USMLE Forum Archives - USMLE Step 2 CS - About Patient Notes
About Patient Notes
ask_question - 06-25-10 04:01
my patients notes were really bad i had few spelling mistakes and history was not in proper sequence.is it going to affect it badly?
ask_question - 06-25-10 04:01
my patients notes were really bad i had few spelling mistakes and history was not in proper sequence.is it going to affect it badly?
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#1
Re: About Patient Notes adonis123 - 06-25-10 09:03 
posted by ask_question on 06-25-10 04:01
my patients notes were really bad i had few spelling mistakes and history was not in proper sequence.is it going to affect it badly?
my patients notes were really bad i had few spelling mistakes and history was not in proper sequence.is it going to affect it badly?
It is not going to afftect u badly as long as u touched all the main headings in patient notes and mentioned the correct relevant information.
Good Luck!
#2
Re: About Patient Notes bingousmle - 07-11-10 03:01 heres a sample PN note for all other future examinees which can be used as a template for most of the cases
HISTORY: Include significant positives and negatives from history of present illness, past medical history, review of system (s), social history and family history.
HPI:
LIQOR
ROS: negative except as above (U-G-S)
PMH: PAM HUGS FOSS
Previous similar problems; other conditions.
Allergies: NKA
Med: Rx and non Rx
Hospitalizations, surgeries, injuries, trauma
FamHx: same/similar complaint, related illnesses/conditions,
other serious illnesses/conditions
Ob/Gyn: LMP, regular, duration, gravis, para, abortion/miscarriage, surgery.
SexH: Active, number of partners, M/F/B, condoms, STDs
SocH: Habits (tobacco, alcohol, recreational drugs), work situation, home life
PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to patient's chief complaint.
Indicate only pertinent positive and negative findings related to CC
VS: WNL, except .
General appearance: Pt supine in apparent non distress
HEENT: Normocephalic, atraumatic, PERRLA, no funduscopic abnormalities
Neck: supple, no carotid bruits, 2+ carotid pulses with good upstroke bilaterally, thyroid normal.
Chest: Clear breath sounds bilaterally.
Heart: RRR, normal S1/S2; no murmurs, rubs or gallops.
Extremities: Symmetric 2+ brachial, radial, and dorsalis pedis pulses bilaterally. (Erythema, tenderness, pain and restricted range of motion on flexion and extension of (limb) compared to (R/L limb). Other joints WNL bilaterally.
Abdomen: Scars? + BS, Soft, nontender, no hepatosplenomegaly, nondistended to palpation, no palpable masses.
Neuro: Mental Status: Alert and oriented x 3 (person, place and time), spells backward, can recall 3 objects.
Cranial nerves: 2-12 grossly intact. Motor: Strength 5/5 throughout. Sensation: Intact to pinprick and soft touch bilaterally, (sharp/dull) DTRs: Symmetric 2+ in upper and lower extremities, Babinski bilaterally. Cerebellar Romberg, finger to nose normal. Gait: normal.
Back: No obvious deformities or signs of trauma. No spinous process or paraspinous tenderness. Range of motion normal anteriorly. Normal gait. Reflexes 2+ patellar, Achilles.
DIFFERENTIAL DIAGNOSES: DIAGNOSTIC WORKUP
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