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  #1  
Old 06-05-2013
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Listening My Patient Notes-Are these enough to pass?

Hi Guys/Gals.

I just typed my practice PNs timed to 9.30 minutes
Are these enough to pass?
Comments welcome.
Attached Files
File Type: pdf PATIENT NOTES PRACTICE.pdf (8.0 KB)
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Is more than enough, just be careful with the orthography.

Check you PM I will send you an example of the ones I used
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Just to clarify, Under DD: On left side are the supporting findings in History and on the Right side are the supporting findings from PE.
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Old 06-05-2013
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really good. I would only add abdominal inspection and organomegaly as it is specifically a Pancreatitis case with alcohol abuse. Not sure if it is important or not but i always mentioned Cage + 4/4.
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Quote:
Originally Posted by kdm0101 View Post
really good. I would only add abdominal inspection and organomegaly as it is specifically a Pancreatitis case with alcohol abuse. Not sure if it is important or not but i always mentioned Cage + 4/4.
Thanks a lot for your input.
I actually ran out of time to write anything more ( I am a slow typer-Yeah, the one who actually looks at the keyboard while typing).
About CAGE-What I have known that if your Eye opener is positive then the CAGE is positive and you do not have to ask any more CAGE questions. This is exactly what happened in this case, so I didn't ask CAG part of the CAGE.
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Not sure about the whole CAGE thing but if my diagnosis is based on one of alcohol based pathology, i would ask all four. Don't worry about speed, it's all about practice. But in this case you could skip few points in ur DD especially the 2nd and 3rd diagnosis. 3 points each is more than enough but u can not miss the specific to the diagnosis examination acc to me(it worked for me very well.good luck and feel free to discuss
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Originally Posted by Novobiocin View Post
Thanks a lot for your input.
I actually ran out of time to write anything more ( I am a slow typer-Yeah, the one who actually looks at the keyboard while typing).
About CAGE-What I have known that if your Eye opener is positive then the CAGE is positive and you do not have to ask any more CAGE questions. This is exactly what happened in this case, so I didn't ask CAG part of the CAGE.
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Quote:
Originally Posted by kdm0101 View Post
Not sure about the whole CAGE thing but if my diagnosis is based on one of alcohol based pathology, i would ask all four. Don't worry about speed, it's all about practice. But in this case you could skip few points in ur DD especially the 2nd and 3rd diagnosis. 3 points each is more than enough but u can not miss the specific to the diagnosis examination acc to me(it worked for me very well.good luck and feel free to discuss
I think you made a very good point. This entire case is based on ETOH, so I should ask & document all 4 CAGE Q's.
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Quote:
Originally Posted by Novobiocin View Post
I think you made a very good point. This entire case is based on ETOH, so I should ask & document all 4 CAGE Q's.
you can write it like CAGE 2/4 or 4/4 (depending on the positive answers)
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I think you need to put some -ve finding at the end of HPI.
Like there is no bowel changes/blood in stool/fever/chills/wt changes and appetite changes.
this is also important -ve finding that should mentioned to exclude other medical condtions.
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Quote:
Originally Posted by usramt View Post
"no bowel changes/blood in stool/fever/chills/wt changes and appetite changes."
I've been wondering: is using "/" to separate symptoms allowed? I think that it is a pretty fast way to write down stuff but I'm concerned if I can use it or not... any insight? Also... any fast way to write right/left arm, right/left leg??? is it LUE, RUE, LLE, RLE okay?
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You can use , between symptoms but i am not sure about /?
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you can usE : to separate the set of symptoms. for example-CC- PAIN EPIGASTRIUM/RADIATING TO BACK/AGGRAVATED BY.../RELIEVED BY .../RELATION TO FOOD: NO NAUSEA/VOMITING/PAIN ABDOMEN:
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Originally Posted by usramt View Post
You can use , between symptoms but i am not sure about /?
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Quote:
Originally Posted by usramt View Post
I think you need to put some -ve finding at the end of HPI.
Like there is no bowel changes/blood in stool/fever/chills/wt changes and appetite changes.
this is also important -ve finding that should mentioned to exclude other medical condtions.
I would love to but I just didn't have time to write all that being a slow typer.
Also, they ask to write pertinent + & -ve findings specifically related to the chief complaint.
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Agree with the above.
Always include pertinent negatives
after analyzing chief complaint.
it shows ur thinking
about the possible diagnoses.
Also in the end
make sure u start off
with simple blood tests
CBC and then move on to
imaging and more invasive tests.
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Old 06-06-2013
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hiii friends,,while typing in cs exam,,if there will be spelling mistakes ,,then there will problemm,,,
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Quote:
Originally Posted by kamidi View Post
hiii friends,,while typing in cs exam,,if there will be spelling mistakes ,,then there will problemm,,,
I cant even begin to describe what im thinking right now...
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Originally Posted by kamidi View Post
hiii friends,,while typing in cs exam,,if there will be spelling mistakes ,,then there will problemm,,,
As long as the word makes sense and is within the context, misspelling won't matter.
e.g. temderness, diziness, constipatipn.
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As long as you don't type PUD as PID, you are fine
Quote:
Originally Posted by kamidi View Post
hiii friends,,while typing in cs exam,,if there will be spelling mistakes ,,then there will problemm,,,
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Help Hey guys

