06-15-2010, 12:53 AM
CC=Abdomen painx 2 weeks,
HPI=48,yo,f,has upper mid-abdomen pain,getting worse,burning type,non radiating,relieved by milk+antacids,aggravated by-fatty ,heavy meals.Intensity=7/10,can go down to 0/10.Has nausea,vomited once yesterday-yellow,sour,non bloody.
ROS=[-]fever,headache,chest pains,irregular heartbeats,joint pains.Bladder/bowel=no problems
PMH=RA=on brufen,OTC multivitamins
PSH=2 c-sec
Alls=NKDA
FH=Father=pancreatic cance
SH=monogamous,married,[-]cig,ETOH,Recreational drugs
LMP=1 week ago,regular,30 day cycle
===========
PE=
VS=NL,not in acute distress
Gen=[-]paolor,icterus,clubbing,rash,palmer erythema,flapping tremor
Abdo=scaphoid,scar+,soft,BS+,No organomegaly/tenderness/rigidity,resonant=all quads
Chest=B/L clear
Heart=RRR,PMI=not displaced,[-]m/r/gallop
=================================
dd=
Gastritis
Peptic ulcer
cholecystitis
Functional dyspepsia
LAB
UGI endoscopy
barium meal
CBC,
Stool-OB
HIDA sca
CT abdomen
============
This is a real PN I typed When Preparing for CS.SO I have not corrected minor typos,as they don't matter much as long as a physician can understand it.
HPI=48,yo,f,has upper mid-abdomen pain,getting worse,burning type,non radiating,relieved by milk+antacids,aggravated by-fatty ,heavy meals.Intensity=7/10,can go down to 0/10.Has nausea,vomited once yesterday-yellow,sour,non bloody.
ROS=[-]fever,headache,chest pains,irregular heartbeats,joint pains.Bladder/bowel=no problems
PMH=RA=on brufen,OTC multivitamins
PSH=2 c-sec
Alls=NKDA
FH=Father=pancreatic cance
SH=monogamous,married,[-]cig,ETOH,Recreational drugs
LMP=1 week ago,regular,30 day cycle
===========
PE=
VS=NL,not in acute distress
Gen=[-]paolor,icterus,clubbing,rash,palmer erythema,flapping tremor
Abdo=scaphoid,scar+,soft,BS+,No organomegaly/tenderness/rigidity,resonant=all quads
Chest=B/L clear
Heart=RRR,PMI=not displaced,[-]m/r/gallop
=================================
dd=
Gastritis
Peptic ulcer
cholecystitis
Functional dyspepsia
LAB
UGI endoscopy
barium meal
CBC,
Stool-OB
HIDA sca
CT abdomen
============
This is a real PN I typed When Preparing for CS.SO I have not corrected minor typos,as they don't matter much as long as a physician can understand it.