Saturday, May 22, 2010

Did we take our Ritalin today?

Reading another doctor's note in a chart, found this:

"Patient has had multiple admissions for similar episodes, in 2002, 2003, 2004, 2006, and now. Blacks-out when standing-up. History of chest pain. Takes daily aspirin. Also had some sort of surgery in 1999, but doesn't know what. Recently started a new drug for his diabetes. Says the surgery might have been on his stomach. As an outpatient he sees Dr. Jones. Says his father had similar issues. Echocardiogram in 2008 showed normal ejection fraction. Retired accountant. Chest pain is gone now, but had some yesterday. All labs normal, but they show anemia and liver issues. Spent yesterday working in yard before the black-out. Felt clammy. Mother died of breast cancer in 1965. Sister living. Says he has an apppointment with a cardiologist as outpatient coming up. Moved here from Michigan. Had a head CT this morning, but hasn't been dictated. Currently is asymptomatic. Should probably consult neurology."

I agree with the last part. But the patient isn't the one who needs me.

21 comments:

Anonymous said...

Squirrel!!

terri c said...

Either ADD on the physician's part or a singularly brainless EMR.

Albinoblackbear said...

Sounds like the reports that are given from my fellow first year medical students.

No wait. That was 100x worse.

oddharmonic said...

I felt tired just reading that!

It does, however, alleviate any guilt I might feel when my fourth-grader asks for writing advice and I say "organize your thoughts after you brainstorm."

Cate said...

wow, i think my clinical medicine prof would die if one of my classmates or I wrote a note like that. and we're first years.

arzt4empfaenger said...

Hah! That's probably why we spent half of a term's class only on doing the anamnesis. Unfortunately, that half was subtracted from the class that would have taught us physical examination... *sigh* Well, can't have everything, right?

medrecgal said...

OMG, that was hilarious! I have not only seen notes like this in a record, I could very well have written one like this if I wasn't careful...even though they make me crazy as a coder. But what killed me wasn't the AD(H)D style, but the "had some sort of surgery... but doesn't know what". Oh, if only I had the luxury of that sort of ignorance! One of the surgeries I've survived happened three DECADES (yes, you're reading that correctly)ago, and physicians still ask a boatload of questions about it. And yes, I think that doc may very well have use for Ritalin!

webhill said...

"all labs normal but they show anemia & liver issues?"

WTF?

stewbert said...

Oh I hate typing reports by doctors/PAs/nurses like that. What makes them "funner" is when they delete entire paragraphs while they're being scatterbrained, too!

Grumpy, M.D. said...

Stewbert- what makes it worse was that this was HANDWRITTEN in the progress notes.

Cate- Yeah, I was more coherent than that as a first year, too. And this person has been in practice for 20 years.

the observer said...

Gack! I write my notes like I do my assessments--from head to toe.

Do you think he does his assessments and asks his questions this way?

Scary...

VF: gracist--someone who practices giving grace--not what someone deserves. A patient seeing this doc is probably a gracist.

Amanda said...

This doc takes notes like my seven-year-old talks. Perhaps the child has a future in medicine!

missaunt said...

OMG. Reading that exhausting. When there's so thoughts going everywhere and then contradictions...OMG.

Kat's Kats said...

Gee, sounds like this... person... takes notes like some of the docs I've had the misfortune to be... mistreated by in my past (my current medical team rocks!).

08armydoc said...

that's almost exactly how one of my interns presents....

Joe said...

Dr ADD,

Please see me after class.

-Dr. Grumpy

RehabNurse said...

Grumpy:

Must have been something shiny going by as Doc was writing his note.

Or the Coke kept calling his name...

Anonymous said...

Interesting... I read this, and I get a mental picture of what taking the history was like (squirrel! indeed) - if this was handwritten, this was probably how the patient was presenting, not how the physician was thinking. Around the 8th tangential comment, "should probably consult neurology" comes in...
This is why, in psychiatry, we try to always dictate.

Maha said...

Oh wow - reading that made me tired. I can't imagine if I had to read that at 0400. But I've looked back on some of my documentation from end of shift and it's just not pretty!

memememe said...

It sounds to me like the doctor was writing as the patient was talking and the patient was likely skipping all over the place. This is why I prefer to write my notes after a visit is over.

A NURSE said...

I worked with an RN years ago who wrote actual nurses notes like this:
"the patient was happy as a little lamb out in the field skipping around amongst the flowers looking for a place to rest...."
ACTUAL words. An MD noted, in the margin "?????????"
We couldn't believe what we were reading. Thank goodness for the forms we now have...initial the box.

 
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