Let's post some PN here to analyze them. One per guy at a time. A few PN to give some feedback and see our weak points? What do you think?
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Quote:
Originally Posted by Dr. Mexito View Post
Let's post some PN here to analyze them. One per guy at a time. A few PN to give some feedback and see our weak points? What do you think?
I am in.........here you go:
Quote:
CC; 21 Y O F C/O WT GAIN
HPI; STARTED 6 MONTHS AND HAS GAINED 20 POUNDS,APPETITE NO CHANGE, COLD INTOLERANCE, DRY HAIR+, NO SKIN CHANGES/RASH, NO CHANGE IN VOICE
NO FEVER, BOWEL/URINATION CHANGES, NO RECENT STRESS, NO SLEEP CHANGES, MOOD-GOOD
PMH; NO PREVIOUS EPISODES, NO MAJOR ILLNESS, NO ALLERGIES. NOT ON ANY Rx
NO PRVIOUS HOPITALIZATION/INJURIES/MAJOR ILNESS
FH; MOTHER & SISTER-OVERWEIGHT, MOTHER DIABETC
OBGYN HX; LMP 2WKS AGO REGULAR, PAP SMEAR 2 YRS AGO NL
SH; 1PPD/5YRS SMOKING, ETOH-OCCASIONAL, NO DRUGS, LIVE WITH PARENTS, COLLEGE STUDENT
SxHx; SEXUALLY ACTIVE WITH BF 5 YRS CONDOMS REGULARLY

GA; NAD
VS; WNL
NO PALLOR/ICTERUS LAP
NO THYROMEGALY
ABD; OBESE,SOFT NON-TENDER NO ORGANOMEGALY BS+4Q
CHEST; CTA&P NO RALES/RHONCHI/WHEEZE
CVS; S1S2 WNL, NO M/R/G RRR

Differential Diagnosis
1. Familial obesity (FH/o Obesity, wt gain, obese abd)
2. Hypothyroidism (COLD INTOLERANCE, DRY HAIR+)
3. Diabetes (FH/o DM, wt gain)


Diagnostic Workup
1. TSH T4 T3 FT4 FT3
2. Urine hCG
3. Glucose, cholesterol, triglycerides
4. Dexamethasone suppression test
5. 24-hour urine free cortisol
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Last edited by Novobiocin; 06-06-2013 at 04:49 PM.
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Quote:
Originally Posted by Novobiocin View Post
I am in.........here you go:
For ABD PE, you can write NT ( nontender ), ND (nondistended ), no HSM (hepatosplenomegaly ).

For CVS: S1+ 0 + S2, RRR
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Quote:
Originally Posted by aknz View Post
For ABD PE, you can write NT ( nontender ), ND (nondistended ), no HSM (hepatosplenomegaly ).

For CVS: S1+ 0 + S2, RRR
You are right about ABD Exam but my CVS Exam is perfectly written (according to Kaplan) except that PMI, JVD & Pulses should be mentioned in a full CVS Exam.
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Quote:
Originally Posted by Novobiocin View Post
I am in.........here you go:
You can use abbreviations in your diagnostic work up: CHOL, GLU, TG. I'm not sure about DEXA suppression test = DST

- why don't "THYROID WNL" or "- thyromegaly" instead of "no thyromegaly" WOULDN'T THAT BE FASTER AND EASIER TO WRITE ?

- Lest write the time we take to write the PN to see our progress
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if you are making DB as diagnosis, you will need to do HbA1c/OGTT, electrolytes, UA.just glucose is not enough.not sure if both dexameth and cortisol are needed. in OBGYN u shd write the length and frequency of cycle. be careful abt PAP smear as a 21 y/f wouldn't have PAP done at 19 unless some STD big history.
in exam in this case i would suggest to do extremities exam and mention about pulses, edema. Also i don't think obesity is a part of abd exam. it shd be in general appearance
you can still make ur notes shorter by modifying but if u r close to test, u shouldn't do many new things and just practice the way u have so far
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I am in.........here you go:
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Quote:
Originally Posted by Dr. Mexito View Post
- Lest write the time we take to write the PN to see our progress
I am doing all my PNs timed to 9.30 minutes using this.
My aim is not to write the best PNs but to write the best possible PNs in 9.30 minutes.
Also, Diet & Exercise history is of paramount importance in this case.
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Last edited by Novobiocin; 06-06-2013 at 05:32 PM.
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yes you are right and in fact council for wt loss. also r/o depression by asking at least 2 specific questions
Quote:
Originally Posted by Novobiocin View Post
I am doing all my PNs timed to 9.30 minutes using this.
My aim is not to write the best PNs but to write the best possible PNs in 9.30 minutes.
Also, Diet & Exercise history is of paramount importance in this case.
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Quote:
Originally Posted by kdm0101 View Post
if you are making DB as diagnosis, you will need to do HbA1c/OGTT, electrolytes, UA.just glucose is not enough.not sure if both dexameth and cortisol are needed. in OBGYN u shd write the length and frequency of cycle. be careful abt PAP smear as a 21 y/f wouldn't have PAP done at 19 unless some STD big history.
in exam in this case i would suggest to do extremities exam and mention about pulses, edema. Also i don't think obesity is a part of abd exam. it shd be in general appearance
you can still make ur notes shorter by modifying but if u r close to test, u shouldn't do many new things and just practice the way u have so far
Thank you, some very good points.
I am close to my test (practically 6 days left) but I am prepared for everything else except PNs where I need to do some more refinements.
Any suggestions?
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Quote:
Originally Posted by Novobiocin View Post
My aim is not to write the best PNs but to write the best possible PNs in 9.30 minutes.
That's the name of the game..."We live or we die by the clock"
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Quote:
Originally Posted by Novobiocin View Post
I would love to but I just didn't have time to write all that being a slow typer.
Also, they ask to write pertinent + & -ve findings specifically related to the chief complaint.
I completly agree with you 10 minutes going very fast for me i can't complete PN
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in the note,
do not mention major illness twice and hospitilization if none,

also say sexually active with BF, uses condoms, no STD

use NKDA, forget about not being on medication if not on.

