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.
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 ovarian cyst
Pelvic exam, Rectal exam
urine HCG, Quantitative serum HCG
how did i do 1-10?
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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