Question about diagnosis terminology.

Aidey

Community Leader Emeritus
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Ok, so I've run into something a few times recently that has finally prompted me to ask about this.

How do you guys address patients who tell you they've been diagnosed with a condition that isn't actually a condition? Like "I've had a nervous breakdown" or "I thew my back out"?

I've had 4-5 patients in the last month tell me the last one, and to be honest, I still haven't figured out what kind of injury that is supposed to be. A sprain? A strain? Spasms?

I've just been documenting it in quotes, but I'm curious how everyone else approaches it.
 

abckidsmom

Dances with Patients
3,380
5
36
For "nervous breakdown," I usually ask some leading questions to probe for a diagnosis. Were you admitted? Were you on medications? What was the outcome?

And this usually if it's relevant. If it's irrelevant, I may or may not chase it down and may write it in quotes.

For "threw my back out" I write back problems or I probe for a more specific diagnosis. A pinched nerve? A disc out of place?
 

fma08

Forum Asst. Chief
833
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Heard a patient tell the doc that another doc diagnosed them with "pseudo-seizures". Made my day. :lol:
 

emt_irl

Forum Captain
255
1
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is it worse now then it was last week?
if this what made you call the ambulance.
or describe throwing your back out, what exactly happened, wheres the pain?

theres just a few that id ask.
 

emt_irl

Forum Captain
255
1
18
Heard a patient tell the doc that another doc diagnosed them with "pseudo-seizures". Made my day. :lol:

they must of thought it was something interesting haha ive seen a pseudo seizure before i know the guy and was saying to myself.. oh no not again
 
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Aidey

Aidey

Community Leader Emeritus
4,800
11
38
The call may have nothing to do with the back problem, I just have no idea what is actually the problem when someone says "I threw my back out". I know how to assess the patient, the problem is that "threw out" isn't a real diagnosis, it's a lay man's term.
 

mgr22

Forum Deputy Chief
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717
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I try to compare patients' meds to history, then ask about discrepancies, e.g. "You mentioned you have a seizure history, but it sounds like you're not taking any medication for that" or "You mentioned you're on Dilantin. Are you being treated for seizures?"
 

MrBrown

Forum Deputy Chief
3,957
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Medicine has enough funny symbols and signs and gadgets to rival Star Trek

Could you not write a description of the chief complaint?

We write either a provisional diagnosis if we have one (eg cardiac arrest, severe asthma, compound fractured tib/fib or hyperglycaemia) or describe the chief complaint eg severe back pain
 

firetender

Community Leader Emeritus
2,552
12
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How do you guys address patients who tell you they've been diagnosed with a condition that isn't actually a condition? Like "I've had a nervous breakdown" or "I thew my back out"?

What's going on right now?
 

adamjh3

Forum Culinary Powerhouse
1,873
6
0
How do you guys address patients who tell you they've been diagnosed with a condition that isn't actually a condition? Like "I've had a nervous breakdown" or "I thew my back out"?

I generally probe a little further if it's pertinent. With the "I threw my back out statement" I'll generally ask them if they have any pain associated with that right now and if that pain is "normal" for the injury or if it's gotten worse. Most of the patients I've run into that complain of "back pain" have it as a chronic issue.

If I can't come to a definite conclusion of whether something was strained/dislocated/sprained etc I'll quote the patient in my PCR. Example: "Ax: Pt found supine on sofa, moved to stretcher via draw-sheet. A&0x2, normal for pt, VS stable, denies nausea/vomitting. Pt complains of pain in 'lower back,' 6/10, stemming from a lifting injury approx. 1.5 wks ago in which pt 'threw out' his back. Point tenderness noted approx. 4" R of midline between L5 and L4."
 
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