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HPI

  • Change “strange symptoms” and use the term that the patient used in stating her problem. Note the amount and consistency of the blood and if how many times she changed pantyliners in one day, if its soaked or not.
  • 1/10 is a pain scale, if there is no pain do not use the scale and instead state that she don’t feel any pain
  • I got confused if weight loss is related to her symptoms or diet
  • HPI means history of present illness, previous illnesses should be on the past health history
  • Change the statement for the negative papsmear result to “but the patient claimed that she has positive result.”

OLDCART” which stands for Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and Treatment

  • Character- should describe the blood/spotting
  • Aggravating factors- for ex.if the bleeding happens after sexual intercourse, during activity etc
  • Relieving factors- does not stop with any remedy

Medications -state how long she is taking the drug and if she’s compliant with her prescriptions

Hospitalizations-rearrange it according to dates, first is when she was 8

Family history-state cause of death of the parents and you stated the age of her siblings twice

Social history

  • occupation is kinda confusing, state the job that she retired on.
  • how many times is a frequent visit? 2-3x a week?once? Pls indicate

ROS

General- is wt loss sudden?

PhysicalExam

General- Appears alert?

Skin – pls describe the color of skin not the race, is the skin cold?warm to touch?

HEENT- describe the color of sclera

GI-what do you mean by the abdomen is obese? Pls describe using appropriate medical terms

Breast-I’m sorry i did not understand what you meant by  breast is selling and palpable axillary lymph?

Musculoskeletal- i think you no longer need to state that you observed the rom on waiting area?

Neuro – are you not required to take the reflexes such as tendon reflex, etc?

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