pt note - kumarameet33

[ArchivalUser]

17 YO M C/O SOB X 2 DAYS THAT STARTED GRADUALLY INTERMITTENT OCCURS 8-10 DAYS AND EXACERBATED BY WALKING , EXERCISE AND RELIEVED BY SITTING AND SLEEP. HE HAS FEVER X 10 INTERMITTENT 100 F OCCURS 2 A DAY , NO CHILLS,ALSO C/O COUGH X 10 , THAT IS DRY , ONCE DAY. DENIES ANY CHEST PAIN , WEIGHT CHANGES, PALPITATIONS, TRAVEL,SLEEP PROBLEMS, VOMITING, HEART PROBLEMS, ITCHING , COLD INTOLERANCE ,RASH,RUNNY NOSE.
ROS: NEGATIVE EXCEPT AS ABOVE
ALLERGIES: POLLEN.
MEDICATION: TYLENOL.
PMH: NO SUCH SYMPTOMS BEFORE, NDM, HTN
PSH: NONE
FH: PARENTS ALIVE HEALTHY , NO DISEASE IN FAMILY
SH: DENIES TOBACOO, TOH, ILLCIT DRUS, SEXUALLY ACTIVE WITH two partners , NO STD, NOT TESTED FOR HIV, NO CONDOMS
, NO CONDOM , USE ,
PATIENT IS NOT IN ACUTE DISTRESS
VS: WNL
HEENT: NC/AT, NO PALLOR,NO ANEMIA
CHEST: NO TENDERNESS , CLEAR BREATH SOUNDS, NOR MAL PERCUSSION NOTE, NOT WHEEZES , NORMAL VOCAL FREMITUS
HEART: RRR,NORMAL S1/S2 NO MURMERS, GALLOPS

[ArchivalUser]

compare ur note here to the one in FA....

there are some mistakes .. clear breath sounds has to be followed by 'bilaterally equal' for eg..
whats TOH.. thats not a known abbreviation.. use the Abb shown on the last page of FA..
fever not 2 a day... twice a day or simply say 2/day..

also, other things with ur data gathering.... in pt with SOB and dry cough always check and ask for pedal edema..

so overall uv got the correct idea.... so its good.. but some critical things u can still work on... which u can easily improve so no worries!

GL!!