Consult-Liaison Medicine Observations

Chart Notes.

While reviewing old chart notes, I frowned as I learned how distressed the patient had been while he was in the emergency department. Without realizing it I murmured a line from a physician’s note:

Rambling historian, only clear complaint is hunger.

A colleague, who is often hungry, overheard me and responded, “That would be my mental status exam.”

A different chart provided this information:

Patient started getting agitated and threw a bagel at staff.

I couldn’t help but snort with amusement[1. All of us who must write clinical notes often dilute details because they’re often not relevant to clinical care, though these details often add context to what happened. Like the writer of this note, I often include factual details without intending to be funny. Sometimes we laugh because we otherwise would feel overwhelmed with sadness, anger, or helplessness.], though then wondered:

  • Was it a whole bagel?
  • Was it an old, stale, and hard bagel?
  • Did the bagel have cream cheese on it?
  • Was it thrown like a frisbee or like a baseball?
  • Did the bagel actually hit anyone?
  • What happened that led the patient to throw the bagel?
  • Did the patient elect to throw the bagel instead of an open carton of milk? or a single serving of jelly?

Yet another chart included this terse note from a medicine resident in the early hours of the morning:

Interval exam changes. Agitated overnight. Double middle finger to providers. Haldol 5mg IV ordered and given.[2. For those of you who are interested, Haldol 5mg IV equals Haldol 10mg PO (by mouth), which is a standard dose for someone with a diagnosis of schizophrenia. The thing about Haldol 5mg IV is that sometimes doctors order this with the intention of inducing calm in a patient so he doesn’t punch staff, destroy property, hurt himself… but, sometimes, the patient instead becomes sedated and is in a deep sleep for many hours. The goal should be to calm, not snow, the patient.] PRN Ativan.

One would hope that a patient doesn’t receive a sedating antipsychotic medication simply for extending both middle fingers to doctors and nurses!