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School of Nursing
Episodic Document
Patient Information:
Initials: JA_______
Age:17________
visit: 9/28/15________
Sex: M_________
Date of
HPI:
Onset Today while running
____________________________
Location of problem
Musculoskeletal______________________________
Duration of problem For approximately an hour (the
patient reported immediately coming to doctors office
after twisting ankle)__
_____
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 he was
running when he twisted his ankle inward when he
stepped on uneven ground and braced his fall with his
hands. He denies hitting his head at this time and
reports a scrape on his ankle, left ankle swelling/pain,
and no other injuries. He reported he was plays
football and was practicing.______
Current Medications:
GCSU Revised Fall 2014
Page 1
Multivitamin
Additional Information:
Allergies:
_NKDA________________________________________________________________________
Current Immunizations: Up-to-date on all immunizations required for his
age, including influenza vaccine; no special immunizations required due to
lack of co-morbidities_____________
PMH, Chronic Problems, Significant birth history (NNICU admission, apgar
scores, bilirubin, other complications of birth): _No past medical history
_____ _________ ___
Past Surgical Hx: None
Substance use/amount: Alcohol Y/N amount N/A
__
Neg.
Chills
Decreased activity
HEENT
Pos.
Neg.
Dysphagia
Ear Discharge
Page 2
Respiratory
Pos.
Neg.
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Pos.
Neg.
Polydipsia
Polyuria
Polyphagia
Brittle Nails
Cold intolerance
Heat intolerance
Hirsute
Thinning Hair
Other:_________
Gastrointestinal
Pos.
Neg.
Esotropia
Exotropia
Eye Discharge
Eye Redness
Headache
Hearing loss
Nasal Congestion
Otalgia
Pharyngitis
Rhinorrhea
Sneezing
Tearing
Vision changes
Vision loss
Other: ____________
Urinary
Pos.
Neg.
Abdominal Pain
Constipation
Diarrhea
Nausea
Enuresis
Flank Pain
Reflux
Vomiting
Other: _____________
Stridor
Sputum Production
Wheezing
Cough:
Quality_______
Freq:_________
Exposure to TB
Other: _________
Cardiovascular and
Vascular
Neg.
Pos.
Chest Pain
Irreg. Heart Beat
Palpitations
Syncope
Cool extremities
Cyanosis
Edema L ankle
Other: _________
Neg.
Immunological
Pos.
Allergic Rhinitis
Environmental Allergy
Food allergy
Seasonal allergy
Urticaria
Other: __________
Neg.
Page 3
Hematologic
Pos.
Easy bleeding
Easy bruising
Lymphadenopathy
Petechiae
Other:_________
Neg.
Female Reproductive
Pos.
Dysmenorrhea
Dyspareunia
Menorrhagia
Vaginal Discharge
Vaginal itching
Menarche age:
Last Menses:
Regular Irregular
Frequency:
Flow:
Duration:
Skin
Neg.
Pos.
Psoriasis
Skin lesion
Other:_____________
Acne
Eczema
Pruritus
Male Reproductive
Pos.
Neg.
Neg.
Musculoskeletal
Pos.
Straining to urinate
Urinary hesitancy
Urinary Retention
Back pain
Bone pain
Joint pain
Joint swelling
Erectile dysfunction
Hematospermia
Penile discharge
Premature ejaculation
Muscle weakness
Myalgia
Other: _________
Scrotal mass
Scrotal pain
Other: _______________
Neurological
Pos.
Neg.
Neg.
Psychiatric
Pos.
Aphasia or dysarthria
Agnosia
Appropriate interaction
Behavioral changes
Balance disturbance
Confusion
Difficulty concentrating
Distorted body image
Obsessive behaviors
Self-conscious
Other:
Paraesthesia
Seizure
Tremor
Memory loss
Other: _______________
Objective Findings:
Vital Signs:
o Blood Pressure: 110/62____ Pulse: 89____________ Respirations:
16___________
o Temperature: 98.4F oral___ Pulse Ox: 99%_______
Head Circ
(percentile): N/A______
o Weight (lbs): 160 (72%)____
Height (inches): 72 (84%)________
BMI:
21.7 (54%)______
Physical Exam:
Physical Exam
Page 4
Constitutional: Show
Level of Distress
No acute distress
Other:
Other: ___________
Age Appropriate
Normocephalic
Facial Features
Other: ______________
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
Page 5
Other:___________
Normal
Iris OD
Cornea OS
Normal
Cornea OD
Normal
Other:___________
Other:___________
Choose an item.
Fundoscopy OS
Other:___________
Fundoscopy
Choose item
OD
Other:___________
Lens OS
Clear
Other:___________
Lens OD
Clear
Other:___________
Ocular Muscles
Red Reflex
Present Bilaterally
Ears: Show
Nose and Sinus: Show
Mouth/Teeth:
Lips
Teeth
Normal dentation
Other:__________________
Other:__________________
Buccal
Other:__________________
Tongue
Normal
Palate
Choose an item.
Uvula
Normal configuration
Other:__________________
Oropharynx
Tonsils
+1
Other:__________________
Other:__________________
Other:__________________
Neck:
Other: Normal____________
Page 6
Describe
Abn:___________________________________
Lymphatic: Show
Respiratory: Show
Cardiac: Show
Abdomen: Show
Male Exam Deferred-Denies injury/pain/abnormality
______________________________________________________________________________________
__
Musculoskeletal Show
Overview: Normal ROM, muscle strength, and Stability
Describe Abn:
___________________________
Muscle Strength: Normal all extremities
sprain_______
Joint Stability: Normal all extremities
sprain________
Assessment of problem area: Antalgic gait, favoring the right leg; left ankle mild
tenderness noted at lateral malleolus, 2+ edema noted, no mechanical instability
(negative clinical stress examination)
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: Abnormal
Page 7
sprain____________
CN II-XII: Grossly intact
Describe Abn:
N/A___________________________________
DTRs: upper 2+ Avg
Lower:
2+ Avg
ankle sprain__________
Sensory: Grossly normal
Body Position: Grossly normal
Describe Abn:_______________________________
Describe Abn:_______________________________
Skin Show
Overview: Abnormal
Describe Abn: Small abrasion (0.5in X 0.5 in) pink tissue noted on left lateral
malleolus (covered with band-aid)
______________
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.
Prior labs drawn at well visit within normal ranges.___________________________
Assessment/Plan:
Page 8
Quantity
84 tablets
No refills
Dose
400 mg
Sig
Take one tablet
every 4-6 hours as
needed for pain.
Maximum 6
tablets per day (24
hours)
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>)
73600
References
American Orthopedic Foot and Ankle Society. (2015). Ankle sprain. from
https://www.aofas.org/footcaremd/conditions/ailments-of-theankle/Pages/Ankle-Sprain-.aspx
Burns, C., Dunn, A., Brady, M. Starr, N., & Blosser, C. (2012). Pediatric Primary Care.
(5th ed.) Saunders.
Kemler, E., van de Port, I., Schmikli, S., Huisstede, B., Hoes, A., & Backx, F. (2015).
Effects of soft bracing or taping on a lateral ankle sprain: a non-randomised
controlled trial evaluating recurrence rates and residual symptoms at one
year. Journal of Foot & Ankle Research, 8(1), 1-8. doi: 10.1186/s13047-0150069-6
Page 9