Why do history and physical write-up sound like transcriptions of interrogations? Specifically, why to doctors write, “Patient denies alcohol use”? It’s as if the patient has been accused of using alcohol and when she says she doesn’t drink, we say she “denies” it. In my experience, the vast majority of patients tell the truth during H&P interviews. There’s a difference between saying, “Patient doesn’t drink alcohol” and “The patient denies alcohol use.”
In reference to the examination of the head, eyes, ears, nose and throat, who is teaching medical students to write things like this?
“HEENT: normocephalic, atraumatic.”
With the exception of Joseph Merrick, known as “The Elephant Man,” just about every person I have ever seen is normocephalic. And other than those who have suffered an injury, the heads of most patients show no trauma.
It is important for a physician to know how to write a coherent sentence and spell words correctly. Poor spelling and grammar reflect either ignorance or sloppiness. Take the word “guaiac” for example. It refers to a reagent used less frequently now for the testing of the stool for blood. It is not spelled “guiac” or “guaic.” If you can’t spell it, use the word “heme” or simply say, “The stool test for blood was negative.”
Worst of all is misstating the plural of the word “diverticulum.” I have seen colorectal surgeons and gastroenterologists, both of whom should know better, refer to more than one diverticulum as “diverticuli” or “diverticulae.” Listen up, people. Diverticulum is derived from a Latin word. Its gender is neuter. Maybe you can remember it by considering other similar words: one bacterium, many bacteria; datum, data; stratum, strata.
Having said all this, I feel better now.