HPI use negatives . rest don't
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Old 06-07-2013
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Help Here is mine....

I actually did the full 25 min encounter with my personal SP . Real elapsed time for the PN: 9:55 min.
Attached Files
File Type: pdf PN 2013-06-07 (CASE 18).pdf (65.9 KB)
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Default I using list. Any advise thank you!!!!!

*HPI: 21 YO F C/C WT GAIN
*SINCE 6 MONTHS, GAINED 20LB; NO CHANGE APPETITE.
*COLD INTOLERANCE; DRY HAIR; NO SKIN/RASH/VOICE CHANGE
*ROS: NO FEVER, BOWEL/URINATION CHANGE, RECENT STRESS, SLEEP CHANGES, OR MOOD-GOOD
*PMH: NO PREVIOUS EPISODES, MAJOR ILLNESS, ALLERGIES, OR ANY Rx
*PSH/TRAUMA/HOSPITALIZATION: NONE
*FH: MOTHER & SISTER-OVERWEIGHT, MOTHER DM.
*OB/GYN: LMP 2WKS AGO REGULAR, PAP SMEAR 2 YRS AGO NL.
*SH; 1PPD/5YRS, ETOH-OCCASIONAL, NO ILLICIT DRUGS, LIVING W/ PARENTS. IS COLLEGE STUDENT.
*SxHx; SEXUAL ACTIVE W/BF 5 YRS CONDOMS REGULARLY

GA; NAD
VS; WNL
NO PALLOR/ICTERUS LAP
NO THYROMEGALY
ABD; OBESE,SOFT NON-TENDER NO ORGANOMEGALY BS+4Q
CHEST; CTAB NO R/R/W.
CVS; S1S2 WNL, NO M/R/G RRR
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Quote:
Originally Posted by romeja View Post
*HPI: 21 YO F C/C WT GAIN
*SINCE 6 MONTHS, GAINED 20LB; NO CHANGE APPETITE.
*COLD INTOLERANCE; DRY HAIR; NO SKIN/RASH/VOICE CHANGE
*ROS: NO FEVER, BOWEL/URINATION CHANGE, RECENT STRESS, SLEEP CHANGES, OR MOOD-GOOD
*PMH: NO PREVIOUS EPISODES, MAJOR ILLNESS, ALLERGIES, OR ANY Rx
*PSH/TRAUMA/HOSPITALIZATION: NONE
*FH: MOTHER & SISTER-OVERWEIGHT, MOTHER DM.
*OB/GYN: LMP 2WKS AGO REGULAR, PAP SMEAR 2 YRS AGO NL.
*SH; 1PPD/5YRS, ETOH-OCCASIONAL, NO ILLICIT DRUGS, LIVING W/ PARENTS. IS COLLEGE STUDENT.
*SxHx; SEXUAL ACTIVE W/BF 5 YRS CONDOMS REGULARLY

GA; NAD
VS; WNL
NO PALLOR/ICTERUS LAP
NO THYROMEGALY
ABD; OBESE,SOFT NON-TENDER NO ORGANOMEGALY BS+4Q
CHEST; CTAB NO R/R/W.
CVS; S1S2 WNL, NO M/R/G RRR
- Why not CC?
- Why not Mo?
- How about putting "no previous episodes" in HPI? Why do you think you have to put "no previous episodes" here?.
- What about putting allergies: NKDA, PMH: none.?
- Is "w/" okay?
- is BF/GF okay?
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  #34  
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yes NKDA and no hx similar symptoms could be pmh or hpi . The w/ is ok, like w/o (without). I have qs ...I saw, at hospital where I work, real patient notes: ~6hr... (about 6 hours)
that kind the abb. is ok???
thank you
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Quote:
Originally Posted by Dr. Mexito View Post
- Why not CC?
- Why not Mo?
- How about putting "no previous episodes" in HPI? Why do you think you have to put "no previous episodes" here?.
- What about putting allergies: NKDA, PMH: none.?
- Is "w/" okay?
- is BF/GF okay?

CC or C/C it doesnt matter.

You to have to put as much as possible.. you have to describe as much as possible even if it is normal.

There he is giving an example on how to describe that there is no history of major illnesses. It makes your note look more professional
Instead of PMH: none you can put: Denies history of diabetes, HTN, MI, endocrine diseases.... This looks much better than just putting "none" or "normal"

There are some mnemonics that the USMLE accepts and some they dont.. you have to be very careful with this.
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Quote:
Originally Posted by Dr. Mexito View Post
I actually did the full 25 min encounter with my personal SP . Real elapsed time for the PN: 9:55 min.
looks like my PN can't be seen... I post it again:


HISTORY
CC: CHEST PAIN. HPI: PT 35 YO F C/O CHEST PAIN FOR 1 D, INTERMITTENT, 45/10, NON RADIATING, TIGHTNESS SENSATION ON CENTRAL ANT CHEST WALL. NOT BETTER OR WORSE WITH ANYTHING. TRIGGERED WHEN GOING OUT TO OPEN AND CROWED PLACES, +SOB/SWEATS/PALPITATIONS. EPISODES STARTED 6 MO AGO, HAPPENING 4-5 A MONTH, CURRENT EPISODES HAPPEN 1X WEEK. TODAY HAD 2X EPISODES. NOT RELATED WITH EXERCISE. TOOK OTC ANTIACIDS WITH NO RELIEF. INCREASED STRESS IN LIFE. +SLEEP DISTURBANCE. NO CHANGES IN URINATION OR BOWEL MOVEMENTS. ROS: NEG EXCEPT ABOVE.

