04-01-2012, 01:59 PM
IS THIS STYLE ACCEPTABLE FOR PATIENT NOTES
HISTORY: Include significant positives and negatives from history of present illness, past medical
history, review of system(s), social history and family history.
PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to
patient’s chief complaint.
DIFFERENTIAL DIAGNOSES: In order of likelihood (with
1 being the most likely), list up to 5 potential or
possible diagnoses for this patient’s presentation (in
many cases, fewer than 5 diagnoses are likely).
DIAGNOSTIC WORK UP: List immediate plans (up to 5)
for further diagnostic workup.
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.
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.
HISTORY: Include significant positives and negatives from history of present illness, past medical
history, review of system(s), social history and family history.
PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to
patient’s chief complaint.
DIFFERENTIAL DIAGNOSES: In order of likelihood (with
1 being the most likely), list up to 5 potential or
possible diagnoses for this patient’s presentation (in
many cases, fewer than 5 diagnoses are likely).
DIAGNOSTIC WORK UP: List immediate plans (up to 5)
for further diagnostic workup.
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.
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.