Pt. is not in acute distress/ pt is in acute distress.
VS: WNL
HEENT:
Head: NC/AT
Eyes : EOM intact, PERRLA, vision WNL , Fundoscopy WNL
Ears: TM & canal- clear
Nose: not congested, WNL
Throat : no erythema, no vesicles, no exudates, no other abnormality seen. Tonsils normal
Neck: no swellings, thyroid normal.
CNS:
A&O x 3 , memory & concentration good, CN ll-Xll intact
motor strength 5/5 UE & LE B/L; Sensations intact to dull & sharp
DTR+ 2 symmetric
Gait WNL, Romberg negative, finger-nose normal
- kernig & / or brudzinski
RS:
- cynosis, clubbing, - rales, rhonchi, respirations normal,
- tenderness , TVF WNL, tympanic/dull on percussion
CVS:
+ S1S2, RRR, - m,r,g, -JVD sitting @ 45
PMI nondisplaced, Pulses 2+ B/L
- pedal oedema
Abd:
- scars or skinabnormalities, NT ND,Tympanic to percussion 4Q, - hsm, +BS in 4Q,
- rebound, - murphy's, posas,obturator
Lumbosacral- Back:
- scars or skinabnormalities, NT , ROM WNL,motor strength 5/5 UE & LE B/L; Sensations intact to dull & sharp,DTR+ 2 symmetric, Gait WNL,
Pulses 2+ DP.
Abbreviations are allowed and they are helpful to save time writng PN and rough note. so it is better to practice with the abbreviations commonly used in the USA hospitals.
Subscribe to:
Post Comments (Atom)
Popular Posts
-
Sample Proforma Knock the door thrice , (smiling patient – not in distress - GIVE SMILE not smiing- in distress – NO SMILE, DO NOT SIT) ...
-
Here I am posting how to ask questions and points to cover on the tricky cases of pediatrics.Include all other questions of normal pediatric...
-
Person who ask question is fool for 5 minutes but who never ask, is fool forever. And one more thing also.... Giving advise is really easier...
-
Pt. is not in acute distress/ pt is in acute distress. VS: WNL HEENT: Head: NC/AT Eyes : EOM intact, PERRLA, vision WNL , Fundoscopy WNL Ear...
-
As we have a very limited time for a single case( 25 mins total ) abbreviations can really help to save time in patient note and a rough not...
-
As of July 17, 2011, all examinees taking the USMLE Step 2 CS will be required to type the patient note. Here are some rules for patient no... -
Mostly all common symptoms / diseases are covered under practice cases of reputed books. here I am posting same, divided in system vise cate...
-
You may have cases in USMLE Step 2 CS exam like this. Cases 1. normal- rs/cvs/gi (number of cases 2-3) 2. psychiatry(number of cases 1-2) – ...
-
At the USMLE Step 2 Clinical Skills examination center, they give you a bunch of only 12 PN sheets and only 12 scrap paper sheets.you can... -
This is Sample Patient note. ( The writer of this had passed exam in first attempt)
Your blog in general has been extremely helpful while preparing for the CS. Thank you for taking time out to help others with your experience.
ReplyDeletehi.... can you also plz give a sample with positive physical findings.
ReplyDeletethankyou
In North Carolina State's MA English program, Alice is at present taking a shot at her ace's proposition - a mixture first-year imaginative genuine educational module consolidating talk and social studies General Writing Services
ReplyDelete