03-16-2012, 07:04 PM
i am writing cs next month, practising pn notes. here i have written a pn for a case of heavy periods as an example. can any kind souls grade this pn on a scale of 1 to 10 and make comments , so that i can improve. thanks.
46 Y0 F, MRS SMITH, TEACHER, C/O HEAVY PERIODS SINCE 2 YEARS, PROGRESSIVELY IN CREASED FOR THE LAST 6 MONTHS, NO VAGINAL DISCHARGE/DRYNESS, HAD HOT FLUSHHES, INITIALLY PERIODS WERE 45 DAYS/6 WEEKS, REST NORMAL, NO PAIN ABDOMEN, NO SYMPTOMS SUGESTIVE OF THYROID DYSFUNCTION, NO GU/GI SYMPTOMS, WEIGHT NORMAL.
NO MAJOR ILL NESS, HOSPITALIZED FOR CHILD BIRTH ONLY, TAKING MVI/IRON TABLETS, NO SURGERIES, NO ALLERGIES.
MOTHER HAD NIDDM & HTN ON RX.
NONSMOKER, NON ALCOHOLIC, NO ILLICIT DRUG USE.
MOOD IS NORMAL, NO STRESS AT WORK/HOME.
SEXUALLY ACTIVE WITH HUSBAND ONLY, NO PROTECTION, HUSBAND HAD VASECTOMY, NO STDS.
NOT IN DISTRESS, VITAL SIGNS:WNL, NO PALLOR/JAUNDICE/PEDAL EDMA, NO PALPABLE NECK NODE/THYROID. NO HAND TREMORS.
CHEST: B/L CLEAR BREATH SOUNDS, NOI ADDED SOUNDS.
HEART: REGULAR RHYTHUM, NORMAL S1 &S2, NO MURMUR
ABDOMEN: NO DISTENSION, BS+, NO TENDERNESS, NO PALPABLE LIVER/SPLEEN/OTHER MASSES.
DTR +2 IN B/L UPPER LIMBS.
1. DYSFUNCTIONAL UTERINE BLEEDING
2. PERI MENOPAUSAL
3. ENDOMETRICAL CANCER
4. ENDOMETRIAL HYPERPLASIA
5. THYROID DYSFUNCTION
PELVIC @ GENITAL EXAMINATION
URINE BETA HCG
CBC, BLOOD SUGAR, SERUM TSH,T3,T4
USG ABDOMEN & PELVIS
ENDOMETRIAL BIOPSY
46 Y0 F, MRS SMITH, TEACHER, C/O HEAVY PERIODS SINCE 2 YEARS, PROGRESSIVELY IN CREASED FOR THE LAST 6 MONTHS, NO VAGINAL DISCHARGE/DRYNESS, HAD HOT FLUSHHES, INITIALLY PERIODS WERE 45 DAYS/6 WEEKS, REST NORMAL, NO PAIN ABDOMEN, NO SYMPTOMS SUGESTIVE OF THYROID DYSFUNCTION, NO GU/GI SYMPTOMS, WEIGHT NORMAL.
NO MAJOR ILL NESS, HOSPITALIZED FOR CHILD BIRTH ONLY, TAKING MVI/IRON TABLETS, NO SURGERIES, NO ALLERGIES.
MOTHER HAD NIDDM & HTN ON RX.
NONSMOKER, NON ALCOHOLIC, NO ILLICIT DRUG USE.
MOOD IS NORMAL, NO STRESS AT WORK/HOME.
SEXUALLY ACTIVE WITH HUSBAND ONLY, NO PROTECTION, HUSBAND HAD VASECTOMY, NO STDS.
NOT IN DISTRESS, VITAL SIGNS:WNL, NO PALLOR/JAUNDICE/PEDAL EDMA, NO PALPABLE NECK NODE/THYROID. NO HAND TREMORS.
CHEST: B/L CLEAR BREATH SOUNDS, NOI ADDED SOUNDS.
HEART: REGULAR RHYTHUM, NORMAL S1 &S2, NO MURMUR
ABDOMEN: NO DISTENSION, BS+, NO TENDERNESS, NO PALPABLE LIVER/SPLEEN/OTHER MASSES.
DTR +2 IN B/L UPPER LIMBS.
1. DYSFUNCTIONAL UTERINE BLEEDING
2. PERI MENOPAUSAL
3. ENDOMETRICAL CANCER
4. ENDOMETRIAL HYPERPLASIA
5. THYROID DYSFUNCTION
PELVIC @ GENITAL EXAMINATION
URINE BETA HCG
CBC, BLOOD SUGAR, SERUM TSH,T3,T4
USG ABDOMEN & PELVIS
ENDOMETRIAL BIOPSY