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patient note of domestic violence - steptwocsusmle - Printable Version

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patient note of domestic violence - steptwocsusmle - ArchivalUser - 01-27-2014

HI FRIENDS , ANY CORRECTION OR SUGGESTION WILL BE HIGHLY APPRECIATED ON MY PATIENT NOTE.

History
31 YO F MS JESSICA LEE C/O FATIGUE X 5 MONTHS PROGRESSIVE, MORE TOWORDS THE END OF THE DAY NOT SAFE AT HOME, LIVES WITH SPOUSE AND 2 KIDS. SPOUSE HURTS WHEN HE IS DRUNK. ALSO HURTS TO KIDS IN DRUNKEN CONDITION. NO EMERGENCY PLAN, NO WEAPON AT HOME. H/O FRACTUR OF LEFT ARM IN THE PAST. WHEN ASKED ABOUT SAFTY, LOOKS ANXIOUS. NO SLEEP PROBLEM, NO SNORING. NO TEMPERATURE INTOLERANCE. NO CHANGE IN APT AND WEIGHT AFFECTS HER DAILY ACTIVITY, FEELS SAD, DECREASE CONCENTRATION AND INTEREST.NO SUICIDAL IDEATION.FEELS GUILTY. INCREASE URINATION X1WK ROS NEG EXCEPT AS ABOVE PMH NONE SH FRACTURE ARM MED NONE ALL NKA SH NO SMOKING, DRINKING OR ILLICIT DRUG ABUSE OB GYN LMP X 2WKS, NL PAP SMEAR, REGULAR CYCLE FJ NON CONTRIBUTIRY

PhysicalExamination
PATIENT IS NOT IN ACUTE DISTRESS VIITALS WNL HEENT NO PALLOR, NO THYROPMEGALY CVS S1S2 NL, NO MR G RESPIRATORY B/L BS NL, NO ADDED SOUND FACE BRUISE +VE EXT DTR NL, NO DRY SKIN

Diagnosis #1
DOMESTIC VIOLENCE
History Finding(s) Physical Exam Finding(s)
H/O ABUSE BY THE SPOUSE
H/O FRACTURE ARM IN THE PAST
H/O CHILDREN ABUSE BRUISE ON THE FACE AND NECK

Diagnosis #2
DIABETES MELITUS
History Finding(s) Physical Exam Finding(s)
H/O POLY UREA, POLYDIPSIA

Diagnosis #3
DIABETES INSIPADUS
History Finding(s) Physical Exam Finding(s)
H/O POLY UREA, POLYDIPSIA
RECENT ONSET
H/O TRAUMA IN THE PAST

Diagnostic Study/Studies
CBC, TSH, FBS, HBA1C ,
CT SCAN HEAD, MRI BRAIN
1/27/2014 4:01:32 PM



0 - ArchivalUser - 01-28-2014

hey,I think we shouldn't mention the patient name.In general appearance we can mention pt is in no acute distress but looks anxious.In ROS :you can write those negative hx like no sleep problem/ snoring/hard time adjusting temperature instead of negative except as above ...coz i think that will save some time..Its just a suggestion...correct me if I am wrong


0 - ArchivalUser - 01-28-2014

hi..i think u r right...that ll save our time....thanks for your reply.


0 - ArchivalUser - 01-28-2014

if the patient is complaining of polyuria/polydipsia check her abdomen as well...and its better to check the muscle strength.If time permits we can do lung and heart examination..but if we have limited time then don't forget to do abdominal examination instead of lung/cvs (if she doesn't have fever/chest pain/racing of heart). In extremities you can check for edema as well...ext:bruises/erythem/edema, dtrs


0 - ArchivalUser - 01-29-2014

yah.. i agree. i could not finish the pn in time. so left abdominal examination. once again thanks.



0 - ArchivalUser - 01-30-2014

you have to also cover the SAFEGARD code for domestic abuse, if it is rape you want to refer to it as sexual assault in the ddx, also the entire case is counseling and ruling out pregnancy and HIV etc


0 - ArchivalUser - 01-31-2014

The note has to also focus on the site of damage


0 - ArchivalUser - 01-17-2021

This is a popular topic in the States. It seems to me that schoolchildren and students should discuss this topic in the classroom. Domestic Violence is the AIDS of our time.


0 - ArchivalUser - 01-20-2021

Domestic violence is a consequence of education and information aggression. I recommend studying psychology in schools and universities in order to resist physical and mental abuse. I recently read a cool educational example about violence and its consequences. We pass on our negative emotions to other people