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  #1  
Old 07-11-2013
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Listening Assessment of Patient Note

hpi
21 y o g1p1 f c/o rlq pain since this morning. The pain is 7/10, sudden , crampy, getting worse, nonradiating, not related to food, excerbates w/ movements, assocaited w/ fever, nausea, vomiting, sour yeloowish fluid, and loose brown bowel habits since morning. Pt alos noticed some browinish vaginal.d/c since morning. No cough/chest pain/chills. Weghit/appetite/sleep nl. Urinary habits nl. Ros: Nl excet as abobe. Obs/gyn: Lmp 5 wks ago, periods regular occuring every4 wks lasting for 7 d. Menarche @ 13. Nsvd at full term 3 y ago. Pmh: 1 std 1 m ago rx w/ antibiotics. Psh: None. Nkda. Med: Ibuprofen for pain. Fh: None.sh: Smokes 1ppd, 2-3 beers on weekends, no illicit drug use. Unprotected sex w/ multiple partners, uses ocps.
p/e
pt is in pain.
Vs; wnl excepr temp 100f
abd: Soft,n/d,hypoactive bs, rlq direct and rebound tenderness, gaurding, +ve psaos sign, roving sign
dx 1
appendicitis
history findings and p/e
rlq pain
nausea vomiting
fever
fever
+ve psoas sign
rlq rebound tenderness
dx 2
pid
history findings and p/e
lower abd pain
fever
ho std
sex with multople partners
fever
-ve cevical d/c
dx 3
ruptured ovarian cyst
history findings and p/e
sudden lowr abd pain
nausae vomiting
fever
work up
rectal exam
pelvic exam
cbc
cervical cultures\
us abd/pelvis
ct abd/pelvis
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  #2  
Old 07-11-2013
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val7 please assess my pn and tell me my mistakes.
i typed it full 10 min. i have target of 8 min but i reach only p/e in 8 min. tips to improve please?
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  #3  
Old 07-11-2013
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I have not looked through it yet but just a few notes first:
why would you target 8 min? You will definitely have 9 full minutes.
I always tried it in 10 min, sometimes 9, and did not have a problem in the exam. The sense behind trying to do the patient encounter in less time is to have more time for the pn, but in my opinion there is no sense behind trying to do it in less than 9 or so.
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  #4  
Old 07-12-2013
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Quote:
Originally Posted by monvy View Post
hpi
21 y o g1p1 f c/o rlq pain since this morning. The pain is 7/10, sudden , crampy, getting worse, nonradiating, not related to food, excerbates w/ movements, assocaited w/ fever, nausea, vomiting, sour yeloowish fluid, and loose brown bowel habits since morning. Pt alos noticed some browinish vaginal.d/c since morning. No cough/chest pain/chills. Weghit/appetite/sleep nl. Urinary habits nl. Ros: Nl excet as abobe. Obs/gyn: Lmp 5 wks ago, periods regular occuring every4 wks lasting for 7 d. Menarche @ 13. Nsvd at full term 3 y ago. Pmh: 1 std 1 m ago rx w/ antibiotics. Psh: None. Nkda. Med: Ibuprofen for pain. Fh: None.sh: Smokes 1ppd, 2-3 beers on weekends, no illicit drug use. Unprotected sex w/ multiple partners, uses ocps.
p/e
pt is in pain.
Vs; wnl excepr temp 100f (I would say: "VS: F 100F, otherwise wnl"
abd: Soft,n/d (what is n/d?) ,hypoactive bs, rlq direct and rebound tenderness, gaurding, +ve psaos sign, rovsing sign
dx 1
appendicitis
history findings and p/e
rlq pain
nausea vomiting
fever (I would not put it twice, would just put it as a physical finding)
fever
+ve psoas sign
rlq rebound tenderness
dx 2
pid
history findings and p/e
lower abd pain
fever
ho std
sex with multople partners
fever
-ve cevical d/c (what do you mean by that?)
dx 3
ruptured ovarian cyst
history findings and p/e
sudden lowr abd pain
nausae vomiting
fever
work up
rectal exam
pelvic exam
cbc
cervical cultures\
us abd/pelvis
ct abd/pelvis

