Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: KS___ Age:36________
visit:8/31/15_____

Sex: Female_______

Date of

Chief Complaint(s) or Reason for Visit: thick white vaginal

discharge, itching for three days, and time for a pap
smear._____________
___________________________________
o

HPI:
Onset: Approximately three days ago
_____________________
Location of problem: Gynecological___
_____________________________
Duration of problem: Aproximately three days
____ ___________
Character of problem: Denies pain at this
time__________ ____________
Intensity rating/10 or other:_0/10
________________________
Aggravating Factors None
______________________________
Relieving Factors None
____________________________________
Treatments Tried None
__________________________________________
Smoking: Never smoked____
_____________________________________
Additional information Patient reported that she was
treated with antibiotics for a upper respiratory
infection about nine days ago and believes she has a
yeast infection. The patient has been in a
monogamous relationship with a male for ten years
and has had a tubal ligation. She denies any odor to
her vaginal discharge and reported getting a yeast
infection after taking antibiotics last year in which she
took Diflucan and it worked. The last Pap smear was
done a little over three years ago.

Current Medications:

Centrum Multivitamin
GCSU Revised Fall 2014

1 tablet once daily

Page 1

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):
None
______________________________________________________________________________
Past Surgical Hx: Bilateral tubal ligation
____
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: Alive 60s; Hypertension, DM II
_______
o Maternal Grandmother: 60s; Hx: Diabetes Mellitus
o Father: Alive 60s; Unknown___________________
o Paternal Grandmother:Deceased 70s MI
o Siblings:(2) sister-alive and well
o Offspring: (2) daughters alive and well

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.

Neg.

Constitutional
Pos.
Chills
Decreased activity
Weight Gain
Weight Loss
Fussiness
Irritability
Lethargy
Fever: duration___
Tmax:____
Other: _____________
Metabolic
Pos.

GCSU Revised Fall 2014

Neg.

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

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Neg.

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

Exposure to TB
Other: _________

Cardiovascular and

Neg.

Neg.

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:12
Last Menses: 8/15/15
Regular Irregular
Frequency :monthly
Flow: normal lasts 6
days
Neg.

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

GCSU Revised Fall 2014

Neg.

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
Tremor
Memory loss
Other: _______________

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Vascular
Pos.
Chest Pain
Irreg. Heart Beat
Palpitations
Syncope

Neg.

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
Other: Anxious/nervous

Cool extremities
Cyanosis
Edema
Other: _________

Objective Findings:
Vital Signs:
o Blood Pressure: _120/70________ Pulse: _81______ Respirations:
__14_______
o Temperature:_98.8 F (orally)____
Pulse Ox: _98________ Weight (lbs):
147__________
o Height (inches): 68___________
BMI: 22.3___________
Physical Exam:
Physical Exam
Constitutional: Show
Level of Distress

No acute distress

Nourishment

Normal Weight BMI 18.5-24.9

Overall Appearance

Age Appropriate

Head/Skull: Show
Appearance

Normocephalic

Facial Features

Normal stucture alignment

Other: ______________
Other:

______________
Hair Distribution

Normal Distribution

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:___________

GCSU Revised Fall 2014

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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:___________

Cornea OD

Choose an item.

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

Other:___________
Abnormal:_____________________

Ears: Show
Auricle Right

Normal structure/placement

Other:____________
Auricle Left

Normal placement/structure

Other:____________
Canal Right

Normal

Other:___________

Canal Left

Normal

Other:___________

GCSU Revised Fall 2014

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TM Right

Light reflex present/TM clear

Other:___________
TM Left

Light reflex present/TM clear

Other:___________
Hearing

Other:___________

Normal Bilaterally

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

Other:__________________
Teeth

Normal dentation

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:

GCSU Revised Fall 2014

Other:__________________

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Palpation of Thyroid: Normal

Describe

Abn:___________________________________
Lymphatic: Show
Overview: No noted abnormal swelling/tenderness

Respiratory: Show
Chest

Normal anatomical configuration

Other:_______________
Inspection
Other:_______________

Normal respiratory effort

Auscultation

Clear Breath Sounds Bilaterally

Location

Choose an item.

Cough

Choose an item.

