Monday, July 21, 2008

What did they mean? Excerpts from discharge summaries, SOAP notes and more

Discharge Summaries

"Patient was a heavy alcoholic but now drinks a pint of whiskey every day."

"Final diagnosis: Foot drop secondary to mononeuropathies (cranial nerve)"

"Review of Systems: The patient refused to dress sometimes."

"The physical exam shows an alert, obese woman who is drowsy."

"She has a history of hypertension, of diabetes and recurrent DVT, even when fully anticoagulated with Coumadin, and for this reason she has had 11 surgeries including a right tibial fracture at age 16."

Job Interview

During a phone interview, a residency candidate replies to the question What made you study medicine?: "Initially, I really wanted to be a very good human being, but after that I chose medicine."

Diagnostic Dilemma

A nurse urgently pages a medical resident: "Mr. Doe's left half of the body is yellow!"

The resident was just about to order LFTs for jaundice workup over the phone when he realized that something did not sound right...

The patient had just returned from a left shoulder surgery and the "left side of the body" was cleaned with iodine.

Image source: OpenClipArt, public domain.

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