I do medical transcription for a living and quite often my job involves editing; we are supposed to transcribe the doctors' dictation "word for word"; however, this doctor has an accent and was a bit agrammatical-- but her words and their story are gripping. I tried as best I could to get "the facts" down while doing full justice to this doctor's heartbroken memorial to her patient, who is dying of a brain hemorrhage.
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(started at the end of "lab studies")
........The most recent CT scan of the head was done on October 30, 2006 and showed the large acute left frontal parenchymal hemorrhage and intraventricular hemorrhage with midline shift and mass effect. Repeat CT of the head is ordered for tomorrow.
ASSESSMENT AND PLAN: The patient is a delightful 87-year-old white female with multiple small medical problems that really have been fairly stable with possibly the exception of her recurrent TIAs which appear to be more frequent despite ongoing antiplatelet therapy.
Despite the diagnosis of dementia the patient was quite appropriate and has always made her own decisions regarding her care. A good example is when we were considering a bone marrow biopsy. She decided on her own that this is what she wanted to proceed with, and her family, including her daughter and son-in-law with whom I discussed the situation, agreed.
The patient has been a patient of mine for approximately five years, and during that time she has clearly expressed to me that she did not want to be kept alive by artificial means. Especially over the last few months with her visits, she would express some frustration with the fact that she was getting older, slower, and having more age-appropriate aches and pains. Therefore, despite a very full active life, she had clearly expressed that she was also ready to die, and that she would not want artificial means put in place to keep her alive.
I have discussed this with the ICU attending....
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And so on. Earlier in the report it's noted that the patient was living more or less independently-- with checks several times a day from her relatives-- and that though her brains were a bit scrambled, she could function well.
She had a terrible stroke and now she's dying. I never knew her in life, but after having typed her history I know her better in some ways than her own family members; I certainly know how much this doctor cared about her.
Usually I don't like doctors (especially if they have heavy accents), but I find that I like this one.
-----------------
(started at the end of "lab studies")
........The most recent CT scan of the head was done on October 30, 2006 and showed the large acute left frontal parenchymal hemorrhage and intraventricular hemorrhage with midline shift and mass effect. Repeat CT of the head is ordered for tomorrow.
ASSESSMENT AND PLAN: The patient is a delightful 87-year-old white female with multiple small medical problems that really have been fairly stable with possibly the exception of her recurrent TIAs which appear to be more frequent despite ongoing antiplatelet therapy.
Despite the diagnosis of dementia the patient was quite appropriate and has always made her own decisions regarding her care. A good example is when we were considering a bone marrow biopsy. She decided on her own that this is what she wanted to proceed with, and her family, including her daughter and son-in-law with whom I discussed the situation, agreed.
The patient has been a patient of mine for approximately five years, and during that time she has clearly expressed to me that she did not want to be kept alive by artificial means. Especially over the last few months with her visits, she would express some frustration with the fact that she was getting older, slower, and having more age-appropriate aches and pains. Therefore, despite a very full active life, she had clearly expressed that she was also ready to die, and that she would not want artificial means put in place to keep her alive.
I have discussed this with the ICU attending....
----------------
And so on. Earlier in the report it's noted that the patient was living more or less independently-- with checks several times a day from her relatives-- and that though her brains were a bit scrambled, she could function well.
She had a terrible stroke and now she's dying. I never knew her in life, but after having typed her history I know her better in some ways than her own family members; I certainly know how much this doctor cared about her.
Usually I don't like doctors (especially if they have heavy accents), but I find that I like this one.