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  #1  
Old 11-12-2011
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Arrow Look at my patient note

VS- WNL
HEEENT- NC/A, PERRLA, EOMI.
CHEST- CTA&P. REST EXCURSION, PERCUSSION AND FREMITUS - NL
HEART- RRR. S1/S2 NL. NO M,R,G. PMI-NL
ABD- SOFT, NT,ND, NO HSM/NO PALPABLE MASS. BS+
CNS- A&O X3
GAIT NL
SENSATION FOR PINPRICK AND LIGHT TOUCH NL IN ALL 4 EXT.
STRENGTH 5/5 IN all 4 EXT.
DTR- 2+ IN ALL 4 EXT.
BABINSKI- -VE
ROMBERG- -VE
IN ALL 4 EXT- STRENGTH 5/5, DTR 2+ AND SENSATION FOR LIGHT TOUCH AND PINPRICK NL
CN 2 TO 12 INTACT

and if pt of Resp or CVS

NECK- NO JVD, NO LYMPHADENOPATHY
EXT- NO CYANOSIS/CLUBBING. PERIPHERAL PULSES- 2+/SYMMETRIC

AND CAN I WRITE JUST P/E IN CAPITALS AND everything else in Normal Letters????

Last edited by drnrpatel; 11-12-2011 at 03:49 PM.
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  #2  
Old 11-12-2011
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IF LIVER DISEASE PATIENT
HEENT- add SCLERA NL
EXT- NO ASTEREXIS
IF EAR COMPLAINT OR DIZZINESS- HEENT- add TMs NL
CNS- add RINNE'S +VE(AC>BC) AND WEBER'S(NO LATERALIZATION)
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Old 11-12-2011
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I'd say your PN is OK.

Also look here
Can we type in all CAPITAL LETTERS on the PN???

-
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  #4  
Old 11-13-2011
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Moral of the story----Capitalizing is very bad idea. And don't use short forms other than shown on the desk where you are typing the patient notes in the exam center.
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Old 12-28-2011
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you have been using so many short forms, is it ookay to use all these for ex chest examination and others
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Old 01-04-2012
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wats NC/AT people?
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Old 01-04-2012
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It is more than ok, i guess.
Are you sure we could finish all these pe in each case? Do we really need to write this much?
Start worrying my typing now. Most examees can do like this?
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Old 01-05-2012
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Quote:
Originally Posted by amberafzal View Post
wats NC/AT people?
normocephalic, atraumatic.

But, all these abbreviations are not on the list with abbreviations that we can use. I'm confused here. I know, FA uses some of them, but I think in the real thing we probably shouldn't use that many abbreviations and just write some of them.
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Old 01-05-2012
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Quote:
Originally Posted by dr_mhm View Post
normocephalic, atraumatic.

But, all these abbreviations are not on the list with abbreviations that we can use. I'm confused here. I know, FA uses some of them, but I think in the real thing we probably shouldn't use that many abbreviations and just write some of them.
any idea where to find abbreviations we can use to shorten our time?
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Old 01-06-2012
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Quote:
Originally Posted by Villageman View Post
any idea where to find abbreviations we can use to shorten our time?
There's a list of them on usmle.org under CS stuff, at least of the ones they accept.
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  #11  
Old 01-11-2012
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what is PMI?
In CNS-what is A&O X3?
What is CT&P ?what is EOMI?

Last edited by aiminghigh; 01-11-2012 at 11:28 AM.
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  #12  
Old 04-16-2012
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Warning!

Pmi - point of maximum impulse (can use it, surely )
a&o -alert and oriented (( can we use it )) are you sure ?


can we use no m,r,g ???? for no murmur,rubs,gallops....!!

Are u sure ??
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  #13  
Old 04-18-2012
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Guys, all the ones that original poster used CAN be used.

He did have some mistakes though:

ex. "CTA&P"

Its suppose to be CTABL = Clear To Ausc. Bi Laterally.

Use of M/R/G for Murmurs, Rubs, or Gallops is okay too.
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  #14  
Old 04-18-2012
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but can we use A&O * 3 ...???
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Old 04-18-2012
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Quote:
Originally Posted by dr.dhruvdesai View Post
but can we use A&O * 3 ...???
I'll make it simple, whatever they have used in FA PN's.. you can use!
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  #16  
Old 04-19-2012
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Quote:
Originally Posted by dr.dhruvdesai View Post
but can we use A&O * 3 ...???
Its used in US hospitals and clinics PNs, I see it daily, so I dont see why not.
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