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  #1  
Old 08-07-2014
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Default correction of patient note

i'll be posting some patient notes for correction an discussion is anyone is interested. anyone who could make any corrections to this patient note / inputs and thoughts will be appreciated..

51 y/o male c/o of sharp 8/10 middle lower back pain which radiates to his left thigh and foot which started 1 week ago when he tried to lift boxes. he has had previous episodes of this pain on and off in the past year accompanied by pain in his legs which goes away when he stops walking and sits down
he has straining during urination and urinary retention, he denies weight loss, fever, other changes in urinary habits, weakness, numbness, night sweats
he has taken ibuprofen for the pain which doesn't give him relief
ALLERGIES: NKDA MEDICATIONS: Ibuprofen
PMH: non contributory PSH: no surgeries
FH: father died of a heart attack
SH: he smokes 1ppd for 18 years , denies illicit drug use and alcohol use, he is a construction worker
ROS: WNL except as stated above

patient is in pain.
VS: WNL
MS: tenderness on palpation of the paraspinal area, - erythema , -warmth, - swelling on the back, pulses intact and symmetric, ROM WNL except on rotation to the left and right, DTR 2+ UE/LE, strength 5/5 UE/LE , gait intact symmetric, straight leg raise -ve, -ve babinski.
CHEST : CTA b/l
heart: RRR normal s1 s2 no m, r, g

Diagnosis #1
lumbar sprain
sharp 8/10 middle lower back pain which
constuction worker
radiates to his left thigh and foot
started 1 week ago when he tried to lift boxes
tendernes on palpation of the paraspinal area
ROM WNL except on rotation to the left and right

Diagnosis #2
lumbar spinal stenosis
sharp 8/10 middle lower back pain
pain goes away on sitting
pain goes away when he stops walking
radiates to his left thigh and foot

Diagnosis #3
degenerative arthritis
sharp 8/10 middle lower back pain
radiates to his ledt thigh and foot
straining during urination and urinary retention

DRE
xray spine
mri spine
urine electrophoresis
cbc electrolytes
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  #2  
Old 08-07-2014
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Default

Quote:
Originally Posted by obinocle View Post
i'll be posting some patient notes for correction an discussion is anyone is interested. anyone who could make any corrections to this patient note / inputs and thoughts will be appreciated..

51 y/o male c/o of sharp 8/10 middle lower back pain which radiates to his left thigh and foot which started 1 week ago when he tried to lift boxes. he has had previous episodes of this pain on and off in the past year accompanied by pain in his legs which goes away when he stops walking and sits down
he has straining during urination and urinary retention, he denies weight loss, fever, other changes in urinary habits, weakness, numbness, night sweats
he has taken ibuprofen for the pain which doesn't give him relief
ALLERGIES: NKDA MEDICATIONS: Ibuprofen
PMH: non contributory PSH: no surgeries
FH: father died of a heart attack
SH: he smokes 1ppd for 18 years , denies illicit drug use and alcohol use, he is a construction worker
ROS: WNL except as stated above

patient is in pain.
VS: WNL
MS: tenderness on palpation of the paraspinal area, - erythema , -warmth, - swelling on the back, pulses intact and symmetric, ROM WNL except on rotation to the left and right, DTR 2+ UE/LE, strength 5/5 UE/LE , gait intact symmetric, straight leg raise -ve, -ve babinski.
CHEST : CTA b/l
heart: RRR normal s1 s2 no m, r, g

Diagnosis #1
lumbar sprain
sharp 8/10 middle lower back pain which
constuction worker
radiates to his left thigh and foot
started 1 week ago when he tried to lift boxes
tendernes on palpation of the paraspinal area
ROM WNL except on rotation to the left and right

Diagnosis #2
lumbar spinal stenosis
sharp 8/10 middle lower back pain
pain goes away on sitting
pain goes away when he stops walking
radiates to his left thigh and foot

Diagnosis #3
degenerative arthritis
sharp 8/10 middle lower back pain
radiates to his ledt thigh and foot
straining during urination and urinary retention

DRE
xray spine
mri spine
urine electrophoresis
cbc electrolytes

This is how I would type it... obinocle
and as someone told me, just stick to mnemonics so that you're sure you dont forget anything, and if you want I can send you the CS "protocol" from medschool...


HPI: MR ?? is a 51 yo M who c/o back pain,
-started 1 wk ago after lifting heavy weights
- pain is intermittent, sharp, starts at lumbar area and radiates to L thigh and foot, 8/10
- exacerbates when walking, alleviates at rest, he is also taking Ibuprofen which provides no relief,
-Has had previous episodes during the last year (I dont know if they are similar in terms of severity or progression)
-Also presents with difficulty urinating and retention (forgot to ask about, nocturia, dysuria, frequency, incontinence, dribbling, weak stream etc....)
- he denies any recent travel, TRAUMA??, headaches, edema, nausea/vomiting, fever, shortness of breath, painful joints (could have METS), bowel habits, seizures ( METS too), appetite?? and weight loss
ROS> negative except as above.
PMH: none, ALL: NKDA, Meds: Ibuprofen, PSH: none, no hospitalizations or trauma, FH: father died of MI at ??? age, SH: is a construction worker, smokes cig for the last 18 yrs, 1ppd. Denies EtOh and illict drug use.
SexHx: ?? you shoud ask for hx of previous STD's, partners, protection..

