Table 1

Significant problems reported by computer histories but not physician histories for 45 hospitalized patients

Organ

System/Issue

Problem Reported by Computer History but not Hospital Chart

Patients with Problem


Heart

Symptoms heart failure (dyspnea on exertion, paroxysmal nocturnal dyspnea, marked fatigue, pitting edema) with no prior diagnosis

10

Symptoms decompensated heart failure in patients with prior diagnosis

2

"Cardiac asthma" versus reactive airway disease

4

Prior diagnosis angina with chest pain

1

Symptoms effort-induced angina versus reactive airway disease manifest as chest tightness

1

Effort induced chest pain, no prior diagnosis angina

3

Prior MI no invasive treatment

2

Prior MI and angioplasty in last year

1

Syncope

1

Hypertension

8

Uncontrolled hypertension by self-reported BP

3

Arrhythmia

12

Peripheral

Symptoms compatible with intermittent claudication

5

Vascular

Symptoms intermittent claudication versus spinal stenosis

1

System

TIAs in patients with prior CVA

2

TIAs in patient with no prior CVA

2

History carotid artery surgery

1

History peripheral arterial surgery

1

Symptomatic asthma in patients with prior diagnosis but no rescue or control meds

5

History treated TB

1

Symptoms obstructive sleep apnea

1

Symptoms sleep apnea

1

Pulmonary

34 old woman with daily cough and sputum throughout year. Onset as child. (Computer and physician history reported new onset fever and dyspnea with history pneumonia 4 months prior to admission)

1

GI

GERD, AM cough and hoarseness in patient with asthma

1

Symptoms active ulcer disease in patient with prior upper GI bleed

1

Daily aspirin use in patient with prior upper GI bleed

1

Dysphagia in patient with scleroderma

1

Erectile dysfunction

5

GU/GYN

Symptoms urinary obstruction in elderly men

7

Stress incontinence (women)

2

Symptoms estrogen deficiency in patients taking HRT

1

Symptoms recurrent cystitis and back pain in woman

1

Urinary incontinence since prostate surgery 1 year PTA plus 6 months dysuria, back pain and polyuria/polydypsia.

1

Endocrine/Metabolic

Uncertain thyroid status in patients treated previously for hyperthyroidism

3

Polyuria/dyspsia, recent onset blurred vision

1

Gout; no symptoms in last 1 year

1

Polyphagia with no weight gain

1

Diabetics with symptoms hypoglycemia

13

Diabetics not monitoring or inadequately monitoring blood glucose

5

Diabetics unaware of treatment regime for blood sugar

5

Glaucoma

2

Tunnel vision in patient with no prior diagnosis glaucoma

1

Symptoms CNS vasculitis in patient with diagnosis SLE

1

Episodic diplopia

1

Tinnitus, hearing loss but no vertigo

1

Current evidence major depression. No treatment.

2

Major depression in setting of bereavement. No treatment.

1

Current evidence moderate depression. No treatment

1

Past history depression; not currently depressed; no meds

1

Past history mania

1

Prior diagnosis bipolar disorder not currently depressed

1

Symptoms migraine; no prior diagnosis; positive FH migraine

1

Neurology

Multiple hospitalizations for falls; negative AUDIT score

3

High risk for falling because of motor weakness, unsteady gait, past history falls not requiring hospitalization

10

Episodic dizziness and abnormal gait in patient with positive AUDIT score

1

Hodgkin's treated with XRT 3 years prior to admission. Now on chemo for 2nd recurrence.

1

Renal cell cancer treated with surgery and radiation 20 years prior to admission. No recurrence.

1

Oncology Rheumatology

Active rheumatoid arthritis on steroids

1

Life Style

Active smokers seeking help to stop smoking

2

Positive AUDIT score

5

Multiple 1st and 2nd degree relative with breast cancer

1

Family History

Multiple 1st degree relatives with diabetes in patient with history gestational diabetes and recent onset chest pain provoked by emotional upset.

1

Vegetative

Night sweats

1

Symptoms

Weight loss > 10 pounds in non-dieting patient

1


The physician history was acquired prior to the computer history, which was obtained within the first 2 days of hospitalization.

Zakim et al. BMC Medical Informatics and Decision Making 2008 8:50   doi:10.1186/1472-6947-8-50

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