Table 2

Comparison of findings reported by physician histories and computer histories for 8 patients presenting to their physicians with a chief complaint of chest pain and for whom there were significant discrepancies between physician and computer histories of the present illness

Age/sex

Physician-based Present Illness

Computer-based Present Illness

Diagnostic Outcome


76/f

Angina

No acute disease

Negative cardiac cath

39/m

Exercise-induced angina

Progressive chest pain for 6 months radiating to L. shoulder, L. elbow and palpitations with emotional upset not effort. Patient also had effort-induced tightness of the chest and shortness of breath. ?Atypical angina and reactive airway disease

Negative cardiac cath; negative stress test.

50/f

Atypical angina

6 months SOB and tightness of chest with exercise and strong odors. No acute changes.

No diagnosis. No treatment.

49/m

Pleuritic chest pain; fatigue; 2 days fever and chills: pneumonia.

DOE progressive to dyspnea at rest at admission: heart failure

Pericarditis

54/m

Chest pain

? angina

No acute disease. Denied chest pain

No work up.

Discharged in 1 day

85/f

New onset recurrent angina

DOE with daily chores. Old MI and denied recurrent chest pain.

Negative cardiac cath

77/m

Effort-induced chest pressure lasting 2 to 3 minutes and not relieved by NTG

No acute disease

Documented CAD by angiogram

76/m

2 years "angina" and dyspnea relieved by NTG

No acute disease

Documented CAD by angiogram

24/f

Acute UTI

No acute GU history

Pyelonephritis


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

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