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  #1  
Old 02-06-2012
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Default Please check my PN.

This was generated from the SP done by my friend who created a patient with excessively long history. Please have a look and tell me how I am doing it. Thanks in advance.
P.S. Even though there is some more data that I collected, the USMLE website PN template didn't give enough space to write all the stuff down. Kindly advice me on this issue as well.

================================================== ==========================================

Patient Notes
Room Number: 15
Candidate Name: Doe, John
Candidate Number: 20
USMLE ID: 1-234-567-8
HISTORY – Include significant positives and negatives from history of present illness, past medical history, review of system(s), social history and family history.

PI-30 Y o Female c/o weight gain.She gained 30 pounds in last 3 months unintentionally.She is concerned about it.She also feels fatigued,feels more cold than usual and is losing hair,for past couple of months.She also vomitted for couple of months two months ago which was early morning and cup-full with no blood in vomit.Noted breast tenderness and enlargement.She reported that her appetite has increased for past 3 months with lots of junk food consumption and stopped exercising 1 year ago.

ROS-Normal
PMH-Bipolar disorder for 14 years.
Allergies-NKA
Medication-Lithium for Bipolar disorder.
FH-Mother and sister obese,father died of natural causes.
PSH-Sexually active with husband of 12 years,no use of condoms or OCPs
SH-Homemaker.Smoker who stopped couple of years ago,before that smoked 2-3 PPD for 10 years.Drinks alcohol 2-3 beers per day, cut down from 5-6 beers per day.CAGE-O/4.Marijuana tried in college.

PHYSICAL EXAMINATION - Indicate only pertinent positive and negative findings related to the patient's chief complaint.
VS-BMI 30, rest WNL. Patient is pleasant and under no acute distress.
HEENT-PERLA,no vision or hearing loss,no scars on face or neck,no JVDs. Check thyroid gland.
Heart-RRR,S1/S2 audible,no murmur or gallops
Chest-Audible breath sounds,normal percussion,no rubs or crackles
Abdomen-BS +, Soft, nondistended,non tender
Extremities-No scars, no motility problems

DIFFERENTIAL DIAGNOSIS - In order of likelihood (with 1 being the most likely), list up to 5 potential or possible diagnoses for this patient's presentation (in many cases, fewer than 5 diagnoses are likely):
1) Hypothyroidism
2) Pregnancy
3) Depression
4) Diet induced weight gain

DIAGNOSTIC WORKUP - List immediate plans (up to 5) for further diagnostic workup:
1) TSH,fT4
2) Thyroid exam
3) US Neck
4) Urine bHCG
5) CBC with differential

Last edited by donofitaly; 02-06-2012 at 03:01 PM. Reason: Notes added.
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  #2  
Old 02-07-2012
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Default

You only have about 2000 characters to use in your H&P. So here's my suggestions. Drop the long write out stuff and use Abv.

Examples with your... Change in (CAPITALS)


PI-30 Y o Female c/o weight gain.She gained 30 pounds in last 3 months unintentionally.She is concerned about it.She also feels fatigued,feels more cold than usual and is losing hair,for past couple of months.She also vomitted for couple of months two months ago which was early morning and cup-full with no blood in vomit.Noted breast tenderness and enlargement.She reported that her appetite has increased for past 3 months with lots of junk food consumption and stopped exercising 1 year ago.

ROS-Normal (-'ve except noted above)
PMH-Bipolar disorder for 14 years. (BIPOLAR- 14 YEARS)
Allergies-NKA
Medication-Lithium for Bipolar disorder. (LITHIUM- BIPOLAR)
FH-Mother and sister obese,father died of natural causes. (MOM & SISTER- OBESE, DAD- DEAD, NATURAL CAUSES)
PSH-Sexually active with husband of 12 years,no use of condoms or OCPs (NO CONTRACEPTION)
SH-Homemaker.Smoker who stopped couple of years ago,before that smoked 2-3 PPD for 10 years.Drinks alcohol 2-3 beers per day (BEER 2-3 /DAY), cut down from 5-6 beers per day.CAGE-O/4.Marijuana tried in college.

PHYSICAL EXAMINATION - Indicate only pertinent positive and negative findings related to the patient's chief complaint.

VS-BMI 30, rest WNL. Patient is pleasant and under no acute distress. (NAD)
HEENT-PERLA,no vision or hearing loss,no scars on face or neck,no JVDs. Check thyroid gland. (PERRLA, EOMI, NO JVD)
Heart-RRR,S1/S2 audible,no murmur or gallops (RRR, NL S1/S2, NO M/R/G)
Chest-Audible breath sounds,normal percussion,no rubs or crackles (CTAB)
Abdomen-BS +, Soft, nondistended,non tender (+BS, SOFT, NT/ND)
Extremities-No scars, no motility problems (FROM)

(NEURO - A&O X3, ECT.....)


You will really have to cut down on your typing. You only have 10 min at most. and that time will go by quick. Use as much abv as possible.
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  #3  
Old 02-07-2012
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Default

Wow, thank you very much for your tips. You make it look easy with those abbreviations. I will surely use them and post few more notes in some days from now. Thanks a lot!
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