Patient Note

Importance of PNs in the USMLE Step 2CS is often underestimated. Many test takers score low on the data gathering because of a poor patient note. Here is a template that I suggest you use for every patient note. Make sure to include every heading. Even if you think it is not important in this particular case. I preferred writing down the Differential Diagnosis and Diagnostic Work Up part before writing the history and physical exam part but you can do either way that you feel comfortable.

History template

[Basic info] 30 yo female c/o [CC] pain in abdomen x 2 days.
[ODP and CC description] Pain is in the lower half of her abdomen, colicky, 7/10 without any radiation. Pain started at rest and gradually worsened to present state. Has taken 2 tabs of Tums today morning with partial relief. There is no specific aggrevating factor.
[Associated symptoms from the affected system] She has associated Nausea and Vomiting. She vomited 2 times today morning. Non bilious/non bloody. No diarrhea.
[Review of other systems] No cough. No pain elsewhere in the body, No trauma, No urinary complaints.

[P]Past medical history is significant for asthma for which she takes [M] budesonide and albuterol. No previous surgeries. [A]Allergic to penicillin and sea food. [S]Is sexually active with her husband and uses condom for contraception. [O] Has one living child that was born vaginally at term 3 years ago. No pregnancy or delivery related complications. [H] That was her only hospitalization. [U] No urinary complaints. [G] LMP was 4 weeks back. Is normally regular every month and lasts 2-3 days. [S] Does not smoke or drink alcohol. Works as a teacher in primary school. [F]Family history significant for grandmother with ovarian cancer. No DM or HTN in family.

Physical exam template

[General] Appears to be in pain but in no acute distress.
[Vitals] Vitals HR: 80/min, RR 20/min, BP 120/80mmHg, Temp 37 C
[GPE] No pallor or icterus. Neck supple. HEENT normal with moist mucous membranes.
[Sytemic Exam]Abdomen: Non distended, Normal bowel sounds in all 4 quadrants. Tenderness on palpation of thr right illiac fossa. No rebound tenderness. No masses or organomegaly.
Chest: Symmetric movements, Normal vesicular breath sounds bilaterally.
Heart: S1S2 normal. No murmur.

Differential diagnosis

1) Acute appendicitis
2) Ectopic pregnancy
3) Ovarian torsion
4) Pelvic inflamatory disease

[Remember to write the Differential in order or possibility]

Diagnostic Work Up

1) Pelvic exam
2) US abdomen and pelvis
3) CBC
4) Urine pregnancy test

[Remember to write Pelvic and other such exams in your Diagnostic Work Up. Examples of commonly forgotten things include

Pelvic exam
Digital rectal exam
Orthostatic vitals
Minimental state exam
Pure tone audiometry]

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