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| * Re:wonderful SAMPLE PN |
| #1848197 |
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btw, i have vista and used the picture n fax viewer... ppl had a problem seeing the pic earlier on..you'll have to figure that one out.. |
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| * Re:wonderful SAMPLE PN |
| #1849182 |
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thanx samomcos.
i tried to download it but the first one has 1/4 of the page....
and second one had already reached its limit....
plz....can you upload it again
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| * Re:wonderful SAMPLE PN |
| #1849455 |
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I think this is the PN you're talking about. I wrote it down and I added some of my own notes, just so I know how to describe ophtalmo exam, etc. You don't have to put all this in your PN, just things you did for the PE, but there are more details in case you need to know how to describe findings. Paranthesis are for your own clarification.
I'm not saying this is perfect, but it's a place to start and make your own the way you like it.
HPI (history of present illness): 30 yo M c/o chest pain x 9 hours
write this at the end; write all you remember from history; leave 4 lines for this
ROS (review of systems) Negative except as above
PMH (past medical history) non-contributory/ or h/o DM since 13 yo
Occupation: bartender (write here if no space)
PSH (past surgical history): h/o Apendectomy 3 yrs back
Meds: Insulin, …
ALL: NKDA, NKA (try and use short forms)
FH (family history): Non contributory / Father diabetes mellitus, Mother heart disease
SxH (sexual history): sexually active with single partner. No H/O multiple sexual partners; uses condoms inconsistently. No H/O of STD. LMP 3 weeks ago.
SH: Non smoker, 2-3 drinks on weekend. CAGE 0/4 (don’t ask in minor cases; just write) No H/O IVDA. Sleep normal. Appetite normal
PE
GA (general appearance): NAD (no acute distress)/pacing around the room/quiet
VS: Always write the 4 vital signs given. If no time: WNL (within normal limits).
HEENT (head, eyes, ears, nose, throat): Atraumatic, normocephalic, EOMI, PERRLA, Fundi: red reflex intact. TM (tympanic membrane) WNL B/L
Neck: supple, no bruit, ∅ lymphadenopaty, thyroid normal
Lungs: CTA & P B/L. (Clear to auscultation and percussion; that’s all they write in PN) Palpation and percution WNL
Heart: S1S2 +, RRR, no murmur (that’s all) or rubs (RMG = rubs, murmur, gallop). PMI not displaced. No JVD. Carotid, radial, DP, PT pulse WNL & equal B/L
ABD: NT ND BS + all 4Q . Neg Rovsig’s, psoas, obturator, Murphy’s, CVA
Extremities: ∅ edema, ∅ lymphadenopaty, pulses + B/L;
Musculoskeletal: ROM normal in shoulders B/L and neck. No tenderness, redness, swelling or effusions noted. No muscle atrophy.
CNS: Grossly normal (if non-CNS case)
(if CNS case)
A & O x3 (or to person only,..etc). CN 2-12 (or 2-7, 9-12 if didn’t do 8) WNL.
Strength 5/5 DTR +2 B/L, sensations intact B/L all 4 ext., Babinski –
Gait normal. No Kernig or Brudzinski. Romberg -. Straignt leg raise -
Skin: non contributory
Note: do not use Negative or Normal (use Non-contributory) |
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