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Old 04-06-2015
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Help FEEDBACK on PN, please help!

30 YO F C/O RIGHT LOW BACK PAIN. PAIN STARTED SUDDENLY 3 DAYS AGO, CONSTANT, DULL, 8/10 INTENSITY, RADIATES TO RIGHT GROIN AREA, ALLEVIATED WITH NOTHING AND EXACERBATED WITH MOVEMENT, MOTRIN DIDNT STOP PAIN, ASSOCIATED NAUSEA W/O VOMITING, SUBJECTIVE FEVER 3 DAYS AGO, DYSURIA AND POLYURIA, H/O HEMATURIA YET TO BE CONFIRMED, APPETITE POOR.
ALLERGIES: PCN, RASH
MED: MOTRIN, DIDNT HELP PAIN
PMH: UTI 2 YEARS AGO PSH: NONE
LMP: 1 WEEK AGO
SH: NO TOBACCO, ETOH, ILLICIT DRUGS, PHOTOGRAPHER, NOT SEXUALLY ACTIVE

PE.
===========
PATIENT IN ACUTE DYSTRESS, ALERT AND ANSWERS APPROPIATELY
VS: FEVER OF 40C, 100/60, RR 22, HR 122

ABDOMEN: NO VISIBLE PULSATIONS, SCARS, +BS, SOFT, TENDERNESS TO PALPATION ON RLQ, NO REBOUND TENDERNESS, + RIGHT CVA TENDERNESS.


=====
first: is this patient note OK?
and
GUYS here is my other question
in patient notes is it better for us to write on "patient words" or truly medical terms, cause Ive seen online patient notes with patient words like "patient refers pain with urination" instead of DYSURIA, or "he reports occasional ringing in the ears" instead of TINNITUS or "she noticed abnormal facial hair" instead of HIRSUTISM.

of course it looks more formal and better with medical terms, but dont know if they want you to portrait better the history with the patient words?? since looking online samples lead for me to have this concern.

please help with this information
thanks in advance.
__________________
Will. Power. Faith. MATCHED IM 2016!

Last edited by drpisho; 04-06-2015 at 05:49 PM.
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