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patient note of domestic violence - steptwocsusmle
#1
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
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