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  #1  
Old 06-27-2013
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Question Can someone assess my PN, please?

Hey everyone,

To forum masters, I promise this is the last thread I am posting for today

I would be really glad if someone can assess my PN and tell me if they are good enough. I used the 1st case of FA. This is directly copied from the note writing page, so all words/line limit are respected. I did some alteration to the case like including OBGYN history.

---------------------------------------------------------------
HPI: 48 Housewife c/o of abd pain that started 2 weeks ago. This is the first time for such a pain. Its intermittent,1x/day,getting worse,7/10,epigastrium,non-radiating,burning,alleviated by Food/anatacids/milk and exacerbated by heavy meals/hunger. Nauseated sometimes and vomited yesterday once - vomit was sour yellow w/o blood. No weight/diet/appetite changes. No fever/chills
ROS: Denies headache/vision problem/dysphagia/chest pain/dyspnea/cough/bowel changes/urination problems/numbness/weakness.
PMHx: URI Rx with Amox; Arthritis in both knees Rx with Ibuprofen
PSHx: 2 C-sections; Allergies/Recent Ill-contacts:None
MEDx: Mallox, Ibuprofen
FMHx: Father died of Pancreatic CA @ 55yr.
OBGYN: LMP 2 weeks ago, normal periods. Last pap yr ago-normal
SOCx: No EtOh/tobacco/illicit drugs. Sexually active with husband only. Denies recent travel. Non-stressful living conditions.


P/E: [I only wrote the negatives for the things that I did, e.g only auscultated CV/RESP]

GEN: Patient is not in acute distress
VS: WNT
ABD: ND/NT, soft, BS+/Tympanic in all 4 quads, no HSM, no peritoneaal signs, scar for C-Section, no /bruises/lesions, no CVA tenderness
CV: RRR, normal S1/S2 w/o gallops/murmurs/rubs
RESP: BS+ vesicular B/L w/o crackles/rhales/rubs
EXT: No clubbing/cyanosis/edema
HEENT: NCAT, Conjunctiva w/o pallor/erythema/icter


Diag 1: Peptic ulcer disease
Epigastric pain, non-radiating
Aggravated by heavy meals/hunger
Alleviated by Food/antacids/milk
P/E findings: None

Diag 2: Cholecystits
Epigastric pain
Aggravated by heavy meals
P/E findings: None

Diag 3: Functional dyspepsia/Nonulcer dyspepsia
Epigastric pain
P/E findings: None

Workup:
Rectal exam
Stool for occult blood
Upper Endoscopy
Abd U/S
AST/ALT/ALP/Direct & Indirect Bilirubin
HIDA Scan
H.Pylori testing (Urease breath test)
--------------------------------------------------------

Also, I had this doubt of using 3-4 information in one line, but I do this to save space. I hope its ok to write like these lines:
"PSHx/Medications/Allergies/Ill-contact: None"
or
"PSHx:2 C-Sect; MED:Ibuprofen; Allergies/Illcontacts:None"


Thanks everyone!
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  #2  
Old 06-27-2013
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This is the format with pertinent negatives in the DDX/P/E findings. Can someone also verify these? If my concept of -ve's is correct, then I will start using them in my PN.

Diag 1: Peptic ulcer disease
+Epigastric pain, non-radiating
+Aggravated by heavy meals/hunger
+Alleviated by Food/antacids/milk
+NSAIDs

P/E findings:
+Abd WNL

Diag 2: Cholecystits
+Epigastric pain
+Aggravated by heavy meals
-No pain radiation to shoulder region(Boas sign)
-Relieved by antacids

P/E findings:
-Absence of Murphy sign
-Abscence of Fever
+Abd WNL

Diag 3: Functional dyspepsia/Nonulcer dyspepsia
+Epigastric pain
+Nonradiating
+Intermittent

P/E findings:
+Abd WNL
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Old 06-28-2013
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Anyone? :sorry:
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Old 06-28-2013
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what can I say man? your PN looks pretty good! In fact the DD part its excellent. I also have the same doubt regarding putting more than one section in the same line, like PSH Meds and allergies, in order to save lines. Maybe you should try and practice a note with a harder case like the ones that come in the core cases by kaplan book. How many minutes did it take you to write this note?
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Old 06-28-2013
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Your PNs are more than enough to pass. In fact, you will pass with stars if you can replicate notes likes these in the real test.
However, if you want to improve them further then here, here and here are some suggestions.
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Old 06-29-2013
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Quote:
Originally Posted by bullonto View Post
what can I say man? your PN looks pretty good! In fact the DD part its excellent. I also have the same doubt regarding putting more than one section in the same line, like PSH Meds and allergies, in order to save lines. Maybe you should try and practice a note with a harder case like the ones that come in the core cases by kaplan book. How many minutes did it take you to write this note?
Hmm..About 9 minutes I think. My typing is quite fast, at least on the laptop. Thanks to the days of using DOS and C languages . Never knew when that skill will come in handy.
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