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  #1  
Old 09-18-2014
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Default Patient notes

Can you please help me with this patient note, how to make it shorter. can someone help with abbreviations?

35 yo F c/o daily headaches for 2 weeks. These headaches occur 23 X/D AND LAST 1-2 H, THE PAIN IS SHARP AND POUNDING, IS LOCATED ON THE RIGHT HEMISPHERE OF THE HEAD, WITH NO RADIATION OR PRECEDING AURA. THE PAIN REACHES 9/10 IN SEVERITY AND PREVENTS THE PATIENT FROM CONTINUING HER ACTIVITIES. PAIN IS EXACERBATED BY STRESS, LIGHT AND NOISES AND ALLEV BY RESTING IN A DARK ROOM, SLEEPING ANS TAKING ASPIRIN.
SOMETIMES ACCOMPANIED BY NAUSEA AND VOMITING.
NO CHANGES IN WEIGHT OR APPETITE:
- ROS ACHES AND PAINS IN JOIN OCCASTIONNALY
- ALL: NKDA
- MED: IBUPROFEN, ASPRIN
- PMH: HEADACHE AT AGE 20 WITH NAUSEA. SINUSITUS 4 MONTHS AGO- RX AMOXICILLIN
- PSH: TUBAL LIGATION - 8 Y AGO
- SH: NO TABACCO, DRUGS, ETOH. WORKS AS ENGENEER, LIVES WITH HUSBAND AND 3 KIDS. SEXUALLY ACTIVE WITH HUSBAND ONLY
- FH: FATHER- DIED OF BRAIN TUMOR- 65. MOTHER- MIOGRAINE

Physical Examination :
GA: SEVERE PAIN
VS: WNLHEENT: NC/AT, NONTENDER, PERRLA, EOMI. NO papilledema, NO NASAL CONGESTION, NO PHARYNGEAL ERYTHEMA OR EXCUDATES, DENTITION GOOD
-NECK; SUPPLE, NO LAD
- CHEST, CLEAR BREATH SOUNDS BIL
- HEART: RRR, S1/S2 NORMAL, NO M-R-G
-NEURO: AOX3, GOOD CONCENTRATION, CN 2-12 GROSSLY INTACT, MOTOR STRENGTH 5/5, DTRs 2 INTACT SYMMETRIC


Diagnosis 1 :
MIGRAINE

History Finding(s) :
1.UNILATERAL SHARP HEADACHE
2.NAUSEA, VOMITING
3.PHOTOPHOBIA

Physical Exam Finding(s) :
1.SEVERE PAIN WITH NO NEUROLOGICAL FINDING
2.
3.

Diagnosis 2 :
TENSION HEADACHE

History Finding(s) :
1.CHRONIC HEADACHE
2.STRESS AT WORK
3.IMPROVE WITH SLEEP

Physical Exam Finding(s) :
1.SEVERE PAIN WITH NO NEUROLOGICAL FINDING
2.
3.

Diagnosis 3 :
INTRACRANIAL MASS LESION

History Finding(s) :
1.HEADACHE WITH VOMITING AND NAUSEA
2.FAMILY HISTORY OF BRAIN ! TUMOR
3.

Physical Exam Finding(s) :
1.
2.
3.

Diagnostic Study/Studies :
1.CBC
2.CT-HEAD OR MRI-HEAD
3.LP
4.CT-SINUS
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  #2  
Old 09-22-2014
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35 yo F c/o daily headaches x 2 weeks, occur 23 X/D, LAST 1-2 H, SHARP AND POUNDING, ON THE RIGHT side (hemisphere is talking about brain imo..) OF THE HEAD, NO RADIATION OR PRECEDING AURA, 9/10 IN SEVERITY, interfere activity. EXACERBATED BY STRESS, LIGHT AND NOISES. ALLEV BY RESTING IN A DARK ROOM, SLEEPING ANS TAKING ASPIRIN.
(+) NAUSEA AND VOMITING.
(-) CHANGES IN WEIGHT/APPETITE (what about other pertinent neg? like tearing, rhinorrhea, visual changes, any weakness/numbness/tingling, projectile vomiting)
- ROS ACHES AND PAINS IN JOIN OCCASTIONNALY
- ALL: NKDA
- MED: IBUPROFEN, ASPRIN
- PMH: HEADACHE AT AGE 20 WITH NAUSEA. SINUSITUS 4 MONTHS AGO- RX AMOXICILLIN
- PSH: TUBAL LIGATION - 8 Y AGO
- SH: NO TOBACCO, DRUGS, ETOH. WORKS AS ENGINEER, LIVES WITH HUSBAND AND 3 KIDS. SEXUALLY ACTIVE WITH HUSBAND ONLY
- FH: FATHER- DIED OF BRAIN TUMOR- 65. MOTHER- MIOGRAINE

Physical Examination :
GA: SEVERE PAIN
VS: WNLHEENT: NC/AT, NONTENDER, PERRLA, EOMI. NO papilledema, NO NASAL CONGESTION, NO PHARYNGEAL ERYTHEMA OR EXCUDATES, DENTITION GOOD
-NECK; SUPPLE, NO LAD
- CHEST, CLEAR BREATH SOUNDS BIL
- HEART: RRR, S1/S2 NORMAL, NO M-R-G
-NEURO: AOX3, GOOD CONCENTRATION, CN 2-12 GROSSLY INTACT, MOTOR STRENGTH 5/5, DTRs 2 INTACT SYMMETRIC


Diagnosis 1 :
MIGRAINE

History Finding(s) :
1.UNILATERAL SHARP pounding HEADACHE
2.NAUSEA, VOMITING
3.PHOTOPHOBIA

Physical Exam Finding(s) :
1.SEVERE PAIN WITH NO NEUROLOGICAL FINDING
2.
3.

Diagnosis 2 :
TENSION HEADACHE

History Finding(s) :
1.CHRONIC HEADACHE
2.STRESS AT WORK
3.IMPROVE WITH SLEEP

Physical Exam Finding(s) :
1.SEVERE PAIN WITH NO NEUROLOGICAL FINDING
2.
3.

Diagnosis 3 :
INTRACRANIAL MASS LESION

History Finding(s) :
1.HEADACHE WITH VOMITING AND NAUSEA
2.FAMILY HISTORY OF BRAIN ! TUMOR
3.

Physical Exam Finding(s) :
1.
2.
3.

Diagnostic Study/Studies :
1.CBC
2.CT-HEAD OR MRI-HEAD
3.LP
4.CT-SINUS

I wouldn't put brain tumor though... not enough supporting findings. As per CS guidelines by USMLE, list the dx based on likelihood and must be well supported. Even mentioned better to list 2 but well supported than 3 but poorly supported. Also why LP? Head CT maybe justified given your DDx. Also why sinus CT?
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The above post was thanked by:
seemaCMC (09-28-2014)
  #3  
Old 05-22-2016
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Default

good example for the exam
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