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  #1  
Old 05-01-2013
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Smile CS Patient Note Example

hii every one...

I have attached my sample patient note of first aid case 2...

I am finding it very difficult to type the pn in 10 min...

Do correct my note and let know what abbreviations could be used to save time...

have exam in few days....


Thanks in advance
Attached Files
File Type: pdf patient-note-.pdf case-2.pdf (86.2 KB)
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Old 05-03-2013
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1)Where is the PMH, SH, FH, MEDS, ALLERGY, PSH?
2)For ROS you can just write ROS: NORMAL EXCEPT ABOVE.
3)About the main complaint, please write about the onset, frequency,progression. AVoid exact date of LMP and age of menarche,
4) Avoid writting "HPI" i.e understood.
5) Avoid writting VS with negaitve findings, just write positive ones.
6) In abdominal pain cases do signs for peritonitis guarding, rebound and mention it in PE.
7) DIAGNOSTIC WORKUP- ALWAYS WRITE CBC WITH DIFF, ELECTROLYTES,
GLUCOSE IF DD IS DM
CBC WITH PERIHERAL SMEAR ,ESR, BLOOD GRAM STAIN, CULTURE IF DD IS INFECTION, CYTOLOGY FOR CANCER
UA CULTURE ,STAIN ,CYTOLOGY SAME AS BLOOD.

TIME SAVERS.
1)TRY COPY PASTING FROM DD to DD AND DD TO HPI . IT REALLY SAVES TIME.
2)AVOID WRITTING NEGATIVE FINDINGS IF YOU ARE CRUSHED FOR TIME IN PE. AND ALWAYS WRITE ONLY THOSE THINGS IN PE WHICH YOU ACTUALLY DO AND NOT WHICH YOU DONT.
3) READ FA FOR OTHER SHORT FORMS , VERY HELPFUL.
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Old 05-03-2013
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Quote:
Originally Posted by hunkpratikcool View Post
1)Where is the PMH, SH, FH, MEDS, ALLERGY, PSH?
2)For ROS you can just write ROS: NORMAL EXCEPT ABOVE.
3)About the main complaint, please write about the onset, frequency,progression. AVoid exact date of LMP and age of menarche,
4) Avoid writting "HPI" i.e understood.
5) Avoid writting VS with negaitve findings, just write positive ones.
6) In abdominal pain cases do signs for peritonitis guarding, rebound and mention it in PE.
7) DIAGNOSTIC WORKUP- ALWAYS WRITE CBC WITH DIFF, ELECTROLYTES,
GLUCOSE IF DD IS DM
CBC WITH PERIHERAL SMEAR ,ESR, BLOOD GRAM STAIN, CULTURE IF DD IS INFECTION, CYTOLOGY FOR CANCER
UA CULTURE ,STAIN ,CYTOLOGY SAME AS BLOOD.

TIME SAVERS.
1)TRY COPY PASTING FROM DD to DD AND DD TO HPI . IT REALLY SAVES TIME.
2)AVOID WRITTING NEGATIVE FINDINGS IF YOU ARE CRUSHED FOR TIME IN PE. AND ALWAYS WRITE ONLY THOSE THINGS IN PE WHICH YOU ACTUALLY DO AND NOT WHICH YOU DONT.
3) READ FA FOR OTHER SHORT FORMS , VERY HELPFUL.
aRE YOU SURE THE ABBREVIATIONS IN FA ARE ACCEPTABLE IN THE EXAM? BECAUSE SOME OF THEM ARE NOT INCLUDED IN THE CS INFORMATION BOOKLET IN THE USMLE WEBSITE. IM REALLY CURIOUS TO KNOW IF ABBREVIATIONS LIKE CTA B/L, NO MGR ETC ARE ACCEPTED
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Old 05-03-2013
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Quote:
Originally Posted by numbndumb View Post
aRE YOU SURE THE ABBREVIATIONS IN FA ARE ACCEPTABLE IN THE EXAM? BECAUSE SOME OF THEM ARE NOT INCLUDED IN THE CS INFORMATION BOOKLET IN THE USMLE WEBSITE. IM REALLY CURIOUS TO KNOW IF ABBREVIATIONS LIKE CTA B/L, NO MGR ETC ARE ACCEPTED


I have learned these abbreviations from lot of people who have passed CS and recommended others to use the same. In the end its upto you to chose.
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Old 05-04-2013
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Quote:
Originally Posted by hunkpratikcool View Post
1)Where is the PMH, SH, FH, MEDS, ALLERGY, PSH?
2)For ROS you can just write ROS: NORMAL EXCEPT ABOVE.
3)About the main complaint, please write about the onset, frequency,progression. AVoid exact date of LMP and age of menarche,
4) Avoid writting "HPI" i.e understood.
5) Avoid writting VS with negaitve findings, just write positive ones.
6) In abdominal pain cases do signs for peritonitis guarding, rebound and mention it in PE.
7) DIAGNOSTIC WORKUP- ALWAYS WRITE CBC WITH DIFF, ELECTROLYTES,
GLUCOSE IF DD IS DM
CBC WITH PERIHERAL SMEAR ,ESR, BLOOD GRAM STAIN, CULTURE IF DD IS INFECTION, CYTOLOGY FOR CANCER
UA CULTURE ,STAIN ,CYTOLOGY SAME AS BLOOD.

TIME SAVERS.
1)TRY COPY PASTING FROM DD to DD AND DD TO HPI . IT REALLY SAVES TIME.
2)AVOID WRITTING NEGATIVE FINDINGS IF YOU ARE CRUSHED FOR TIME IN PE. AND ALWAYS WRITE ONLY THOSE THINGS IN PE WHICH YOU ACTUALLY DO AND NOT WHICH YOU DONT.
3) READ FA FOR OTHER SHORT FORMS , VERY HELPFUL.
Thanks a lot for your opinion....

I had taken a print screen of my sample pn so the other part of Hx was not visible ....sorry for not being clear...

I have few more doubts...

How to write obs/gyn Hx if it is very relevant?

In the pn sample given by ecfmg.org they have not given R.O.S - negative as above..so is it wise to write that?

I am really worried about the pn...got exam in 2 days..

Thanks in advance.......
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Old 05-05-2013
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There is an excellent thread here where you will find the answers to most of your questions.

Random Tips for the CS exam
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