many medical issues
of his own. Her stepson reported that he has not been
able to rest for the last two days because she is very
confused, refuses to eat, refuses to take her

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medications, and occasionally tries to leave the house.

Her stepson also stated she does not seem to
remember anything that has happened and what she
is doing. __

Current Medications and how patient takes the medications:

Folic Acid 1 mg

Take one tablet once a day

Additional Information:
Allergies:
_N.K.D.A.___________________________________________________________________________
__
Current Immunizations: _Up-to date on current vaccinations. Son reported
patient did not receive influenza
vaccination._________________________________________________________________
PMH, Chronic Problems, Significant birth history (NNICU admission, Apgar
scores, bilirubin, other complications of birth): _Past medical history of
Alcoholism_____________________________________
Past Surgical Hx:_None___
_
Substance use/amount: Alcohol Y/N amount Stepson reported patient does
have a history of alcohol use but has not been drinking for several weeks
and is unsure of her prior consumption amount.
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how long:
Stepson reported that she is a smoker, however has not been smoking that
he is aware of since she became confused approximately a
week._____________ _
Illicit drugs Y/N amount
__
Family Hx: Heart disease, DM, cancer, HTN, COPD, strokes, other
___________________________
o Mother: Deceased; family history
unknown___________________________________
o Father: Deceased; family history
unknown___________________________________
o Siblings:_1 brother, 2 sistershealthy_________________________________________

INTERVAL HISTORY: _The patient received treatment at the local ER

approximately a week ago for hypokalemia, and hyponatremia. The stepson
did not bring any discharge instructions and did not request medical records
to be sent to practice. The stepson is unaware of any recent procedures or
any other recent provider visits. _______________________________________

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Review of Systems:
Neg.

Neg.

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
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:_____________

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Neg.

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: ____________

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

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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

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: _________

Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:

Neg.

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

Neg.

Scrotal mass
Scrotal pain
Other: _______________

Neurological
Pos.
Aphasia or dysarthria
Agnosia
Balance disturbance
Confusion
Paresthesia
Seizure
Tremor
Memory loss
Other: _______________

Psychiatric
Neg. Pos.

Inappropriate
interaction

Behavioral changes

Difficulty concentrating

Distorted body image

Obsessive behaviors

Self-conscious

Other: _Restless,
Anxious, Hallucinations

Objective Findings:
Vital Signs:
o Blood Pressure: _108/60______ Pulse: __88________ Respirations:
_18___________
o Temperature:_98.7_________ Pulse Ox: _98________
Head Circ
(percentile): _N/A____
o Weight : _92.2 lbs.____________
Height : _64.5 inches___
BMI :
_15.58_______
Physical Exam:
Physical Exam
Constitutional: Show
Confused

Level of Distress
Restless
Nourishment

Other:

___

Overall Appearance

Under Weight BMI < 18.5

Flat Affect

Other: _Anxious__________
Other:_________________________________________________
Head/Skull: Show

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Other: ___________

Appearance

Normocephalic

Fontanels

Choose an item.

an item.

Other: ______________

Choose

Other:________________

Facial Features

Normal stucture alignment

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:___________

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

Choose an item.

Other:___________

Cornea OD

Choose an item.

Other:___________

Fundoscopy OS

Choose an item.

Other:___________

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Fundoscopy

Choose item

OD

Other:___________

Lens OS

Choose an item.

Other:___________

Lens OD

Choose an item.

Other:___________

Choose an item.

Ocular Muscles

Other:___________

Red Reflex
Present Bilaterally
Abnormal:_____________________
Vision Screen:
OS:________ OD:_________ OU:__________________
Patient uncooperative during portions of exam.
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: Gross hearing

intact_________
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

Choose an item.

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Other:________________

Frontal Sinus Left

Choose an item.

Other:________________

Maxillary Sinus Right Choose an item.

Maxillary Sinus Left

Other:________________

Choose an item.

Other:________________

Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Numerous Dental Caries

Other:__________________
Other: Missing

teeth______
Buccal

pink and moist

Other:__________________
Tongue

Normal

Other:__________________
Palate
Uvula

Other: Normal hard palate

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

Location of Abn:

Choose an item.

Choose an item.

Description of Abn:

Choose an item.

Choose an item.

Size: ______________________

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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: __None___________________________________
Location:____________________________
Capillary Refill__Less than 2 sec in all four extremities______________________________
Pedal Pulses:__2+____________________________
Carotid Bruits:_Negative______________________________________
Other Findings:_______________________________________
EKG Results:__________________________________
Abdomen: Show

Morbid Obesity Limits Exam Accuracy: Yes or N/A

Inspection

Normal Contour Symmetry

Auscultation

Normal Bowel Sounds

Choose an item.