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 _______________________________________
EKG Results:N/A__________________________________

Female Exam Show

Genitalia

Morbid Obesity Limits Exam Accuracy: Yes or No

Tanner Stage: V

Inspection

Normal structures & pubic hair distribution

Description____________________
Perineum

No swelling, mass, or tenderness noted

Other______________________________
Anus

GCSU Revised Fall 2014

Normal meatus and tone

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Other

Other______________________________
Cervix

Discharge

Pink, nontender, smooth

White

Odor: None_____

Os: Horizontal slit__________

position:_Anteflexed_______________
Adnexa: Normal without masses___
N/A_______________________

Uterus
Stool Hemocult:

Pelvic Deferred for _N/A________________

Other:__G2, T2 A0 L2; thick white, cottage cheese consistency vaginal discharge and
mild inflammation of the vagina noted on pelvic examination. Vaginal wet mount KOH
slide revealed pseudohyphae and buds; negative for trichomoniasis and bacterial
vaginosis
_____________
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
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

GCSU Revised Fall 2014

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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

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
(CBC, CMP, Lipid Profile), PAP test completed and last pap smear done was
normal________

GCSU Revised Fall 2014

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Assessment/Plan:
First Diagnosis: Gynecological exam for papanicolaou cervical smear_____ ICD-9:
V72.3 ____________
o

Additional teaching or comments: _Patient was informed to allow two

weeks for Pap smear results and any abnormalities will be discussed in
a scheduled follow-up appointment once results are received. The
patient was instructed to inform office of any abnormal bleeding,
discharge, new medical diagnosis, and any other abnormal
signs/symptoms. Furthermore, that her next Pap smear needs to be
scheduled in three years if results are normal, unless follow-up
required concerning Pap results or other abnormalities. Patient
verbalized understanding and denies any concerns/questions at this
time._______

Second Diagnosis: Vaginal Candidiasis_____________________________ ICD9:112.1______________

o

Additional teaching or comments: Patient was informed that broad

spectrum antibiotics kill lactobacillus bacteria which can allow yeast to
overgrow. The patient was educated on ways to help prevent yeast
infections by avoiding items that may inflame the vaginal membrane
or change the normal balance of the vagina such as scented
detergents, feminine sprays or powders, scented toilet paper or
tampons/pads, douching, perfumed soaps, and bubble baths.
Furthermore, wearing wet bathing suits or tight clothing (pants,
pantyhose, tights, leggings) that trap sweat in the vaginal area for long
periods of time should be avoided, as well as sitting in hot tubs
frequently. She was encouraged to wear breathable cotton underwear,
change out of wet or sweaty clothing, wipe from front to back after
using the toilet, wash underwear in hot water, change feminine
products frequently, and eat yogurt or take supplements with
lactobacillus. The patient was informed that Diflucan is a one-time
dose used to treat yeast infections and that if symptoms persist or
worsen to contact the office immediately. Patient verbalized
understanding and denies any concerns/questions at this time.

Medications Added This Visit

Medication Name
Diflucan

Quantity
1 tablet

GCSU Revised Fall 2014

Dose
150 mg

Page 10

Sig
Take 1 tablet by
mouth (one time
dose)

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>)

Additional Procedure Codes,

Immunization, Lab, etc.

References
Mikamo, H., Matsumizu, M., Nakazuru, Y., Okayama, A., & Nagashima, M. (2015).
Original article:
Efficacy and safety of a single oral 150 mg dose of fluconazole
for the treatment of vulvovaginal
candidiasis in Japan. Journal Of Infection And
Chemotherapy, 21520-526.
doi:10.1016/j.jiac.2015.03.011
Pendharkar, S., Brandsborg, E., Hammarstrm, L., Marcotte, H., & Larsson, P. (2015).
Vaginal
colonisation by probiotic lactobacilli and clinical outcome in women
conventionally treated for
bacterial vaginosis and yeast infection. BMC
Infectious Diseases, 15(1), 1. doi:10.1186/s12879- 015-0971-3
Schuiling, K. & LIkis, F. (2011) Womens Gynecologic Health 2nd Edition. Jones &
Bartlett Publishers
ivadinovi, R., Petri, A., & Krtini, D. (2014). VAGINAL CANDIDIASIS GYNECOLOGICAL ASPECT OF THE
PROBLEM. Acta Medica Medianae,53(4), 46.
doi:10.5633/amm.2014.0409

GCSU Revised Fall 2014

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