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  #1  
Old 01-30-2013
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Default Patient note stupid questions

I have one stupid question..
Is it ok to put normal findings on the PE of the patient note even if its not related? IE. Pain during sex and put the normal cardiac findings/Chest findings?

They do this also on CSE videos patient notes
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Old 01-30-2013
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you are graded for your patient note

each component should be complete like HPI,PE etc

just an example if a patient has pain abdomen and you find no positive findings
your PN should look like

VS:WNL HEENT:OROHARYNX NO EXUDATES OR ERYTHEMA,PERRLA,EOMI
ABD:SOFT,NONTENDER,BS+,NO ORGANOMEGALY
HEART:RRR,S1S2 NL,NO M/G/R
CHEST:CTA B/L

i do it this way depending on how much time you have
write the PN,just make sure you wrote something in each component.
in a neuro case you might not have time to write the heart and chest PE,dont worry about that
just write what you did and dont put what you did not do you might lose marks for that

i hope this answers your question
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Old 01-30-2013
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Quote:
Originally Posted by galaxy View Post
you are graded for your patient note

each component should be complete like HPI,PE etc

just an example if a patient has pain abdomen and you find no positive findings
your PN should look like

VS:WNL HEENT:OROHARYNX NO EXUDATES OR ERYTHEMA,PERRLA,EOMI
ABD:SOFT,NONTENDER,BS+,NO ORGANOMEGALY
HEART:RRR,S1S2 NL,NO M/G/R
CHEST:CTA B/L

i do it this way depending on how much time you have
write the PN,just make sure you wrote something in each component.
in a neuro case you might not have time to write the heart and chest PE,dont worry about that
just write what you did and dont put what you did not do you might lose marks for that

i hope this answers your question
Not entirely, i mean when supporting your Ddx right at the end of the patient note, on physical findings.
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Old 01-30-2013
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write what ever is positive from the history supporting your diagnosis
if you write 2-3 point in support it should be enogh
most of the times you will not find anything positive on PE
but definitely write whatever you gather from history
make sure that you have more supportive points for your 1 st diagnosis ,even if you have 1 supportive finding for the 3 DD it wont make much of a difference. at least in in uworld its like that.there is a case of a female coming up for prenatal check up there they give just 1 dd as pregnancy which makes sense and write only the supportive findings based on history
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