PHYSICAL EXAMINATION
VS: WNL EXCEPT HR 98.
GA: ANXIETY.
CV: RRR, NL S1, S2.
EXT: NO EDEMA, NO RASH, PULSES 2/4 RADIAL AND TP.

Diagnosis #1: PANIC ATTACK
History Finding --- (Physical Exam Finding)
CHEST PAIN IN OPEN PUBLIC --- (HR 98)
HOSPITALIZATION 6 MO AGO DUE TO SIMILAR EPISODES

Diagnosis #2: HYPRTHYROIDISM
History Finding --- (Physical Exam Finding)
SISTER WITH HYPOTHYROIDISM --- (HR 98)

Diagnosis #3: PHEOCHROMOCYTOMA
History Finding --- Physical Exam Finding)
CHEST PAIN HR --- (HR 98)
PALPITATIONS

Diagnostic Study/Studies
CBC, ELECTROLYTES, TSH, FREE T4, ECG, HOLTER MONITOR
CATHECOLAMINES, METANEPHRINES
ABD CT, CXR,
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i think you missed quite a few things---
-no past/family/personal/social/sexual history
-u need abd exam in this.A CT abdomen without eve examining it is not a good idea: pulses are not written 2/4 i think. they are 2+, u need HEENT exam in this including thyroid especially when it's in ur diagnosis
-u need carotid pulses
-u need Resp exam too
-you can not get away with a retrosternal chest pain and not thinking of CAD especially if u r making a diagnosis of Hyperthyroid only based on tachycardia and f/h of HYPOthyroid
-in Pheochromocytoma, u shd mention that it is episodic in the diagnosis part
-in tests, mention URINE for catecholamines and not just blood level. in fact be specific about VMA etc levels. I would in fact do a stress test in this pt
-Panic attack is a diagnosis of exclusion so not sure if it shd be ur first diagnosis
not trying to put you down but i do think, u need these changes and in fact i must have missed lot of things here
-
Quote:
Originally Posted by Dr. Mexito View Post
looks like my PN can't be seen... I post it again:


HISTORY
CC: CHEST PAIN. HPI: PT 35 YO F C/O CHEST PAIN FOR 1 D, INTERMITTENT, 45/10, NON RADIATING, TIGHTNESS SENSATION ON CENTRAL ANT CHEST WALL. NOT BETTER OR WORSE WITH ANYTHING. TRIGGERED WHEN GOING OUT TO OPEN AND CROWED PLACES, +SOB/SWEATS/PALPITATIONS. EPISODES STARTED 6 MO AGO, HAPPENING 4-5 A MONTH, CURRENT EPISODES HAPPEN 1X WEEK. TODAY HAD 2X EPISODES. NOT RELATED WITH EXERCISE. TOOK OTC ANTIACIDS WITH NO RELIEF. INCREASED STRESS IN LIFE. +SLEEP DISTURBANCE. NO CHANGES IN URINATION OR BOWEL MOVEMENTS. ROS: NEG EXCEPT ABOVE.

PHYSICAL EXAMINATION
VS: WNL EXCEPT HR 98.
GA: ANXIETY.
CV: RRR, NL S1, S2.
EXT: NO EDEMA, NO RASH, PULSES 2/4 RADIAL AND TP.

Diagnosis #1: PANIC ATTACK
History Finding --- (Physical Exam Finding)
CHEST PAIN IN OPEN PUBLIC --- (HR 98)
HOSPITALIZATION 6 MO AGO DUE TO SIMILAR EPISODES

Diagnosis #2: HYPRTHYROIDISM
History Finding --- (Physical Exam Finding)
SISTER WITH HYPOTHYROIDISM --- (HR 98)

Diagnosis #3: PHEOCHROMOCYTOMA
History Finding --- Physical Exam Finding)
CHEST PAIN HR --- (HR 98)
PALPITATIONS

Diagnostic Study/Studies
CBC, ELECTROLYTES, TSH, FREE T4, ECG, HOLTER MONITOR
CATHECOLAMINES, METANEPHRINES
ABD CT, CXR,
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  #38  
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Quote:
Originally Posted by kdm0101 View Post
i think you missed quite a few things---
-no past/family/personal/social/sexual history
-u need abd exam in this.A CT abdomen without eve examining it is not a good idea: pulses are not written 2/4 i think. they are 2+, u need HEENT exam in this including thyroid especially when it's in ur diagnosis
-u need carotid pulses
-u need Resp exam too
-you can not get away with a retrosternal chest pain and not thinking of CAD especially if u r making a diagnosis of Hyperthyroid only based on tachycardia and f/h of HYPOthyroid
-in Pheochromocytoma, u shd mention that it is episodic in the diagnosis part
-in tests, mention URINE for catecholamines and not just blood level. in fact be specific about VMA etc levels. I would in fact do a stress test in this pt
-Panic attack is a diagnosis of exclusion so not sure if it shd be ur first diagnosis
not trying to put you down but i do think, u need these changes and in fact i must have missed lot of things here
-
I do agree with kdm, when you are ordering specific tests for weird diseases you have to specify if they are urine or blood.

Panic attack would need to be your second or third differential.. never ever your first..

The USMLE doesnt want US to miss life threatening diagnoses just because we are biased (woman, 35) in fact her pain can be easily associated with Prinzmetal angina (common in younger people, paroxystical episodes etc).

When you put hyperthyroidism you do need HEENT and neck exam with thyroid and carotid exams.

