is this short style of patient note is acceptable - sarwatny03

[ArchivalUser]

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.

[ArchivalUser]

It is good for coming CS exam . They recommend above style HPI PE

[ArchivalUser]

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.......