Saturday, July 10, 2010
One of the most valuable tools of electronic medical records his being able to review a patients previous visits quickly. I saved this note from residency b/c it was so funny. It had to be written by an off service resident, b/c there is no way an ER resident would write in such detail (hence all my short hand). Anyway, the resident does a great job of painting a picture of this glorious patient.
HPI: 48 yo WF with past med history of extensive alcohol and drug abuse, bipolar disorder, Hepatitis C cirrhosis, and hypertension who presents after being found down at the bus stop across the street from this hospital. Patient reports that she woke up this morning and drank 2 bottles of wine and injected heroin subcutaneously, per her daily routine, and then set out on a bus ride to buy more wine and ask people for money. After buying the wine, she spent a few hours behind the hospital asking people for money. Then she went to the bus stop across the street to catch a ride back to her apartment. This is the last thing she remembers before awaking in the ambulance while being transported to the ER. Patient denies any fever/chills, nausea/vomiting, chest pain, loss of bowel or bladder incontinence. She does report she becomes very ill when she stops drinking, and has had seizures and hallucinations in the past while withdrawing from alcohol. Pt has reported to the ER countless times over the past 5 years for a series of injuries both from assaults and falls, and has been found down and treated for alcohol intoxication and withdrawal in the past. She is also wheelchair-bound secondary to a R hip injury which she sustained in 2007.
Posted by SerenityNow at 6:30 PM