Liz's New Zealand Adventurings

Saturday, June 24, 2006

my history of present illness

HPI text: This is a usually healthy 23-year-old female who presents to the ED for evaluation of 2-day hx of productive cough that has been constant and increasing in severity since onset. She also complains of low-grade fever, rhinorrhea, mild sore throat secondary to rhinorrhea, cold sweats, sinus congestion, diffuse body aches, and nausea that has resolved. She denies any headache, vomiting, dysuria, abdominal pain, chest/neck/ear pain, or any other acute concerns. Patient reports that she has been working everyday for the past 9 days and has not been sleeping well. She has no other complaints at this time.

3 Comments:

  • I like that: "She denies any headache, vomiting, dysuria..."

    By Anonymous Anonymous, at 25 June, 2006 21:00  

  • This is the actual, factual format that I use for each and every patient that "presents to the ED for evaluation..."

    Since starting this job, I literally run that phrase through my mind. It won't go away. You tell me you have had shortness of breath and I take off into a realm of questions and descriptions. And my forehead is all squinchy because of looking at computers all day. I can hardly get it to relax.

    Oh yeah. And then there are all those highly-contageous people who come in and share the love with immune-helpless scribes such as myself.

    By Blogger liz, at 26 June, 2006 00:15  

  • Deary me. You sound busy busy busy! well, hope you chill out sometime man! Groovy....or something...cough...

    By Blogger jessIe, at 28 June, 2006 05:31  

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