St Francis Physician Network â​¢ 7243 Hwy 64, OAKLAND TN 38060-3403

POWERS, Peyton (id #507238, dob: 06/27/2006)

Patient
Name POWERS, PEYTON (18yo, F) ID# Appt. Date/Time 07/09/2024 08:15AM
507238
DOB 06/27/2006 Service Dept. SFP_SFMP - Oakland
Provider CATHERINE A LIPSEY, APRN
Insurance Med Primary: BCBS-TX (PPO)
Insurance # : GAR829114312
Prescription: PRIME TEXAS - Member is eligible.
Chief Complaint
Cough, Eye Problem
Patient's Pharmacies
WALGREENS DRUG STORE #09112 (ERX): 14860 HIGHWAY 194, OAKLAND, TN 38060, Ph (901) 466-9956, Fax (901)
466-1476
Vitals
Ht: 5 ft 8 in (172.72 cm; Wt: 158 lbs (71.67 kg; BP: 110/70 (33rd % /
93rd %ile) 89th %ile) 58th %) 07/09/2024
07/09/2024 08:15 am 07/09/2024 08:23 am 08:23 am

T: 97.1 F° (36.17 C) BMI: 24 (76th %ile: Age Body Surface 1.85 m² 07/09/2024
07/09/2024 08:23 am and sex) 07/09/2024 Area: 08:23 am
08:23 am

HR: 82 07/09/2024 08:24 O2Sat: 99% 07/09/2024 RR: 18 07/09/2024 08:24

am 08:24 am am

Allergies
Reviewed Allergies
NKDA

Medications
Reviewed Medications
azelastine 137 mcg (0.1 %) nasal spray 07/09/24 prescribed
Spray 2 spray(s) twice a day by intranasal route.

erythromycin 5 mg/gram (0.5 %) eye ointment 07/09/24 prescribed

APPLY 1 CM RIBBON INTO THE LOWER CONJUNCTIVAL SAC(S) IN THE AFFECTED
EYE(S) BY OPHTHALMIC ROUTE 2 TIMES PER DAY

Vaccines
None recorded.
Problems
Reviewed Problems
No known problems
GYN History
GYN History not reviewed (last reviewed 11/27/2023)
Date of LMP: 08/02/2018.
Obstetric History
Obstetric History not reviewed (last reviewed 11/27/2023)
Family History
Family History not reviewed (last reviewed 11/27/2023)
Father - No current problems or disability
Mother - No current problems or disability
Social History
Reviewed Social History
St Francis Physician Network â​¢ 7243 Hwy 64, OAKLAND TN 38060-3403
POWERS, Peyton (id #507238, dob: 06/27/2006)
Substance Use
Do you or have you ever smoked tobacco?: Never smoker
Do you or have you ever used any other forms of tobacco or nicotine?: No
What was the date of your most recent tobacco screening?: 07/09/2024
What is your level of alcohol consumption?: None
Gender Identity and LGBTQ Identity
Gender identity: Identifies as Female
Sexual orientation: Straight or heterosexual
Surgical History
Surgical History not reviewed (last reviewed 11/27/2023)
Past Medical History
Past Medical History not reviewed (last reviewed 11/27/2023)
Screening
Name Score Notes
PHQ-2/PHQ-9 0 (for the PHQ-2), Finding: Negative

HPI
The patient has had a cold and now has an irritated eye. Red and swollen eyelid and itching on the right
ROS
Patient reports eye pain but reports no vision change, no photophobia, no itching, and no red eyes;right eyelid swollen,
painful. She reports nasal discharge but reports no sinus pain, no nosebleeds, and no nasal blockage. She reportscough
but reports no shortness of breath, no pain on deep breath, no dyspnea, and no wheezing; congestion. She reports no fever,
no chills, no sweats, no fatigue/malaise, and no significant weight change. She reports no headaches and no facial pain. She
reports no sore throat, no dry mouth, and no bleeding gums. She reports no chest pain, no radiating pain, no SOB, and no
dyspnea during exertion. She reports no nausea, no vomiting, no diarrhea, and no constipation. She reports no dysuria and no
frequency. She reports regular menses (LMP 07/06/2024). She reports no muscle pain, no muscle weakness, no joint pain,
and no joint stiffness. She reports no redness, no scale, no itching, and no new lesions. She reports no headaches, no change
in headache pattern, no dizziness, and no vertigo. She reports no fatigue and no sweats. She reports no depression and no
anxiety. She reports no easy bruising and no unusual bleeding.
Physical Exam
Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD.

