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  1. #1
    skrm is offline Newbie 510 points
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    grading patient notes

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    hi, i am writing cs next month. i want to practise pn. i just written notes for a caseof heavy periods as an example. can any of the kind souls can grade this pn on 1 to 10 and make comments, so that i can improve on it.

    46 Y0 F, MRS SMITH, TEACHER, C/O HEAVY PERIODS SINCE 2 YEARS, PROGRESSIVELY IN CREASED FOR THE LAST 6 MONTHS, NO VAGINAL DISCHARGE/DRYNESS, HAD HOT FLUSHHES, INITIALLY PERIODS WERE 4 to 5 DAYS/6 WEEKS, REST NORMAL, NO PAIN ABDOMEN, NO SYMPTOMS SUGESTIVE OF THYROID DYSFUNCTION, NO GU/GI SYMPTOMS, WEIGHT NORMAL.
    NO MAJOR ILL NESS, HOSPITALIZED FOR CHILD BIRTH ONLY, TAKING MVI/IRON TABLETS, NO SURGERIES, NO ALLERGIES.
    MOTHER HAD NIDDM & HTN ON RX.
    NONSMOKER, NON ALCOHOLIC, NO ILLICIT DRUG USE.
    MOOD IS NORMAL, NO STRESS AT WORK/HOME.
    SEXUALLY ACTIVE WITH HUSBAND ONLY, NO PROTECTION, HUSBAND HAD VASECTOMY, NO STDS.

    NOT IN DISTRESS, VITAL SIGNS:WNL, NO PALLOR/JAUNDICE/PEDAL EDMA, NO PALPABLE NECK NODE/THYROID. NO HAND TREMORS.
    CHEST: B/L CLEAR BREATH SOUNDS, NOI ADDED SOUNDS.
    HEART: REGULAR RHYTHUM, NORMAL S1 &S2, NO MURMUR
    ABDOMEN: NO DISTENSION, **+, NO TENDERNESS, NO PALPABLE LIVER/SPLEEN/OTHER MASSES.
    DTR +2 IN B/L UPPER LIMBS.


    1. DYSFUNCTIONAL UTERINE BLEEDING
    2. PERI MENOPAUSAL
    3. ENDOMETRICAL CANCER
    4. ENDOMETRIAL HYPERPLASIA
    5. THYROID DYSFUNCTION

    PELVIC @ GENITAL EXAMINATION
    URINE BETA HCG
    CBC, BLOOD SUGAR, SERUM TSH,T3,T4
    USG ABDOMEN & PELVIS
    ENDOMETRIAL BIOPSY

  2. #2
    DrPG is offline Member 525 points
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    I'd say about a 7/10, just cause of some slight spelling errors and also because you didnt put in different categories like
    HPI, PMH, Medications, Allergies, ROS... makes it easier for the physician grading to read, and thus can affect the grade they give you for it.
    Good job.

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