Notes Breast Cancer

HPIChange “strange symptoms” and use the term that the patient used in stating her problem. Note the amount and consistency of the blood and if how many times she changed pantyliners in one day, if its soaked or not.1/10 is a pain scale, if there is no pain do not use the scale and instead state that she don’t feel any painI got confused if weight loss is related to her symptoms or dietHPI means history of present illness, previous illnesses should be on the past health historyChange the statement for the negative papsmear result to “but the patient claimed that she has positive result.”OLDCART” which stands for Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and TreatmentCharacter- should describe the blood/spottingAggravating factors- for ex.if the bleeding happens after sexual intercourse, during activity etcRelieving factors- does not stop with any remedyMedications -state how long she is taking the drug and if she’s compliant with her prescriptionsHospitalizations-rearrange it according to dates, first is when she was 8Family history-state cause of death of the parents and you stated the age of her siblings twiceSocial historyoccupation is kinda confusing, state the job that she retired on.how many times is a frequent visit? 2-3x a week?once? Pls indicateROSGeneral- is wt loss sudden?PhysicalExamGeneral- Appears alert?Skin – pls describe the color of skin not the race, is the skin cold?warm to touch?HEENT- describe the color of scleraGI-what do you mean by the abdomen is obese? Pls describe using appropriate medical termsBreast-I’m sorry i did not understand what you meant by  breast is selling and palpable axillary lymph?Musculoskeletal- i think you no longer need to state that you observed the rom on waiting area?Neuro – are you not required to take the reflexes such as tendon reflex, etc?