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Old 02-18-2012
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Help Please rate my Patient Note

can someone help me..tell me if im on the right path?


HPI: 21 yo F c/o crampy RLQ abdominal pain since this morning. has gotten progressively worse till it reached a severity of 7/10. Pain aggravated by moving and no relieving factors. Associated with nausea and vomiting that occured 2 hours ago. vomiyus is sour, yellow with no blood. Also noted one loose bowel movement this morning which contained no blood or mucus. No tenesmus. No fever or chills. No headache.
ROS: Ngeative except as above
OB/GYN: Brownish vaginal spotting this morning. LMP: 5 weeks ago. Menarche at age 15. No itch, discharge or dysuria. SVD 3 years ago. Uses OCP.
Allergies: NKA
Medication: Ibuprofen
PMH: STD 2 month ago treated with antibiotic (partner not treated)
PSH: Not treated
SH: 1 PPD for 6 years. No illicit drugs. 2-3 beers/week. Sexually active with her boyfriend.
FH: Non contributary

General: Patient is in severe pain. No jaundice or cyanosis. No LAD
VS: WNL except temperature 100.5F
Chest: Clear breath sounds bilaterally
Heart: RRR, S1/S2 NL. No murmurs, rubs or gallops.
Abdomin: Soft, non distended. BS+. RLQ tenderness and rebound tenderness. Psoas sign +. Rovsing's sign +. No HSM

Ruptured EP
Ruptured ovarian cyst

work up:
Pelvic exam, Rectal exam
urine HCG, Quantitative serum HCG
vaginal swab
U/S- Pelvis

how did i do 1-10?
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Old 02-18-2012
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looks good....just try not to make a lot of spelling mistakes. also make sure that you type it in the stipulated time. you are definitely on the right track...just keep practicing. best of luck! 7/10
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The above post was thanked by:
rwass (02-18-2012)



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