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, 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 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 jessIe, at 28 June, 2006 05:31
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