The thing I dont agree with is with Resp system.. you could probably skip it if you are finding that you are short on time.. but the rest kdm said is pretty much correct
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  #39  
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Quote:
Originally Posted by kdm0101 View Post
i think you missed quite a few things---
-no past/family/personal/social/sexual history

I Don't know what happened to the PMH, SH, FH, SX, ALLERGIES AND MEDS
because I did asked them and wrote them...
PMH: 1 previous episode 6 mo ago, but exams didn't find anything.
FH: mom with hypochondriasis and sister with hyperthyroidism,
SH: live alone, 1 PPD x 15 y, -ETOH/lllegal drugs. Works as a secretary.

...And some other thins that I've already forget because I did it in the USMLE.org webpage and then just copy-paste it to UW. I was really happy with it when I finished it.

Thank you for the feed back

Quote:
Originally Posted by kdm0101 View Post
not trying to put you down but i do think, u need these changes and in fact i must have missed lot of things here
Not at all man... I'll be more careful with the next PN I post here. Thank you for your help
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  #40  
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Quote:
Originally Posted by XpaezX View Post
Panic attack would need to be your second or third differential.. never ever your first..
It was actually the 1st in UW ...

Quote:
Originally Posted by XpaezX View Post
When you put hyperthyroidism you do need HEENT and neck exam with thyroid and carotid exams.
Yup... have to be careful with that one, it is important... Muchas gracias Señor

I was thinking ABD CT for the pheochromocytoma. The tip off that made me think of panic attack was the fact that she had the symptoms only in open and crowed places +SOB/SWEATS/PALPITATIONS and not related to exercise. I was running out of time so I skipped the Abd, Chest, CV PE and gave more counseling (Because I was not thinking about something else as 1st Dx).

Now that I see my PN compared with the original... it does looks crappy and amateur .


Thank you for the feedback guys... I'll be more careful with the next one
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Quote:
Originally Posted by Dr. Mexito View Post
It was actually the 1st in UW ...



Yup... have to be careful with that one, it is important... Muchas gracias Señor

I was thinking ABD CT for the pheochromocytoma. The tip off that made me think of panic attack was the fact that she had the symptoms only in open and crowed places +SOB/SWEATS/PALPITATIONS and not related to exercise. I was running out of time so I skipped the Abd, Chest, CV PE and gave more counseling (Because I was not thinking about something else as 1st Dx).

Now that I see my PN compared with the original... it does looks crappy and amateur .


Thank you for the feedback guys... I'll be more careful with the next one
Dont get me wrong sir, I do think it is Panic attack.. however as I mentioned earlier you just cant put it as a first dx without ruling out other diseases..

The fact that Uworld put it as first is irrelevant.. here you have to reason and think like a real physician.. If she was your patient would you just let her walk out of the office/ER without ruling out ACS or any other disease?

I would put Panic attack as a third diagnosis (eventho IT IS the diagnosis) just for the sake of mental sanity haha
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totally agree....plz don't think only along UW/FA lines as you will find lot of variations in actual test.That material is for reference only and practicing
Quote:
Originally Posted by XpaezX View Post
Dont get me wrong sir, I do think it is Panic attack.. however as I mentioned earlier you just cant put it as a first dx without ruling out other diseases..

The fact that Uworld put it as first is irrelevant.. here you have to reason and think like a real physician.. If she was your patient would you just let her walk out of the office/ER without ruling out ACS or any other disease?

I would put Panic attack as a third diagnosis (eventho IT IS the diagnosis) just for the sake of mental sanity haha
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Also, don't forget to do an Abd exam in a case with Chest pain since it could be GERD especially when you don't find any risk factors for CV disease. This is also the time to ask some additional questions regarding GERD while doing abd exam.
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here are my PN please help welcome.

46 YO M C/O CHEST PAIN * TODAY MORNING. HPI- SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY. NOTHING MAKES IT BETTER OR WORSE.A/W NAUSEA, SWEATING, PALPITATIONS, HEARTBURN. DENIES, DIZZINESS , LOC, RELATION TO BREATHING, SOB AND COUGH.
ROS- NONE EXCEPT ABOVE
PMH- HTN( 5 YEARS), SAME EPISODES BEFORE LASTING 5-10 MINUTES WORSENED BY WALKING.
PSH- NONE
MEDS-MALOX, ANTACIDS, DIURETIC ALLS- NKA, NKDA
FH- DAD (LUNG CANCER), MOTHER(PUD)
SH- STOPPED SMOKING, ETOH OCCASIONALLY, COCAIN SMOKING OCCASIONALLY, SEXUALLY ACTIVE WITH WIFE( BUT HAVE NOT BEEN ABLE TO HAVE SEX DUE TO CHEST PAIN.



GA- NAD. AAO *3
VS-WNL
CVS-RRR, NO M/G/R, S1/S2 AND PMI- NL. PULSES + 2 BL
LUNGS-CTABL.
NECK- NO BRUIT.
EXT- NO CYANOSIS, CLUBBING , EDEMA ON HANDS AND FEET.

COCAIN INDUCED MI
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
COCAIN USE LAST NIGHT

UNSTABLE UNGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HTN

STABLE ANGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HAD SUCH EPISODES IN THE PAST

Workup
CBC WITH DIFF, ELECTROLYTES, ESR,CK-MB, TROPONINS I AND T , ECG, ECHOCARDIOGRAPHY
ANGIOGRAPHY, STRESS TEST, DOPPLER CORONARY USG
DOBUTAMINE AND THALLIUM ECHO, UA, URINE TOXICOLOGY
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Are these OK? I copied and pasted the Vitals in this case.
In (...) are my own corrections (things I should have done instead).
Quote:
CC; 21 Y O M C/O SORE THROAT
HPI; 1 WK DURATION, DISCOMFORT WITH SWALLOWING. FEELS HOT. ALSO FEELS "LUMP IN THROAT" NO RASH
WORSE W/ SWALLOWING BETTER W/ TYLANOL
(DENIES) NO COUGH OR SPUTUM NO FATIGUE, NAUSEA OR VOMTTING
WT STABLE APPETITE GOOD, NO CHANGE IN BOWEL/URINARY HABITS
NO CHANGE IN SLEEP, NO RECENT STRESS H/O URI+ RUNNY NOSE
PMH; NONE NO ALLERGIES (NKA NKDA), NO MEDS (except as above)
FH; NOT CONTRIBUTORY (NONE)
SH; 1 PPDX5 YRS, 1-2 BEERS /DAY NO DRUGS
SXHX' SEXAUALLY ACTIVE W/ GF USES CONDOMS REGULARLY, (DENIES STD, HIV TESTING)

