Notes Breast Cancer


 

HPI

  • Change "strange symptoms" and use the order that the unrepining used in stating her completion. Note the whole and analogy of the rank and if how numerous times she newfangled pantyliners in one day, if its soaked or not. 
  • 1/10 is a affliction layer, if there is no affliction do not use the layer and instead narrate that she don't arrive-at any affliction
  • I got promiscuous if efficacy waste is kindred to her symptoms or diet
  • HPI instrument narrative of give ailment, earlier ailmentes should be on the departed sanity narrative
  • Change the narratement for the privative papsmear termination to "but the unrepining claimed that she has express termination."

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

  • Character- should picture the rank/spotting
  • Aggravating factors- for ex.if the bleeding happens succeeding sexual intercommunication, during earnestness etc
  • Relieving factors- does not plug delay any remedy

Medications -narrate how hanker she is initiative the garbage and if she's expert delay her prescriptions

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

Family narrative-narrate suit of cessation of the parents and you narrated the age of her siblings twice

Social narrative 

  • occupation is kinda confusing, narrate the job that she lonely on. 
  • how numerous times is a continual mark? 2-3x a week?once? Pls indicate 

ROS

General- is wt waste unanticipated?

PhysicalExam

General- Appears wakeful? 

Skin - pls picture the tint of husk not the course, is the husk indifferent?zealous to reach?

HEENT- picture the tint of sclera

GI-what do you moderation by the abdomen is fertile? Pls picture using expend medical orders

Breast-I'm doleful i did not conceive what you moderationt by  breast is selling and gross axillary lymph?

Musculoskeletal- i fancy you no hankerer insufficiency to narrate that you observed the rom on doubt area?

Neuro - are you not required to charm the reflexes such as tendon reflex, etc?