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  #1  
Old 07-16-2012
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Help Please Assess My Patient Notes!

Case; 16 yo f with amenorrhoea

history:
16 y/o/ f c/o no periods for the past 2 months.her periods started at age 13. Had been regular since then.28 day cycle,3-4 days of bleeding,no pain during periods, moderate bleeding,no vaginal dischagrge.has been comlaining of headches but no visual changes. Has been going through a lot of stress due to final exams.has anxiety but no plapitation, sweating,hair loss, voice changes, skin changes, ha slost 10 lbs in lsat 6 months, no nipple discharge.ros: No nausea, vomitting, breats changes,diarrhoea, constipation,increased frequency,constipatipn, appttite changes.all: Nkda. Meds: Nkne.pmh; none. Osh: None
fh: Not significant.sh: No smoker, no etoh, no drugs, sexualy actve wiht one partneer does ot use condoms in safe period

physical:

Vs: Wnl
chest: Cts bilaterally,
cvs: Rr, no m//g/r
abd: Soft, non tender, non distended, bs +, no hepatosplenomegaly,, resonant
extremities: No oedema, skin cjanges,


d/d:
Pergnancy
ameorrhoea dut to stress

amenorrhoea dut to pituatary disease
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  #2  
Old 07-16-2012
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for jaundice:
35 YO F CO JAUNDICE X 5 DAYS. SHE HAD FEVRE 3 DAYS AGO, 101.F, CONSTANT ASSOCIATED WIHT CHILLS AND RIGOR LATER SHE DEVELOPED JAUNIDCE OF HJER WHOLE BODY, AND HAS BEEN PROGRESSIVE SINCE THEN, HER STOOLS ARE EPLAE A NDURINE IS DARK, DOES NOT COMPLAIN OF ITCHIHNG.HAD BEEN AHVING VAGUE ABDOMINAL PAIN IN RT UPPER ABDOMEN X 2 DAYS, 4/10 , DULL ACHE , NO RADIATION, NO AGGREAVATING OR RELIEVING FACTORS, NO ASSOCOIATED WIHT MEALS, SHE RETURNED FROM INDIA 20 DAYS BACK, HAD NOT TAKEN ANY VACCINATION ROS: NO HEADACHES, BLEEDING FROM ANY WHERE, NO DIARHOES,HAD BLOOD TRANSFUSIN 2 YRS BACK, NO WT LOSS,ALL: NKDA. MEDS: TYLENOL. PMH: NOT SINGINFICANT, PSH: NONE
FH: NONE SH: DRINKS 3 BEERS/ DAY X 20 YRS, NON SMOKER, NO RECERATIONAL OR IV DRUGS, USES CONDOMS WIHT HUSBAND
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  #3  
Old 07-17-2012
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Try to write all positive findings first, and then negative findings.
You could add some abbreviations for physical, such HSM for hepatospelonomegaly, B/L for bilateral.
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