GA; NAD
VS;Temperature: 98.8°F (37.1°C)
Blood Pressure: 120/76 mm Hg
Heart Rate: 78/min
Respirations: 15/min
NO PALLOR, TENDER CERVICAL LAP
ABD; RUQ TENDERNESS
MURPHY'S -VE
REST OF ABD SOFT, NON-TENDER, NO ORGANOMEGALY
BS+4Q
NO ASCITES

INFECTOUS MONONUCLEOSIS
SORE THROAT
SUBJECTIVE FEVER
FEELS "LUMP IN THROAT"
NO FATIGUE
TENDER CERVICAL LAP
RUQ TENDERNESS

STREP PHYRENGITIS
SORE THROAT
SUBJECTIVE FEVER
FEELS "LUMP IN THROAT"
TENDER CERVICAL LAP

VIRAL PHARYNGITIS
SORE THROAT
SUBJECTIVE FEVER
H/O URI+ RUNNY NOSE
TENDER CERVICAL LAP?

WORKUP:
RAPID STREP ANTIGEN
CBC W/ DIFF, PERIPHERAL SMEAR, ESR
MONOSPOT TEST
THROAT C/S
AST, ALT ALP
US ABD
ELISA FOR HIV
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Hey guys..I heard that there is a large group of indian doctors preparing for CS in houston. Does anyone know that place or their contact information? If anyone know about that, kindly let me know. I have exam on 24th June in Houston. Need lots of prayers!
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very good. here is what acc to me you couls do--
-mention fever/no fever in history
-mention occupation
-in examination, you sure it was RUQ and not LUQ tenderness ?? in case it is LUQ, No need for Murphy's sign
-in the tests, u need to mention specific antibodies test for EBV and also probably a CXR
-in ur exam, it's not clear whether cervcial LAP is + or -ve. plz be careful ab it. i know someone who struggled because of it
but in general good enough i think
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Are these OK? I copied and pasted the Vitals in this case.
In (...) are my own corrections (things I should have done instead).
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i think you are talking about Greenway INN where all the desis camp. it's in US-59S. Google it and you will find it easily
Quote:
Originally Posted by Nouman View Post
Hey guys..I heard that there is a large group of indian doctors preparing for CS in houston. Does anyone know that place or their contact information? If anyone know about that, kindly let me know. I have exam on 24th June in Houston. Need lots of prayers!
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very good. here is what acc to me you couls do--
-mention fever/no fever in history
-mention occupation
-in examination, you sure it was RUQ and not LUQ tenderness ?? in case it is LUQ, No need for Murphy's sign
-in the tests, u need to mention specific antibodies test for EBV and also probably a CXR
-in ur exam, it's not clear whether cervcial LAP is + or -ve. plz be careful ab it. i know someone who struggled because of it
but in general good enough i think
Thanks for catching my mistakes.
Think I messed up the Abd Quadrant--It should be LUQ and not RUQ (since usually the spleen is on left side).
I did two cases one after the another and mixed up the abd findings. One was RUQ pain (typical Gallstones) and this one with sore throat. Hope this doesn't happen in the real test.
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My SP and I used to practice 4 cases in a row each person to get used to the exam drill. That helped us a lot.
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Thanks for catching my mistakes.
Think I messed up the Abd Quadrant--It should be LUQ and not RUQ (since usually the spleen is on left side).
I did two cases one after the another and mixed up the abd findings. One was RUQ pain (typical Gallstones) and this one with sore throat. Hope this doesn't happen in the real test.
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My SP and I used to practice 4 cases in a row each person to get used to the exam drill. That helped us a lot.
Did you and your SP used to write the PNs at the same time (i.e just after doing each case)?
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yes after each case. but we set the encounter time for 12-13 and notes time for 8 min
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Did you and your SP used to write the PNs at the same time (i.e just after doing each case)?
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Originally Posted by kdm0101 View Post
i think you are talking about Greenway INN where all the desis camp. it's in US-59S. Google it and you will find it easily

Yup!! ,, US-595? Do you know about the contact information of the person in charge for the CS prep there??
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there is no official preparation or an in-charge. ppl just live there and practice together. just sit in the lobby with FA or if you see any INDIAN, he is there for CS. just talk to them. call the place well in time for booking.
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Yup!! ,, US-595? Do you know about the contact information of the person in charge for the CS prep there??
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Quote:
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there is no official preparation or an in-charge. ppl just live there and practice together. just sit in the lobby with FA or if you see any INDIAN, he is there for CS. just talk to them. call the place well in time for booking.
Any group like that in L.A.?
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Quote:
Originally Posted by Matchmegod View Post
here are my PN please help welcome.

