what to write in PN ? - jsr20

[ArchivalUser]

in case of DM and HTN follow up what do we need to write in patient note if everything is normal.,do we need to mention screenig procedure

[ArchivalUser]

a 50 yo m with c/o drug refill for DM2,diagnosed 20yrs back,taking glyburide 5mg od ,compliant with medication,regular blood sugar monitoring which ranges between 120-150mg/dl,denies any side effect,denies any SOB,chest pain,blurry vision,numbness in limbs,edema,abd pain,urinary difficulties.
ros-negative except above
medication-glyburide,lisinopril
allergy-none
pmh-htnX5 yrs ,on lisinopril
fh-nonsignificant
sh-drink 2-3 beer/week,non smoker,no illicit drug use,sexually active with wife,uses condoms intermittently,no stress at home,no change in diet,moderate exercise.

vs-b.p135/95 rest wnl
HEENT-WNL
Chest-clear BS,B/L
heart-rrr,s1/s2 n,no murmur,gallop
abdoment-soft,non distended,nt,no organomegaly,bs+
ext-no edema,pulse good and symmetric,muscle strength good,dtr2+,senstaion intact to soft and crude touch.


DD-1.DM2
2.HTN

W/U-CBC WITH DIFFERENTIAL
BUN/CR
BLOOD GLUCOSE, HBA1C
AST/ALT/BILIRUBIN


THIS IS WHAT i could write in 9 min ,though PE is not prefect but do you really have that much time to write just like FA ,i dont think so .so write which is pertinent to case(many will say why no mention of fundoscopy -WNL of heent will cover that specially when you are running outa time).
any input appreciated

[ArchivalUser]

and one point i missed copying here was ---Pt is not in acute distress

[ArchivalUser]

thank you.

[ArchivalUser]

You are writing in lower case, is this acceptable.?

[ArchivalUser]

anything either lower or upper case is acceptable,sentences has tomake sense thats itand btw if you see the sample note on USMLE.ORG,thats in lower case .so nothing to be bother and another thing is Noone can write lengthy and artistic PN as given in FA during those anxious 10 min,so have to be realistic,just imp pertinent positive and some negative finding has to be mentioned.Those so called professional tutors (rippers) are creating a havoc for a perfect PN,dude PN is just a part of grading not everything,a less than perfect PN still acceptable as you see on USMLE.ORG ,that PN nowhere close to FA but thats what USMLE wants from us