Disclaimer:
This is a HIPAA de-identified open-online-patient-record shared here by Ravi Jain, Souptik Biswas and Avinash Kumar, 3rd Semester, MBBS, WBUHS, West Bengal and UCMS, Nepal autumn 2016 after collecting informed patient consent
(forms downloadable here: http://www.udhc.co.in/
The students have tried to present it in the SOAP format (as detailed here: http://med.fsu.edu/userfiles/file/MedInfo_SOAPnote_Jobaid.pdf)
A 30 years old woman
presented with
the complaints of:
Subjective -
Persistent Vomiting - greenish yellow colored. 8-9 times
Heart Burn
Pain abdomen, in epigastric region,
Fever
Sleep improper
Didn’t pass stool for 5-6 days
She was suffering from pain in the stomach since 8-9 days before admission
Objective -
General examination and abdominal examination: (to be filled up by Ravi Jain and Souptik using this link: https://www.ucl.ac.uk/pc
Investigations:
WBC count increased (11,700)
Hb Normal
MCH decreased (26.
S. creatine decreased (0.6)
A:G decreased (1.1)
Initial clinical assessment of the student -
Stomach tumor
Acute Pancreatitis
Student queries on reflection (More about the learning and assessment methodology here :http://globaludhc18.blogspot.in/2015/12/formative-assessment-of-2014-batch-3rd.html)
Q. - 1. Why heart burn?
Q. - 2. Why she didn’t pass stool for 5-6 days?
Later more objective findings below:
Most of our students don't type. They still use handwritten notes as below (original note that was typed by another student elsewhere):
This is a HIPAA de-identified open-online-patient-record shared here by Ravi Jain, Souptik Biswas and Avinash Kumar, 3rd Semester, MBBS, WBUHS, West Bengal and UCMS, Nepal autumn 2016 after collecting informed patient consent
(forms downloadable here: http://www.udhc.co.in/
The students have tried to present it in the SOAP format (as detailed here: http://med.fsu.edu/userfiles/file/MedInfo_SOAPnote_Jobaid.pdf)
A 30 years old woman
presented with
the complaints of:
Subjective -
Persistent Vomiting - greenish yellow colored. 8-9 times
Heart Burn
Pain abdomen, in epigastric region,
Fever
Sleep improper
Didn’t pass stool for 5-6 days
She was suffering from pain in the stomach since 8-9 days before admission
Objective -
General examination and abdominal examination: (to be filled up by Ravi Jain and Souptik using this link: https://www.ucl.ac.uk/pc
Investigations:
WBC count increased (11,700)
Hb Normal
MCH decreased (26.
S. creatine decreased (0.6)
A:G decreased (1.1)
Initial clinical assessment of the student -
Stomach tumor
Acute Pancreatitis
Student queries on reflection (More about the learning and assessment methodology here :http://globaludhc18.blogspot.in/2015/12/formative-assessment-of-2014-batch-3rd.html)
Q. - 1. Why heart burn?
Q. - 2. Why she didn’t pass stool for 5-6 days?
Later more objective findings below:
Most of our students don't type. They still use handwritten notes as below (original note that was typed by another student elsewhere):
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