46 YO M C/O CHEST PAIN * TODAY MORNING. HPI- SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY. NOTHING MAKES IT BETTER OR WORSE.A/W NAUSEA, SWEATING, PALPITATIONS, HEARTBURN. DENIES, DIZZINESS , LOC, RELATION TO BREATHING, SOB AND COUGH.
ROS- NONE EXCEPT ABOVE
PMH- HTN( 5 YEARS), SAME EPISODES BEFORE LASTING 5-10 MINUTES WORSENED BY WALKING.
PSH- NONE
MEDS-MALOX, ANTACIDS, DIURETIC ALLS- NKA, NKDA
FH- DAD (LUNG CANCER), MOTHER(PUD)
SH- STOPPED SMOKING, ETOH OCCASIONALLY, COCAIN SMOKING OCCASIONALLY, SEXUALLY ACTIVE WITH WIFE( BUT HAVE NOT BEEN ABLE TO HAVE SEX DUE TO CHEST PAIN.



GA- NAD. AAO *3
VS-WNL
CVS-RRR, NO M/G/R, S1/S2 AND PMI- NL. PULSES + 2 BL
LUNGS-CTABL.
NECK- NO BRUIT.
EXT- NO CYANOSIS, CLUBBING , EDEMA ON HANDS AND FEET (No need to mention, because we are in EXT, so maybe just: no cyanosis/clubbing/edema.).

COCAIN INDUCED MI
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
COCAIN USE LAST NIGHT

UNSTABLE UNGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HTN

STABLE ANGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HAD SUCH EPISODES IN THE PAST (what about just: H/O chest pain)

Workup
CBC WITH DIFF, ELECTROLYTES, ESR,CK-MB, TROPONINS I AND T (Why troponin T? I remember T is also positive for kidney injury) , ECG, ECHOCARDIOGRAPHY (Just TTE?)
ANGIOGRAPHY, STRESS TEST, DOPPLER CORONARY USG
DOBUTAMINE AND THALLIUM ECHO (You already have stress test), UA, URINE TOXICOLOGY

What about:
- just substernal, pressure like.
- DENIES, DIZZINESS , LOC, SOB AND COUGH. Not related to breathing.
- HTN x 5 yrs
- putting "SAME EPISODES BEFORE LASTING 5-10 MINUTES WORSENED BY WALKING" in PMH.
- Write smoking for how long, ppd used to smoke, and for how long he hasn't been smoking.
- Last time he used cocaine. Is in DDx but not in SH.
- SX: active,with wife only.
- VS before GA
- HEENT; nose with/without nasal septum perforation (cocaine)
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  #57  
Old 06-09-2013
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Quote:
Originally Posted by Matchmegod View Post
here are my PN please help welcome.

46 YO M C/O CHEST PAIN * TODAY MORNING. HPI- SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY. NOTHING MAKES IT BETTER OR WORSE.A/W NAUSEA, SWEATING, PALPITATIONS, HEARTBURN. DENIES, DIZZINESS , LOC, RELATION TO BREATHING, SOB AND COUGH.
ROS- NONE EXCEPT ABOVE
PMH- HTN( 5 YEARS), SAME EPISODES BEFORE LASTING 5-10 MINUTES WORSENED BY WALKING.
PSH- NONE
MEDS-MALOX, ANTACIDS, DIURETIC ALLS- NKA, NKDA
FH- DAD (LUNG CANCER), MOTHER(PUD)
SH- STOPPED SMOKING, ETOH OCCASIONALLY, COCAIN SMOKING OCCASIONALLY, SEXUALLY ACTIVE WITH WIFE( BUT HAVE NOT BEEN ABLE TO HAVE SEX DUE TO CHEST PAIN.



GA- NAD. AAO *3
VS-WNL
CVS-RRR, NO M/G/R, S1/S2 AND PMI- NL. PULSES + 2 BL
LUNGS-CTABL.
NECK- NO BRUIT.
EXT- NO CYANOSIS, CLUBBING , EDEMA ON HANDS AND FEET.

COCAIN INDUCED MI
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
COCAIN USE LAST NIGHT

UNSTABLE UNGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HTN

STABLE ANGINA
CHEST PAIN
SUDDEN ONSET, CONSTANT, NON PROGRESSING, 7/10 INTENSITY,SUBSTERNAL LOCATION ,PRESSURE LIKE QUALITY.
HAD SUCH EPISODES IN THE PAST

Workup
CBC WITH DIFF, ELECTROLYTES, ESR,CK-MB, TROPONINS I AND T , ECG, ECHOCARDIOGRAPHY
ANGIOGRAPHY, STRESS TEST, DOPPLER CORONARY USG
DOBUTAMINE AND THALLIUM ECHO, UA, URINE TOXICOLOGY

stress test contraindication in current chest pain. may be fatal.
it's just order in patient with hx of chest pain on exertion and patient not on pain before the test.
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  #58  
Old 06-09-2013
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what is a/w nausea (emesis)??
thanks you
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Quote:
Originally Posted by romeja View Post
what is a/w nausea (emesis)??
thanks you
Associate with nausea. Nausea = just nausea. Emesis would be vomit.
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  #60  
Old 06-09-2013
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thank you!!!
and yes nausea is nausea and emesis is vomited
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Default My patient notes............hit the submit button at 10 min.

