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  #1  
Old 12-17-2013
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Listening Please Evaluate my Patient Note

any suggestion to make this pt note BETTER will be highly appreciated ,i wrote this in 9 min

48 YO F, C/O BURNING EPIGASTRIC PAIN -2 WKS,GETTING WORSE,NON RADIATING ,INTERMITTANT,VARY BETWEEN 7/10-0/10,RELIEVED BY ANT ACID,MILK ,FOOD,AGGREVATED BY HEAVY FATTY MEALS,NEVER HAD THIS PAIN BEFORE,WITH NAUSEA,VOMITED YESTERDAY,YELLOW,SOUR,NO BLOOD ,NO CHANGE IN APPETITE,DIAHEA,CONSTIPATION,OR COLOR OF STOOL
ROS-NEGATIVE EXCEPT AS ABOVE
PMH-ARTHRITIS BOTH KNEES-TAKING IBUPROFEN,UTI-TREATED WITH AMOXICILLIN
MEDS-IBUPROFEN,MAALOX
PSH-2 C.SECTIONS
NKDA
FH-FATHER DIED OF PANCEATIC CA AT 55 YR
SH-SEXUALLY ACTIVE WITH HUSBAND ONLY
SH-NON SMOKER,NO ETOH,OR ILLICIT DRUG USE,HOUSE WIFE

PT IS IN NAD
VS-WNL
HEENT-NCAT,PERRLA,MOIST MM,NO LAD
CHEST-CTA B/L
HEART- S1,S2-NORMAL,RRR,NO M,R,G
ABD-SOFT,ND,NO HSM,TENDERNESS IN EPIGASTRIUM,MURPHYS +,BS 4+


PUD
EPIGASTRIC PAIN -2 WKS
NON RADIATING ,INTERMITTANT
RELIEVED BY ANT ACID,MILK ,FOOD

P/E
TENDERNESS IN EPIGASTRIUM


ACUTE CHOLYCYSTITIS

EPIGASTRIC PAIN -2 WKS
,INTERMITTANT
NAUSEA,AGGREVATED BY HEAVY FATTY MEALS

P/E
TENDERNESS IN EPIGASTRIUM,MURPHYS +

GASTRITIS
EPIGASTRIC PAIN -2 WKS
NON RADIATING ,INTERMITTANT
H/O INTAKE OF IBUPROFEN

P/E
TENDERNESS IN EPIGASTRIUM

DIAGNOSTIC WORKUP

RECTAL EXAM
FOBT
ALT/AST/BILIRUBIN/ALK.PHOSPHATASE
UPPER ENDOSCOPY
U/S ABD
H.PYLORI AB TESTING
HIDA SCAN
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  #2  
Old 12-17-2013
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anyone????
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  #3  
Old 12-22-2013
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Well, I think that overall it is a good patient note. Honestly I think that it includes almonst anything and that should be more than enough to get a pass in ICE. But it is my opinion only... I would have included something like "neg skin color changes, chest pain, dyspnea or urine color changes" to rule out jaundice and referred pain from the heart. Also in the PE I would have written a "skin" section. But overall, I think it should be more than enough to pass...
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  #4  
Old 12-22-2013
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Default

Looks adequate to me.
However, this is one out of 12. Did you perform well on the majority of patient encounters?
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