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  #1  
Old 07-02-2013
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Help PN opinion

Guys... my exam is this next monday. Please... I'd like to know your opinion about my PN.

Thanks in advance
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"Disease is very old, and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible." JMC
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  #2  
Old 07-02-2013
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Cc: 52 yo f c/o yellow skin and eyes. Hpi: Jaundice started 3 wks ago. Pt has licht colored stool and dark urine. Ruq pain: 3/10, dull, intermittent, no radiation, non related to meals, better w/tylenol. +fatigue, anorexia, pruritus, pruritus, nausea, recent travel to mexico. H/o blood transfusion 20 yrs ago. No diarrhea, constipation, wt loss. Ros: None except above.
Allergies: To penicillin (rash).
Meds: Tylenol, synthroid.
Pmh: Hypothyroidism.
Psh: X2 c-section, tubal ligation.
Sh: No tobacco. Etoh: 1-2 glasses/day x 3o yrs. Cage 0/4. No recreational drugs.
Sx: Active w/husband only.
Fh: Father died of pancreatic cnacer at 55 yo.

---------------------------

vs: Wnl.
Ga: Nad.
Heent: Icteric sclera.
Chest: Ctap.
Cv: Rrr, nl s1/s2, no r/m/g.
Abd: Appear nl. Soft, nt, nd, c-section scar. Mild ruq tenderness, -murphy's sign, -blumberg sign. No guarding. +bs x4q. -hsm. No ascites.
Skin: Jaundice, exorations dut to scratching, no spider/telangiectasias/palmar erythema.
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"Disease is very old, and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible." JMC
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  #3  
Old 07-03-2013
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Any fever in hx? Change in mentation? And be careful of spelling - licht and double words - pruritus. Otherwise, it's good.

Quote:
Originally Posted by Dr. Mexito View Post
Cc: 52 yo f c/o yellow skin and eyes. Hpi: Jaundice started 3 wks ago. Pt has licht colored stool and dark urine. Ruq pain: 3/10, dull, intermittent, no radiation, non related to meals, better w/tylenol. +fatigue, anorexia, pruritus, pruritus, nausea, recent travel to mexico. H/o blood transfusion 20 yrs ago. No diarrhea, constipation, wt loss. Ros: None except above.
Allergies: To penicillin (rash).
Meds: Tylenol, synthroid.
Pmh: Hypothyroidism.
Psh: X2 c-section, tubal ligation.
Sh: No tobacco. Etoh: 1-2 glasses/day x 3o yrs. Cage 0/4. No recreational drugs.
Sx: Active w/husband only.
Fh: Father died of pancreatic cnacer at 55 yo.

---------------------------

vs: Wnl.
Ga: Nad.
Heent: Icteric sclera.
Chest: Ctap.
Cv: Rrr, nl s1/s2, no r/m/g.
Abd: Appear nl. Soft, nt, nd, c-section scar. Mild ruq tenderness, -murphy's sign, -blumberg sign. No guarding. +bs x4q. -hsm. No ascites.
Skin: Jaundice, exorations dut to scratching, no spider/telangiectasias/palmar erythema.
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Dr. Mexito (07-03-2013)



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