About patient note writing, negative findings

[Smashingdude]

---

Members don't see this ad.

Hey everyone,

I need help in writing the PN. Basically, I am ok with HPI and P/E, but I don't know if I should also put the -ve findings in the 3 ddx. I am putting all the pertinent negatives in the HPI and P/E, but I am not sure how important it is to put the -ve findings in the 3 differentials. Is it really important, or I can make do with the +ve findings only?

I usually only put the +ve findings, but I am trying to put the -ve ones from now on. For example, this is the 3 ddx for the Case 1 of FA. Can someone please verify it, and let me know if my concept of pertinent -ves is correct?

Diag 1: Peptic ulcer disease
+Epigastric pain, non-radiating
+Aggravated by heavy meals/hunger
+Alleviated by Food/antacids/milk
+NSAIDs

P/E findings:
+Abd WNL

Diag 2: Cholecystits
+Epigastric pain
+Aggravated by heavy meals
-No pain radiation to shoulder region(Boas sign)
-Relieved by antacids

P/E findings:
-Absence of Murphy sign
-Abscence of Fever
+Abd WNL

Diag 3: Functional dyspepsia/Nonulcer dyspepsia
+Epigastric pain
+Nonradiating
+Intermittent

P/E findings:
+Abd WNL


Thanks!

 

[HelloGoodbye]

Wondering the same thing...how do we indicate they are pertinent positives or negatives?

i.e. If I am really thinking appendicitis, but list for my second diff dx...

Acute Cholecystitis....would I also list psoas/obturator sign here, because it helps point to the alternative dx?

 

[HelloGoodbye]

Anybody with suggestions on this...I take the test in 2 days...Thank you!