P.E
Patient doesn't appear to be in acute distress, he looks in pain
V/s: WNL
HEENT: no lymphadenopathy
Heart: non displaced PMI, nl S1/S2, RRR, no MRG
Lungs: CTABL
Abd: ( just to be sure it doesn't radiate..) soft, BS+, nontender
Ms: ( the order I follow is this: isnp> pal>sens/strength> ROM pas/active/ reflexes) back appears symmetric, no deformities or traumatic inj, tender to palpation paraspinal ( Lumbar/sacral??) senstivity and strength conserved, ROM hyperextension and flexion do not reproduce pain, lateral flexion and rotation produces pain. Achilles (s1-S2) and Patellar reflexes (l3-l-4) 2/4. Straight leg test and Babinski (-). Gait: did not reproduce pain.
Extr: symmetric, non edematous, palpable distal pulses.

DDX
1. Lumbar sprain> or compression fracture??
-Onset-> lifting W - tenderness to palp
-starts at lumbar area and radiates to L thigh and foot. - (-) leg raise t
-exa when walking - strength/ sensory intact

2. Lumbar stenosis
- all at rest
- exc walking
- radiates to L thigh and F ( shold be bilat)

3. Prostate Ca (mets)
- smoker - tenderness to palpation
- difficulty urinating
-

tests: try to be more specific
-L and S spine XR
-L and S spine MRi
-rectal and genital exam
-prostatic U/S if rectal abnl
-PSA


something like that, just try to be as specific as you can and stick to the mneumonics, use more medical terms and abbreviations to save time, and if you like I can send you what we use here... and just one last thing in the HPI write as many negatives you can otherwise the doctor that checks it will know if you thought of everything
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  #3  
Old 08-09-2014
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Default

Quote:
Originally Posted by Esteps View Post
This is how I would type it... obinocle
and as someone told me, just stick to mnemonics so that you're sure you dont forget anything, and if you want I can send you the CS "protocol" from medschool...


HPI: MR ?? is a 51 yo M who c/o back pain,
-started 1 wk ago after lifting heavy weights
- pain is intermittent, sharp, starts at lumbar area and radiates to L thigh and foot, 8/10
- exacerbates when walking, alleviates at rest, he is also taking Ibuprofen which provides no relief,
-Has had previous episodes during the last year (I dont know if they are similar in terms of severity or progression)
-Also presents with difficulty urinating and retention (forgot to ask about, nocturia, dysuria, frequency, incontinence, dribbling, weak stream etc....)
- he denies any recent travel, TRAUMA??, headaches, edema, nausea/vomiting, fever, shortness of breath, painful joints (could have METS), bowel habits, seizures ( METS too), appetite?? and weight loss
ROS> negative except as above.
PMH: none, ALL: NKDA, Meds: Ibuprofen, PSH: none, no hospitalizations or trauma, FH: father died of MI at ??? age, SH: is a construction worker, smokes cig for the last 18 yrs, 1ppd. Denies EtOh and illict drug use.
SexHx: ?? you shoud ask for hx of previous STD's, partners, protection..

P.E
Patient doesn't appear to be in acute distress, he looks in pain
V/s: WNL
HEENT: no lymphadenopathy
Heart: non displaced PMI, nl S1/S2, RRR, no MRG
Lungs: CTABL
Abd: ( just to be sure it doesn't radiate..) soft, BS+, nontender
Ms: ( the order I follow is this: isnp> pal>sens/strength> ROM pas/active/ reflexes) back appears symmetric, no deformities or traumatic inj, tender to palpation paraspinal ( Lumbar/sacral??) senstivity and strength conserved, ROM hyperextension and flexion do not reproduce pain, lateral flexion and rotation produces pain. Achilles (s1-S2) and Patellar reflexes (l3-l-4) 2/4. Straight leg test and Babinski (-). Gait: did not reproduce pain.
Extr: symmetric, non edematous, palpable distal pulses.

DDX
1. Lumbar sprain> or compression fracture??
-Onset-> lifting W - tenderness to palp
-starts at lumbar area and radiates to L thigh and foot. - (-) leg raise t
-exa when walking - strength/ sensory intact

2. Lumbar stenosis
- all at rest
- exc walking
- radiates to L thigh and F ( shold be bilat)

3. Prostate Ca (mets)
- smoker - tenderness to palpation
- difficulty urinating
-

tests: try to be more specific
-L and S spine XR
-L and S spine MRi
-rectal and genital exam
-prostatic U/S if rectal abnl
-PSA


something like that, just try to be as specific as you can and stick to the mneumonics, use more medical terms and abbreviations to save time, and if you like I can send you what we use here... and just one last thing in the HPI write as many negatives you can otherwise the doctor that checks it will know if you thought of everything
Ok thanks very much very helpful I actually fell sick right after this message and slowly recovering. I'll sure take notes from these.
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