Once you complete any encounter, you’ll be given at least 10 mins to compose a PN.
I will start by saying for practice purposes try as much to be completing your PN in 8-9 mins( may be challenging initially but keep praticing).
You need to strategize how to flow, navigate and complete this task. After you exit the patient’s (SP’s) room, try to take a few seconds to review the information you gathered, prepare your mind.
Be confident that you can compose the best note; trust yourself (very important).
Decide on the PN style you will use: ‘’narrative ‘’or ‘’Bullet’’ style.
Chief complaint: CC, onset, freq, it’s progression, main presenting symptoms (a lot of mnemonics everywhere choose what works for you: ‘LIQORAAA’ for location, intensity, onset, radiation, aggravating factors, alleviating/relieving factors, associated symptoms).
Now that you’ve explored this case, then R/O differential diagnosis ( Neg. for : blah blah blah, or No: blah, blah , blah, or Denies blah, blah , blah)
Document other key points:
Previous episode, PMH/PSH, Allergy, Meds, Hospitalization, Urinary habits, GI habits, Sleep, FH, OBGYN, Sex, SOCIAL: Smoking, ETOH, Illicit drugs, occupation, diet , exercise, relationship status(married, single) , living condition etc..
PHYSICAL EXAM: key physical findings, includes pertinent positives and negatives
Pt. is in or no acute distress
HEENT: NC/AT, EOMI, PERRLA, no cyanosis, no icterus, no pallor
NECK: supple, Thyroid wnl, no LAD, no nuchal rigidity
MOUTH AND PHARYNX: clear, moist, no erythema, no exudates, no lesions
CHEST/RESP: CTAB, no rales, rhonchi, wheezing, or rubs, no tenderness on palpation
CVS: RRR, S1/S2 WNL, no murmurs, rubs, or gallops, no JVD , PMI not displaced
ABD: soft, NT, ND, BS+ in all 4Q, no HSM. Neg. for: rebound tenderness, psoas etc..
MSK: motor strength 5/5 in all 4 ext. full ROM at joints.., sensation intact to sharp and dull bilaterally, special tests..
Extremities: pulses(radial or Dorsalis pedis....) +2 b/l, no cyanosis, clubbing or edema .
NEURO: Mental status(Alert &Oriented x3...), CN’s , DTRs, special tests..
DIFFERENTAIL DIAGNOSIS DDX: closest possible 2 or 3 DDX with pertinent history or physical findings
WORK UP PLANS;
Physical exam for all Peds cases
Pelvic, genital exam for all OBGYN cases
Start with simple inexpensive, affordable tests first for all cases ( such as ultrasounds, CXR, TSH, electrolytes).
With iUSMLE Course, score high!
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