If you ever wondered why the doctor presses you to give more specific information, it's because we don't want our dictations to sound like this:
Mr. Smith is an old man with pain everywhere for an amount of time he won't tell me. He rates his pain as "okay" out of 10, can't describe it, and says it is associated with a funny feeling in his legs. He takes a medication for the pain that starts with the letter R. He is not sure of the dose. He went to an emergency room somewhere for the pain a while ago and they took X-rays and gave him a shot of some kind, which didn't help. He had an MRI ordered by some doctor. He doesn't have the MRI or report, but he thinks it showed a disc.
Haha. Elderly people as a group just do not seem to be impressed by that pain scale. "What's my pain? It's there! I don't know! It's a pain! It's a hurting pain! These faces are stupid!"
ReplyDeleteLOVE that HPI!
ReplyDeletereminds me of a patient yesterday....I kept asking her how LONG her panic attacks last and she kept saying she didn't know....finally she stated, "maybe a few years?" that certainly helped with the diagnosis!
LOL classic!
ReplyDeleteAbsolutely typical for how the history starts. I would love to write one that way. It really is an art.
ReplyDeleteLMAO!!
ReplyDeleteOMG! IThat is so funny and scarely true! I had a patient once coming in saying he was sick, but didnt know where or how or what or anything! lol
ReplyDeleteBrilliant. I should do that one of these days.
ReplyDeleteAbsolutely hilarious, and I'm not even a medical professional.
ReplyDeleteHilarious! Poor historians don't make for nicely/accurately transcribed records! :)
ReplyDeleteLOL...this kind of HPI is almost worse than none at all. At times a lousy HPI makes it mighty tough to code a record, particularly if there's a limited exam and/or just a nebulous symptom code or two given as a dx. Poor historians don't make for accurate coding, either!
ReplyDeleteTO be honest, I am only 30 and when I am having neurological problems for example after my stroke a few years ago, I am sure I said stuff just like this. It probable made sense to me at the time. But I wasn't firing correctly. There are still days that my head gets muddled. Also I have absence seizures....I don't generally know about them unless someone notices something odd or the few times it happens when I am driving. Scary stuff.
ReplyDeleteTI: *most* patients say stuff like that... that's why we think it's funny :)
ReplyDeleteAnd yet, how often does some of that inevitably end up in a history? There's always something. No one knows how their doctor's name is spelled. No one knows whether that medication that has an L or maybe an M in it is for their diabetes or their blood pressure. I recently acquired some sympathy, though - I had a nasty bug recently and ended up in the ER from dehydration. They asked me who my PCP was and I just totally blanked and had to say I didn't know, just like every other patient, haha.
ReplyDeleteI took a police report like that once from a lady wearing a foil hat. "They broke in my house..." "I don't know how they got it..." "I'm not sure what's missing...." "They ate my ice cream...." "I can't remember what flavor it was...." The house was secure when I got there and she had never left......WTF? I can relate!
ReplyDeleteYour post made me laugh so hard I cried. I am a family doctor and I have had pretty much that exact conversation many times. It's even better when the EMR is down and I have no access to their chart. Then we pretty much just sit there and stare at each other.
ReplyDelete