Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: JA_______
Age:17________
visit: 9/28/15________

Sex: M_________

Date of

Chief Complaint(s) or Reason for Visit: Left ankle injury while

running________________
o

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:
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Multivitamin

Take one tablet by mouth daily

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

__

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 30s; alive and well__________________________
________________________
o Father: Alive 40s; alive and
well____________________________________________________
o Maternal Grandmother: Deceased 70s
MI____________________________________________
o Maternal Grandfather:
Unknown___________________________________________________
o Paternal Grandmother: Deceased 60s Breast
cancer____________________________________
o Paternal Grandfather: Deceased 60s Lung
cancer______________________________________
o Siblings: 2-brothers;-alive and healthy
____________________________________

INTERVAL HISTORY: Patient denies being seen by any other providers, ER

visits and receiving any recent
procedures.______________________________________________________________
Review of Systems:
Constitutional
Pos.

Neg.

Chills
Decreased activity

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HEENT
Pos.

Neg.

Dysphagia
Ear Discharge

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Respiratory
Pos.

Neg.

Accessory muscles use

Dyspnea

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

Decreased Urine Output

Dysuria

Diarrhea
Nausea

Enuresis
Flank Pain

Reflux
Vomiting
Other: _____________

Foul urine odor

Hematuria
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.

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Hematologic
Pos.

Easy bleeding
Easy bruising

Lymphadenopathy
Petechiae

Other:_________

Neg.

Female Reproductive
Pos.

Dysmenorrhea
Dyspareunia
Menorrhagia

Vaginal Discharge
Vaginal itching

Foul vaginal odor

Other:_____________

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

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Constitutional: Show
Level of Distress

No acute distress

Facial grimace noted with movement of left ankle

Nourishment
Normal Weight BMI 18.5-24.9
Overall Appearance

Other:

Other: ___________

Age Appropriate

Other: Appropriate attire for weather

Appropriate
interaction______
Head/Skull: Show
Appearance

Normocephalic

Facial Features

Normal stucture alignment

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

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Normal

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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

Normal cardinal gaze

Red Reflex

Present Bilaterally

Ears: Show
Nose and Sinus: Show
Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Palate

Choose an item.

Uvula

Normal configuration

Other:__________________

Oropharynx

pink and moist

Tonsils

+1

Other:__________________
Other:__________________
Other:__________________

Neck:

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Other: Normal____________

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Palpation of Thyroid: Normal

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

except for area of

injury (left ankle sprain)

Posture: No structural abnormalities
ROM: Normal ROM all extremities

Describe Abn:

___________________________
Muscle Strength: Normal all extremities

Describe Abn: Grade I left ankle

sprain_______
Joint Stability: Normal all extremities

except Abnormal:_Grade I left ankle

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

GCSU Revised Fall 2014

Describe Abn: Antalgic gait due to ankle

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sprain____________
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: Grade I Left

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:

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 (15-20 minutes) 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 alphabet with their foot and ankle several
times per day is one simple activity to recommend. Adverse reactions
of Ibuprofen explained (abdominal pain, bleeding, decreased urine
output, vomiting, heartburn, indigestion, flatulence, headache,
dizziness). Drug administration, dosage and possible adverse reactions
to report discussed with mother and patient. Follow-up scheduled in

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one week for reevaluation of physical activity, and contact office if

signs/symptoms worsen. Patient and mother verbalized understanding.
Medications Added This Visit
Medication Name
Ibuprofen

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)

Office Code for Visit:

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

Additional Procedure Codes,

Immunization, Lab, etc.

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

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