Hey folks,
For the CS Patient Note, when we give our differential diagnosis and back it up with history findings and physical exam findings, I’m having a difficult time deciding what should and should not be included, especially physical exam findings regarding pertinent negatives. I know we should put in appropriate pertinent negatives, but what is considered appropriate? Reading Phloston’s experiences, he had similar issues: “Wrote very few negative findings in the DDx section of the note. In fact, I may have written no more than two or three the whole exam in this section; I was very confused by the need to include negative findings when supporting the DDx at the end of the note because often times the negative findings help exclude a condition, rather than suggest it, so it didn’t make sense to write them.”
In FIRST AID CS Case 1 (Myocardial ischemia), here is all that FA wrote to support MI as a diagnosis:
Hx:
- Pressure-like substernal chest pain
- Pain radiates to left arm, upper back, and neck
- Patient awakens patient at night
Physical exam findings
– (none!)
To me, this seems like a BAD example, right!? What would you guys do differently? And how about epidemiology? Can you guys critique this and give suggestions?
MY VERSION to support MI on FA CS Case 1:
Hx:
- Pressure-like substernal chest pain (same as FA)
- Pain radiates to left arm, upper back, and neck (same as FA)
- Patient awakens patient at night (same as FA)
- Dyspnea
- Pain not relieved with antacids
- Hx of hypertension and high cholesterol
- No regular exercise
- Hx of angina-like chest pain lasting 5-10 minutes
Physical exam findings:
- Equal BP in both arms [rules out/away from Aortic Dissection]
- No chest wall tenderness [rules out costochondritis]
Your suggestions and advice would be coveted. Thanks!
For the CS Patient Note, when we give our differential diagnosis and back it up with history findings and physical exam findings, I’m having a difficult time deciding what should and should not be included, especially physical exam findings regarding pertinent negatives. I know we should put in appropriate pertinent negatives, but what is considered appropriate? Reading Phloston’s experiences, he had similar issues: “Wrote very few negative findings in the DDx section of the note. In fact, I may have written no more than two or three the whole exam in this section; I was very confused by the need to include negative findings when supporting the DDx at the end of the note because often times the negative findings help exclude a condition, rather than suggest it, so it didn’t make sense to write them.”
In FIRST AID CS Case 1 (Myocardial ischemia), here is all that FA wrote to support MI as a diagnosis:
Hx:
- Pressure-like substernal chest pain
- Pain radiates to left arm, upper back, and neck
- Patient awakens patient at night
Physical exam findings
– (none!)
To me, this seems like a BAD example, right!? What would you guys do differently? And how about epidemiology? Can you guys critique this and give suggestions?
MY VERSION to support MI on FA CS Case 1:
Hx:
- Pressure-like substernal chest pain (same as FA)
- Pain radiates to left arm, upper back, and neck (same as FA)
- Patient awakens patient at night (same as FA)
- Dyspnea
- Pain not relieved with antacids
- Hx of hypertension and high cholesterol
- No regular exercise
- Hx of angina-like chest pain lasting 5-10 minutes
Physical exam findings:
- Equal BP in both arms [rules out/away from Aortic Dissection]
- No chest wall tenderness [rules out costochondritis]
Your suggestions and advice would be coveted. Thanks!
