This way or that?

[ericdamiansean]

In your schools, when you are writing your portfolios, in the PC/HPC, are you encouraged to write in the patient's words, or do you use medical terms?
For example:
The patient noticed bloody show vs blood stained mucus
The patient noted painful micturition vs dysuria

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[Tired]

In your schools, when you are writing your portfolios, in the PC/HPC, are you encouraged to write in the patient's words, or do you use medical terms?
For example:
The patient noticed bloody show vs blood stained mucus
The patient noted painful micturition vs dysuria

I was taught to use quotes for the chief complaint (ie - "My stomach is sore"), and in general, medical terms in the history of present illness. There are exceptions, for example when the patient uses odd ways of describing the quality of their pain (ie - "I feel like I was punched in the stomach"). But in general, my attendings seemed to prefer medical terminology because it is more succinct.

 

[Mayhem]

PC: Patient's word
HPC: Medical terminology

It makes for interesting PC's though.

 

[Dr JPH]

Agreed.

Chief complaint is what the patient says to you.

And yes, some are indeed funny.

In fact...Im going to start a thread about this.