eng
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step2cs general

created Jan 21st 2018, 00:22 by DanicaStephens


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182 words
24 completed
00:00
30yo f occupation c/o few days sudden onset quality pain in location that radiates somewhere. severity some number, exacerbated by this, alleviated by that. associated with abc.
ros- no changes in mood, skin, hair, weight, diet, sleep, bowel habits, urination, or temperature tolerance. denies cough, SOB, LOC, HA, fatigue, night sweats, nausea, vomiting, palpitations or chest pain.  
meds-acetaminophen   allergy-penicillin causes rash.
pmh-nothing much. no surgeries. lmp 2 weeks ago, 5day cycle q28, menarche 14yo. g2p2 without complications.
sh-no tobacco, etoh or illicit drug use. sexually active with 1 m partner, consistent condom use.  recently traveled somewhere without immunizations.
 
pt in nad, vs wnl
heent nc/at, perrla, eomi, patent nares, pharynx without exudate or erythema, good dentition, sinuses nt
neck without thyromegaly or jvd. carotids 2+
heart s1s2 rrr without m,r,g
resp ctabl with normal tactile fremitus
abd bs+4q, soft, nt, nd, no organomegaly or masses
ext no clubbing, cyanosis or edema. dtr's and pulses 2+symmetric
 
rectal exam with fobt
urine hcg, ua and culture
cbc with diff
arthrocentesis with crystal analysis, gram stain and culture, cell count
 

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