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+--- Thread: is this short style of patient note is acceptable - sarwatny03 (/showthread.php?tid=668557)
is this short style of patient note is acceptable - sarwatny03 - ArchivalUser - 04-01-2012
THIS IS USMLE.OR RELEASE
HPI:
48yo female - Chest pain x 90 mins
HPI- Burning
No radiation
Slight burning
Slight nausea & diaphoresis
Resolved spontaneously
Similar episodes 2-3 mos, after heavy meal or exertion
Some relief with antacids
PMH- Increased cholesterol, no follow-up or treatment
Tennis weekly
Smoked 30 pk yrs, stopped 3 yrs ago
No unusual stress
Mother w/ NIDDM, brother with unknown heart
No hx of HTN, has not seen MD x 2 yrs.
PHYSICAL EXAME:
BP 160/80 No obvious distress, anxious to leave.
Chest- non tender, clear BS bilat, no wheezes, crackles or rales
Heart- PMI not displaced, reg rhythm, no murmur or rubs
Abdomen- +BS, non-distended, no masses or organomegaly, tenderness in epigastrum w/o rebound
1. Esophageal reflux disease
2. Peptic ulcer
3. Coronary artery disease
4. Cholecystitis
5. Musculoskeletal chest pain
1. Stool for OB
2. EKG
3. CXR
4. Upper GI endoscopy
5.
0 - ArchivalUser - 04-01-2012
It is good for coming CS exam . They recommend above style HPI PE
0 - ArchivalUser - 04-01-2012
Hei....there is a space and word limitation. I faced this problem in real exam. I would suggest you to write like this ......
.
CC: Chest pain x 90 mins
HPI: 48yo female c/o chest pain X90 min- - Burning /No radiation/Slight burning/ Resolved spontaneously. Similar episodes 2-3 mos, after heavy meal or exertion which was relieved with antacids. (+) nausea & diaphoresis. Denies/No h/o...write down some inp negatives.
PMH/PSH: Increased cholesterol, no follow-up or treatment.No H/O HTN, has not seen MD x 2 yrs.
NKA
F/H: Mother w/ NIDDM, brother with unknown heart dis
S/H: occupation...Tennis weekly . Smoked 30 pk yrs, stopped 3 yrs ago. No unusual stress
Sex H: if any.......