Rounding on post-partum patients can get pretty monotonous. You ask the same littany of questions about bleeding, breast feeding and birth control to everybody. Once in awhile someone has a hemorrhage or fever, but the vast majority would do just fine without our monitoring or assistance. As a result, your post-partum notes all tend to look very similar. My physical exam section usually looks like this on pretty much every patient:
Gen - A and O x 3 CV - rrr, no murmurs Abd - soft, nt/nd; fundus firm below umbilicus Ext - no c/c/e
For those of you unfamiliar with medical abbreviations and terminology, allow me to draw your attention to the last line, "Ext - no c/c/e." It stands for, "Extremities - no cyanosis, clubbing or edema." Translation = her legs and hands are not blue, not swollen and her fingernails do not look like those of a person who suffers from chronic low blood oxygen levels. I wrote one such note on a patient this week, seeing her on post-partum day #1. Someone else saw her on post-partum day #2. I returned to see her on post-partum day #3. Upon reviewing the note from day #2 I find the following in the other resident's physical exam section:
Gen - A and O x 3 CV - rrr, no murmurs Abd - soft, nt/nd; fundus firm below umbilicus Ext - no clubbing or cyanosis. previously patient was noted to have no lower extremity edema but on this resident's exam, trace lower extremity is present
What? Are you serious? You thougt it was worth using valuable ink and using up the valuable pen-stroke time to write that piece of baloney! Please, unless you're worried about DVT or some other pathology and plan to use your physical exam findings to justify a change in the management of this patient, keep your editorial comments to yourself. Am I out of line here?