Psychiatric: Insight: good judgement. Mental Status: normal mood and affect and active and alert. Orientation: to time, place,
and person. Memory: recent memory normal and remote memory normal.

Head: Head: normocephalic.

ENMT: Ears: no lesions on external ear, TMs clear, and TM mobility normal. Hearing: no hearing loss. Nose: no lesions on
external nose, sinus tenderness, or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no
mouth or lip ulcers or bleeding gums. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not
enlarged.

Neck: Neck: supple, trachea midline, and no masses. Thyroid: non-tender and no enlargement.

Lymphatics: Lymph Nodes: no cervical LAD.

Lungs: Respiratory effort: no dyspnea. Inspection: normal. Auscultation: no wheezing, rales/crackles, or rhonchi and breath
sounds normal and good air movement.

Cardiovascular System: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops;
and RRR. Neck vessels: no JVD or carotid bruits. Pulses: pedal pulses normal bilaterally. Peripheral Vascular: no cyanosis,
edema, or varicosities and coloration normal.

Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness or guarding and soft and non-distended.

Musculoskeletal:: Motor Strength and Tone: UPPER extremities: bilateral normal strength and tone and LOWER extremities:
bilateral normal strength and tone.

Neurologic: Gait and Station: normal gait. Cranial Nerves: grossly intact. Sensation: grossly intact. Coordination and
Cerebellum: no tremor. Ambulation: no limitations when ambulating.

Skin: Inspection and palpation: no rash, ulcerations, or jaundice and good turgor.
St Francis Physician Network â​¢ 7243 Hwy 64, OAKLAND TN 38060-3403
POWERS, Peyton (id #507238, dob: 06/27/2006)
Assessment / Plan
1. Hordeolum externum of upper eyelid of right eye-

Apply medications as directed. Wash lashes with baby shampoo. Throw away old mascara. Discussed compresses

H00.011: Hordeolum externum right upper eyelid

STYES AND CHALAZIA: CARE INSTRUCTIONS
erythromycin 5 mg/gram (0.5 %) eye ointment - APPLY 1 CM RIBBON INTO THE LOWER CONJUNCTIVAL SAC(S) IN
THE AFFECTED EYE(S) BY OPHTHALMIC ROUTE 2 TIMES PER DAY Qty: (1) 3.5 gram tube Refills: 0
Pharmacy: WALGREENS DRUG STORE #09112

2. Common cold -

Apply medications as directed.

J00: Acute nasopharyngitis [common cold]

azelastine 137 mcg (0.1 %) nasal spray - Spray 2 spray(s) twice a day by intranasal route. Qty: (1) 200 spray squeeze
bottle Refills: 0 Pharmacy: WALGREENS DRUG STORE #09112

3. Body mass index 20-24 - normal -

Encourage lifestyle modifications

Z68.24: Body mass index [BMI] 24.0-24.9, adult

A HEALTHY LIFESTYLE: CARE INSTRUCTIONS

Discussion Notes
15 minutes spent in chart review and 15 minutes spent in face to face encounter

Return to Office
Patient will return to the office as needed.
Encounter Sign-Off
Encounter signed-off by Catherine A Lipsey, APRN, 07/09/2024.

Oversight: Encounter reviewed by Forrest C Ward, MD on 07/09/2024 at 12:42pm

Encounter performed and documented by Catherine A Lipsey, APRN
Encounter reviewed & signed by Catherine A Lipsey, APRN on 07/09/2024 at 9:43am

Screening: PHQ-2/PHQ-9