Ok, so first of all, you have a lot of spelling mistakes. Even though they don't hurt you much, it does not look nice. You misspelled a lot of words including medical tests (rovsing's sign, guarding, ...) , which could lead the person looking at your note to think you don't know the spelling of the test.
Also, you are using way too many abbreviations in my opinion! I hope someone else here will comment on that as well, maybe it is ok this way. I only used the ones on the list. I would, however, type the abbreviations in caps that are usually in caps (like LMP, PMH, PSH, ROS, NSVD, NKDA, SH, PPD, OCPs, abdominal quadrants). This just makes it easier to read the note. Others, like wnl, are usually not in caps.
I like that you are not typing all in caps. Makes it more professional.

Your PE:
this is definitely not enough. You should have done a quick HEENT exam, lung and heart auscultation, looked at the extremities, checked pulses.

Your DDx:
I don't agree with your differential but lets not talk about that for now.
I put my comments on the DDx section

Workup:
not sure about ordering a CT. This might be a pregnancy/abortion/ectopic pregnancy.
Since she has a fever, I would also order CRP but I know they don't do that much in the US.
I would definitely order beta HCG.

Please read through all this and then get back to us here so we can discuss it further if you like.
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  #5  
Old 07-14-2013
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Quote:
Originally Posted by val7 View Post
Ok, so first of all, you have a lot of spelling mistakes. Even though they don't hurt you much, it does not look nice. You misspelled a lot of words including medical tests (rovsing's sign, guarding, ...) , which could lead the person looking at your note to think you don't know the spelling of the test.
Also, you are using way too many abbreviations in my opinion! I hope someone else here will comment on that as well, maybe it is ok this way. I only used the ones on the list. I would, however, type the abbreviations in caps that are usually in caps (like LMP, PMH, PSH, ROS, NSVD, NKDA, SH, PPD, OCPs, abdominal quadrants). This just makes it easier to read the note. Others, like wnl, are usually not in caps.
I like that you are not typing all in caps. Makes it more professional.

Your PE:
this is definitely not enough. You should have done a quick HEENT exam, lung and heart auscultation, looked at the extremities, checked pulses.

Your DDx:
I don't agree with your differential but lets not talk about that for now.
I put my comments on the DDx section

Workup:
not sure about ordering a CT. This might be a pregnancy/abortion/ectopic pregnancy.
Since she has a fever, I would also order CRP but I know they don't do that much in the US.
I would definitely order beta HCG.

Please read through all this and then get back to us here so we can discuss it further if you like.
well, thanx alot. as its my 1st pn so i ll try my best to improve at that level.
spell mistakes r due to rush as im slow typer.
i have seen some threads here in this forum 4 pn, they r saying the same abbr as i have used. if too much abbr affect my result then i wont use them except ecfmg known abbr.
n/d is nondistended.
d/c is discharge.
thanx alot and please help me to improve as im preparing alone no one to assess.plz plz...
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  #6  
Old 07-14-2013
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Quote:
Originally Posted by monvy View Post
well, thanx alot. as its my 1st pn so i ll try my best to improve at that level.
spell mistakes r due to rush as im slow typer.
i have seen some threads here in this forum 4 pn, they r saying the same abbr as i have used. if too much abbr affect my result then i wont use them except ecfmg known abbr.
n/d is nondistended.
d/c is discharge.
thanx alot and please help me to improve as im preparing alone no one to assess.plz plz...
It is up to you which abbreviations you use. I am just saying, we don't know if they are accepted, so everyone has to decide for him-/herself if he/she wants to take the risk.
Especially if you are a slow type I would not try to do the PN in less than 9 minutes. Give yourself 9.5 minutes or something like that. In my practice I usually gave myself 10, sometimes 9, because I don't see the point of trying to do it faster than that.


Quote:
Originally Posted by monvy View Post
-ve cevical d/c
Assuming you mean cervical discharge - how can you know what kind of discharge it is (e.g. from the cervix) if you don't do a pelvic exam? stick to vaginal discharge...
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