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Location:
Other:________

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Normal

Palpation
Choose an item.

Associated Findings

Location:
Other:________

Choose an item.

Hernia _____________________
CVA Tenderness _____________
Other:__Concave abdomen____________________
Female Exam Show
Male Exam

Show

Musculoskeletal Show
Overview: Walks with assistance
Posture: No structural abnormalities
ROM: Normal ROM all extremities

Describe

Abn:_______________________________
Muscle Strength: Normal all extremities

Describe

Abn:_______________________________
Joint Stability: Choose an item.

Describe

Abn:_______________________________
Assessment of problem area:___________________________________________________
___________________________________________________________________________
Neurological Show
Mental Status: Impaired Mental Status

Describe Abn:

_Disoriented x 3 and confused. Visual/Auditory hallucinations noted in past medical

history. None noted at this time. Intermittent episodes of agitation.
Appearance: Good Hygiene

Describe

Abn:_______________________________
Thought Process: Confabulation
Describe Abn:_Anxious, restless, talkative, mumbling and displaying repetitive
behaviors______________________________
MMSE Score: Patient uncooperative______
Gait: Abnormal

Describe

Abn:_Ataxia__________________________________

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CN II-XII:

Describe Abn:__Patient

uncooperative_____________________
DTRs: upper 2+ Avg

Lower:

2+ Avg

Muscle Bulk, Tone and Strength: Grossly normal

Describe

Abn:_______________________________
Sensory: Grossly normal
Body Position: Ataxia

Describe Abn:_______________________________
Describe Abn:_______________________________

Other findings: Patient lacks insight into her current condition and believes that her
memory is functioning normally. She is anxious and restless constantly moving and
attempting to leave the exam room. Her speech is intermittently incoherent and she
mumbles. The patient was unable to recall what she did yesterday, as well as today,
and reported that she was riding a horse. Her stepson informed me that when she
was in her 20s she did ride horses. Furthermore, she was unable to recall speaking
with me when I left the room, and returned and had an inability to recall a series of
objects she was instructed to remember.
Skin Show
Overview: Normal overview but detail exam not done

Describe

Abn:___________________________________
Lesion Description:
Mole Description:
Rash Description:
Other:___________________________________________________________________________
Results of labs done today: __N/A_________________________________________________
Other labs: ___N/A______________________________________________________________

Assessment/Plan:

First Diagnosis: Psychoses_____________ ICD-9:__298.9_______________

o Additional teaching or comments: _Immediate referral made to
Coliseum psychiatric facility for medical treatment & evaluation.
Family member informed due to patients illness she does not believe
she is ill. This can be very frustrating for friends and families and in
trying to convince someone that they are ill which may result in
arguments. In this situation, it is often useful to talk about the

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problems that the person themselves thinks they are having and trying
to agree on how the treatment being offered may help with those,
rather than focusing on getting the person to see that they are ill. In
addition, with the patient being ill you will have to keep her safe for
example not allowing her to drive, go for walks, have access to
medications, etc. The problem will not go away on its on and the
sooner treatment has begun the better. She needs to be taken
immediately to the hospital for treatment and at the hospital necessary
labs, radiology and evaluations will be done. Family member
verbalized understanding & agrees.
Second Diagnosis:_Alcohol-induced persisting amnestic disorder____ ICD9:_291.1
o Additional teaching or comments: _Immediate referral made to
Coliseum psychiatric medical facility for medical treatment &
evaluation. Family member informed due to patients illness she does
not believe she is ill. This can be very frustrating for friends and
families and in trying to convince someone that they are ill which may
result in arguments. In this situation, it is often useful to talk about the
problems that the person themselves thinks they are having and trying
to agree on how the treatment being offered may help with those,
rather than focusing on getting the person to see that they are ill. In
addition, with the patient being ill you will have to keep her safe for
example not allowing her to drive, go for walks, have access to
medications, etc. The problem will not go away on its on and the
sooner treatment has begun the better. She needs to be taken
immediately to the hospital for treatment and at the hospital necessary
labs, radiology and evaluation will be done. Family member verbalized
understanding & agrees. ________________________________

Medications Added This Visit: No medications prescribed at this time.

Immediate referral made to Coliseum psychiatric facility for medical
treatment.
Medication Name

Quantity

Dose

Sig

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>)

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Additional Procedure Codes,

Immunization, Lab, etc.

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