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1.LINK FOR PRACTICING YOU PATIENT NOTES:

http://www.usmle.org/practice-materials/step-2-cs/patient-note- practice2.html

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2.Sample PN 1:(New Format Applicable from 1st January 2013)


History:(Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s). )

Cc= ‘’I sound kind of funny’’ x 2 days

HPI= 35 yo, M, Afro American, c/o voice changes x 2 days. Sudden onset, constant problem, Friend noticed his voice change on a telephone call. Worse in the morning. He feels his voice is hoarse. Never had similar problem before. Works as a drill sergeant in the Army, has been shouting a lot recently in drill rehearsals .+ fever/neck pain/anterior neck swelling .No trauma/runny nose/sore throat/swallowing difficulty/ cough, chest pain/ weight loss/ skin rash.

ROS= no headaches, visual problems, sick contacts, bally belly pain, urination problems.

PMH= HTN x 10 years, on lisinopril,2.5mg,od, visits doctor every 2 months    MEDS=multivitims

ALLs= amoxicillin,rash

PSH= Apendicites appendectomy 15yrs ago.

FH= no similar problems, parents good health.

SH= no cigerettes/ EtOH/ recreational drugs. Sexually active, male, 1 partner, not using condoms , no STD, never tested for HIV

Physical exam: Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of examination you performed inthis encounter.

no acute distress

VS= HR=99/min,T=100 F, rest wnl

HEENT= AT/NC,no sinus tenderness,no post nasal drip,throat=non congested,TM=intact

Neck= supple, no carotid bruit, no thyromegaly, no lymphadenopathy

Lungs= CTA and P b/l

Extremities= no edema, pulses + b/l,skin=not dry

DATA INTERPRETATION: Based on what you have learned from the history and the physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1:Acute laryngitis

History Finding(s)

Physical Exam Finding(s)

Acute –2 days

Voice=hoarse

Hoarse voice

Febrile,T=100 F

Had sore throat 1 mo ago

 

Diagnosis #2:voice abuse

History Finding(s)

Physical Exam Finding(s)

Army drill seargent

Hoarse voice

Doing excessive shouting lately

 

 

 

Diagnosis #3:subacute granulomatous thyroiditis

History Finding(s)

Physical Exam Finding(s)

Voice changes

Looks thin built

Weight loss

Anterior neck tenderness

Anterior Neck pain/swelling

 

Work up

1.       laryngoscopy

2.       CBC, eletrolytes,  ESR

3.       US neck and thyroid

4.       TSH,FT4,FT3

5.       CT neck

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download it from :www.skype.com

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