70 yo M with c/ o confusion and weakness in body started 1 hour ago,palpitations and sweating +,feeling dizziness,blurred vission since 1 hour.Appetite decreased for 3 days, fullnes after few bites,eats mixed diet.ROS: negative except above. PMH: DM 20 years using glucophage amd getril, last BSL was 1 week ago, fasting reading 110- 120, postprandial : 140- 150. PSH: none ALLERGIES:none MEDICATIONS: Described above FH:Mother and father diabetic SH:nonalcoholic,non smoker,no illicit drug, active with wife
PHYSICAL EXAMINATION:
Patient has confusion and weakness of body, BP : 120/80, P : 80 /min, T : 98F , R : 14 /min HEENT: NC/ AT, no carotid bruit CHEST: BS normal HEART:RRR, S1 + 0 + S2 NEURO: MMS exam : A & O times 3,intact sensations, DTR 2 + in L limbs
DATA INTERPRETATION:
Diagnosis #1
Hypoglycemia
History Finding(s) Physical Exam Finding(s)
Sweating HR : 80/min
Racing of heart
H/O DM 20 years
Confusion
Diagnosis #2
Stroke
History Finding(s) Physical Exam Finding(s)
weakness in body
DM 20 years
Confusion
Diagnosis #3
TIA
History Finding(s) Physical Exam Finding(s)
weakness in body
Confusion
Diagnostic Study/Studies
BSL
CBC
HBA 1 c
Ct scan brain
serum electrolytes
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  #62  
Old 06-09-2013
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Quote:
Originally Posted by aknz View Post
70 yo M with c/ o confusion and weakness in body started 1 hour ago,palpitations and sweating +,feeling dizziness,blurred vission since 1 hour.Appetite decreased for 3 days, fullnes after few bites,eats mixed diet.ROS: negative except above. PMH: DM 20 years using glucophage amd getril, last BSL was 1 week ago, fasting reading 110- 120, postprandial : 140- 150. PSH: none ALLERGIES:none MEDICATIONS: Described above FH:Mother and father diabetic SH:nonalcoholic,non smoker,no illicit drug, active with wife
PHYSICAL EXAMINATION:
Patient has confusion and weakness of body, BP : 120/80, P : 80 /min, T : 98F , R : 14 /min HEENT: NC/ AT, no carotid bruit CHEST: BS normal HEART:RRR, S1 + 0 + S2 NEURO: MMS exam : A & O times 3,intact sensations, DTR 2 + in L limbs
DATA INTERPRETATION:
Diagnosis #1
Hypoglycemia
History Finding(s) Physical Exam Finding(s)
Sweating HR : 80/min
Racing of heart
H/O DM 20 years
Confusion
Diagnosis #2
Stroke
History Finding(s) Physical Exam Finding(s)
weakness in body
DM 20 years
Confusion
Diagnosis #3
TIA
History Finding(s) Physical Exam Finding(s)
weakness in body
Confusion
Diagnostic Study/Studies
BSL
CBC
HBA 1 c
Ct scan brain
serum electrolytes

looks good especially the ddx and follow up but there are few points :-

forget fundoscopy exam, also respiratory and abdomen exam. DTRs, and Bubinski.
in hx feel fullness right after meal better than after few bites.
also should mention some important -ve symptoms like any resp. infection, urinary symptoms, wt. changes to figure out why he refuse eating.
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Old 06-16-2013
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Default plz give me a pass or fail

Quote:
Originally Posted by XpaezX View Post
Is more than enough, just be careful with the orthography.

Check you PM I will send you an example of the ones I used


red flags i missed,in history so put them in red in pt note,also spell mistakes in red

28 YO F C/O PAIN DURING SEX FOR 3 MO.BOTH SUPERFICIAL AND DEEP PAIN AGGRAVATED BY SEX,ALSO HAS SCANT VEGINAL DISCHARGE,WHITISH W/ FISHY ODOR AND PRURITUS,DENIES POSTCOITAL AND INTERMENSTRUAL BLEEBING,SEXUALLY ACTIVE W/ BOYFRIEND W/ GOOD DESIRE,USES PATCH FOR CONTRACEPTION,HAD STD IN COLLEGE 10 YRS AGO ,ALSO C/O OLIGO AND HYPOMENORRHEA FOR PAST 1 YR,BEFORE THAT PERIODS WERE 30/4 WITH GOOD FLOW,NEVER BEEN PREGNENT,LAST PAP WAS 10 MO. AGO NORMAL.NO ABNORMAL PAP SMEARS BEFORE.NO C/O FEVER,VEGINAL DRY NESS OR MOOD CAHNGESDENIES ANY CONFLICT W/ BOY FRUEND AND FEELS SAFE AT HOME
PMH;AS PER HPI
NKDA
NO MEDS OR HOSPITALIZATIONS
FH;PARENTS ALIVE AND WELL
WORKS AS A NURSE
SH;DENIES SMOKING,DRINKS 2 -3 BEAR / WK CAGE NO TO ALL,MERIJUAN IN COLLAGE
SXHX;AS PER HPI

PHYSICAL EXAM;
PT IS IN NO ACUTE DISTRESS
VS;WNL
HEENT;,WNL.NO LAP,THYROID NORMAL
CHEST;CLEAR BREATH SOUNDS BILATERLLY
HEART;RRR.S1 S2 NORMAL.NO ADDED SOUNDS
NO SKIN RASHES ON EXTREMITIES

DD; HISTORY PHYSICAL
VULVOVEGINITIS
PAIN DURING SEX PELVIC EXAM
HISTORY OF STD
DYSMENORRHEA

ENDOMETRIOSIS
DEEP PAIN DURING SEX. PELVIC EXAM
DYSMENORRHEA
IRRUGULAR PERIODS FOR 1 YR

CERVICITIS
DEEP PAIN DURING SEX


LABS
PAELVIC EXAM
WET MOUNT,KOH PREP
CBC,CERVICAL CULTURES
VEGINAL SWAB AND CULTURES
PELVIS U/S

THER ARE LOTS OF SPELL MISTAKES IF YOU CAN GIVE A LOOK TO THEM THEN GIVE ME A YOUR EXPERT OPENION
THANKS A LOT
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Old 06-16-2013
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Looks good enough to pass but look at this thread for some improvements, especially using abbreviations to save time (and using that time to check/correct mistakes)
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