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  #1  
Old 05-09-2014
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Default can you check my pn

hello , can you guys check my pn for any fatal mistakes?



A 32 YO F C/O FATIGUE FOR THE FIRST TIME THAT STARTED 5 MONTHS AGO.
-FATIGUE WORSE AT THE END OF THE DAY
-SHE IS BEING PHYSICALLY ABUSED ONCE BY HER HUSBAND
-SHE FEELS NOT SAFE AT HOME WHEN HER HUSBAND IS DRUNK
-HER YOUNGER SON HAS BEEN SLAPPED ONCE FOR BREAKING A GLASS
-POLYURIA ,POLYDIPSIA ,NOCTURIA
-HER FATHER HAD DM AND DIED OF MI
-HER MENSTRUAL PERIODS ARE REGULAR ,HEAVY AND LASTS FOR 7 DAYS
-THERE WAS NO COLD INTOLERANCE , NO LOSS OF WEIGHT/APPETITE .
- NO PMHX , NO MEDS AND SHE WORKS AS A NURSE AND DOESNT SMOKE OR DRINK ALCOHOL.




p/e


THE PATIENT WAS IN NO ACUTE DISTRESS AND HER VS WERE WNL.THERE WAS MUTPLE BRUISES ON HER ARMS AND HER FACE AND THERE WAS NO PALE CONHUCTIVAE , NO THYROMEGALY AND HER CHEST WAS CLEAR TO AUSCULTATE AND THERE WAS NL S1 AND S2.






DOMESTIC VIOLENCE
SHE IS BEING PHYSICALLY ABUSED ONCE BY HER HUSBAND
SHE FEELS NOT SAFE AT HOME WHEN HER HUSBAND IS DRUNK
HER YOUNGER SON HAS BEEN SLAPPED ONCE FOR BREAKING A GLASS
FATIGUE



DM
POLYURIA
POLYDIPSIA
NOCTURIA
HER FATHER HAD DM AND DIED OF MI
FATIGUE




MYASTHENIA GRAVIS
FATIGUE
FATIGUE WORSE AT THE END OF THE DAY






CBC
ACH ANTIBODIES
NECK CT SCAN
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  #2  
Old 05-09-2014
thind's Avatar
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Seems ok. But this is how i will write this.

32 YO F C/O (PROGRESSIVE?) FATIGUE X 5 MO, MORE IN THE EVENING. C/O PHYSICAL ABUSE BY ALCOHOLIC HUSBAND X (TIME PERIOD),NOT SAFE AT HOME, REPORTS ABUSE TO YOUNG SON AS WELL, (EMERGENCY PLAN?). C/O POLYURIA, POLYDIPSIA, NOCTURIA X (HOW LONG?).(MENSTURAL HISTORY - MORE DETAILS ABOUT NO. OF DAYS CYCLE LAST FOR, PAP SMEAR, PREG) DENIES COLD INTOLERANCE, WEIGHT AND APPETITE CHANGES. (PROB ASK ABOUT HOSPITALIZATIONS D/T TRAUMA).
ALLERGY - NKA
PMH - NONE
PSH - NONE
FH - FATHER WAS DIABETIC ,DIED OF MI.
SH - NURSE, SEXUALLY ACTIVE? (SEXUAL ABUSE), DENIES ETOH, SMOKING, ILLICIT DRUGS.



P/E
PT IN NO ACUTE DISTRESS.
VS WNL
GEN - NO PALLOR, CYANOSIS, PULSES 2+ B/L UL LL, BRUISES ON ARM AND FACE.
NECK - NO THYROMEGAALY
CVS - S1S2 +, RRR (REGULAR IN RHYTHM AND RATE), NO M/R/G.
CHEST - CTA B (CHEST CLEAR TO AUSCULTATION B/L ), NO R/R/W.
CNS - A&O X 3, CN 2 -12 GROSSLY INTACT, SENSATIONS INTACT TO SOFT AND SHARP TOUCH, DTR 2+ B/L UL LL, POWER 5+ ALL MUSCLE GRPS.


WORKUP

MENTAL STATUS EXAM
CBC, CHEM 7
GLU, HBA1C
UA
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  #3  
Old 05-09-2014
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thanks man ,,
i checked usmle.org and there is a bullet style PN and it seemed very concise
and easy


what do you think ??
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  #4  
Old 05-09-2014
thind's Avatar
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Yea either way is fine..but don't miss out imp information on pn . i do it this eat as less lines are used. ee have to complete on in 15 lines.
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  #5  
Old 05-09-2014
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Nice review Thind! Just adding minor things:
1. Dodo, do practice w usmle.org template. I like Thind's version. Concise. Try to make it as concise as you can. Maxing out the space will take your time to choose which to delete and rephrase.

2. Always r/o chronic inf, insomnia in fatigue. Just mention about fever, weight change, difficulties sleeping.

3. Thind, we should not write chem 7. Describe what you want exactly electrolyte, bun, cr, glucose. Eg: instead of LFT write AST/ALT, indrirect/direct/total bili, Alk phos, GGT. Otherwise your PN version is great.
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  #6  
Old 05-10-2014
thind's Avatar
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Hey Thanks even i was not sure about writing chem 7, i asked some ppl who already gave their CS and they have written it this way. But still i think i will write electrolytes.
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